European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

International expert consensus on the surgical anatomic classification of radical hysterectomies

BACKGROUND

The anatomic descriptions and extents of radical hysterectomy often vary across the literature and operative reports worldwide. The same nomenclature is often used to describe varying procedures, and different nomenclature is often used to describe the same procedure despite the availability of guideline and classification systems. This makes it difficult to interpret retrospective surgical reports, analyze surgical databases, understand technique descriptions, and interpret the findings of surgical studies.

OBJECTIVE

In collaboration with international experts in gynecologic oncology, the purpose of this study was to establish a consensus in defining and interpreting the 2017 updated Querleu-Morrow classification of radical hysterectomies.

STUDY DESIGN

The anatomic templates of type A, B, and C radical hysterectomy were documented through a set of 13 images taken at the time of cadaver dissection. An online survey related to radical hysterectomy nomenclature and definitions or descriptions of the associated procedures was circulated among international experts in radical hysterectomy. A 3-step modified Delphi method was used to establish consensus. Image legends were amended according to the experts' responses and then redistributed as part of a second round of the survey. Consensus was defined by a yes response to a question concerning a specific image. Anyone who responded no to a question was welcome to comment and provide justification. A final set of images and legends were compiled to anatomically illustrate and define or describe a lateral, ventral, and dorsal excision of the tissues surrounding the cervix.

RESULTS

In total, there were 13 questions to review, and 29 experts completed the whole process. Final consensus exceeded 90% for all questions except 1 (86%). Questions with relatively lower consensus rates concerned the definitions of types A and B2 radical hysterectomy, which were the main innovations of the 2017 updated version of the 2008 Querleu-Morrow classification. Questions with the highest consensus rates concerned the definitions of types B1 and C, which are the most frequently performed radical hysterectomies.

CONCLUSION

The 2017 version of the Querleu-Morrow classification proved to be a robust tool for defining and describing the extent of radical hysterectomies with a high level of consensus among international experts in gynecologic oncology. Knowledge and implementation of the exact definitions of hysterectomy radicality are imperative in clinical practice and clinical research.

Impact of Hospital Case Volume on Uterine Sarcoma Prognosis: SARCUT Study Subanalysis

BACKGROUND

High-complexity and low-prevalence procedures benefit from treatment by referral centers. The volume of cases necessary to maintain high training in the treatment of gynecologic sarcoma is currently unknown. This study aimed to determine differences in survival and recurrence as a function of the volume of patients treated per center.

METHODS

The multicentric cross-sectional SARComa of the Uterus (SARCUT) study retrospectively collected cases of uterine sarcomas from 44 centers in Europe from January 2001 to December 2007. The survival of patients treated in high case-volume (HighCV) centers was compared with the survival of patients treated in low case-volume (LowCV) centers.

RESULTS

The study enrolled 966 patients: 753 in the LowCV group and 213 in the HighCV. Overall survival (OS) was 117 months, and cancer-specific survival (CSS) was 126 months. The difference was significant (respectively p = 0.0003 and 0.0004, log rank). After adjustment for other confounding factors, the remaining significant factors were age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.03-1.05), histology (HR, 1.19; 95% CI, 1.06-1.34), extrauterine involvement (HR, 1.61; 95% CI, 1.24-2.10) and persistent disease after treatment (HR, 3.22; 95% CI, 2.49-4.18). The cytoreduction performed was significantly associated with the CSS and OS in both groups. The log rank for surgical cytoreduction was a p value lower than 0.0001 for OS, lower than 0.0001 for the LowCV centers, and 0.0032 for the HighCV centers.

CONCLUSIONS

The prognosis for patients with uterine sarcoma is directly related to complete tumor cytoreduction, histologic type, and FIGO stage, with significant differences between low and high case-volume centers. Patients with uterine sarcomas should be centralized in HighCV centers to improve their oncologic outcomes.

Role of Adjuvant Radiotherapy in Patients with Cervical Cancer Undergoing Radical Hysterectomy

The benefit of adjuvant radiotherapy (RT) after radical hysterectomy in patients with cervical cancer remains controversial. The aim of this study was to determine adjuvant RT's impact on survival in accordance with Sedlis criteria. Patients with early-stage cervical cancer undergoing radical hysterectomy between 2005 and 2022 at a single tertiary care institution were included. A multivariate analysis was performed to determinate if RT was an independent prognostic factor for recurrence or death. We also analysed whether there was a statistically significant difference in overall survival (OS) between patients who met only one or two Sedlis criteria, depending on whether they received adjuvant RT or not. 121 patients were included in this retrospective study, of whom 48 (39.7%) received adjuvant RT due to the presence of unfavourable pathological findings. In multivariate analysis, RT was not found to be a statistically significant prognostic factor for OS (p = 0.584) or disease-free survival (DFS) (p = 0.559). When comparing patients who met one or two Sedlis criteria, there were no statistically significant differences in OS between RT and no adjuvant treatment in either group. Since the selection of patients with cervical cancer eligible for surgery is becoming more accurate, adjuvant RT might not be necessary for patients with intermediate risk factors.

Urological Complications in Radical Surgery for Cervical Cancer: A Comparative Meta-Analysis before and after LACC Trial

BACKGROUND

After the LACC trial publication in 2018, the minimally invasive approach (MIS) has severely decreased in favor of open surgery: MIS radical hysterectomy was associated with worse oncological outcomes than open surgery, but urological complications were never extensively explored in pre- versus post-LACC eras, even if they had a great impact on post-operative QoL. The purpose of this meta-analysis is to compare functional and organic urological complication rates before and after LACC trial.

