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Sickinghe A, Nobbenhuis M, Nelissen E, Heath O, Ind T. Proficiency-based progression training in robot-assisted laparoscopy for endometrial cancer: peri-operative and survival outcomes from an observational cohort study. Front Med (Lausanne) 2024; 11:1370836. [PMID: 38903811 PMCID: PMC11188306 DOI: 10.3389/fmed.2024.1370836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/06/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Over the last decade there has been a transition from traditional laparoscopy to robotic surgery for the treatment of endometrial cancer. A number of gynecological oncology surgical fellowship programmes have adopted robot-assisted laparoscopy, but the effect of training on complications and survival has not been evaluated. Our aim was to assess the impact of a proficiency-based progression training curriculum in robot-assisted laparoscopy on peri-operative and survival outcomes for endometrial cancer. Methods This is an observational cohort study performed in a tertiary referral and subspecialty training center. Women with primary endometrial cancer treated with robot-assisted laparoscopic surgery between 2015 and 2022 were included. Surgery would normally include a hysterectomy and salpingo-oophorectomy with some form of pelvic lymph node dissection (sentinel lymph nodes or lymphadenectomy). Training was provided according to a training curriculum which involves step-wise progression of the trainee based on proficiency to perform a certain surgical technique. Training cases were identified pre-operatively by consultant surgeons based on clinical factors. Case complexity matched the experience of the trainee. Main outcome measures were intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and 5-year disease-free and disease-specific survival for training versus non-training cases. Mann-Witney U, Pearson's chi-squared, multivariable regression, Kaplan-Meier and Cox proportional hazard analyses were performed to assess the effect of proficiency-based progression training on peri-operative and survival outcomes. Results Training cases had a lower BMI than non-training cases (30 versus 32 kg/m2, p = 0.013), but were comparable in age, performance status and comorbidities. Training had no influence on intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and median 5-year disease-free and disease-specific survival. Operating time was longer in training cases (161 versus 137 min, p = < 0.001). The range of estimated blood loss was smaller in training cases. Conversion rates, critical care unit-admissions and lymphoedema rates were comparable. Discussion Proficiency-based progression training can be used safely to teach robot-assisted laparoscopic surgery for women with endometrial cancer. Prospective trails are needed to further investigate the influence of distinct parts of robot-assisted laparoscopic surgery performed by a trainee on endometrial cancer outcomes.
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Affiliation(s)
- Ariane Sickinghe
- Department of Gynecological Oncology, Royal Marsden Hospital, London, United Kingdom
- Faculty of Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Marielle Nobbenhuis
- Department of Gynecological Oncology, Royal Marsden Hospital, London, United Kingdom
| | - Ellen Nelissen
- Department of Gynecological Oncology, Royal United Hospitals, Bath, United Kingdom
| | - Owen Heath
- Department of Gynecological Oncology, Royal Marsden Hospital, London, United Kingdom
| | - Thomas Ind
- Department of Gynecological Oncology, Royal Marsden Hospital, London, United Kingdom
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Rosati A, Vargiu V, Certelli C, Arcieri M, Vizza E, Legge F, Cosentino F, Ferrandina G, Fanfani F, Scambia G, Corrado G. Is the sarcomatous component (homologous vs heterologous) the prognostic "driving force" in early-stage uterine carcinosarcomas? A retrospective multicenter study. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04594-5. [PMID: 36773091 PMCID: PMC10356890 DOI: 10.1007/s00432-023-04594-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/18/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE Uterine carcinosarcomas (UCSs) are aggressive biphasic malignancies, with a carcinomatous/epithelial component and a sarcomatous/mesenchymal counterpart. The aim of this study was to evaluate the impact of the sarcomatous component (homologous vs heterologous) on the overall survival (OS) and progression-free survival (PFS). METHODS This is a multicenter observational retrospective study conducted in patients with stage I and II UCSs. RESULTS Ninety-five women with histological diagnosis of early-stage UCSs were retrieved: 60 (63.2%) had tumors with homologous sarcomatous components, and 35 (36.8%) with heterologous. At univariate analysis, a stromal invasion ≥ 50%, the presence of clear cell, serous or undifferentiated carcinomatous component, the heterologous sarcomatous component and FIGO stage IB and II were shown to be variables with a statistically significant negative impact on PFS. Similarly, a depth of invasion ≥ 50%, the heterologous sarcomatous component and FIGO stage IB and II were statistically negative prognostic factors also concerning OS. At multivariate analysis, only the heterologous sarcomatous component was confirmed to be a statistically significant negative prognostic factor both on PFS (HR 2.362, 95% CI 1.207-4.623, p value = 0.012) and on OS (HR 1.950, 95% CI 1.032-3.684, p = 0.040). CONCLUSION Carcinomatous and sarcomatous components both played a role in tumor progression and patients' survival. However, only the sarcomatous component retained a statistical significance at the multivariable model suggesting its preeminent prognostic role in early-stage UCSs.
