European Journal of Surgical Oncology

Target region resection in patients undergoing cytoreductive surgery for peritoneal metastases-is it necessary in absence of visible disease?

The aim was to study the patterns of target region (greater omentum, lesser omentum, falciform and umbilical round ligament) involvement in patients undergoing cytoreductive surgery (CRS) from various primary tumors, factors affecting involvement and implications on surgical practice. All patients undergoing CRS from July 2018 to December 2018 were included in this prospective study. The incidence of target region involvement in presence and absence of visible disease and the impact of primary tumor site, PCI and other variables on target region involvement was evaluated. In 191 patients, greater omentum was involved in over 15% of patients irrespective of the primary tumor type and in 15.7% in absence of visible disease. 75% of these had PCI <20. The involvement of the other three target regions was higher than 20% in ovarian cancer, appendiceal tumors and peritoneal mesothelioma. Involvement of these 3 regions was associated with a higher PCI (p < 0.001 for all) and omental involvement (p < 0.001for all). 2.1% of colorectal cancer patients had umbilical round ligament involvement, 4.2% had falciform ligament involvement and none had lesser omentum involvement. Target region involvement varies according to primary tumour site and disease extent. Resection of the greater omentum should be performed during CRS for PM arising from all primary sites. Resection of other target organs may be performed for selected patients with ovarian cancer, peritoneal mesothelioma and mucinous appendiceal tumors in absence of visible disease. For other patients, it should be done only in presence of visible disease.

Surgical treatment of vaginal and vulvar melanoma: a 18-year retrospective study

Vaginal and vulvar melanomas are rare and seems to have extremely poor prognosis, often diagnosed with locally advance stage, with difficulties to obtain free surgical margin. The aim of this study was to describe long term outcomes of vaginal and vulvar melanomas after surgical treatment. Retrospective observationnal cohort study between January 2002 and december 2020 at Gustave-Roussy Institute. A total of 57 patients were treated for vulvar and vaginal melanoma between january 2002 and december 2020. Among them 38.6 % (22/57) had surgery for vaginal (10/22) or vulvar melanoma (12/22). The main symptoms at diagnosis were vaginal bleeding for 40.9 % (n = 9/22), and vaginal mass for 36.4 % (n = 8/22) of the patients. Median tumor size was 15 mm (10-30). Free margins was obtained in 55.5 % of the cases (n = 12/20). Mutation (c-KIT, BRAF, NRAF) were found in 27 .3 % of the patients (6/22). Median progression free survival was 7.5 (5-11) months and overall survival 24 (12-41) months. Vaginal and vulvar melanoma have a poor prognosis. Extensive surgery with anterior or posterior pelvectomy shoud only be performed to obtained free margin with caution in well selected patient. Radiological lymph node should contraindicate primary surgical strategy. Neodjuvant immunotherapy could help to obtained free margin in patient with high risk of invaded margin, these patients should be included in randomized controlled clinical trials.

Predictors of recurrence in early-stage cervical cancer without adjuvant treatment after radical surgery

The role of adjuvant radiotherapy after radical surgery for early-stage cervical cancer is controversial in the absence of high-risk factors. This study aimed to evaluate predictors of recurrence in patients with early-stage cervical cancer undergoing observation after radical surgery. Patients with FIGO 2018 stage I cervical cancer who underwent radical surgery without adjuvant therapy at the European Institute of Oncology, IEO (Milan, Italy) between 2010 and 2023 were retrospectively identified. Patients with high-risk factors for recurrence (positive margins, parametria, or lymph nodes) were excluded. Recurrence-free survival following surgery was estimated using the Kaplan-Meier method. Log-rank test and Cox regression analyses were performed to assess predictors of recurrence. A total of 340 patients were identified: 7 (2.0 %) stage IA1, 31 (9.1 %) IA2, 191 (56.2 %) IB1, 108 (31.8 %) IB2, and 3 (0.9 %) IB3. Twenty-two (6.5 %) patients had a recurrence. The estimated 5-year recurrence-free survival for the overall cohort was 93.5 % (95 % CI, 89.9-95.8). On multivariate analysis, factors associated with a higher risk of recurrence included tumor size ≥2 cm (HR 3.04, 95 % CI 1.26-7.35; p = 0.01) and grade 3 (HR 2.76, 95 % CI 1.1-6.9; p = 0.03). In the absence of high-risk factors, the risk of recurrence in patients with early-stage cervical cancer who did not receive adjuvant treatment after radical surgery was low overall. Patients with individual risk factors such as tumor size ≥2 cm or tumor grade 3 may be at higher risk of recurrence. Further research is warranted to redefine risk groups and tailor adjuvant treatment based on timely clinicopathological risk factors.

Do surgeons overestimate diaphragmatic peritoneal disease in interval debulking surgery of ovarian cancer?

Cytoreductive surgery is a key point in ovarian cancer treatment. Substantial morbidity may be consecutive to this major radical surgery. However, the objective of no residual tumor (CC-0) had demonstrated its clear improvement of prognosis. Could macroscopically-driven interval debulking surgery (IDS) overestimate active cancer cells and be unnecessarily morbid? This retrospective cohort study was conducted in Center Leon Berard Cancer Center between 2000 and 2018. We included women with advanced epithelial ovarian cancer who received neoadjuvant chemotherapy and underwent an IDS including resection of peritoneal metastases on the diaphragmatic domes. The primary endpoint was the pathological outcome of peritoneal resections of diaphragmatic domes. Peritoneal resections of diaphragmatic domes consisted of 117 patients. 75 patients required resection of nodules from the right cupola only, 2 patients from the left cupola only, and 40 patients bilaterally. Pathological analysis of the diaphragmatic domes found that 84.6% of samples demonstrated the presence of malignant cells, and only 12.8% found no tumor involvement. Pathology analysis could not be performed for 3 patients (2.6%) (vaporization). Surgical evaluation after neoadjuvant chemotherapy in ovarian cancer does not often overestimate peritoneal involvement by active carcinomatosis. Potential surgical morbidity due to peritoneal resection in IDS is admissible.

Pattern of recurrence in patients with endometrial cancer: A retrospective study

Endometrial cancer (EC) known prognostic factors are not sufficient to predict either outcome or recurrence rate/site: to investigate EC recurrence patterns according to ESMO-ESGO-ESTRO risk classes, could be beneficial for a more tailored adjuvant treatment and follow-up schedule. 758 women diagnosed with EC, and a 5-years follow-up, were enrolled: they were divided into the ESMO-ESGO-ESTRO risk classes (low LR, intermediate IR, intermediate-high I-HR, and highrisk HR) and surgically treated as recommended, followed by adjuvants therapies when appropriate. Higher recurrence rate (RR) was significantly detected (p < 0,001) in the HR group (40,3%) compared to LR (9,6%), IR (16,7%) and I-HR (17,1%). Recurrences were detected more frequently at distant sites (64%) compared to pelvic (25,3%) and lymph nodes (10,7%) recurrences (p < 0,0001): only in LR group, no differences were detected between local and distant recurrences. 5-Year distant-free (LR 99%, IR 94%,I-HR 86%, HR 88%) and local-free survivals (LR 99%, IR 100%,I-HR 98%, HR 95%) significantly differ between groups (p < 0,0001 and p = 0,003, respectively). Adjuvant therapy modifies RRs only in LR group (p = 0,01). To identify biological factors to stratify patients at higher risk of relapse is needed. Distant site relapse could be the main reason of endometrial cancer failure follow-up, independently or in addition to their risk class prognosis.

Risk factors for late-onset lower limb lymphedema after gynecological cancer treatment: A multi-institutional retrospective study

Late-onset lower limb lymphedema (LLL) is a significant clinical challenge for physicians dealing with patients that undergo treatment involving the pelvic cavity. We aimed to clarify the prevalence of and risk factors for late-onset LLL after treatment for gynecological cancer. We conducted a multicenter retrospective study using records of cases in which LLL diagnosed by physical findings and measurement of limbs girths. Patients with LLL after treatment for uterine cervical, endometrial, and ovarian cancer were sequentially enrolled. We examined the timing of LLL onset and the associations between the time to onset and clinical characteristics, including age, type of cancer, lymphadenectomy sites, and performance of radiotherapy. We also investigated the risk factors for late-onset LLL and their effects on the cumulative incidence of late-onset LLL. In total, 711 patients fulfilled the required criteria. Mean age of was 50.2 years old and median follow-up period was 5.05 years. More than half of them (50.5%) presented with LLL ≥5 years after undergoing treatment for gynecological cancer. A substantial number of patients (29.4%) developed LLL ≥10 years after undergoing treatment for gynecological cancer. Being aged <50 years [(odds ratio (OR): 1.919, P = 0.001), cervical cancer (OR: 1.912, P = 0.001), and radiotherapy (OR: 1.664, P = 0.017) were identified as significant risk factors for late-onset LLL in multivariate logistic regression analysis. A substantial number of patients present with LLL ≥5 years after receiving treatment for gynecological malignancies. Clinicians are required to identify high-risk patients and inform them of the risk of late-onset LLL.

Incidence and potential predictors of thromboembolic events in epithelial ovarian carcinoma patients during perioperative period

To assess the incidence and the risk factors of venous thromboembolism (VTE) in patients with epithelial ovarian carcinoma (EOC) during the perioperative period. A retrospective analysis was conducted on the patients with epithelial ovarian cancer treated in our hospital, between January 2017 and July 2019, and a comprehensive review of the medical documentation was performed to collect relevant data. We then analyzed the related factors of the thrombosis in the EOC patients, using univariate and multivariate analysis to identify significant risk factors for VTE, and bootstrap resampling method was used to verify the multivariate analysis results. The ROC curve methods were conducted to evaluate the diagnostic value for the prediction of VTE. We analyzed 233 cases of patients with EOC, of whom the incidence of VTE was 11.16%. According to multivariate and 5000 bootstrap samples analysis, preoperative D-dimer levels (>4.215 μg/ml, p = 0.041 and p = 0.032) and comorbid of cerebral infarction (p 50.5 years old, p = 0.019 and p = 0.002) and nonoptimal debulking surgery (p = 0.007 and p = 0.002) showed significance in predicting VTE after surgery; bootstrap analysis also found the D-dimer levels (>4.215 μg/ml) and tuberculosis had statistical significance. More effective thromboprophylaxis and pre-test assessment is necessary for EOC patients. For prediction VTE events, D-dimer levels (>4.215 μg/ml) were the independent predictors before operation. Age and debulking surgery were the independent predictors post operation.

Comparison of minimally invasive surgery with laparotomic approach in the treatment of high risk endometrial cancer: A systematic review

To analyze all published studies comparing minimally invasive surgery (MIS) with laparotomic one in the surgical treatment of high-risk endometrial cancer (EC) in term of operative, peri-operative and oncological outcomes. We conducted a systematic literature search in PubMed between January 1995-March 2019. Titles and abstracts were analyzed by two reviewers. A set of explicit criteria was used for selection of literature: 1) randomized controlled trials (RCT), prospective or retrospective cohort studies, given the rarity of this tumor and the concomitant lack of data in the form of large trials, all reviewed original report publications with an appropriate number of subjects were considered and included; 2) participants of interest being patients who have suffered from high risk EC 3) the outcome measures including overall survival (OS), disease-free survival (DFS) and recurrence, (4) English language, (5) abstract available. Thirty relevant articles were selected for full reading. For final analysis 20 studies were selected. Then, as second step, the full articles were evaluated to determine whether full inclusion criteria were met. In total, 9 papers were identified and included. MIS appears to be safe in the management of high-risk EC patients, showing better perioperative and postoperative outcomes and comparable oncological outcomes than open surgery. Prospective randomized trial would be needed to confirm this data.

Pancreatic resections for metastases: A twenty-year experience from a tertiary care center

Literature data about pancreatic resections for metastases are limited to small series, so that the role of surgery in this setting remains unclear. We herein report our experience from a tertiary care center, analyzing the outcomes of patients who underwent pancreatic resections for metastases and discussing the role of surgical resection in their management. From January 1999 to January 2019, 26 patients underwent pancreatic resections for metastases from renal cell carcinoma (RCC-group) or other primitive tumors (non-RCC-group). Details regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in a database of pancreatic resection, were retrospectively analyzed and compared. RCC-group was composed of 21 patients, non-RCC-group of 5 patients. RCC-group presented a longer disease-free interval: 96.4 vs. 5.4 months (p < 0.001). In 9/21 patients (42.9%) of RCC-group the surgical resection of other organs or vascular structures was performed, while in non-RCC-group pancreatic resection alone was performed in all cases, p = 0.070. No local recurrence was reported in all cases. The systemic recurrence rate was 42.9% (9/21 patients) in RCC-group and 80% (4/5 patients) in non-RCC-group, p = 0.135. RCC-group presented a longer DFS and OS: 107.5 vs. 25.2 months (p = 0.002), and 109.1 vs. 36.2 months (p = 0.016), respectively. Radical pancreatic resection may confer a survival benefit for RCC metastases, while for other primitive tumors it should be applied more selectively. For RCC pancreatic metastases, an aggressive surgical approach, even in patient with locally advanced tumors, or associated extra-pancreatic localizations, or recurrent metastases should be taken in consideration.

Challenges and management options of tubo-ovarian cancer in the midst of SARS-CoV-2 pandemic

Pathological findings following risk-reducing salpingo-oophorectomy in BRCA mutation carriers: A systematic review and meta-analysis

To evaluate the benefit of risk-reducing salpingo-oophorectomy (RRSO) by estimating the pathological positive rate of occult lesions, including serous tubal intraepithelial carcinoma (STIC) and occult cancers (OCCs). BRCA1/2 mutation carriers who underwent RRSO in a Chinese study center between 2014 and 2018 were included. A literature review was performed, followed by a meta-analysis of the literature to further validate the findings. Twenty-four BRCA1/2 mutation carriers who underwent RRSO were identified; one patient (4.2%) had STIC, and one patient (4.2%) had occult fallopian tube cancer complicated by STIC. Thirty-four articles were ultimately included in the meta-analysis. Of the reported cases of OCC, 61.3% occurred in the fallopian tubes and 32.3% in the ovaries, and 81.5% were in the early stages. The estimated rate of overall pathological positive events was 5%. The estimated rates of overall STIC events and OCC were 1% and 3%, respectively. The rates of STIC and OCC were 1% and 3%, respectively, for BRCA1 mutation carriers and 1% and 1%, respectively, for BRCA2 mutation carriers. No significant difference was observed between the results of a routine examination of pathological sections and those of the Sectioning and Extensively Examining the Fimbriae (SEE-FIM) protocol. This study is the first report of RRSO results in China. In this systematic review, the positive rates of STIC or OCC after RRSO were no more than 3%, which are 200-fold higher than the risk of the general population. The use of a strict SEE-FIM protocol would likely increase positive results.

A comparison of outcomes following total and selective peritonectomy performed at the time of interval cytoreductive surgery for advanced serous epithelial ovarian, fallopian tube and primary peritoneal cancer – A study by INDEPSO

To compare clinical outcomes following total and selective peritonectomy performed during interval cytoreductive surgery (CRS) for stage IIIC/IVA serous epithelial ovarian cancer. In this retrospective study, extent of peritonectomy was classified as total parietal peritonectomy (TPP) which comprised of removal of the entire parietal peritoneum and the greater and lesser omenta or selective parietal peritonectomy (SPP) that included 1/>1 of parietal peritonectomies performed to resect sites of residual disease. A comparison of patient and disease characteristics, morbidity, mortality and survival outcomes between the two groups was made. From January 2013 to December 2017, 79 patients underwent CRS (TPP-30, SPP-49) with or without intraperitoneal chemotherapy (IPC). The median PCI was 14 for TPP and 8 for SPP. The 90-day grade 3-4 morbidity (23.3% for TPP, 14.2% for SPP, p = 0.58) the 90-day mortality was similar (p = 0.58). The median disease free survival (DFS) was 37 months for SPP and 33 months for TPP (p = 0.47) and median overall survival (OS) not reached for both. The 3-year OS was 95% for TPP and 70.8% for SPP (p = 0.06). The only independent predictor of OS was grade 3-4 morbidity (p = 0.01) and not TPP (p = 0.09). Microscopic residual disease was seen in 23.3% with normal looking peritoneum in TPP group. TPP was not associated with increased morbidity compared to SPP. There was a trend towards a longer OS in the TPP group and the finding of residual disease in 'normal looking' peritoneum' warrants prospective evaluation of the benefit of TPP in this setting.

The role of hyperthermia on abdominal tissue concentrations of cisplatin during and after intraperitoneal chemotherapy – insights from a porcine model

Epithelial ovarian cancer remains a leading cause of mortality among gynecological malignancies, with a high incidence of peritoneal carcinomatosis at diagnosis. Hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a promising treatment for advanced-stage epithelial ovarian cancer, potentially improving recurrence-free and overall survival rates. The study aimed to investigate the impact of hyperthermia on cisplatin concentrations in healthy abdominal tissues by comparing HIPEC with normothermic intraperitoneal chemotherapy (NIPEC) in a novel porcine model. Sixteen cancer-free pigs underwent cytoreductive surgery followed by either HIPEC or NIPEC, with cisplatin administered intraperitoneally. Microdialysis was used to measure local cisplatin concentrations in various abdominal tissues over a 6-h period. The analysis revealed no statistically significant or clinically relevant difference in cisplatin concentrations between the HIPEC and NIPEC groups. In both groups, cisplatin concentrations were consistently higher in the peritoneum than in other tissues, and plasma levels were significantly lower than those in abdominal tissues. Hyperthermia did not enhance cisplatin's tissue penetration, suggesting that NIPEC may be an effective alternative to HIPEC, particularly for fragile and elderly patients. Future studies should investigate whether hyperthermia improves cisplatin delivery and cytotoxicity in tumor-infiltrated peritoneal tissues.

Sentinel lymph node biopsy in apparently early-stage ovarian cancer: beyond removal of green nodes and surgical experience

Systematic pelvic and para-aortic lymphadenectomy is the standard procedure for surgical staging in apparently early-stage ovarian cancer. The role of sentinel lymph node biopsy remains unclear. To evaluate the diagnostic accuracy, feasibility, and safety of sentinel lymph node biopsy when performed by a single operator with a standardized technique. Case series of 36 patients with apparently early-stage ovarian cancer who underwent surgery performed by a single operator following the SELLY trial protocol. Sentinel lymph node mapping was performed by injecting the tracer into the infundibulopelvic and utero-ovarian ligaments. Sentinel node biopsy was followed by systematic pelvic and para-aortic lymphadenectomy. Thirty-six consecutive patients with apparently early-stage ovarian cancer were enrolled; 22 patients underwent immediate surgery and 14 delayed procedures after incidental diagnosis. 86.1 % of patients had successful mapping of at least one SLN, and 54.8 % had successful mapping in both pelvic and para-aortic regions. Three patients had isolated tumor cells (ITCs) and one patient had macro-metastasis in SLN. No cases of false negative SLN were observed. The sensitivity and negative predictive value were 100 %. We had five (13.9 %) postoperative complications not related to the SLN procedure itself. SLN is a reliable and safe surgical procedure in apparent early-stage ovarian cancer regardless of immediate and delayed surgery, but strict protocol adherence and expert surgeons are mandatory. SLN mapping in apparent early-stage ovarian cancer is feasible and accurate in detecting lymph node metastasis.

Extensive cytoreductive surgery in stage IV ovarian cancer may not be a justified treatment strategy

Complete macroscopic surgical cytoreduction improves survival in advanced ovarian cancer. However, our previous results suggest that the survival benefits of aggressive surgery to achieve complete macroscopic resection may vary across different subgroups. This study aimed to identify a potential poor-prognosis subgroup among patients with complete macroscopic resection. This cohort study included all patients with advanced ovarian cancer who underwent complete macroscopic resection in a public and centralized health care system setting. Two 3-year cohorts were compared: pre-implementation (cohort 1, n = 101) and post-implementation (cohort 2, n = 172) of a very high surgical proficiency setting. Overall survival was compared by relative risks (RR) stratified by stage and surgical extent. Cox regression estimated hazard ratios (HR) adjusted for relevant covariates. In patients with stage IV, median survival was 33 (cohort 2) vs 47 months (cohort 1), 7-year RR 1.01 (95 % CI 0.78 to 1.31). When extensive surgery was required in stage IV median survival was 27 (cohort 2) vs 58 months (cohort 1), 5-year RR 0.91 (95 % CI 0.81 to 1.01). By contrast, in stage III, median survival was 93 (cohort 2) vs 59 (cohort 1) months, 7-year RR 0.76 (95 % CI 0.59 to 0.98), with the greatest difference when less extensive surgery was required; Not reached vs 65 months, 7-year RR 0.62 (95 % CI, 0.43 to 0.88). Adjusted analysis confirmed improved survival in cohort 2 only after less extensive surgery, HR 0.56 (95 % CI, 0.33-0.95). The implementation of a very high surgical proficiency setting was not associated with improved survival in patients with stage IV despite complete macroscopic resection, as opposed to patients with stage III.

Risk reducing mastectomy in Norwegian BRCA1/2 carriers

Sentinel node mapping, sentinel node mapping plus back-up lymphadenectomy, and lymphadenectomy in Early-sTage cERvical caNcer scheduled for fertilItY-sparing approach: The ETERNITY project

To investigate the safety of sentinel node mapping for patients with early-stage cervical cancer undergoing cervical conization plus nodal evaluation. The ETERNITY project is a retrospective, multi-institutional study collecting data of patients with early-stage cervical cancer undergoing fertility-sparing treatment. Here, we compared outcomes related to three methods of nodal assessment: sentinel node mapping (SNM), SNM plus backup lymphadenectomy (SNM + LND); pelvic lymphadenectomy (LND). Charts of 123 patients (with stage IA1-IB1 cervical cancer) were evaluated. Median patients' age was 34 (range, 22-44) years. SNM, SNM + LND, and LND were performed in 32 (26 %), 31 (25.2 %), and 60 (48.8 %) patients, respectively. Overall, eight (6.5 %) patients were diagnosed with positive nodes. Two (3.3 %), three (9.7 %), and three (9.4 %) patients were detected in patients who had LND, SNM + LND, and SNM respectively. Considering the 63 patients undergoing SNM (31 SNM + LND and 32 SNM alone), macrometastases, micrometastases, and isolated tumor cells were detected in four (3.2 %), three (2.4 %), and one (0.8 %) patients, respectively. All patients with positive nodes discontinued the fertility sparing treatment. Other two patients (one (1.7 %) in the LND group and one (3.1 %) in the SNM group) required hysterectomy even after negative nodal evaluation. After a median follow-up of 53.6 (range, 1.3, 158.0) months, nine (7.3 %) and two (1.6 %) patients developed cervical and pelvic nodes recurrences, respectively. Disease-free (p = 0.332, log-rank test) and overall survival (p = 0.769, log-rank test) were similar among groups. In this retrospective experience, SNM upholds long-term oncologic effectiveness of LND, reducing morbidity.

Uterine transposition versus uterine ventrofixation before radiotherapy as a fertility sparing option in young women with pelvic malignancies: Systematic review of the literature and dose simulation

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) with cisplatin and doxorubicin in patients with ovarian cancer: A systematic review

PIPAC consists in delivering normothermic chemotherapy solution directly into the peritoneal cavity as an aerosol under pressure. Currently PIPAC is considered as a palliative treatment for patients suffering from non-resectable peritoneal carcinomatosis. We performed a SR to assess tolerance and response of this novel method among patient with OC. We searched electronic database PubMed, Embase, Web of Science, Clinical Trials.gov. We only included clinical studies reporting PIPAC with cisplatin and doxorubicin in patients with ovarian cancer. This systematic review included 4 studies. In 3 studies all patients were pretreated with cytoreductive surgery, in 1 study surgery was performed in 8/34 (23 %) patients. Mean PCI at first PIPAC procedure ranged from 16.3 to 19.6. All studies reported the proportion of patients with ascites at the first PIPAC with a pooled rate of 48,3 %. Pooled rate of CTCAE Grade 3 toxicity calculated on the total number of PIPAC was 6 % and Grade 4 was 0.9 %. One study reported two cases of small bowel perforation related or potentially related to PIPAC. On study reported a cumulative survival after 400 days of 62 % and a mean actuarial survival time of all patients who underwent PIPAC of 442 days. In another study the mean time to progression was 144 days (95 % CI 122-168 days). This systematic review demonstrated that PIPAC with cisplatin and doxorubicin appear to have a good safety profile with low toxicity and encouraging trend in terms of overall survival.

Prognostic value of lymph node ratio in patients with non-metastatic cervical cancer treated with radical hysterectomy: A population-based study

The lymph node ratio (LNR) is an emerging prognostic biomarker in multiple malignancies. This study aimed to explore the prognostic role of LNR in patients with non-metastatic cervical cancer undergoing radical hysterectomy. Data were extracted from the SEER 17 registry. Univariate and multivariate Cox analyses were performed to identify the prognostic factors associated with cancer-specific survival (CSS). A nomogram was constructed to predict the 5-year and 10-year CSS. Survival analyses stratified by the status of LNR and different adjuvant treatments were performed using the Kaplan-Meier method. A total of 8128 female patients with non-metastatic cervical cancer who underwent radical hysterectomy and regional node examination (≥8) were enrolled. Of these, 1269 (15.6%) were confirmed as lymph node-positive. Cox regression analyses showed that age, race, tumor size, tumor grade, histology, and LNR were significant factors affecting CSS. A nomogram was developed for predicting the 5-year and 10-year CSS, which showed good discrimination and calibration. Patients without lymph node involvement had inferior CSS with adjuvant treatments compared to those who did not receive further treatment. In patients with LNR ≤10%, only those receiving adjuvant radiotherapy had a trend of better CSS. In patients with an LNR between 10% and 30% and more than 30%, concurrent radiochemotherapy (CCRT) proved to be the best treatment. LNR is an independent prognostic factor in patients with non-metastatic cervical cancer undergoing radical hysterectomy. For patients with negative lymph nodes, no further treatment is recommended. Patients with positive lymph nodes could benefit more from CCRT.

Machine learning for prediction of concurrent endometrial carcinoma in patients diagnosed with endometrial intraepithelial neoplasia

To identify predictive clinico-pathologic factors for concurrent endometrial carcinoma (EC) among patients with endometrial intraepithelial neoplasia (EIN) using machine learning. a retrospective analysis of 160 patients with a biopsy proven EIN. We analyzed the performance of multiple machine learning models (n = 48) with different parameters to predict the diagnosis of postoperative EC. The prediction variables included: parity, gestations, sampling method, endometrial thickness, age, body mass index, diabetes, hypertension, serum CA-125, preoperative histology and preoperative hormonal therapy. Python 'sklearn' library was used to train and test the models. The model performance was evaluated by sensitivity, specificity, PPV, NPV and AUC. Five iterations of internal cross-validation were performed, and the mean values were used to compare between the models. Of the 160 women with a preoperative diagnosis of EIN, 37.5% (60) had a post-op diagnosis of EC. In univariable analysis, there were no significant predictors of EIN. For the five best machine learning models, all the models had a high specificity (71%-88%) and a low sensitivity (23%-51%). Logistic regression model had the highest specificity 88%, XG Boost had the highest sensitivity 51%, and the highest positive predictive value 62% and negative predictive value 73%. The highest area under the curve was achieved by the random forest model 0.646. Even using the most elaborate AI algorithms, it is not possible currently to predict concurrent EC in women with a preoperative diagnosis of EIN. As women with EIN have a high risk of concurrent EC, there may be a value of surgical staging including sentinel lymph node evaluation, to more precisely direct adjuvant treatment in the event EC is identified on final pathology.

Survival associated with the use of one-step nucleic acid amplification (OSNA) to detect sentinel lymph node metastasis in cervical cancer

Sentinel lymph node (SLN) biopsy is part of surgical treatment of apparent early-stage cervical cancer. SLN is routinely analyzed by ultrastaging and immunohistochemistry. The aim of this study was to assess the survival of patients undergoing SLN analyzed by one-step nucleic acid amplification (OSNA) compared with ultrastaging. Single-center, retrospective, cohort study. Patients undergoing primary surgery and SLN mapping ( ±pelvic lymphadenectomy) for apparent early-stage cervical cancer between May 2017 and January 2021 were included. SLN was analyzed exclusively with OSNA or with ultrastaging. Patients with bilateral SLN mapping failure, with SLN analyzed alternatively/serially with OSNA and ultrastaging, and undergoing neo-adjuvant therapy were excluded. Baseline clinic-pathological differences between the two groups were balanced with propensity-match analysis. One-hundred and fifty-seven patients were included, 50 (31.8%) in the OSNA group and 107 (68.2%) in the ultrastaging group. Median follow up time was 41 months (95%CI:37.9-42.2). 5-year DFS in patients undergoing OSNA versus ultrastaging was 87.0% versus 91.0% (p = 0.809) and 5-year overall survival was 97.9% versus 98.6% (p = 0.631), respectively. No difference in the incidence of lymph node recurrence between the two groups was noted (OSNA 20.0% versus ultrastaging 18.2%, p = 0.931). In the group of negative SLN, no 5-year DFS difference was noted between the two groups (p = 0.692). No 5-year DFS and OS difference was noted after propensity-match analysis (87.6% versus 87.0%, p = 0.726 and 97.4% versus 97.9%, p = 0.998, respectively). The use of OSNA as method to exclusively process SLN in cervical cancer was not associated with worse DFS compared to ultrastaging. Incidence of lymph node recurrence in the two groups was not different.

Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry

A laparoscopic approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (L-CRS+HIPEC) in highly selected patients has been reported in small cohorts with a demonstrable reduction in length of stay and post-operative morbidity. This study aims to analyse individual patient data from these international centres collected through the Peritoneal Surface Oncology Group International (PSOGI) L-CRS+HIPEC registry. An international registry was designed through a networking database (REDCAP®). All centres performing L-CRS+HIPEC were invited through PSOGI to submit data on their cases. Patient's characteristics, postoperative outcomes and survival were analysed. Ten international centres contributed a total of 143 L-CRS+HIPEC patients during the study period. The most frequent indication was low grade pseudomyxoma peritonei in 79/143 (55%). Other indications were benign multicyst mesothelioma in 21/143(14%) and peritoneal metastasis from colon carcinoma in 18/143 (12,5%) and ovarian carcinoma in 13/143 (9%). The median PCI was 3 (2-5). The median length of stay was 6 (5-10) days, with 30-day major morbidity rate of 8.3% and 30-day mortality rate of 0.7%. At a median follow-up of 37 (16-64) months 126/143 patients (88.2%) were free of disease. Analysis of these data demonstrates that L-CRS+HIPEC is a safe and feasible procedure in highly selected patients with limited peritoneal disease when performed at experienced centres. While short to midterm outcomes are encouraging in patients with less invasive histology, longer follow up is required before recommending it for patients with more aggressive cancers with peritoneal dissemination.

Stage I juvenile granulosa cell tumors of the ovary: A multicentre analysis from the MITO-9 study

Juvenile type granulosa cell tumor (JGCTs) are extremely rare, mainly diagnosed in young women and pre-pubertal girls at stage I disease. Literature is scanty and guidelines regarding the optimal management are still controversial. The aim of this study is to add on the experience of the MITO group (Multicenter Italian Trials in Ovarian Cancer). Clinicopathological data from patients with stage I JGCTs were retrospectively collected. Descriptive statistics were used to characterize the patient population. Clinicopathological features and treatment variables were evaluated for association with relapse. Seventeen patients were identified. Surgical approach was laparoscopic and open for 7 (41%) and 10 (59%) patients, respectively. Fertility sparing surgery (FSS) was performed in 15 patients (88%): unilateral salpingo-oophorectomy (USO) in 11 patients, cystectomy with subsequent USO in 2 patients and cystectomy alone in the remaining 2. Adjuvant chemotherapy was given in 2 cases. After a median follow up time of 80 months, no recurrences were registered. Given the available data, minimally invasive surgery is safe in stage I JGCTs. Because of the good prognosis and of the young age of patients, FSS can be chosen in most of the cases. The role of cystectomy deserves further validation. The need of adjuvant chemotherapy in stage I disease is still unclear, even if available data does not seem to support treatment over surveillance.

Risks and benefits of systematic lymphadenectomy during interval debulking surgery for advanced high grade serous ovarian cancer

Lymphadenectomy is debated in patients with ovarian cancer. The aim of our study was to evaluate the impact of lymphadenectomy in patients with high-grade serous ovarian cancer receiving neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). A retrospective, unicentric study including all patients undergoing NACT and IDS was carried out from 2005 to 2018. Patients with and without lymphadenectomy were compared in terms of recurrence free survival (RFS), overall survival (OS), and complication rates. We included 203 patients. Of these, 133 had a lymphadenectomy (65.5%) and 77 had involved nodes (57.9%). Patients without a lymphadenectomy were older, had a more extensive disease and less complete CRS. No differences were noted between the lymphadenectomy and no lymphadenectomy group concerning 2-year RFS (47.4% and 48.6%, p = 0.87, respectively) and 5-year OS (63.2% versus 58.6%, p = 0.41, respectively). Post-operative complications tended to be more frequent in the lymphadenectomy group (18.57% versus 31.58%, p = 0.09). In patients with a lymphadenectomy, survival was significantly altered if the nodes were involved (positive nodes: 2-year RFS 42.5% and 5-year OS 49.4%, negative nodes: 2-year RFS 60.7% and 5-year OS 82.2%, p = 0.03 and p < 0.001, respectively). Lymphadenectomy during IDS does not improve survival and increases post-operative complications.

Primary site disease and recurrence location in ovarian cancer patients undergoing primary debulking surgery vs. interval debulking surgery

The natural history and patterns of ovarian cancer (OC) relapse are still unclear. Recurrent disease can be peritoneal, parenchymal, or nodal. This study aims to analyze the location and pattern of OC recurrence according to the primary site of disease and to the type of surgical approach used. All OC patients underwent primary debulking surgery (PDS) or interval debulking surgery (IDS), with 2014 FIGO stage III-IV, and with platinum-sensitive recurrence were included in the study. Primary disease location and site of recurrences were divided into peritoneal, parenchymal, and nodal, according to the presence of peritoneal carcinomatosis, parenchymal metastasis, and nodal involvement, respectively. A total of 355 patients were initially considered; of them, 295 met the inclusion criteria. Two hundred thirty-three patients obtained no macroscopic residual tumor at the end of primary surgical treatment. Primary parenchymal disease relapsed in 84.6% cases at a parenchymal site (p < 0.001), 97.2% of peritoneal diseases relapsed on the peritoneum (p < 0.001), and 100% of nodal diseases had a nodal recurrence (p < 0.001). Stratifying by the surgical approach all these correlations have been confirmed both in the PDS (p < 0.001) and IDS (p < 0.001) groups. Our study shows that the site of relapse in cases of platinum-sensitive OC recurrence is closely related to the primary location of the disease, regardless of the type of initial treatment. Therefore, more attention during followup should be paid to areas where the initial tumor was present.

Seeing the whole picture: Added value of MRI for extraperitoneal findings in CRS-HIPEC candidates

In colorectal cancer (CRC) patients the selection of suitable cytoreductive surgery and hyperthermic peritoneal chemotherapy (CRS-HIPEC) candidates is based on the location and extent of peritoneal metastases (PM) and presence of extraperitoneal metastases. MRI is increasingly being used to accurately assess the extent of PM, however, the significance of extraperitoneal findings in these scans has never been evaluated before. CRC patients who had undergone an additional MRI scan after standard work-up with CT for preoperative staging between January 2016-January 2020 were selected. CT and MRI reports were reviewed for new abdominopelvic extra-peritoneal findings on MRI (MR-EPF) and MR-EPFs concerning lesions previously indicated as equivocal (uncertain benign/malignant) on CT. Reference standard were surgical results or follow-up imaging. In 158 included patients 60 MR-EPFs (in 58/158 patients) were noted: twenty-six (43%) were new findings and thirty-four (57%) were equivocal findings on CT. Of the 34 equivocal findings 27 were 'rejected/less likely malignant' and 7 'confirmed/more likely malignant' based on MRI. In 29 patients (18%) the MR-EPFs had direct influence on treatment planning. Three patients (2%), eligible for CRS-HIPEC on CT, were deemed inoperable due to MR-EPFs. MRI had an added value in more than a third of the patients due to abdominopelvic extraperitoneal findings that were undetected or indeterminate on CT and therefore influenced the treatment in a substantial part of the patients. Combined with the known accurate detection of peritoneal disease on MRI, MRI seems a logical addition to the diagnostic workup of potential CRS-HIPEC candidates.

Prognostic factors of overall survival for patients with FIGO stage IIIc or IVa ovarian cancer treated with neo-adjuvant chemotherapy followed by interval debulking surgery: A multicenter cohort analysis from the FRANCOGYN study group

The aim of this study was to identify prognostic factors of overall survival in patients with FIGO stage IIIc or IVa ovarian cancer (OC) treated by neo-adjuvant chemotherapy (NAC) followed by interval debulking surgery. Data from 483 patients with ovarian cancer were retrospectively collected, from January 1, 2000 to December 31, 2016, from the FRANCOGYN database, regrouping data from 11 centers specialized in ovarian cancer treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analysis were performed to define prognostic factors of overall survival. The median overall survival was 52 after a median follow up of 30 months. After univariate analysis, factors significantly associated with decreased overall survival were; no pelvic and/or para-aortic lymphadenectomy (p = 0.002), residual disease (CC1/CC2/CC3) after surgery (p < 0.001), positive cytology after NAC (p < 0.001), omental disease after NAC (p = 0.002), no pathologic complete response (pCR) (p = 0.002). In multivariate analysis, factors significantly associated with decreased overall survival were; residual disease after surgery (HR = 1.93; CI95% (1.16-3.21), p = 0.01) and positive cytology after NAC (HR = 1.59; CI95% (1.01-2.55), p = 0.05). Patients with no residual disease after surgery had a median overall survival of 64 months versus 35 months for patients with residual disease. Patients with negative cytology after NAC had a median overall survival of 71 months versus 43 months for patients with positive cytology after NAC. In this first and largest French based retrospective study, complete cytoreductive surgery in ovarian cancer remains the main prognostic factor of overall survival.

Metformin as a radiosensitiser for pelvic malignancy: A systematic review of the literature

The treatment of pelvic malignancies has continued to improve over recent years, with neoadjuvant radiotherapy often considered the gold standard to downstage disease. Radiosensitisers are routinely employed in an attempt to improve response of cancers to radiotherapy. Previous preclinical evidence has suggested a role for metformin, a commonly used drug for type 2 diabetes. A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string 'Metformin' AND ('Radiosensitivity' OR 'radiosensitising' OR 'radiosensitising'). Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated proforma. The review was registered on the PROSPERO database (ID: CRD42020199066). A total of 242 papers were identified, 11 of which were included in this review; an additional 5 papers were obtained from reference searches. Metformin has been demonstrated to reduce cell-viability post-radiotherapy in both rectal and prostate cancer cell lines, with an enhanced effect in tumours with a p53 mutation and increased apoptosis post-radiotherapy for cervical cancer. Clinical trials demonstrate improved tumour and nodal downstaging and pCR rates for rectal cancer using metformin as a radiosensitiser. With an increasing understanding of the underlying mechanism of the effects on metformin prospective studies are required to assess the effect of routine use on cancer related outcomes. Progressive future studies may be better served by the use of predictive biomarker guided treatment to enable identification of the appropriate cohort to target.

Salvage lymphadenectomy in recurrent ovarian cancer patients: Analysis of clinical outcome and BRCA1/2 gene mutational status

This study is aimed to analyze the clinical outcome of recurrent ovarian cancer patients bearing isolated lymph-node recurrence (ILNR) who underwent salvage lymphadenectomy (SL). The prognostic role of clinicopathological variables and the mutational status of BRCA1/2 have also been investigated. This retrospective, single-institutional study included women with platinum-sensitive lymph node recurrence underwent to SL between June 2008 and June 2018. Univariate and multivariate analysis was performed to evaluate the impact of clinical parameters, and BRCA1/2 mutational status on post salvage lymphadenectomy progression-free survival (PSL-PFS). As of June 2019, the median follow-up after SL was 30 months, and the relapse has been documented in 48 (56.5%) patients. In the whole series, the median PSL-PFS was 21 months, and the 3-year PSL-PFS was 36.7%. The median PSL-PFS, according to patients with ILNR (N = 71) versus patients with lymph-nodes and other sites of disease (N = 14), was 27 months versus 12 months, respectively. Univariate analysis of variables conditioning PSL-PFS showed that platinum-free interval (PFI) ≥12 months, normal Ca125 serum levels, and number of metastatic lymph-nodes ≤3 played a statistically significant favorable role. In multivariate analysis, PFI duration ≥12 months and the number of metastatic lymph nodes ≤3 were shown to keep their favorable, independent prognostic value on PSL-PFS. In the context of SL, the patients with long PFI and low metastatic lymph node numbers at ILNR diagnosis have the best outcome. The BRCA mutational status seems not associated with clinical variables and PSL-PFS, differently from other sites of disease in ROC patients.

Survival outcome and perioperative complication related to neoadjuvant chemotherapy with carboplatin and paclitaxel for advanced ovarian cancer: A systematic review and meta-analysis

To compare the effectiveness and safety of neoadjuvant chemotherapy with carboplatin/paclitaxel followed by interval debulking surgery (NACT-IDS) to primary debulking surgery plus postoperative chemotherapy (PDS) for advanced ovarian cancer. A comprehensive systematic review and meta-analysis were conducted by an Expert Panel of the Japan Society of Gynecologic Oncology Ovarian Cancer Committee. Multiple public search engines including PubMed/MEDLINE and the Cochrane Database, were searched in March 2019 using the entry keywords "ovarian cancer [all fields]" AND "interval debulking surgery [all fields]", AND "neoadjuvant chemotherapy [all fields]". Key inclusion criteria were prospective clinical trials examining platinum-based NACT for stage II-IV epithelial ovarian cancer. The primary outcome of interest was survival, and the secondary outcome was adverse events with each intervention. After screening 333 studies, four phase III randomized clinical trials were identified that met the inclusion criteria. These trials included 1692 women (847 receiving NACT-IDS and 845 receiving PDS). It was found that NACT-IDS and PDS had similar overall survival (hazard ratio [HR]: 0.97, 95% confidence interval [CI]: 0.87-1.07, P = 0.53) and progression-free survival (HR: 0.98, 95%CI: 0.90-1.08, P = 0.74). In contrast, NACT-IDS was associated with significantly lower rates of perioperative complications (odds ratio [OR] 0.27, 95%CI: 0.20-0.36, P < 0.001) and perioperative mortality (OR: 0.17, 95%CI: 0.06-0.50, P < 0.001) compared to PDS. This systematic review and meta-analysis suggests that NACT-IDS with carboplatin and paclitaxel does not negatively impact the survival of women with advanced ovarian cancer compared to PDS, while perioperative complications and mortality are significantly reduced by 70-80%.