METHODS

An independent search of the literature was conducted 4 years before and after the LACC trial and 50 studies were included.

RESULTS

The overall rate of urologic complications was higher in pre-LACC studies while no differences were found for organic urological complications. Conversely, the overall risk of dysfunctional urological complications showed a higher rate in the pre-LACC era. This is probably related to a sudden shift to open surgery, with potential lower thermal damage to the urinary tract autonomic nervous fibers.

CONCLUSIONS

This meta-analysis showed that the incidence of urological complications in radical cervical cancer surgery was higher before the LACC trial, potentially due to the shift to open surgery. Nevertheless, further studies are needed to shed light on the connection between minimally invasive surgery and urological damage.

ESGO/ESTRO quality indicators for radiation therapy of cervical cancer

BACKGROUND

The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer.

OBJECTIVE

To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques.

METHODS

Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n = 99).

RESULTS

Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes.

DISCUSSION

This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.

ESGO/ESTRO quality indicators for radiation therapy of cervical cancer

BACKGROUND

The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer.

OBJECTIVE

To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques.

METHODS

Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n=99).

RESULTS

Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes.

DISCUSSION

This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.

Consensus on the Gemelli terminology of surgical anatomy for radical hysterectomy

OBJECTIVES

To report on a consensus survey of experts on a recently proposed simplified nomenclature of surgical anatomy of the female pelvis for radical hysterectomy. The aim was to standardize surgical reports in clinical practice and understanding of the techniques in future surgical literature.

METHODS

The anatomical definitions were included in 12 original images taken at the time of cadaver dissections. Denomination of the corresponding anatomical structures was based on the nomenclature recently proposed by the same team. A three step modified Delphi method was used to establish consensus. After a first round of online survey, the legends of the images were amended to respond to the comments of the experts. Second and third rounds were performed. Consensus was defined as a yes vote to each question regarding the images provided, and 75% was defined as the cut-off for agreement. Comments justifying the no votes were taken into account to amend the set of images and legends.

RESULTS

A group of 32 international experts from all continents was convened. Consensus exceeded 90% for all five images documenting the surgical spaces. Consensus ranged between 81.3% and 96.9% for the six images documenting the ligamentous structures surrounding the cervix. Finally, consensus was lowest (75%) for the most recently defined denomination of the broad ligament (lymphovascular parauterine tissue or upper lymphatic pathway).

CONCLUSION

Simplified anatomic nomenclature is a robust tool to describe the surgical spaces of the female pelvis. The simplified definition of ligamentous structures reached a high level of consensus, even if the terms paracervix (instead of lateral parametrium), uterosacral ligament (replaced by rectovaginal ligament), vesicovaginal ligament, and lymphovascular parauterine tissue remain matters of debate.

Efficacy of lymph node dissection on stage IIICr of cervical cancer before CCRT: study protocol for a phase III, randomized controlled clinical trial (CQGOG0103)

BACKGROUND

Cervical cancer is still present a major public health problem, especially in developing countries. In International Federation of Gynaecology and Obstetrics 2018, allowing assessment of retroperitoneal lymph nodes by imaging and/or pathological findings and, if deemed metastatic, the case is designated as stage IIIC (with r and p notations). Patients with lymph node metastases have lower overall survival (OS), progression free survival (PFS), and survival after recurrence, especially those who have unresectable macroscopical positive lymph nodes. Retrospective analysis suggests that there may be a benefit to debulking macroscopic nodes that would be otherwise difficult to sterilize with standard doses of radiation therapy. However, there are no prospective study reporting that resecting macroscopic nodes before concurrent chemoradiation therapy (CCRT) would improve PFS or OS of cervical cancer and no guidelines for surgical resection of bulky lymph nodes. The CQGOG0103 study is a prospective, multicenter and randomized controlled trial (RCT) evaluating lymph node dissection on stage IIICr of cervical cancer.

METHODS

Eligible patients are histologically confirmed cervical squamous cell carcinoma, adenocarcinoma, adeno-squamous cell carcinoma. Stage IIICr (confirmed by computed tomography [CT]/magnetic resonance imaging/positron emission tomography/CT) and the short diameter of image-positive lymph node ≥15 mm. 452 patients will be equally randomized to receive either CCRT (pelvic external-beam radiotherapy [EBRT]/extended-field EBRT + cisplatin [40 mg/m²] or carboplatin [the area under curve=2] every week for 5 cycles + brachytherapy) or open/minimally invasive pelvic and para-aortic lymph node dissection followed by CCRT. Randomization is stratified by status of para-aortic lymph node. The primary endpoint is PFS. Secondary endpoints are OS and surgical complications. A total of 452 patients will be enrolled from multiple hospitals in China within 4 years and followed up for 5 years.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04555226.

Effect of annualized surgeon volume on major surgical complications for abdominal and laparoscopic radical hysterectomy for cervical cancer in China, 2004-2016: a retrospective cohort study

BACKGROUND

Previous studies have suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery; however, the effect of surgeon volumes on surgical outcomes might differ according to the surgical approach used. This paper attempts to evaluate the effect of surgeon volume on complications or cervical cancer in an abdominal radical hysterectomy (ARH) cohort and laparoscopic radical hysterectomy (LRH) cohort.