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Affiliation(s)
- A Rosati
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
| | - V Vargiu
- Department of Gynecologic Oncology, Gemelli Molise, Campobasso, Italy
| | - C Certelli
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
| | - M Arcieri
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
| | - E Vizza
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - F Legge
- Gynecologic Oncology Unit, Dept. Obstetrics/Gynecology "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - F Cosentino
- Department of Gynecologic Oncology, Gemelli Molise, Campobasso, Italy.,Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio" Università degli studi del Molise, Campobasso, Italy
| | - G Ferrandina
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italia
| | - F Fanfani
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italia
| | - G Scambia
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italia
| | - G Corrado
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy.
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Shui C, Ran L, Tian Y, Qin L, Gu X, Xu H, Hu C, Zhang LL, Xu Y, Cheng C, Huan W. Survival after laparoscopy versus laparotomy for apparent early-stage uterine clear cell carcinoma: Results of a large multicenter cohort study. Front Oncol 2022; 12:975485. [PMID: 36132126 PMCID: PMC9483121 DOI: 10.3389/fonc.2022.975485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To compare the long-term survival between laparoscopic surgery and open surgery in patients with apparent early-stage uterine clear cell carcinoma (UCCC). Patients and methods 254 patients with apparent early-stage UCCC were reviewed. Comparisons were made between patients who underwent laparoscopic surgery versus those who underwent open surgery. Baseline data, clinicopathological data, and oncological outcomes were analyzed. 5-year disease-free survival (DFS) rate and 5-year overall survival (OS) rate were estimated and compared using the Kaplan-Meier method and the Log-rank test. The Cox proportional hazard regression model was employed to control the confounding factors. Results 147 patients underwent laparoscopic surgery, and 107 patients were managed by open surgery. No differences in terms of recurrence rate (laparoscopy versus laparotomy: 10.9% versus 12.9%, P=0.842) and recurrence pattern were observed. For patients who underwent open surgery and patients who underwent laparoscopic surgery, the 5-year DFS rates and 5-year OS rate were 75.8% (95% CI: 65.8%-83.2%) and 69.1% (95% CI: 58.8%-77.4%), 66.0% (95% CI: 57.1%-73.5%) and 60.8% (95% CI: 52.0%-68.5%), respectively. The Cox proportional hazards regression model shown that for apparent early-stage UCCC, the approach of surgical staging was not an independent predictor for survival (laparoscopy versus laparotomy: for DFS, aHR=1.06, 95% CI=0.64-1.75, P=0.826; for OS, aHR=1.10, 95% CI=0.72-1.68, P=0.671). Conclusion For apparent early-stage UCCC, in terms of oncological survival, laparoscopic surgery was as safe as open surgery.