Lymphadenectomy, obesity and open surgery are associated with surgical complications in endometrial cancer

To investigate surgical complications related to the staging procedure for endometrial cancer (EC) and to explore complication associations towards patient characteristics and survival. A population-based cohort study of women diagnosed with EC where primary surgery was performed at a tertiary centre between 2012 and 2016. The Swedish Quality Registry for Gynecological Cancer was used for identification, medical records reviewed and surgical outcomes, including complications according to Clavien-Dindo (CD), and comorbidity (Charlson's index) registered. Uni- and multivariable logistic regression analyses were performed with complications as outcome and multivariable Cox regression analysis with overall survival (OS) as endpoint. In total 549 women were identified where 108 (19.7%) had CD grade II-V complications. In the multivariable regression analysis; surgical technique, BMI and lymph node dissection, but not comorbidity or age, were found to be risk factors for complications CD grade II-V, with OR of 0.32 (95%CI:0.18-0.56) for minimalinvasive surgery (MIS) compared to open, OR 2.18 (95%CI:1.37-3.49) for BMI ≥30 and OR 2.63 (95%CI:1.32-5.31) for pelvic and paraaortic lymphnode dissection. In Cox regression analysis, a significant lower OS was found within the first 1.5 years for the cohort of complications (CD II-V) compared to no complications. Surgical staging with lymphadenectomy was found a risk factor for complications together with high BMI in EC. Using MIS was significantly associated with less complications. Overall survival was found to be negatively affected within the first years after complications. Our results may be taken into consideration when performing updated treatment guidelines including surgical staging.

What women want: Fertility sparing surgery in Borderline ovarian tumours patients and pregnancy outcome

Borderline ovarian tumours (BOTs) are characterized by the presence of cellular proliferation and nuclear atypia without stromal invasion. Compared to malignant ovarian tumours, BOTs have better prognoses. The most important treatment of BOT is surgery. Considering the good prognosis of BOT, fertility-sparing surgery (FSS) can be considered for young women who desire to preserve fertility. Our study evaluated the pregnancy rate in patients with childbearing desire, the efficacy and risk of recurrence of women affected by BOTs who have undergone FSS. Patients characteristics have been restrospectively retrieved for diagnosis made from June 2000 to December 2017 from San Raffaele Hospital and Policlinico Cagliari. Patients underwent FSS for BOT were interviewed about child wishing and pregnancy outcomes. 85 patients were recruited for the study. Median age at diagnosis was 33 years. Unilateral salpingo-oophorectomy was performed in 33 patients (38%), unilateral cystectomy in 40 (47%) and 12 underwent both procedures (14%). 40 women (50%) tried to conceive after surgery. The pregnancy rate was 73% and live birth rate was 67%. Childbearing desire and age at diagnosis were significantly associated with the pregnancy rate. Conservative surgical treatment seems to be a reasonable therapeutic option for women with BOTs who wish to preserve fertility. Our results suggest that the obstetric outcomes after FSS are promising. Maternal desire and the age of diagnosis are the most important factors affecting PR after surgery. Fertility counselling should be an integral part of the clinical management of women with BOT.

Toxicity profile of chemotherapy agents used in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies

Morbidity associated with cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is due to the synergistic effect of cytoreduction, effect hyperthermia and the cytotoxic agents used for HIPEC. This study was done to analyse the postoperative morbidity in relation to the chemotherapy agent used in patients undergoing CRS-HIPEC for peritoneal surface malignancy (PSM) in Indian set up. Patient with PSM, underwent CRS-HIPEC as per the institutional protocol. Patients were stratified as per the chemotherapy drug used during HIPEC & perioperative outcome were documented. 163 patients underwent CRS-HIPEC for PSM: 67.4% were of ovarian primary. Others were colorectal, appendicular, gastric primary and rare tumors.Cisplatin was the most common drug used: as alone (57.05%) or in combination with Adriamycin (12.88%). Mitomycin-C (MMC) was used in 20% and oxaliplatin in 10%.Grade 3-5 morbidity in the whole cohort was 44.8% and grade 1-2 was 74%.Grade 1-2 electrolyte abnormality was the most common morbidity overall and grade 3-4 hematological toxicity was the most common severe morbidity. Frequency of grade 3-5 morbidity were 38.7%, 48.5%,50% and 61.9% for Cisplatin alone, MMC, oxaliplatin and Adriamycin + cisplatin respectively. None of the patients had grade 3-4 nephrotoxicity as sole complication. All major complications were highest in the group who received Adriamycin. Cisplatin was associated with higher rate of electrolyte imbalance, oxaliplatin with post-operative bleeding. Rates of other complications did not differ significantly. Cisplatin followed by MMC were the well tolerated drugs during HIPEC and tolerance to Adriamycin combination regimen in Indian patients was poor.

Peroperative scoring systems for predicting the outcome of cytoreductive surgery in advanced-stage ovarian cancer – A systematic review

The extent of peritoneal metastases (PM) largely determines the possibility of complete or optimal cytoreductive surgery in advanced ovarian cancer. An objective scoring system to quantify the extent of PM can help clinicians to decide whether or not to embark on CRS. Therefore several scoring systems have been developed by different research teams and this review summarizes their performance in predicting a complete or optimal cytoreduction in patients with advanced ovarian cancer. A systematic search in the MEDLINE database revealed 19 articles that described a total of five main scoring systems to predict the completeness of CRS in patients with FIGO stage III-IV ovarian cancer based on the surgical exploration of the abdominal cavity; PCI, PIV, Eisenkop, Espada, and Kasper. The Peritoneal Cancer Index (PCI) and the Predictive Index Value (PIV) were mentioned most frequently and showed AUCs of 0.69-0.92 and 0.66-0.98, respectively. Due to the use of different cut-offs sensitivities and specificities greatly varied. Therefore with the current data, no scoring system could be identified as best. An objective measure of the extent of disease can be of great clinical use for identifying ovarian cancer patients for which a complete (or optimal) CRS is achievable, however due to local differences in treatment strategies and surgical policy a widely adopted objective scoring system with a standard cut-off value is not feasible. Nevertheless, objective scoring systems can play an important role to guide treatment decisions.

Results of complete cytoreductive strategy in patients with peritoneal metastases of colorectal origin with or without extraperitoneal metastases: A bicentric analysis

Increased survival can be achieved in patients with colorectal cancer peritoneal metastases (CRPM) treated with cytoreductive surgery. The benefit of this strategy remains uncertain when CRPM are associated with extraperitoneal metastases (EPM). The aim of this study was to compare short- and long-term outcomes of patients treated with CRS for CRPM, with or without EPM. This study included 413 consecutive patients who underwent CRS for CRPM: 120 with EPM (EPM+) and 293 without (EPM-). Patients with isolated ovarian metastases were included in EPM-group (n = 83). EPM were mainly located to the liver (66 %,n = 79), retroperitoneal lymph nodes (33 %,n = 40); less frequently to the spleen (9 %,n = 12), lung (9 %,n = 10) or pleura (1 %,n = 1). Ovarian metastases were present in 126 patients (83 in EMP-, 43 in EPM+). Peritoneal carcinomatosis index (PCI) was similar in EPM- (8 [4-14]) and EPM+ (8 [3-13],p = 0.335) groups, as postoperative mortality (3 % vs 3 %,p = 1) and major morbidity rates (28 % vs 35 %,p = 0.223). Median overall survival (mOS) and disease-free survival were significantly higher in the EPM-group (58m vs 39m, and 16m vs 10m,p = 0.003). We highlighted 3 prognostic groups 1) EPM-with PCI15 regardless EPM (mOS 26m, p < 0.001). Complete cytoreductive surgery seems to be feasible in patients with EPM, without increase in postoperative morbidity and mortality compared to patients without EPM. This strategy provides prolonged survival in selected patients with limited peritoneal metastases from colorectal cancer.

Surgical outcomes and morbidity in open and videoendoscopic inguinal lymphadenectomy in vulvar cancer: A systematic review and metanalysis”

Surgical evaluation of inguinal lymph nodes is essential to correctly guide the adjuvant treatment of vulvar cancer patients. Open inguinal lymphadenectomy (OIL) approach is the preferred route, while the videoendoscopic inguinal lymphadenectomy (VEIL) seems to be associated with better results. This meta-analysis aimed to compare the surgical outcomes of OIL vs VEIL in vulvar cancer. The meta-analysis was conducted according to the PRISMA guideline. The search string included the following keywords: "(vulvar cancer) AND ((inguinal) OR (femoral)) AND ((lymph node dissection) OR (lymphadenectomy))". Three double-blind researchers independently extracted data. Seventeen studies were considered eligible for the analysis. Seven studies were included in the OIL group and ten studies in the VEIL group. A total of 372 groins were included in OIL group and 197 groins in VEIL group. 153 groins (41.1 %) in the OIL group and 25 groins (12.6 %) in the VEIL group developed major complications. The analysis of all lymphatic and wound complications showed that VEIL had a lower rate of lymphatic and wound complications. Estimated blood loss (p = 0.4), hospital stay (p = 0.18), time of drainage (p = 0.74), number of lymph node excised (p = 0.74) did not show significant difference between the two approaches. VEIL route may be a valid alternative to OIL route with no differences in terms of surgical outcomes, except for operative time that is shorter for OIL. Future analysis of randomized controlled trials in this specific patient population are warranted to confirm these results.

Health-related quality of life after interval cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with stage III ovarian cancer

The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improves recurrence-free (RFS) and overall survival (OS) in patients with FIGO stage III ovarian cancer. We evaluated the effect of HIPEC on patient's health-related quality of life (HRQoL) in the OVHIPEC trial. OVHIPEC was a multicentre, open-label, randomized phase III trial for patients with stage III ovarian cancer. Patients were randomly assigned (1:1) to receive interval CRS with or without HIPEC with cisplatin. HRQoL was assessed using the EORTC QLQ-C30, and the ovarian (QLQ-OV28) and colorectal cancer (QLQ-CR38) modules. HRQoL questionnaires were administered at baseline, after surgery, after end of treatment, and every three months thereafter. HRQoL was a secondary endpoint, with the prespecified focus on the QLQ-C30 summary score and symptom scores on fatigue, neuropathy and gastro-intestinal symptoms. HRQoL was analysed using linear and non-linear mixed effect models. In total, 245 patients were randomized. One-hundred-ninety-seven patients (80%) completed at least one questionnaire. No significant difference over time in the QLQ-C30 summary scores was observed between the study arms (p-values for linear and non-linear growth: p > 0.133). The pattern over time for fatigue, neuropathy and gastro-intestinal symptoms did not significantly differ between treatment arms. The addition of HIPEC to interval CRS does not negatively impact HRQoL in patients with stage III ovarian cancer who are treated with interval CRS due to the extent of disease. These HRQoL results, together with the improvement in RFS and OS, support the viability of HIPEC as an important treatment option in this patient population. CLINICALTRIALS. NCT00426257. 2006-003466-34.

Comparison of oncological outcomes and major complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy for stage IB1 cervical cancer with a tumour size less than 2 cm

To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm. We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals. (1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups. The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula.

The exciting journey of progress: Exploring FIGO 2023 staging for endometrial cancer at a leading ESGO institution

The 2023 FIGO staging of endometrial cancer integrates tumor grade and histology along with molecular features that recognize the prognostic significance of p53 and POLE mutations, accounting for potential conflicts such as lymphovascular space invasion and subserosal invasion. In this single-institution retrospective study, data were collected on 229 endometrial cancer patients from January 2020 to September 2024 and re-stage them according to FIGO 2023 criteria. From FIGO stage 2009 IA, 70 patients do not cross stage (21 are FIGO 2023 IA1 and 49 IA2), 8 patients are upgraded to FIGO IC because of aggressive histotype; 1 is upstaged because of substantial LVSI, and 12 because of aggressive myoinfiltrating tumors (23 % of upstaging). From FIGO 2009 stage IB 34 patients remain in FIGO 2023 IB, while 5 become stage IIB (LVSI) and 27 IIC (aggressive myoinfiltrating), for a total of 32 upstages (48 % of upstaging). Within FIGO 2009 stage II, no proper upstage was possible. We observed a statistical correlation between stages and BMI, as well as between stages and age, for both FIGO 2009 (p = 0.009 and p < 0.001 respectively) and FIGO 2023 (p = 0.002 and p = 0.003 respectively) classifications. Additionally, a correlation was found between tumor grade and BMI (p = 0.02). The FIGO 2023 staging system is gaining importance as recent studies highlight the role of molecular classification in prognosis and personalized therapy. Updating our study's follow-up data will clarify its impact in clinical practice.

How to predict para-aortic node involvement in advanced cervical cancer? Development of a predictive score. A FRANCOGYN study

Node involvement is one of the main prognostic factors for cervical cancer. Para-aortic lymph node (PALN) assessment is crucial for treating advanced cervical cancer, to define irradiation fields. Objective of this study was to develop a score predicting para-aortic lymph node involvement in patients with advanced cervical cancer. We performed a multicenter, retrospective, study on 9 French centers from 2000 to 2015, including patients with advanced squamous cell cervix carcinoma who had PALN status assessed by imaging and/or by surgery. Factors associated with a risk of PALN involvement were determined by univariate and multivariate analysis using a logistic regression model. A score was then developed and validated. A total of 1446 patients treated for cervical cancer were included. Of these, 498 had an advanced squamous cell cervical cancer. Ninety-one patients (18.3%) had positive PALN. After univariate and multivariate analysis, tumor size on pelvic MRI, initial SCC, and suspected pelvic node involvement on PET-CT were included in our score. This model allowed the population to be divided into 3 risk groups. Area under the ROC curve of the score was 0.81 (95%CI = 0.72-0.90). In the low-risk group, 9% (28/287) had PALN involvement, whereas in the high-risk group, 43% (22/51) had PALN involvement. We developed a simple score predicting PALN involvement in advanced cervical cancers. Three risk groups can be defined, and patients considered to be at low risk may avoid para-aortic staging as well as extensive field irradiation.

Reply to “Why perform pelvic exenterations when cure is not an option?”

Long-term clinical outcomes of preoperative brachytherapy in early-stage cervical cancer

The treatment of early-stage cervical cancer (CC) is primarily based on surgery. Adjuvant (chemo)radiotherapy can be necessary in presence of risk factors for relapse (tumor size, deep stromal invasion, lymphovascular space invasion (LVSI), positive margins, parametrial or lymph node involvement), increasing the risk of treatment toxicity. Preoperative brachytherapy can reduce tumor extension before surgery, potentially limiting the need for adjuvant radiotherapy. This study reports long-term clinical outcomes on efficacy and toxicity of preoperative pulse-dose-rate (PDR) brachytherapy in early-stage CC. All patients treated at Institut Curie between 2007 and 2022 for early-stage CC by preoperative brachytherapy were included. A PDR technique was used. Patients underwent hysterectomy associated with nodal staging following brachytherapy. 73 patients were included. The median time from brachytherapy to surgery was 45 days [range: 25-78 days]. With a median follow-up of 51 months [range: 4-185], we reported 3 local (4 %), 1 locoregional (1 %) and 8 metastatic (11 %) relapses. At 10 years, OS was 84.1 % [95 % CI: 70.0-100], DFS 84.3 % [95 % CI:74.6-95.3] and LRFS 92.8 % [95 % CI:84.8-100]. Persistence of a tumor residue, observed in 32 patients (44 %), was a significant risk factor for metastatic relapse (p = 0.02) and was associated with the largest tumor size before brachytherapy (p = 0.04). Five patients (7 %) experienced grade 3 toxicity. One patient (1 %) developed grade 4 toxicity. Ten patients (14 %) received adjuvant radiotherapy, increasing the risk of lymphedema (HR 1.31, 95 % CI [1.11-1.54]; p = 0.002). PDR preoperative brachytherapy for early-stage cervical cancer provides high long-term tumor control rates with low toxicity.

Predictive factors of sentinel lymph node mapping failure in cervical cancer: A systematic review and meta-analysis

Sentinel lymph node (SLN) mapping is crucial in cervical cancer, helping to assess lymph node status while reducing unnecessary systemic lymph node dissection. However, bilateral SLN mapping fails in 5 %-20 % of cases, with various contributing factors. This meta-analysis aims to identify predictive factors associated with SLN mapping failure in cervical cancer. A comprehensive literature search was conducted across Cochrane, MEDLINE, Embase, PubMed, Web of Science, CBM, CNKI, WFDB, and VIP from inception to July 2024. Additional data were obtained from SRCTN, Physicians Data Query, ClinicalTrials, and the International Clinical Trials Registry Platform. Two independent researchers screened studies, assessed quality, and extracted data. The associations between predictive factors and SLN mapping failure were evaluated using odds ratios (ORs) with 95 % confidence intervals (CIs). A total of 27 observational studies comprising 4059 patients were included. Significant predictive factors for SLN mapping failure included tumor size ≥2 cm [OR = 1.35, 95 % CI (1.05, 1.74), P = 0.018], age ≥50 years [OR = 2.71, 95 % CI (1.85, 3.97), P ≤ 0.001], FIGO stages II-IV [OR = 2.11, 95 % CI (1.20, 3.72), P = 0.009], pelvic lymph node metastasis [OR = 2.15, 95 % CI (1.10, 4.20), P = 0.025], and neoadjuvant chemotherapy (NACT) [OR = 1.44, 95 % CI (1.09, 1.90), P = 0.010]. Other factors including obesity, surgical approach, cervical conization, tumor differentiation, lymphovascular space invasion (LVSI), and histologic type were not associated with SLN mapping failure. Larger tumor, older age, advanced FIGO stage, pelvic lymph node metastasis, and NACT are predictive factors for SLN mapping failure. These findings highlight the importance of preoperative assessment before SLN mapping.

The malignant transformation of endometriosis: Is there a left lateral predisposition of ovarian clear cell and endometrioid carcinomas?

Endometriosis affects 10% of women of reproductive age. There is evidence for a left lateral predisposition of endometriotic lesions and a 1.9-fold greater risk of ovarian cancer in endometriosis. The aim of this study is to determine whether a left lateral predisposition of ovarian clear-cell carcinoma (CCC) and endometrioid carcinoma (EC) exists. A retrospective cohort study of all EC and CCC patients in Northern Ireland between March-2011 and June-2018. ANOVA was used to analyse preoperative prediction of stage, chi-squared (χ2) was used to compare left- and right-sided masses. Survival was estimated using Kaplan-Meier and log-rank test. A p-value <0.05 was considered significant. 158 patients were identified (95 EC, 55 CCC, 8 mixed). Mean age was 57.65 years with 69% presenting at stage 1. The mean CA125 was 559 U/mL (p = 0.850) and mean abdominal mass size was 14.12 cm (p = 0.732). The most common presenting symptom was an abdominal mass (37%). Despite 67% of patients having endometriosis on final pathology, only 8.9% had a known history pre-operatively. 51% of tumours were located on the left (p = 0.036). For unilateral tumours this was significant for EC (P = 0.002) but not for CCC (P = 0.555). The 1-, 3- and 5-year overall survival for all types/stages was 85%, 78% and 71% respectively. While CCC and EC are associated with endometriosis, only EC exhibits a left lateral predisposition. There is no association between preoperative CA125 or abdominal mass size and stage of disease.

Factors associated with bilateral sentinel lymph node mapping failure using indocyanine green in patients with apparent early-stage cervical cancer: An Italian retrospective multi-center study

The primary aim of this study was to assess the factors associated with bilateral mapping failure in patients with apparent early-stage cervical cancer undergoing sentinel lymph node (SLN) biopsy using indocyanine green (ICG). Secondary aims were sensitivity, negative predictive value and lymph node recurrence. Retrospective multi-center study. Patients with cervical cancer apparent FIGO stage IA1 to IIA2, treated with primary surgery between 04/2015 and 12/2023 and undergoing SLN mapping attempt with ICG injection, were included. Appropriate statistical analysis was performed to assess study endpoints. Timeframe was divided in first period 04/2015-12/2019 and second period 01/2020-12/2023. 618 patients were included. Bilateral SLN mapping was achieved in 531 (85.9 %) women (36 of them, 5.8 %, underwent cervical re-injection of ICG). SLN unilateral mapping and mapping failure was observed in 71 (11.5 %) and 16 (2.6 %), respectively. The sensitivity, negative predictive value and accuracy were 85.9 %, 98.1 % and 98.3 %, respectively. False negative rate was 4/68 (5.9 %) in patients with unilateral mapping versus 6/316 (1.9 %) in those with bilateral mapping (p = 0.061). BMI>30 (p = 0.001) and pathologic tumor diameter >20 mm (p = 0.023) were the only factors independently associated with bilateral SLN mapping failure. ICG re-injection increased the rate of bilateral SLN detection from 81.3 % to 85.9 %. The rate of bilateral detection was 82.8 % versus 88.3 % in the first versus second study period, respectively (p = 0.061). 3-year DFS and OS in all patients were 89.7 % and 98.2 %, respectively. Seven patients (1.2 %) had lymph node recurrence in the group of any SLN mapping versus 1 (6.3 %) in no mapping group (p = 0.190). High BMI and larger tumors were associated with bilateral SLN mapping failure using ICG. The ICG cervical re-injection increased the rate of bilateral mapping. No lymph node recurrence difference was found in patients undergoing SLN mapping versus patients with mapping failure.

Oncological outcomes after vaginal and robotic-assisted radical trachelectomy in patients with cervical cancer - A single-center prospective cohort study

The aims of this study are to evaluate the oncological outcomes of robotic-assisted radical trachelectomy (RART) compared with radical vaginal trachelectomy (RVT) for localized early-stage cervical cancer in a national cohort. RVT was introduced in 2003 in Denmark and nationally centralized to Copenhagen Univeristy Hospital. In 2014 the procedure advanced to a robotic-assisted approach. Perioperative and oncological data has been prospectively reported to the Danish Gynecological Cancer Database (DGCD) which is continuously developed and updated. All patients undergoing radical trachelectomy were included in this prospective cohort study. Data was extracted from DGCD and manually validated through electronic medical journals and The Danish Pathology Registry. A total of 206 patients underwent radical trachelectomy, with 78 patients undergoing RART and 128 patients undergoing RVT. No significant differences were observed in the microscopic free margins of the trachelectomy specimens. A total of seven (5.5%) patients undergoing RVT and two (2.6%) patients undergoing RART had recurrences (p = 0.403). No significant differences in recurrence-free survival were found between the groups, both in the unadjusted (HR 0.51 (0.11-2.47)) and adjusted analyses (HR 0.80 (0.16-3.96)). In this large single-center cohort, oncological safety of RART is equal to RVT for patients with localized cervical cancer and a fertility desire.

Construction and validation of a prognostic model for stage IIIC endometrial cancer patients after surgery

To explore the most predictive lymph node (LN) scheme for stage IIIC endometrial cancer (EC) patients after hysterectomy and develop a scheme-based nomogram. Data from 2626 stage IIIC EC patients, diagnosed between 2010 and 2014, were extracted from the Surveillance, Epidemiology, and End Results (SEER) registry. The predictive ability of four LN schemes was assessed using C-index and Akaike information criterion (AIC). A nomogram based on the most predictive LN scheme was constructed and validated. The comparison of the predictive ability between nomogram and FIGO stage was conducted using the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). FIGO stage (stage IIIC1/stage IIIC2) was not an independent risk factor for OS in stage IIIC EC patients (P = 0.672) and log odds of positive lymph nodes (LODDS) had the best predictive ability (C-index: 0.742; AIC: 8228.95). A nomogram based on LODDS was constructed and validated, which had a decent C-index of 0.742 (0.723-0.762). The nomogram showed a better predictive ability than that of the FIGO staging system. FIGO IIIC1/FIGO IIIC2 could not differentiate the prognosis for stage IIIC EC patients. We developed and validated a nomogram based on LODDS to predict OS for post-operative patients with stage IIIC EC.

Trophoblastic disease and choriocarcinoma

Gestational trophoblastic disease (GTD) is a group of diseases associated with pregnancies that demonstrate abnormal development of trophoblastic cells. GTD includes hydatidiform moles (HM) that may continue to further develop into gestational trophoblastic neoplasms (GTN), such as choriocarcinoma (CC). Gestational CC is a malignant mass development that may arise from HM, from other (normal) pregnancies or from other gestational events (such as ectopic pregnancies). The aim of this review is to outline current understating of the genetics and epigenetics of GTD and gestational CC and the link between the two diseases.

Systematic review of cost-effectiveness studies on cervical cancer screening across Europe

Cervical cancer (CC) is a type of cancer with poor prognosis when diagnosed in advanced stage with a big socioeconomic burden. The incidence rates have wide variations among European countries depending on the implementation or not of screening, vaccination programs and the human development index (HDI). Most studies on cost-effectiveness of CC screening programs are carried out in countries with a high HDI, however more recent reviews of screening approaches are coming from countries with lower HDI aiming to identify the best screening strategies. Our study aims to identify which are the currently applied and most cost-effective strategies of CC screening in Europe. This is a systematic review conducted in three different databases (PubMed, Scopus and ScienceDirect) and reported following the PRISMA guidelines. General key terms for all databases were the following: cost-effectiveness, cervical cancer, screening, Europe. We included studies in English, Italian, Spanish and Bulgarian, published in the last 25 years, reporting data on cost-effectiveness of CC screening, costs and outcome measures. The methodological quality of the articles was evaluated with a standardized tool. A total of 262 studies were identified and 22 studies were included in the final analysis. In 90.1 % of the economic studies, the new screening strategy was shown to be more cost-effective compared to the current one or compared to no screening. The optimal strategy mostly involved primary HPV testing, combined with cytology or as stand-alone screening technique. Several scenarios differing on starting age and periodicities for CC screening, combination of techniques and triage, were found to be cost-effective and below the willingness to pay (WTP) threshold. The methodology of all included studies was assessed from 10 to 11 on the JBI standardized tool and Drummond 11-point checklist. Numerous cost-effective options for CC screening in different European countries were identified in this systematic review. HPV testing, with or without cytology, mainly starting at 30 years of age and repeated every 5 years or more was the most cost-effective technique. Future studies should focus on the most appropriate CC screening approach for each context and setting, also considering HPV vaccination in Europe.

The role of diagnostic laparoscopy in locally advanced cervical cancer staging

Peritoneal involvement may be overlooked in patients with locally advanced cervical cancer (LACC). This may lead to underestimation of prognosis and to undertreatment limited to locoregional disease locations. However, staging laparoscopy in LACC is not routinely performed. The primary aim of this study was to determine the proportion of peritoneal metastasis by laparoscopy and the factors associated with peritoneal metastasis in patients with LACC. Secondary aims were to evaluate the performance of staging imaging in detecting peritoneal disease and the prognosis of patients with peritoneal metastasis. Retrospective single-institution study including consecutive patients with newly diagnosed LACC (FIGO 2018 stage IB3 and IIA2-IVA) between 06/2015 and 06/2020. All women underwent PET/CT scan, MRI scan and diagnostic laparoscopy at the time of examination under anesthesia (EUA), as part of cervical cancer staging. Peritoneal metastasis was histologically confirmed in all cases. 251 patients were included. 33 (13.2 %) had peritoneal metastasis. The treatment plan was changed for 28/33 (84.8 %) patients with peritoneal metastasis (11.1 % of the entire LACC cohort). Multivariate analysis demonstrated that grade 3 (OR:1.572, 95%CI:1.021-2.419; p = 0.040) and AJCC stage T3-4 (OR:3.435, 95%CI:1.482-7.960; p = 0.004) were variables associated with increased risk of peritoneal metastasis. Sensitivity of PET/CT-scan and MRI-scan in detecting peritoneal metastasis was 4.5 % (95%CI:0.1-22.8) and 13.8 % (95%CI:3.9-31.7), respectively. Peritoneal metastasis was independently associated with worse PFS and OS (HR:3.008, 95%CI:1.779-5.087, p < 0.001 and HR:4.078, 95%CI:2.232-7.451; p < 0.001, respectively). LACC patients with grade 3 histology and/or AJCC stage T3-4 had high-risk of peritoneal metastasis and diagnostic laparoscopy might be considered as part of cervical cancer staging in these patients. Peritoneal metastasis was an independent factor associated with worse PFS and OS.

Efficacy of hyperthermic intraperitoneal chemotherapy in advanced ovarian cancer: a bibliometric analysis and updated meta-analysis

Advanced ovarian cancer is the most lethal gynecologic malignancy, and the clinical value of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. This study aimed to define the efficacy of HIPEC by integrating the highest level of evidence and to delineate the research landscape of the field. We conducted a systematic search of multiple databases, including randomized controlled trials (RCTs) up to June 2025, for a meta-analysis and bibliometric review. Study selection was guided by the PICOS framework to define eligibility criteria. The primary outcomes were overall survival (OS) and progression-free survival (PFS). Statistical pooling for the meta-analysis was executed with the Review Manager, and bibliometric analysis was performed and plotted by Bibliometrix and VOSviewer software. Nine RCTs (1621 patients) were included in the meta-analysis. HIPEC significantly improved OS in both primary (HR = 0.71[0.60 to 0.84], P < 0.001) and recurrent ovarian cancer (HR = 0.73[0.58 to 0.92], P = 0.008), and improved PFS in primary cancer (HR 0.74, 95 % CI 0.61-0.91). Subgroup analysis revealed that the greatest benefit was observed in patients who received HIPEC after neoadjuvant chemotherapy (NACT) and when the open technique was used. The bibliometric analysis revealed an annual rise in the number of studies in this field, with the United States and China making leading contributions. This meta-analysis indicated HIPEC had a positive prognosis for advanced ovarian cancer, especially for primary ovarian cancer and patients undergoing neoadjuvant chemotherapy. The bibliometric analysis highlighted the need for more large-sample and high-quality clinical trials to establish higher-level evidence in subsequent research.

An onco-vascular surgical approach: Internal iliac artery transposition for external iliac artery repair during cytoreductive surgery

Cytoreductive surgery (CRS) in advanced pelvic malignancies may require resection of major vessels, including the external iliac artery (EIA). The aim of this study was to assess the feasibility and safety of ipsilateral transposition of the internal iliac artery as a reconstructive technique for the management of external iliac artery defects. Between 2015 and 2024, six patients underwent CRS with EIA resection and reconstruction using ipsilateral IIA transposition at an expert center in surgical oncology. Postoperative vascular assessment was performed using Doppler ultrasonography and ankle-brachial index (ABI) measurements in all patients, with the exception of one patient who underwent CT angiography and conventional angiography. The cohort included four female and two male patients with a mean age of 58.5 years. Diagnoses included serous ovarian carcinoma (n = 2), liposarcoma (n = 2), and colorectal carcinoma (n = 2); four patients had recurrent disease. Postoperative complications occurred in four patients (67 %), including surgical site infection in two patients, urinary leakage in one patient, and enterocutaneous fistula in one patient; however, no vascular complications were observed. There was no 30-day postoperative mortality, and two patients died within the first year; one from enterocutaneous fistula complications and one from metastatic disease. Among the surviving patients, none developed chronic limb ischemia or any other symptoms related to the vascular anastomosis. Internal iliac artery transposition is a safe and effective autologous reconstruction technique for EIA defects during CRS. This approach offers reliable vascular repair without extending operative time and may support complete oncologic resection while minimizing morbidity.

The association between low muscle mass and sarcopenic obesity, survival, and major complications in patients with advanced ovarian cancer undergoing primary cytoreductive surgery: A retrospective study

The aim of this study is to determine whether imaging-derived estimates of muscle mass or sarcopenic obesity are associated with survival and surgery-related complications in patients with advanced epithelial ovarian cancer treated with primary cytoreductive surgery (PCS). A skeletal muscle index (SMI) was determined by normalizing the muscle area at the level of third lumbar vertebra with the patient's height. Patients with SMI <38.5 cm Ninety-two patients were retrospectively included, of whom 35 (38.0 %) and 12 (13.0 %) had low muscle mass or were affected by sarcopenic obesity, respectively. Among 73 (79.3 %) patients with high-grade serous OC, the 1-year survival rates were 66.7 % and 95.3 % (hazard ratio [HR] 9.19 [95 % confidence interval (CI): 1.85-45.75]) and the 3-year survival rates were 58.3 % and 68.8 % (HR 2.95 [95 % CI: 1.10-7.92]) for patients with and without sarcopenic obesity, respectively. Neither low muscle mass nor sarcopenic obesity was associated with major complications. Sarcopenic obesity was a marker of poor 1-year and 3-year survival in patients with high-grade serous OC. Neither low muscle mass nor sarcopenic obesity was associated with major complications in PCS.

Association of cul-de-sac seeding with intraperitoneal tumor burden in advanced ovarian cancer (CIEL, KGOG 4003)

To evaluate the relationship between tumor seeding in the cul-de-sac, assessed by transvaginal or transrectal ultrasound, and intraperitoneal tumor burden in advanced ovarian cancer. We prospectively enrolled 101 patients scheduled for surgery due to suspected or newly diagnosed ovarian, fallopian tube, or peritoneal cancer at three hospitals in Korea (Feb 2022-Dec 2023). Five were excluded for missing ultrasound or surgery, and eleven for benign or other malignancies. Preoperative ultrasound was used to assess cul-de-sac tumor seeding, categorized as no seeding, reticulonodular, serosal, or mass seeding. Intraperitoneal tumor burden was evaluated using the Peritoneal Cancer Index (PCI) and Fagotti score. Associations with bowel surgery and residual tumors >1 cm were also analyzed. Eighty-five patients were included; 28 received neoadjuvant chemotherapy. Cul-de-sac seeding was classified as no seeding (42 %), reticulonodular (14 %), serosal (18 %), or mass (26 %). Higher PCI and Fagotti scores correlated with more severe seeding. Intraoperative confirmation of seeding was seen in 69 % of cases. Bowel surgery was less frequent in patients without seeding. No significant differences were found in residual tumors >1 cm between groups. Cul-de-sac tumor seeding identified by transvaginal or transrectal ultrasound may reflect intraperitoneal tumor burden and could help predict surgical complexity in advanced ovarian cancer.

Exploring the cost-effectiveness of the OSNA method for patients facing endometrial cancer: Insights from a single-institution experience

The one-step nucleic acid amplification (OSNA) method has emerged as a potential alternative to ultrastaging for diagnosing lymph node metastasis. This study aims to assess the cost-effectiveness of the OSNA technique compared to ultrastaging for detecting SLN metastasis in patients with early-stage endometrial cancer (EC). This retrospective, observational, single-center study included 30 patients with EC who underwent surgical treatment. SLN mapping was performed using an intracervical injection of indocyanine green. SLNs were analyzed and classified as negative, as having isolated tumor cells, micrometastases, or macrometastases. The study evaluated and quantified the costs of the OSNA and ultrastaging procedures in euros. A total of 54 lymph nodes were analyzed using both the OSNA and ultrastaging methods. Concordant negativity was identified in 48 cases (89 %), while micrometastases were detected concordantly in 1 case (1.8 %). The cost for a single ultrastaging lymph node analysis, including immunohistochemistry, is approximately € 250, with a total processing time of 2 days. The cost for a single OSNA analysis is approximately € 236, boasting a significantly shorter processing time of 30-40 min. While materials and staff costs are comparable between both techniques, considering time-related expenses, the OSNA method proves to be more cost-effective than ultrastaging (p < 0.001). The OSNA method demonstrates diagnostic accuracy comparable to histopathological examination in detecting lymph node metastases, reinforcing its reliability for lymph node assessment in patients with EC. Our cost analysis reveals that the OSNA method is more cost-effective than ultrastaging when time-related expenses are considered.

Analysis of the molecular profile of endometrial cancer depending on microsatelite instability

The absence of precise classification and effective predictive biomarkers in endometrial cancer (EC) leads to suboptimal treatment decisions and outcomes, underscoring the urgent need for improved diagnostic and therapeutic approaches. Endometrial cancer represents 4.8 % of the cases of malignant tumors, being in the sixth place worldwide in terms of incidence of malignant tumors in women. The treatment of endometrial cancer, especially stage I, which affects 70-75 % of patients, remains a subject of debate. According to the current European Society of Medical Oncology (ESMO) recommendations, for the management of patients with endometrial cancer, the treatment strategy is influenced by the results of risk stratification. Regarding endometrial cancer, a large number of prognostic factors are described, which create certain difficulties in their application in clinical practice. Most factors are morphological, and information about them is obtained after surgery on the basis of a standard histological examination. Of particular interest is the study of risk factors in the case of individual endometrial cancer variants. The molecular classification of endometrial tumors has the potential to become an indispensable element of histopathological classification, which would contribute to determining the prognosis and treatment strategies of the disease. In addition, it can lead to the development of a new targeted therapy, as well as to the implementation of molecular diagnostic tests for the detection of endometrial cancer in the early stages, when the prognosis is much more favorable. Despite the large amount of research which focuses on the study of the biological and molecular aspects of endometrial cancer, currently none of the tumor markers is recommended for widespread clinical use in endometrial cancer because there is insufficient information concerning their application into clinical practice.

Incidence and survival of rare female genital tract cancers in Europe: The EUROCARE-6 study

Cancers of female genital tract (FGTC) account in Europe for 14 % of all female malignancies, and many of them are rare. FGTC epidemiological indicators are usually reported by anatomical site, but they are a heterogeneous group of diseases in terms of morphological characteristics and clinical management. We show incidence and survival population-based estimates and time trends in the European population for FGTC, defined combining topography and morphology codes. We analyzed data of females aged 15 years or more diagnosed with 25 FGTC of which 23 rare. Data were provided by 100 European population-based cancer registries to the EUROCARE-6 project. Incidence was estimated for the period of diagnosis 2001-2013 in terms of both crude and age-adjusted rates. Observed and relative survival was estimated with the complete approach for the period of diagnosis 2008-2013 and with the period approach for trends, considering years of follow-up from 2001 to 2014. Over a total of 793,715 considered diagnoses of FGTC, 279,667 were classified as rare entities. Their crude incidence rate per 100,000 largely varied from almost zero for adenoid cystic carcinoma of corpus uteri to 5.9 for squamous cell carcinoma of cervix uteri. During the period 2001-13, a significant increment was reported for clear cell adenocarcinoma, Mullerian mixed tumor and serous/papillary carcinoma of corpus uteri, for the Mullerian mixed tumor, adenocarcinoma of fallopian tube, and primary peritoneal serous/papillary carcinoma, and malignant/immature teratoma of ovary. Incidence rates significantly reduced for squamous cell carcinoma of cervix uteri, mucinous adenocarcinoma and sex cord tumor of ovary. Five-year relative survival was >84 % for all the non-epithelial tumors of ovary and for choriocarcinoma of placenta. Survival under 40 % was estimated for Mullerian mixed tumors and undifferentiated carcinomas of all the considered sites. Major survival improvements were observed for placenta choriocarcinoma, sex cord tumor, malignant/immature teratoma and mucinous adenocarcinoma of ovary, in adenocarcinoma of fallopian tube and in serous/papillary carcinoma of corpus uteri. Relative survival significantly reduced in squamous cell carcinoma of corpus uteri. The increasing incidence and survival of many rare FGTC can be in part attributed to better diagnostic ability and to a better organisation of care of patients with rare tumors. The epidemiological indicators here provided can be taken as a starting point to evaluate the effectiveness of the future activities of the European Rare Cancers Networks.

Impact of lymphadenectomy rates in the quality assurance program in early ovarian cancer of the AGO Study Group – Real-world observations

The German quality assurance program (QS-Ovar) representatively documents treatment and survival for patients with the initial diagnosis of primary ovarian cancer in the third quarters of 2004, 2008, 2012, 2016, and 2021. We evaluate lymphadenectomy (LNE) rates in dependence on histologic subtype and outcome for early ovarian cancer FIGO I. Therapy quality was defined according to national guidelines. Surgical quality was categorized as "optimal" (SUR+: maximum 1 surgical item missing), versus "suboptimal" (SUR-); analogous categorization "optimal" systemic treatment (CT+) and "suboptimal" (CT-). Overall, 832 pts. (19.3 %) were diagnosed with FIGO I, of them 47.6 % with FIGO IC, 35.7 % had a high-grade serous subtype, 5.0 % low-grade serous, 6.9 % low-grade endometrioid, 18 % high-grade endometrioid, 11 % clear cell, and 18 % mucinous tumors. The optimal surgical standard increased from 21.1 % (2004) to 53.0 % (2012). Surgical quality has remained unchanged in 2021 with 53.8 % and SUR + -subgroup with 74.2 %. The rate of pelvic and para-aortic lymphadenectomy increased over time for high-grade serous and clear cell carcinoma and decreased for mucinous carcinoma. In 2021, 67.6 % had ≥25 resected lymph-nodes in high-grade serous, 46.2 % in low-grade serous, 52.2 % in high-grade endometrioid, 35.3 % in low-grade endometrioid, 74.1 % in clear cell and 35.7 % in mucinous tumors. In 2021, the SUR+/CT + -subgroup decreased to 62.9 % versus 69.2 % in 2016. Four-year-disease-free-survival was 86 % for SUR+/CT+, 78 % for SUR-/CT+, 68 % for SUR+/CT- and 57 % for SUR-/CT- (p < 0.001). One therapy modality cannot replace another one. Although urgently required, quality of therapy has not improved in 2021.