METHODS

We conducted a population-based retrospective study using the Major Surgical Complications of Cervical Cancer in China (MSCCCC) database to analyse patients who underwent radical hysterectomy (RH) from 2004 to 2016 at 42 hospitals. We estimated the annualized surgeon volumes in the ARH cohort and in the LRH cohort separately. The effect of the surgeon volume of ARH or LRH on surgical complications was examined using multivariable logistic regression models.

RESULTS

In total, 22,684 patients who underwent RH for cervical cancer were identified. In the abdominal surgery cohort, the mean surgeon case volume increased from 2004 to 2013 (3.5 to 8.7 cases) and then decreased from 2013 to 2016 (8.7 to 4.9 cases). The mean surgeon case volume number of surgeons performing LRH increased from 1 to 12.1 cases between 2004 and 2016 (P < 0.01). In the abdominal surgery cohort, patients treated by intermediate-volume surgeons were more likely to experience postoperative complications (OR = 1.55, 95% CI = 1.11-2.15) than those treated by high-volume surgeons. In the laparoscopic surgery cohort, surgeon volume did not appear to influence the incidence of intraoperative or postoperative complications (P = 0.46; P = 0.13).

CONCLUSIONS

The performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have no effect on intraoperative or postoperative complications after LRH.

Association of Hospital Surgical Volume With Survival in Early-Stage Cervical Cancer Treated With Radical Hysterectomy

OBJECTIVE

To evaluate the association of number of radical hysterectomies performed per year in each center with disease-free survival and overall survival.

METHODS

We conducted an international, multicenter, retrospective study of patients previously included in the Surveillance in Cervical Cancer collaborative studies. Individuals with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIA1 cervical cancer who underwent radical hysterectomy and had negative lymph nodes at final histology were included. Patients were treated at referral centers for gynecologic oncology according to updated national and international guidelines. Optimal cutoffs for surgical volume were identified using an unadjusted Cox proportional hazard model, with disease-free survival as the outcome and defined as the value that minimizes the P-value of the split in groups in terms of disease-free survival. Propensity score matching was used to create statistically similar cohorts at baseline.

RESULTS

A total of 2,157 patients were initially included. The two most significant cutoffs for surgical volume were identified at seven and 17 surgical procedures, dividing the entire cohort into low-volume, middle-volume, and high-volume centers. After propensity score matching, 1,238 patients were analyzed-619 (50.0%) in the high-volume group, 523 (42.2%) in the middle-volume group, and 96 (7.8%) in the low-volume group. Patients who underwent surgery in higher-volume institutions had progressively better 5-year disease-free survival than those who underwent surgery in lower-volume centers (92.3% vs 88.9% vs 83.8%, P=.029). No difference was noted in 5-year overall survival (95.9% vs 97.2% vs 95.2%, P=.70). Cox multivariable regression analysis showed that FIGO stage greater than IB1, presence of lymphovascular space invasion, grade greater than 1, tumor diameter greater than 20 mm, minimally invasive surgical approach, nonsquamous cell carcinoma histology, and lower-volume centers represented independent risk factors for recurrence.

CONCLUSION

Surgical volume of centers represented an independent prognostic factor affecting disease-free survival. Increasing number of radical hysterectomies performed in each center every year was associated with improved disease-free survival.

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

OBJECTIVE

To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer.

METHODS

In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort.

RESULTS

A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy.

CONCLUSIONS

Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

Providing Patients with Locally Advanced Cervical Cancer Access to Brachytherapy: Experience from a Referral Network for Women Treated in Overseas France

Image-guided adaptive brachytherapy (IGABT) is part of the standard of care for locally advanced cervical cancer (LACC). Access to IGABT is limited in many regions, thus leading to treatment care disparities. We report the experience of a referral network for women with LACC between radiotherapy facilities in Overseas France and Gustave Roussy. This is a retrospective review of patients with LACC referred to Gustave Roussy, for pulsed-dose-rate (PDR) image-guided adaptive BT after initial radiation therapy in the French overseas between 2014 and 2021. Sixty-four patients were eligible to receive IGABT. Overall treatment time (OTT) was 60.5 days (IQR: 51−68.5). The median follow-up time was 17 months. At two years, estimated probabilities of LC, progression-free survival, and overall survival (OS) were 94.6% (95% CI: 88.9−100.0%), 72.7% (95% CI: 61.1−86.5%), and 82.5% (95% CI: 72.0−94.5%). In multivariable analysis, a D90CTVHR < 85GyEQD2 and a CTVHR volume > 40 cm3 were significant for poorer PFS (p = 0.001 and p = 0.009, respectively) and poorer OS (p = 0.004 and p = 0.004). The centralization of this advanced technique to expert centers requires a well-defined workflow and appropriate dimensioning of resources to minimize OTT.

Adjuvant therapy in early-stage cervical cancer after radical hysterectomy: are we overtreating our patients? A meta-analysis

OBJECTIVE

There is a gap in knowledge regarding the ideal management of patients with early-stage cervical cancer and intermediate-risk features. Here, we present a meta-analysis of the published literature on oncological outcomes in these patients and determine trends in postoperative management.

