Journal of Surgical Oncology

Treatment Strategy and Residual Disease as Determinants of Survival in Stage IVB High‐Grade Serous Ovarian Cancer: A Retrospective Cohort Study

ABSTRACT Background and Objective Stage IVB high‐grade serous ovarian cancer (HGSOC) carries a poor prognosis. We aimed to: (1) describe the characteristics and survival of patients treated with primary cytoreductive surgery (PCS), interval cytoreductive surgery (ICS) or chemotherapy alone, (2) investigate the correlation between disease distribution and treatment type, and (3) evaluate the impact of cytoreductive surgery (CS) “aggressiveness” and outcome on survival. Methods A single‐center retrospective cohort study of Stage IVB HGSOC patients. Demographics, tumor characteristics, treatment including “aggressive” CS (upper abdominal and extraperitoneal procedures), and outcomes were analyzed using descriptive statistics and survival analysis, with nonparametric tests and Cox‐proportional hazard models. Results Of 110 patients, 24 (22%) underwent PCS, 73 (66%) ICS, and 13 (12%) chemotherapy alone. Median overall survival (OS) was 76.2 (PCS), 36.9 (ICS), and 20.1 months (chemotherapy alone) ( p  = 0.014). Supradiaphragmatic lymph‐node metastasis differed across groups ( p  = 0.042). “Aggressive” CS was performed in 53.6% of the surgical cohort, with 54.86% no‐gross‐residual (NGR), 34% optimal ≤ 1 cm ≤ and 11.3% suboptimal/aborted surgical outcome. Median OS post CS for NGR, optimal ≤ 1 cm, and suboptimal was 67.55, 35.26, and 20.97 months, respectively ( p  = 0.006). Conclusions OS for Stage IVB HGSOC follows a hierarchical pattern: PCS, ICS, and chemotherapy. Disease distribution guides treatment and residual tumor after CS correlates with survival.

Liver Resection With Extrahepatic Disease: A Population‐Based Analysis of Thoughtful Selection

ABSTRACT Background The oncologic benefit of liver resection for colorectal liver metastases (CRLM) in the setting of concurrent extrahepatic disease (EHD) is controversial. We performed a population‐based, cross‐sectional study to determine the practice patterns and overall survival (OS) of patients with CRLM + EHD who underwent liver resection. Methods Patients with CRLM + EHD were identified using the California Cancer Registry from 2000 to 2019. Records were linked to the Office of Statewide Health Planning Inpatient Database. Patient demographics, clinical characteristics, and survival were compared between CRLM + EHD patients with and without liver resection. Results Of 170 978 patients with CRLM, 62 003 (36%) had concurrent EHD (CRLM + EHD). In all, 3736 (6%) of CRLM + EHD underwent liver resection compared to 22% of patients with liver limited CRLM. Compared to CRLM + EHD without liver resection, CRLM + EHD with resection were younger, had fewer comorbidities, received higher frequencies of perioperative chemotherapy, and were more likely to have only a single site of EHD rather than multiple sites. Median OS was significantly higher for CRLM + EHD with resection compared to without (52 vs. 27 months, HR 0.46 [95% CI 0.44–0.47], p  < 0.001). Regarding the location of EHD, this survival benefit was observed with liver resection for lung, peritoneal, intraabdominal lymph nodes, ovarian, and bone metastases. Conclusions In a large population‐based setting, subsets of CRLM + EHD patients that undergo liver resection are associated with prolonged survival. These results support surgery with thoughtful patient selection to optimize survival outcomes in this population.

Predictive Factors for Failed Sentinel Lymph Node Mapping in Endometrial Cancer: A Retrospective Multicenter Study

ABSTRACT Background and Objectives This study aims to evaluate the predictive factors associated with failed sentinel lymph node (SLN) mapping in a large, retrospective cohort of patients with early‐stage endometrial cancer (EC). Methods We retrospectively evaluated a series of EC patients who underwent laparoscopic SLN mapping with intracervical indocyanine green (ICG) injection in five referred oncological centers from January 2019 to March 2024. We compared the clinical and pathological features of bilateral and failed SLN mapping, which was defined as either unilateral mapping or no SLN mapping. Logistic regression was used to identify predictors of failure. Results Among 623 analyzed patients, 437 (70.14%) had a successful bilateral procedure. On univariate analysis, age ( p  = 0.03), non‐endometrioid histology ( p  = 0.02) and previous vaginal delivery ( p  = 0.015) were significant associated with failed SLN mapping. On multivariable analysis, only increasing age (OR 1.03; 95% CI, 1.01–1.04, p  = 0.03) and non‐endometrioid histology (OR 1.81; 95% CI, 1.01–3.19) were independently associated with unsuccessful procedure. No significant differences were observed for BMI, enlarged lymph nodes, intraoperative lysis of adhesion, LVSI, grade 3, and FIGO stage. Conclusions Increasing age and non‐endometrioid histology are independent predictors of bilateral SLN mapping failure in EC patients undergoing SLN mapping with cervical ICG injection.

Analysis of Sentinel Lymph Node Adoption Compared to Systematic Lymphadenectomy in Staging Early Endometrial Cancer at a Tertiary Center: An Ambispective Study

ABSTRACTObjectiveThe purpose of this study was to assess the impact of changing endometrial carcinoma staging from systematic lymph node dissection to the sentinel lymph node approach.MethodsThis is an ambispective study including patients with endometrial carcinoma (EC) limited to the uterus (FIGO 2018 IA/IB). From December 2015 to October 2021, a group of patients underwent systematic staging with lymph node dissection (LND). From December 2021 to April 2024, another group of patients underwent surgical staging with the sentinel lymph node‐indocyanine green (SLN) algorithm and pathology ultrastaging analisys. The groups were matched (1 LND: 1 SLN) based on age, body mass index (BMI), tumor type, tumor size, and myometrial invasion. The primary endpoints were lymph node involvement, length of surgery, and complications. Complications were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsTwo hundred fifty‐seven patients were surgically treated during the study period (156 in the LND cohort, 101 in the SLN cohort). Propensity score matching revealed two equivalent groups containing 84 patients each. The rate of positive lymph nodes was similar between the LND group (3.6%) and the SLN group (8.3%) (OR: 2.46, 95% CI: 0.61–9.84; p = 0.205). The length of surgery was significantly lower in the SLN group (152.2 ± 51.9 min) compared to the LND group (304 ± 77.8 min) (p < 0.001). Intraoperative blood loss greater than 100 mL was significantly lower in the SLN group (9.5%) compared to the LND group (29.8%) (p < 0.001). CTCAE grades requiring intervention (grades 3, 4, and 5) were higher in the LND group (14.3%) compared to the SLN group (4.8%) (p = 0.049).ConclusionThe transition from LND to SLN approach was similar compared to systematic lymphadenectomy, allowing the reduction of surgical length, blood loss and severity of complications without compromising surgical complications and lymph node positivity.

Molecular Classification of Endometrial Cancers Using an Integrative DNA Sequencing Panel

ABSTRACT Background and Objectives Adoption of molecular classification in endometrial cancer (EC) into clinical practice remains challenging due to complexity in coordination of multiple assays. We aimed to develop a simple molecular technique to classify ECs into four subgroups using our custom‐designed targeted sequencing panel. Methods Patients with newly diagnosed ECs were prospectively recruited from three cancer centres in Ontario, Canada. Using our panel, 181 ECs were sequenced. Variants were analysed for pathogenicity and clinicopathologic information was collected through medical records retrospectively. Results Of 181, 86 (48%) were mismatch repair deficient (MMRd), of which 62 (72%) harboured MLH1 promoter methylation and 24 (28%) had pathogenic variants in MMR genes. Of single classifiers, three (1.8%) had pathogenic POLE ( POLE mut), 15 (9%) had TP53 mutations (p53abn) and 61 (37%) had no specific molecular profile subtype (NSMP). Sixteen (9%) had more than one molecular classifying feature, with eight (4%) MMRd‐p53abn, six (3%) POLE mut‐MMRd, one (0.5%) POLE mut‐MMRd‐p53abn and one (0.5%) POLE mut‐p53abn. When MMRd group was further subclassified according to mechanism of MMR loss, MLH1 promoter methylated group had worse outcomes than those with somatic MMR pathogenic variants. Conclusions Our panel can classify ECs into four subgroups through a simplified process and can be implemented reflexively in clinical practice.

The fluorescence imaging for laparoscopic and laparotomic endometrial sentinel lymph node biopsy (FILLES) trial: Siriraj gynecologic sentinel node of endometrial cancer (SiGN‐En) study

AbstractBackground and ObjectivesThe objective of this study is to establish the detection rate of sentinel lymph node (SLN) biopsies and to determine the sensitivity and false‐negative rate of SLN biopsies compared with those of systematic pelvic and para‐aortic lymphadenectomies in endometrial cancer.MethodsThis prospective cohort study enrolled patients with endometrial cancer who were scheduled for surgical staging. Patients with a history of chemotherapy or radiotherapy, an abnormal liver function test, or an allergy to indocyanine green (ICG) were excluded. All patients underwent surgical staging with an ICG injection at the cervix. SLNs were identified by a near‐infrared fluorescent camera. All SLNs were sent to a pathologist for ultrastaging.ResultsFrom November 2019 to June 2023, 142 patients underwent SLN mapping and surgical staging. SLNs were not detected bilaterally in 8 patients. The detection rate of the SLN biopsies in this study was 91.2%. Thus, the accuracy of the SLN biopsies was 97.6%. The sensitivity for finding metastatic SLNs was 84.2%, with a negative predictive value of 97.22%.ConclusionsA SLN biopsy in endometrial cancer has a high detection rate and high accuracy. However, surgical expertise and a learning curve are required.

Cancer risk‐reducing surgery: Brazilian society of surgical oncology guideline part 1 (gynecology and breast)

AbstractBackgroundRisk‐reducing operations are an important part of the management of hereditary predisposition to cancer. In selected cases, they can considerably reduce the morbidity and mortality associated with cancer in this population.ObjectivesThe Brazilian Society of Surgical Oncology (BSSO) developed this guideline to establish national benchmarks for cancer risk‐reducing operations.MethodsThe guideline was prepared from May to December 2021 by a multidisciplinary team of experts to discuss the surgical management of cancer predisposition syndromes. Fourteen questions were defined and assigned to expert groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments, classified the level of evidence, and voted on the recommendations.ResultsFor all questions including risk‐reduction bilateral salpingo‐oophorectomy, hysterectomy, and mastectomy, major agreement was achieved by the participants, always using accessible alternatives.ConclusionThis and its accompanying article represent the first guideline in cancer risk reduction surgery developed by the BSSO, and it should serve as an important reference for the management of families with cancer predisposition.