Efficacy and safety of subtotal pelvic peritonectomy for colorectal cancer patients with peritoneal metastasis confined to the pelvic cavity

Cytoreductive surgery has shown survival benefits for colorectal cancer (CRC) patients with peritoneal metastasis. However, the optimal extent of peritonectomy remains controversial in cases of limited peritoneal metastases. This study modified selective pelvic peritonectomy (SPP) into subtotal pelvic peritonectomy (STPP) for metastasis confined to pelvic cavity, and aimed to evaluate its feasibility, safety, and impact on survival outcomes. CRC patients with limited peritoneal metastasis confined to the pelvic cavity who underwent CC0 (no macroscopic residual cancer remained) resection were included from a prospectively collected database. Surgical complications, disease-free survival (DFS), and overall survival (OS) were analyzed. A total of 67 patients were included (26 in the STPP group and 41 in the SPP group). Clinically, STPP was found to be feasible and without increased surgical complications or mortality rates. At a median follow-up of 33.9 months, the 3-year DFS was 65.9 % and 30.7 % in STPP and SPP groups, respectively (P= 0.002). The 3-year OS was 84.1 % and 68.5 % in STPP and SPP groups, respectively (P= 0.006). Moreover, STTP was independently associated with improved DFS (HR = 0.351, 95 % CI 0.165-0.745, P= 0.006) and OS (HR = 0.324, 95 % CI 0.116-0.902, P=0.032). Female gender was also independently associated with poor DFS (HR = 2.146, 95 % CI 1.078-4.271, P= 0.031). Among 24 female patients with remaining ovaries, 9 (37.5 %) cases developed metachronous ovarian metastasis, and of these 6 underwent a second operation. Subtotal pelvic peritonectomy is associated with promising long-term outcomes in CRC patients with peritoneal metastasis confined to the pelvic cavity. Prophylactic bilateral oophorectomy should be strongly considered during cytoreductive surgery.

Prevalence and indicators of cure of Italian women with vulvar squamous cell carcinoma: A population-based study

Five-year net survival and conditional survival from vulvar squamous cell carcinoma (VSCC) patients in Italy have shown no progress during the past three decades. This study aims to estimate the complete prevalence and multiple indicators of cure. Observed prevalence was estimated using 31 Italian cancer registries covering 47 % of Italian women. A subset of 22 cancer registries was used to estimate model-based long-term survival and indicators of cure, i.e., complete prevalence, cure fraction (CF), time to cure (TTC), proportion of 'already cured' patients, and cure prevalence. In 2018, VSCC patients alive in Italy (complete prevalence) were 6620 or 22 per 100,000 women. The cure fraction (the proportion of newly diagnosed patients who will not die of VSCC) did not change between 2000 and 2010 both for all patients (32 %) and in each age group. The time to cure (5-year conditional net survival >95 %) was 11 years for patients aged ≥44 years, but excess mortality remained for >15 years in the other age groups. This led to a negligible (5 %) proportion of 'already cured' patients (living longer than time to cure). The proportion of patients alive <2 years (21 %) was the same as that of patients surviving ≥15 years. The cure prevalence (patients who will not die of VSCC) was 64 %. A considerable proportion of patients will not be cured even among those who survived ≥5 years. There is an urgent need to reshape the current vulvar care model in Italy.

The impact of Substantial LYMphovascular space invasion on sentinel lymph nodes status and recurrence in Endometrial Cancer patients: SLYM-EC a multicenter retrospective study

To evaluate the prognostic impact of substantial lymph vascular space invasion (LVSI) on the sentinel lymph node involvement and recurrence rate of patients with apparent uterine-confined endometrial cancer. We enrolled consecutive patients with apparent confined endometrial cancer who underwent surgical staging with sentinel node mapping from 14 European reference centers. LVSI was analyzed semi-quantitatively, according to a 3-tiered scoring system classified as absent, focal, and substantial. Among 2352 eligible patients, 1980 were included in the analysis. Upon final pathology 226 patients (11.4 %) had SLNs involvement. LVSI was diagnosed focal in 152 patients (7.7 %), whereas 357 patients (18.0 %) showed substantial LVSI. Focal or substantial LVSI rate were significantly higher in patients with positive SLNs when compared to patients without SLNs involvement (p < 0.0001). On overall patient-based analysis, the sensitivity, specificity, positive predictive value, and negative predictive value of LVSI for sentinel lymph node metastases were 73 %, 80 %, 32 %, and 96 %, respectively. The 3-year multivariate analysis of recurrence-free survival showed that only the presence of substantial LVSI, and grade 3 disease were associated with relapse. Neither positive sentinel lymph node, deep myometrial infiltration, nor age at surgery were statistically significant. In patients having undergone sentinel node biopsy, positive LVSI demonstrated moderate sensitivity and reasonable specificity in detecting SLN involvement. LVSI positivity does not correlate with nodal involvement. The presence of substantial LVSI remains a strong independent risk factor for recurrence, indicating a role for potential hematogenous dissemination in patients with early-stage disease.

Prognostic impact of intraoperative rupture in early-stage epithelial ovarian cancer: an ancillary study of GORILLA-3002

To evaluate whether intraoperative rupture affects oncological outcomes in patients with early-stage epithelial ovarian cancer (EOC). A multicenter retrospective study was conducted on patients with early-stage EOC based on surgical and final pathological reports between 2007 and 2021. Oncologic outcomes were compared between the unruptured group (International Federation of Gynaecology and Obstetrics [FIGO] stage IA/IB) and ruptured group (FIGO stage IC1). The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) was performed to adjust for the imbalance in prognostic factors between the groups. Overall, 197 (58.3 %) patients comprised the unruptured group (FIGO stage IA/IB), and 141 (41.7 %) were in the intraoperatively ruptured group (FIGO stage IC1). No significant difference in the 5-year PFS was observed between the two groups before PSM (92.65 % vs. 92.80 %, P = 0.93). After PSM, the 5-year PFS showed a noticeable decrease in the ruptured group compared to the unruptured group, although this difference showed borderline statistical significance (96.90 % vs. 89.82 %, P = 0.061). This trend was particularly discernible in cases with aggressive tumor characteristics; intraoperative rupture remained an independent prognostic factor for shorter PFS in patients with high-grade histology (adjusted hazard ratio = 14.4, 95 % confidence interval = 2.8-74.1). Although not statistically significant, intraoperative rupture may negatively affect PFS in these patients after PSM. Therefore, rupture during surgery should be avoided as it can cause upstaging and unnecessary chemotherapy.

Trials of interventions for ovarian and testicular germ cell tumors registered in ClinicalTrials.gov: A cross-sectional study

There is unmet need in the treatment of ovarian and testicular germ cell tumors (GCTs). This study analyzed registered trials of interventions for GCTs. We included trials of interventions for GCTs registered on ClinicalTrials.gov by July 29, 2022. We analyzed their interventions, outcome measures and study design. We included 142 trials registrations; 42 (30 %) for ovarian GCTs, 50 (35 %) for testicular GCTs, and 50 (35 %) trials for both. The majority of the trials were completed (56 %) and did not have results available (75 %). Most trials were in Phase 2. Information about the study design were not reported for many analyzed trials. Most trials had a single-group assignment (44 %) and were open-label (68 %). The median planned number of enrolled participants was 43. Most registrations used medicine(s) (87 %), either as a single type of intervention or in combination. The most commonly used type of medicine was chemotherapy (54 %). Primary outcome was not reported in 23 % of registrations, and secondary outcomes were not reported in 35 % of registrations. Overall survival was used in 6 % of registrations as a primary outcome and in 31 % of registrations as a secondary outcome. Few trials on GCTs were registered on ClinicalTrials.gov, and their number was declining in recent times. Most registrations did not report relevant information about the study design, or results if completed. More effort is needed to foster trials on GCTs, as well as to optimize the management of the registrations and foster the publication of research results.

Impact of age on tumor size in vulvar cancer: A multicenter study by the Francogyn group

Vulvar cancer is a rare pathology affecting mainly elderly women. This study aims to evaluate the impact of age on tumor size in vulvar cancer. This was a multicenter retrospective observational study carried out between January 1, 1998, and December 31, 2020, in patients operated on for vulvar cancer. Univariate analysis was performed according to patients' age ≥ or <65 years. Factors associated with tumor size found to be significant according to age were then included in a multiple linear regression model. Of the 382 patients included, there were 133 patients aged <65 years and 249 ≥ 65 years. Radical total vulvectomy surgeries were more frequently performed in women ≥65 years (n = 72 (28.9 %) versus n = 20 (15 %); p = 0.004). The median histological tumor size and interquartile range was 20 mm [13-29] in the <65 years and 30 mm [15-42] in patients ≥65 years (p = 0.001). Multiple linear regression showed that age ≥65 years had a regression coefficient of 7.15 95 % CI [2.32; 11.99] (p = 0.004), constituting a risk factor for larger histological tumour size. Patients aged ≥65 years old had a higher early complication rate (n = 150 (62 %) versus n = 56 (42.7 %), p = 0.001). They also had a greater risk of recurrence (HR = 1.89 (95%CI (1.24-2.89)), p = 0.003) with a worse overall survival (HR = 5.64 (95%CI (1.70-18.68)), p = 0.005). Age is a risk factor for larger tumor size, leading to more radical surgery and a greater risk of complications in already fragile patients, with a greater risk of recurrence and an impact on overall survival.

Perineural invasion: An independent risk factor for cervical cancer prognosis and a possible pathway for a future targeted treatment?

Prognostic characteristics, recurrence patterns, and survival outcomes of vulval squamous cell carcinoma – A twelve-year retrospective analysis of a tertiary centre

Vulval cancer is a rare gynaecological malignancy. In this study, we present a tertiary centre case analysis to examine the recurrence patterns and survival outcomes of vulval squamous cell carcinoma (SCC). This is a retrospective cohort study of women who received treatment at Oxford University Hospitals between February 2010 and July 2022 for primary vulval SCC. We included 98 cases. The median age at diagnosis was 68 years. Human Papillomavirus (HPV) infection and lichen sclerosis were observed in 21 and 50 cases, respectively. Surgical excision was the primary treatment. Recurrence within 2 years was more common with advanced stage (p = 0.047, RR = 2.26) and extracapsular lymph node spread (p = 0.013, RR = 2.88). Local recurrence was not associated with a specific cut-off value for tumour-free margin. Poor survival outcomes were observed with higher grade (p = 0.01), advanced FIGO stage (p < 0.001), HPV-independent cancer (p = 0.048), lymph node involvement (p < 0.001, HR = 7.14), extracapsular spread (p < 0.001, HR = 7.93), lymphovascular space invasion (p = 0.002, HR = 3.17), tumour diameter wider than 23 mm (p = 0.029, HR = 2.53) and depth of invasion more than 6 mm (p = 0.006, HR = 3.62). Perineural invasion is associated with shorter disease-free survival. Five-year cancer-specific survival rates for stages I, III, and IV were 90.2%, 40.8%, and 14.3%, respectively.

Application of novel algorithm on a retrospective series to implement the molecular classification for endometrial cancer

The study aimed to validate the Betella algorithm, focusing on molecular analyses exclusively for endometrial cancer patients, where molecular classification alters risk assessment based on ESGO/ESTRO/ESP 2020 guidelines. Conducted between March 2021 and March 2023, the retrospective research involved endometrial cancer patients undergoing surgery and comprehensive molecular analyses. These included p53 and mismatch repair proteins immunohistochemistry, as well as DNA sequencing for POLE exonuclease domain. We applied the Betella algorithm to our population and evaluated the proportion of patients in which the molecular analysis changed the risk class attribution. Out of 102 patients, 97 % obtained complete molecular analyses. The cohort exhibited varying molecular classifications: 10.1 % as POLE ultra-mutated, 30.3 % as mismatch repair deficient, 11.1 % as p53 abnormal, and 48.5 % as non-specified molecular classification. Multiple classifiers were present in 3 % of cases. Integrating molecular classification into risk group calculation led to risk group migration in 11.1 % of patients: 7 moved to lower risk classes due to POLE mutations, while 4 shifted to higher risk due to p53 alterations. Applying the Betella algorithm, we can spare the POLE sequencing in 65 cases (65.7 %) and p53 immunochemistry in 17 cases (17.2 %). In conclusion, we externally validated the Betella algorithm in our population. The application of this new proposed algorithm enables assignment of the proper risk class and, consequently, the appropriate indication for adjuvant treatment, allowing for the rationalization of the resources that can be allocated otherwise, not only for the benefit of settings with low resources, but of all settings in general.

Enhancing cervical cancer prognosis: Integrating machine learning and clinical insights for personalized patient care and improved outcomes

A restrictive stoma policy after colorectal anastomosis in ovarian cancer based on ghost ileostomy use

The incidence of anastomotic leak after colorectal anastomosis in ovarian cancer has been reported to be much lower than that in colorectal cancer patients. Regarding the use of protective manoeuvres (diverting ileostomy) as suggested by clinical guidelines, the goal should be the implementation of a restrictive stoma policy for ovarian cancer patients, given the low rate of anastomotic leakage in this population. Patients who underwent cytoreduction surgery in a single centre (University Hospital La Fe, Valencia Spain) due to ovarian cancer between January 2010 and June 2023 were classified according to two groups: a non-restrictive stoma policy group (Group A) and a restrictive stoma policy group (Group B). A total of 256 patients were included in the analysis (group A 52 % vs group B 48 %). The use of protective diverting ileostomy was lower in the restrictive stoma policy group (14 % vs 6.6 %), and the use of ghost ileostomy was 32 % vs 87 % in groups A and B, respectively (p < 0.00001). No differences were found in the anastomotic leak rate, which was 5.2 % in the non-restrictive group and 3.2 % in the restrictive stoma policy group (p = 0.54). The use of a restrictive stoma policy based on the use of ghost ileostomy reduces the rate of diverting ileostomy in patients with ovarian cancer after colorectal resection and anastomosis. Furthermore, this policy is not associated with an increased rate of anastomotic leakage nor with an increased rate of morbi-mortality related to the leak.

Oncological outcomes of intraperitoneal chemotherapy in advanced ovarian cancer: BRCA mutation role

The knowledge of BRCA status offers a chance to evaluate the role of the intraperitoneal route in patients selected by biomolecular profiles after primary cytoreduction surgery in advanced ovarian cancer. We performed a retrospective, multicenter study to assess oncological outcomes depending on adjuvant treatment (intraperitoneal [IP] vs intravenous [IV]) and BRCA status (BRCA1/2 mutated vs. BRCA wild type [WT]). The primary endpoint was to determine progression-free survival. The secondary objectives were overall survival and toxicity. A total of 288 women from eight centers were included: 177 in the IP arm and 111 in the IV arm, grouped into four arms according to BRCA1/2 status. Significantly better PFS was observed in BRCA1/2-mutated patients with IP chemotherapy (HR: 0.35; 95% CI, 0.16-0.75, p = 0.007), which was not present in BRCA1/2-mutated patients with IV chemotherapy (HR: 0.65; 95% CI, 0.37-1.12, p = 0.14). Significantly better OS was also observed in IP chemotherapy (HR: 0.17; 95% CI, 0.06-043, p < 0.0001), but was not present in IV chemotherapy in relation with BRCA mutation (HR: 0.52; 95% CI, 0.22-1.27, p = 0.15). For BRCA WT patients, worse survival was observed regardless of the adjuvant route used. The IP route was more toxic compared to the IV route, but toxicity was equivalent at the long-term follow-up. This retrospective study suggests that BRCA status can help to offer an individualized, systematic treatment after optimal primary surgery for advanced ovarian cancer, but is limited by the small sample size. Prospective trials are essential to confirm these results.

Enhancing cervical cancer surveillance: Utilizing inflammatory markers for improved recurrence detection in low-resource settings and a call for prospective multi-centric studies

Survival after minimally invasive radical hysterectomy with protective colpotomy for early-stage cervical cancer: A systematic review and meta-analysis

Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior oncological outcome. Evidence on whether protective colpotomy could optimize minimally invasive technique and improve prognoses of women with early-stage cervical cancer remains limited. We produced a systematic review and meta-analysis to compare oncological outcomes of the patients treated by minimally invasive radical hysterectomy with protective colpotomy to those treated by open surgery according to existing literature. We explored PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to December 2022. Inclusion criteria were: (1) randomized controlled trials or observational studies published in English, (2) studies comparing minimally invasive radical hysterectomy with protective colpotomy to abdominal radical hysterectomy in early-stage cervical cancer, and (3) studies comparing survival outcomes. Two reviewers performed the screening, data extraction, and quality assessment independently. A total of 8 retrospective cohort studies with 2020 women were included in the study, 821 of whom were in the minimally invasive surgery group, and 1199 of whom were in the open surgery group. The recurrence-free survival and overall survival in the minimally invasive surgery group were both similar to that in the open surgery group (pooled hazard ratio, 0.88 and 0.78, respectively; 95% confidence interval, 0.56-1.38 and 0.42-1.44, respectively). Minimally invasive radical hysterectomy with protective colpotomy on treatment of early-stage cervical cancer had similar recurrence-free survival and overall survival compared to abdominal radical hysterectomy. Protective colpotomy could be a guaranteed approach to modifying minimally invasive technique.

The significance of lower uterine segment involvement in endometrial cancer

Limited data suggests lower uterine segment involvement (LUSI) in endometrial cancer may be associated with other poor prognostic factors. We assessed the unclear impact of LUSI on prognosis in endometrial cancer. ology: A revision of pathological samples following surgical staging between the years 2002-2022 was performed and clinical data collected from patients' records. Characteristics and outcomes of women with and without LUSI were compared and analysed. Kaplan Meyer survival curves compared overall survival (OS) and progression-free survival (PFS). 429 women were included, of which 45 (10.5%) had LUSI. No differences were found between the groups regarding demographic or clinical characteristics. LUSI was significantly associated with lympho-vascular space invasion (40% vs. 22% p = 0.01), lymph node involvement (6.4% vs. 9.1%, p = 0.05), shorter PFS (4 vs. 5.5 years, p = 0.01) and OS (5.6 vs. 11.5 years, p = 0.03). Multivariate analysis showed higher hazard ratios for OS and PFS (1.55 95%CI 0.79-3.04 and 1.29 95%CI 0.66-2.53, respectively) but these were insignificant even in a sub-analysis of endometrioid histology (1.76 95%CI 0.89-3.46 and 1.35 95%CI 0.69-2.65, respectively). A trend towards decreased PFS and OS was demonstrated in the Kaplan Meyer survival curves for all cases (log rank test p = 0.5 and 0.29 respectively), endometrioid histology (log rank test p = 0.06 and 0.51 respectively) and early-stage disease (log rank test p = 0.63 and 0.3 respectively). LUSI may be related to poorer outcome of endometrial cancer and may represent an additional factor to consider when contemplating adjuvant treatment, especially in endometrioid-type and early-stage disease.

Chemotherapy is not needed when complete evacuation of gestational choriocarcinoma leads to hCG normalization

The standard treatment for gestational choriocarcinoma is chemotherapy. To describe the risk of recurrence with expectant management of gestational choriocarcinoma that has reached a normal human chorionic gonadotropin level after tumor removal without adjuvant chemotherapy. A retrospective multicenter international cohort study was conducted from 1981 to 2017 involving 11 gestational trophoblastic disease reference centers with patient's follow-up extended until 2023. Clinical and biological data of included patients were extracted from each center's database. The inclusion criteria were i) histological diagnosis of gestational choriocarcinoma in any kind of placental tissue retrieved, ii) spontaneous normalization of human chorionic gonadotropin level following choriocarcinoma retrieval, iii) patient did not receive any oncological treatment for the choriocarcinoma, iv) and at least 6 months of follow-up after the first human chorionic gonadotropin level normalization. Among 80 patients with retrieved gestational choriocarcinoma and whose human chorionic gonadotropin level normalized without any other oncological therapy, none had a recurrence of choriocarcinoma after a median follow-up of 50 months. The median interval between choriocarcinoma excision and human chorionic gonadotropin level normalization was 48 days. The International Federation of Gynecology and Obstetrics/World Health Organization risk score was ≤6 in 93.7% of the cases. This multicenter international study reports that selected patients with gestational choriocarcinoma managed in gestational trophoblastic disease reference centers did not experience any relapse when the initial tumor evacuation is followed by human chorionic gonadotropin level normalization without any additional treatment. Expectant management may be a safe approach for highly selected patients.

Quality of surgery and treatment and its association with hospital volume: A population-based study in more than 5000 Belgian ovarian cancer patients

Different sets of quality indicators are used to identify areas for improvement in ovarian cancer care. This study reports transparently on how (surgical) indicators were measured and on the association between hospital volume and indicator results in Belgium, a country setting without any centralisation of ovarian cancer care. From the population-based Belgian Cancer Registry, patients with a borderline malignant or invasive epithelial ovarian tumour diagnosed between 2014 and 2018 were selected and linked to health insurance and vital status data (n = 5119). Thirteen quality indicators on diagnosis and treatment were assessed and the association with hospital volume was analysed using logistic regression adjusted for case-mix. The national results for most quality indicators on diagnosis and systemic therapy were around the predefined target value. Other indicators showed results below the benchmark: genetic testing, completeness of staging surgery, lymphadenectomy with at least 20 pelvic/para-aortic lymph nodes removed, and timely start of chemotherapy after surgery (within 42 days). Ovarian cancer care in Belgium is dispersed over 100 hospitals. Lower volume hospitals showed poorer indicator results compared to higher volume hospitals for lymphadenectomy, staging, timely start of chemotherapy and genetic testing. In addition, surgery for advanced stage tumours was performed less often in lower volume hospitals. The indicators that showed poorer results on a national level were also those with poorer results in lower-volume hospitals compared to higher-volume hospitals, consequently supporting centralisation. International benchmarking is hampered by different (surgical) definitions between countries and studies.

A clinical marker-based modeling framework to preoperatively predict lymph node and vascular space involvement in endometrial cancer patients

Endometrial cancer (EC) has high mortality at advanced stages. Poor prognostic factors include grade 3 tumors, deep myometrial invasion, lymph node metastasis (LNM), and lymphovascular space invasion (LVSI). Preoperative knowledge of patients at higher risk of lymph node involvement, when such involvement is not suspected, would benefit surgery planning and patient prognosis. This study implements an ensemble machine learning approach that evaluates Cancer Antigen 125 (CA125) along with histologic type, preoperative grade, and age to predict LVSI, LNM and stage in EC patients. A retrospective chart review spanning January 2000 to January 2015 at a regional hospital was performed. Women 18 years or older with a diagnosis of EC and preoperative or within one-week CA125 measurement were included (n = 842). An ensemble machine learning approach was implemented based on a stacked generalization technique to evaluate CA125 in combination with histologic type, preoperative grade, and age as predictors, and LVSI, LNM and disease stage as outcomes. The ensemble approach predicted LNM and LVSI in EC patients with AUROC An ensemble machine learning approach offers the potential to preoperatively predict LVSI, LNM and stage in EC patients with adequate accuracy based on CA125, histologic type, preoperative grade, and age.

Patterns of recurrence in FIGO stage IB1-IB2 cervical cancer: Comparison between minimally invasive and abdominal radical hysterectomy

Aim of our study was to evaluate whether the different laparotomic (ARH) or minimally invasive (laparoscopic and robotic) approaches (MIS) in FIGO stage IB1-IB2 cervical cancer, present different patterns of recurrence of the disease. The secondary endpoint of the study was the evaluation of the variables most involved with the risk of relapse and therefore lower DFS and OS. The study enrolled patients with definitive histological diagnosis of squamous or adenocarcinoma stage IB1-IB2 cervical cancer who underwent minimally invasive or abdominal radical hysterectomy from 2001 to 2018. The study enrolled 360 patients and 59 patients (16.4 %) reported a disease relapse. The data showed that ARH group was not associated with different recurrence patterns than MIS group (p = 0.14). Moreover, there was no statistically significant difference regarding DFS (p = 0.52) and OS (p = 0.29) between the ARH group and the MIS group. MIS, in FIGO stage IB1-IB2 cervical cancer, is not associated with different relapse patterns compared to ARH, nor with a higher risk of distance metastasis and finally, without significant difference in term of DFS and OS. More studies are needed to determine the factors that modify the site of relapse.

Is routine admission to a critical care setting following hyperthermic intraperitoneal chemotherapy for ovarian cancer necessary?

Hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly being used in patients with stage III ovarian cancer undergoing interval cytoreductive surgery (CRS). It is uncertain whether routine postoperative admission to a critical care setting after CRS-HIPEC is necessary. This study aims to estimate the incidence of patients requiring critical care, and to create a prediction model to identify patients who may forego admission to a critical care setting. We analyzed 154 patients with primary ovarian cancer undergoing interval CRS-HIPEC at two Dutch centers between 2007 and 2021. Patients were routinely admitted to a critical care setting for 12-24 h. Patients that received critical support as defined by pre-specified definitions were retrospectively identified. Logistic regression analysis with backward selection was used to predict the need for critical care and the model was validated using bootstrapping. Thirty-eight percent of patients received postoperative critical care, consisting mainly of hemodynamic interventions. Independent predictors of critical care were blood loss, norepinephrine dose during surgery, and age (bootstrapped AUC = 0.76). Using a probability cut-off of 20%, one-third of patients are defined as low-risk for requiring critical care, with a negative predictive value of 0.88. The majority of patients,primarily undergoing low to intermediate complexity surgeries, did not receive critical care interventions after CRS-HIPEC. Selective admission to a critical care setting may be warranted and its feasibility and safety needs to be evaluated prospectively. Our prediction model can help identify patients in whom admission to a critical care setting may be omitted. Hospital costs and burden on critical care units will benefit from patient selection.

Impact of guideline adherence and expert center referral on the early management and outcomes of uterine sarcoma patients: A retrospective analysis from the French NETSARC network

Uterine sarcomas are rare tumors with a poor prognosis. Their diagnosis is often incidental, following surgery. Our goal was to examine the early management strategies for uterine sarcomas, and to assess the impact of guideline adherence and expert center referral on both the management approaches and the clinical outcomes in patients with uterine sarcomas. We retrospectively analyzed medical records from patients with uterine sarcoma referred to the Institut Curie and registered in the database of the French NETSARC network. In total, 100 patients, with a median age of 54 years, were included in the analyses. On MRI scans (n = 36), all patients had at least two signs suggestive of malignancy, and 77.8 % had four or more signs. No preoperative biopsy was performed in 65.6 % of cases. Only 14.1 % of patients underwent initial surgery at an expert center. Surgery performed outside the network was significantly associated with morcellation (32.9 % vs. 0 %; p = 0.036), fewer negative margins (R0 margins 52.4 % vs. 100 %; p = 0.006), and poor adherence to surgical guidelines (28.3 vs. 72.7 %; p = 0.013). Multivariate analysis showed that non-adherence to surgical recommendations was not significantly associated with relapse-free survival (HR = 0.54; 95 % CI [0.21-1.38]), but was an independent predictor of poor overall survival (HR = 0.12; 95 % CI [0.03-0.52]; p = 0.005). Despite a high frequency of suspicious clinical and radiological signs, a large proportion of women undergoing sarcoma surgery are treated outside of expert networks. We provide guidelines, integrating the clinical context and radiological signs to encourage early referral to reference centers for sarcoma.

Surgical timing in advanced ovarian cancer during the TRUST trial era: A systematic review, meta-analysis and study-level meta-regression of randomized controlled trials

The best surgical timing for advanced epithelial ovarian cancer, whether primary debulking surgery or interval debulking surgery, remains debated. Recent data, including the preliminary ones from TRUST trial, necessitates an updated critical evaluation. A systematic search of PubMed identified only randomized controlled trials comparing interval debulking surgery versus primary debulking surgery in patients with newly diagnosed advanced ovarian cancer. Primary outcomes included overall survival (OS) and progression-free survival (PFS). A random-effects meta-analysis, meta-regression, cumulative synthesis, and leave-one-out influence analysis were performed. A total of 2303 patients were included. Compared to primary debulking surgery, interval debulking surgery was associated with lower rates of postoperative complications (OR = 0.37; 95 % CI: 0.18-0.79; P = 0.01) and mortality (OR = 0.23; 95 % CI: 0.09-0.57; P = 0.002). Meta-analysis showed higher rates of complete cytoreduction with interval debulking surgery (OR = 3.84; 95 % CI: 2.14-6.91; P < 0.00001) and lower rates of macroscopic residual disease (OR = 0.20; 95 % CI: 0.13-0.30; P < 0.00001). Pooled data revealed no significant difference in OS (HR = 0.95; 95 % CI: 0.87-1.04; P = 0.26) or PFS (HR = 0.94; 95 % CI: 0.85-1.03; P = 0.16). Subgroup analyses by stage and residual disease confirmed similar survival outcomes. The meta-regression results suggested that even in trials with very high complete cytoreduction rates, no clinically meaningful OS benefit was observed for upfront surgery. In conclusion, interval debulking surgery offers comparable survival outcomes to primary debulking, with reduced perioperative morbidity and mortality, supporting its role as a valid surgical alternative. PROSPERO REGISTRATION NUMBER: CRD420251105308.

Risk of ovarian recurrence after ovarian conservation in early-stage cervical cancer treated with radical surgery: A propensity match analysis

The primary aim of the present study was to assess the incidence of ovarian metastasis/recurrence and the survival of patients undergoing radical hysterectomy with ovarian conservation (CONSERV) versus oophorectomy (OOPHOR). Secondary aim was to assess the incidence and the characteristics of menopausal symptoms in both groups. Retrospective, multi-center, observational cohort study including patients <50 years with clinical FIGO 2009 stage IA1-IB1/IIA1 cervical carcinoma, treated by primary surgical treatment between 02/2007 and 07/2019. One-to-one case-control matching was used to adjust the baseline prognostic characteristics in survival analysis. 419 patients were included. 264 in the OOPHOR (63.0%) and 155 (37.0%) in the CONSERV group. Ovarian transposition was performed in 28/155 (18.1%) patients. 1/264 (0.4%) patient had ovarian metastasis from endocervical adenocarcinoma. After propensity-matching, 310 patients were included in the survival analysis (155 per group). 5-year disease-free survival of patients undergoing CONSERV versus OOPHOR was 90.6% versus 82.2%, respectively (p = 0.028); 5-year overall survival was 94.3% versus 90.8%, respectively (p = 0.157). Two patients (1.3%) developed recurrence on the conserved ovary. CONSERV represented an independent protective factor of recurrence (HR:0.361, 95%CI 0.169-0.769; p = 0.008). 28 (20.6%) in the CONSERV group versus 116 (60.4%) in the OOPHOR group complained of menopausal symptoms during follow up (p < 0.001). HRT was prescribed to 12.0% of patients (median HRT time was 20 months). CONSERV was associated with reduced risk of recurrence and menopausal symptoms in early-stage cervical cancer. As the risk of ovarian metastasis and ovarian recurrence is relatively low, CONSERV in pre-menopausal women has to be considered.

Minimally invasive surgical staging for early stage ovarian cancer: A long-term follow up

The standard treatment for epithelial early stage ovarian cancer (eEOC) includes laparotomic surgical staging, according to ESGO-ESMO guidelines. In the last decade, many investigators have assessed the safety and feasibility of minimally invasive surgery (MIS) staging in properly selected patients. However, survival data related to different surgical approaches (open versus MIS) are extremely limited. The aim of this study is to analyze the long-term oncological outcomes in eEOC patients treated with MIS. This is a multicenter observational retrospective study conducted in two tertiary oncological centers. We selected all consecutive women who underwent a laparoscopic or robotic staging for eEOC. From January 2008 to December 2016, 254 eEOC patients underwent a MIS staging (188 laparoscopic staging and 66 robotic staging). Overall, 18.1% of patients were upstaged due to pathological findings. A total of 203 (79.9%) patients received platinum-based adjuvant chemotherapy. After a median follow-up of 61 months (range 13-118), 39 (15.3%) patients experienced recurrence. The 5-years progression free survival (PFS) and overall survival rates were 84.0% and 93.8%, respectively. In the univariate analysis, favorable variables influencing PFS were young age (≤45 years), non-serous histotype, tumor grade 1-2, and FIGO stage IA/IB. In the multivariate analysis, only grade 3 was shown to keep its negative independent prognostic value (HR = 3.47; p = 0.004), whereas FIGO stage ≥ IC showed a trend toward significance (HR = 1.75; p = 0.099). This retrospective study represents the longest follow-up of eEOC patients managed by MIS. The MIS is a valuable therapeutic option in appropriately selected patients, although a randomized controlled trial is needed.

Fertility sparing surgery for early-stage clear cell carcinoma of the ovary; A systematic review and analysis of obstetric outcomes

Clear cell carcinoma of the ovary (CCOC), accounts for 5-25% of epithelial ovarian cancer (EOC) cases. A significant proportion of patients with CCOC are of reproductive age, wishing to preserve their fertility. The application of fertility sparing surgery (FSS) in those patients has been extensively criticized, due to the high reported recurrence rates and chemotherapy resistance. The aim of the present study was to accumulate the current knowledge on obstetric and fertility outcomes of patients with early stage CCOC who underwent fertility sparing surgery. A meticulous search of 3 electronic databases was conducted for articles published up to June 2020 relevant in the field using the terms "ovarian cancer", "clear cell", "fertility sparing", "conservative treatment". Studies that reported pregnancy and maternal outcomes after fertility sparing surgery for the management of early stage CCOC were considered eligible. A total of 5 studies which comprised of 60 patients with early stage CCOC, who underwent fertility-sparing surgery, were reviewed. Ten patients (16.6%) had disease recurrence. The total clinical pregnancy rate of 32% with a proportion of 24% of live birth rates in 12 of the included patients. The median interval from surgery to pregnancy was 41.5 months, while no evidence of disease was recorded among the patients who achieved pregnancy. No difference in survival and recurrence rates among patients who underwent fertility-sparing surgery and those who had radical surgical procedures. Fertility-sparing treatment for International Federation of Gynaecology and Obstetrics (FIGO) Stage IA/IC CCOC seems to be an acceptable treatment option for selected premenopausal women who strongly wish to preserve their childbearing potential. However, larger studies are needed to validate the safety of the procedure.

A comparison of end-to-end and end-to-side anastomosis following rectosigmoid resection in ovarian cancer cytoreductive surgery

A rectosigmoid resection with anastomosis is a common component of cytoreductive surgery for ovarian cancer. Evidence from colorectal studies suggests that end-to-side anastomoses may be associated with fewer complications than end-to-end approaches, but these have not previously been compared in an ovarian cancer patient cohort. Over a 51-month period, 239 patients underwent cytoreductive surgery for FIGO stage III/IV ovarian cancer. A rectosigmoid resection was performed in 79 (33.1%) with anastomosis in 59 (74.7%). Pre-operative and intra-operative factors associated with anastomotic leak, and post-operative complications were compared by anastomotic technique. Anastomoses were end-to-end in 33 (55.9%) and end-to-side in 26 (44.1%) patients. There was a greater proportion of patients with a higher American Society of Anaesthesiologists score in the end-to-side group, but no other statistically significant differences in pre-or intra-operative factors between the groups. There were three (9.1%) cases of anastomotic leak in the end-to-end group, and no leaks in the end-to-side group, but the difference did not reach statistical significance. Both leaks were small, and successfully conservatively managed. There was no significant difference in rate of Clavien Dindo grade III/IV complications, although there was a higher rate of grade II complications following an end-to-side anastomosis (p = 0.036). There was no difference in length of stay, time to restarting chemotherapy, re-operation or 90-day mortality rate. There was no significant difference in major morbidity following end-to-end or end-to-side anastomosis. Prospective randomised trials specifically focussed in ovarian cancer are needed.

Response to treatment and prognostic significance of supradiaphragmatic disease in patients with high-grade serous ovarian cancer

This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated. Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8-176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes. Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined. Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed. 42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes. Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Risk of contralateral ovarian cancer in patients undergoing conservative surgery for ovarian cancer

Among patients with ovarian cancer (OC), the risk of contralateral OC remains controversial and few studies have focused on the occurrence of contralateral OC after conservative surgery. Basing on the Surveillance, Epidemiology, and End Results (SEER) database registered between 2000 and 2018, Logistic and Cox regressions were established to test the risk factors of contralateral OC. Kaplan-Meier mothed was used to calculate the cumulative risk curve for contralateral OC and compared using log-rank test. Furthermore, the frequency of contralateral OC and standardized incidence ratios (SIRs) were evaluated. 18807 patients were included, 69 patients developed contralateral OC. Logistic and Cox regressions showed patients diagnosed >50 years had lower risk of contralateral OC (Odds ratio [OR]:0.42, 95% confidence interval [CI]: 0.24-0.73; Hazard ratios [HR]:0.44, 95%CI:0.24-0.77). Patients with radical surgery had lower contralateral OC risk (OR:0.20, 95%CI: 0.11-0.36; HR: 0.17, 95%CI: 0.09-0.30). The SIR for contralateral OC was high in all patients (SIR: 2.37, 95%CI: 1.85-3.00) and highest if patients diagnosed <50 years with conservative surgery (SIR: 27.33, 95%CI: 19.86-36.69). However, the SIR for contralateral OC was low in patients diagnosed ≥50 years with radical surgery (SIR: 0.54, 95%CI: 0.26-1.00). No statistically significant SIRs were observed in patients diagnosed ≥50 years with conservative surgery and patients diagnosed <50 years with radical surgery. Our study provided some information for clinicians to assess the risk of contralateral OC and suggested young patients should not undergo hysterectomy to prevent contralateral OC. Moreover, clinical surveillance cannot be relaxed.

Prevalence of computed tomography-based sarcopenia and the prognostic value of skeletal muscle index and muscle attenuation amongst women with epithelial ovarian malignancy: A systematic review and meta-analysis

Sarcopenia represents an index of frailty amongst cancer patients and it is associated with poor oncological outcomes and a higher risk of surgical complications in several types of malignancy. To further delineate the impact of sarcopenia assessed via computed tomography scan (CT) on oncological outcomes and post-operative complications amongst women with epithelial ovarian carcinoma (EOC). Our secondary objective was to quantify and understand the prevalence of sarcopenia in EOC. We systematically searched MEDLINE, SCOPUS, ClinicalTrials.gov, and Cochrane Database, from inception up to August 2021. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Outcomes consisted of prevalence, overall survival (OS), progression-free survival (PFS) and post-operative complications. Pooled analyses of proportion estimates, hazard ratios (HRs) and odds ratios (ORs) were performed with STATA and Review Manager 5.3. 21 studies were included in this meta-analysis. NOS scores ranged from six to nine. Pooled analysis yielded an overall sarcopenia prevalence of 41%. Pooled analysis of adjusted HRs demonstrated significant association between low muscle attenuation (MA) [aHR = 1.23, (95% CI 1.02-1.47), p-value = 0.03] and OS, whilst low skeletal muscle index (SMI) trended towards shorter OS [aHR = 1.37, (95% CI 0.99-1.90), p-value = 0.05. Low-SMI was also associated with higher risk of total post-operative complications [uOR = 1.56, (95% CI 1.16-2.11), p-value = 0.004]. Our findings suggest that CT-assessed skeletal mass and radiodensity represent rather accurate indices of nutritional status and could prospectively be incorporated into the decision-making process in women with EOC.

Fluorescence guided surgery to improve peritoneal cytoreduction in epithelial ovarian cancer: A systematic review of available data

During surgery for advanced epithelial ovarian cancer (EOC), the most important prognostic factor is the absence of residual tumor. Invisible microscopic peritoneal metastasis (mPM) are not removed during surgery and can be responsible of peritoneal recurrences. The aim of this current systematic review is to assess the role of fluorescence in evaluating mPM in EOC. We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. MeSH terms for fluorescence, EOC and peritoneal carcinomatosis were combined and not restricted to the English language. The final search was performed on September 1rst, 2021. The primary outcome was to determine the diagnostic accuracy of fluorescence. We also reviewed the different techniques used. Eighty-seven studies were identified. Of these, 10 were included for analysis. The sensitivity and specificity of fluorescence ranged between 66.7-100% and 54.2-100%, respectively. Most importantly, the negative predictive value (NPV) ranged from 90 to 100% Due to the heterogeneity of the studies, no consensus was reached concerning the optimal use of fluorescence in terms of type of dye, type and timing of injection and imager to use. No adverse event was reported. Fluorescence can safely be used in EOC to evaluate mPM with a high NPV. However, a randomized controlled trial is needed to homogenize current practice.

Risk-reducing salpingo-oophorectomy and breast cancer risk in BRCA1 or BRCA2 mutation carriers: A systematic review and meta-analysis

BRCA mutation carriers have a high lifetime risk of developing breast cancer (BC) and ovarian cancer (OC). Risk-reducing salpingo-oophorectomy (RRSO) has been shown to reduce OC risk. This meta-analysis was aim to analyze the effect of RRSO on the BC risk among BRCA1/2 mutation carriers. Embase, PubMed, Web of Science, and Cochrane databases were searched for all studies investigating the effect of RRSO on BC risk. The pooled results were used to evaluate the association between RRSO and BC risk. This meta-analysis included 13,965 BRCA1 and 7,057 BRCA2 mutation carriers from 14 observational studies. The pooled results showed that RRSO lowered BC risk among BRCA1 mutation carriers [hazard ratio (HR) = 0.63, 95% confidence interval (CI): 0.49-0.81, P < 0.01] and BRCA2 mutation carriers (HR = 0.51, 95% CI: 0.34-0.75, P < 0.01). RRSO reduced BC risk in younger women with BRCA1 mutation (HR = 0.48, 95% CI: 0.30-0.77, P < 0.01) and BRCA2 mutation (HR = 0.22, 95% CI: 0.08-0.65, P < 0.01). Analysis of the efficacy of RRSO at different time intervals after surgery showed a reduction of BC risk at <5 years after surgery in BRCA1 mutation carriers (HR = 0.60, 95% CI: 0.40-0.89, P = 0.01) and BRCA2 mutation carriers (HR = 0.42, 95% CI: 0.20-0.86, P = 0.02). RRSO is an effective way to reduce BC risk among women with BRCA1/2 mutation, especially in younger women. BRCA1/2 mutation carriers could benefit from RRSO in the immediate 5 years after surgery.