METHODS

MEDLINE and PubMed were used for literature searches. The inclusion criteria were: English language articles including ≥ 10 patients, patients who underwent radical hysterectomy, nodes negative, studies reporting oncological outcomes and complications treatment-related and compare a surgery-only cohort with a radiotherapy cohort. The PRISMA guidelines were followed. Combined relative risk was calculated using DerSimonian-Laird random-effects model and a forest plot was drawn.

RESULTS

We collected 183 manuscripts on early-stage cervical cancer treated with radical hysterectomy alone or with adjuvant radiotherapy after surgery. A total of eight studies met the inclusion criteria. Regarding oncological outcomes, survival was reported in five studies. The relative risk of recurrence and the relative risk of mortality was similar in both groups independently whether receive or not adjuvant therapy. Most of the studies did not report significant differences regarding morbidity treatment related between the groups, except for a higher rate of lymphedema after radiotherapy.

CONCLUSION

We found that the relative risk of recurrence and mortality was similar in both groups not depending on adjuvant therapy. Therefore, whether radiotherapy adjuvant treatment is indicated remains a topic of debate.

SUCCOR Risk: Design and Validation of a Recurrence Prediction Index for Early-Stage Cervical Cancer

Objective

Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence.

Methods

Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group.

Results

A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17–0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33–3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00–2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001).

Conclusion

Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11671-5.

Surgical Outcomes of Laparoscopic Pelvic Lymph Node Debulking during Staging Aortic Lymphadenectomy in Locally Advanced Cervical Cancer: A Multicenter Study

Simple Summary

Lymph node metastasis is an important prognostic factor in locally advanced cervical cancer (LACC), which makes correct staging crucial. In contrast to existing studies evaluating pelvic lymphadenectomy after aortic lymphadenectomy, this study focuses on the pelvic node (PLN) debulking technique which has the dual objective of staging and cytoreduction. This is a multicenter retrospective study of patients with LACC and positive pelvic nodes on imaging tests. Feasibility, morbidity and delay in the initiation of chemoradiotherapy (CRT) were evaluated for the PLN debulking by comparing it with a control group of aortic lymphadenectomy alone. Excision of the bulky nodes was possible in 99.4% of patients. There were no differences in complications between the groups and a shorter time from diagnosis and from surgery to the start of CRT was observed in the study group.

Abstract

Background: Few studies have evaluated laparoscopic pelvic lymph node (PLN) debulking during staging aortic lymphadenectomy in locally advanced cervical cancer (LACC). It allows us to know the lymph node status and facilitates the action of chemoradiotherapy (CRT) by reducing tumor burden. We evaluated its feasibility and compared the perioperative morbidity and the time to CRT with a control group. Methods: This was a multicenter retrospective study of patients with LACC FIGO stage IIIC1r who were recipients of CRT. We compared two cohorts: group 1, which consisted of 164 patients with surgical staging by laparoscopic aortic lymphadenectomy and PLN debulking, and group 2, which consisted of 111 patients with aortic lymphadenectomy alone. Results: Excision of the bulky nodes was possible in all patients in group 1 except for one. Surgery lasted a median of 82 min longer in group 1 but there was no greater intraoperative bleeding or increased hospital stay. There were no significant differences in intraoperative or postoperative complications between the groups. A significantly shorter time from surgery to the start of RT was observed in group 1. Conclusions: It is feasible to perform laparoscopic PLN debulking in the same procedure as the staging aortic lymphadenectomy in LACC without increasing surgical or postoperative complications and without delaying the start of CRT compared to single aortic lymphadenectomy.

Minimally Invasive Surgery for Cervical Cancer in Light of the LACC Trial: What Have We Learned?

Cervical cancer is the most common gynecologic malignancy and the fourth most common cancer in women worldwide. Over the last two decades, minimally invasive surgery (MIS) emerged as the mainstay in the surgical management of cervical cancer, bringing advantages such as lower operative morbidity and shorter hospital stay compared to open surgery while maintaining comparable oncologic outcomes in numerous retrospective studies. However, in 2018, a prospective phase III randomized controlled trial, “Laparoscopic Approach to Carcinoma of the Cervix (LACC)”, unexpectedly reported that MIS was associated with a statistically significant poorer overall survival and disease-free survival compared to open surgery in patients with early-stage cervical cancer. Various hypotheses have been raised by the authors to try to explain these results, but the LACC trial was not powered to answer those questions. In this study, through an exhaustive literature review, we wish to explore some of the potential causes that may explain the poorer oncologic outcomes associated with MIS, including the type of MIS surgery, the size of the lesion, the impact of CO2 pneumoperitoneum, prior conization, the use of uterine manipulator, the use of protective measures, and the effect of surgical expertise/learning curve.