Quality of Life Post Cervical Cancer Treatment: A Comparison Between Radical Surgery Approach and Radiotherapy and Chemotherapy

ABSTRACTIntroductionThe assessment of quality of life (QoL) in women with cervical cancer is crucial due to the profound changes they undergo during and after treatment. Often, the significance of sexual factors is underestimated, likely due to societal taboos surrounding such discussions.ObjectiveThis study aimed to determine the long‐term QoL outcomes, particularly focusing on sexuality, among three therapeutic approaches for cervical cancer: chemotherapy, radiotherapy, and brachytherapy; isolated hysterectomy; and hysterectomy combined with radiotherapy.MethodsConducted from November 2022 to July 2023, this cross‐sectional study involved 131 cervical cancer patients. Their QoL was assessed using the MDASI, FACIT‐Cx, and risk factor questionnaires. Results were compared across the three treatment groups, revealing notable differences.ResultsPatients undergoing chemo/radio/brachytherapy showed significantly lower QoL scores compared to those undergoing isolated hysterectomy. This was evident in reduced scores across FACIT‐Cx subscales for physical well‐being, specific concerns, and FACIT‐total (p < 0.05). The MDASI results similarly indicated greater symptoms and interference in daily activities for the chemo/radio/brachytherapy group.ConclusionIn conclusion, isolated hysterectomy, demonstrated superior QoL outcomes compared to chemo/radio/brachytherapy. Furthermore, the study underscored the importance of addressing sexual concerns in QoL assessments of cervical cancer survivors, emphasizing the need for comprehensive care to enhance overall well‐being posttreatment.

Association of Socio‐Environmental Burden and Inequality With Cancer Screening and Mortality

ABSTRACT Background and Objectives Social and environmental injustice may influence accessibility and utilization of health resources, affecting outcomes of patients with cancer. We sought to assess the impact of socio‐environmental inequalities on cancer screening and mortality rates for breast, colon, and cervical cancer. Methods Data on cancer screening and environmental justice index social and environmental ranking (SER) was extracted from the CDC PLACES and ATSDR, respectively. Mortality rates were extracted using CDC WONDER. Screening targets were defined by Healthy People 2030 . Results Among census tracts, 14 659 were classified as “low,” 29 534 as “moderate,” and 15 474 as “high” SER (high SER denoting greater socioenvironmental injustice). Screening targets were achieved by 31.1%, 16.2%, and 88.6% of tracts for colon, breast, and cervical cancers, respectively. High SER tracts were much less likely to reach screening targets compared with low SER tracts for colon (OR: 0.06), breast (OR: 0.24), and cervical cancer (OR: 0.05) (all p  < 0.001). Median mortality rates for low and high SER were 16.7, and 21.0, respectively, for colon, 13.4, 14.75, respectively, for breast, and 1.0, 1.6, respectively, for cervical cancer (all p  < 0.05). Conclusion Socioenvironmental disparities negatively influence cancer screening and mortality, underscoring the need to reduce environmental injustices through measures like equitable cancer screening services.

Oncological outcomes of unexpected uterine leiomyosarcoma: A single‐center retrospective analysis of 5528 consecutive hysterectomies

AbstractBackground and MethodsUterine leiomyosarcomas (uLMS) are rare malignant tumors, often incidentally discovered, with an estimated annual incidence of five cases per one million women in the United States. This study aimed to compare the oncological outcomes of two groups of patients: those with uLMS incidentally found during surgery and those who underwent surgery due to suspected or confirmed uLMS before the procedure. The study assessed patients who had undergone hysterectomy and were diagnosed with stage I uLMS at a tertiary gynecologic oncology referral center in Italy between January 2000 and December 2019. Data on patients' baseline characteristics, surgical procedures, and oncological outcomes were collected. The patients were classified into two groups based on whether uLMS was unexpectedly discovered or suspected before the surgery. Survival rates and factors influencing recurrence were analyzed.ResultsThe study included 36 patients meeting the inclusion criteria, with 12 having preoperatively suspected or proven uLMS and 24 having incidentally discovered uLMS. No significant differences were observed between the two groups regarding disease‐free survival (23.7 vs. 27.3 months, log rank = 0.28), disease‐specific survival (median not reached, log rank = 0.78), or sites of relapse. Notably, among patients who underwent laparoscopic hysterectomy (compared to open surgery), a significantly higher rate of locoregional recurrence was found (78% vs. 33.3%, p = 0.04). Nevertheless, no significant differences in survival were observed based on the surgical approach.ConclusionsPreoperative suspicion for uLMS did not seem to impact survival outcomes or the pattern of recurrence. Furthermore, although patients who underwent laparoscopic hysterectomy showed a higher rate of locoregional relapse, this did not affect their overall survival.

Treatment outcomes and predictive factors in patients ≥70 years old with advanced ovarian cancer

AbstractObjectiveTo evaluate treatment outcomes, survival, and predictive factors in patients ≥70 with advanced epithelial ovarian cancer (AEOC).MethodsA retrospective single institution cohort study of women ≥70 with Stage III–IV AEOC between 2010 and 2018. Patients had either primary cytoreductive surgery (PCS), neoadjuvant chemotherapy (NACT) with interval cytoreductive surgery (ICS), chemotherapy alone, or no treatment. Demographics, surgical outcome, complications, and survival outcome were compared between groups.ResultsAmong 248 patients, 69 (27.7%) underwent PCS, 99 (39.9%) had ICS, 56 (22.5%) had chemotherapy alone. Twenty‐four (9.6%) remained untreated. Optimal cytoreduction (≤1 cm) was achieved in 72.4% of PCS and 77.8% of NACT/ICS (p = 0.34), without difference in grade ≥3 postoperative complications (15.9% vs. 9.1%, p = 0.37). Progression‐free survival (PFS) was 23.5 months in PCS and 15.0 months in ICS patients (hazard ratio [HR]: 1.4, p = 0.041). Patients in the surgical arms, PCS or ICS, had better 2‐year overall survival (OS) compared to chemotherapy alone (79%, 68%, 41%, respectively, HR: 3.58, p < 0.001). In a subgroup analysis, patients ≥80 had improved 2‐year OS when treated with NACT compared to PCS (82% vs. 57%) and a trend toward improved PFS. Age, stage, and CA‐125 were determinants of undergoing PCS.ConclusionIn patients ≥70 with AEOC, surgery should not be deferred based on age alone. Fit, well selected patients ≥70 can benefit from PCS, while patients ≥80 might benefit from NACT over PCS.

Cytoreductive or debulking surgery in ovarian cancer: The name does matter!

Impact of cytoreductive surgery on survival of patients with low‐grade serous ovarian carcinoma: A multicentric study of Turkish Society of Gynecologic Oncology (TRSGO‐OvCa‐001)

AbstractBackground and ObjectivesThe aim of this study was to analyze the factors affecting recurrence‐free (RFS) and overall survival (OS) rates of women diagnosed with low‐grade serous ovarian cancer (LGSOC).MethodsDatabases from 13 participating centers in Turkey were searched retrospectively for women who had been treated for stage I–IV LGSOC between 1997 and 2018.ResultsOverall 191 eligible women were included. The median age at diagnosis was 49 years (range, 21–84 years). One hundred seventy‐five (92%) patients underwent primary cytoreductive surgery. Complete and optimal cytoreduction was achieved in 148 (77.5%) and 33 (17.3%) patients, respectively. The median follow‐up period was 44 months (range, 2–208 months). Multivariate analysis showed the presence of endometriosis (p = .012), lymphovascular space invasion (LVSI) (p = .022), any residual disease (p = .023), and the International Federation of Gynecology and Obstetrics (FIGO) stage II–IV disease (p = .045) were negatively correlated with RFS while the only presence of residual disease (p = .002) and FIGO stage II–IV disease (p = .003) significantly decreased OS.ConclusionsThe maximal surgical effort is warranted for complete cytoreduction as achieving no residual disease is the single most important variable affecting the survival of patients with LGSOC. The prognostic role of LVSI and endometriosis should be evaluated by further studies as both of these parameters significantly affected RFS.

Experience with PlasmaJet™ in debulking surgery in 87 patients with advanced‐stage ovarian cancer

AbstractObjectiveThe aim was to evaluate the effectiveness and safety of PlasmaJet™ in cytoreductive surgery in patients with advanced‐stage ovarian cancer.MethodsAll patients between September 2013 and January 2018 undergoing surgical cytoreduction for advanced‐stage ovarian cancer with the help of PlasmaJet™ were identified and analyzed retrospectively.ResultsEighty‐seven patients diagnosed with advanced‐stage ovarian cancer underwent surgery with PlasmaJet™. Primary debulking surgery was performed in 15 cases. Fifty‐seven patients underwent interval debulking after neoadjuvant chemotherapy. Secondary and tertiary debulking was done in, respectively, 11 and three patients, and one patient underwent quaternary debulking using PlasmaJet™. In all 87 patients but one, complete resection of all macroscopic disease was obtained. PlasmaJet™ was used to remove carcinomatosis on the peritoneum, bowel serosa, intestinal mesentery, and lesions in the upper abdomen (diaphragm and liver surface). No damage to the bladder or ureter was noted in relation to the use of PlasmaJet™. Three patients developed a bowel leakage postoperatively. In one of these patients, PlasmaJet™ was used to treat tumoral implants in the affected region.ConclusionsOur series suggests that the use of PlasmaJet™ is efficient and safe in obtaining complete resection of all macroscopic tumoral lesions in advanced‐stage ovarian cancer.

Using a machine learning algorithm to predict outcome of primary cytoreductive surgery in advanced ovarian cancer

AbstractObjectiveTo develop a machine learning (ML) algorithm to predict outcome of primary cytoreductive surgery (PCS) in patients with advanced ovarian cancer (AOC)MethodsThis retrospective cohort study included patients with AOC undergoing PCS between January 2017 and February 2021. Using radiologic criteria, patient factors (age, CA‐125, performance status, BRCA) and surgical complexity scores, we trained a random forest model to predict the dichotomous outcome of optimal cytoreduction (<1 cm) and no gross residual (RD = 0 mm) using JMP‐Pro 15 (SAS). This model is available at https://ipm-ml.ccm.sickkids.ca.ResultsOne hundred and fifty‐one patients underwent PCS and randomly assigned to train (n = 92), validate (n = 30), or test (n = 29) the model. The median age was 58 (27–83). Patients with suboptimal cytoreduction were more likely to have an Eastern Cooperative Oncology Group 3–4 (11% vs. 0.75%, p = 0.004), lower albumin (38 vs. 41, p = 0.02), and higher CA125 (1126 vs. 388, p = 0.012) than patients with optimal cytoreduction (n = 133). There were no significant differences in age, histology, stage, or BRCA status between groups. The bootstrap random forest model had AUCs of 99.8% (training), 89.6%(validation), and 89.0% (test). The top five contributors were CA125, albumin, diaphragmatic disease, age, and ascites. For RD = 0 mm, the AUCs were 94.4%, 52%, and 84%, respectively.ConclusionOur ML algorithm demonstrated high accuracy in predicting optimal cytoreduction in patients with AOC selected for PCS and may assist decision‐making.

Treatment specialty‐specific characteristics and outcomes in women with vulvo‐vaginal melanoma: A JGOG‐JSCS joint study

Hyperthermic intraperitoneal chemotherapy in the treatment of recurrent ovarian cancer: When, and for whom?