Prognosis impact of posttreatment pelvic MRI in patients treated for stage IB2-IIB cervical cancer with chemoradiation therapy

To evaluate the performances of systematic posttreatment pelvic magnetic resonance imaging (PPMRI) in predicting prognosis of patients treated with chemoradiation therapy (CRT) for locally advanced cervical cancer (LACC). Multi-institutional data from 216 patients presenting FIGO IB2-IIB cervical cancer for which PPMRI was performed following CRT were retrospectively reviewed. Incomplete response was defined as the identification of persistent lesion on PPMRI. Primary endpoints were patients' 5-year recurrence free (RFS) and overall (OS) survivals. Secondary endpoint was the identification of residual histologic disease on hysterectomy specimens when completion surgery was performed. PPMRI identified an incomplete response in 102 (47.2%) cases. A 70% or more reduction in tumor size on PPMRI was identified as the best predictive cut-off for recurrence (37.7% sensitivity and 78.7% specificity) and death (50% sensitivity and 77.9% specificity) with significant impact on those risks (HRa: 0.42; 95%CI: 0.23-0.77 and HRa: 0.18; 95%CI: 0.06-0.50, respectively). Completion hysterectomy was performed in 117 (54.4%) cases, with histologic residual disease in 55 (47.4%). PPMRI demonstrated 74.5% sensitivity and 50.8% specificity in predicting residual disease. Although survival of patients with complete response at PPMRI was not impacted by completion hysterectomy, it significantly increased 5-year RFS and OS of those with incomplete response: 38.7% vs. 65.3% (p < 0.001) and 63% vs. 82.9% (p = 0.038), respectively. A 70% or more reduction of in tumor size on PPMRI following CRT in patients with LACC is predictive of RFS and OS. PPMRI could help triaging patients who could benefit from completion hysterectomy.

Investigating the possible impact of peritoneal tumor exposure amongst women with early stage cervical cancer treated with minimally invasive approach

Recent findings show a detrimental impact of the minimally invasive approach on patients with early stage cervical cancer (ECC). Reasons beyond these results are unclear. The aim of the present article is to investigate the possible role of peritoneal contamination during intracorporeal colpotomy. patients with early stage cervical cancer were divided into 2 groups: no intraperitoneal exposure (N-IPE) intraperitoneal exposure (IPE) during minimally invasive surgery. Patients of the 2 groups were propensity-matched according to the major risk factors. 226 cases of the IPE group had a significant worst prognosis than the 142 cases of the N-IPE group (4.5-years disease free survival: 86.6% vs 95.9% respectively, p = 0.005), while N-IPE had similar survival to open surgery (4.5-years disease free survival: 95.0% vs 90.5% respectively, p = 0.164). Distant recurrence was more frequent among IPE patients with a borderline significance (3.5% vs 0.4% among IPE and N-IPE respectively, p = 0.083). On multivariate analysis, intraperitoneal tumor exposure was an independent prognostic factors for worse survival; patients belonging to the N-IPE group had a risk of recurrence of about 3-fold lower compared to patients of the IPE group (hazard ratio: 0.37, 95% confidence interval: 0.15-0.88, p = 0.025). it would be advisable that further prospective studies investigating the efficacy of different surgical approach in ECC take into consideration of this issue. Moreover, all other measures that could potentially prevent peritoneal exposure of tumor should be adopted during minimally invasive surgery for early stage cervical cancer to provide higher survival outcomes.

Impact of neoadjuvant chemotherapy on the postoperative pathology of locally advanced cervical squamous cell carcinomas: 1:1 propensity score matching analysis

To assess the impact of neoadjuvant chemotherapy on postoperative pathology for stage IB2 and IIA2 cervical squamous cell carcinoma. Postoperative pathology was compared between patients who received neoadjuvant chemotherapy followed by radical hysterectomy (NACT group) and patients who received upfront radical hysterectomy (URH group). Then, patients in the NACT group were divided into a chemotherapy-sensitive group and a chemotherapy-insensitive group according to their response to chemotherapy. After 1:1 propensity score matching (PSM), the positive rates of lymphovascular space invasion (LVSI) (7.9% vs 17.7%, P = 0.001) and cervical deep stromal invasion (60.4% vs 76.2%, P < 0.001) in the NACT group were significantly lower than those in the URH group, while the positive rates of parametrial invasion, lymph node metastasis, and vaginal margin invasion were not significantly different between the two groups. The rate of positive lymph node metastasis in the chemotherapy-sensitive group was significantly lower than that in the URH group (18.1% vs 26.5%, P = 0.037). Among patients with stage IB2 and IIA2 cervical squamous cell carcinomas, NACT can reduce the positive rate of intermediate-risk factors, such as deep cervical stromal invasion and LVSI, but cannot reduce the positive rate of high-risk factors. For patients who are chemotherapy sensitive, NACT can reduce the positive rate of lymph node metastasis.

Effects of preoperative radiotherapy or chemoradiotherapy on postoperative pathological outcome of cervical cancer——from the large database of 46,313 cases of cervical cancer in China

To investigate the effect of preoperative radiotherapy or chemoradiotherapy combined with radical surgery on pathological outcomes in cervical cancer patients. Based on a large Chinese cervical cancer database of clinical diagnosis and treatment (C4 Project), the postoperative pathological outcomes of patients who received preoperative radiotherapy or chemoradiotherapy followed by open surgery (PR group) or surgery alone (SD group) were compared. Among the strictly selected patients, the incidence of lymph node metastasis in the PR group (n = 574) was higher than that in the SD group (231 VS 9; P < 0.001), while the incidence of vascular space invasion was lower than that in the SD group (72 VS 2041; P < 0.001). The logistic regression analysis showed that preoperative radiotherapy was a protective factor for parametrial involvement, positive surgical margins, deep cervical stromal invasion, and vascular space invasion (P < 0.05). The median number of resected lymph nodes in both groups was 18. After 1:1 case matching, the incidence of deep cervical stromal invasion and vascular space invasion was reduced by preoperative radiotherapy (292 vs 376, P < 0.001; 60 vs 106, P < 0.001). Logistic regression analysis indicated that preoperative radiotherapy was a protective factor for deep cervical stromal invasion and vascular space invasion (P < 0.05). The median numbers of resected lymph nodes in the two groups were 18 and 19, separately. Preoperative radiotherapy can reduce both the incidence of deep cervical stromal invasion and vascular space invasion, but it cannot reduce lymph node positivity, parametrial involvement and positive surgical margins.

A comparison of ICG-NIR with blue dye and technetium for the detection of sentinel lymph nodes in vulvar cancer

The sentinel lymph node (SLN) procedure for vulva cancer is a safe alternative to a radical inguino-femoral lymphadenectomy (IFLN) for small unifocal tumours. SLN evaluation through biopsy and ultra-staging has helped gynaecological oncology surgeons improve operative morbidity with no cost to oncologic safety. Established techniques for groin SLN detection and excision in vulvar cancer use 92% of patients had a successful SLN procedure. The per-groin detection rate was 84%. All successfully mapped SLN were identified with the combination of ICG-NIR and Incorporation of ICG-NIR into standard SLN mapping protocols may allow for the abandonment of routine use of BD and its poor side effect profile.

Characteristics and outcomes of women with adenocarcinoma versus squamous cell carcinoma of the vulva: A Japanese Gynecologic Oncology Group study

Studies on vulvar adenocarcinoma are lacking. Thus, we aimed to compare the characteristics and survival outcomes between vulvar adenocarcinoma and squamous cell carcinoma (SCC). This was a preplanned sub-analysis of a previously organized nationwide retrospective observational study in Japan conducted between 2001 and 2010 (JGOG-1075S). Surgically treated women with stage I-IV vulvar invasive adenocarcinoma were compared to those with SCC. Multivariable analysis was performed to identify patient and tumor characteristics related to adenocarcinoma. Inverse probability of treatment weighting was used to balance the background differences, and a Cox proportional hazards regression model was fitted to estimate the effect of the histological type on survival. Forty-eight women with adenocarcinoma were compared with 537 women with SCC. On multivariable analysis, women with adenocarcinoma were younger (median age, 64.5 vs. 70 years, adjusted odds ratio [OR] per age 0.975, 95% confidence interval [CI] 0.955-0.995, P = 0.016) and had higher positive surgical margin rates (31.2% vs. 18.4%, adjusted OR 2.376, 95% CI 1.188-4.754, P = 0.014) than those with SCC. However, according to the weighted model, the survival outcomes were comparable (hazard ratio for progression-free survival, 1.088, 95% CI 0.740-1.601, P = 0.667 and hazard ratio for overall survival, 1.008, 95% CI 0.646-1.573, P = 0.973). Similar associations were observed when the cohort was stratified by age (≤70 or >70 years), stage (I-II or III-IV), and surgical margin (negative or positive) (all, P > 0.05). Vulvar adenocarcinoma is characterized by a younger age at diagnosis and higher positive surgical margin rates than SCC, but the survival outcomes are comparable.

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

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

Intratumoral budding: A novel prognostic biomarker for tumor recurrence and a potential predictor of nodal metastasis in uterine cervical cancer

To evaluate the prognostic and predictive significance of lymphovascular invasion (LVI) and lymph node metastasis of intratumoral budding (ITB) and its correlation with clinicopathological parameters in patients with cervical cancer. Total 151 patients with cervical cancer who underwent radical hysterectomy with pelvic and/or paraaortic lymphadenectomy were included. We assessed the status of ITB and peritumoral budding (PTB) in all available hematoxylin and eosin-stained specimens. Univariate and multivariate analyses were performed for ITB, PTB, and other clincopathological parameters as predictors of recurrence. ITB ITB

Comparison of retroperitoneal and transperitoneal surgical routes in laparoscopic nodal staging for locally advanced cervical cancers (FIGO IB3-IVA)

This study compares morbidity and mortality associated with retroperitoneal and transperitoneal para-aortic lymphadenectomy (PAAL) for pretherapeutic nodal staging of locally advanced cervical cancers (FIGO IB3-IVA). Pre-, per- and postoperative data of patients treated for locally advanced stage cervical cancer between 1999 and 2018 in 12 French referral centers (FRANCOGYN Study Group) were retrospectively collected. The study was conducted using a sample of 448 patients, of whom 223 (49,8%) underwent retroperitoneal (group 1) and 225 (50,2%) had transperitoneal PAAL (group 2). No differences were noted concerning clinical and histological characteristics between the two groups. Among these 448 patients, 23 (5,1%) had an intraoperative complication (9 (2,0%) in group 1 and 14 (3,1%) in group 2, p = 0.28) and 47 (10,5%) had a postoperative complication (22 (4,9%) in group 1 and 25 (5,6%) in group 2, p = 0.44), only one of which required revision surgery but the patient died. The length of hospital stay was significantly shorter in group 1 than in group 2 (3.97 versus 4.88 days, p < 0.001). There was no significant difference in mortality between the two groups; 34 of 223 patients in group 1 (15.3%) and 40 of 225 patients in group 2 (15.6%) died (HR = 0.968, 95% CI [0.591-1.585]). There was no significant difference in recurrence-free or overall survival between the two groups. Retroperitoneal PAAL appears as a valuable and safety surgical route for nodal staging in locally advanced cervical cancer compared with standard transperitoneal PAAL.

Locally advanced cervical carcinoma patients treated with chemoradiation followed by radical surgery: clinical response and oncological outcomes according to histotype after propensity score analysis

The aims of this study were to analyze the pathological response, and survival outcomes of adenocarcinoma/adenosquamous (AC/ASC) versus squamous cell carcinoma (SCC) in patients with locally advanced cervical cancer (LACC) managed by chemoradiotherapy followed by radical surgery. Retrospective, multicenter, observational study, including patients with SCC and AC/ACS LACC patients treated with preoperative CT/RT followed by tailored radical surgery (RS) between 06/2002 and 05/2017. Clinical-pathological characteristics were compared between patients with SCC versus AC/ASC. A 1:3 ratio propensity score (PS) matching was applied to remove the variables imbalance between the two groups. After PS, 320 patients were included, of which 240 (75.0%) in the SCC group, and 80 (25.0%) in the AC/ASC group. Clinico-pathological and surgical baseline characteristics were balanced between the two study groups. Percentage of pathologic complete response was 47.5% in SCC patients versus 22.4% of AC/ASC ones (p < 0.001). With a median follow-up of 51 months (range:1-199), there were 54/240 (22.5%) recurrences in SCC versus 28/80 (35.0%) in AC/ASC patients (p = 0.027). AC/ASC patients experienced worse disease free (DFS), and overall survival (OS) compared to SCC patients (p = 0.019, and p = 0.048, respectively). In multivariate analysis, AC/ACS histotype, and FIGO stage were associated with worse DFS and OS. In LACC patients treated with CT/RT followed by RS, AC/ASC histology was associated with lower pathological complete response to CT/RT, and higher risk of recurrence and death compared with SCC patients. This highlights the need for specific therapeutic strategies based on molecular characterization to identify targets and develop novel treatments.

Analysis of postoperative adjuvant therapy in 102 patients with gastric-type mucinous carcinoma of the uterine cervix: A multi-institutional study

Gastric-type mucinous carcinoma (GAS) is a novel variant of uterine cervix mucinous carcinoma. GAS is a distinct entity that can be distinguished from typical endocervical adenocarcinoma (UEA). In Japan, postoperative adjuvant therapy for cervical cancer includes not only radiation therapy (RT) or concurrent chemoradiotherapy (CCRT) but also chemotherapy in many cases. However, no previous studies have analyzed adjuvant therapy for GAS. In the present study, we investigated the efficacy of adjuvant therapy for GAS. This was a preplanned secondary analysis of a dataset from previous nationwide, retrospective, observational study. The study population comprised women with stage I-II GAS who underwent surgery. Progression-free survival (PFS) and overall survival (OS) were compared among patients who did and did not receive adjuvant therapy using the Kaplan-Meier method. Data were analyzed for a total of 102 enrolled patients, who were classified as low- (17 patients), intermediate- (37 patients), or high risk (48 patients) based on the risk of postoperative cervical cancer recurrence. In the intermediate-risk group, median survival could not be assessed due to a lack of sufficient events, but the no-adjuvant and RT groups tended to exhibit better prognoses. In contrast, within the high-risk group, patients in the RT subgroup exhibited a trend towards better PFS and OS than those in the CCRT and chemotherapy groups. The prognosis of GAS was confirmed to be poor, even in cases of early-stage cancer and following surgical resection. Chemotherapy strategies, including CCRT as postoperative adjuvant therapy, tend to have a poor prognosis.

Stromal Tumor infiltrating lymphocytes (sTILs) as a prognostic biomarker in Ovarian Cancer After Neoadjuvant chemotherapy

The aim of the study was to evaluate the prognostic impact of sTILs on survival in a specific cohort of patients of high grade serous epithelial ovarian cancer following interval cytoreductive surgery ± HIPEC. Formalin fixed, paraffin embedded (FFPE) tumor tissue of high grade serous ovarian cancer of 168 patients, undergoing interval cytoreductive surgery were evaluated by dedicated oncopathologists. The average stromal TIL percentage was calculated for each patient, for ovary and omentum. To determine a threshold for TILS in Ovarian cancer which can serve as a reference value for validation as a prognostic biomarker, we applied maximally distributed rank statistics using the 'maxstat' package from 'R-stats'. Overall survival was the endpoint for measuring prognosis. The prognostic significant of TILs on survival was determined using univariable log rank test and multivariable cox-regression analysis. The Intraclass coefficient for sTILS in the ovary was 0.882 [95 %CI 0.85-0.90] and 0.93 for sTILs in the omentum was 0.93 [95 %CI 0.91-0.95] showing that there was good interobserver agreement between the pathologist. Threshold for sTILS was 20 % for the ovary and 26 % for the omentum. sTILS in the ovary separated by the cut-off 20 %, showed an improvement in overall survival (OS) in both univariate as well as multivariate analysis. (Log rank 0.97 (0.94-0.99, p = 0.007), cox regression analysis, [HR 0.96 (95 %CI 0.93-0.99, p = 0.003) ] respectively. While our study provides some evidence for the prognostic role of sTILs in advanced high-grade serous epithelial ovarian cancer, the determined cut-off threshold warrants additional validation in future studies.

Enhanced Recovery After Surgery linked to lower CRS-HIPEC costs: micro-costing analysis in a European public hospital

Exploring PIPAC for managing platinum resistant and refractory ovarian cancer with peritoneal spread: A collaborative multi-institutional study

Platinum-resistant or refractory epithelial ovarian cancer (EOC) remains a significant clinical challenge, often leading to rapid progression and poor prognosis. Palliative treatments aimed at improving quality of life are warranted. To assess the feasibility and potential benefits of Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in patients with platinum-resistant or refractory EOC. Prospective multicenter observational study (2016-2023). feasibility, defined as completion of ≥3 planned PIPAC cycles within 120 days without ≥ grade 3 treatment related adverse events (CTCAE v5.0). Secondary endpoints: safety; disease control (RECIST 1.1); changes in Peritoneal Cancer Index and Fagotti score; ascites control; CA-125 response; conversion to cytoreductive surgery (±HIPEC); and overall survival (OS). Forty patients were enrolled. Ninety-seven percent of procedures were completed. Feasibility was 65.0 % (26/40; 95 % CI 49.51-77.87); no grade ≥3 events occurred. Key secondary outcomes included a clinical benefit rate of 35 % in the intention-to-treat (ITT) population and 53.8 % in the per-protocol (PP) population, median time to ascites resolution of one cycle, and median overall survival of 14 months (17 months in PP). Higher white blood cell count and ascites volume were significantly associated with progression (p = 0.035 and p = 0.025). Three platinum-refractory patients became eligible for surgery, two underwent optimal cytoreduction. Median OS was 14 months (17 months in PP). A non-significant trend toward longer OS was observed in platinum-refractory versus platinum-resistant disease (18 vs 9 months; p = 0.093). PIPAC is a feasible, well-tolerated option in platinum-resistant and refractory EOC with potential to stabilize disease, relieve ascites and enable surgery in selected cases.

Evaluation of risk-reducing radical fimbriectomy followed by delayed oophorectomy in high-risk Women: A single-center retrospective study

Ovarian carcinoma is a leading cause of cancer-related mortality in women. Approximately 20 % of cases are hereditary, mainly BRCA mutations. Current clinical guidelines recommend bilateral salpingo-oophorectomy between ages 35-45 for high-risk individuals, leading to premature menopause. Given evidence supporting the tubal origin of most ovarian cancers, radical fimbriectomy followed by delayed oophorectomy may offer a menopause-sparing alternative for women refusing early ovariectomy. To evaluate the oncologic safety and clinical outcomes of this two-step risk-reducing strategy. This retrospective single-center study included all high-risk premenopausal women who had completed childbearing, declined BSO and underwent radical fimbriectomy between 2014 and 2022. The primary outcome was the incidence of ovarian or pelvic cancer following radical fimbriectomy, estimated using the Kalbfleisch-Prentice method. Secondary outcomes included surgical complications, tubal lesions, menopause onset, breast cancer incidence and delayed oophorectomy rate. A total of 132 women were included; 62.9 % had BRCA1, 25.8 % BRCA2, and 11.3 % other high-risk mutations (RAD51C, PALB2). No tubal lesions were found in 121 cases (91.7 %), while 11 (8.3 %) had abnormalities: one high-grade serous carcinoma, six serous tubal intraepithelial carcinoma, and four minor lesions. After a median 30.4-month follow-up, no high-grade serous carcinoma was reported. Delayed bilateral oophorectomy was performed in 24 women (18.5 %), and menopause occurred in 27 at a median age of 45. One pregnancy occurred post-fimbriectomy via assisted reproductive technology. Radical fimbriectomy with delayed oophorectomy may be a safe and feasible option for high-risk women seeking to avoid early menopause. Longer-term prospective studies are needed.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for primary advanced-stage or recurrent ovarian cancer: A systematic review and meta-analysis of randomized control trials

Ovarian cancer has the highest mortality among gynecologic malignancies. Despite cytoreductive surgery (CRS) and systemic therapy, peritoneal recurrence remains common. Hyperthermic intraperitoneal chemotherapy (HIPEC) delivers heated chemotherapy directly to the peritoneal cavity, enhancing local cytotoxicity and offering a potential therapeutic strategy. We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs) comparing CRS plus HIPEC versus CRS alone. Hazard ratios (HR), odds ratios (OR), and mean differences (MD) were pooled using Review Manager 5.4. Heterogeneity was assessed using I Eight RCTs (1259 patients) were included; 636 (50.52%) received CRS with HIPEC. HIPEC significantly improved OS (HR 0.79; 95% CI 0.67-0.94; p = 0.006; I In ovarian cancer, HIPEC significantly improved OS, especially in primary disease and following NACT. However, increased morbidity was observed. Further studies should refine patient selection and optimize protocols.

Continuing chemotherapy beyond 6 cycles increases the chances of complete cytoreduction surgery in patients with advanced ovarian cancer

To evaluate the impact of receiving more than 6 cycles of NACT on survival outcomes and chemotherapy-related toxicity in patients with advanced epithelial ovarian cancer (AOEC) ineligible for primary debulking surgery. This retrospective, monocentric, observational study analyzed AEOC patients who received at least 6 cycles of NACT followed by IDS. They were grouped by number of NACT cycles (6 vs ≥ 7) and cytoreduction rate (CC0 vs CC ≥ 1), with a non-surgical group for comparison. A total of 335 patients were evaluated over a 20-year period. Pre-surgical variables were similar across groups, except for older age (p < 0.001) and higher Peritoneal Cancer Index (PCI) (p = 0.04) in the non-surgery cohort. Chemotherapy-related toxicities led to delays in subsequent NACT cycles, mainly in the non-surgery group (p = 0.02). After a median follow-up of 67.7 months, patients with CC0 demonstrated the longest median progression-free survival (PFS): 22 months (NACT=6) vs 21 months (NACT≥7). In CC ≥ 1 patients, PFS was 15 months (NACT=6) and 19 months (NACT≥7), while the non-surgery group had 10 months. CC0 was the primary predictor of overall survival (OS). Patients with CC0-NACT=6 had a median OS of 59 months, compared to 40 months for CC0-NACT≥7 group (p = 0.4), while patients with CC≥1, both NACT=6 and NACT≥7 presented a median OS of 27 months. Achieving CC0 after NACT≥7 significantly improved survival compared to NACT=6-CC≥1 (HR = 1.71, p = 0.019 for PFS; HR = 2.1, p = 0.009 for OS). Extending NACT beyond 6 cycles may benefit selected patients by enhancing cytoreduction rates and survival without increasing toxicity.

Evaluating the role of robotic surgery in gynecological cancer treatment

Robotic surgery has emerged as a transformative force in the field of gynecologic oncology, offering a minimally invasive yet versatile approach to managing a wide range of gynecologic cancers. Robotic platforms, with their enhanced precision, magnified visualization, and ergonomic advantages, have been translated into tangible benefits for patients, including reduced blood loss, shorter hospital stays, and faster recovery times. In the context of endometrial cancer, robotic-assisted hysterectomy has become an increasingly preferred approach for early-stage disease, demonstrating comparable, if not superior, surgical and oncologic outcomes compared to traditional open or laparoscopic methods across various histopathological subtypes. Similarly, robotic surgery has gained traction in the treatment of early-stage cervical cancer, with robotic-assisted radical hysterectomy offering a minimally invasive alternative with favorable early results. However, recent studies highlighting the importance of long-term survival data underscores the need for ongoing research and careful patient selection. While the role of robotic surgery in advanced ovarian cancer remains less definitive compared to endometrial and cervical cancers, ongoing research is exploring its potential benefits in specific scenarios, such as interval debulking surgery and patients with limited disease burden. Despite its demonstrable advantages, robotic surgery in gynecologic oncology is not without its challenges, including the high initial cost, the need for specialized surgical training, and the inherent limitations of robotic platforms. However, as technology continues to advance and surgical expertise grows, robotic surgery holds immense promise for further refining the surgical management of gynecologic cancers, ultimately striving to provide all women facing these diseases with the most effective, safest, and compassionate care possible.

Mature cystic teratoma and their malignant transformation

Mature cystic teratomas (MCT) are benign germ cells tumors which are fairly common and are often diagnosed incidentally. In most cases they don't present a significant risk to survival, but in some rare cases they can progress to a malignant phenotype. In such cases the treatment must be adjusted to the new conditions and tailored to suit the malignant phenotype. In this review, we aim to describe the main clinical and biological features of various types of recorded malignant transformations and/or complications, as well as stress their differences in clinical behavior and therapeutic options. The management of benign vs. malignant MCT differs greatly and a specific subtype of transformation should be taken into consideration when designing therapy, as it can greatly improve the survival and quality of life.

The impact of laterality on the incidence and prognosis of epithelial ovarian cancer

Epithelial ovarian cancer (EOC) is the most prevalent type of ovarian cancer, yet the impact of ovarian laterality has received limited attention. We conducted a comprehensive investigation into the impact of laterality (left-right and bilateral-unilateral) on EOC incidence and prognosis, focusing on distinct subtypes. Binomial tests and Pearson's χ2 tests were employed to compare occurrence rates among laterality groups. Cox regression analyses were used to create a proportional hazards model for tumor prognosis. Nomograms were developed and validated, including internal validation via bootstrapping. Our study encompassed 20,790 EOC patients, revealing disparities in incidence and prognosis between unilateral and bilateral cases. Unilateral tumor development was notably predominant in clear cell, endometrioid, brenner, and mucinous subtypes, while bilateral involvement was more frequent in serous ovarian cancer. Laterality differences, reflecting disparities between the left and right sides, were chiefly evident in the incidence rates across various stages and in the prognosis of specific subtypes. Notably, mucinous ovarian cancer exhibited significantly better prognosis on the right side compared to the left (right tumors: HR = 0.745, p = 0.015, CI: 0.587-0.945). These findings emphasize the importance of considering ovarian laterality -both left-right and bilateral-unilateral aspects -as a critical factor influencing EOC incidence and prognosis, necessitating attention in clinical practice.

Failure of early interval debulking surgery after standard neoadjuvant chemotherapy: May bevacizumab add something? A large retrospective study

Data are limited on the use of bevacizumab in neoadjuvant setting for High-Grade Serous ovarian Cancer (HGSC) patients. This study explores the effect of adding bevacizumab to standard neoadjuvant chemotherapy (NACT) following the failure of early Interval Debulking Surgery (eIDS). This monocentric study retrospectively enrolled FIGO stage IIIC-IV HGSC patients (2017-2021), persisting unresectable after three NACT cycles. Eligible patients had an ECOG performance status ≤2, were aged 40-75 years, and had no contraindications to bevacizumab administration. Patients were stratified whether they added bevacizumab from cycles 4 to 6 (CPB group) or not (CP group). The primary endpoint was the cytoreduction rate after six cycles (delayed IDS, dIDS). Overall, 58(23 %) patients received neoadjuvant bevacizumab(CPB), and 190 (77 %) did not (CP). Delayed IDS was performed in 117(47.6 %) patients (CPB:31-53.4 %; CP:86-45.8 %; p = 0.38), with complete gross resection rates of 83.9 % and 88.5 %, respectively (p = 0.72). Severe postoperative complications were comparable (CP: 8 %, CPB: 9.7 %, p = 0.069). Median overall survival (OS) for dIDS patients showed no significant difference (CPB: not reached, CP:38 months, p = 0.55), nor did progression-free survival (PFS; CPB:14 months, CP:12 months, p = 0.830). Conversely, among 130(52 %) patients persisting unresectable, bevacizumab significantly improved OS in the CPB group (not reached vs.18 months, p = 0.015), although PFS remained similar (CPB: 6 months, CP: 7 months, p = 0.741). While adding bevacizumab to NACT does not seem to increase the dIDS rate, it significantly extends OS in unresectable patients. Its use may be a valuable option in selected cases after eIDS' failure.

Is total mesorectal excision mandatory in advanced ovarian cancer patients undergoing posterior pelvic exenteration? Prognostic role of mesorectal space involvement in a prospective ovarian cancer cohort

In advanced epithelial ovarian cancer (AEOC), debulking surgery with posterior pelvic exenteration (PPE) is performed in 35-70 % of the patients to achieve no macroscopic residual disease. This study aims to evaluate the incidence of mesorectal involvement and its prognostic role in AEOC patients undergoing PPE. This prospective study analyzes data from a cohort of AEOC patients who underwent primary debulking surgery (PDS) or interval debulking surgery (IDS) with PPE at the Léon Bérard Cancer Center in Lyon between 2018 and 2022. 73 patients underwent debulking surgery with PPE during the study period. 27 (34 %) underwent PPE during PDS and 46 (66 %) during IDS. 23 patients (31.5 %) had only serosal involvement, 19 (26 %) had bowel involvement up to the muscularis propria, and 7 (9.6 %) had up to the mucosa. Mesorectal involvement was observed in 40 cases (54.7 %) and was significantly associated with positive MLNs and higher liver recurrence rates. Hepatic metastases had an early onset (months, 9.8 vs 28.8; p = 0.0001) and were correlated with poorer OS (months, 20.9 vs 51.5) compared to recurrences in other sites. The persistence of positive mesorectum after neoadjuvant chemotherapy in the IDS group seemed to be linked to poor OS (NR vs 42.7 months). Debulking surgery with PPE in AEOC patients is often needed. Total mesorectal excision should be performed in AEOC to achieve no residual disease because positive mesorectum after neoadjuvant chemotherapy seemed to be linked with poor OS, with early onset and increased incidence of liver metastasis.

Ovarian cancer in children and adolescents: A unique clinical challenge

Ovarian cancer in children and adolescents is rare, presenting unique diagnostic and management challenges distinct from adult cases. This paper provides a comprehensive overview of this disease, focusing on the importance of a multidisciplinary approach to care. We discuss the common presentation of ovarian malignant masses in young patients, highlighting the role of imaging and tumor markers in diagnosis. The paper delves into the surgical management of these tumors, emphasizing the importance of fertility-sparing techniques whenever possible. We explore the role of adjuvant chemotherapy, considering histological subtypes and disease stage. Furthermore, we address the good prognosis associated with early diagnosis and treatment, with survival rates exceeding 90 % in many cases. Finally, the need for long-term follow-up to monitor for potential recurrence is underscored and the long-term treatment-related effects are addressed. This review aims to guide clinicians in providing optimal care for this unique patient population, emphasizing the importance of balancing oncological control with the preservation of future fertility and quality of life.

Characteristics and outcomes of surgically staged multiple classifier endometrial cancer

The growing adoption of molecular and genomic characterization is changing the current landscape of treatment of endometrial cancer patients. Using the surrogate molecular classification, endometrial cancer patients can be classified in four subgroups: POLE mutated (POLEmut), MMRd/MSI-H, p53 abnormal (p53abn), and no specific mutational profile (NSMP). However, some patients can harbor two or more molecular features (defined as multiple classifier). Since the rarity of this occurrence, evidence regarding multiple classifiers is still limited. Here, we described characteristics and outcomes of multiple classifiers. This is a multi-institutional retrospective study. Data of consecutive patients having 2 or more molecular features were collected. Survival was assessed using the Kaplan-Meier and Cox proportional hazard methods. Charts of 72 multiple classifiers were reviewed. Median (range) follow-up was 9.8 (1.2, 37.5) months. Overall, 31 (43%) patients had POLEmut. Patients with POLEmut-MMRd/MSI-H, POLEmut-p53abn, and POLEmut-MMRd/MSI-H-p53abn were 6 (8.3%), 20 (27.8%), and 5 (6.9%), respectively. Among those 31 patients, no recurrence occurred within a median follow-up of 10.5 months (only seven (22.6%) patients had at least 2-year follow-up). The remaining 41 (56.9%) patients were diagnosed with tumors harboring both p53 and MMRd/MSI-H. Among them, four (9.8%) recurrences occurred at a median follow-up time of 8.9 months. Adjuvant therapy (other than vaginal brachytherapy) was administered in 5/31 (16%) and 25/41 (61%) patients with and without POLEmut, respectively (p < 0.001). Multiple classifiers endometrial cancer with POLEmut are characterized by good prognosis even in case of presence of MMRd/MSI-H and/or p53abn. Additional studies with long-term follow-up are needed.

Efficacy of Neoadjuvant Chemotherapy as pre-habilitation program in advanced epithelial ovarian cancer

Approximately 70 % of ovarian cancer patients present at diagnosis with advanced disease(AOC) and impaired clinical conditions, making them not ideal surgical candidates. We aimed to investigate whether neoadjuvant chemotherapy(NACT) can modify pre-operative characteristics of patients at high risk(HR) of perioperative complications, as defined in the Mayo Clinic Algorithm. We also compared their morbidity and survival outcomes with comparable HR women undergoing primary surgery (PCS). We retrospectively collected FIGO stage III and greater AOC patients undergoing either NACT-interval cytoreductive surgery(HR-NACT) or PCS from 01/2013 to 12/2022. HR features included: Albumin  1, stage IV disease, or complex surgery likely (more than hysterectomy, salpingo-oophorectomy and omentectomy). 400 patients were included. Among them, 298 met the criteria for the HR-NACT group; 203(68.1 %) underwent ICS after 3-4 cycles whislt 95(31.9 %) completed 6 NACT cycles. We reported an improvement in clinical variables in women undergoing 3-4 cycles of NACT: raise of ECOG = 0 rate(53.3 % vs 81.8 %; p < 0.001) and median albumin serum levels(3.0 g/dl vs 4.0 g/dl; p < 0.001). We identified 102 comparable HR-PCS patients. No difference in intraoperative complications was detected, while a difference was found in severe post-operative complications, favoring patients treated with both 3-4(5.4 % vs 18.6 % p = 0.0003) and 6 NACT cycles(7.8 % vs 18.6 %, p = 0.053). No difference in both DFS and OS was reported. We offer a rationale to combine non interventional pre-habilitation procedure with short term chemotherapy cycles, aiming to improve pre-operative conditions of selected HR patients.

Ovarian cancer care in Belgium: The elephant in the country

Breast cancer outcomes in women with ovarian cancer and a pathogenic germline BRCA mutation

Women with ovarian cancer (OC) and a pathogenic variant in the BRCA1 or BRCA2 genes are at increased risk of developing breast cancer (BC). Evidence for long term outcomes in these patients who undergo bilateral risk reduction mastectomy (RRM) after ovarian cancer is sparse. The aim of this study was to analyse the long-term breast cancer-related outcomes of patients who have been diagnosed with ovarian cancer and found to have BRCA1 or 2 pathogenic variants. Local approval was granted. The hospital clinical genetics database was interrogated to identify women who have been diagnosed with OC and a germline BRCA1/2 pathogenic variant between January 2010-March 2020. Patient demographics, OC treatment as well as any BC related information was analysed. 148 women were diagnosed with OC and a pathogenic variant in BRCA1/2 in the study period. 47 patients were excluded as they did not have treatment at our institution. 101 patients were included. The median age at diagnosis of OC was 52 years (IQR 46-61). Eighty-four (82 %) were FIGO stage 3 or 4 OC. At a median follow-up of 63 months (IQR 39-94), 55 (54.4 %) women had been diagnosed with a recurrence of ovarian cancer and 38 (37 %) women have died. Twenty-one (21 %) women were diagnosed with BC. 13 (12.9 %) had BC before OC, 4 after and 4 synchronous with OC. Of the remaining patients who did not have BC, 6 underwent bilateral risk reduction mastectomy (RRM) after treatment for OC. Risk of disease recurrence and death due to stage 3 and 4 ovarian cancer remained high in this time period. RRM can be undertaken in carefully selected patients, however we would recommend reserving this for women who have favourable OC disease prognosis.

Exploring the impact of exercise on women with ovarian cancer: A call for more methodologically standardized RCTs to enable a realistic systematic review

Ovarian cancer remains a leading cause of mortality among gynecological malignancies, often diagnosed at advanced stages due to nonspecific symptoms and limited screening tools. Standard treatment, including cytoreductive surgery and chemotherapy, can cause fatigue, physical dysfunction, and psychological distress, impacting quality of life. Exercise interventions have shown potential to mitigate these effects, but inconsistent methodologies in randomized controlled trials (RCTs) limit reliable conclusions and clinical integration. A systematic review was conducted following PRISMA guidelines. RCTs assessing physical exercise effects on women with ovarian cancer were included, excluding pilot trials, reviews, and combined therapies. Data extraction and GRADE assessments were performed by two independent reviewers, and a narrative synthesis was conducted due to study heterogeneity. Eleven RCTs were analyzed, covering aerobic, resistance, and yoga interventions. Findings indicated improvements in physical function, fatigue, and psychological outcomes, such as reduced depressive symptoms and cognitive enhancements. Patients adhering to ≥150 min of moderate-intensity exercise per week experienced the most consistent benefits. Preoperative walking expedited recovery, though significant heterogeneity in study protocols precluded meta-analysis. Evidence supports the feasibility and benefits of exercise across ovarian cancer stages. However, inconsistency in exercise intensity, duration, and reporting hinders the development of standardized protocols. Compared to cardiological rehabilitation, ovarian cancer exercise guidelines remain underdeveloped, emphasizing the need for tailored, evidence-based interventions. Exercise interventions can improve physical and mental health in ovarian cancer patients. Standardized RCTs are urgently needed to establish robust exercise protocols and enable clinical implementation, enhancing survivorship outcomes and quality of life.

Optimizing prehabilitation in gynecologic malignancies: Improving acceptance, overcoming barriers, and managing program complexity

Prehabilitation aims to improve patients' physical condition before a stressful event, such as surgery, and enhance recovery. Despite its potential benefits, many emerging prehabilitation programs face challenges in enrolling or retaining patients. In our prehabilitation study PHOCUS, which aims to prepare ovarian cancer patients for surgery, we have also encountered lower acceptance and retention rates. Particularly the most vulnerable patients, who are old and frail, and may benefit the most from the prehabilitation, decline participation due to the complexity of the proposed program. In our review we discussed obstacles and barriers that prevent patients' participation based on both literature and our experience. Among the main reasons are patient's low motivation, high intensity of the program and a lack of social support. To overcome these challenges, we suggest increasing the program's flexibility, adapting the program according to individual patient's needs and enhancing patients' education about the benefits of prehabilitation.

Diagnostic laparoscopy for pre-operative selection of patients with known peritoneal carcinomatosis for CRS-HIPEC: A systematic review and meta-analysis

Preoperative selection of patients with Peritoneal Carcinomatosis (PC) for Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is challenging due to associated risks. Diagnostic laparoscopy (DL), an emerging alternative to conventional radiological imaging, has uncertain efficacy. This study aims to evaluate DL's diagnostic performance through a systematic review of available literature. A comprehensive search of MEDLINE and SCOPUS databases from January 1987 to September 2023 identified studies investigating DL's diagnostic accuracy in selecting PC patients for CRS-HIPEC. Methodological bias assessment and analysis of performance metrics such as positive predictive value (PPV), sensitivity, specificity, and diagnostic odds ratio (DOR) were conducted. Subgroup analyses were performed for primary ovarian cancer studies, and false positive sites were identified. The summary receiver operating characteristic curve (sROC) was plotted to assess overall diagnostic efficacy, with meta-regression conducted to identify sources of heterogeneity across studies. This study included 25 studies comprising 3820 patients. Pooled PPV was 93.04 %, with a complication rate of 1.61 %. Pooled sensitivity was 98.26 % and pooled specificity was 83.67 %. The pooled DOR was 139.18, and sROC plot yielded an area under the curve of 0.96. Meta-regression found the ovarian subgroup as a strong source of heterogeneity. Subgroup analysis indicated similar findings in primary ovarian cancer studies, while false positives were commonly observed in the celiac axis, mesentery, ureters and para-aortic lymph nodes. DL demonstrates robust diagnostic accuracy in selecting PC patients for CRS-HIPEC, with potential benefits in patient outcomes and resource optimization. Further multicenter investigations are warranted to validate DL's efficacy across diverse primary cancer types.

The role of microRNA-9 in ovarian and cervical cancers: An updated overview

Ovarian and cervical cancers are the two most frequent kind of gynaecological cancers (GCs). In spite of advances in prevention, screening and treatment, cervical cancer still leads to an increased morbidity and mortality worldwide. Ovarian cancer is often detected at a late stage, which significantly reduces the effectiveness of available treatments. Therefore, novel methods are desperately needed to improve the clinical care of GC patients. MicroRNAs, also known as short noncoding RNAs (miRNAs/miRs), are a diverse group of RNAs with a length of 22 nucleotides. These typically cause translational repression and mRNA degradation by interacting with target mRNAs' 3' untranslated region (3'-UTR), together with other regions and gene promoters. Under certain conditions, they are also able to activate translation or regulate transcription. It has been demonstrated that miRNAs are crucial to several biological processes leading to tumorigenesis, including GCs. Recent research has shown that miR-9 affects carcinogenesis. In this review, we will provide an overview of current research on the potential utility of miR-9 in the diagnosis, prognosis, and therapy of ovarian and cervical malignancies.

Sarcopenia in gynaecological cancers

Comparison of survival and complications between minimally invasive and open staging surgeries in non-endometrioid endometrial cancer

This study aimed to compare survival and complications between minimally invasive surgery and open surgery and evaluate related risk factors in patients with non-endometrioid endometrial cancer. Clinicopathologic characteristics; survival outcomes; complications; and prognostic factors associated with progression-free survival and overall survival were compared among patients with non-endometrioid endometrial cancer who underwent primary staging surgery using laparoscopic, robotic, or open abdominal surgery (2004-2017). In total, 91 patients were included: 41 and 50 underwent minimally invasive surgery and open surgery, respectively. The minimally invasive surgery and open surgery groups showed similar progression-free survival (5-year progression-free survival rate, 58.7 % vs. 58.5 %; P = .925) and overall survival (5-year overall survival rate, 73.6 % vs. 80.3 %; P = .834). Intraoperative (7.2 % vs. 6.0 %; P = .111) and postoperative surgical complications (14.6 % vs. 26.0 %; P = .165) were similar between the groups. However, blood loss was lower (mean, 305.1 vs. 561.2 ml, P < .001) and hospital stay was shorter (mean, 8.2 vs. 15.4 days, P < .001) in the minimally invasive surgery group. Using multivariate analysis, lymphovascular space invasion was identified as poor prognostic factor for progression-free survival (adjusted hazard ratio [HR], 3.054; 95 % confidence interval [CI], 1.521-6.132; P = .002) and overall survival (adjusted HR, 3.918; 95 % CI, 1.455-10.551; P = .007), whereas age ≥ 60 years was poor prognostic factor for only overall survival (adjusted HR, 5.0953; 95 % CI, 1.660-15.378; P = .004). Surgical outcomes did not differ between the minimally invasive and open surgery group in patients with non-endometrioid endometrial cancer. Lymphovascular space invasion was a significant survival factor in this context.