Assessment of ESGO Quality Indicators in Cervical Cancer Surgery: A Real-World Study in a High-Volume Chinese Hospital

The ESGO developed a list of fifteen quality indicators for cervical cancer surgery in order to audit and improve clinical practice in 2020. However, data from the developing countries with high incidence rates of cervical cancer is still lacking. Therefore, we conducted a retrospective study of 7081 cases diagnosed as cervical cancer between 2014 and 2019 in a Chinese single center according to the quality indicators proposed by ESGO. A total of 5952 patients underwent radical procedures, with an average of 992.0 per year. All surgeries were performed or supervised by a certified gynecologic oncologist as surgical qualification grading system has been established. Compared with the low-volume group, patients in the high-volume group (≥15 cases/year) had a shorter hospital stay (P<0.001), more free surgical margins (P=0.031), and less complications (P<0.001), but the 5-year recurrence-free survival and overall survival rates were similar (P>0.05). Treatment was not planned at a multidisciplinary team meeting but with the consultation system. The required preoperative workup was incomplete in 19.7% of patients with pelvic MRI and 45.7% of patients with PET-CT. A total of 1459 (20.6%) patients experienced at least one complication after surgery. The CDC grade IIIb or higher complications occurred in 80 patients, accounting for 5.5% complications. The urological fistula rate within 30 postoperative days were 0.3%. After primary surgical treatment, 97.4% patients had clear vaginal and parametrial margins. After restaging FIGO 2009 to FIGO 2018 system, 14.7% patients with a stage T1b disease were T-upstaged. After a median follow-up of 42 months, recurrence occurred in 448 patients, and 82.1% patients recurred within 2 years. The 2-year RFS rate of patients with pT1b1N0 was 97.3% in 2009 FIGO staging system. Lymph node staging was performed in 99.0% patients with a stage T1 disease. After a primary surgical treatment for a stage pT1b1N0 disease, 28.3% patients received adjuvant chemoradiotherapy. Above all, most of quality indicators reached the targets, except four quality indicators. The quality indicators of ESGO should be popularized and applied in China to guarantee quality of surgery.

The Impact of Surgical Practice on Oncological Outcomes in Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer, Spanish National Registry

Simple Summary

Minimal invasive surgery (MIS) has been associated with lower disease-free survival than open surgery among women who underwent radical hysterectomy for early-stage cervical cancer. However, the mechanisms by which MIS increases mortality in cervical cancer remain uncertain. We aimed to determine if surgical practice among centers using robotic surgery has an impact on oncological outcomes. We evaluated 215 women with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) who underwent robot-assisted radical hysterectomy in five Spanish tertiary centers between 2009 and 2018. A higher surgical volume, higher participation in clinical trials, higher rate of MRI use for diagnosis, greater use of sentinel lymph node biopsies, and a favorable learning curve with low rates of early recurrences were observed for the centers with better oncological outcomes. These factors might have a significant impact on oncological outcomes in all surgical approaches.

Abstract

This study aimed to assess whether surgical practice had a significant impact on oncological outcomes among women who underwent robot-assisted radical hysterectomy for early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009). The secondary objective was to audit the pre-surgical quality indicators (QI) proposed by the European Society of Gynaecological Oncology (ESGO). The top 5 of 10 centers in Spain and Portugal were included in the analysis. The hospitals were divided into group A (n = 118) and group B (n = 97), with recurrence rates of <10% and >10%, respectively. After balancing both groups using the propensity score, the ORs for all events were higher and statistically significant for group B (recurrences OR = 1.23, 95% CI = 1.13–1.15, p-value = 0.001; death OR = 1.10, 95% CI = 1.02–1.18, p-value = 0.012; disease-specific mortality OR_r = 1.11, 95% CI = 1.04–1.19, p-value = 0.002). A higher surgical volume, higher participation in clinical trials, higher rate of MRI use for diagnosis, greater use of sentinel lymph node biopsies, and a favorable learning curve with low rates of early recurrences were observed among the centers with better oncological outcomes. These factors might have a significant impact on oncological outcomes not only after robot-assisted surgery, but also after laparoscopies and open surgeries in the treatment of cervical cancer.

Quality of training in cervical cancer radical surgery: a survey from the European Network of Young Gynaecologic Oncologists (ENYGO)

BACKGROUND

The European Society of Gynaecological Oncology (ESGO) and partners are committed to improving the training for gynecologic oncology fellows. The aim of this survey was to assess the type and level of training in cervical cancer surgery and to investigate whether the Laparoscopic Approach to Cervical Cancer (LACC) trial results impacted training in radical surgery for gynecologic oncology fellows.

METHODS

In June 2020, a 47-question electronic survey was shared with European Network of Young Gynaecologic Oncologists (ENYGO) members. Specialist fellows in obstetrics and gynecology, and gynecologic oncology, from high- and low-volume centers, who started training between January 1, 2017 and January 1, 2020 or started before January 1, 2017 but finished their training at least 6 months after the LACC trial publication (October 2018), were included.

RESULTS

81 of 125 (64.8%) respondents were included. The median time from the start of the fellowship to completion of the survey was 28 months (range 6-48). 56 (69.1%) respondents were still fellows-in-training. 6 of 56 (10.7%) and 14 of 25 (56.0%) respondents who were still in training and completed the fellowship, respectively, performed ≥10 radical hysterectomies during their training. Fellows trained in an ESGO accredited center had a higher chance to perform sentinel lymph node biopsy (60.4% vs 30.3%; p=0.027). There was no difference in the mean number of radical hysterectomies performed by fellows during fellowship before and after the LACC trial publication (8±12.0 vs 7±8.4, respectively; p=0.46). A significant reduction in number of minimally invasive radical hysterectomies was noted when comparing the period before and after the LACC trial (38.5% vs 13.8%, respectively; p<0.001).

CONCLUSION

Exposure to radical surgery for cervical cancer among gynecologic oncology fellows is low. Centralization of cervical cancer cases to high-volume centers may provide an increase in fellows' exposure to radical procedures. The LACC trial publication was associated with a decrease in minimally invasive radical hysterectomies performed by fellows.