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Affiliation(s)
- Chengyu Shui
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Lin Ran
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Yong Tian
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
- *Correspondence: Yong Tian,
| | - Li Qin
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Xin Gu
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Hui Xu
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Cui Hu
- Department of Obstetrics and Gynecology, Mianzhu City People’s Hospital, Mianzhu, China
- Department of Obstetrics and Gynecology, Sichuan University West China Hospital (Mianzhu Hospital), Mianzhu, China
| | - Lin-Lin Zhang
- Department of Obstetrics and Gynecology, Mianzhu City People’s Hospital, Mianzhu, China
- Department of Obstetrics and Gynecology, Sichuan University West China Hospital (Mianzhu Hospital), Mianzhu, China
| | - You Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chen Cheng
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Wu Huan
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chengdu Medical College, Chengdu, China
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Niu LN, Wang JX, Li X, Xu YJ, Qiu LR, Guo S, Zhang LZ, Shang Y. Clinical Analysis of the Discovery of Malignant Gynecological Tumors in the Diagnosis and Treatment of Pelvic Organ Prolapse. Front Surg 2022; 9:877857. [PMID: 35651690 PMCID: PMC9149274 DOI: 10.3389/fsurg.2022.877857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background Clinically, malignant gynecological tumors found by chance during the diagnosis and treatment of pelvic organ prolapse (POP) are rare, and they are usually missed, leading to delayed diagnosis and treatment. The initial treatment of these tumors cannot be standardized, and, as a single surgical intervention may not be able to treat both the tumor and prolapse, secondary surgery is usually needed, affecting the quality of life of patients. Case presentation The present study retrospectively analyzed the data of three patients who were diagnosed with malignant gynecological tumors during the diagnosis and treatment of POP. These patients were among 215 patients with POP treated in Yuncheng Central Hospital of Shanxi Province between January 2011 and May 2020. The case characteristics, surgical interventions, postoperative treatments, and follow-ups were summarized, and the characteristics of diagnosis and treatment were analyzed in the context of relevant literature. Conclusion As long as clinicians operate in strict accordance with the standards of diagnosis and treatment, obtain a complete medical history, undertake a physical examination, and remain diligent in auxiliary examinations, following existing clinical methods and diagnosis and treatment processes, patients with POP complicated with malignant gynecological tumors can be clearly diagnosed before and during surgery. In this way, initial treatment can be standardized, and surgical methods can be selected that address both the tumor and prolapse, thereby avoiding secondary surgery and improving the patient’s quality of life.
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Affiliation(s)
- Li-Na Niu
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
| | - Jun-Xia Wang
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
| | - Xia Li
- Department of General Family medicine, Yuncheng Central Hospital, Yuncheng, China
| | - Yong-Jun Xu
- Department of Pharmacy, Yuncheng Central Hospital, Yuncheng, China
| | - Li-Rong Qiu
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
| | - Sheng Guo
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
| | - Li-Zhen Zhang
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
| | - Yun Shang
- Department of Gynecology, Yuncheng Central Hospital, Yuncheng, China
- Correspondence: Yun Shang
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Huber D, Hurni Y. Sentinel Node Biopsy for Endometrial Cancer by Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Preliminary Study. Front Surg 2022; 9:907548. [PMID: 35615644 PMCID: PMC9125023 DOI: 10.3389/fsurg.2022.907548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe primary objective was to determine the intraoperative and postoperative surgical complications of sentinel lymph node biopsy (SLNB) by retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES). The secondary objective was to assess the feasibility of this surgical technique.MethodsThis was a descriptive study realized in a non-university hospital in Switzerland. Seven patients with endometrial cancer or endometrial complex atypical hyperplasia underwent surgical staging with SLNB by retroperitoneal vNOTES using an indocyanine green-based near-infrared fluorescence imaging technique (October 2021–February 2022).ResultsThe median operative time was 113 (81–211) minutes. The median estimated blood loss was 20 (20–400) mL. The overall bilateral detection rate was 100% (7/7). Upon histopathological examination, 5 patients presented an endometrial adenocarcinoma, and we found endometrial complex atypical hyperplasia in 2 cases. We successfully completed all procedures without significant intraoperative complications, but 1 case required conversion to conventional laparoscopy. The median postoperative stay was 2 (2–4) days, and we observed no postoperative complications during this period. We observed 1 case of postoperative deep vein thrombosis and an asymptomatic vaginal vault hematoma in the same patient.ConclusionsOur preliminary study suggests that retroperitoneal vNOTES could be a feasible, safe, and valuable approach to perform SLNB in endometrial cancer. However, strong evidence of its feasibility, the effective benefits, and the long-term oncological outcomes is needed before expanding the use of vNOTES in endometrial cancer outside study settings.
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Affiliation(s)
- Daniela Huber
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Yannick Hurni
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
- Correspondence: Yannick Hurni
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Initial surgical management of bulky malignant type II tumors of the endometrium by a robotic approach. J Robot Surg 2021; 16:899-903. [PMID: 34709539 DOI: 10.1007/s11701-021-01314-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
Type II uterine tumors often present with very large, necrotic tumor burden in the uterus that leads to dilation and effacement of the cervix. In patients with this presentation, conventional hysterectomy poses a much greater challenge as the ureters are composed of the mass of the tumor and are at an increased risk for injury. Given this surgical challenge, many of these patients may begin with neoadjuvant chemo-radiation. However, these treatment modalities are associated with significant toxicity and negatively impact patient quality of life. Therefore, we describe a minimally invasive robotic surgical approach that aims to optimize quality of life without sacrificing prognosis. Outcomes of 4 patients are presented.