AbstractObjectiveThe aim of this study is to evaluate the progression‐free survival (PFS) of recurrent ovarian cancer (ROC) patients treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC).Materials and MethodsROC patients who underwent cytoreductive surgery plus HIPEC between 2015 and 2021 were retrospectively evaluated. Patients' demographic information and clinicopathological characteristics including cancer type, histology, platinum status, presence of ascites, type of surgery, complications, chemotherapy history, and disease progression were documented. PFS was calculated using the Kaplan–Meier method.ResultsA total of 104 patients with ROC were included. The median age was 57 years and the median follow‐up time was 15 months (range: 5–69 months). In Cox regression multivariate analyses, platinum resistance (hazard ratio [HR]: 3.32, 95% confidence interval [CI]: 1.91–5.76, p = 0.00), more than one relapse prior HIPEC (HR: 2.81, 95% CI: 1.65–4.87, p = 0.024), and presence of ascites (HR: 1.88, 95% CI: 1.08–3.26, p = 0.00) were found to be negative prognostic factors for PFS. In subgroup analyses of patients with the first recurrence, the median PFS was 21 months for platinum‐sensitive patients and 6 months for platinum‐resistant patients (p = 0.032).ConclusionHIPEC at the time of first platinum‐sensitive relapse may lead to favorable PFS in the treatment ROC. However, HIPEC as salvage treatment even with R0 cytoreductive surgery does not seem effective.

Treatment delay and treatment pattern modifications among epithelial ovarian cancer patients during the COVID‐19 pandemic: A retrospective cohort study

AbstractBackground and ObjectivesThe coronavirus disease 2019 (COVID‐19) pandemic disrupted healthcare access and medical treatment, including oncological care. Treatment delay in ovarian cancer could impact survival. We aimed to assess if there were delays and treatment changes in a cohort of epithelial ovarian cancer patients.MethodsA retrospective cohort of epithelial ovarian cancer patients included cases diagnosed during the first 22 months of the COVID‐19 pandemic in the state of Sao Paulo and those diagnosed in the 22 months preceding the outbreak. Time‐to‐treat was measured in days. In each group, surgery and chemotherapy proportions were assessed according to healthcare insurance status.ResultsA 56.2% reduction in epithelial ovarian cancer diagnosis was identified during the pandemic group compared to the prepandemic group; fewer patients were diagnosed in stage I (p < 0.01). Time‐to‐treat increased from 18.9 to 23 days (p < 0.01). Surgery in the public sector fell from 74.6% to 65.3% during the pandemic, compared to 87.1% to 68.8% in the private sector.ConclusionThere were fewer overall diagnoses, reduced stage I diagnosis, increased time‐to‐treat, and a reduction in the proportion of patients submitted to surgery. Brazil's public healthcare system demonstrated a higher resiliency to treatment change than the private sector.

Detection of sentinel lymph node in laparoscopic surgery for uterine cervical cancer using carbon nanoparticles

AbstractBackground and ObjectivesCarbon nanoparticles (CNPs) has been widely confirmed the efficiency in sentinel lymph node (SLN) mapping for various solid tumors. This study aims to explore the feasibility and effectiveness of CNPs during laparoscopic surgery for cervical cancer.MethodsWe analyzed 45 women with stage IB1‐IIA1 cervical cancer who underwent SLN mapping using CNPs during laparoscopic surgery. The effectiveness of CNPs was evaluated by the detection rate and accuracy parameters. Factors associated with SLN laterality and SLNs localizations were analyzed.ResultsThe overall and bilateral detection rate was 93.3% (42/45) and 60.0% (27/45), respectively. Elevated body mass index was associated with decreased bilateral detection rate (P = .015). A total of 225 SLNs were harvested, with a mean number of 5.0 ± 3.6. A total of 81.3% of SLNs were in expected localizations including external iliac (39.1%), internal iliac (25.8%), and obturator (16.4%) regions, while 18.7% in unusual localizations including common iliac (10.7%), parametrial (7.6%), and presarcal (0.4%) regions. None positive lymph node was found in non‐SLNs with a false‐negative rate of 0%.ConclusionLaparoscopic SLN mapping with CNPs appears to be simple and efficient for patients with early‐stage cervical cancer.

Association between surgical approach and survival following resection of abdominopelvic malignancies

AbstractBackground and ObjectivesRecent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5‐year survival following resection of abdominopelvic malignancies.MethodsPatients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010‐2015 were identified from the National Cancer Data Base. The association between surgical approach and 5‐year survival was assessed using propensity‐score‐matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional‐hazard models.ResultsThe rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05‐1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39‐1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10‐1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44‐0.82; P = .003).ConclusionsThese results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.

Analysis of the relationship between hospital characteristics and survival in ovarian cancer: A historical cohort

AbstractBackground and ObjectivesThe management of ovarian cancer requires complex surgical and medical interventions. Specialized care is associated with superior outcomes in early and advanced stages. This study aimed to estimate the effect of hospital characteristics on the overall survival of women with epithelial ovarian cancer.MethodsWe established a cohort with data recorded by the Fundação Oncocentro de São Paulo cancer registry. We included 6111 women treated for ovarian cancer in the state of Sao Paulo from January 2000 to December 2018. From 76 hospitals analyzed, 7 were high volume (20 or more cases a year) and 69 low volume. Twenty‐nine were teaching and 47 community hospitals. A 10‐year survival was analyzed using the Kaplan‐Meyer estimator and the Cox model.ResultsFifty‐two percent of the epithelial ovarian cancer patients were treated in high‐volume hospitals. High‐volume ‐ (HR, 0.86; 95% CI, 0.8‐0.92; P < .001) and teaching ‐ (HR, 0.91; 95% CI, 0.85‐0.99; P = .019) were hospital characteristics associated with low risk of death in 10 years.ConclusionsHigh‐volume and teaching hospitals are associated with better overall survival in ovarian cancer. Our data suggest that both hospital characteristics are important indicators of good quality of care in ovarian cancer treatment.

Proposal for modified inguinofemoral lymphadenectomy derived from investigation of anatomic distribution of sentinel and metastatic nodes in vulvar cancer

AbstractObjectiveWe aimed to develop a less invasive inguinofemoral lymphadenectomy (IFL) approach for vulvar cancer based on the investigation of the anatomic distribution of sentinel and metastatic nodes.MethodsPatients with vulvar cancer treated by surgery between 1995 and 2019 were retrospectively reviewed. A seven‐field method was adopted to assign the anatomic locations for lymph nodes removed via IFL or sentinel node biopsy. Only patients with nodal metastasis or sentinel nodes were included.ResultsA total of 102 patients with eligible data were analyzed. Nodal metastasis was confirmed in 118 groins undergoing IFL; sentinel node detection succeeded in 46 groins. The medial‐inguinal field had the highest rate of nodal metastasis involvement (59.3%, 70/118) and sentinel nodes present (73.9%, 34/46). The inferior‐femoral field was involved only in one groin with quadruple‐field metastases. The lateral‐inguinal field was not involved in any groin. Neither the lateral‐inguinal nor the inferior‐femoral field presented sentinel nodes.ConclusionThe lateral‐inguinal and inferior‐femoral fields of the groins have a low risk of developing nodal metastasis. Therefore, a modified IFL preserving these fields can be established to reduce surgical morbidity without sacrificing its therapeutic effect.

Pathological factors associated with non‐sentinel lymph node metastasis in early stage cervical cancer

AbstractObjectiveTo analyze the predictive factors for non‐sentinel lymph node (non‐SLN) metastasis in early‐stage cervical cancer.MethodsWe analyzed a series of 113 patients who underwent sentinel lymph node (SLN) mapping for cervical cancer. The SLNs were examined by immunohistochemistry (IHC) when the hematoxylin–eosin stain was negative.ResultsThe overall bilateral detection rate was 81.5%, with a median of two SLNs resected. The study ultimately included 92 patients with SLNs that were mapped who had also undergone systematic pelvic lymph node dissection. Thirteen (14.1%) patients had positive SLNs, with a median of one positive SLN. Regarding the size of SLN metastasis, one (1.1%) had isolated tumor cells (ITC), seven (7.6%) had micrometastases, and five (5.4%) had macrometastases. Notably, 46.1% (6/13) had lymph node metastases detected only after IHC. Five (38.5%) cases had positive non‐SLNs, with a median count of one positive lymph node. Parametrial invasion was the only risk factor for positive non‐SLN (p = .045). Regarding the size of SLN metastasis, non‐SLN involvement was present in the only case with ITC (1/1), 42.9% (3/7) of cases with micrometastases, and in 20% (1/5) with macrometastases.ConclusionsOur data suggest that parametrial invasion correlates with the risk of non‐SLN metastasis in cervical cancer.

Brazilian Society of Surgical Oncology consensus on fertility‐sparing surgery for cervical cancer

AbstractObjectiveSeveral controversies remain on conservative management of cervical cancer. Our aim was to develop a consensus recommendation on important and novel topics of fertility‐sparing treatment of cervical cancer.MethodsThe consensus was sponsored by the Brazilian Society of Surgical Oncology (BSSO) from March 2020 to September 2020 and included a multidisciplinary team of 55 specialists. A total of 21 questions were addressed and they were assigned to specialists' groups that reviewed the literature and drafted preliminary recommendations. Further, the coordinators evaluated the recommendations that were classified by the level of evidence, and finally, they were voted by all participants.ResultsThe questions included controversial topics on tumor assessment, surgical treatment, and surveillance in conservative management of cervical cancer. The two topics with lower agreement rates were the role of minimally invasive approach in radical trachelectomy and parametrial preservation. Additionally, only three recommendations had <90% of agreement (fertility preservation in Stage Ib2, anti‐stenosis device, and uterine transposition).ConclusionsAs very few clinical trials have been developed in surgery for cervical cancer, most recommendations were supported by low levels of evidence. We addressed important and novel topics in conservative management of cervical cancer and our study may contribute to literature.

Surveillance Visits for Ovarian Cancer: Is It Time to Reconsider?

ABSTRACT Background and Objectives The objective of this study was to examine patterns of recurrence and presentation of ovarian cancer (OC) patients. Methods This was a retrospective review of all patients at a single academic institution diagnosed with OC between January 1, 2014, and December 31, 2022. Demographic and clinical characteristics were extracted. Cox proportional hazards models were utilized to compare these characteristics, while the Kaplan‐Meier method was employed to determine overall survival (OS). Results During our study, 437 patients were diagnosed with OC, and 173 (39.6%) were diagnosed with recurrence. For those diagnosed with recurrence, 68 (39.3%) were symptomatic. Forty‐eight (72.7%) symptomatic patients had abdominal pain or increased abdominal girth, 5 (7.6%) had shortness of breath, 1 (1.5%) had vaginal bleeding, and 12 (18.1%) had nonspecific symptoms. Among the 105 (60.7%) asymptomatic patients, 57 (54.3%) had increasing CA‐125 levels. Four (2.32%) patients with recurrence were diagnosed on a routine pelvic exam, and only one (0.5%) patient was asymptomatic and incidentally diagnosed. Conclusions The majority of patients were asymptomatic at the time of diagnosis, and the pelvic exam was not the primary means of detecting OC recurrence. Guidelines for surveillance visits for OC patients and the utility of a pelvic exam should be examined.