Increasing global accessibility to high-level treatments for cervical cancers

Human papillomaviruses (HPV)-related gynecological cancers are a major health care issue, and a leading cause of cancer death in low- and middle-income countries (LMIC). In 2020, the World Health Organization launched a program aimed at cervical cancer elimination, by screening and vaccination strategies. Offering the best possible care to women diagnosed with invasive cancer is a complementary objective. Treatment of cervical cancer as per modern standards is complex and multimodal, mainly relying on surgery, external-beam radiotherapy (+/-chemotherapy) and brachytherapy. In parallel with the pivotal role of multidisciplinary discussion, international societies provide guidance to define the most effective and least toxic anti-cancer strategy, homogenize treatment protocols and provide benchmark quality indicators as a basis for accreditation processes. The challenge is to offer the appropriate diagnostic workup and treatment upfront and to avoid non- evidence-based treatment that consumes resources, impairs quality of life (QoL), and compromises oncological outcome. Various strategies may be applied for improving treatment quality: development of surgical mentorship, companion-training programs and international cooperation. The lack of radiotherapy/brachytherapy facilities is a major concern in LMIC. Reinforcing international support in terms of education, training, research and development and technical cooperation with national projects is required to increase access to minimum requirements but also introduce modern techniques, upgrade radiotherapy/brachytherapy services, and expand access to modern systemic treatments. In countries with robust economies, compliance to standards should also be increased. Integrative cancer care and multidisciplinary approaches are needed to tackle the dual challenge of increasing cure rates while minimizing QoL impairment. Appropriate dimensioning of the resources to avoid harmful treatment delays and access to expert referral centers is also a priority.

Up-Front Multigene Panel Testing for Cancer Susceptibility in Patients With Newly Diagnosed Endometrial Cancer: A Multicenter Prospective Study

PURPOSE

Clinical utility of up-front multigene panel testing (MGPT) is directly related to the frequency of pathogenic variants (PVs) in the population screened and how genetic findings can be used to guide treatment decision making and cancer prevention efforts. The benefit of MGPT for many common malignancies remains to be determined. In this study, we evaluated up-front MGPT in unselected patients with endometrial cancer (EC) to determine the frequency of PVs in cancer susceptibility genes.

METHODS

Patients with EC were prospectively enrolled at nine Ohio institutions from October 1, 2017, to December 31, 2020. Nine hundred and sixty-one patients with newly diagnosed EC underwent clinical germline MGPT for 47 cancer susceptibility genes. In addition to estimating the prevalence of germline PVs, the number of individuals identified with Lynch syndrome (LS) was compared between MGPT and tumor-based screening.

RESULTS

Likely pathogenic variants or PVs were identified in 97 of 961 women (10.1%). LS was diagnosed in 29 of 961 patients (3%; 95% CI, 2.1 to 4.3), with PVs in PMS2 most frequent. MGPT revealed nine patients with LS in addition to the 20 identified through routine tumor-based screening. BRCA1 and BRCA2 PVs were found in 1% (10 of 961; 95% CI, 0.6 to 1.9) of patients and that group was significantly enriched for type II ECs.

CONCLUSION

This prospective, multicenter study revealed potentially actionable germline variants in 10% of unselected women with newly diagnosed EC, supporting the use of up-front MGPT for all EC patients. The discovery that BRCA1 or BRCA2 heterozygotes frequently had type II cancers points to therapeutic opportunities for women with aggressive histologic EC subtypes.

Impact of surgeon learning curve in minimally invasive radical hysterectomy on early stage cervical cancer patient survival

Background

Recently, it has been sustained that only surgeons skilled in minimally invasive radical hysterectomy (MI-RH) could provide valuable oncological outcomes in early-stage cervical cancer. Still, literature lacks data correlating surgeon experience with patient survival rate.

Objective

To investigate the impact of surgeon training patient survival rate following MI-RH for early stage cervical cancer.

Methods

This was a retrospective study of 243 early-stage cervical cancer treated with MI-RH. Multiple regression analyses were undertaken to investigate the impact of the surgeons learning curve, according to the number of MI-RH, on patients prognosis.

Results

A steady trend of reduction in disease recurrence risk is associated with increased surgeon experience. The peak of the learning curve was shown at the 19th MI-RH (hazard ratio of disease-free survival: 0.321; 95%CI: 0.140-0.737; p= 0.007). The 3 years disease-free survival that a surgeon could provide to patients is significantly lower at the beginning of his/her learning path comparing to what he/she could guarantee once adequate experience had been achieved (75.4% and 91.6% respectively, p=0.005). Surgeon experience appears to be an independent prognostic factor.

Conclusion

The experience that a surgeon can achieve practicing in MI-RH significantly influences oncological outcomes of early-stage cervical cancer patients. Future studies comparing minimally invasive and open surgery should take this into account. It would be advisable that the scientific community precisely establishes the minimum training required in the field of MI-RH for early-stage cervical cancer.

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators

INTRODUCTION

Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce.

OBJECTIVE

To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database.

METHODS

The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified.

RESULTS

The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m² (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0-84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation.

CONCLUSIONS

In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.