Is it safe to operate selected low-risk endometrial cancer patients in secondary hospitals?

The aim of this study was to assess the accuracy of a preoperative screening algorithm in identifying low-risk endometrial cancer (EC) patients to ensure optimal care. A total of 277 patients with primary EC confirmed through biopsy underwent magnetic resonance imaging (MRI). Patients with risk factors for advanced high-risk EC, such as non-endometrioid histology, high-grade differentiation status, deep myometrial invasion, or spread beyond the uterine corpus, were systematically excluded. The remaining preoperatively screened patients with stage IA low-grade endometrioid EC (EEC) (n = 93) underwent surgery in a tertiary hospital. The accuracy of the preoperative diagnosis was evaluated by comparing the findings with the postoperative histopathological results. Disease-free survival (DFS) and overall survival (OS) were analyzed using 8-year follow-up data. Postoperative histopathological analysis revealed that all patients had grade 1-2 EEC localized to the corpus uteri. Only three patients had deep myometrial invasion (stage IB), but they remained disease-free after 6-9 years of follow-up. The median follow-up time for all patients was 8.7 years. The DFS was 7.6 years, and the OS was 8.6 years. Two patients with stage IA grade 1 EEC experienced relapse and, despite treatment, died of EC. No other EC-related deaths occurred. The screening algorithm accurately identified low-risk EC patients without compromising survival. Therefore, the algorithm appears to be feasible for selecting patients for surgery in secondary hospitals.

Prognostic evaluation of lymph-vascular space invasion in patients with endometrioid and non-endometrioid endometrial cancer: A multicenter study

The prognostic value of lymph-vascular space invasion (LVSI) on endometrial cancer (EC) remains controversial. This study aimed to explore the impact of LVSI on patients with endometrioid and non-endometrioid EC in China. We analyzed EC patients who underwent surgery from 2010 to 2019 in seven Chinese hospitals retrospectively and stratified patients based on histopathologic types and LVSI status. Endpoints were disease-free survival (DFS) and overall survival (OS). Propensity score matching (PSM) algorithm was used to balance the confounding factors. The survival was examined using Kaplan-Meier analysis. Cox proportional hazards regression analyses were used to find prognostic independent risk factors. Among 3715 EC patients, LVSI positive rate was 9.31% (346/3715). After matching, LVSI present group had shorter DFS (P = 0.005), and similar OS (P = 0.656) than LVSI absent group for endometrioid EC patients. For non-endometrioid EC patients, there was no statistical difference in either DFS (P = 0.536) or OS (P = 0.512) after matching. The multivariate Cox analysis showed that LVSI was an independent risk factor of DFS [hazard ratio (HR) 2.62, 95% confidence intervals (CI) 1.35-5.10, P = 0.005] and not OS (HR 1.24, 95%CI 0.49-3.13, P = 0.656) for endometrioid EC patients. It was not a prognostic factor of either DFS (HR 1.28, 95%CI 0.58-2.81, P = 0.539) or OS (HR 1.33, 95%CI 0.55-3.13, P = 0.515) for non-endometrioid EC patients. LVSI is an adverse prognostic factor for endometrioid EC patients and has no impact on non-endometrioid EC patients. Necessity of postoperative adjuvant therapy based on LVSI needs to be carefully considered for non-endometrioid EC patients.

Is minimally invasive surgical approach a reasonable option in apparent early stage epithelial ovarian cancer restaging? Results from a multicentric retrospective study

To perform surgical staging of early stage ovarian cancer (EOC), conventional laparoscopy (LS) and robot-assisted laparoscopy (RLS) appear to be reliable procedures compared to open surgery. But oncologicals results with long-term follow up are limited in the literature. The objective of this study is to evaluate the surgical and long-term survival for patients managed by minimally invasive surgery (MIS). We conducted a multicentric retrospective study in 6 institutions. All patients referred for epithelial EOC (apparent stage I-IIa) managed with LS and RLS were involved. From December 2008 to December 2017, 140 patients were included (109 in LS group and 31 in RLS group). A total of 27 (19.2 %) patients were upstaged to an advanced ovarian cancer (FIGO stage > IIA), and 73 % of patients received chemotherapy. Mean operative time was 265,8 ± 88,4 min and significantly longer in RLS group (LS = 254,5 ± 86,8; RLS = 305,6 ± 85,5; p = 0,008). Rate of severe post-operative complications (grade 3) was 5,7 %. Thirteen conversion to laparotomy occurred, including one per-operative hemorrhaege. After a mean follow-up of 60,7 months, 29 (20.7 %) patients recurred, with a time to recurrence was >24 months in 51,7 % of cases. Overall survival (OS) was 88.6 % and disease-free survival (DFS) was 79.3 %. Oncologic outcomes were similar between LS and RLS group (OS: p = 0,504 and DFS: p = 0,213). Surgical staging of EOC by LS or RLS approach has long-term equivalent surgical and oncological approach. These results seem to be equivalent to open surgery according to literature review.

The impact of lymphadenectomy on the survival outcomes of ovarian clear cell carcinoma: A retrospective study of the SEER database and Chinese registry

Ovarian clear cell carcinoma (OCCC) is a rare pathological type of ovarian cancer with a poor prognosis, and lymphadenectomy is controversial in patients with OCCC. The objective of this study was to evaluate the impact of lymphadenectomy on the prognosis of patients with OCCC. In this retrospective study, we collected data from the Surveillance, Epidemiology and End Results (SEER) database and institutional registries in China. The SEER cohort included 1777 women diagnosed with OCCC between 2010 and 2019, while the Chinese cohort included 199 women diagnosed between April 2004 and April 2021. Recurrence-free survival (RFS) and overall survival (OS) were studied using Kaplan-Meier curve and Cox regression analysis. We also employed propensity score matching (PSM) to adjust for baseline imbalances between the lymphadenectomy group and the no-lymphadenectomy group. Multivariate cox regression analysis showed that lymphadenectomy was not associated with better overall survival (OS) in either early (hazard ratio [HR] 0.84[0.50-1.43], p = 0.528) or advanced (HR 0.78[0.50-1.21], p = 0.270) patients in the SEER cohort after PSM. Additionally, in the Kaplan-Meier curve analysis, lymphadenectomy did not significantly improve OS in both early (p = 0.28) and advanced (p = 0.49) patients in the SEER cohort after PSM. Similarly, in the Chinese cohort, lymphadenectomy had no significant effect on OS (early p = 0.22; advanced p = 0.61) or RFS (early p = 0.18; advanced p = 0.83) in both early and advanced patients. In completely homogeneous groups, lymphadenectomy in women diagnosed with OCCC had no effect on either recurrence-free survival or overall survival compared to patients without lymphadenectomy.

Reproductive, obstetrical and oncological outcomes of fertility-sparing treatment for cervical cancer according to the FIGO 2018 staging system: A systematic review

We assessed reproductive, obstetrical, and oncological outcomes in patients who underwent fertility-sparing treatment by including studies that adhere to the FIGO 2018 staging system. Data on recurrence, mortality, pregnancy rate, live birth rate, and preterm delivery rate were collected. In patients with stages IA1, IA2, and IB1, the recurrence rate was 4.7 % and the death rate was 0.6 %. For patients with stage IB2, the recurrence rate was 12.1 % and the death rate was 3.2 %. Pregnancy rates for conization/simple trachelectomy and radical trachelectomy were 61.7 % and 50 %, respectively. A higher live birth rate (84.4 % vs 58.6 %), and lower preterm birth rate (18.3 % vs 33.3 %) were observed in patients undergoing conization compared to radical trachelectomy. We found a recurrence rate of 4.7 % in patients with stage less than or equal to IB1 and 12.1 % in those with stage IB2. A higher rate of preterm delivery was observed in patients who underwent radical trachelectomy.

External beam radiotherapy boost versus surgical debulking followed by radiotherapy for the treatment of metastatic lymph nodes in cervical cancer: A systematic review and meta-analysis

We aimed to assess disease-free survival (DFS), overall survival (OS) and treatment-related toxicity of two therapeutic strategies for treating bulky lymph nodes on imaging in patients with locally advanced cervical cancer (LACC): radiotherapy boost versus surgical debulking followed by radiotherapy. We performed a systematic review of studies published up to October 2023. We selected studies including patients with LACC treated by external beam radiotherapy (EBRT) boost or lymph node debulking followed by EBRT (with or without boost). We included two comparative (included in the meta-analysis) and nine non-comparative studies. The estimated 3-year recurrence rate was 28.2% (95%CI:18.3-38.0) in the EBRT group and 39.9% (95%CI:22.1-57.6) in the surgical debulking plus EBRT group. The estimated 3-year DFS was 71.8% and 60.1%, respectively (p = 0.19). The estimated 3-year death rate was 22.2% (95%CI:11.2-33.2) in the EBRT boost group and 31.9% (95%CI:23.3-40.5) in the surgical debulking plus EBRT group. The estimated 3-year OS was 77.8% and 68.1%, respectively (p = 0.04). No difference in lymph node recurrence between the two comparative studies (p = 0.36). The meta-analysis of the two comparative studies showed no DFS difference (p = 0.13) but better OS in the radiotherapy boost group (p = 0.006). The incidence of grade≥3 toxicities (ranging 0-50%) was not different between the two approaches in the two comparative studies (p = 0.31). No DFS and toxicity difference when comparing EBRT boost with surgical debulking of enlarged lymph nodes and EBRT in patients with cervical cancer was evident. Radiotherapy boost had better OS. Further investigation is required to better understand the prognostic role of surgical lymph node debulking in light of radiotherapy developments.

Peritonectomy and resection of mesentery during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer: A phase I-II trial

To describe the surgical technique, assess feasibility, efficacy, and safety of peritonectomy and/or resection of mesentery (P-Rme) during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC). In April 2009 we registered a protocol study on the safety and feasibility of P-Rme. In the period April 2009-December 2022, 687 patients with FIGO stage IIIC-IV ovarian cancer underwent VPD. One hundred and twenty-nine patients (18.7%) had extensive disease on the mesentery and underwent P-Rme. Feasibility was assessed as the number of procedures completed. Efficacy was measured as the rate of Complete Resection (CR). Safety was defined by the intra- and post-operative morbidity rate specifically associated with these procedures. In all patients P-Rme was successfully completed. P-me was performed in 82 patients and R-me in 47, both procedures in 23 patients. CR was achieved in all 129 patients with an efficacy of 100%. Intra-operatively 5 patients out of 129 experienced small bowel loop surgical devascularization. They required small bowel resection and anastomosis. The procedure specific morbidity was 3.8%. No post-operative complication was related to P-Rme. At 64 months median follow-up, survival outcomes in the study group were similar to patients in the control group. Overall, almost 20% of the VPD patients needed P-Rme to obtain a CR. P-Rme was a safe and effective step during VPD. The rate of CR in the study group was 100% achieved thanks to the addition of the P-Rme. No procedure specific post-operative complications occurred but 3.8% of the patients had unplanned additional surgery related to these procedures.

Secondary cytoreductive surgery followed by olaparib tablets as maintenance therapy in patients with BRCA mutated recurrent ovarian cancer: A multi-center retrospective study

To evaluate the effect of secondary cytoreductive surgery (SeCRS) followed by platinum-based chemotherapy (PBC) and olaparib tablets as maintenance therapy in patients with BRCA mutated recurrent epithelial ovarian cancer. This was a retrospective study of a prospective database. We collected information on 623 patients diagnosed with BRCA mutated recurrent epithelial ovarian cancer, all of whom underwent SeCRS followed by PBC in combination with or without olaparib. Overall survival and progression-free survival were measured to evaluate treatment effectiveness. Of the 623 patients recruited, 240 underwent SeCRS plus hyperthermic intraperitoneal chemotherapy followed by PBC and olaparib maintenance therapy (Group A), 248 underwent SeCRS followed by PBC and olaparib maintenance therapy (Group B), and 135 underwent SeCRS followed by PBC only upon recurrence (Group C). The median progression-free survival for Group A was significantly longer than that for Group B (32.5 vs. 24.2 months, P<0.001), and Group B was significantly longer than Group C (24.2 vs. 15.1 months, P<0.001). The median overall survival for Groups A was significantly longer than that for Group B (71.4 vs. 63.5 months, P<0.001), and Group B was significantly longer than Group C (63.5 vs. 47.5 months, P<0.001). This study suggested that SeCRS followed by PBC and olaparib maintenance therapy resulted in longer overall survival and progression-free survival than SeCRS followed by PBC only in patients with BRCA mutated recurrent ovarian cancer, especially in patients treated with SeCRS plus hyperthermic intraperitoneal chemotherapy.

Collaborative expertise of gynecological and surgical oncologists in managing advanced epithelial ovarian cancer

Most patients with epithelial ovarian cancer (EOC) present with significant peritoneal spread. We assessed collaborative efforts of surgical and gynecological oncologists with expertise in cytoreductive surgery (CRS) in the management of advanced EOC. Using a prospective single-center database (2014-2022), we described the operative and oncologic outcomes of stage IIIC-IVA primary and recurrent EOC perioperatively managed jointly by gynecological and surgical oncologists both specializing in CRS and presented components of this collaboration. Of 199 identified patients, 132 (66 %) had primary and 53 (27 %) had recurrent EOC. Due to inoperable disease, 14 (7 %) cases were aborted and excluded from analysis. Median peritoneal cancer index (PCI) in primary and recurrent patients was 21 (IQR: 11-28) and 21 (IQR: 6-31). Upper abdominal surgery was required in 95 % (n = 125) of primary and 89 % (n = 47) of recurrent patients. Bowel resections were performed in 83 % (n = 110) and 72 % (n = 38), respectively. Complete cytoreduction (CC-0/1) with no disease or residual lesions <2.5 mm was achieved in 95 % (n = 125) of primary and 91 % (n = 48) of recurrent patients. Ninety-day Clavien-Dindo grade III-IV morbidity was 12 % (n = 16) and 21 % (n = 11), respectively. Median follow-up was 44 (95%CI: 33-55) months. Median overall survival in primary and recurrent EOC was 68 (95%CI: 45-91) and 50 (95%CI: 16-84) months. Median progression-free survival was 26 (95%CI: 22-30) and 14 (95%CI: 7-21) months, respectively. Perioperative collaboration between surgical and gynecological oncologists specializing in CRS allows safe performance of complete cytoreduction in the majority of patients with primary and recurrent EOC, despite high tumor burden.

Sentinel lymph node biopsy in gynecological malignancies: A modern approach to surgical staging – A narrative review

Sentinel lymph node biopsy (SLNB) has emerged as a valuable alternative to traditional lymphadenectomy in the surgical management of gynecological cancers. This narrative review delves into the advantages, practical applications, and future research directions of SLNB in this context. Compared to the more extensive lymphadenectomy, SLNB offers a minimally invasive approach to lymph node staging, leading to reduced surgical morbidity, faster recovery times, and improved quality of life for the patients involved. This narrative review highlights the high detection rates and accuracy of SLNB in predicting lymph node metastasis, particularly in early-stage endometrial, cervical and vulvar cancers. By accurately assessing lymph node status, SLNB provides crucial information for treatment planning, potentially guiding decisions regarding adjuvant therapies and assessing the need for further lymph node dissection. From clinical practice guidelines, prospective studies, and relevant research articles, this review provides a thorough understanding the evolving role of SLNB in managing gynecological malignancies. The findings presented underscore the potential of SLNB to improve patient outcomes by providing accurate staging while minimizing surgical complications.

Preoperative evaluation and a nomogram prediction model for pelvic lymph node metastasis in endometrial cancer

The primary objective of this study is to explore the preoperative risk factors of pelvic lymph node metastasis (PLNM) in endometrial cancer patients, and construct a nomogram prediction model. We retrospectively collected various preoperative clinical characteristics of patients and analyzed their relationship with PLNM. Logistic regression analysis was used to screen for independent risk factors for PLNM of endometrial cancer. A nomogram prediction model was constructed, the receiver operating characteristic (ROC), calibration curve and decision curve analysis (DCA) were constructed and used to assess discrimination, calibration, and net benefit. Out of the 276 patients, 74 (26.81%) with postoperative pathological confirmation of PLNM. Multivariate logistic regressive analysis demonstrated that preoperative depth of myometrial invasion (DIM) ≥50% determined by Magnetic Resonance Imaging (MRI) (p = 0.003), carbohydrate antigen 125 (CA125) (p = 0.030), carbohydrate antigen 19-9 (CA 19-9) (p = 0.044), and platelet/lymphocyte ratio (PLR) (p = 0.025) could serve as independent risk factors for PLNM. A risk factors-based nomogram prediction model was constructed, which showed good discrimination (AUC = 0.841, p < 0.001) and good efficacy (C-index = 0.842) and good calibration (mean absolute error = 0.046). DCA showed that the model can provide clinical benefits. Preoperative DIM ≥50% determined by MRI, serum CA 19-9, CA125 and PLR could be utilized to predict PLNM in endometrial cancer patients. This nomogram prediction model can provide preoperative help for evaluation and identification of patients with endometrial cancer, and provide a theoretical basis for clinical intervention.

Randomized trial of autologous ovarian graft to preserve ovarian function in young women undergoing pelvic radiotherapy for cervical cancer

To evaluate the short-term feasibility and efficacy of fresh autologous ovarian tissue grafting into the subcutaneous tissue for the prevention of hypoestrogenism in young women with cervical cancer undergoing pelvic radiotherapy. Single center, nonblinded, exploratory phase II randomized trial conducted at Instituto do Câncer do Estado de São Paulo, Brazil, from June 2022 to April 2025. Women aged ≤35 years with locally advanced cervical cancer (FIGO 2018 stages IB3-IVA), preserved ovarian function, and histologic subtypes of squamous cell carcinoma or usual adenocarcinoma, eligible for definitive pelvic radiotherapy. Participants were randomized 1:1 to an intervention group (n = 12) with underwent autologous fresh ovarian tissue grafting into the subcutaneous tissue prior to pelvic radiotherapy, or to a control group (n = 10), with did not undergo grafting. Hormonal ovarian function assessed by serum estradiol and follicle-stimulating hormone (FSH) levels. A total of 22 patients were enrolled, with three excluded from the intervention group due to clinical conditions. The median follow-up was 18.9 months. At six months, 85% of patients in the intervention group maintained hormonal profiles consistent with preserved ovarian function and were free of climacteric symptoms, whereas all controls exhibited profiles compatible with premature ovarian insufficiency. Baseline assessments confirmed normal ovarian function in all participants. Fresh autologous subcutaneous ovarian grafting was technically safe, feasible and effective in preventing hypoestrogenism and climacteric symptoms during short-term follow-up in young women undergoing pelvic radiotherapy for cervical cancer.

Sentinel node mapping in high-intermediate and high-risk endometrial cancer: Analysis of 5-year oncologic outcomes

To assess 5-year oncologic outcomes of apparent early-stage high-intermediate and high-risk endometrial cancer undergoing sentinel node mapping versus systematic lymphadenectomy. This is a multi-institutional retrospective, propensity-matched study evaluating data of high-intermediate and high-risk endometrial cancer (according to ESGO/ESTRO/ESP guidelines) undergoing sentinel node mapping versus systematic pelvic lymphadenectomy (with and without para-aortic lymphadenectomy). Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard methods. Overall, the charts of 242 patients with high-intermediate and high-risk endometrial cancer were retrieved. Data on 73 (30.1%) patients undergoing hysterectomy plus sentinel node mapping were analyzed. Forty-two (57.5%) and 31 (42.5%) patients were classified in the high-intermediate and high-risk groups, respectively. Unilateral sentinel node mapping was achieved in all patients. Bilateral mapping was achieved in 67 (91.7%) patients. Three (4.1%) patients had site-specific lymphadenectomy (two pelvic areas only and one pelvic plus para-aortic area), while adjunctive nodal dissection was omitted in the hemipelvis of the other three (4.1%) patients. Sentinel nodes were detected in the para-aortic area in eight (10.9%) patients. Twenty-four (32.8%) patients were diagnosed with nodal disease. A propensity-score matching was used to compare the aforementioned group of patients undergoing sentinel node mapping with a group of patients undergoing lymphadenectomy. Seventy patient pairs were selected (70 having sentinel node mapping vs. 70 having lymphadenectomy). Patients undergoing sentinel node mapping experienced similar 5-year disease-free survival (HR: 1.233; 95%CI: 0.6217 to 2.444; p = 0.547, log-rank test) and 5-year overall survival (HR: 1.505; 95%CI: 0.6752 to 3.355; p = 0.256, log-rank test) than patients undergoing lymphadenectomy. Sentinel node mapping does not negatively impact 5-year outcomes of high-intermediate and high-risk endometrial cancer. Further prospective studies are warranted.

Feasibility of ERAS guidelines for cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CRS-HIPEC): An international multicenter study

Enhanced Recovery After Surgery (ERAS) protocols aim to optimize perioperative care and improve recovery after major surgery. While ERAS pathways are well established in several oncologic disciplines, their feasibility and consistency in the setting of cytoreductive surgery, with or without hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC), remain uncertain due to the complexity and heterogeneity of these procedures. A prospective multicenter observational study was conducted across 10 expert CRS-HIPEC centers to assess the feasibility and real-world implementation of the ERAS Society guidelines for cytoreductive surgery, with or without hyperthermic intraperitoneal chemotherapy. Perioperative practices were compared before (PRE-ERAS) and after (POST-ERAS) structured ERAS guideline implementation. ERAS adherence, clinical outcomes, and predictors of 90-day postoperative complications and prolonged length of stay were analyzed using multivariable logistic regression models. In addition, a predefined subgroup analysis compared outcomes between ovarian and non-ovarian primary tumors. Between 2021 and 2022, 497 patients were included (PRE-ERAS: 288; POST-ERAS: 209). Baseline characteristics were similar except for more ovarian primaries in POST-ERAS (26.4% vs 44%, p = 0.004). POST-ERAS patients showed higher adherence to anemia screening (60% vs 69%, p = 0.042), carbohydrate loading (4% vs 30%, p 70% ERAS adherence (OR 0.19, 95% CI 0.06-0.54, p = 0.003) predicted fewer complications. Ovarian primary (OR 0.50, 95% CI 0.28-0.87, p = 0.016), >70% adherence (OR 0.33, 95% CI 0.12-0.82, p = 0.025), and POST-ERAS status (OR 0.61, 95% CI 0.37-0.99, p = 0.046) correlated with shorter LOS. ERAS implementation for CRS ± HIPEC shortened hospital stay but remained incomplete and was associated with increased readmissions, without reducing complication rates. These findings highlight the need to focus on a pragmatic set of high-impact ERAS elements to improve feasibility in complex cytoreductive surgery.

Enhancing surgical precision in ovarian cancer with FRα-fluorescence-guided surgery

Complete cytoreduction is a key prognostic factor in advanced ovarian cancer. Folate receptor alpha (FRα)-targeted intraoperative fluorescence imaging has emerged as a promising tool to enhance identification of tumor localization. Agents like pafolacianine (OTL38) and EC17 improve real-time visualization of malignant lesions, overcoming limitations of conventional methods relying on visual inspection and palpation. we conducted a systematic review to evaluate the safety, efficacy, and feasibility of FRα-targeted fluorescence imaging in ovarian cancer surgery. Studies were identified through comprehensive searches in PubMed, Scopus, and Web of Science. Clinical and preclinical studies assessing FRα-targeted agents with near-infrared or other fluorescence modalities were included. Bias risk was assessed using the Cochrane Risk of Bias Tool for randomized trials and the Newcastle-Ottawa Scale for non-randomized studies. Eleven studies, including clinical and preclinical trials, were analyzed. OTL38 significantly improved lesion detection, identifying additional malignant lesions in 33 % of patients undergoing debulking surgery and enhancing detection by 29 % over standard methods, with sensitivity exceeding 85 %. EC17, assessed in smaller studies, identified 16 % more malignant lesions undetected by conventional methods, though autofluorescence was a challenge. Adverse events, predominantly mild, included nausea, vomiting, and transient skin flushing. FRα-targeted imaging may enhance lesion detection during cytoreductive surgery, increasing resection completeness. While EC17 shows feasibility, larger trials support the potential of OTL38. Future research should optimize imaging agents to reduce autofluorescence and assess their impact on survival outcomes.

Iron deficiency restrains short-term recovery in patients undergoing surgery for advanced ovarian cancer

Patients with advanced ovarian cancer (AOC) who undergo primary and interval debulking surgery are often anemic at diagnosis, with iron deficiency being the most common cause. The aim was to investigate whether preoperative anemia and iron deficiency impact short-term recovery. This retrospective cohort study included 262 patients with AOC who underwent surgery at Skane University Hospital Lund, Sweden, between January 2020 and December 2023. Patients were divided into four groups, according to preoperative anemia and iron deficiency. Iron deficiency was defined as transferrin saturation (TSAT) < 0.20. Severe complications were defined as Clavien-Dindo (CD) grade ≥3. Logistic regression analyses were used to investigate the difference between patients with and without iron deficiency. Among patients with iron deficiency anemia, 24 % of patients had more than 1 cm of residual tumor at the end of surgery, compared to 6-8 % of patients with no anemia and/or no iron deficiency, (p 0.005). The rate of severe complications (CD ≥ 3) was higher for patients with iron deficiency, odds ratio 2.47 (95 % CI 1.11-5.50), than for patients with no iron deficiency, adjusted for the Aletti score, operating time and hemoglobin (Hb) level. There was no difference between groups regarding length of hospital stay. Patients with iron deficiency anemia, were less likely to undergo radical or optimal surgery. Severe postoperative complications were more common in patients with iron deficiency, with or without anemia. These analyses indicate that iron deficiency is associated with more advanced disease and complex surgical procedures.

Is less already enough? Minimally invasive interval debulking surgery for advanced ovarian cancer

Minimally invasive surgery (MIS), including laparoscopy and robotic-assisted techniques, has increasingly been explored as an alternative to laparotomy for interval debulking surgery (IDS) following neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian cancer (EOC). This systematic review evaluates the current evidence on the surgical feasibility, patient selection, perioperative outcomes, and oncological safety of MIS in this setting. Following PRISMA guidelines, a systematic search of PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov was conducted for studies published between January 2015 and June 2025. Eligible studies included prospective and retrospective cohorts, randomized trials, and meta-analyses reporting outcomes of MIS for IDS in FIGO stage III-IV EOC patients after NACT. Data extraction and risk of bias assessment were independently performed by two reviewers. Sixteen studies involving 9299 patients were included. MIS demonstrated high rates of complete cytoreduction (R0: 85-100 %) in selected patients, with significantly lower estimated blood loss, shorter hospital stays, fewer major complications, and earlier resumption of chemotherapy compared to open surgery. Operative times were generally longer, and conversion rates varied by tumor burden and selection criteria. Oncologic outcomes, including progression-free and overall survival, were comparable between MIS and laparotomy across multiple studies. Robotic-assisted IDS showed similar feasibility and outcomes, but evidence for this approach was mainly derived from small, retrospective cohorts. In appropriately selected patients and experienced centers, MIS for IDS appears to be a feasible and oncologically safe alternative to open surgery, offering meaningful perioperative benefits. Further randomized studies are needed to confirm long-term oncological equivalence.

Robotic single-port (da Vinci SP) versus multiport (da Vinci Xi) for the treatment of atypical endometrial hyperplasia and endometrial cancer: A multi-institutional comparison of surgical outcomes

The da Vinci SP robotic platform offers a novel single-port approach for minimally invasive surgery. Despite its potential, data on its safety and performance in gynecologic oncology remain limited. We aimed to compare surgical outcomes of da Vinci SP versus da Vinci Xi systems in the staging of endometrial cancer (EC). This is a multi-institutional study. Data of consecutive patients with apparent early-stage EC or atypical endometrial hyperplasia who underwent robotic surgery between January 2023-March 2025 were collected. The primary outcome was to compare the surgical outcomes between da Vinci SP and da Vinci Xi. A total of 189 patients were included: 97 (51.3 %) underwent SP surgery and 92 (48.7 %) Xi. The median (range) of operative time, estimated blood loss, and postoperative hospital stay were comparable for SP and Xi groups (140 [70-296] vs. 143 [60-297] min, p = 0.66, 40 [0-250] vs. 64 [0-1300] mL, p = 0.12, 3 [1-11] vs. 3[1-10] days, p = 1). Docking time was significantly shorter in the SP group (10 [4-31] vs. 12 [7-30] min for SP and Xi, respectively, p = 0.004). Intraoperative or post-operative complications rates were comparable (p = 0.30 and p = 0.14,respectively). The patient-reported pain score was significantly lower at 12h and 24h in the Xi group (p = 0.001), while was comparable at 48h after surgery (p = 1). The da Vinci SP system appears to be non-inferior to the multiport da Vinci Xi for surgical staging of early-stage EC. Comparable perioperative outcomes support its clinical use, although patient selection criteria and long-term results require further investigation.

Pattern of recurrence in endometrial cancer. The murderer always returns to the scene of the crime

Endometrial cancer recurrence occurs in about 18 % of patients. This study aims to analyze the pattern recurrence of endometrial cancer and the relationship between the initial site of primary disease and the relapse site in patients undergoing surgical treatment. We retrospectively reviewed all surgically treated patients with endometrial cancer selecting those with recurrence. We defined primary site disease as uterus, lymph nodes, or peritoneum according to pathology analysis of the surgical specimen. The site of recurrence was defined as vaginal cuff, lymph nodes, peritoneum, and parenchymatous organs. Our primary endpoint was to correlate the site of initial disease with the site of recurrence. The study enrolled 1416 patients. The overall recurrence rate was 17,5 % with 248 relapses included in the study. An increase of 9.9, 5.7, and 5.7 times in the odds of relapse on the lymph node, peritoneum, and abdominal parenchymatous sites respectively was observed in case of nodal initial disease (p < 0.001). A not significant difference in odds was observed in terms of vaginal cuff relapse (OR 0.9) between lymph node ad uterine primary disease (p = 0.78). An increasing OR of 8.7 times for nodal recurrences, 46.6 times for peritoneum, and 23.3 times for parenchymatous abdominal recurrences were found in the case of primary peritoneal disease (p < 0.001). Endometrial cancer tends to recur at the initial site of the disease. Intraoperative inspection of the adjacent sites of primary disease and targeted instrumental examination of the initial sites of disease during follow-up are strongly recommended.

Sentinel lymph node biopsy in endometrial cancer: When, how and in which patients

The role of nodal dissection in patients with endometrial cancer has been intensively studied in several studies. Historically, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess potential nodal involvement and consequently define the appropriate stage of the tumor. Over the last years, sentinel node biopsy (SLNB) has been introduced as a more targeted alternative to lymph node dissection for lymph node staging and it has become popular among gynecologic oncologists. However, no level A evidence is still available, and several features of the SLNB technique have been matter of discussion among clinicians and a universally accepted methodology is still not currently available. This narrative review aims to summarize the body of knowledge on SLNB to offer the reader a complete picture about the evolution of this technique over the last decades.

Survival and perioperative outcomes of pelvic exenteration in primary advanced and recurrent endometrial carcinoma: A systematic review and meta-analysis

To assess survival and perioperative complications and mortality of pelvic exenteration (PE) in recurrent and advanced endometrial carcinoma (EC) patients. A systematic review and a meta-analysis was performed searching 7 electronic databases from their inception to May 2024 for all peer-reviewed studies that reported as a study outcome at least the 5 years-overall survival (OS) of PE in recurrent and/or advanced EC patients. Our outcomes were 5 year-OS from PE as primary outcome, and all extractable outcomes about PE survival [overall OS, 5 year- and overall disease specific survival (DSS), 5 year- and overall progression free survival (PFS)] and perioperative mortality and complications. Rates of survival outcomes and perioperative mortality and complications were calculated as individual and pooled estimates, with 95 % confidence intervals (CI). Subgroup analyses were planned for all study outcomes based on recurrent or advanced EC, separately. 6 studies with 166 patients were included. In women underwent PE for advanced or recurrent EC, pooled rate was: 41.7 % (95 % CI: 25.6-57.8 %) for 5 year-OS; 30.4 % (95 % CI: 14.9-45.8 %) for 5 year-DSS; 26.6 % (95 % CI: 10.6-42.5 %) for overall DSS; 51.8 % (95 % CI: 25.6-78.0 %) for 5 year-PFS; 9.7 % (95 % CI: 5.7-16.1 %) for perioperative mortality; 56.1 % (95 % CI: 32.3-76.4 %) for perioperative complications. Subgroup analyses were suitable exclusively in the "recurrent EC" subgroup and showed even worsened outcomes. In women with advanced or recurrent EC, PE shows not encouraging survival outcomes, with relatively high rates of perioperative mortality and complications. These outcomes further worsened in the subgroup of only recurrent EC. However, they should be confirmed by more updated studies.

Revisiting the paradigm: Asymptomatic high-grade endometrial cancer diagnosis is not associated with improved outcomes

To compare the survival of women with high grade endometrial cancer between asymptomatic and women presenting bleeding symptoms. An Israel Gynecologic Oncology Group multi-center retrospective cohort study. The study included women who underwent surgery for high-grade endometrial cancer. We compared outcomes between women presenting with postmenopausal bleeding and asymptomatic women diagnosed with high-grade endometrial cancer. Recurrence-free, disease-specific and overall survival were assessed using the Kaplan Meier method and compared using the log-rank test. Risk factors for recurrence and death were evaluated using Cox regression analysis; the primary exposure variable assessed was the presence of postmenopausal bleeding. Of the 584 women with high-grade histology, 498 (85.3 %) presented with postmenopausal bleeding and 86 (14.7 %) were asymptomatic. The median follow-up was 52 months (12-120 months). There was no difference in recurrence-free survival between women diagnosed with postmenopausal bleeding and asymptomatic women (70.1 % vs.64.6 % at 5 years, p = 0.35, respectively). There were no significant differences in disease-specific survival (66.3 % vs. 64.2 % at 5 years, p = 0.83) or in overall survival (56.4 % vs. 58 % at five years, p = 0.55) between study groups. The multivariate Cox regression analysis did not reveal any significant association between postmenopausal bleeding and survival. In this study, the diagnosis of high-grade endometrial cancer in asymptomatic women was not associated with earlier disease stage at diagnosis. In women with incidental ultrasonographic findings of a thickened endometrium or polyp, routine invasive evaluation may be unnecessary.

Fertility-sparing management of low-grade endometrial stromal sarcoma: A systematic review of oncologic and reproductive outcomes

Low-grade endometrial stromal sarcoma (LG-ESS) is a rare malignancy and the standard of care, precludes future childbearing. Although fertility-sparing treatment (FST) may be considered in carefully selected patients, high-quality evidence regarding its efficacy and safety is limited. This review aims to systematically evaluate the oncologic and reproductive outcomes associated with conservative treatment for LG-ESS. Pubmed Database, Scopus Database and Embase Database were screened in September 2024 from the first publication about women with LG-ESS treated with a surgical FST. We included the studies containing data about oncologic, and reproductive outcomes. This study adheres to PRISMA guidelines and is registered with PROSPERO (CRD42024605140). The quality of the studies was assessed using the Newcastle-Ottawa scale. 9 studies fulfilled inclusion criteria, and 89 patients were analyzed. Recurrence was observed in 51 out of 89 patients (57.3 %) with a mean recurrence-free interval ranging between 3 and 40.5 months. A mortality rate of 1.1 % was observed, with a mean follow-up duration ranging from 38.5 to 84.5 months. The overall pregnancy rate was 41.5 % and the live birth rate was 78.1 %. The preterm delivery rate was 8 % and 3.9 % of patients required assisted reproduction technology. Considering the limitations of the available evidence, FST in women with LG-ESS carries a relatively high risk of tumor relapse, though it does not increase the risk of death. Fertility outcomes seem to be encouraging. Resection of the malignant uterine lesion combined with adjuvant hormonal treatment may be considered for selected early-stage patients, with close follow-up.

Detection rate of sentinel lymph nodes in early-stage endometrial cancer according to age

Sentinel lymph node (SNL) mapping plays a crucial role in staging patients with an apparent early-stage endometrial cancer. Older age may be associated with lower detection rates due to factors such as decreased lymphatic flow; but consensus is lacking. This study aims to evaluate the impact of age on the SNL detection rate in patients undergoing minimally invasive surgical staging for endometrial cancer. This multicenter retrospective study included apparent early-stage endometrial cancer patients undergoing minimally invasive surgical staging, including SLN mapping across four ESGO-accredited centers (2020-2023). Patients were categorized into two age groups: <65 years, defined as younger adults and ≥65 years, defined as older adults. Univariate and multivariate logistic regression models were used to identify predictors of bilateral mapping. Overall, 642 patients were identified: 342 (53.3%) patients were classified as younger adults and 300 (46.7%) as older adults. The overall bilateral SLN detection rate was 89.3%, with no or unilateral detection in 10.7% of patients. Older adults had a significantly lower bilateral detection rate than younger adults (85.0% vs. 93.0%, p = 0.005). Multivariate analysis identified age ≥65 years as the only independent predictor of failed bilateral mapping (OR 2.2, 95 % CI 1.3-3.8, p = 0.003). Other clinical, surgical, and pathological factors were not associated with mapping failure. Age ≥65 is independently associated with decreased bilateral SLN detection in early-stage endometrial cancer. Nevertheless, SLN biopsy remains a feasible and reliable staging method in older adults when performed using standardized techniques by experienced surgeons.

Prognostic significance of molecular classification in high-risk endometrial cancer patients undergoing sentinel lymph node mapping

The adoption of selective sentinel lymph node biopsy (SLNB) as a viable alternative to lymphadenectomy, along with the redefinition of nodal risk groups based on molecular classification, has significantly changed the management of early-stage, high-risk preoperative endometrial cancer. A retrospective, multicenter study was conducted under the auspices of the Spanish Gynecologic Oncology Group to evaluate recurrence rates and oncologic outcomes in patients stratified by molecular risk. Three groups were compared: SLNB alone (G1), SLNB combined with pelvic and/or para-aortic lymphadenectomy (G2), and pelvic and/or para-aortic lymphadenectomy without SLNB (G3). The primary endpoint was recurrence rate; secondary endpoints included disease-free survival (DFS), overall survival (OS), recurrence patterns. A total of 221 patients from 14 centers were included, with a median follow-up of 24.4 months (IQR 17-42). Forty-four patients (19.9 %) experienced recurrence. Relapse rates were 15.4 % in G1, 15.8 % in G2, and 22.2 % in G3 (p = 0.479). DFS rates were 84.6 % in G1, 84.1 % in G2, and 77.8 % in G3 (p = 0.56). OS rates were 94.2 %, 90.9 %, and 92.6 %, respectively (p = 0.651). Among the 44 patients with documented recurrence, seven had nodal recurrences, with only two occurring in the group managed with SLNB alone. In this study, patients with early-stage, high-risk preoperative endometrial cancer-classified by molecular subgroups-showed no significant differences in relapse rates, disease-free survival, or overall survival across the three management strategies. Further prospective studies with longer follow-up are warranted to validate these preliminary findings.

Is there a role for the sentinel lymph node in endometrial atypical hyperplasia? Insights from an ESGO-accredited Institution

This study investigates the outcomes of patients with premalignant endometrial findings on biopsy who underwent hysterectomy with sentinel lymph node (SLN) excision and were subsequently diagnosed with endometrial cancer (EC). It aims to highlight the role of nodal assessment in guiding postoperative treatment strategies. Additionally, the study compares surgery complication rates between patients who underwent SLN mapping and those who did not. This retrospective, observational, single-center study was conducted at Udine Hospital between April 2021 and July 2024. 63 patients diagnosed with atypical hyperplasia on endometrial biopsy who underwent hysterectomy and bilateral salpingo-oophorectomy, with or without SLN mapping, were included. All procedures were performed using minimally invasive surgery. Of the 63 patients, 35 (55.6 %) had confirmed atypical hyperplasia on uterine pathology, while 23 (36.5 %) were diagnosed with EC on final pathology. Of the patients who underwent SLN mapping, 18 (43 %) received a final diagnosis of EC and were accurately staged and treated accordingly. In contrast, within the group of patients treated without SLN mapping, 5 (24 %) were diagnosed with EC on final pathology and didn't receive proper staging. No nodal metastases were found in both groups. There was no statistically significant difference in operating time and complication rates between the two groups (with or without SLN mapping), further supporting the procedure's safety. This study's findings underscore the significance of incorporating SLN mapping into hysterectomy and bilateral salpingo-oophorectomy for patients with atypical hyperplasia. This approach enhances accurate staging for patients diagnosed with endometrial cancer on final pathology.

Endometrioid borderline ovarian tumour: A multicentre analysis from the MITO-14 study

The Endometrioid Borderline ovarian tumor (EBOT) is the third most common histological subtype of borderline ovarian tumors. Due to the low incidence of disease, literature is scanty about the prognosis and management of this entity. The aim of this study is to evaluate clinical, surgical characteristics and risk of recurrence in EBOT patients with the experience of the MITO group (Multicenter Italian Trials in Ovarian Cancer). Clinicopathological data from patients with EBOT were retrospectively collected. Descriptive statistics were used to characterize the patient population. Clinicopathological features and treatment variables were evaluated for association with relapse. Fifty-six patients were recruited for this study. Median age of the patient at diagnosis was 49 years (range 34-84). Nineteen women (34 %) had a previous history of endometriosis. Forty-nine (87 %) were with unilateral tumors. Radical surgery was performed for 36 patients and FSS for 20 patients (14 USO, 5 Cystectomy, 1 both procedures). Three patients (6,5 %) had concomitant endometrial cancer (EC) and 4 (8,5 %) had atypical endometrial hyperplasia. Median time to follow up was 89 months (range 3-202). No disease-specific death was observed. During follow up time, 4 patients developed recurrent disease. EBOT is characterized by a good prognosis. Most EBOT tumors are stage I and unilateral. FSS is feasible if performed by experienced surgeons. However, uterine curettage should be done in case of uterine preservation.