Multisocietal Consensus on the Use of Cytoreductive Surgery and HIPEC for the Treatment of Epithelial Ovarian Cancer: A GRADE Approach for Evidence Evaluation and Recommendation

ABSTRACTIntroductionThe locoregional treatment of high grade serous ovarian cancer (HGSOC) comprises of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Recent evidence form randomized trials, has led to controversy related to the use of HIPEC in addition to interval CRS (iCRS) and the role of secondary CRS (sCRS) in patients with the first platinum‐sensitive recurrence from high‐grade serous ovarian cancer (HGSOC). This multi‐society consensus, coordinated by the Peritoneal Surface Oncology Group International (PSOGI) with inputs from ISSPP, SSO, ESSO, and IGCS, evaluated the role of these interventions using the GRADE ADOLOPMENT methodology.Patients and MethodsAn international expert panel reviewed evidence for the use of HIPEC in addition to iCRS in stage 3 high grade serous ovarian cancer (HGSOC) and the role of sCRS for patients with platinum‐sensitive recurrent HGSOC. A systematic review assessed randomized controlled trials (RCTs) for recurrence‐free survival (RFS), overall survival (OS), safety, and quality of life (QoL). Recommendations were formulated using the GRADE Evidence‐to‐Decision framework.ResultsHIPEC in addition to iCRS was strongly recommended based on the results of the OVHIPEC‐1 trial, which showed significant benefit in RFS (3.5 months) and OS (12 months) without increasing the grade 3–4 morbidity. For the first platinum‐sensitive recurrence, a conditional recommendation was made either for sCRS with systemic therapy or systemic therapy alone, reflecting variability in trial outcomes due to heterogeneity in the patient population in the trials and lack of surgical standardization.ConclusionThis consensus highlights the benefits of HIPEC in addition of iCRS and key factors that limit its wide‐spread use. It underlines the need for individualized decision‐making while selecting patients for sCRS. Future research integrating advanced systemic therapies is essential to refine these recommendations and provide equitable access to these complex locoregional treatments.

Postoperative Complications in Elderly Patients Undergoing Surgery for Ovarian Cancer: A NSQIP Analysis

ABSTRACTBackground and ObjectivesElderly patients with ovarian cancer (OC) commonly receive modified treatment due to the assumption of higher risk. The aim of this study is to evaluate postoperative complications in elderly patients undergoing surgery for OC.MethodsRetrospective cohort study of patients with OC identified in the NSQIP database, (2013–2021). Younger patients included 40–69 years old, and elderly patients were ≥ 70 years old. Major complications included: pulmonary embolism, deep vein thrombosis, acute kidney injury, stroke, cardiac arrest, space surgical site infection, myocardial infarction, sepsis, septic shock, and return to the operating room.ResultsOf the 11,108 patients, 8214 (74%) were in the younger patient and 2894 (26%) in the elderly patient group. Elderly patients had higher rates of postoperative pneumonia (2.6% vs. 1.2%), myocardial infarction (1.4% vs. 0.3%), and major complications (3.5% vs. 2.0%), p < 0.0001 for all. Discharge to rehab was higher in elderly patients (3.1% vs. 0.5%, p < 0.001). On multivariate logistic regression, older age was associated with “major complications” (aOR 1.79, 95% CI 1.38–2.31, p < 0.0001).ConclusionsIn OC patients selected for surgery, elderly patients are at higher risk of Postoperative complications and are less likely to be discharged home. This should be considered when counseling patients pre‐operatively and planning for peri‐operative care and disposition.

Understanding Trends in Incidence and Management of Pregnancy‐Associated Breast Cancer in a National Sample Using Claims Data

ABSTRACTBackground and ObjectivesBreast cancer incidence in young women is increasing globally. Here, we examine trends in incidence, management, and reconstruction for pregnancy‐associated breast cancer (PABC) in women 18–45.MethodsFemales aged 18–45 with breast cancer between 2007 and 2021 were identified in the Merative MarketScan Commercial and Multi‐State Medicaid Databases. We analyzed trends in incidence of PABC, treatments, and latency to treatments for PABC versus non‐PABC.ResultsA total of 1189 patients with PABC and 36 683 with non‐PABC were included. Over the study period, the proportion of breast cancer cases classified as PABC increased (2.36% of cases from 2007 to 2009, to 3.94% from 2019 to 2021; p < 0.001). Patients with PABC experienced higher rates of neoadjuvant chemotherapy, mastectomy, trastuzumab, and ovarian suppression therapy than patients with non‐PABC, and lower rates of adjuvant radiation and breast conserving surgery (p ≤ 0.001). PABC status did not independently predict increased latency from diagnosis to tumor resection surgery when controlling for receipt of neoadjuvant chemotherapy (p = 0.154). Patients with PABC experienced comparable rates of delayed or immediate implant and autologous reconstruction as patients with non‐PABC, but experienced increased latency to delayed implant reconstruction (p < 0.001).ConclusionsPABC rates are increasing among women 45 and younger. Patients with PABC experience differences in types of medical/surgical treatments received and timing of post‐mastectomy reconstruction.

Patient and Surgeon Attitudes Toward Opportunistic Salpingectomy During Nongynecological Surgeries for the Prevention of Ovarian Cancer: A Qualitative Study

ABSTRACT Background and Objectives Opportunity salpingectomy (OS), or prophylactic removal of the fallopian tubes during an operation for another indication, is broadly accepted as a risk‐reduction strategy for ovarian cancer during gynecological operations. However, OS during nongynecological abdominal surgery is rare in the United States. A better understanding of surgeon and patient attitudes and perceived barriers to OS during nongynecological surgeries may facilitate implementation in the United States. Study Design Qualitative interviews were conducted with general surgeons ( n  = 10), gynecologic surgeons ( n  = 10), and patients ( n  = 20) to assess perspectives and barriers towards OS during nongynecological surgeries. Interviews were transcribed and inductive analysis was carried out to identify themes and categorize responses using NVivo data analysis software. Results OS during nongynecological surgery was viewed favorably by most patients and surgeons interviewed. While patients emphasized the importance of raising awareness of OS, both subsets of surgeons highlighted coordination, counseling, and billing barriers that would need to be overcome for efficient implementation. Conclusion OS was positively accepted by both patients and surgeons in our cohort. Improved attention to the shared barriers to implementation from our study may facilitate OS implementation during nongynecological surgery in the United States.

Delay in Time to Adjuvant Chemotherapy and its Impact on Oncological Outcomes in Patients Undergoing Optimal Cytoreductive Surgery for Advanced Ovarian Cancer: Analysis of 1480 Cases From the Indian HIPEC Registry

ABSTRACTBackground and ObjectivesThe impact of delay in initiation of adjuvant chemotherapy following optimal CRS in different settings of treatment for advanced ovarian cancer needs to be studied with special reference to CRS HIPEC.MethodsThe 1480 advanced EOC patients underwent optimal CRS, followed by adjuvant chemotheraphy, with or without intraperitoneal (IP) chemotherapy in Normothermic or Hyperthermic form. Interval between the day of surgery and start of adjuvant chemotherapy and its impact on outcome was analyzed.ResultsCRS, CRS with IP or HIPEC was done in 400, 480, and 600 patients respectively. Median interval of starting adjuvant chemotherapy was 32 days CRS group, 34 days CRS + IP group and 41 days CRS + HIPEC group. Delay in chemotherapy impacted on recurrence free survival (RFS) in CRS + IV group (36 vs. 17 months: p = 0.02) and some impact in CRS + IP group (38 vs. 28 months; P 0.78) and no impact on CRS + HIPEC group (35 vs. 32 months; p = 0.17).ConclusionsDelay in starting adjuvant chemotherapy adversely affects RFS in patients undergoing optimal CRS alone. However, the delay didn't have an impact in the CRS + HIPEC group. Well‐designed clinical studies are required to evaluate the impact of single dose of HIPEC.

The impact of perioperative transfusions on the oncologic outcomes of patients with ovarian cancer: A population‐based study

AbstractPerioperative blood transfusion in ovarian cancer patients was associated with a 28% increase in all‐cause mortality. The negative impact of perioperative blood transfusion extends beyond the immediate postoperative period.ObjectivesThe effect of perioperative blood transfusions on long‐term oncologic outcomes of patients with advanced ovarian cancer undergoing cytoreductive surgery remains uncertain. Our study aims to determine the association between perioperative blood transfusion and all‐cause mortality in this population.MethodsUsing province‐wide administrative databases, patients with advanced ovarian cancer who underwent surgery between 2007 and 2021 as part of first‐line treatment were identified. Perioperative transfusion was defined as any transfusion from date of surgery to discharge from hospital. Multivariable Cox proportional hazards regression models were used to determine if there was an independent association of transfusion with all‐cause mortality, accounting significant confounders.ResultsA total of 5891 patients had cytoreductive surgery for advanced ovarian cancer between 2007 and 2021, of which 2898 (49.2%) had interval cytoreductive surgery (ICS) and 2993 (50.8%) had primary cytoreductive surgery (PCS). Perioperative blood transfusion was given to 37.3% of patients (40.5% ICS and 34.2% PCS). On multivariable analysis, there was an increased hazard of all‐cause mortality for patients receiving perioperative transfusion compared to those who did not (hazard ratio: 1.28; 95% CI: 1.20–1.37). The association of increased all‐cause mortality was observed starting 1 year after surgery, was sustained thereafter, and seen in both ICS and PCS groups.ConclusionPerioperative blood transfusion after cytoreductive surgery for ovarian cancer is common in Ontario, Canada and was significantly associated with an increase in all‐cause mortality. Blood transfusion is a poor prognostic factor, and the negative impact of blood transfusion persists beyond the immediate postoperative period.

First birth after uterine transposition in low‐volume lymph node metastasis of cervical cancer: A long journey for success

AbstractLocally advanced cervical cancer poses a significant challenge to fertility‐sparing treatments. Pelvic radiotherapy impairs reproductive potential owing to ovarian, uterine, and endometrial side effects. This study presents a literature review of the main fertility‐sparing therapeutic alternatives for locally advanced cervical cancer and a case report of the first childbirth following uterine transposition for gynecological malignancies.

Cervical Cancer Prevention and Treatment Disparities Among Native Hawaiian and Pacific Islanders: A Systematic Review and Meta‐Analysis

ABSTRACT Background Native Hawaiian and Pacific Islander (NHPI) populations face significant disparities in cervical cancer prevention and treatment. This systematic review and meta‐analysis examines cervical cancer prevention metrics, treatment disparities, and effective interventions among NHPI populations. Methods Following PRISMA guidelines, we systematically searched PubMed, Scopus, and Embase for studies published between 2000 and 2024 that reported cervical cancer prevention metrics in NHPI populations. Eligible studies included quantitative and qualitative designs with NHPI‐specific or disaggregated data. Pap testing and HPV vaccination rates were pooled using a random‐effects meta‐analysis. Narrative synthesis summarized findings from studies unsuitable for meta‐analysis. Results A total of 27 studies were included. The pooled Pap testing rate was 62% (95% CI: 46%–75%), with substantial heterogeneity (I² = 98.7%). The pooled HPV vaccine initiation rate was 25% (95% CI: 16%–37%; I² = 84.3%). Barriers included limited healthcare access, lack of physician recommendations, cultural stigma, and geographic isolation. Effective interventions, such as culturally tailored educational materials and community‐based participatory approaches, demonstrated improved screening and vaccination rates. NHPI patients were less likely to receive timely and guideline‐concordant cervical cancer treatment and had higher rates of late‐stage diagnoses and mortality. Conclusions NHPI populations face persistent cervical cancer prevention and treatment disparities. Culturally tailored interventions and policies addressing systemic barriers are critical to reducing these inequities. Future research should focus on longitudinal studies and scalable interventions to improve outcomes in NHPI communities.