Treatment Outcomes of Early Carcinoma Cervix Before and After Sub-specialization

This study aimed to compare the treatment outcomes in carcinoma cervix before and after gynecologic oncology sub-specialization at a tertiary care hospital, in India. This was a retrospective cohort study comparing women with operable cervical cancer who underwent radical hysterectomy before and after gynecologic oncology sub-specialization. Electronic medical records of women operated for early carcinoma cervix between 2001 and 2010 and 2011-2015 were reviewed and compared for treatment and oncological outcomes. Seventy-four patients were operated over 5 years after sub-specialization as against 59 over 10 years before sub-specialization, with similar clinical characteristics. After surgical-pathological examination, both cohorts were comparable with regard to mean tumor size, lymph nodes retrieved, deep stromal invasion, and involvement of lymph nodes, parametrium, and vaginal margins. After sub-specialization, the rate of intraoperative (3% versus 14%, p = 0.018) and postoperative complications (15% versus 46%, p < 0.001) was lower. Adjuvant radiation was used more after sub-specialization (50% versus 24%, p < 0.001). The follow-up rates were similar in both groups with comparable 5-year recurrence-free survival and overall survival rates. The hazard ratio for death after sub-specialization was 0.39 (95% CI 0.12 to 1.22) after adjusting for histology, stage, grade, and presence of intermediate or high risk factors. Gynecological oncologic sub-specialization decreased intraoperative and postoperative complications, improved pathological reporting, and enabled appropriate tailoring of adjuvant therapy.

Prognostic value of the number of the metastatic lymph nodes in locally early-stage cervical cancer: squamous cell carcinoma versus non-squamous cell carcinoma

PURPOSE

To clarify the prognostic value of the number of metastatic lymph nodes (mLNs) in squamous and non-squamous histologies among women with node-positive cervical cancer.

METHODS

One hundred ninety-one node-positive cervical cancer patients who had undergone radical hysterectomy plus systematic pelvic and para-aortic lymphadenectomy followed by concurrent radiochemotherapy were retrospectively reviewed. The prognostic value of the number of mLNs was investigated in squamous cell carcinoma (SCC) v (n = 148) and non-SCC (n = 43) histologies separately with univariate log-rank test and multivariate Cox regression analyses.

RESULTS

In SCC cohort, mLNs > 2 was significantly associated with decreased 5-year disease-free survival (DFS) [hazard ratio (HR) = 2.06; 95% confidence interval (CI) 1.03-4.09; p = 0.03) and overall survival (OS) (HR = 2.35, 95% CI 1.11-4.99; p = 0.02). However mLNs > 2 had no significant impact on 5-year DFS and 5-year OS rates in non-SCC cohort (p = 0.94 and p = 0.94, respectively). We stratified the entire study population as SCC with mLNs ≤ 2, SCC with mLNs > 2, and non-SCC groups. Thereafter, we compared survival outcomes. The non-SCC group had worse 5-year OS (46.8% vs. 85.3%, respectively; p < 0.001) and 5-year DFS rates (31.6% vs. 82.2%, respectively; p < 0.001) when compared to those of the SCC group with mLNs ≤ 2. However, the non-SCC group and the SCC group with mLNs > 2 had similar 5-year OS (46.8% vs. 65.5%, respectively; p = 0.16) and 5-year DFS rates (31.6% vs. 57.5%, respectively; p = 0.06).

CONCLUSION

Node-positive cervical cancer patients who have non-SCC histology as well as those who have SCC histology with mLNs > 2 seem to have worse survival outcomes when compared to women who have SCC histology with mLNs ≤ 2.

Risk Factors for Recurrence after Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer: A Multicenter Retrospective Study

Simple Summary

In 239 women with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) undergoing robot-assisted radical hysterectomy in Spanish and Portuguese centers between 2009 and 2018, the overall survival rate was 94.1% after a median follow-up of 51 months. Recurrence was diagnosed in 26 patients. In the multivariate analysis, independent risk factors for recurrence were tumor size > 20 mm, adenocarcinoma as histological type, presence of positive pelvic lymph nodes, tumor grades 2 and 3, and not performing sentinel lymph node biopsy. The present oncological and surgical results surpassed the target of quality indicators in cervical cancer proposed by the European Society of Gynecology Oncology. When selecting a robot-assisted surgical approach to perform radical hysterectomy in the surgical treatment of primary early-stage cervical cancer, it is recommended to take into account the tumor grade and histological type, results of the sentinel lymph node biopsy, and the size of the tumor.

Abstract

This retrospective analysis aimed to assess the risk factors for recurrence in patients diagnosed with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) undergoing robot-assisted radical hysterectomy in Spain and Portugal between 2009 and 2018. A second primary objective was to audit the oncological outcomes according to quality indicators (QI) proposed by the European Society of Gynecology Oncology (ESGO). The study population included 239 women. After a median follow-up of 51 months, recurrence occurred in 26 patients (10.9%). Independent factors for recurrence were clinical tumor size > 20 mm (hazard ratio (HR) 2.37), adenocarcinoma as histological type (HR 2.51), positive pelvic lymph nodes (HR 4.83), tumor grade 2 (HR 4.99), tumor grade 3 (HR 8.06), and having not performed sentinel lymph node biopsy (SLNB) (HR 4.08). All 5 QI selected were surpassed by our results. In patients with early-stage cervical cancer undergoing robotic radical hysterectomy, clinicians should be aware that tumor grade 2 and 3, tumor size > 20 mm, adenocarcinoma, positive pelvic nodes, and lack of performance of SLNB are risk factors for recurrence. Fulfillment of QI targets of the ESGO might be considered as an objective oncological outcome indicator supporting the minimally invasive approach for early-stage cervical cancer treatment.