Safety of minimally invasive surgery in early-stage endometrial cancer: A systematic Retrospective analysis based on 2023 FIGO staging system☆

To evaluate the efficacy and safety of minimally invasive surgery in the management of early-stage endometrial cancer. This study involved a retrospective analysis of clinical data and prognosis for 382 patients diagnosed with early-stage endometrial cancer (stage I and II) who underwent either laparoscopy or laparotomy at Shanghai Sixth People's Hospital between June 2011 and November 2022. The postoperative pathological diagnoses were based on 2023 FIGO staging system. A total of 189 patients underwent laparotomy and 193 patients underwent laparoscopic surgery. The intraoperative blood loss and postoperative complications (pulmonary embolism, pulmonary infection, intestinal obstruction, suboptimal healing or infection of surgical incision) rates in laparoscopy group was significantly lower than that in laparotomy group (P  0.05). By integrating the new FIGO staging with risk factors for stratified analysis, the results still indicated that there were no significant differences in DFS or OS between laparoscopy group and laparotomy group across all risk stratification (P > 0.05). In the management of early-stage EC, laparoscopy significantly reduces intraoperative blood loss and postoperative complication rates, which facilitate patient recovery without adversely affecting recurrence or survival outcomes.

Oncologic and pregnancy outcomes of fertility-sparing treatment with medroxyprogesterone acetate in women with premalignant and malignant endometrial lesions: A case series

Current trends of delaying childbearing and the increasing incidence of endometrial cancer in nulliparous woman necessitate research and development of fertility sparing treatments. Hormonal therapy with progestins offers an alternative to surgical treatment for a select group of patients of reproductive-age, who wish to preserve their reproductive potential. The study evaluates the effectiveness of medroxyprogesterone acetate therapy in patients with early-stage endometrial cancer, atypical endometrial hyperplasia or atypical polypoid adenomyoma, seeking to preserve fertility. This prospective case series encompasses nine patients (6 with endometrial cancer, 2 with atypical endometrial hyperplasia and 1 with atypical polypoid adenomyoma) treated in the period between 2015 and 2022 with high-dose medroxyprogesterone acetate therapy. Treatment and monitoring were conducted at the University Clinic for Gynecology and Obstetrics in Skopje, R. Macedonia, with clinical assessments carried out every three to six months via hysteroscopy with endometrial biopsy or exploratory curettage. Primary response was achieved in 4 patients (44.4 %). Secondary response was achieved in the remaining 5 cases (55.6 %). Therefore, all 9 patients (100 %) showed complete response to progestin treatment in the time interval 3-9 months. Recurrence occurred in 3 cases (33.3 %) after follow-up of 15, 33 and 84 months, respectively. During the study period, 2 patients (22.2 %) underwent definitive surgery with hysterectomy because of disease recurrence (both with endometrial cancer, stage IA). Fertility was achieved in 1 patient (11.1 %), who had a full-term delivery with caesarean section. Conservative treatment approach to patients with endometrial cancer aiming to preserve fertility can be safe and have acceptable outcomes in terms of oncologic response as well as pregnancy results, with high-dose medroxyprogesterone acetate therapy being an effective option. The selection of endometrial cancer patients, for whom fertility-sparing progestin therapy is appropriate, is of great importance to achieve the best outcomes. Continuous and careful monitoring of patients undergoing conservative treatment is essential, due to the risk of disease recurrence and progression.

Short- and long-term outcomes of vaginal, laparoscopic, and robotic-assisted surgery in “oldest old” endometrial cancer

To assess the safety and long-term effectiveness of minimally invasive approach in managing "oldest old" endometrial cancer patients. This is a retrospective cohort, multi-institutional study. Consecutive patients, treated between 2000 and 2020, with apparent early-stage endometrial cancer patients, aged ≥85 years. Surgery-related outcomes of robotic-assisted, laparoscopic, and vaginal surgery were compared. Survival was evaluated in patients with at least 3-year follow-up data. Charts of 82 endometrial cancer patients "oldest old" were retrieved. Intermediate-high and high-risk endometrial cancer patients accounted for 26 (31.7 %) and 17 (20.7 %), respectively. In total, 12 (15 %), 45 (55 %), and 25 (30 %) patients underwent robotic-assisted, laparoscopic, and vaginal surgery, respectively. Looking at surgery-related outcomes, robotic-assisted surgery correlated with a longer operative time (p < 0.001) and longer length of hospital stay (p = 0.002) in comparison to laparoscopic and vaginal approaches. Overall, seven (8.5 %) conversions from the planned approach occurred. The surgical approach did not influence disease-free survival (p = 0.6061) and overall survival (p = 0.4950). Via multivariate analysis, only serosal/adnexal invasion correlated with the risk of death (HR: 3.752, p = 0.038). All three minimally invasive approaches are safe and effective methods for managing endometrial cancer in the oldest old population. Chronological age, per se, should not be considered a contraindication for receiving minimally invasive surgery.

Exploring the protein signature of endometrial cancer: A comprehensive review through diverse samples and mass spectrometry-based proteomics

Endometrial cancer (EC) is increasing incidence among women, and it constitutes a health problem for women globally. An important aspect of EC management involves the use of protein biomarkers for early detection and monitoring. Protein biomarkers allow the identification of high-risk patients, the detection of the disease in its early stages, and the assessment of treatment responses. Mass spectrometry (MS)-based proteomics offers robust analytical techniques and a comprehensive understanding of proteins. Proteomics methods allow scientists to investigate both the quantities and functions of proteins. Thus, it provides valuable insights into how proteins are altered under different conditions. This review summarizes recent advances in MS-based proteomic biomarker discovery for EC, focusing on different sample types and MS-based techniques used in clinical studies. The review emphasized in detail the most commonly used key sources such as blood, urine, vaginal fluids and tissue. Furthermore, MS-based proteomics techniques such as untargeted, targeted, sequential window acquisition of all theoretical mass spectra (SWATH-MS) and mass spectrometry imaging used in the discovery and validation/validation phases were evaluated. This review highlights the importance of biomarker discovery and clinical translation to improve diagnostic and therapeutic outcomes in EC. It aims to provide a comprehensive overview of MS-based proteomics in EC, guiding future research and clinical applications.

Hysteroscopic endometrial tumor localization and sentinel lymph node mapping. An upgrade of the hysteroscopic role in endometrial cancer patients

Given the growing interest in sentinel node mapping (SLN) biopsy in Endometrial Cancer (EC) patients, many efforts have been made to maximize the SLN bilateral detection rate. However, at present, no previous research assessed the potential correlation between primary EC location in the uterine cavity and SLN mapping. In this context, this study aims to investigate the possible role of intrauterine EC hysteroscopic localization in predicting SLN nodal placement. EC patients surgically treated from January 2017 to December 2021 were retrospectively analyzed. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN mapping. During hysteroscopy, the location of the neoplastic lesion was described as follows: uterine fundus (comprising the most cranial portion of the uterine cavity up to the tubal ostium including the cornual areas), corpus uteri (from the tubal ostium to the inner uterine orifice), and diffuse (when the tumor invades more than 50% of the uterine cavity). Three hundred ninety patients met the inclusion criteria. The tumor pattern diffused to the whole uterine cavity was statistically associated with SLN uptake on common iliac lymph nodes (OR 2.4, 95%CI 1-5.8, p = 0.05). Patients'age is an independent factor associated with SLN failure (OR: 0.95, 95%CI 0.93-0.98, p < 0.001). The study showed a statistically significant association between EC hysteroscopically spread throughout the whole uterine cavity and SLN uptake at the common iliac lymph nodes. Furthermore, patient age negatively affected the SLN detection rate.

A population-based risk scoring system to individualize adjuvant treatment for stage IIIC endometrial cancer patients after surgery

To develop a risk scoring system to tailor the adjuvant treatment for stage IIIC EC patients after surgery. Data source was from the Surveillance, Epidemiology, and End Results (SEER) registry, where 3251 post-operative stage IIIC EC patients with different adjuvant treatment were included. Cox regression analysis was used to identify risk factors. The exp (β) of each independent risk factors generating from the cox analysis was used to construct the risk scoring system, which was further utilized to divide the patients into different risk subgroups and the efficacy of different adjuvant modalities in each risk subgroups would be compared accordingly. Six independent risk factors were identified to develop the scoring system, which further divided the patients into three risk subgroups based on the total risk score (Low-risk≤8.46, 8.47 ≤ Middle-risk≤9.94, High-risk≥9.95). This study revealed that CRT was not superior to RT alone (HR:1.208, 95%CI: 0.852-1.741; P = 0.289) or CT alone (HR:1.260, 95%CI: 0.750-2.116; P = 0.382) in Low-risk subgroup. We also observed that CRT had a survival advantage over other treatment modalities in the Middle-risk subgroup (All P < 0.001), but CRT and CT alone to be superimposable in the High-risk subgroup (HR: 1.395, 95%CI: 0.878-2.216; P = 0.159). A risk scoring system has been developed to tailor the adjuvant treatment for stage IIIC EC patients after surgery, where RT or CT alone could be a substitute for CRT in Low-risk patients and CT alone was a potential alternative for High-risk patients while CRT remained to be the optimal choice for the Middle-risk patients.

Hysterectomy alone vs. hysterectomy plus sentinel node mapping in endometrial cancer: Perioperative and long-term results from a propensity-score based study

To compare outcomes after hysterectomy and hysterectomy plus sentinel node mapping (SNM) in endometrial cancer (EC) patients. This is a retrospective study, collecting data of EC patients treated between 2006 and 2016 in nine referral centers. The study population included 398 (69.5%) and 174 (30.5%) patients having hysterectomy and hysterectomy plus SNM. As the results of the adoption of a propensity-score matched analysis, we selected two homogeneous cohort of patients (150 having hysterectomy only vs. 150 having hysterectomy plus SNM). The SNM group had a longer operative time, but did not correlate with length of hospital stay and estimated blood loss. Overall severe complication rates were similar between groups (0.7% in the hysterectomy group vs. 1.3% in the hysterectomy plus SNM group; p = 0.561). No lymphatic-specific complication occurred. Overall, 12.6% of patients having SNM were diagnosed with disease harboring in their lymph nodes. Adjuvant therapy administration rate was similar between groups. Considering patients having SNM, 4% of patients received adjuvant therapy on the basis of nodal status alone; all the other patients received adjuvant therapy also on the basis of uterine risk factors. Five-year disease-free (p = 0.720) and overall (p = 0.632) survival was not influenced by surgical approach. Hysterectomy (with or without SNM) is a safe and effective method for managing EC patients. Potentially, these data support the omission of side specific lymphadenectomy in case of unsuccessful mapping. Further evidence is warranted in to confirm the role SNM in the era of molecular/genomic profiling.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis

The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer. We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software. This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03). This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.

A large multicenter propensity match study of sentinel lymph node biopsy feasibility in endometrioid variants of endometrial cancer

Sentinel lymph node (SLN) biopsy algorithm has been routinely applied in all endometrial endometrioid tumors, however, no studies analyzed the feasibility of SLN mapping in endometrioid variants (EV), which included villoglandular, secretory, ciliated cell, mucinous, and squamous differentiation. This study aimed to demonstrate the feasibility of SLN biopsy in EV of EC. All patients undergoing minimally invasive surgical treatment for early-stage EC were included in the study. Patients were divided into 2 study groups: Group 1 which included patients with EV, and Group 2 which included patients with typical endometrioid histology. A propensity match analysis was performed according to age (≥65 years vs. no), BMI (≥30 kg/m After a 1:5 propensity-matched analysis, a total of 458 patients were identified (Group 1 n = 77, Group 2 n = 381). Overall detection rate was not statistically significant between the EV and the typical endometrioid group (94.8% vs. 92.4%, p = 0.319). Furthermore, neither bilateral nor unilateral detection rate was different between the two groups (70.1% vs. 74.8%, p = 0.267, and 23.4% vs. 17.8%, p = 0.120). BMI ≥30 kg/m SLN research/detection for EV of endometrial cancer is a feasible and highly sensitive technique. Obesity was confirmed to be a risk factor for SLN failure.

Pattern of recurrence in patients with endometrial cancer: A retrospective study

Increased ultrasonographic endometrial thickness is associated with poor survival in patients with endometrial cancer: An Israel gynecologic oncology group study

We aimed to assess the association of pre-operatively evaluated ultrasonographic endometrial thickness with outcomes of patients with endometrial cancer. An Israel Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer who underwent surgery between 2002 and 2014 in one of eleven academic centers. Patients were categorized by endometrial thickness into two groups: ≤20 mm and >20 mm. Clinical and pathological features were compared using Student T-test for continuous variables and Chi-square or Fisher's exact test for categorical variables. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations. 1113 patients in whom endometrial thickness data was recorded were the subject of this study and included 2 groups: ≤20 mm (n = 930), >20 mm (n = 183). The median follow-up was 52 months (range 12-120 months). Patients with endometrial thickness >20 mm had significantly lower recurrence-free survival (log rank, p 20 mm remained independently associated with an increased hazard of recurrence and death (HR = 1.77, 95% CI 1.07-2.96, p = .03 for recurrence; and HR = 1.68; 95% CI 1.07-2.65; p = .03 for overall survival). In patients with endometrial cancer, endometrial thickness>20 mm as measured preoperatively by ultrasound, is independently associated with decreased recurrence-free and overall survival. This finding suggests that thick endometrium may be considered as one of the risk factors for poor prognosis.

Pathological features, immunoprofile and mismatch repair protein expression status in uterine endometrioid carcinoma: focus on MELF pattern of myoinvasion

Microcystic, elongated, and fragmented (MELF) pattern of myoinvasion has been related with increased risk of lympho-vascular space invasion (LVSI) and lymph node metastasis. We analysed a cohort of endometrioid endometrial carcinomas (EECs) to examine the relationships between the MELF pattern of invasion and the clinico-pathological and immunohistochemical features of EEC. 129 EECs were evaluated for the presence of MELF pattern and immunohistochemically tested for Mismatch repair (MMR) proteins, p16, p53 and beta-catenin. We observed 28 MELF + EECs and 101 MELF- EECs. LVSI was observed in 20 MELF + cases and in MELF- tumors. Lymph-node metastases were observed in 7 MELF + cases (2 macrometastases, 3 micrometastases and 2 ITCs). None of the MELF- cases showed micrometastases or ITCs, 18 cases had macrometastatic lymph-nodes. Statistical analysis showed that MELF + tumors carry an increased risk of developing nodal metastasis independent of tumor dimension and LVSI. Loss of MMR proteins expression was observed in 11 MELF + cases and 45 MELF- cases, respectively. Our data showed a higher frequency of immunohistochemical MLH1-PMS2 loss in MELF- pattern of invasion (32.67% of MELF- cases vs 21.43% of MELF + cases) but a higher prevalence of MSH2-MSH6 loss in MELF + pattern (7.14% in MELF + population vs 3.96% of MELF- population) CONCLUSIONS: The morphological recognition of MELF pattern is more reliable than immunohistochemical and molecular signatures of EEC in predicting the risk of nodal involvement. The observed higher prevalence of MSH2-MSH6 loss in MELF + group and MLH1-PMS2 loss in MELF- group may suggest a different molecular signature.

Risk reducing surgery with peritoneal staging in BRCA1-2 mutation carriers. A prospective study

International guidelines recommend risk-reducing salpingo-oophorectomy (RRSO) in BRCA1-2 mutations carriers to decrease ovarian cancer occurrence. In this prospective study, we describe the incidence of occult malignancies and the surgical outcomes in asymptomatic BRCA mutation carriers submitted to RRSO. Data on BRCA1-2 carriers undergoing RRSO with peritoneal washing and peritoneal/omental biopsies (PeS), between January 2019 until March 2021, were prospectively collected. A total of 132 patients were enrolled: 74 BRCA1 and 58 BRCA2 mutation carriers. 31.1% women underwent RRSO and PeS (16.2% of BRCA1 and 50% of BRCA2 carriers), while 68.9% patients were submitted also to concomitant hysterectomy. Almost all the procedures (99.2%) were performed by minimally invasive surgery. Postoperative complications occurred in twelve patients (9.1%): 10 in the concomitant hysterectomy group and two complications in the RRSO group. At the final pathological examination, 6 (4.5%) occult carcinomas were diagnosed: 3 fallopian tube carcinomas, one ovarian carcinoma and two serous tubal intraepithelial carcinomas (STICs), with negative PeS. Median age of occult carcinomas patients at RRSO was 54 (range: 48-79) years. The mean follow up was 20 (range: 7-34) months. During the follow up, no primary peritoneal cancer has been diagnosed. Occult pathologic findings in RRSO occurred in 4.5% (3% invasive carcinomas, STIC 1.5%) among our patients. The routine use of peritoneal biopsies does not improve the detection of occult malignancies. Our data confirm the importance of timely performing RRSO in BRCA1-2 carriers.

Assessment of peritoneal metastases with DW-MRI, CT, and FDG PET/CT before cytoreductive surgery for advanced stage epithelial ovarian cancer

Preoperative assessment of peritoneal metastases is an important factor for treatment planning and selection of candidates for cytoreductive surgery (CRS) in primary advanced stage (FIGO stages III-IV) epithelial ovarian cancer (EOC). The primary aim was to evaluate the efficacy of DW-MRI, CT, and FDG PET/CT used for preoperative assessment of peritoneal cancer index (PCI). In this prospective observational cohort study, 50 advanced stage EOC patients were examined with DW-MRI and FDG PET/CT with contrast enhanced CT as part of the diagnostic program. All patients were deemed amenable for upfront CRS. Imaging PCI was determined for DW-MRI, CT, and FDG PET/CT by separate readers blinded to the surgical findings. The primary outcome was agreement between the imaging PCI and PCI determined at surgical exploration (the reference standard) evaluated with Bland-Altman statistics. The median surgical PCI was 18 (range: 3-32). For all three imaging modalities, the imaging PCI most often underestimated the surgical PCI. The mean differences between the surgical PCI and the imaging PCI were 4.2 (95% CI: 2.6-5.8) for CT, 4.4 (95% CI: 2.9-5.8) for DW-MRI, and 5.3 (95% CI: 3.6-7.0) for FDG PET/CT, and no overall statistically significant differences were found between the imaging modalities (DW-MRI - CT, p = 0.83; DW-MRI - FDG PET/CT, p = 0.24; CT - FDG PET/CT, p = 0.06). Neither DW-MRI nor CT nor FDG PET/CT was superior in preoperative assessment of the surgical PCI in patients scheduled for upfront CRS for advanced stage EOC.

Clinical impact of surgical energy device (Caiman®) IN elderly patients with Endometrial Cancer (protocol ID: Cineca)

To investigate the clinical performance of the Caiman® energy device in class A radical laparoscopic hysterectomy (RLH) according to Querleu-Morrow classification, combined with bilateral salpingo-oophorectomy (BSO) and pelvic lymph node assessment in elderly patients with early-stage endometrial cancer (EC), specifically focusing on hemostatic effectiveness and safety. Single-institution, prospective observational study. Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Forty-three women over 65 years with FIGO stage IA or IB endometrioid EC were enrolled from September 2021 to August 2023. Use of Caiman® energy device in RLH combined with BSO and pelvic lymph node assessment in elderly patients. The primary endpoint was operative time, with secondary endpoints including perioperative outcomes and postoperative complications. Results demonstrated a median surgical time of 135 min, with no significant intraoperative complications attributed to the Caiman® device. Postoperative complications were minimal, with no severe complications (Grade 4 or 5) and a median hospital stay of two days. The study highlights the advantages of the Caiman® in enhancing surgical efficiency while minimizing risks for elderly patients, suggesting its potential for improving resource allocation and patient outcomes in oncologic surgery. The findings of this study suggest the feasibility of using the Caiman® device for surgical procedures in elderly patients with early-stage endometrial cancer. Future prospective randomized trials are needed to establish its efficacy compared to traditional surgical methods.

Locally advanced cervical cancer and para-aortic lymphadenectomy: impact of the number of removed lymph nodes, a FRANCOGYN group study

Cervical cancer is the fourth most common cancer worldwide among women. Surgical staging by para-aortic lymph node dissection (PALND) is performed when the cancer is locally advanced (LACC). There are no recommendations concerning the number of lymph node that must be removed during this surgery which hasn't prove is effectiveness concerning survival. We conducted a retrospective multicenter descriptive and comparative study with data from FRANCOGYN group. We included 578 patients with LACC (IB3-IVA FIGO 2028) who underwent a PALND, 190 with <10 nodes and 388 with at least 10 nodes. The primary outcome was to evaluate the impact of the number of lymph nodes removed on the positivity of the staging. The secondary outcomes were to evaluate the impact of the number of lymph nodes removed on the treatment, the morbidity and the survival of the patients. There was no significant difference concerning the positivity of the staging between the two groups with 17,4 % and 16,2 % of positive staging (p = 0,8). There were no significant differences concerning the peri and post operative complications, the modification of the stage and treatment or the OS and DFS. It would appear that para-aortic staging with at least 10 or more nodes does not confer any advantage in terms of positivity and survival over staging with fewer than 10 nodes.

Comedo-like growth pattern in invasive early-stage cervical cancer: A new feature related to parametrial involvement

The standard surgical treatment for early-stage cervical cancer includes hysterectomy and bilateral oophorectomy along the removal of parametrial tissue to achieve surgical radicality. However, in recent years, the role of simple hysterectomy for cervical cancer with favorable prognostic characteristics has been re-evaluated. One of the challenges in early-stage cervical cancer is identifying predictive factors for neoplastic parametrial infiltration and lymph node metastases that cannot be detected during the preoperative assessment. We hypothesized that histological tumor growth patterns may be associated with these features and could thus be useful for the management of apparent early-stage cervical cancer. We identified 3 different histological patterns: the comedo-like, the infiltrative, and the expansive. We analyzed a series of clinic-pathological characteristics to determine the association of eachpatternwith aggressive features. Furthermore, we estimated odd ratios (ORs) in univariate and multivariate analyses for parametrial infiltration and lymph node metastasis. We found that comedo-like pattern is associated to advanced FIGO stages, larger tumor size, lymphovascular space invasion, deeper invasion depth, parametrium involvement, and lymph node metastases. By univariate analysis, comedo-like pattern was statistically associated with both parametrial involvement (OR: 19.3, CI 5.47-68.6, p-value = < 0.001) and lymph node metastases (OR: 4.98, CI 1.71-14.5, p-value = 0.003). By multivariate analysis, the association between comedo-like pattern and parametrial involvement was confirmed (OR: 8.76, CI 2.34-32.75, p-value = 0.01). The specific growth pattern of cervical cancer, assessed in a conization specimen before hysterectomy, can be useful to tailor surgical radicality.

Advancements in uterine sarcoma management: A review

Uterine sarcomas are rare, accounting for 3-7% of uterine malignancies. This review aims to summarize advancements in diagnostics and treatment over the last decade, focusing on innovative imaging techniques, molecular diagnostics, and treatment modalities. Recent diagnostic advancements include enhanced imaging techniques such as MRI and AI-driven algorithms, improving accuracy in differentiating between benign and malignant uterine tumors. Biomarkers like lactate dehydrogenase (LDH) and microRNAs have shown potential in preoperative identification. Treatment strategies continue to evolve, with surgical resection being the cornerstone. The role of lymphadenectomy and adnexectomy varies by histopathological subtype, emphasizing personalized approaches. Adjuvant therapies remain controversial, tailored to patient risk factors and tumor characteristics. Fertility-sparing options are viable for selected patients, though not recommended for high-grade tumors. Significant progress in diagnostic techniques and personalized treatment approaches has improved the management of uterine sarcomas. Future guidelines from major oncology groups are expected to standardize care. Continued research is essential for refining treatment protocols and enhancing patient outcomes.

Impact of surgical variables on residual glandular tissue in risk-reducing mastectomies: Results of a retrospective monocentric study from a center of the German consortium for hereditary breast and ovarian cancer

Residual glandular tissue (RGT) after risk reducing mastectomy (RRME) is associated with a risk of developing breast cancer for women with a familial predisposition. We aim to examine various surgery-related variables to make risk more easily assessable and to aid in decision-making. Pre- and postoperative breast MRI scans from 2006 to 2021 of patients with proven pathogenic mutation were included. The postoperative remaining skin flap was recorded using distance measurements at 8 equally distributed clockwise points and retromamillary. Each breast was volumetrized, as well as existing RGT. Patient-related covariates were further recorded and their influence on RGT was investigated uni- and multivariately. 81 patients (49 with BRCA1, 24 with BRCA2, 9 with other mutations), who were on average 39 years old, had 117 breasts analyzed. The mean follow-up was 71 months. In multivariate analysis, the independent variable skin flap thickness had a positive effect (p ≤ 0.01), while surgeon experience negatively affected RGT (p ≤ 0.05). The incision type was found to impact RGT as well, with nipple-sparing mastectomy (NSM) with inframammary fold incision leading to more RGT (p ≤ 0.01 - p ≤ 0.05), and skin-sparing mastectomy (SSM) with an inverted T incision leading to less (p ≤ 0.01). Different surgical variables have an impact on postoperative RGT, which is an important tool to quantify the risk of developing breast cancer after RRME. In order to effectively consider these variables in future preoperative/intraoperative management, they must be carefully taken into account.

Outcomes of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer progressed after prior poly (adenosine diphosphate-ribose) polymerase inhibitors: A retrospective cohort study

To evaluate the impact of previous poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitor therapy on the effectiveness of secondary cytoreductive surgery (SCS) in patients with platinum-sensitive recurrent ovarian cancer (PSROC). We identified patients with PSROC who underwent SCS at the Cancer Hospital, Chinese Academy of Medical Science, between January 2010 and December 2022. Postoperative complications within 30 days were categorized using the Accordion Severity Grading System. The Kaplan‒Meier method was used to estimate both overall survival (OS) and progression-free survival (PFS), and multivariate analysis was used to identify independent prognostic factors. Of the 265 patients included, 39 received prior PARP inhibitor therapy (Group A), and 226 did not (Group B). The rates of complete resection after SCS did not significantly differ between the two groups (79.5 % for Group A vs. 81.0 % for Group B; p = 0.766). As of December 2023, Group A exhibited a significantly shorter median PFS (14.2 months) than Group B (22.5 months; p = 0.002). Furthermore, the 3-year OS rate was lower in Group A (72.5 %) than in Group B (82.7 %; p = 0.015). The incidence of severe postoperative complications was comparable between Groups A and B (7.7 % vs. 1.8 %; p = 0.061). Multivariate analysis revealed that prior PARP inhibitor therapy significantly reduced the median PFS (hazard ratio (HR) = 4.434; p = 0.021) and OS (HR = 2.076; p = 0.010). SCS for PSROC demonstrated reduced efficacy in patients previously treated with PARP inhibitors compared to those without prior PARP inhibitor treatment.

Safety of fertility-sparing surgery in young women with stage I endometrioid epithelial and mucinous ovarian cancer: A population-based analysis

The aim of this study was to assess the safety of fertility-sparing surgery (FSS) in stage I endometrioid epithelial cancer (EEOC) and mucinous ovarian cancer (MOC). A retrospective case‒controlled study was conducted using the Surveillance, Epidemiology, and End Results (SEER) database, focusing on stage I EEOC and MOC between 2000 and 2016. The effects of FSS on overall survival (OS) were compared using log-rank tests. Univariate and multivariate Cox analyses were performed to control for confounders. The study identified 970 patients with FIGO stage I EEOC and 810 with stage I MOC. Of these patients, 116 (12.0%) EEOC and 268 (33.1%) MOC patients underwent fertility-sparing surgery. The results showed that patients with G3 EEOC had a worse 5-year OS than patients with G1 EEOC (96.1% vs. 90.1%, p = 0.020). IC stage MOC patients had a worse prognosis than IA and IB stage patients (94.9% vs. 88.7%, p = 0.001). FSS did not significantly affect the 5-year OS of patients with EEOC (94.8% vs. 95.4%, p = 0.687) or MOC (95.9% vs. 92.3%, p = 0.071). Further subgroup analysis according to tumor stage and histological grade did not show a worse OS with FSS in stage I EEOC or MOC patients, even with high-risk types such as G3 histology and IC phase. In a multivariable analysis, the application of FSS was not associated with inferior OS in EEOC or MOC. FSS for patients with stage I EEOC or MOC does not lead to worse outcomes than radical surgery, making it a viable option for young patients with early-stage disease wishing to preserve fertility.

Prognosis and treatment regimens for patients with different lymph node statuses in locally advanced cervical cancer

The survival outcomes of Stage IIIC1 in FIGO 2018 showed significant heterogeneity and it seems unreasonable to administer a uniform treatment regimen for Stage IIIC1 patients. This study aimed to assess the survival outcomes among patients with locally advanced cervical cancer based on various lymph node statuses, T-stage classifications, and treatment modalities. This is a population-based cohort study utilizing the Surveillance, Epidemiology, and End Results Program from 2004 to 2018. Propensity score-based inverse probability of treatment weighting was used to achieve covariate balance. Women with locally advanced cervical cancer on different lymph node statuses who underwent radical hysterectomy + pelvic lymphadenectomy + chemoradiotherapy, chemoradiotherapy, or radiotherapy alone were examined. Trends, patient characteristics, and survival outcomes were compared across different treatment regimens. Among 8777 patients analyzed, patients with early T-stage and married were identified as independent protective factors for cancer-specific survival regardless of lymph node status. The survival outcomes ranked in descending order as follows: T1N0>T2N0>T1N1 = T2N1>T3N0>T3N1. Therefore, the FIGO Stage IIIC1 was re-stratified into IIC (T1N1+T2N1) and IIIC1(T3N1). Patients who underwent radical hysterectomy combined with adjuvant therapy exhibited superior 5-year cancer-specific survival rates compared to those treated with chemoradiotherapy among IB3, IIA2, and IIC. The therapeutic efficacy of chemoradiotherapy surpassed that of radiotherapy alone in IIIA, IIIB, IIIC1(T3N1), and IVA patients. Restratification of Stage IIIC1 based on T-stage effectively discerns patients with divergent prognoses. Radical surgery + chemoradiotherapy is significantly associated with improved survival in early T-stage, regardless of lymph node status in locally advanced cervical cancer.

Prognosis and treatment of uterine sarcoma found incidentally after myomectomy

To determine prognosis and factors associated with survival of women with uterine sarcoma found incidentally after myomectomy. We performed a retrospective study for patients who had previously undergone myomectomy for presumed benign uterine fibroid disease and were found to have uterine confined sarcoma after myomectomy surgery. In total, 50 patients were identified. There were 23 (46.0 %) patients undergoing myomectomy were performed by minimal invasive surgery: laparoscopic (Lap, n = 22, 44.0 %) or transvaginal (TV, n = 1, 2.0 %) approach; while, 24 (48.0 %) and 3 (6.0 %) patients had myomectomy through abdominal (Abd) or hysteroscopic (Hys) approach. All patients received the re-exploration and staging surgery in our center. The median time from myomectomy to the staging surgery was 43 days (range 15-90 days). 17 patients had remnant sarcomas on the remaining uterus and 6 patients had disseminated disease after re-exploration. In the entire cohort, 5-year RFS and 5-year OS was 79.4 % and 88.0 %, respectively. Patients who received initial Lap/TV myomectomy had a tendency towards a worse 5-year RFS compared with Abd/Hys approach (63.0 % vs 88.9 %, P = 0.080). No difference in 5-year OS was found between the two groups (90.3 % vs 91.8 %, P = 0.768). For stage I disease (n = 44), patients who received Lap/TV myomectomy had a worse 5-year RFS compared with Abd/Hys approach (58.3 % vs 95.7 %, P = 0.009). No difference in 5-year OS was found (P = 0.121). Patients with incidental uterine sarcoma who received primary Lap/TV myomectomy may have a worse RFS. Re-exploration can detect remnant or disseminated sarcomas.

Long term clinical outcomes of cervical cancer patients who were recommended surgery but did not undergo it: A SEER database study

This study analyzed the long-term clinical outcomes of cervical cancer patients recommended surgery but who did not undergo it using the Surveillance, Epidemiology, and End Results (SEER) database. The aim was to identify the subgroups with comparable overall survival (OS) and cancer-specific survival (CSS) through stratified analysis. Cases of cervical cancer were retrieved from SEER database using SEER*Stat software. This included patients in the non-surgery group (recommended surgery but did not undergo it), and a reference surgery group. Propensity score matching balanced differences between the non-surgery and surgery groups. Stratified analysis and log-rank tests were used to identify subgroups within the non-surgery group with comparable OS and CSS to the surgery group. A total of 30,807 cervical cancer patients were included in the OS and CSS analysis. In the matched cohort (n = 1278), patients in the non-surgery group had significantly lower 5-year CSS (63.2 % vs. 80.1 %, P < 0.001) and 5-year OS (59.0 % vs. 78.0 %, P < 0.001). However, within the matched cohort, there was no statistically significant difference in OS and CSS between the non-surgery and surgery groups in subgroups diagnosed during 2010-2014 (P = 0.064, P = 0.182), 2015-2020 (P = 0.122, P = 0.518), T2 stage (P = 0.139, P = 0.052), T3 stage (P = 0.502, P = 0.317), or with distant metastasis (M1) (P = 0.411, P = 0.520). Patients in the non-surgery group generally exhibited lower long-term clinical outcomes compared to those in the surgery group. However, with advancements in non-surgical treatment techniques, particularly notable in patients with T2, T3, and M1 stages, these differences are gradually diminishing.

Comprehensive assessment of postoperative recurrence and survival in patients with cervical cancer

The prediction of postoperative recurrence and survival in cervical cancer patients has been a major clinical challenge. The combination of clinical parameters, inflammatory markers, intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI), and MRI-derived radiomics is expected to support the prediction of recurrence-free survival (RFS), disease-free survival (DFS), tumor-specific survival (CSS), and overall survival (OS) of cervical cancer patients after surgery. A retrospective analysis of 181 cervical cancer patients with continuous follow-up was completed. The parameters of IVIM-DWI and radiomics were measured, analyzed, and screened. The LASSO regularization was used to calculate the radiomics score (Rad-score). Multivariate Cox regression analysis was used to construct nomogram models for predicting postoperative RFS, DFS, CSS, and OS in cervical cancer patients, with internal and external validation. Clinical stage, parametrial infiltration, internal irradiation, D-value, and Rad-score were independent prognostic factors for RFS; Squamous cell carcinoma antigen, internal irradiation, D-value, f-value and Rad-score were independent prognostic factors for DFS; Maximum tumor diameter, lymph node metastasis, platelets, D-value and Rad-score were independent prognostic factors for CSS; Lymph node metastasis, systemic inflammation response index, D-value and Rad-score were independent prognostic factors for OS. The AUCs of each model predicting RFS, DFS, CSS, and OS at 1, 3, and 5 years were 0.985, 0.929, 0.910 and 0.833, 0.818, 0.816 and 0.832, 0.863, 0.891 and 0.804, 0.812, 0.870, respectively. Nomograms based on clinical and imaging parameters showed high clinical value in predicting postoperative RFS, DFS, CSS, and OS of cervical cancer patients and can be used as prognostic markers.

Neuroendocrine cervical cancer: Have we made any steps forward in its management?

Neuroendocrine tumors (NEC) were first described by Albores-Saavedra in 1972 and these tumors account for only 0.9% to 1.5% of all invasive cervical cancers. We searched for all available interventional studies, reviews, case reports and meta-analyses published from 1995 to 2023. In 2017 Castle et al. Current therapeutic modalities are mainly based on experience in the treatment of SCNEC of the lung. Certainly, a multidisciplinary approach is very important inorder to design a personalized management plan.

Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer

Compare the surgical complexity and histological accuracy of visual inspection of disease in patients undergoing primary debulking (PDS) versus delayed debulking surgery (DDS) following neo-adjuvant chemotherapy (NACT) for advanced ovarian cancer (AOC). All patients undergoing PDS or DDS for stage III / IV AOC at a UK cancer centre between January 2014-October 2021 were included. Retrospective data was collected accessing an electronic gynaecological oncology database, operation and histology records. Comparative frequencies of surgical procedures performed were calculated for primary versus delayed cohorts; and correlation between intra-operative suspicion of disease and specimen histology at PDS and DDS compared. N=232. PDS was performed in 45.3% and DDS in 54.7% of patients; achieving complete cytoreduction in 77.2%. Appendicectomy, pelvic and para-aortic nodal dissection were undertaken significantly more often at primary surgery; whilst right diaphragm stripping, pelvic peritonectomy, splenectomy and cholecystectomy were more likely following NACT. We found no variation in bowel resection rates between cohorts. For the majority of specimens, there was no difference in correlation between intra-operative suspicion of disease and final histopathology - with a significantly lower positive predictive value for visual assessment demonstrated only for liver capsule and pelvic peritoneum at DDS. NACT does not appear to reduce the complexity of surgery, including rates of bowel resection; nor accuracy of intra-operative visual assessment of disease. We therefore caution against both deferring to NACT to facilitate less radical delayed debulking; and any presumption that macroscopically abnormal tissue at DDS may represent inert post-NACT 'burn-out', mitigating indication for excision. We instead suggest reservation of the neo-adjuvant pathway for patients with poor PS and radiologically-confirmed surgical stopping points; and advocate equivalent and maximal cytoreductive effort to remove all visibly abnormal tissue in both the upfront and delayed surgical settings.

Are biomarkers expression and clinical-pathological factors predictive markers of the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer?

To predict the overall pathologic response to neoadjuvant chemotherapy (NACT) of patients with locally advanced cervical cancer (LACC) creating a prediction model based on clinical-pathological factors and biomarkers (p53, Bcl1 and Bcl2) and to evaluate the prognostic outcomes of NACT. This is a retrospective study of 88 consecutive patients with LACC who underwent NACT followed by nerve sparing surgery with retroperitoneal lymphadenectomy at National Cancer Institute of Milan, between January 2000 and June 2013. Clinical pathologic data were retrieved from the institutional database. Biomarkers (p53, Bcl1 and Bcl2) were evaluated before and after NACT in the specimen. To investigate their role as predictors of response, we tried several statistical machine learning algorithms. Responders to NACT showed a 5-years survival between 100%(CR) and 85.7%(PR). Clinical factors were the most important predictor of response. Age, BMI and grade represented the most important predictors of response at random forest analysis. Tree-based boosting revealed that after adjusting for other prognostic factors, age, grade, BMI and tumor size were independent predictors of response to NACT, while p53 was moderately related to response to NACT. Area under the curve (crude estimate): 0.871. Whereas Bcl1 and Bcl2, were not predictors for response to NACT. The final logistic regression reported that grade was the only significant predictor of response to NACT. Combined model that included clinical pathologic variables plus p53 cannot predict response to NACT. Despite this, NACT remain a safe treatment in chemosensitive patients avoiding collateral sequelae related to chemo-radiotherapy.

PARP inhibitors in epithelial ovarian cancer: what are their potential implications for surgical management?

Reply to: 'Enhancing cervical cancer surveillance: Utilizing inflammatory markers for improved recurrence detection in low-resource settings and a call for prospective multi-centric studies'

Development and validation of a prognostic model for cervical cancer by combination of machine learning and high-throughput sequencing

Cervical cancer holds the highest morbidity and mortality rates among female reproductive tract tumors. However, the curative outcomes for patients with persistent, recurrent, or metastatic cervical cancer remain unsatisfactory. There is a lack of comprehensive prognostic indicators for cervical cancer. This study aims to develop a model that evaluates the prognosis of cervical cancer in combination of high-throughput sequencing and various machine learning algorithms. In this study, we combined two single-cell RNA sequencing (scRNA-seq) projects and TCGA data for cervical cancer to obtain shared differentially expressed genes (DEGs). A LASSO regression and several learners were applied for signature feature selection. Six machine learning algorithms including Linear Discriminant Analysis, Naive Bayes, K Nearest Neighbors, Decision Tree, Random Forest, and eXtreme Gradient Boosting were utilized to construct a prognostic model for cervical cancer. External validation was conducted using the CGCI-HTMCP-CC dataset, and the accuracy of the model was assessed through ROC curve analysis. The results demonstrated the successful construction of a prognostic model based on DEGs from bulk- and scRNA-seq data. Ten genes CXCL8, DLC1, GRN, MPLKIP, PRDX1, RUNX1, SNX3, TFRC, UBE2V2, and UQCRC1 were screened by feature selection and applied for model construction. Random Forest exhibited the best performance in predicting the risk of cervical cancer. Patients in the high-risk group presented worse overall survival compared to those in the low-risk group. Conclusively, our model based on DEGs from bulk-seq and scRNA-seq data effectively evaluates the prognosis of cervical cancer and provides valuable insights for comprehensive clinical management.

Deep epigastric lymph nodes implication in patients’ recurrence pattern after cytoreductive surgery in ovarian peritoneal metastases

Although complete cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) offers a good prognosis in patients with peritoneal metastasis of ovarian cancer (PMOC), recurrences are quite common. These recurrences can be intra-abdominal or systemic in nature. Our objective was to study and illustrate the global recurrence pattern in patients operated for PMOC, shedding light on a previously overlooked lymphatic basin at the level of the epigastric artery, the deep epigastric lymph nodes (DELN) basin. This was a retrospective study including patients with PMOC who underwent surgery with curative-intent, from 2012 until 2018, at our cancer center, and who presented with any type of disease recurrence on follow-up. CT-scans, MRIs and PET-scans were reviewed in order to determine solid organs and lymph nodes (LN) recurrences. During the study period, 208 patients underwent CRS ± HIPEC, 115 (55.3%) presented with organ or lymphatic recurrence over a median follow-up of 81 months. Sixty percent of these patients had radiologically enlarged LN involvement. The pelvis/pelvic peritoneum was the most common intra-abdominal organ recurrence site (47%), while the retroperitoneal LN was the most common lymphatic recurrence site (73.9%). Previously overlooked DELN were found in 12 patients, with 17.4% implication in lymphatic basin recurrence patterns. Our study revealed the potential role of the DELN basin, previously overlooked in the systemic dissemination process of PMOC. This study sheds light on a previously unrecognized lymphatic pathway, as an intermediate checkpoint or relay, between the peritoneum, an intra-abdominal organ, and the extra-abdominal compartment.