Moving into the modern era of molecular classification for endometrial cancer

AbstractThe molecular subtypes of endometrial carcinoma (EC) were first described by The Cancer Genome Atlas (TCGA) a decade ago. Using surrogate approaches, the molecular classification has been demonstrated to be prognostic across EC patients and to have predictive implications. Starting in 2020, the molecular classification has been incorporated into multiple guidelines as part of the risk assessment and most recently into the International Federation of Gynecology and Obstetrics (FIGO) staging. This review article discusses the implementation of the EC molecular classification into clinical practice, the therapeutic implications, and the molecular and clinical heterogeneity of the EC molecular subtypes.

Predicting recurrence and recurrence‐free survival in high‐grade endometrial cancer using machine learning

AbstractObjectiveTo develop machine‐learning models to predict recurrence and time‐to‐recurrence in high‐grade endometrial cancer (HGEC) following surgery and tailored adjuvant treatment.MethodsData were retrospectively collected across eight Canadian centers including 1237 patients. Four models were trained to predict recurrence: random forests, boosted trees, and two neural networks. Receiver operating characteristic curves were used to select the best model based on the highest area under the curve (AUC). For time to recurrence, we compared random forests and Least Absolute Shrinkage and Selection Operator (LASSO) model to Cox proportional hazards.ResultsThe random forest was the best model to predict recurrence in HGEC; the AUCs were 85.2%, 74.1%, and 71.8% in the training, validation, and test sets, respectively. The top five predictors were: stage, uterus height, specimen weight, adjuvant chemotherapy, and preoperative histology. Performance increased to 77% and 80% when stratified by Stage III and IV, respectively. For time to recurrence, there was no difference between the LASSO and Cox proportional hazards models (c‐index 71%). The random forest had a c‐index of 60.5%.ConclusionsA bootstrap random forest model may be a more accurate technique to predict recurrence in HGEC using multiple clinicopathologic factors. For time to recurrence, machine‐learning methods performed similarly to the Cox proportional hazards model

Can risk groups accurately predict non‐sentinel lymph node metastasis in sentinel lymph node‐positive endometrial cancer patients? A Turkish Gynecologic Oncology Group Study (TRSGO‐SLN‐004)

AbstractBackground and ObjectivesThe purpose of this study was to find out the risk factors associated with non‐sentinel lymph node metastasis and determine the incidence of non‐sentinel lymph node metastasis according to risk groups in sentinel lymph node (SLN)‐positive endometrial cancer patients.MethodsPatients who underwent at least bilateral pelvic lymphadenectomy after SLN mapping were retrospectively analyzed. Patients were categorized into low, intermediate, high‐intermediate, and high‐risk groups defined by ESMO‐ESGO‐ESTRO.ResultsOut of 395 eligible patients, 42 patients had SLN metastasis and 16 (38.1%) of them also had non‐SLN metastasis. Size of SLN metastasis was the only factor associated with non‐SLN metastasis (p = .012) as 13/22 patients with macrometastasis, 2/10 with micrometastasis and 1/10 with isolated tumor cells (ITCs) had non‐SLN metastasis. Although all 4 metastases (1.8%) among the low‐risk group were limited to SLNs, the non‐SLN involvement rate in the high‐risk group was 42.9% and all of these were seen in patients with macrometastatic SLNs.ConclusionsNon‐SLN metastasis was more frequent in higher‐risk groups and the risk of non‐SLN metastasis increased with the size of SLN metastasis. Proceeding to complete lymphadenectomy when SLN is metastatic should further be studied as the effect of leaving metastatic non‐SLNs in‐situ is not known.

A prospective comparison of costs between robotics, laparoscopy, and laparotomy in endometrial cancer among women with Class III obesity or higher

AbstractBackground and ObjectivesTo compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher.MethodsA multicentre prospective observational study examined outcomes of women, with early stage EC, treated surgically. Resource use was collected for OR costs including OR time, equipment, and inpatient costs. Median OR, inpatient, and overall costs across surgical modalities were analyzed using an Independent‐Samples Kruskal–Wallis Test among patients with BMI ≥ 40.ResultsOut of 520 women, 103 had a BMI ≥ 40. Among women with BMI ≥ 40: median OR costs were $4197.02 for laparotomy, $5524.63 for non‐robotic assisted laparoscopy, and $7225.16 for robotic‐assisted laparoscopy (p < 0.001) and median inpatient costs were $5584.28 for laparotomy, $3042.07 for non‐robotic assisted laparoscopy, and $1794.51 for robotic‐assisted laparoscopy (p < 0.001). There were no statistically significant differences in the median overall costs: $10 291.50 for laparotomy, $8412.63 for non‐robotic assisted laparoscopy, and $9002.48 for robotic‐assisted laparoscopy (p = 0.185).ConclusionThere was no difference in overall costs between the three surgical modalities in patient with BMI ≥ 40. Given the similar costs, any form of minimally invasive surgery should be promoted in this population.

The Significance of the Morphological Appearance of Peritoneal Lesions on Imaging in Patients With Peritoneal Malignancies—A Report From Phase 1 of the PRECINCT Study

ABSTRACTBackground and AimThis is a report from Phase 1 of the prospective, observational, PRECINCT (Pattern of peritoneal dissemination and REsponse to systemic Chemotherapy IN Common and uncommon peritoneal Tumours) study, in which we studied the incidence of disease at pathological evaluation in different morphological appearances of peritoneal malignancies (PM) on imaging.MethodsRadiological findings were captured in a specific format that included a description of the morphological appearance of PM and a correlation performed with pathological findings.ResultsIn 630 patients enroled at seven centres (September 2022–December 2023), 24 morphological terms were used. Among prespecified terms (N = 8 used in 6350 [92.2%] regions), scalloping was pathologically positive in 93.5%, confluent disease in 78.8%, tumour nodules in 69.6%, thickening in 66.1%, infiltration in 56.3%. Among unspecified appearances (N = 16) for 540 (7.8%) regions, ‘enhancement’ was positive in 41.5%, micronodules in 65.3% and nodularity in 60.2%. Hierarchal clustering placed gastric cancer and rare tumours together and colorectal cancer, ovarian cancer and peritoneal mesothelioma in one cluster.ConclusionsThe incidence of disease at pathological evaluation for most morphological appearances was high (> 50%). Morphological description should be provided in routine radiology reports. A set of standardized terms with their description should be developed by a consensus among experienced radiologists.

Efficacy of sentinel lymph node mapping in endometrial cancer with low‐ or high‐intermediate risk

AbstractBackground and ObjectivesThis study was aimed to evaluate the efficacy of sentinel lymph node (SLN) mapping using indocyanine green (ICG) in Chinese women with endometrial cancer (EC).MethodsConsecutive EC patients undergoing SLN mapping at Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed. Overall and bilateral SLN detection rates and SLN locations were presented. Sensitivity, negative predictive value (NPV), and agreement rate were calculated and were compared between patients with low‐intermediate (LIR) or high‐intermediate risk (HIR).ResultsThere were 454 patients screened, with SLN mapping with ICG performed in 428 patients and systematic lymphadenectomy performed in 159 patients. Overall and bilateral SLN detection rates were 96.50% and 82.71%, respectively. The sensitivity of SLN mapping was 80.00%, and the NPV was 97.76%. SLNs were most commonly located in obturator and external iliac regions. Efficacy of SLN mapping was higher in LIR patients than in HIR patients, with sensitivities of 100.00% and 75.00% (p > 0.05), NPVs of 100.00% and 90.00% (p = 0.002), and agreement rates of 100.00% and 92.31% (p = 0.007), respectively.ConclusionSLN mapping with ICG had acceptable diagnostic efficacy in Chinese women with EC, but may cause more missed diagnoses in patients with HIR due to relatively low NPV and agreement rate.

The efficiency of a combined injection technique for sentinel lymph node mapping in intermediate‐high‐risk endometrial cancer

AbstractBackground and ObjectivesSentinel lymph node (SLN) mapping was considered for treating endometrial cancer (EC) which was apparent confined to the uterus. Nevertheless, intermediate‐high‐risk EC patients have super high risk to undergo isolated para‐aortic lymph node metastases comparing with low‐risk patients. Therefore, this investigation aimed to compare the efficacy of two SLN methods in detecting para‐aortic lymph node metastases.MethodsAccording to SLN mapping injection methods, intermediate‐high‐risk EC patients who received both SLN mapping and systematic lymphadenectomy were divided into the combined group (fundal and cervical injections) and the cervical group (cervical injection only).ResultsThe para‐aortic SLN detection rate in the combined group (40.4%) was higher than that in the cervical group (4.4%) with p < 0.001. While the differences concerning the sensitivity, false‐negative rate, and negative predictive value between the two groups were not significant. The survival outcomes of patients were comparable between the two groups.ConclusionOur data showcased that the combined (fundal and cervical) injection had a higher detection rate of para‐aortic SLNs than cervical injection only. The efficiency of SLN mapping and the survival outcomes were not significantly different between the two groups. Further investigations are warranted to assess the value of combined injection regarding SLN technique.

Clinical outcomes of patients with endometrioid epithelial ovarian cancer following surgical treatment

AbstractBackgroundEndometrioid epithelial ovarian cancer (EEOC) is rare, and its management poorly defined. We examined factors associated with 5‐year progression‐free survival (PFS) after surgery for EEOC.MethodsRetrospective study: treatment and outcomes of all EEOC patients undergoing initial surgery at, or presenting to, our institution within 3 months of initial surgery, 1/2002‐9/2017.ResultsIn total, 212 patients were identified. Median follow‐up, 63.9 months (range, 0.7–192); median age at diagnosis, 52 years (range, 20–88); disease stage: I, n = 145 (68%); II, n = 47 (22%); III/IV, n = 20 (9%); FIGO grade: 1, 127 (60%); 2, 66 (31%); 3, 17 (8%); unknown, 2 (1%). One hundred twenty‐eight (60%) had endometriosis; 75 (35%), synchronous endometrioid endometrial cancer (80%, IA); 101 (48%), complete surgical staging; 8 (5%), positive pelvic lymph nodes (LNs); 6 (4%), positive para‐aortic LNs; 176 (97%), complete gross resection; 123 (60%), postoperative chemotherapy; 56(28%), no additional treatment. Five‐year PFS, 83% (95% confidence interval [CI]: 76.6%–87.8%); 5‐year overall survival (OS), 92.7% (95% CI: 87.7%–95.8%). Age, stage, and surgical staging were associated with improved 5‐year PFS, and younger age at diagnosis with improved 5‐year OS (p < 0.001). Chemotherapy did not improve 5‐year PFS in IA/IB versus observation, but improved survival in IC (hazard ratio [HR]: 1.01, 95% CI: 0.22–4.59, p = 0.99; HR: 0.17, 95% CI: 0.04–0.7, p = 0.006).ConclusionsAge, stage, and full surgical staging were associated with improved 5‐year PFS. Chemotherapy showed no benefit in IA/IB disease.