Patterns of recurrence after laparoscopic versus open abdominal radical hysterectomy in patients with cervical cancer: a propensity-matched analysis

Objective

Recent evidence has suggested that laparoscopic radical hysterectomy is associated with an increased risk of recurrence in comparison with open abdominal radical hysterectomy. The aim of our study was to identify patterns of recurrence after laparoscopic and open abdominal radical hysterectomy for cervical cancer.

Methods

This a retrospective multi-institutional study evaluating patients with recurrent cervical cancer after laparoscopic and open abdominal surgery performed between January 1990 and December 2018. Inclusion criteria were: age ≥18 years old, radical hysterectomy (type B or type C), no recurrent disease, and clinical follow-up >30 days. The primary endpoint was to evaluate patterns of first recurrence following laparoscopic and open abdominal radical hysterectomy. The secondary endpoint was to estimate the effect of the primary surgical approach (laparoscopy and open surgery) in post-recurrence survival outcomes (event-free survival and overall survival). In order to reduce possible confounding factors, we applied a propensity-matching algorithm. Survival outcomes were estimated using the Kaplan-Meier model.

Results

A total of 1058 patients were included in the analysis (823 underwent open abdominal radical hysterectomy and 235 patients underwent laparoscopic radical hysterectomy). The study included 117 (14.2%) and 35 (14.9%) patients who developed recurrent cervical cancer after open or laparoscopic surgery, respectively. Applying a propensity matched comparison (1:2), we reduced the population to 105 patients (35 vs 70 patients with recurrence after laparoscopic and open radical hysterectomy). Median follow-up time was 39.1 (range 4–221) months and 32.3 (range 4–124) months for patients undergoing open and laparoscopic surgery, respectively. Patients undergoing laparoscopic radical hysterectomy had shorter progression-free survival than patients undergoing open abdominal surgery (HR 1.98, 95% CI 1.32 to 2.97; p=0.005). Patients undergoing laparoscopic radical hysterectomy were more likely to develop intrapelvic recurrences (74% vs 34%; p<0.001) and peritoneal carcinomatosis (17% vs 1%; p=0.005) than patients undergoing open surgery.

Conclusions

Patients undergoing laparoscopic radical hysterectomy are at higher risk of developing intrapelvic recurrences and peritoneal carcinomatosis. Further evidence is needed in order to corroborate our findings.

Rho GTPases in Gynecologic Cancers: In-Depth Analysis toward the Paradigm Change from Reactive to Predictive, Preventive, and Personalized Medical Approach Benefiting the Patient and Healthcare

Rho guanosine triphospatases (GTPases) resemble a conserved family of GTP-binding proteins regulating actin cytoskeleton dynamics and several signaling pathways central for the cell. Rho GTPases create a so-called Ras-superfamily of GTPases subdivided into subgroups comprising at least 20 members. Rho GTPases play a key regulatory role in gene expression, cell cycle control and proliferation, epithelial cell polarity, cell migration, survival, and apoptosis, among others. They also have tissue-related functions including angiogenesis being involved in inflammatory and wound healing processes. Contextually, any abnormality in the Rho GTPase function may result in severe consequences at molecular, cellular, and tissue levels. Rho GTPases also play a key role in tumorigenesis and metastatic disease. Corresponding mechanisms include a number of targets such as kinases and scaffold/adaptor-like proteins initiating GTPases-related signaling cascades. The accumulated evidence demonstrates the oncogenic relevance of Rho GTPases for several solid malignancies including breast, liver, bladder, melanoma, testicular, lung, central nervous system (CNS), head and neck, cervical, and ovarian cancers. Furthermore, Rho GTPases play a crucial role in the development of radio- and chemoresistance e.g. under cisplatin-based cancer treatment. This article provides an in-depth overview on the role of Rho GTPases in gynecological cancers, highlights relevant signaling pathways and pathomechanisms, and sheds light on their involvement in tumor progression, metastatic spread, and radio/chemo resistance. In addition, insights into a spectrum of novel biomarkers and innovative approaches based on the paradigm shift from reactive to predictive, preventive, and personalized medicine are provided.

Report from the 21st meeting of the European Society of Gynaecological Oncology (ESGO 2019)

This is a report from the 21st Meeting of the European Society of Gynaecological Oncology (ESGO 2019) held in Athens, Greece, November 2–5, 2019. The conference offered state of the art educational sessions, and oral and poster abstract presentations. The general sessions throughout the meeting focused not only on prevention, screening, diagnosis, treatment, and translational research but also on emerging trends. Current innovations in gynecological cancers were also discussed. The new rare tumor guidelines project, a joint initiative with the ESGO-Gynecologic Cancer InterGroup, was officially presented for the first time. Moreover, other developments achieved with other societies, such as the European Society for Medical Oncology for ovarian cancer, the European Federation for Colposcopy for cervical cancer prevention and screening, and the European Society for Pediatric Oncology for gynecologic cancers in adolescents, were presented. Here we highlight the key results of the latest gynecological cancer trials that were presented for the first time at ESGO 2019 and added great value to this prestigious scientific congress.