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Cianci S, Rosati A, Vargiu V, Capozzi VA, Sozzi G, Gioè A, Gueli Alletti S, Ercoli A, Cosentino F, Berretta R, Chiantera V, Scambia G, Fanfani F. Sentinel Lymph Node in Aged Endometrial Cancer Patients "The SAGE Study": A Multicenter Experience. Front Oncol 2021; 11:737096. [PMID: 34737952 PMCID: PMC8560967 DOI: 10.3389/fonc.2021.737096] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The incidence of endometrial cancer is increasing in elderly people. Considering that aging progressively affects lymphatic draining function, we aimed to define its impact on IGC uptake during SLN mapping. METHODS A multicenter retrospective cohort of endometrial cancer patients with apparently early-stage endometrial cancer undergoing complete surgical staging with SLN dissection was identified in four referral cancer centers from May 2015 to March 2021. Patients were classified in Group 1 (<65 years old) and Group 2 (≥65 years old). The primary endpoint was the assessment of the overall, bilateral, and unsuccessful SLN mapping in the two groups. Secondary outcomes were the evaluation of SLN anatomical distribution and the identification of predictors for mapping failure applying a logistic regression. RESULTS A total of 844 patients were enrolled in the study (499 in Group 1 and 395 in Group 2). The overall detection rate, the successful bilateral mapping, and the mapping failure rate of the SLN were 93.8% vs. 87.6% (p = 0.002), 77.1% vs. 66.8% (p = 0.001), and 22.9% vs. 33.2% (p = 0.001), respectively, in Group 1 vs. Group 2. The advanced age affects the anatomical distribution of the SLN leading to a stepwise reduction of "unexpected" mapping sites (left hemipelvis: p < 0.001; right hemipelvis: p = 0.058). At multivariate analysis age ≥ 65 (OR: 1.495, 95% CI: 1.095-2.042, p = 0.011), BMI (OR: 1.023, 95% CI: 1.000-1.046, p = 0.047), non-endometrioid histotype (OR: 1.619, 95% CI: 1.067-2.458, p = 0.024), and LVSI (OR: 1.407, 95% CI: 1.010-1.961, p = 0.044) represent independent predictors of unsuccessful mapping. Applying binomial logistic regression analysis, there was a 1.280-fold increase in the risk of failed mapping for every 10-year-old increase in age (OR: 1.280, 95% CI: 1.108-1.479, p = 0.001). A higher rate of surgical under-staging (0.9% vs. 3.3%, p = 0.012) and adjuvant undertreatment (p = 0.018) was reported in Group 2. CONCLUSIONS Old age represents a risk factor for SLN mapping failure both intrinsically and in relation to the greater incidence of other independent risk factors such as LVSI, non-endometrioid histotype, and BMI. Surgeons should target the usual uptake along UPP during the SLN dissection in this subgroup of patients to minimize mapping failure and the consequent risk of surgical under-staging and adjuvant undertreatment.
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Affiliation(s)
- Stefano Cianci
- Department of Gynecologic Oncology and Minimally-invasive Gynecologic Surgery, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Andrea Rosati
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Virginia Vargiu
- Department of Gynecologic Oncology, Gemelli Molise, Campobasso, Italy
| | | | - Giulio Sozzi
- Department of Gynecologic Oncology, Aziende di Rilievo Nazionale di Alta Specializzazione (ARNAS) Civico Di Cristina Benfratelli, Palermo, Italy
| | - Alessandro Gioè
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alfredo Ercoli
- Department of Gynecologic Oncology and Minimally-invasive Gynecologic Surgery, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Francesco Cosentino
- Department of Gynecologic Oncology, Gemelli Molise, Campobasso, Italy
- Department of Gynecologic Oncology, Università degli studi del Molise, Campobasso, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics, Università di Parma, Parma, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, Aziende di Rilievo Nazionale di Alta Specializzazione (ARNAS) Civico Di Cristina Benfratelli, Palermo, Italy
- Department of Gynecologic Oncology, Università di Palermo, Palermo, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Department of Women and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Department of Women and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
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