Clinico‐pathological significance of suspicious peritoneal cytology in endometrial cancer

AbstractBackground and ObjectivesSuspicious peritoneal cytology refers to the result of peritoneal cytology testing that is insufficient in either quality or quantity for a definitive diagnosis of malignancy. This study examined characteristics and survival outcomes related to suspicious peritoneal cytology in endometrial cancer.MethodsA population‐based retrospective study by querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program was conducted. A total of 41,229 women with Stage I–III endometrial cancer who had peritoneal cytologic sampling at hysterectomy from 2010 to 2016 were examined. A Cox proportional hazard regression model and a competing risk analysis with Fine‐Gray model were fitted to assess survival outcome related to suspicious peritoneal cytology.ResultsSuspicious peritoneal cytology was seen in 702 (1.7%) cases. In multivariable models, suspicious peritoneal cytology was associated with increased risk of endometrial cancer mortality (subdistribution‐hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.29–2.20, p < 0.001) and all‐cause mortality (adjusted‐HR: 1.55, 95% CI: 1.27–1.90, p < 0.001) compared with negative peritoneal cytology. Sensitivity analysis demonstrated that suspicious peritoneal cytology had discrete overall survival improvement compared with malignant peritoneal cytology in a propensity score weighting model (HR: 0.85, 95% CI: 0.72–0.99, p = 0.049).ConclusionOur study suggests that suspicious peritoneal cytology may be a prognostic factor for decreased survival in endometrial cancer.

High prevalence of pulmonary embolism prior to cancer therapies in patients with ovarian and endometrial cancers detected by contrast‐enhanced CT using D‐dimer as an index

AbstractObjectiveWe aimed to evaluate the prevalence of pulmonary embolism (PE) before cancer therapies in patients with ovarian and endometrial cancers with enhanced computed tomography (CT) using D‐dimer (DD), and determine the optimal cut‐off level of DD.MethodsSince 2009, we have performed preoperative venous thromboembolism (VTE) screening of patients with ovarian and endometrial cancer. For patients with DD levels of more than 1.0 μg/ml, enhanced CT images were obtained from the pulmonary apex to the foot to detect PE and deep venous thrombosis (DVT) simultaneously.ResultsAmong patients with ovarian cancer, 84 of 413 (20.3%) had VTEs (DVT alone, n = 31 [7.5%]; PE with or without DVT, n = 53 [12.8%]; PE alone, n = 12 [2.9%]). Among patients with endometrial cancer, 50 of 455 (11.0%) had VTEs (DVT alone, n = 19 [4.2%]; PE with or without DVT, n = 31 [6.8%], PE alone, n = 14 [3.1%]). The optimal cut‐off level of DD was estimated to be ≥1.5 and ≥1.2 μg/ml in ovarian and endometrial cancers, respectively.ConclusionOur study revealed a high prevalence of PE before cancer therapies in patients with ovarian and endometrial cancers by enhanced CT using DD.

Surgical lymph node assessment influences adjuvant therapy in clinically apparent stage I endometrioid endometrial carcinoma, meeting Mayo criteria for lymphadenectomy

AbstractObjectiveTo evaluate the impact of surgical lymph node assessment for clinically apparent, stage I endometrioid endometrial adenocarcinoma meeting Mayo criteria for lymphadenectomy.MethodsPatients with endometrioid endometrial adenocarcinoma meeting Mayo criteria for lymphadenectomy who underwent hysterectomy and lymphadenectomy were identified. Algorithms for adjuvant therapy with and without lymphadenectomy were developed utilizing NCCN guidelines, PORTEC 1, and PORTEC 2. Patients served as their own control to determine the frequency of treatment modification.ResultsA total of 357 patients were analyzed. Using our algorithms treatment modification would have occurred because of lymphadenectomy in 62.8% of patients if whole pelvic external beam radiation was used for patients meeting inclusion criteria for PORTEC 1. Treatment modification would have occurred in 16.2% of patients if vaginal brachytherapy was used for patients meeting the inclusion criteria for PORTEC 2. Of the total, 53.8% of patients meeting inclusion criteria for PORTEC 1 would have had a reduction in adjuvant therapy from whole pelvic radiotherapy to vaginal brachytherapy alone. Only 9.0% of patients would have adjuvant therapy increased to include external beam radiotherapy and chemotherapy based on the presence of positive lymph nodes.ConclusionsApplying standard adjuvant treatment algorithms to real patient data, surgical lymph node assessment appears to frequently alter treatment allocation.

The combined ratio of estrogen, progesterone, Ki‐67, and P53 to predict the recurrence of endometrial cancer

AbstractBackground and ObjectivesWe aimed to explore the capacity of the combined ratio of biomarkers to predict the recurrence of Stage I–III endometrial cancer (EC).MethodsA total of 473 patients were enrolled after screening. The cut‐off value of the ratio was calculated by the receiver operating characteristic curve (ROC). The univariate and multivariate Cox regression analysis was used to assess the correlation between the combined ratio and the recurrence of EC. The differences of clinicopathological parameters between the two groups divided based on the threshold were compared.ResultThe ROC curve showed that 0.92 was the optimal cut‐off value of the ratio ([ER + PR]/[P53 + Ki67]). The multivariate analysis demonstrated that only International Federation of Gynecology and Obstetrics stage (p = .031) and the combined ratio (p = .004) were independent risk factors of recurrence. The 3‐year recurrence‐free survival (RFS) and overall survival of patients in the low‐ratio group were 54.1% and 66.8%, respectively; while in the high‐ratio group were 94.9% and 97.9%, respectively (p < .001). The 3‐year RFS of 194 patients, who did not receive the adjuvant therapy, was 54.7% and 97.2% between two groups (p < .001).ConclusionsThe optimal cut‐off value (0.92) of the combined ratio was demonstrated to be better to predict the recurrence of EC than a single immunohistochemical marker.

Prognostic value of different metastatic sites for patients with FIGO stage IVB endometrial cancer after surgery: A SEER database analysis

AbstractObjectiveThis study aimed to investigate the association between different metastatic sites and survival in endometrial cancer (EC) patients with International Federation of Gynecology and Obstetrics (FIGO) stage IVB disease.MethodsFIGO stage IVB patients with EC were selected from the surveillance, epidemiology, and end results database. Overall survival (OS) and cause‐specific survival (CSS) were analyzed with Kaplan‐Meier analysis and log‐rank tests. Univariate and multivariate Cox proportional hazard models were used to identify the prognostic factors for OS and CSS.ResultsA total of 929 FIGO stage IVB patients with EC were identified. Patients with peritoneum metastasis were associated with significantly better OS and CSS compared to those with organ‐specific metastasis (median OS: 29 vs 19 months, P = .005; median CSS: 47 vs 25 months, P < .001). Moreover, the survival superiority of peritoneum metastasis remained significant when organ‐specific metastasis was further classified into specific single‐organ metastasis. The multivariate analysis also indicated that compared with peritoneum metastasis, bone, brain, and lung metastasis were independent prognostic factors for worse OS. Similarly, distant lymph node, bone, brain, liver, and lung metastasis were associated with worse CSS.ConclusionMetastatic sites affected prognosis in FIGO stage IVB patients with EC. Patients with peritoneum metastasis had significantly better survival outcomes than those with organ‐specific metastasis.

The impact of wait times on oncological outcome in high‐risk patients with endometrial cancer

AbstractObjectiveTo evaluate the impact of surgical wait times on outcome of patients with grade 3 endometrial cancer.MethodsAll consecutive patients surgically treated for grade 3 endometrial cancer between 2007 and 2015 were included. Patients were divided into two groups based on the time interval between endometrial biopsy and surgery: wait time from biopsy to surgery ≤12 weeks (84 days) vs more than 12 weeks. Survival analyses were conducted using log‐rank tests and Cox proportional hazards models.ResultsA total of 136 patients with grade 3 endometrial cancer were followed for a median of 5.6 years. Fifty‐one women (37.5%) waited more than 12 weeks for surgery. Prolonged surgical wait times were not associated with advanced stage at surgery, positive lymph nodes, increased lymphovascular space invasion, and tumor size (P = .8, P = 1.0, P = .2, P = .9, respectively). In multivariable analysis adjusted for clinical and pathological factors, wait times did not significantly affect disease‐specific survival (adjusted hazard ratio [HR]: 1.2, 95% confidence interval [CI], 0.6‐2.5, P = .6), overall survival (HR: 1.1, 95% CI, 0.6‐2.1, P = .7), or progression‐free survival (HR: 0.9, 95% CI, 0.5‐1.7, P = .8).ConclusionProlonged surgical wait time for poorly differentiated endometrial cancer seemed to have a limited impact on clinical outcomes compared to biological factors.

Learning curve for sentinel lymph node mapping in gynecologic malignancies

AbstractBackground and ObjectivesOnly a few studies have reported the learning curve for sentinel lymph node (SLN) detection in gynecologic malignancies. We investigated the learning curve for SLN detection during robot‐assisted laparoscopic surgery for endometrial and cervical carcinomas.MethodsThis retrospective analysis included patients with stage IA to IIA1 cervical cancer or stage I to III endometrial cancer who underwent SLN mapping using indocyanine green during robot‐assisted laparoscopic surgery performed by a single surgeon. Learning curves were analyzed in consecutive cases using SLN detection rates and the cumulative sum (CUSUM) method.ResultsSLN mapping was achieved in 81.25% (65/80), 77.50% (62/80), and 66.25% (53/80) of the cases involving the right, left, and simultaneous bilateral pelvic areas, respectively. Learning curve analysis based on the cumulative detection rate showed initial fluctuations followed by stabilization; the time required for proficiency was discordant among the LN regions. However, the CUSUM method showed proficient mapping of the right, left, and bilateral SLNs after 27 to 28 cases.ConclusionAt least 27 cases were required for SLN mapping proficiency in gynecologic cancer; the learning period could influence the surgical quality. Further studies are warranted to confirm the impact of this learning curve on disease outcomes.

Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources

AbstractBackgroundApproximately 70% of cancer‐related deaths occur in low‐ and middle‐income countries. In addition to social and racial inequalities, treatment options in these countries are usually limited because of the lack of trained staff and equipment, limited patient access to health services, and a small number of clinical guidelines.ObjectivesThe Brazilian Society of Surgical Oncology developed this guideline to address these barriers and guide physicians treating patients with endometrial cancer (EC) in regions with limited resources and few specialized centers.MethodsThe guideline was prepared from 10 January to 25 October 20192019 by a multidisciplinary team of 56 experts to discuss the main obstacles faced by EC patients in Brazil. Thirteen questions considered critical to the surgical treatment of these patients were defined. The questions were assigned to groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments for presentations in meetings, classified the level of evidence, and voted on the recommendations.ResultsFor all questions including staging, fertility spearing treatment, genetic testing, sentinel lymph node use, surgical treatment, and other clinical relevant questions, major agreement was achieved by the participants, always using accessible alternatives.ConclusionsIt is possible to provide adequate treatment for most EC patients in resource‐limited areas, but the first option should be referral to specialized centers with more resources.

Metastatic benign leiomyoma: A case report of an uncommon presentation

AbstractUterine leiomyoma is a benign tumor of myometrial tissue which usually affects women of reproductive age. Its prevalence increases with age and has a peak incidence at the age of 40. Metastasizing leiomyomas are dense connective tissue and smooth myometrial muscle cells tumors located outside the uterus. We present the case report of a 55‐year‐old female referred to investigate pulmonary nodules with the diagnosis of metastasizing leiomyoma.

Postoperative complications in women with ovarian cancer stratified by cytoreductive surgery outcome

AbstractObjectiveTo compare 30‐day postoperative complications for patients with advanced ovarian cancer who underwent resection to no gross residual disease versus optimal and suboptimal cytoreduction.MethodsA retrospective cohort study of women drawn from the National Surgical Quality Improvement Program who underwent cytoreductive surgery for advanced ovarian cancer between 2014 and 2019 was performed. Exposure of interest was extent of surgical resection defined as no gross residual disease; residual disease <1 cm (optimal); and residual disease >1 cm (suboptimal). Primary outcome was postoperative complication. Associations were examined with bivariable tests and multivariable logistic regression.ResultsA total of 2248 women underwent cytoreductive surgery; 68.4% (n = 1538) underwent resection to no gross residual disease, 22.4% (n = 504) had an optimal, and 9.2% (n = 206) had a suboptimal cytoreduction. Optimal cytoreduction patients had the highest rates of any postoperative complication (35.5%, p < 0.001). They also had the longest operative times and procedures that were most surgically complex (203 min, 43.6 relative value units, both p < 0.05). However, patients who underwent optimal cytoreduction did not have increased odds of major complications (adjusted odds ratio: 1.20, 95% confidence interval: 0.91–1.58).ConclusionPatients who underwent optimal cytoreduction had more postoperative complications, required the most operating room time, and represented more complex surgeries compared with suboptimal cytoreduction or resection to no gross residual disease.

Treatment and survival of patients with malignant ovarian sex cord‐stromal cell tumours: An analysis of the Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) study group CORSETT database

AbstractBackgroundMalignant sex cord‐stromal cell tumours (SCST) account for only 7% of ovarian malignancies. The Arbeitsgemeinschaft fuer Gynaekologische Onkologie (AGO) study group has established a clinicopathological database to provide an overview of the current treatment strategies and survival of SCST patients and to identify research needs.MethodsTwenty centres provided mixed retro‐ and prospective data of patients with tumour specimens and second‐opinion pathology review treated between 2000 and 2014. Descriptive analyses of treatment strategies, Kaplan–Meier curves and cox regression analyses were conducted.ResultsTwo hundred and sixty‐two SCST patients were included. One hundred and ninety‐one Granulosa‐cell tumour (GCT) and 17 Sertoli‐Leydig cell tumour (SLCT) patients were stage I disease (>80%). Forty four GCT (18.7%) and two (8.3%) SLCT patients received adjuvant systemic treatment. After a median observation time of 78.2 months, 46% of all SCST patients experienced disease recurrence, treated predominantly with secondary debulking surgery (> 90%). Advanced FIGO stage, lymph node involvement and intra‐operative capsule rupture were associated with disease recurrence on univariate analysis (all p < 0.05). Median OS time was not reached.DiscussionIn this analysis of SCST patients, adjuvant chemotherapy was unable to prevent disease recurrence. Despite high recurrence rates, overall survival rates were excellent.

Surgery in Ovarian Cancer—Brazilian Society of Surgical Oncology Consensus

ABSTRACTSurgical management in epithelial ovarian cancer (EOC) has a significant impact on overall survival (OS) and progression‐free survival (PFS). The Brazilian Society of Surgical Oncology (BSSO) supported an expert‐led task force for consensus: the best EOC surgery is provided by experienced and specialized trained surgeons in cancer centers. Laparoscopic or radiological staging can predict the possibility of complete cytoreduction (CC0) and help to reduce unnecessary laparotomies. Carcinomatosis and nodal extension should be evaluated at imaging. Multidisciplinary input is essential for determining the need for the selection of patients for surgery and adjuvant chemotherapy in patients with EOC. The BSSO proposes quality assurance criteria and the need for national consensus. Genetic counseling was deemed mandatory for all patients with EOC. This consensus states the final recommendations from BSSO for the management of EOC.

Optimum selection criteria for secondary cytoreductive surgery in patients with recurrent epithelial ovarian cancer: A multicenter study from the Gynecologic Oncology Research Investigators coLLaborAtion group (GORILLA‐3001)

AbstractBackgroundTo identify those most likely to benefit from secondary cytoreductive surgery (SCS), we evaluated the survival outcomes and factors predictive of prognosis in patients with recurrent ovarian cancer.MethodsWe retrospectively reviewed the medical records of patients with recurrent ovarian cancer treated at five high‐volume Korean hospitals between 2010 and 2021. Recurrence characteristics, treatment methods, and potential predictors of survival were compared between the chemotherapy and surgery groups.ResultsAmong all 670 patients, 88.1% had initial stage III/IV disease, and 215 (32.1%) underwent SCS. Among patients who underwent SCS, only those who achieved complete resection exhibited improved survival. Even in patients with residual disease < 1 cm after SCS, we observed no significant survival benefit (p = 0.942). In the multivariate Cox analysis, residual disease at primary surgery, progression‐free interval, recurrence sites (≤3 regions or limited carcinomatosis), ascites, and SCS were significant predictors of survival. Meanwhile, the only factor predictive of complete resection after SCS was recurrence sites (p < 0.001).ConclusionsThe benefits of SCS appear to be exclusive to cases of complete resection. We propose limited regional platinum‐sensitive recurrence (≤3 regions or limited carcinomatosis) without ascites as the optimum selection criteria for SCS.

Minimally invasive interval cytoreductive surgery for advanced ovarian cancer

AbstractWith the increasing use of neoadjuvant chemotherapy, it has also become apparent that some patients will require a less extensive interval cytoreductive surgery which could be performed as a minimally invasive procedure. This observation, and expertise with minimally invasive surgery for other indications in gynecologic oncology, has driven surgeons in the United States and other countries to perform an increasing portion of interval cytoreductive surgery using minimally invasive techniques. Further observational and trial data will continue to inform which patients are best suited for this approach.

Sentinel lymph node mapping in endometrial cancer: Current evidence and practice

AbstractSurgical staging with total hysterectomy, bilateral salpingo‐oophorectomy, and lymph node assessment is the standard of care for patients with clinical early‐stage endometrial cancer. Traditionally, complete pelvic and para‐aortic lymphadenectomy (LND) was performed to assess for nodal metastases; however, numerous prospective studies have demonstrated that sentinel lymph node biopsy has similar diagnostic accuracy, and is an acceptable alternative to complete LND. This has led to a paradigm shift in endometrial cancer staging.

Fertility‐sparing and minimally invasive surgery for early‐stage cervical cancer

Evaluating equity of access and predictors of minimally invasive hysterectomy for endometrial and cervical cancer from 2000 to 2017 in Ontario, Canada: A population‐based cohort study

AbstractIntroductionWe sought to assess the uptake of minimally invasive hysterectomy among patients with endometrial and cervical cancer in Ontario, Canada, and assess the equity of access to minimally invasive surgery (MIS) by evaluating associations with patient, disease, institutional, and provider factors.MethodsThis is a retrospective population‐based cohort study of hysterectomy for endometrial and cervical cancer in Ontario (2000–2017). Surgical approach, clinicopathologic, sociodemographic, institutional, and provider factors were identified through administrative databases. Fisher's exact, χ2, Wilcoxon rank sum, logistic regression, and Cox proportional hazards modeling were used to explore factors associated with MIS.ResultsA total of 27 652 patients were included. In total, 6199/24 264 (26%) endometrial and 842/3388 (25%) cervical cancer patients received MIS. The proportion of MIS to open surgeries increased from <0.1% in 2000 to over 55% in 2017 (odds ratio [OR] = 1.31, confidence interval [CI] = 1.28–1.34). Low‐income quintile, rurality, low hospital volume, nonacademic hospital, nongynecologic oncology surgeon, and earlier year of surgeon graduation were associated with reduced odds of MIS (OR < 1).ConclusionsThe uptake of MIS hysterectomy increased steadily over the time period. Receipt of MIS is dependent upon multiple social determinants, provider variables, and systems factors. These disparities raise concern for health equity in Ontario and have significant implications for health systems planning and resource allocation.

Factors associated with the involvement of lymph nodes in low‐grade serous ovarian cancer

AbstractBackground and ObjectivesEvaluating nodal metastases in low‐grade serous ovarian cancer (LGSOC) patients.MethodsWomen with LGSOC who had undergone primary cytoreductive surgery comprising systematic pelvic‐paraaortic lymphadenectomy were included. Data were obtained retrospectively from 12 oncology centers.ResultsOne hundred and forty‐eight women with LGSOC who had undergone comprehensive surgical staging were included. Seventy‐one (48.0%) patients had metastatic lymph nodes. Preoperative serum CA‐125 levels of ≥170 U/ml (odds ratio [OR]: 3.84; 95% confidence interval [CI]: 1.22–12.07; p = 0.021) and presence of lymphovascular space invasion (LVSI) (OR: 13.72; 95% CI: 3.36–55.93; p < 0.001) were independent predictors of nodal metastasis in LGSOC. Sixty (40.5%) patients were classified to have apparently limited disease to the ovary/ovaries. Twenty (33.3%) of them were upstaged after surgical staging. Twelve (20.0%) had metastatic lymph nodes. Presence of LVSI (OR: 12.96; 95% CI: 1.14–146.43; p = 0.038) and preoperative serum CA‐125 of ≥180 U/ml (OR: 7.19; 95% CI: 1.35–38.12; p = 0.02) were independent predictors of lymph node metastases in apparent Stage Ⅰ disease.ConclusionsClinicians may consider to perform a reoperation comprising systematic lymphadenectomy in patients who had apparently limited disease to the ovary/ovaries and had not undergone lymphadenectomy initially. Reoperation may be considered particularly in patients whose preoperative serum CA‐125 is ≥180 U/ml and/or whose pathological assessment reported the presence of LVSI.

Inferior epigastric artery lymph nodes: A pathway for systemic dissemination from peritoneal carcinomatosis?