The potential role of systemic inflammatory markers in predicting recurrence in early-stage cervical cancer

The influence of systemic inflammatory markers on early-stage cervical cancer (ECC) patients is contradictory. No previous study analyzed whether these markers may be suggestive of recurrence. The aim of this study was to assess whether the inflammatory markers level of patients with recurrence during surveillance was different from those of patients without recurrence representing a risk factor for recurrence. Retrospective, single-center, observational study. Patients with 2009 FIGO EEC surgically treated between 2012 and 2019 were included. Baseline inflammatory markers were evaluated on the results of the complete blood count (CBC) and coagulation tests. Inflammatory markers of relapsed patients were evaluated on the last CBC performed before the relapse diagnosis. Inflammatory markers of patients with no recurrence were evaluated on the available CBC taken at the same median follow-up time as the one from relapsed patients. 174 patients were included. Baseline Systemic immune inflammation index (SII) > 663 and Systemic inflammation response index (SIRI) > 0.98 were associated with significant risk of recurrence. SII>663 and Neutrophil to lymphocyte ratio (NLR) > 2.41 were associated with increased risk of death. Significant changes between relapsed (n = 23) and non-relapsed (n = 151) patients in median values of SII (615 versus 490, p-value = 0.001), SIRI (0.74 versus 1.05, p-value = 0.005), NRL (2.95 versus 2.15, p-value = 0.0035), and MLR (0.26 versus 0.22 p-value = 0.020), showed that different levels of inflammatory markers could help identifying recurrent disease during surveillance. Baseline SII>663 and SIRI>0.98 were associated with increased risk of recurrence. Higher median values of SII, SIRI, NLR and MLR in relapsed patients highlight their potential association with recurrence.

Time-interval to adjuvant chemotherapy and postoperative management after upper abdominal surgical procedures in advanced ovarian cancer

In advanced epithelial ovarian cancer (EOC), longer time-interval from surgery to initiation of adjuvant chemotherapy (TITC) is associated with decreased survival. Adding upper abdominal surgical procedures (UAP) increases rates of both complete gross resection and postoperative complications in EOC. Our objective was to investigate the association of UAP and TITC. Moreover, if specific postoperative monitoring after the most prevalent UAP increases early detection and management of complications. Women diagnosed with EOC 2014-2016 in the Stockholm/Gotland Region in Sweden were identified in the Swedish Quality Registry for Gynaecologic Cancer. The association between UAP and TITC was investigated by multivariable linear regression and adjusted for predefined confounders. The follow-up and detection of postoperative complications after diaphragm resection, splenectomy and cholecystectomy was examined. 240 women were selected for analysis. The TITC in women subjected to UAP was similar with a median of 30 days (p = 0.99). Moreover, despite a higher rate of postoperative and major complications (p < 0.001) and longer hospital stay (p < 0.001), in the adjusted analysis there was no association between UAP and prolonged TITC, with a mean difference of -2.27 days (95% Confidence Interval (CI), -5.99 to -1.45, p = 0.23). After the most prevalent UAP (diaphragm resection, splenectomy and cholecystectomy), eventual postoperative interventions were based on routine clinical management rather than procedure-specific postoperative surveillance. UAP does not prolong TITC despite an increased rate of postoperative complications and longer length of hospital stay. Clinical non-specific surveillance is sufficient to detect postoperative complications after the most prevalent UAP.

Pelvic exenteration for vulvar cancer: contemporary outcomes from a multinational cohort study

Women with vulvar cancer are considerably older than those with other gynaecological malignancies, raising concerns about the tolerability of radical surgery. Yet, for locally advanced or recurrent disease, pelvic exenteration may be the only curative option. Robust evidence to guide decision-making in this population is lacking. This multicentre observational cohort study used data from the COREPEX registry including women who underwent anterior or total pelvic exenteration between 2005 and 2023 across 20 European tertiary referral centres. The primary outcome was overall survival (OS); secondary outcomes were progression-free survival (PFS) and major postoperative complications. Associations were assessed using multivariable Cox and binomial regression models adjusted for relevant covariates. Among 861 women, 79 (9.2%) had vulvar cancer. Median follow-up was 49 months for OS and 40 months for PFS. Women with vulvar cancer were older and more often overweight. Five-year OS was 32% (95% CI, 19-46) in vulvar cancer versus 29% (95% CI, 25-34) in other cancers, adjusted HR 1.05 (95% CI, 0.75-1.46). Five-year PFS was 34% versus 29%, adjusted HR 0.96 (95% CI, 0.69-1.34). Major complications occurred in 33% vs 29%, adjusted RR 1.12 (95% CI, 0.77-1.58). Lymph node metastases, positive margins, and recurrent or persistent disease independently predicted poorer survival. Despite their older age, women with vulvar cancer had survival and morbidity comparable to those with other gynaecological malignancies. These findings support pelvic exenteration as a curative option for selected women with vulvar cancer when complete resection is feasible.

Days alive and out of hospital after surgical treatment of epithelial ovarian cancer: A Danish nationwide cohort study

Days alive and out of hospital (DAOH) is a validated outcome measure in perioperative trials integrating information on primary hospitalization, readmissions, and mortality. It is negatively associated with advanced age. However, DAOH has not been described for surgical treatment of epithelial ovarian cancer (EOC), primarily diagnosed in older patients. We conducted a Danish nationwide cohort study including patients undergoing debulking surgery for EOC from 2013 to 2018. DAOH was explored for 30 (DAOH30), 90 (DAOH90), and 180 (DAOH180) postoperative days in younger (<70 years) and older (≥70 years) patients with advanced-stage disease stratified by surgical modality (primary (PDS) or interval debulking surgery (IDS)). We examined the associations between patient- and surgical outcomes and low or high DAOH30. Overall, 1168 patients had stage IIIC-IV disease and underwent debulking surgery. DAOH30 was 22 days [interquartile range (IQR): 18, 25] and 23 days [IQR: 18, 25] for younger and older patients treated with PDS, respectively. For IDS, DAOH30 was 25 days [IQR: 22, 26] for younger and 25 days[IQR: 21, 26] for older patients. We found no significant differences between age cohorts regarding DAOH30, DAOH90, and DAOH180. Low DAOH30 was associated with poor performance status, PDS, extensive surgery, and long duration of surgery in adjusted analysis. DAOH did not differ significantly between age cohorts. Surgical rather than patient-related factors were associated with low DAOH30. Our results likely reflect a high selection of fit older patients for surgery, reducing the patient-related differences between younger and older patients receiving surgical treatment.

Complications and risk factors in vulvar cancer surgery – A population-based study

Primary surgery for vulvar cancer has become less radical in past decades. This study investigates risk factors and prevalence of short-and long-term complications after up-to-date vulvar cancer surgery. Population-based cohort study of surgically treated primary vulvar cancer at a national center of vulvar cancer, assessing surgical outcome. The Swedish Quality Registry for Gynecological Cancer was used for identification, journals reviewed and surgical outcome including complications within 30 days and one year registered. Multivariable logistic regression analysis comprising risk factors of short-term complications; age>80 years, BMI, smoking, diabetes, lichen sclerosus and FIGO stage was performed. 182 patients were identified, whereas 55 had vulvar surgery only, 53 surgery including sentinel lymph node biopsy (SLNB) and 72 surgery including inguinofemoral lymphadenectomy (IFL), with short-term complication rates of 21.8%, 39.6% and 54.2% respectively. Vulvar wound dehiscence was reported in 6.0% and infection in 13.7%. Complication rates were lower after SLNB than IFL (wound dehiscence 0% vs 8.3%; p = 0.04, infection 15.1% vs 36.1%; p = 0.01 and lymphocele 5.7% vs 9.7%; p = 0.52). Severe complications were rare. Persisting lymphedema evolved in 3.8% after SLNB and in 38.6% after IFL (p = 0.001), ubiquitous after adjuvant radiotherapy. In multivariable regression analysis, no associations between included risk factors and complications were found. Surgical complications are still common in vulvar cancer surgery and increase with the extent of groin surgery. To thrive for early diagnosis and to avoid IFL seem to be the most important factors in minimizing short-and long-term complications.

Prognosis and adjuvant chemotherapy for patients with malignant peritoneal cytology in early-stage non-endometrioid endometrial cancer

To investigate the influence of malignant peritoneal cytology (MPC) on the prognosis of early-stage patients with endometrial clear cell carcinoma(CCC) and serous carcinoma(SC), and the value of chemotherapy in their treatment. A retrospective observational cohort study was conducted by querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program from 2010 to 2019. Women with early-stage CCC and SC with available peritoneal cytology results were enrolled. Propensity score matching(PSM) and propensity score inverse probability of treatment weighting (IPTW) was used to balance the measured covariates in each sub-cohort. A total of 3,616 eligible patients were included, and 368 patients had MPC (10.2%). Women with MPC were more likely to receive postoperative chemotherapy (OR 2.033; 95%CI 1.589-2.602). In PSM model, MPC had worse overall survival(OS) and cancer-specific survival (CSS) (All,p < 0.001). The 5-year OS rates were 56.5% for women with MPC and 74.4% for those with negative peritoneal cytology, and the 5-year CSS rates were 60.8% versus 80.0%(All, p < 0.0001). In the subgroup analyses, MPC was associated with decreased OS and CSS in serous, clear cell histology group, and stage IA cases(All,p < 0.001), but not for stage IB or stage II disease. In multivariate analysis, chemotherapy improved the prognosis of patients with MPC(OS:p = 0.005; CSS:p = 0.010). Additionally, in stage IA subgroup, chemotherapy improved survival outcomes in patients with MPC(OS:P = 0.025; CSS:P = 0.038), in NPC patients, however, chemotherapy was a good prognostic factor for OS (P = 0.001) but not for CSS(P = 0.300). MPC was a prognostic factor for decreased survival in early-stage endometrial CCC and SC, and those with MPC could further benefit from chemotherapy.

Endometriosis-associated ovarian cancer is not a distinct clinical entity among young patients: A 12-year cohort study

To investigate the clinicopathological features and prognostic value of endometriosis in young patients with ovarian endometrioid carcinoma (OEC) and ovarian clear cell carcinoma (OCCC). The medical files and clinical follow-up data of patients aged 40 years or younger with OEC or OCCC between January 2006 and December 2017 who had undergone complete surgical staging followed by systemic chemotherapy were retrospectively reviewed. A total of 94 women were included in this study. Univariate analysis revealed that the progression-free survival (PFS) and overall survival (OS) rates of patients with endometriosis-associated ovarian carcinoma (EAOC) did not improve compared with those of patients without EAOC (5-year PFS: 80.0% vs. 75.9% and 5-year OS: 85.0% vs. 86.0%, respectively). Multivariate analyses confirmed that FIGO stage (II-IV), cytology-positive ascites or peritoneal washes and residual disease > 1 cm were independent predictors of PFS and that residual disease > 1 cm was the only predictor of OS. Endometriosis is not independently associated with the prognosis of OEC and OCCC among young patients. The intrinsic relationship between endometriosis and ovarian cancer warrants further investigation.

Simple hysterectomy versus radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis

This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer. We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4. Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group. This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system – Single centre study

This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs. The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Clinical auditing as an instrument to improve care for patients with ovarian cancer: The Dutch Gynecological Oncology Audit (DGOA)

The Dutch Gynecological Oncology Audit (DGOA) was initiated in 2014 to serve as a nationwide audit, which registers the four most prevalent gynecological malignancies. This study presents the first results of clinical auditing for ovarian cancer in the Netherlands. The Dutch Gynecological Oncology Audit is facilitated by the Dutch Institute of Clinical Auditing (DICA) and run by a scientific committee. Items are collected through a web-based registration based on a set of predefined quality indicators. Results of quality indicators are shown, and benchmarked information is given back to the user. Data verification was done in 2016. Between January 01, 2014 and December 31, 2018, 6535 patients with ovarian cancer were registered. The case ascertainment was 98.3% in 2016. The number of patients with ovarian cancer who start therapy within 28 days decreased over time from 68.7% in 2014 to 62.7% in 2018 (p < 0.001). The percentage of patients with primary cytoreductive surgery decreased over time (57.8%-39.7%, P < 0.001). However, patients with complete primary cytoreductive surgery improved over time (53.5%-69.1%, P < 0.001). Other quality indicators did not significantly change over time. The Dutch Gynecological Oncology Audit provides valuable data on the quality of care on patients with ovarian cancer in the Netherlands. Data show variation between hospitals with regard to pre-determined quality indicators. Results of 'best practices' will be shared with all participants of the clinical audit with the aim of improving quality of care nationwide.

Perineural invasion in cervical cancer: A multicenter retrospective study

The study aimed to evaluate the accuracy of perineural invasion (PNI) diagnosis in cervical cancer, and to analyze the impact of PNI on the prognosis and postoperative adjuvant treatment decisions for cervical cancer. A retrospective pathological review of PNI in cervical cancer was conducted from 2004 to 2016 in 15 hospitals. This study included a total of 1208 cases, comprising 273 cases with PNI and 935 cases without. The false positive rate and false negative rate of PNI diagnosis were 5.35% (50/935) and 33.33% (91/273), respectively. Adenocarcinoma, deep stromal invasion, lymphovascular space invasion (LVSI) (+), and margin involvement were independent risk factors for PNI. Both 5-year overall survival rate (OS) and 5-year disease-free survival rate (DFS) of PNI group were worse than non-PNI group. PNI was an independent risk factor for 5-year OS and 5-year DFS. In cases receiving standard postoperative adjuvant treatment, among those with two intermediate-risk factors, both 5-year OS and DFS were worse in the PNI group. Among cases with three intermediate-risk factors or at least one high-risk factor, there was no difference in 5-year OS between the two groups, but 5-year DFS was worse in the PNI group. The diagnosis of PNI in cervical cancer was not accurate. Adenocarcinoma, deep stromal invasion, LVSI, and margin involvement were independent risk factors for PNI. PNI was an independent risk factor for 5-year OS and DFS. PNI has the potential to serve as a new high-risk factor, thus providing guidance for postoperative adjuvant therapy.

Rare gynaecological cancers in Malta – An analysis of incidence between 2010 and 2021

Whilst about 18 % of all cancers in females are gynaecological cancers, more than 50 % of these can be classified as rare tumours (defined as an annual incidence of <6 per 100,000). Such cancers represent an important challenge for small countries like Malta where the small caseload may limit the expertise of clinicians in the diagnosis and treatment of such cancers. The study uses data from the Maltese population-based cancer registry to examine trends in incidence rate of the rare gynaecological cancers for the 12-year period between 2010 and 2021. It employs the RARECAREnet list to identify the rare gynaecological cancers by major rare gynaecological cancer categories and histological types and analyses the number of cases and incidence rates in Malta to monitor trends and provide an insight of the burden of such cancers. A total of 709 new cases of rare gynaecological cancers were discovered during the 12-year period. Globally, these rare gynae cancers, constituted 42.6 % of all the gynae cancers that occurred during this period. Most of these rare cancers were ovarian (399 cases, 56.3 %), followed by rare cancers of the vulva and vagina (122 cases, 17.21 %), rare cancers of the corpus uteri (93 cases, 13.12 %) and rare cancers of the cervix uteri (73 cases, 10.3 %). Other rare gynaecological cancers (10 cases, 1.41 %) and cancers of the placenta (2 cases, 0.04 %) were much rarer. The outcomes in terms of 5-year survival was worse for the rare cancers compared with the commoner types of gynae cancers with an overall 5-year survival of 45.10 % and 45.48 % for rare gynae cancers for the 2010-2014 and 2015-2019 cohorts respectively and an overall 5-year survival of 69.94 % and 73.44 % for the common gynae cancers for the 2010-2014 and 2015-2019 cohorts respectively. The study shows that globally rare gynaecological cancers in a small state like Malta are in fact not so rare - with a total of 709 rare gynaecological cancers in 12 years for Malta. These cases are however few when considering that they are divided into over 30 different histopathological groups. Numbers are also small when it comes to accumulating statistical power for analysis. The caseload for the individual sub-categories is small and will often be shared amongst the different individual gynaecologists and/or their clinical team. Thus, it might be difficult for these specialists to gather enough technical expertise that is crucial for early diagnosis and the treatment of these rare cancers. This study provides a rationale for international collaboration where there is scope for joint research and sharing of expertise. Establishment of common databases for the various types of rare gynaecological tumours will provide statistical power, enabling analysis of outcomes for these rare cancers and establishment of guidelines.

Impact of histological subtypes on clinical outcome of endocervical adenocarcinoma

This multicenter study aimed to investigate the disparity in clinical features and prognosis among different histopathologic subtypes of endocervical adenocarcinoma (EA) based on the 2014 World Health Organization (WHO) classification. We retrieved and analyzed data from the Chinese Four C Database between 2004 and 2018. 672EA patients with radical hysterectomies from 32 institutions were retrospectively reviewed. Clinicopathologic characteristics, five-year overall survival (OS), and disease-free survival (DFS) were compared based on histological subtypes. The 5-year DFS and OS rates for usual, endometrioid, mucinous, gastric, villoglandular, clear cell/serous/mesonephric EAs were as follows: 81.3 %, 89.1 %, 63.0 %, 35.6 %, 88.6 %, 79.9 %, respectively (P < 0.0001); 87.4 %, 96.6 %, 74.7 %, 34.0 %, 96.7 %, 86.3 %, respectively (P < 0.0001). Gastric- and mucinous-type exhibited a higher frequency of lymph node metastasis, deep stromal invasion, uterine corpus invasion, and recurrence than the usual -type (recurrence rate:50.00 % vs 29.90 % vs 15.50 %, P < 0.0001). Multivariate analysis revealed gastric-type was significantly associated with inferior DFS (HR,3.018; 95 % CI, 1.688-5.397; P < 0.0001) and OS(HR, 4.114; 95 % CI, 2.002-8.453; P < 0.0001). Furthermore, compared to the usual -type, mucinous-type demonstrated significantly worse DFS (HR, 1.773; 95 % CI,1.123-2.8; P = 0.014) and OS (HR, 2.168; 95 % CI,1.214-3.873; P = 0.009) whereas endometrioid-type was an identified as independent factor for better DFS (HR, 0.365; 95 % CI,0.143-0.928; P = 0.034). Villoglandular subtype displayed similar features and favorable prognosis as the usual type. Relevant clinical features and prognosis varied significantly among histological subtypes of EA, thus offering valuable guidance for the development of subtype-specific treatment strategies to optimize EA management.

Ovarian-sparing surgery for ovarian tumors in children: A systematic review and meta-analysis

An increased number of children and adolescents with ovarian tumors have been managed with ovarian-sparing surgery in the last few years. However, comprehensive data on fertility outcomes and local relapse are scarce. In this study, we systematically describe the contemporary outcomes of ovarian-sparing surgery, as reported in the literature. Using PRISMA guidelines, we analyzed studies reporting ovarian-sparing techniques for ovarian tumors in children and adolescents. from 1980 to 2022. Reports with fewer than three patients, narrative reviews, and opinion articles were excluded. Statistical analysis was performed for dichotomous and continuous variables. Of 283 articles screened, 16 papers (3057 patients) met inclusion criteria (15 retrospective/1 prospective) and were analyzed. The vast majority of studies had no long-term fertility follow-up data and direct comparison between ovarian-sparing surgery vs oophorectomy was reported in only a few studies. Ovarian sparing surgery was not associated with worse oncologic outcomes in terms of (i) tumour spillage or (ii) recurrence rates, and of key importance allowed a higher ovarian reserve at long term follow-up. Ovarian-sparing surgery is a safe and feasible technique for benign tumors. Long-term outcome studies are needed to show efficacy and fertility preservation.

Outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal dissemination from ovarian carcinosarcoma

Ovarian carcinosarcoma (OCS) is an uncommon and aggressive malignancy, with poor response to current treatment approaches and no clear guidelines. Our aim is to evaluate the outcomes of an OCS cohort after cytoreduction with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). A descriptive cohort study was performed. Patients who underwent CRS/HIPEC for peritoneal dissemination from tubo-ovarian malignancies (1999-2021) were retrospectively reviewed. Patients with confirmed histopathologic diagnosis of FIGO stage III/IV OCS were included. Overall (OS) and progression-free survival (PFS) were determined with the Kaplan-Meier method. Of 267 patients with tubo-ovarian malignancies reviewed, 7.5% (20/267) had OCS. Of these, 16 underwent CRS/HIPEC, including 9 for a new diagnosis and 7 for disease recurrence. Median age at surgery was 66.5 (IQR: 54.5-74.5) years. Nine (56.2%) patients were FIGO stage IV. Median peritoneal cancer index was 22 (IQR: 14-28). Complete cytoreduction was achieved in 15/16 (93.7%) cases. HIPEC agents included carboplatin (n = 7), cisplatin+doxorubicin (n = 4), and melphalan (n = 5). Major complications occurred in 4/16 (25%), with no 90-day mortality. Median follow-up was 41.8 months. Median PFS was 11.7 (95%CI: 10.5-17.1) months. Malignant bowel obstruction occurred in 3/16 (18.7%). Median OS from CRS/HIPEC was 21.3 (95%CI: 16.3-31.6) months, not reached for newly diagnosed vs 19.7 months for recurrent patients (p = 0.23). CRS/HIPEC showed promising survival and abdominal disease control with low rates of malignant obstruction in patients with advanced stage OCS. Collaborative studies with larger cohorts and longer follow-up may further elucidate the role of CRS/HIPEC in OCS.

MDT practice determines treatment pathway for patients with advanced ovarian cancer: A multi-centre observational study

To investigate decision making for patients with advanced ovarian cancer as a possible explanation of geographical variation in treatment patterns. We carried out a multi-centre observational study in multidisciplinary teams meetings for five major UK cancer centres. All patients presenting to five cancer centres with advanced ovarian cancer over a six-week period. The GO-MDT-MODe tool was used to provide a measure of participation and quality of case discussion for all cases of advanced ovarian cancer. MDT scores were correlated with surgical data extracted from national audit data. Data were recorded for overall MDT performance. A total of 870 case discussions, including 145 cases of advanced ovarian cancer, were observed. MDTs varied in structure, format and time allocation between centres. Cluster analysis showed significant variation in quality and participation of discussion between centres (p < 0.0025) and this correlated with the proportion of patients in the wider cancer alliance undergoing surgery. We have shown that at least part of the variation in practice seen in the UK correlates with different behaviours within MDTs. Increasing time for discussion and encouraging participation from all staff groups may increase proportions of patients undergoing optimal treatment regimens.

The paradigm shift in advanced ovarian cancer: Outcomes of extensive primary cytoreductive surgery. A single-center retrospective analysis

The standard surgical treatment of advanced ovarian carcinoma is primary debulking surgery (PDS) aiming to complete cytoreduction. The need to achieve complete cytoreduction has shifted the surgical paradigm to more complex procedures, whose impact on morbidity is controversial. The objective of this retrospective analysis is to explore the impact of extensive PDS on morbidity and oncologic outcomes in a real-world scenario. A retrospective single-center analysis was performed on 137 patients with advanced high-grade ovarian carcinoma (HGOC) who received PDS in 2015-2020. Patients treated in 2015-2017 (Group 1) were compared to patients treated in 2018-2020 (Group 2). The two periods were chosen according to the higher complexity of surgical procedures introduced in 2018. The increase in complete cytoreduction observed in Group2 (RD 0: 33 % vs 61 %, p = 0,008) was related to a higher surgical complexity (Aletti Score: 4 vs 6, p = 0,003) and did not reflect an increase in peri-operative complications (CCI: 20,9 vs 20,9, p = 0,11). After a median FUP of 44 months, PFS and OS at 24 months were 33,60 % vs 47,33 % (p = 0,288) and 72,10 % vs 80,37 % (p = 0,022) in Group 1 and 2, respectively. An extensive surgical effort leads to a significant increase in complete cytoreduction with acceptable morbidity. Arm-in-arm with novel maintenance therapies, it contributes to increasing the outcomes of patients with advanced HGOC.

Postoperative quality of life in patients with early-stage cervical cancer: A prospective 10-year follow-up study

The substantial improvement in early-stage cervical cancer survival rates has given rise to the significance of subsequent quality of life. This study aims to assess the quality of life in patients subjected to radical and conservative surgeries for cervical cancer. One hundred patients diagnosed with early-stage cervical cancer (stages IA2-IIA1) undergoing surgical treatment were enrolled in our study between 2007 and 2011. Patients completed quality of life questionnaires EORTC QLQ-C30 and QLQ-CX24, distributed before the surgery, 6, 12, and 120 months after the procedure. At the final 120-month follow-up, 54 patients remained eligible for inclusion. 23 patients ("CONS group") underwent laparoscopic lymphadenectomy combined with hysterectomy or simple trachelectomy. The remaining 31 patients ("RAD group") underwent abdominal radical hysterectomy type C1. At the 6-month post-surgery assessment, the RAD group reported a significantly higher incidence of menopausal symptoms, decline in physical functioning and concern regarding their sexual well-being. CONS group patients reported notable exacerbation of lymphedema and neuropathy-related symptoms but only a slight decline in physical functioning. Additionally, their role functioning, emotional well-being, and social functioning significantly improved compared to their preoperative baseline. At the 120-month postoperative assessment the RAD group showed a significant decline in several parameters, including lymphedema, peripheral neuropathy, postmenopausal symptoms, fatigue, pain, and physical functioning. Cervical cancer treatment is invariably associated with a negative long-term impact on quality of life, RAD group demonstrated poorer outcomes than the CONS group across multiple parameters but even the CONS group exhibited long-term effects of the surgery.

SLYMEC II study: Overall survival analysis of the impact of LVSI in apparent early stage endometrioid endometrial cancer

In our initial report of the SLYMEC study we published the results evaluated the prognostic impact of substantial lymphovascular space invasion (LVSI) on the sentinel lymph node status and the impact of the different types of LVSI on 3-year disease-free survival. The aim of the SLYMEC II study was to assess the impact of focal and substantial lymphovascular space invasion on 5-years overall survival in the subgroup of patients with endometrioid endometrial cancer. A total of 2030 patients were included in the analysis from the original data set. Focal LVSI were identified in 131 patients (6.4 %), whereas 319 patients (15.7 %) showed substantial LVSI at final pathology. Among 1876 patients who underwent minimally invasive surgery (92.6 %), 442 patents (21.8 %) underwent robotic assisted surgery, whereas and 150 patients (7.6 %) patients underwent open surgery. Rate of overall survival at 5 years was 83.6 % versus 100 % for substantial and focal LVSI groups, respectively (HR for death = 2.1 [95 % CI, 1.4 to 3.2]; P < 0.0001). Patients with endometrioid endometrial cancer having substantial LVSI after surgery showed an increased risk of death in the after 5-years overall survival when compared to patients with negative, or focal LVSI. The presence of positive LVSI in patients with positive sentinel nodes showed a trend toward reduced 5-year overall survival compared to SLN-negative patients, although it did not reach statistical significance.

Greater-omentum lesion-score (GOLS) as a predictor of residual disease in different regions of the peritoneal cavity in patients undergoing interval cytoreductive surgery for advanced ovarian cancer and its potential clinical utility

The greater omentum(GO) is a common site of residual disease in patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer. The presence of tumor in the GO could predict presence of disease in other peritoneal regions. The goal of this study was to perform a correlation between the greater-omentum lesion-score(GOLS) and presence of disease in different peritoneal regions and determine its potential utility in guiding interval cytoreductive surgery(CRS). This prospective study included 134 patients undergoing interval CRS from July 1, 2018 to June 30, 2020. Each region of Sugarbaker's Peritobneal Cancer Index(PCI) was given a lesion score(LS) from 0 to 3 according to the diameter of the largest tumor in the region. The GOLS was recorded separately from other structures in the region. Correlation between the GOLS and surgical and pathological LS in each region was performed. As the GOLS increased, the incidence of disease(surgical LS) in other regions of the peritoneal cavity increased. Receiver operating characteristic(ROC) curves showed area under curve more than 80% for regions 1-2 and 7-8 indicating a high probability of disease in these regions in patients with GOLS 1-3. The positive predictive value(PPV) of preoperative imaging for GOLS was 95.7%. No cut-off of the GOLS could predict presence of disease on pathology with more than 70% accuracy. Presence of disease in the GO warrants performing upper abdominal exploration and/or cytoreduction and interval CRS should be planned accordingly in these patients. Imaging has a high PPV in detecting disease in the GO.

The relationship between household income and prognosis of patients with cervical adenocarcinoma in the United States: A retrospective cohort study based on the SEER database

To investigate the association between household income and overall survival (OS) of patients with cervical adenocarcinoma. We conducted a retrospective cohort study involving participants selected from the Surveillance, Epidemiology, and End Results (SEER) database. Data were collected on various variables, including demographic variables such as median household income and clinicopathological characteristics for all participants. Cox regression analysis was utilized to examine the association between household income and OS. Subgroup analysis, sensitivity analysis, and E-value were used to further confirm the association. A total of 2217 patients were included in the study. Compared with low-income (<$35,000-$54,999), middle-income (55,000-$69,999) or high-income (≥$70,000) was significantly associated with a higher 5-year OS (70.8 %, 58.7 % vs 50 %) in patients with cervical adenocarcinoma. The HR was 0.49, 95 % CI 0.41-0.58, p < 0.001 and 0.66 (0.55-0.78), p < 0.001 respectively, in the unadjusted model. After adjustment for potential confounders, the results were similar (adjusted HR 0.54 (0.45-0.65), p < 0.001) and 0.79 (0.66-0.94), p = 0.01), respectively. This significant association was also present in the various adjusted models. Subgroup and sensitivity analyses suggested that the relationship remained robust and reliable. The E-value analysis indicated robustness to unmeasured confounding. There was evidence of an interaction between age at diagnosis, race, primary site, tumor grade, T, N, M, or Scope Reg LN Sur, and household income on increasing the 5-year OS of cervical adenocarcinoma. Our study found that middle or high household income was significantly associated with a better 5-year OS compared with low household income in patients with cervical adenocarcinoma.

The efficacy of pre-operative conization in patients undergoing surgical treatment for early-stage cervical cancer: A meta-analysis

Minimal invasive surgery (MIS) has been reported to increase the risk of cancer relapse and death compared with traditional open surgery in patients with early-stage cervical cancer (CC). Pre-operative conization is a protective procedure that as developed to reduce the risk caused by MIS. Relevant publications were identified by searching medical databases prior to the December 31, 2022. The primary aim of this meta-analysis was to evaluate the efficacy of pre-operative conization on disease-free survival (DFS) in early-stage CC. The secondary objective was to assess the efficacy of pre-operative conization on overall survival (OS) in early-stage CC. Twelve studies were eligible for analysis. The pooled result of pre-operative conization showed a significantly improved DFS when compared with non-conization patients (HR, 0.28; 95% CI, 0.19-0.41), furthermore, pre-operative conization improved DFS by 75% (HR, 0.25; 95% CI, 0.13-0.46) in stage IB1 patients. In patients who underwent MIS, pre-operative conization also led to a significant improvement in DFS when compared with non-conization patients (HR, 0.21; 95% CI, 0.09-0.54). However, in patients who underwent pre-operative conization, MIS increased the risk of recurrence by 34% when compared with open abdominal radical hysterectomy (HR, 1.34; 95% CI, 0.41-4.38), although this difference was not statistically significant. Finally, the OS of early-stage CC was not significantly affected by surgical approach or conization. Pre-operation conization represents a protective effect and can improve DFS when compared with non-conization in early-stage CC, especially in stage IB CC. There was no statistical evidence to indicate that pre-operation conization could improve OS. High-quality randomized controlled trials are required to verify these results.

Loss of skeletal muscle density during neoadjuvant chemotherapy in older women with advanced stage ovarian cancer is associated with postoperative complications

To assess the association between loss of lumbar skeletal muscle mass and density during neoadjuvant chemotherapy (NACT) and postoperative complications after interval cytoreductive surgery (CRS) in older patients with ovarian cancer. This multicenter, retrospective cohort study included patients aged 70 years and older with primary advanced stage ovarian cancer (International Federation of Gynecology and Obstetrics stage III-IV), treated with NACT and interval CRS. Skeletal muscle mass and density were retrospectively assessed using Skeletal Muscle Index (SMI) and Muscle Attenuation (MA) on routinely made Computed Tomography scans before and after NACT. Loss of skeletal muscle mass or density was defined as >2% decrease per 100 days in SMI or MA during NACT. In total, 111 patients were included. Loss of skeletal muscle density during NACT was associated with developing any postoperative complication ≤30 days after interval CRS both in univariable (Odds Ratio (OR) 3.69; 95% Confidence Interval (CI) 1.57-8.68) and in multivariable analysis adjusted for functional impairment and WHO performance status (OR 3.62; 95%CI 1.27-10.25). Loss of skeletal muscle density was also associated with infectious complications (OR 3.67; 95%CI 1.42-9.52) and unintended discontinuation of adjuvant chemotherapy (OR 5.07; 95%CI 1.41-18.19). Unlike loss of skeletal muscle density, loss of skeletal muscle mass showed no association with postoperative outcomes. In older patients with ovarian cancer, loss of skeletal muscle density during NACT is associated with worse postoperative outcomes. These results could add to perioperative risk assessment, guiding the decision to undergo surgery or the need for perioperative interventions.

Which factors predict parametrial involvement in stage IB cervical cancer? A Chinese multicentre study

To explore the clinicopathological risk factors influencing parametrial involvement (PI) in stage IB cervical cancer patients and compare the oncological outcomes between Q-M type B radical hysterectomy (RH) group and Q-M type C RH group. Univariate and multivariate analyses were performed to explore the clinicopathological factors related to PI. Overall survival (OS) and disease-free survival (DFS) in patients with stage IB cervical cancer who underwent Q-M type B or Q-M type C RH under different circumstances of PI were also compared before and after propensity score matching (1:1 matching). A total of 6358 patients were enrolled in this study. Depth of stromal invasion>1/2 (HR: 3.139, 95% CI: 1.550-6.360; P = 0.001), vaginal margin (+) (HR: 4.271, 95% CI: 1.368-13.156; P = 0.011), lymphovascular space invasion (LVSI) (+) (HR: 2.238, 95% CI: 1.353-3.701; P = 0.002) and lymph node metastases (HR: 5.173, 95% CI: 3.091-8.658; P < 0.001) were associated with PI. Among the 6273 patients with negative PI, those in the Q-M type B RH group had a higher 5-year OS and DFS than those in the Q-M type C RH group before and after 1:1 matching. Among the 85 patients with positive PI, Q-M type C RH showed no survival benefits before and after 1:1 matching. Stage IB cervical cancer patients with no lymph node metastasis, LVSI(-) and depth of stromal invasion ≤1/2 may be considered for Q-M type B radical hysterectomy.

Prognostic role of perineural invasion in vulvar squamous cell carcinoma: A systematic review and meta-analysis

The prognostic role of perineural invasion (PNI) in vulvar squamous cell carcinoma (VSCC) has not been fully established since few studies on this topic are currently available in the literature. In the present study, we conducted a systematic review and metanalysis of literature data in order to determine if PNI could be an independent prognostic predictor of patient's survival in VSCC. Four electronic databases (PubMed, ISI Web of Science, Scopus and Google Scholar) were searched from their inception to December 2021 for all studies assessing the prognostic value of PNI in VSCC. Multivariate hazard ratios (HRs) for overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS) were pooled. Six studies with 1048 patients were included. PNI was significantly associated with decreased OS (HR = 2.687; p < 0.001), DSS (HR = 2.375; p = 0.014) and PFS (HR = 1.757; p = 0.001), with no statistical heterogeneity among studies and no significant risk of bias across studies. The present meta-analysis highlights that PNI is independently associated with unfavorable prognosis in patients with VSCC. Therefore, PNI should be included in the pathological report of VSCC and considered in combination with other risk factors as a possible criteria for prognostic assessment adjuvant treatment planning inclusion.

Peritoneal cancer index predicts severe complications after ovarian cancer surgery

prediction and importance of severe postoperative complications after ovarian cancer surgery is a strong issue in patient selection and evaluation. Pre- and early peroperative predictors of severe 30-days postoperative complications (Clavien-Dindo class ≥3) after surgery for primary ovarian cancer are not fully established, neither their impact on patients' survival. A prospective observational study included 256 patients with primary ovarian cancer FIGO stages IIB-IV, operated during 2009-2018 in a primary or interval debulking surgery setting. Patient variables were analysed in relation to severe postoperative complications (Clavien-Dindo class ≥3) and overall survival. High-grade postoperative complications occurred in 24.2% patients. Class 3a complications were observed in 12.5% cases. High-grade complications class ≥3 were observed in 31.6% after primary debulking surgery compared to 12.2% after interval debulking surgery (p = 0.0004). Peritoneal cancer index ≥21 and preoperative albumin concentration ≤33 g/L were independent predictors of high-grade complications. Peritoneal cancer index correlated with the surgical complexity score and completeness of cytoreduction. Increased peritoneal cancer index was a negative predictor of overall survival, but high-grade complications did not influence survival negatively. Peritoneal cancer index ≥21 was an independent predictor of high-grade complications after ovarian cancer surgery. Increased peritoneal cancer index also impacted overall survival negatively, but high-grade complications did not influence overall survival.

Asian perspective on debulking surgery for advanced ovarian cancer: An E-survey

We performed an E-survey to evaluate the practice patterns in debulking surgery for advanced ovarian cancer in Asia. We designed a questionnaire, including 50 questions related to debulking surgery for advanced ovarian cancer. The questionnaire was sent to Gynecologic Oncologic Groups in Asia from December 2016 to February 2017. A total of 253 gynecologic oncologists from Japan (58.9%), the Republic of Korea (19%), Taiwan (12.6%), and the other counties including China (7.5%), Malaysia (0.8%), Indonesia (0.8%), and Thailand (0.4%) participated in this E-survey. The median number of debulking surgeries per year was 20, and 46.8% of the respondents preferred <1 cm as the criterion for optimal debulking surgery (ODS). The most common barrier and surgical finding precluding ODS were performance status (74.3%) and disease involving the porta hepatis (71.5%). Moreover, 63.2% had a fellowship program, and only 15% or less had opportunities to receive additional training courses in general, thoracic, or urologic surgery. The median percentage of patients receiving neoadjuvant chemotherapy (NAC) was 30%, and the achieved rate of ODS in primary debulking surgery (PDS) and interval debulking surgery (IDS) was 65% and 80%, respectively. Most of the respondents required three to 6 h for PDS (48.6%) and IDS (58.9%). Moreover, more than 50% depended on ultra-radical surgery conducted by specialists. The ODS criteria are relatively lenient with a preference for NAC in 30% of the respondents in Asia. This trend might be associated with the dependence on aggressive surgery performed by specialists.

Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia

Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.

Distribution of residual disease in the peritoneum following neoadjuvant chemotherapy in advanced epithelial ovarian cancer and its potential therapeutic implications

Residual disease in 'normal appearing' peritoneum is seen in nearly 30% of the patients following neoadjuvant chemotherapy (NACT) for advanced ovarian cancer. The goal was to study the sequence of response in different regions, the commonest sites of occult residual disease, its incidence in different peritoneal regions and the potential therapeutic implications of these. This was a prospective multi-centre study (July 2018-June 2019). Pathological evaluation of cytoreductive surgery specimens was performed according to a fixed protocol. Prevalence of residual disease in different regions was used to study patterns of response and distribution of residual disease. In 85 patients treated between July 2018 to June 2019, microscopic disease in 'normal appearing' peritoneal regions was seen in 22 (25.2%) and in normal peritoneum around tumor nodules in 30 (35.2%) patients. Regions 4 and 8 of Sugarbaker's PCI had the highest incidence of occult disease and regions 9 and 10 the lowest. The response to chemotherapy occurred in a similar manner in over 95%- the least common site of residual disease was the small bowel mesentery, followed by upper regions (regions 1-3), omentum and middle regions (regions 0, 4, 8), lower regions (regions 5-7) and lastly the ovaries. During interval CRS, based on the disease mapping provided in this manuscript, regions that have a high probability of residual disease should be explored and dissected. Complete resection of involved the peritoneal region can completely address the occult disease. The role of resection of the entire region as well as 'normal appearing' parietal peritoneal regions should be prospectively evaluated.

Inflammatory biomarkers to predict postoperative infectious complications after cytoreductive surgery and HIPEC for peritoneal carcinomatosis

Early detection of postoperative infectious complications (IC) is crucial after Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). The aim of this study was to evaluate the predictive role of early postoperative inflammatory biomarkers level for the detection of postoperative IC. a retrospective study was performed including 199 patients treated with complete CRS/HIPEC for PC from various primary origins from September 2012 to January 2021. Patients were monitored by a routine measurement of inflammatory biomarkers (CRP, leukocytes, neutrophils, lymphocytes, neutrophile-to-lymphocyte ratio and platelets-to-lymphocyte ratio). Inflammatory biomarkers were compared between patients with vs without IC. IC occurred for 68 patients (34.2%). CRP values were significantly higher in patients with IC on POD 3, 5 and 7 (CRP = 166 mg/L [128-244], 155 mg/L [102-222] and 207 mg/L [135-259], respectively). The CRP on POD7, with a cut-off value of 100 mg/L, was an excellent predictor of postoperative IC (AUC = 90.1%). The CRP on POD 5, with a cut-off value of 90 mg/L, was a good predictor of postoperative IC (AUC = 83.2%). NLR values were significantly higher in patients with IC on POD 3, 5 and 7. NLR on POD 5 and 7 higher than 9.7 and 6.3, respectively, were fair predictors (AUC = 70.8 and 79.6, respectively). CRP levels between POD3 and 7 are the best predictors of postoperative IC after CRS/HIPEC. The presence of postoperative IC should be suspected in patients with CRP higher than 140 mg/L, 90 mg/L or 100 mg/L on PODs 3, 5 or 7.