AbstractBackground and ObjectivesWe report, for the first time in the literature, a metastatic lymphatic pathway along the inferior epigastric vessels, through the inferior epigastric lymph nodes (IELNs), in patients with peritoneal carcinomatosis (PC). Interestingly, these lymph nodes (LNs) in the anterior retroperitoneum were not detectable on preoperative imaging. They may, however, represent a pertinent systemic dissemination pathway for PC.Patients and MethodsIn patients undergoing indocyanine green‐fluorescence imaging during cytoreductive surgery for PC, an incidental finding of a hyperfluorescent LN, harboring metastatic tumorous cells, around the inferior epigastric artery was made.ResultsIn three out of five patients with clear fluorescent hotspot, the harvested LN was harboring metastatic cancerous cells. None of these nodes, whether negative or positive, was visible on any preoperative imaging modalities. A protocol to sample, in a systematic manner, the IELN in patients with PC, is currently being devised at our institution.ConclusionThese lymphatic nodes basin and channels might reveal to be a potential passage from peritoneal metastasis to the extraperitoneal lymphatic compartment, representing an independent pathway for cancerous cell dissemination. This will bring us to further investigate the prevalence and the prognostic significance of these LNs.

Upfront or intermediate treatment of advanced ovarian cancer patients with cytoreduction plus HIPEC: Results of a retrospective study

AbstractBackgroundNewly diagnosed advanced‐stage ovarian cancer patients are treated with neoadjuvant chemotherapy, primary or intermediate cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to evaluate the optimal timing of cytoreduction plus HIPEC for advanced ovarian cancer patients.MethodsAdvanced ovarian cancer patients treated with cytoreductive surgery plus HIPEC at three different hospitals between 2005 and 2019 were subgrouped regarding their time of management with cytoreduction plus HIPEC, upfront or intermediate. We retrospectively assessed the overall survival (OS), the progression‐free survival (PFS), and the disease‐free survival (DFS) of these groups.ResultsA total of 112 ovarian cancer patients were contained. Of whom, 47 patients were in the upfront group with 24 (51.1%) to be alive, while 65 patients were included in the intermediate group with 34 (52.3%) to be alive. OS (48 vs. 30 months) and DFS (42 vs. 20 months) indicated no significant difference. Although the same median PFS was observed in both groups (10 months), a higher mean PFS was observed in the upfront group (11.9 vs. 9 months, p = 0.023).ConclusionThe treatment of advanced ovarian cancer patients with upfront cytoreductive surgery plus HIPEC is feasible with the same survival results. Further, larger prospective studies need to verify our results.

Near‐infrared dye‐labeled antibody COC183B2 enables detection of tiny metastatic ovarian cancer and optimizes fluorescence‐guided surgery

AbstractObjectiveWe aimed to evaluate the ability of the fluorescent monoclonal antibody probe COC183B2‐Cy7 (Cy7‐conjugated COC183B2 antibody) to detect tiny metastatic lesions of ovarian cancer and thus guide precise tumor resection.MethodsThe expression of the tumor‐associated antigen OC183B2 in lymph nodes and SKOV3‐Luc cells was detected using immunohistochemistry and immunofluorescence. A subcutaneous mouse tumor model and an intraperitoneal ovarian cancer metastasis model were constructed using SKOV3‐Luc cells. Near‐infrared fluorescence (NIRF) imaging was performed to determine the imaging parameters and evaluate the ability of COC183B2‐Cy7 to detect tiny metastatic lesions.ResultsOC183B2 was expressed in metastatic lymph nodes and SKOV3‐Luc cells. NIRF imaging of the subcutaneous mouse tumor model showed that the tumor background ratio was significantly higher in the COC183B2‐Cy7 group than in the control group at different time points postinjection. Biodistribution study showed that COC183B2‐Cy7 did not accumulate in other organs. COC183B2‐Cy7 can detect tiny metastatic lesions of ovarian cancer. The smallest intraperitoneal metastatic tumor detected by COC183B2‐Cy7 was approximately 1 mm.ConclusionsCOC183B2‐Cy7 probe has relatively high specificity and sensitivity. Our study suggests that COC183B2‐Cy7 probe is a promising diagnostic tool for the complete and accurate resection of malignant lesions in fluorescence‐guided surgery.

Readmissions after ovarian cancer cytoreduction surgery: The first 30 days and beyond

AbstractBackground and ObjectivesPostoperative readmissions are often used to assess quality of surgical care. This study compared 30‐day vs 31‐ to 90‐day readmission following surgery for ovarian, fallopian tube, or primary peritoneal cancer.MethodsThis retrospective study of the 2010‐2015 Nationwide Readmissions Database characterized 90‐day readmissions following cytoreductive surgery for these cancers. Each patient's first postoperative hospitalization was included. Univariate analysis compared patient demographics and reasons for readmission. Multivariable regression identified independent predictors of readmission.ResultsOf an estimated 76 652 patients, 10 264 (13.4%) were readmitted within 30 days, and 6942 (9.1%) between 31 and 90 days. The 30‐day readmissions were more frequently associated with postoperative infection, while 31‐ to 90‐day readmissions were more frequently associated with renal or hematologic diagnoses. Predictors of any 90‐day readmission included index hospitalization longer than 7 days (adjusted odds ratio (AOR) 1.61 [1.48‐1.75], P < .001), extended surgical procedure (AOR 1.41 [1.30‐1.53], P < .001), pulmonary circulation disorder (AOR = 1.34 [1.13‐1.60], P = .001), and diabetes mellitus (AOR = 1.12 [1.02‐1.24], P = .020).ConclusionsReadmission rates remain high during the 31‐ to 90‐day postoperative period in ovarian cancer patients, although these readmissions are less frequently related to postoperative complications. Prospective study is merited to optimize surveillance beyond the initial 30 days after ovarian cancer surgery.

Metastatic patterns do not provide additional prognostic information for patients with FIGO stage IV high‐grade serous ovarian cancer

AbstractBackgroundThe aim of our study was to investigate whether metastatic patterns were associated with the prognosis of patients with FIGO stage IV high‐grade serous ovarian cancer (HGSC).MethodsWe retrospectively investigated 83 consecutive patients with FIGO stage IV HGSC who underwent primary surgery between April 2005 and June 2013 at our institution. Metastatic patterns were defined as pleural effusion (stage IVA), parenchymal metastases (stage IVB), and extra‐abdominal lymph node metastases (stage IVB). Correlations of clinical characteristics and prognosis with metastatic patterns were analyzed.ResultsForty‐two (50.6%) patients were stage IVA with pleural effusion. Among the remaining stage IVB patients, 19 (22.9%) patients had parenchymal metastases and 22 (26.5%) had extra‐abdominal lymph node metastases. FIGO IVA and IVB subclassification did not have a prognostic impact on progression‐free survival (PFS) (P = .361). In addition, no differences in PFS were observed among patients presenting the three metastatic patterns (P = .506). The 5‐year overall survival (OS) rates of patients with stage IVA and IVB diseases were 35.2% and 34.3%, respectively, (P = .856). In addition, metastatic patterns did not provide additional prognostic information for OS (P = .292).ConclusionNeither the subclassification into FIGO IVA and IVB stages nor metastatic patterns of FIGO stage IV provided additional prognostic information.

Management of patients with ovarian cancer in the COVID‐19 era

AbstractAt the beginning of 2020, coronavirus disease 2019 (COVID‐19) spreads worldwide. Patients with ovarian cancer should be considered at high‐risk of developing severe morbidity related to COVID‐19. Most of them are diagnosed in advanced stages of disease, and they are fragile. Here, we evaluated the major impact of COVID‐19 on patients with ovarian cancer, discussing the effect of the outbreak on medical and surgical treatment.

Clinicopathological and survival characteristic of mismatch repair status in ovarian clear cell carcinoma

AbstractBackground and ObjectivesWe sought to explore the expression of mismatch repair (MMR) status and its correlation with clinicopathologic and survival characteristics in ovarian clear cell carcinoma (OCCC).MethodsExpression of four MMR proteins (MLH1, PMS, MSH2, and MSH6) were measured using tissue microarray‐based immunohistochemistry in 120 OCCC patients. The associations of clinicopathologic parameters with recurrence‐free survival (RFS) and overall survival (OS) were analyzed by the Kaplan‐Meier method, and multivariate analysis was further performed by the Cox regression model.ResultsOverall, 120 OCCC patients met the entry criteria, and their MMR status was detected, consisting of 24 patients with dMMR and 96 patients with proficient MMR (pMMR). Patients with dMMR were strongly associated with platinum‐sensitive disease (P = .006) and large tumor volume (P = .038). Among all the patients who have received surgery, tumors with dMMR had a better RFS and OS than those with pMMR (hazard ratio [HR] for recurrence: 0.459 [95% confidence interval {95% CI} = 0.224‐0.940], P = .029; HR for death: 0.381 [95% CI = 0.170‐0.853], P = .015). In subgroup analysis, dMMR patients experienced a better trend of RFS (HR = 0.273; P = .055) and OS (HR = 0.165; P = .040) than pMMR cases among early stages (I‐II), but this difference was not observed in advanced stage (III‐IV) patients. Meanwhile, pMMR was associated with a more favorable trend of prognosis than dMMR in platinum‐resistant patients (RFS: HR = 0.317, P = .051; OS: HR = 0.370, P = .046). Multivariate analysis revealed that only advanced stages (III‐IV) were adverse independent prognosticators for both RFS (HR = 5.938 [95% CI = 2.804‐12.574]; P < .001) and OS (HR = 6.209 [95% CI = 2.724‐14.156]; P < .001).ConclusionTumors with dMMR were related to better OS in OCCC on univariate analysis. Only the tumor stage was an independent prognosticator for both RFS and OS. MMR status is a potentially valuable prognostic index in OCCC patients, and larger prospective studies are required to validate its prognostic role.

Utilization of lymph node evaluation at hysterectomy for cervical carcinoma in situ

AbstractBackground and ObjectivesThis study examined the utilization and characteristics of lymph node evaluation at hysterectomy for carcinoma in situ of the uterine cervix.MethodsThis retrospective cohort study queried the Healthcare Cost and Utilization Project's National Inpatient Sample, evaluating 7395 patients with cervical carcinoma in situ who underwent hysterectomy from 2016 to 2019. A multivariable binary logistic regression model was fitted to identify independent characteristics related to lymph node evaluation. A classification‐tree was constructed with recursive partitioning analysis to examine utilization patterns of lymph node evaluation.ResultsLymph node evaluation at hysterectomy was performed in 4.6%. In amultivariable analysis, older age, higher income, use of robotic‐assisted hysterectomy, and surgery at large bed capacity or urban teaching centers in the northeast US region were associated with increased likelihood of lymph node evaluation (all, p < 0.05). Of those independent factors, robotic‐assisted surgery exhibited the largest effect size (adjusted odds ratio 3.23, 95% confidence interval 2.54–4.10). Utilization pattern analysis identified nine unique characteristics, of which robotic‐assisted surgery was the primary indicator for cohort allocation (12.4% vs. 3.2%, p < 0.001). The difference between the lowest–highest patterns was 33.3% (range, 0%–33.3%).ConclusionLymph node evaluation was rarely performed for cervical carcinoma in situ overall and robotic surgery was associated with increased utilization of lymph node evaluation.