Quality of advanced ovarian cancer surgery: A French assessment of ESGO quality indicators

In 2016, the European Society of Gynecology Oncology (ESGO) published indicators defining the quality of surgical management of advanced ovarian cancer. The objective of the study was to assess the quality of ovarian cancer patient management in regional centers authorized for gynecological cancer, based on the ESGO list of quality indicators. A multicenter retrospective observational cohort study was conducted from January 1 to June 30, 2016. The following quality indicators 1 "rate of complete surgical resection", 4 "center participating in clinical trials in gynecologic oncology", 5 "treatment planned and reviewed at a multidisciplinary team meeting", 6 "required preoperative workup", 8 "minimum required elements in operative reports" and 9 "minimum required elements in pathology reports" were selected. 91 patients were evaluated in 16 centers. The required preoperative workup was incomplete in 25% of cases. Treatment was not planned at a multidisciplinary team meeting for 24%. An evaluation score of peritoneal involvement was included in 40% of the operative reports and the quality of surgical resection was reported in 72%. Primary surgery was most often performed in a peripheral hospital (48%), interval surgery in a private center (37%), and closure surgery in a regional cancer center (43%). No institution respected the six quality indicators evaluated. One regional cancer center respected five items and two private centers did not respect any. Whilst the ESGO quality indicators provide objective, validated and evaluable support which centers can use to improve quality of care, we observed heterogeneous practices amongst the centers evaluated.

Extent and distribution of peritoneal disease in patients undergoing cytoreductive surgery for first platinum sensitive recurrence in ovarian cancer and its potential therapeutic implications

Selected patients with platinum sensitive recurrent ovarian cancer may benefit from cytoreductive surgery (CRS). The aim was to study the pattern of peritoneal involvement in these patients that has not been done before. A comparison was made between the surgical and pathological findings in 60 patients undergoing salvage CRS from July 2018 to December 2019. The sites of residual disease, correlation with surgical and pathological peritoneal cancer index (PCI), small bowel involvement and regional lymph node involvement were studied. Fifty-eight (96.6%) had serous carcinoma and 2 (3.4%) clear cell carcinoma. The median surgical PCI (sPCI) was 7 [range 0-27] and median pathological PCI (pPCI) 4 [range 0-21]. CC-0 resection was performed in 81.6%. The upper regions (region 1,2,3) were the commonest sites of residual disease (63.3%) followed by lower regions (region 5,6,7) in 55.0%, middle regions (regions 0,4,8) in 53.3% and small bowel regions (regions 9-12) in 26.6%. Small bowel involvement was associated with a higher sPCI and pPCI (p < 0.001 for both). Regional nodes were involved in 46.6%. A pathological complete response was seen in 8 (13.3%) patients of which 2 had residual disease in regional nodes. Microscopic disease in 'normal appearing' peritoneum was seen in 21%. The parietal peritoneum was the commonest site of recurrence. Small bowel involvement occurred late and was associated with more extensive disease. Regional lymph node involvement was seen nearly 50% and was a common site for occult disease. The role of more extensive parietal peritoneal resection for recurrent disease should be evaluated prospectively.

Ovarian and peritoneal psammocarcinoma: Results of a multicenter study on 25 patients

Psammocarcinoma (PK) is a rare disease of unknown origin. We aimed to report the characteristics, management and survival of patients operated on for PK within the French Network for Rare Peritoneal Malignancies (RENAPE) expert centers. All consecutive cases of PK operated within all 26 RENAPE centers between 1997 and 2018 were retrospectively analyzed. Twenty-five patients were identified. The median age was 53 years [range 17-78]. None of the patients had extra peritoneal metastases at diagnosis. A median of 6 cycles of carboplatin-based systemic chemotherapy was delivered in 52% preoperatively (n = 13) and 56% postoperatively (n = 14); associated with placlitaxel for 12 patients. All patients were operated on. The median PCI was 23 [0-33]. Eighty-four percent had a complete cytoreductive surgery through digestive (n = 7), spleen (n = 3), pancreas (n = 1) resections and/or multiple peritonectomies (n = 11). Five patients (20%) had intraperitoneal chemotherapy. Morbidity (Dindo-Clavien ≥3) was 12%. No postoperative death occurred. After a median follow-up of 42 months (range [2-194]), the median overall (OS) and progression-free (DFS) survival times were respectively 128 months and 31 months. Eighteen patients recurred (72%), mainly in the peritoneum (n = 16). Four of them (22%) were reoperated. The 5 and 10-year DFS rates were both 20.3%. The 5 and 10-year OS rates were 62% and 51.7%, respectively. A complete cytoreductive surgery was associated with a better OS and DFS in a univariate analysis. Complete cytoreductive surgery is the cornerstone of the PK's management as a primary treatment. Recurrence remains common and new adjuvant strategies seem needed.

Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review

In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality. The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery. Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality. The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency. Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.

Variability of treatment of locally advanced cervical cancer: How French multidisciplinary teams follow European guidelines?

Cervical cancer is a global public health concern. Despite ESGO recommendations and FIGO classification changes, management of locally advanced cervical cancer (LACC) remains debated in France. Our study aimed to review LACC treatment practices and assess adherence to ESGO recommendations among different practitioners. From February 2021 to August 2022, we conducted a survey among gynecologic oncology surgeons, radiation oncologists, and medical oncologists practicing in France and managing LACC (FIGO stages IB3-IVA) according to the 2018 FIGO classification. We analyzed responses against the 2018 ESGO recommendations as a "gold standard." Among 115 respondents (56% radiation oncologists, 30% surgeons, 13% medical oncologists), 48.6% of gynecologic surgeons didn't perform para-aortic lymphadenectomy (PAL) with significant radiologic pelvic involvement. PAL, when indicated by PET-CT, was more common in university hospitals (66.7% of surgeons). Surgeons in university hospitals also followed ESGO recommendations more closely. Overall, compliance with all ESGO recommendations was low: 5.7% of surgeons, 21.5% of radiation oncologists, and 60% of medical oncologists. Prophylactic para-aortic irradiation, per ESGO, was more frequent in comprehensive cancer centers (52% of radiation oncologists). Adherence to ESGO recommendations for LACC treatment appears low in France, particularly in surgery, with limited PAL in cases of lymph node negativity on PET-CT. However, these recommendations are more often followed by surgeons in university hospitals and radiation oncologists in cancer centers. Adherence to these recommendations may impact patient survival and warrants evaluation of care quality, justifying the organization of LACC management in expert centers.

Maximal surgical effort increases the risk of postoperative complications in the treatment of advanced ovarian cancer

Surgery is the cornerstone of the treatment for advanced ovarian cancer. Reaching complete cytoreduction resulting in no gross residual disease often requires complex surgery. The aim of this study was to assess the impact of increased surgical radicality on the risk of complications in the treatment of advanced ovarian cancer. All consecutive patients with advanced ovarian cancer (FIGO Stage IIIB-IVB) who had undergone primary or interval debulking surgery during a six-year study period were identified. In the midst of the study period, a surgical practice change towards maximal surgical effort occurred. Two groups were formed for the analysis: cohort A, that consisted of patients operated before the surgical paradigm shift and cohort B, that consisted of patients operated under the period of increased surgical radicality. 252 patients were included in the analysis. Complete resection (R0) was achieved in 21.3% of surgeries in cohort A and in 51.2% in cohort B. The total postoperative complication rate was 76.2%. Most of the complications (86.5%) were minor (Clavien-Dindo I-IIIA). The patients in cohort B were at increased risk for complications, OR 2.94 (95%CI 1.58-5.47; p = 0.001). As for the approach to cytoreduction (primary vs. interval debulking), there was no statistically significant association with the occurrence of postoperative complications (p = 0.659). In the present study more extensive surgeries led to better surgical results but increased postoperative morbidity. Postoperative complication rates were similar in both primary and interval debulking surgeries.

Multi-omic and immune landscapes of HPV-negative versus HPV-positive cervical cancer reveal implications for immunotherapy

HPV-negative cervical cancer (3-8% of cases) presents distinct clinical challenges and poorer prognosis compared to HPV-positive disease. We aimed to conduct an exploratory study to characterize its unique tumor immune microenvironment (TIME) and molecular drivers to inform immunotherapy development. We analyzed 70 cervical cancer patients (50 HPV-positive/HPV-A, 20 HPV-negative/HPV-I) using targeted next-generation sequencing and multiplex immunofluorescence. Clinical features, mutational profiles, immune cell infiltrates, and prognostic factors were compared between groups. Strict FDR correction and effect size analysis (Cliff's Delta) were applied to statistical comparisons. HPV-I tumors showed significant association with gastric-type adenocarcinoma (p < 0.001) and higher CA125 levels (p = 0.011). Molecularly, HPV-I tumors were substantially enriched for TP53 mutations (46.2% vs 2.2%, OR = 0.030, p < 0.001), while PIK3CA mutations predominated in HPV-A tumors (41.3% vs 7.7%, OR = 7.78, p = 0.047), suggesting notable mutual exclusivity. Immunologically, HPV-A tumors showed substantially higher stromal M2 macrophage density (Cliff's Delta = -0.51, Large Effect), while HPV-I tumors displayed significantly higher stromal immune cell ratios: M1/M2 (5.34 vs 0.87, p = 0.003), CD8+/M2 (13.65 vs 2.66, p = 0.004), and NK/M2 (8.43 vs 0.59, p = 0.012), revealing the paradox of favorable immune balance coexisting with immune exclusion. In HPV-I subgroup analysis, high CD8+/M2 ratio was associated with superior progression-free survival (16.7% vs 71.4% event rates, p = 0.014). HPV-negative and HPV-positive cervical cancers represent distinct entities with unique molecular and immunological profiles. Our exploratory findings suggest that HPV-I tumors exhibit the paradox of favorable stromal immune cell ratios coexisting with immune-excluded phenotype, while HPV-A tumors show higher M2 macrophage infiltration. The prognostic significance of CD8+/M2 ratio in HPV-I patients may provide a valuable biomarker and suggest specific therapeutic strategies targeting immune exclusion and macrophage polarization based on HPV status.

Development and validation of a predictive model for severe complications following ovarian cancer cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy

To construct and validate a risk prediction model for severe complications in ovarian cancer patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Patients who underwent CRS-HIPEC were enrolled from January 2021 to June 2025 and were randomly divided (4:1) into training and validation sets. Predictors of severe complications were identified and integrated into a nomogram. The nomogram's performance was evaluated through calibration, discrimination, and clinical utility. a total of 391 patients were included, with 313 in the training set and 78 in the validation set. Severe complications were diagnosed in 142(36.3%) patients, including 113(36.1%) in the training set and 29(37.2%) in the validation set. The final model incorporated four predictors: nutritional risk screening score (NRS-2002), high-sensitivity C-reactive protein, PCI, and operative duration. The nomogram demonstrated robust discrimination, with AUCs of 0.888 (95% CI 0.853-0.924) in training set and 0.857 (95% CI 0.767-0.950) in validation set. The Hosmer-Lemeshow tests for the model training and validation sets were χ Severe complications are common after CRS-HIPEC. Independent risk factors include high-sensitivity C-reactive protein, nutritional risk screening score, PCI, and operative duration. The visualized nomogram and risk stratification provided in this study conceptualize a preliminary framework for differentiated management pathways.

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

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

Liver-directed surgical procedures during cytoreductive surgery for stage IV ovarian cancer

The incorporation of liver-directed surgical procedures into cytoreductive surgery represents a challenge in stage IV epithelial ovarian cancer. Overall, 49 patients undergoing primary or interval debulking surgery with at least one hepatobiliary procedure were retrospectively analyzed. One intraoperative complication occurred and severe postoperative morbidity (grade III or higher according to the Clavien-Dindo classification) was observed in 8 (16.4%) patients. Only one of these complications (biliary leakage requiring endoscopic stenting) was directly attributable to liver surgery. Although limited by the small sample size, these findings suggest that, in carefully selected patients and within a multidisciplinary framework, hepatobiliary surgery can be safely incorporated into cytoreductive strategies to achieve complete tumor removal.

Perioperative trajectories of acute-phase proteins and their association with major postoperative complications in advanced ovarian cancer

Acute-phase proteins (APPs) reflect systemic inflammation and nutritional status, yet their perioperative trajectories and clinical utility as biomarkers of outcome in advanced ovarian cancer (aEOC) remain unclear. We aimed to characterise perioperative APP fluctuations and assess their associations with postoperative complications. This observational study included patients undergoing cytoreductive surgery for aEOC across two prospective studies (n = 274). Serial serum albumin, transthyretin, C-reactive protein (CRP), fibrinogen, and procalcitonin were measured preoperatively and on postoperative days (PoD) 1, 3, and 5. Associations between APP levels and major postoperative complications, classified by Clavien-Dindo (CD ≥ III), were examined using multivariable logistic regression. Length of stay (LOS) was evaluated for biomarkers showing significant associations. Predictive thresholds were derived by ROC analysis. Positive APPs peaked postoperatively (CRP and fibrinogen on PoD 3; procalcitonin on PoD 1), while negative APPs reached nadirs on PoD 3. Neither preoperative albumin (>35 g/L) nor transthyretin (>0.2 g/L) predicted major postoperative complications. In contrast, elevated CRP measured on PoD 3 was associated with both major postoperative complications, OR 2.78 (95% CI 1.45-5.48) and prolonged LOS (>7 days) OR 3.0 (95% CI 1.67-5.47), with optimal cut-offs of ≥287 mg/L and ≥322 mg/L respectively (AUC 0.80). Preoperative APPs were not associated with postoperative outcomes in this cohort. CRP measured on postoperative day 3 was the most informative biomarker associated with major postoperative complications and prolonged hospital stay after cytoreductive surgery for advanced ovarian cancer and may support postoperative surveillance and recovery assessment when interpreted alongside clinical findings.

The role of artificial intelligence in pre-operative prediction of completeness of cytoreduction for peritoneal surface malignancies: a scoping review

Complete cytoreduction is the most important prognostic factor for patients with peritoneal surface malignancies (PSM) and its prediction remains a clinical challenge. Artificial intelligence (AI) offers a novel opportunity to integrate clinical and imaging features to support surgical decision-making. This scoping review aimed to analyse applications of AI for predicting cytoreduction completeness in PSM. A scoping review was conducted in accordance with PRISMA-ScR guidelines and registered with Open Science Framework. PubMed, Scopus, and Embase were searched from 2000 to 2025. Eligible studies applied AI models to predict cytoreduction completeness in patients with PSM using pre-operative data. Data were extracted on study design, disease type, model architecture, input predictors, performance metrics and explainability strategies. From 262 records identified from the search strategy, nine studies were included. Seven focused on ovarian cancer, one on synchronous colorectal peritoneal metastases, and one on a mixed PSM. Area under the curve (AUC) values ranged from 0.70 to 0.98. Radiomics-clinical nomograms consistently outperformed single-modality models. The DeAF deep learning framework achieved the strongest multicentre validation (AUC of 0.90), underscoring the potential of deep feature extraction. However, explainability was limited to nomograms, feature importance plots, or calibration analyses; no study adopted modern explainable AI techniques. AI models demonstrate potential for pre-operative prediction of cytoreduction completeness in PSM, particularly when radiomics are combined with clinicopathological factors or when deep learning is applied. Future research should prioritise multicentre external validation, integration of multimodal data and the adoption of explainability tools to enable clinical translation.

Integrating molecular classification into endometrial cancer management

Endometrial carcinoma is biologically heterogeneous. Molecular classification derived from The Cancer Genome Atlas (TCGA) identifies clinically relevant molecular subtypes, each with distinct prognostic and therapeutic implications. FIGO 2023 recognizes tumor biology in staging, and the new 2025 ESGO guidelines incorporate molecular data into risk-stratified management. This is a position paper on the incorporation of molecular classification in endometrial cancer. We focused on molecular taxonomy, diagnostic surrogates, prognostic validation, and therapeutic implications of immune and targeted agents. The five molecular subtypes (POLEmut; MMRd/MSI-H; p53abn; NSMP ER-positive; NSMP ER-negative) provide stronger prognostic discrimination than grade or histotype alone. We recommend that molecular subtype should guide adjuvant treatment de-escalation or intensification, inform the use of immunotherapy and targeted agents, and refine risk stratification beyond conventional parameters. We also discussed implementation challenges, including test standardization, reporting, equity of access, and areas of ongoing uncertainty. This position paper aims to support consistent, equitable, and biologically informed management of endometrial carcinoma in contemporary practice.

Association between tumor laterality and prognosis across different ovarian cancer subtypes: Results from SEER database and a Chinese multicenter cohort

To investigate the association between tumor laterality and prognosis across different histological subtypes of ovarian cancer. In this study, we enrolled patients with ovarian serous cancer (SC), endometrioid cancer (EC), mucinous cancer (MC), clear cell cancer (CCC), sex cord-stromal tumor (SCST) and malignant germ cell tumor (MGCT) from the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2017. Additionally, we enrolled MGCT patients from a Chinese multi-institutional registry between 2003 and 2020 for complementary analyses. The primary outcomes were cancer-specific survival (CSS) and disease-free survival (DFS) in the SEER cohort and Chinese cohort, respectively. Multivariate Cox regression and Kaplan-Meier analyses were used to assess the association of tumor laterality with prognosis. In the SEER cohort with 13597 ovarian cancer patients, the fully-adjusted multivariate Cox regression model showed the right-sided tumor was significantly associated with a better CSS than the left-sided tumor (hazard ratio [HR] 0.51, 95 % confidence interval [CI]: 0.27-0.97; P = 0.041) among MGCT patients, whereas no significant association between tumor laterality and CSS was found among patients with SC, EC, MC, CCC and SCST (all P > 0.05). Furthermore, among the 288 MGCT patients in the Chinese cohort, the significant association of right-sided disease with better DFS (HR: 0.18, 95 % CI: 0.05-0.68; P = 0.011) was also observed. Similar results were found in the Kaplan-Meier analyses. Patients with right-sided tumor had a better prognosis than those with left-sided tumor in MGCT, but not in other ovarian cancer subtypes. Our findings suggested that personalized treatment strategies based on the tumor laterality might be necessary among MGCT patients.

Comparative study on the oncological prognosis of laparoscopy and laparotomy for stage IIA1 cervical squamous cell carcinoma

To compare the 5-year overall survival (OS) and disease-free survival (DFS) rate of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IIA1 cervical squamous cell carcinoma. Based on a large database containing information on the clinical diagnosis and treatment of cervical cancer in China, the oncological outcomes of the two surgical approaches for stage IIA1 cervical squamous cell carcinoma were compared after 1:2 propensity score matching (PSM). After 1:2 propensity score matching (PSM), 510 patients were included in the LRH group, and 999 patients were included in the ARH group. LRH showed a similar 5-year OS but a lower DFS rate (81.3% vs. 87.4%, P = 0.018) than ARH. In the multivariate analysis, LRH was identified as an independent risk factor for worse 5-year DFS (HR = 1.569, 95% CI: 1.131-2.176, P = 0.007). Among patients with a tumour size <2 cm, the LRH and ARH groups showed similar OS and DFS rates after 1:2 PSM, and multivariate analysis showed that the surgical approach was not an independent risk factor affecting the OS or DFS rate. Among patients with a tumour size ≥2 cm and <4 cm, there was no difference in OS between the LRH and ARH groups after matching, but the DFS in the LRH group was significantly lower than that in the ARH group (81.1% vs 86.2%, P = 0.034). In the multivariate analysis, the laparoscopic approach was not associated with OS but was independently associated with worse DFS (HR = 1.546, 95% CI: 1.094-2.185, P = 0.014). LRH was associated with poorer 5-year DFS than ARH in patients with stage IIA1 cervical squamous cell carcinoma. However, LRH showed 5-year OS and DFS rates similar to those of ARH among patients with a tumour size <2 cm. For patients with a tumour size ≥2 cm and <4 cm, LRH showed a lower DFS rate than ARH.

Biobanking and gynecologic oncology - Special considerations, challenges and opportunities

Biobanks of gynecological tissues occupy a critical niche in oncologic research. They are essential components of contemporary research strategies on gynecologic malignancy by integrating clinical, molecular and longitudinal biospecimen data. They also implement protocols for quality control, regulate sample and data sharing, provide ethical and regulatory oversight, and establish governance mechanisms to regulate their function. Gynecologic tissue biobanks also face some unique challenges. The broad heterogeneity of disease entities encompassed under this domain include common and rare malignancies, each with unique molecular subtypes that must be integrated into biobank information systems. Specimen acquisition extends beyond conventional tissues to include cervicovaginal microbiomes and ascitic fluid. Thus, gynecologic tissue biobanks should develop tailored collection strategies and the establishment of dedicated gynecologic tissue repositories that enable the aggregation of rare specimens through collaborative networks. This article emphasizes the need for high-quality annotation of biospecimens, the incorporation of multi-omics approaches to enhance the translational approaches, challenges associated with integration of high dimensional datasets, the role of biobank networks, and various ethical and cultural considerations concerning gynecologic biobanks. Emerging technologies that integrate multi omics, spatial biology and liquid biopsies now offer enhanced opportunities that augment classical specimen collection and should be integrated into standardized protocols.

Neuroendocrine tumors of the gynecological tract: A narrative literature review

Neuroendocrine neoplasms (NENs) of the gynecological tract are a rare, heterogenous and aggressive group of neoplasms, with high recurrence rates and poor prognosis. In this review we focus on NENs of the gynecological system emphasizing the classification, epidemiological and clinical characteristics of NENs across the gynecological tract (cervix, endometrium, ovary, vagina, and vulva), risk/prognostic factors, pathology and molecular biology (including actionable genomic mutations), imaging, staging and the most effective treatment modalities in the "standard of care" approach as well as the pipeline products. We also focused on metastatic spreading patterns of gynecological NENs. We searched for all available literature reviews, interventional studies, short series, case reports and meta-analyses published from 1990 to 2024. Deteriorated survival rate is essentially impacted by early development of lymph node, distant organ metastases and vascular propagation toward rapid extra-pelvic metastasis to the brain, liver, lung, bone marrow, lymph nodes and bones. Management of NENs needs to be customized on a case-based manner and comprises a multidisciplinary approach that involves gynecologists, surgeons, medical oncologists, radiologists, radiation oncologists, nuclear medicine specialists, pathologists, molecular biologists, qualified nurses etc. The treatment of extrapulmonary NENs arising in the female genital tract is basically extrapolated from that for small cell lung cancer. This includes, but is not limited to: surgery, chemotherapy, radiotherapy, peptide receptor radionuclide therapy, somatostatin analogs, and immunotherapy as well as investigational drugs in rare prospective clinical trials. Establishing modern therapeutic thesaurus is conditioned by the existence of well-designed clinical trials targeting a tumor's genomic profile and the incorporation of these data into the actual treatment landscape.

Efficacy of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after gynecological cancer surgery: A systematic review and meta-analysis

To evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to enoxaparin, a low molecular weight heparin (LMWH). for postoperative thromboprophylaxis in patients undergoing gynecologic cancer surgery. This systematic review and meta-analysis followed Cochrane Handbook guidelines and PRISMA recommendations. We searched PubMed, Embase, Scopus, and CENTRAL for randomized controlled trials (RCTs) and observational studies comparing DOACs and LMWHs for postoperative VTE prophylaxis in gynecologic cancer surgeries. Outcomes included VTE incidence, major bleeding, clinically relevant non-major bleeding (CRNMB), hospital readmission, and drug adherence. The risk of bias was assessed using the Cochrane tools (RoB-2 and ROBINS-I), and statistical analyses were conducted using Review Manager 5. Five studies (1436 patients) were included: two RCTs and three observational studies. There was no significant difference in 30-day VTE incidence between DOAC and LMWH groups (OR, 0.55; 95 % CI, 0.17 to 1.77; P = 0.31). Similarly, major bleeding rates showed no difference (OR, 1.13; 95 % CI, 0.29 to 4.42; P = 0.90). DOACs significantly reduced CRNMB events compared to LMWHs (OR, 0.44; 95 % CI, 0.23 to 0.82; P = 0.01). Hospital readmissions (OR, 0.68; 95 % CI, 0.33 to 1.41; P = 0.30) and drug adherence rates (OR, 0.95; 95 % CI, 0.36 to 2.52; P = 0.29) were comparable between the groups. DOACs provide a safe and effective alternative to LMWH for postoperative thromboprophylaxis in gynecologic cancer surgeries. The significant reduction in CRNMB events suggests a potential safety advantage of DOACs.

Gynecological cancers: Bridging the gap between research and cure

Approximately 1.5 million women suffer from gynecological malignancies every year. Around 60 % of these cancers are classified as rare in the European population. Because of their rarity, the management of these tumors requires specific approaches by the cancer community and national health systems. Effective international collaborations in the area of gynecological cancer are underway, thanks to various initiatives such as GYNOCARE and other Collaboration in Science and Technology (COST) Actions. This special issue of EJSO collects expert opinions on the ongoing research and treatment options in various types of gynecological malignancy.

Transperitoneal versus extraperitoneal laparoscopic aortic lymph nodal staging for locally advanced cervical cancer: A systematic review and meta-analysis

Cervical cancer is the fourth most common neoplasm in women. In locally advanced cervical cancers, the international guidelines recommend nodal aortic assessment. Two techniques have been described to perform laparoscopic aortic lymphadenectomy: transperitoneal laparoscopic lymphadenectomy (TLL) and extraperitoneal laparoscopic lymphadenectomy (ELL). This meta-analysis aims to compare the surgical outcomes of TLL and ELL for staging purposes. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Two hundred and twenty studies were analyzed, and 19 studies were included in the review (7 for TLL and 12 for ELL group). 1112 patients were included in the analysis: 390 patients were included in group 1 and 722 patients in group 2.38 patients (9.7%) in the TLL group and 69 (9.5%) patients in the ELL group developed major complications. The analysis of all complications (intraoperative and postoperative) rate through pooled analysis did not show a significant difference between the two groups (p = 0.979), although a significantly higher intraoperative complication rate (p = 0.018) occurred in the TLL group compared to ELL. No significant differences were found between groups for BMI (p = 0.659), estimated blood loss (p = 0.889), length of stay (p = 0.932), intraoperative time (p = 0.932), conversion to laparotomy rate (p = 0.404), number of lymph node excised (p = 0.461) and postoperative complication (p = 0.291). TLL approach shows a higher rate of intraoperative complications, while no significant difference was found between the two techniques when postoperative complications were analyzed.

Added value of para-aortic surgical staging compared to 18F-FDG PET/CT on the external beam radiation field for patients with locally advanced cervical cancer: An ONCO-GF study

Extended field chemoradiation is recommended for patients with locally advanced cervical cancer (LACC) and para-aortic lymph node (PALN) metastases. The radiation planning may be based on PET/CT while others recommend to rely on surgical staging. We report the rate of patients for whom the radiation field defined on PET/CT was modified by the histological PALN status. Between March 2010 and December 2016, 168 consecutive patients with LACC underwent a pre-therapeutic PET/CT and PALN dissection. The data were reviewed retrospectively. The diagnostic performance of the PET/CT for definition of PALN status was calculated. We determined the percentage of patients for whom PALN dissection altered the external beam radiotherapy (EBRT) field defined on the PET/CT basis. Of 151 patients with negative PALNs on PET/CT, 26 had histological PALN metastases. Of 17 patients with positive PALNs on PET/CT, 9 were negative on histology of which 7 were located in the common iliac region. Sensitivity, specificity, positive and negative predictive value of PET/CT were 23.5, 93.3, 47.1 and 82.8% respectively. In total, 35 out of 168 patients underwent EBRT - field adaptation (pelvic vs extended field). The rate of radiation field modification (27,7%) was particularly high in the subgroup of patients with metastatic pelvic lymph nodes (PLNs) on PET/CT. Para-aortic surgical staging contributes significantly to individualize the radiation treatment of patients with LACC, particularly for those with positive PLNs at PET/CT. Indication of surgical staging deserves particular attention when the PET/CT suggests positive LNs in the common iliac region.

Predictive value of preoperative serum squamous cell carcinoma antigen (SCC–Ag) level on tumor recurrence in cervical squamous cell carcinoma patients treated with radical surgery: A single-institution study

We seek to explore the clinical significance of serum squamous cell carcinoma antigen (SCC-Ag) and the optimal cut-off value for predicting tumor recurrence and survival in operable cervical squamous cell carcinoma patients. A total of 3471 patients with cervical squamous cell carcinoma who underwent radical surgery were enrolled in this study. The cut-off value of serum SCC-Ag for tumor recurrence was calculated using the receiver operating characteristic (ROC) curve. The progression-free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier method and multivariate analysis was further performed. The optimal cut-off value of serum SCC-Ag level for predicting tumor recurrence was calculated and set at 2.75 ng/mL. Compared to the value of 1.5 ng/mL used in clinical practice, our results showed that serum SCC-Ag level >2.75 ng/mL was closely related to extrapelvic metastases in relapsed patients (P = 0.035). Multivariate analysis showed that neither serum SCC-Ag level >1.5 ng/mL nor serum SCC-Ag level >2.75 ng/mL was independent risk factors for PFS and OS in all patients. However, among 964 patients with at least one high-risk factor (parametrial invasion, vaginal margin invasion and lymph node metastasis), serum SCC-Ag level > 2.75 ng/mL, instead of serum SCC-Ag level > 1.5 ng/mL, could be used as an independent factor affecting PFS (P = 0.018). Preoperative serum SCC-Ag level > 2.75 ng/mL is closely related to extrapelvic recurrence, and is an independent factor for tumor recurrence and survival in cervical squamous cell carcinoma patients with high-risk factors.

Sentinel lymph node procedure in early-stage vulvar cancer: Correlation of lymphoscintigraphy with surgical outcome and groin recurrence

In early-stage vulvar squamous cell carcinoma (VSCC) a sentinel lymph node (SLN) procedure is regarded successful if at least one SLN is removed with minimal residual radioactivity. An inguinofemoral lymphadenectomy is considered if not all SLNs visualized on lymphoscintigraphy can be found, with subsequent increased morbidity. We correlated lymphoscintigraphy findings with surgical outcome and groin recurrence with focus on number of SLNs found. This study concerns a retrospective cohort of 171 women treated for early-stage VSCC who underwent a SLN procedure between 2000 and 2020. The risk of groin recurrence was compared after either a successful or complete SLN procedure, i.e. removal of all SLNs that were visualized on lymphoscintigraphy. In 13 (7.6%) groins of 171 patients SLN visualization on lymphoscintigraphy failed. In 230 of the 246 (93.5%) groins in which a SLN was visualized, at least one SLN was found during surgery. In 224 of the 246 (91.1%) groins the SLN procedure was regarded either successful (n = 14) or complete (n = 210). An isolated groin recurrence was documented in 5 out of 192 (2.6%, 95%-CI; 0.34 to 4.9) SLN-negative groins after a median follow-up of 47.0 months. All recurrences were noted in the complete SLN group (5/180 groins). The difference with the successful SLN group (0/12 groins) was not significant. Risk of groin recurrence was 2.6% after SLN negative biopsy in early-stage VSCC. The risk appeared not increased if at least one SLN was found with minimal residual radioactivity, in case more SLNs were visualized on lymphoscintigraphy.

Detection rates of sentinel lymph node in vulvar cancer using the new protocol with indocyanine-green fluorescence: Time to abandon both blue dye as well as 99mTc-labeled colloid lymphoscintigraphy protocols?

Research waste among randomized controlled trials in ovarian cancer: A cross-sectional study

To examine the association between trial characteristics and research waste in randomized controlled trials (RCTs) on ovarian cancer over the past two decades. ClinicalTrials.gov was searched for RCTs registered between 2000 and 2020 using the keyword ovarian cancer. Publication status of RCTs was determined through systematic searches of the PubMed and Google Scholar databases. Reporting adequacy was evaluated using the CONSORT checklist. Design limitations were assessed based on the risk of bias and whether a relevant systematic review was cited in the manuscript. The primary outcome was research waste, defined as an RCT that was unpublished, inadequately reported, or had avoidable design limitations. Among the 117 RCTs evaluated, 89 (76.1 %) were published as of February 14, 2024. Published RCTs were more likely to be pharmacological, conducted in North America or Europe, have a multicenter or multinational design, have a larger sample size (over 200 participants), and receive external funding (P < 0.05). Among the published RCTs, 73 (82.0 %) and 24 (27.0 %) were considered adequately reported and free from design limitations, respectively. Overall, 96 of the 117 RCTs (82.1 %) were associated with research waste. Factors independently associated with research waste were an open-label design and smaller sample size (P < 0.05). Over 80 % of the RCTs on ovarian cancer demonstrated at least one feature of research waste. Future efforts should focus on minimizing the potential waste in unblinded small-scale RCTs.

Validation of the FIGO2023 staging system for early-stage endometrial cancer

In 2023, the International Federation of Gynecology and Obstetrics (FIGO) updated the endometrial cancer staging system (FIGO2023). Our study aimed to validate the prognostic value of FIGO2023 in patients with early-stage EC (Stage I and Stage II). After screening eligible EC patients from the Surveillance, Epidemiology and End Results (SEER) database, Kaplan-Meier cancer-specific survival (CSS) curves were used to evaluate the prognosis of patients with different stages. In addition, AUC, C-index, Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and Decision curve analysis (DCA) were used to comprehensively compare the efficacy of the new and the old staging system in predicting prognosis. A total of 33,156 patients were enrolled. The introduction of FIGO2023 significantly increased the proportion of stage II patients from 5.53 % to 24.76 %. The FIGO2023 defines different substages for patients, which show significant differences in CSS. Compared with FIGO2009, FIGO2023 performed better in discrimination, goodness of fit and clinical decision making. Compared with FIGO2009, FIGO2023 had a higher accuracy in predicting CSS in patients with early-stage EC in the SEER database.

Risk factors for pelvic and para-aortic lymph node metastasis in non-endometrioid endometrial cancer

The aim of this study was to evaluate the risk factors for pelvic lymph node metastasis (LNM) and para-aortic LNM in non-endometrioid endometrial cancer (non-EEC). A total of 283 patients with non-EEC hospitalized in the First Affiliated Hospital of Zhengzhou University from January 2012 to December 2020 were included. Various characteristics were retrospectively analyzed in relation to LNM. Univariable and multivariable logistic regression analysis revealed cervical stromal invasion (OR = 3.441, 95% CI = 1.558-7.6, p = 0.002), myometrial invasion ≥1/2 (OR = 2.661, 95% CI = 1.327-5.337, p < 0.006), lymphovascular space involvement (LVSI) (OR = 4.118, 95% CI = 1.919-8.837, p < 0.001), positive peritoneal cytology (OR = 2.962, 95% CI = 1.344-6.530, p = 0.007), CA125 (OR = 1.002, 95% CI = 1-1.004, p = 0.026) were the independent risk factors for pelvic LNM. And myometrial invasion ≥1/2 (OR = 5.881, 95% CI = 2.056-16.427, p = 0.001), LVSI (OR = 4.962, 95% CI = 1.933-12.740, p = 0.001), adnexal (OR = 5.921, 95% CI = 2.003-17.502, p = 0.001) were the independent risk factors for para-aortic LNM. With the increase of independent risk factors, the rates of LNM were increased significantly. Cervical stromal invasion, myometrial invasion ≥1/2, LVSI, positive peritoneal cytology, and CA125 were risk factors for pelvic LNM. Myometrial invasion ≥1/2, LVSI and involvement of the adnexa were risk factors for para-aortic LNM which could provide a good basis to help predict which non-EEC patients are at higher risk for LNM.

Robot-assisted surgery for women with endometrial cancer: Surgical and oncologic outcomes within a Belgium gynaecological oncology group cohort

To evaluate surgical and oncologic outcomes of patients treated by robot-assisted surgery for endometrial cancer within the Belgium Gynaecological Oncology Group (BGOG). We performed a retrospective analysis of women with clinically Stage I endometrial cancer who underwent surgical treatment from 2007 to 2018 in five institutions of the BGOG group. A total of 598 consecutive women were identified. The rate of conversion to laparotomy was low (0.8%). The mean postoperative Complication Common Comprehensive Index (CCI) score was 3.4. The rate of perioperative complications did not differ between age groups, however the disease-free survival was significantly lower in patients over 75 years compared to patients under 65 years of age (p=0.008). Per-operative complications, conversion to laparotomy rate, post-operative hospital stay, CCI score and disease-free survival were not impacted by increasing BMI. Robot-assisted surgery for the surgical treatment of patients suffering from early-stage endometrial cancer is associated with favourable surgical and oncologic outcomes, particularly for unfavourable groups such as elderly and obese women, thus permitting a low morbidity minimally-invasive surgical approach for the majority of patients in expert centres.

Sentinel lymph node biopsy in apparently early-stage epithelial ovarian cancer: a systematic review and meta-analysis

To evaluate the detection rate, sensitivity, and negative predictive value (NPV) of sentinel lymph node (SLN) biopsy in patients with apparently early-stage epithelial ovarian cancer (EOC). A systematic search of multiple electronic databases was conducted from inception to October 31, 2025. Studies reporting detection rate, sensitivity, and NPV of SLN biopsy in apparently early-stage EOC, with completion pelvic and para-aortic lymphadenectomy as reference standard, were included. Study selection, risk-of-bias assessment, and data extraction were independently performed by four reviewers. Pooled estimates with 95 % confidence intervals (CI) were calculated using random-effects models on a per-patient basis and by anatomical site. Heterogeneity was assessed using the I Fourteen studies comprising 365 patients were included. Most studies used indocyanine green injected into the infundibulopelvic ligament for para-aortic mapping and the utero-ovarian ligament for pelvic mapping. The pooled para-aortic detection rate was 79.9 % (95 %CI 66.1-91.4 %; I In apparently early-stage EOC, SLN biopsy shows acceptable para-aortic detection but limited pelvic detection. Nonetheless, sensitivity and NPV indicate high diagnostic accuracy. Further studies are needed to optimize pelvic mapping strategies and confirm these findings. At present, sentinel lymph node mapping in apparently early-stage epithelial ovarian cancer should be regarded as investigational and not as standard of care.

Lymphadenectomy for high-grade endometrial cancer: Does it impact lymph node recurrence?

The diagnostic role of lymph node (LN) assessment is established in endometrial cancer. Our study assesses whether surgical removal of metastatic LNs has oncologic benefit in high-grade endometrial cancer. High-grade endometrial cancer cases (2000-2010) were collected from two tertiary cancer centres. In patients with at least one positive LN, recurrence free survival (RFS) was compared by the number of LNs removed. Factors predicting nodal recurrence (NR) were explored. Univariate statistical analyses by log rank test and multivariable cox proportional hazards model were performed using SAS version 9.4. Of 570 patients identified, 334 patients underwent staging lymphadenectomy, 74 (22.2%) patients had at least one positive LN. The median RFS with at least one positive lymph node was 87.1 months (95% CI ≥ 14.3) when greater than 15 LNs were removed, compared to 16.9 months (95% CI, 13.6-35.6) and 17.3 months (95% CI, 8.5-39.8) when 5-15 and less than 5 LNs were removed, respectively (p = 0.02). In the cohort of 570 patients, there were 167 disease recurrences with location described on imaging, 98 (58.7%) had a NR and 69 (41.3%) recurred at other sites. Multivariable modeling identified that only positive LNs at surgical staging predicted NR (HR 3.8, 95% CI 1.4-10.2). In high-grade endometrial cancer, positive LNs predict NR, and RFS is longer with a more extensive LN dissection in women with positive LNs. Future prospective studies should evaluate the oncologic benefit of surgical removal of metastatic LNs in high-grade endometrial cancer.

Artificial intelligence-based radiomics models in endometrial cancer: A systematic review

Radiological preoperative assessment of endometrial cancer (EC) is in some cases not precise enough and its performances improvement could lead to a clinical benefit. Radiomics is a recent field of application of artificial intelligence (AI) in radiology. To investigate the contribution of radiomics on the radiological preoperative assessment of patients with EC; and to establish a simple and reproducible AI Quality Score applicable to Machine Learning and Deep Learning studies. We conducted a systematic review of current literature including original articles that studied EC through imaging-based AI techniques. Then, we developed a novel Simplified and Reproducible AI Quality score (SRQS) based on 10 items which ranged to 0 to 20 points in total which focused on clinical relevance, data collection, model design and statistical analysis. SRQS cut-off was defined at 10/20. We included 17 articles which studied different radiological parameters such as deep myometrial invasion, lympho-vascular space invasion, lymph nodes involvement, etc. One article was prospective, and the others were retrospective. The predominant technique was magnetic resonance imaging. Two studies developed Deep Learning models, while the others machine learning ones. We evaluated each article with SRQS by 2 independent readers. Finally, we kept only 7 high-quality articles with clinical impact. SRQS was highly reproducible (Kappa = 0.95 IC 95% [0.907-0.988]). There is currently insufficient evidence on the benefit of radiomics in EC. Nevertheless, this field is promising for future clinical practice. Quality should be a priority when developing these new technologies.

Surgical complications occurring during minimally invasive sentinel lymph node detection in endometrial cancer patients. A systematic review of the literature and metanalysis

Endometrial cancer (EC) is the most common gynecological cancer. Sentinel lymph node (SLN) technique has been adopted worldwide and showed lower morbidity and superimposable survival outcomes than the systematic lymphadenectomy (LND). Although these encouraging results, no meta-analyzes were performed on surgical complications during SLN research among patients undergoing laparoscopic (L) versus robotic surgery (R). The present review aims to report surgical complications during laparoscopic versus robotic SLN technique. The Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines have been followed for the present meta-analysis. Six studies, including 769 participants, were included. L-LND resulted in a significantly higher risk of operative complications relative to L-SLN (RR 2.10 [95% CI 1.37 to 3.21]). The risk of complications was comparable between R-SLN and L-SLN (RR 2.32 [95% CI 0.04-121.02]) and between R-LND and L-LND (RR 2.17 [95% CI 0.04-126.69]). According to the SUCRA analysis, L-SLN and R-SLN had the highest chances of being ranked first among proposed surgical procedures (SUCRA 48.9% and 28.4% respectively). Our study reported a lower surgical complications rate in patients undergoing L-SLN technique compared to L-LND. A lower rate of surgical complications was also reported for the R-SLN technique compared to the R-LND. Both laparoscopic and robotic SLN surgical techniques were found to be safe surgical procedures.