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Yang EJ, Lee AJ, Hwang WY, Chang SJ, Kim HS, Kim NK, Kim Y, Kong TW, Lee EJ, Park SJ, Son JH, Suh DH, Son DH, Shim SH. Lymphadenectomy in clinically early epithelial ovarian cancer and survival analysis (LILAC): a Gynecologic Oncology Research Investigators Collaboration (GORILLA-3002) retrospective study. J Gynecol Oncol 2024; 35:e75. [PMID: 38497109 PMCID: PMC11262888 DOI: 10.3802/jgo.2024.35.e75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the therapeutic role of lymphadenectomy in patients surgically treated for clinically early-stage epithelial ovarian cancer (EOC). METHODS This retrospective, multicenter study included patients with clinically early-stage EOC based on preoperative abdominal-pelvic computed tomography or magnetic resonance imaging findings between 2007 and 2021. Oncologic outcomes and perioperative complications were compared between the lymphadenectomy and non-lymphadenectomy groups. Independent prognostic factors were determined using Cox regression analysis. Disease-free survival (DFS) was the primary outcome. Overall survival (OS) and perioperative outcomes were the secondary outcomes. RESULTS In total, 586 patients (lymphadenectomy group, n=453 [77.3%]; non-lymphadenectomy groups, n=133 [22.7%]) were eligible. After surgical staging, upstaging was identified based on the presence of lymph node metastasis in 14 (3.1%) of 453 patients. No significant difference was found in the 5-year DFS (88.9% vs. 83.4%, p=0.203) and 5-year OS (97.2% vs. 97.7%, p=0.895) between the two groups. Using multivariable analysis, lymphadenectomy was not significantly associated with DFS or OS. However, using subgroup analysis, the lymphadenectomy group with serous histology had higher 5-year DFS rates than did the non-lymphadenectomy group (86.5% vs. 74.4%, p=0.048; adjusted hazard ratio=0.281; 95% confidence interval=0.107-0.735; p=0.010). The lymphadenectomy group had longer operating time (p<0.001), higher estimated blood loss (p<0.001), and higher perioperative complication rate (p=0.004) than did the non-lymphadenectomy group. CONCLUSION In patients with clinically early-stage EOC with serous histology, lymphadenectomy was associated with survival benefits. Considering its potential harm, lymphadenectomy should be performed according to histologic subtype and subsequent chemotherapy in patients with clinically early-stage EOC. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0007309.
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Affiliation(s)
- Eun Jung Yang
- Department of Obstetrics and Gynecology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - A Jin Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Woo Yeon Hwang
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeorae Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae Wook Kong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Eun Ji Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Jin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Joo-Hyuk Son
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Hee Son
- Research Coordinating Center, Konkok University Medical Center, Seoul, Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea.
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Nero C, Bizzarri N, Di Berardino S, Sillano F, Vizzielli G, Cosentino F, Vargiu V, De Iaco P, Perrone AM, Vizza E, Chiofalo B, Uccella S, Ghezzi F, Turco LC, Corrado G, Giannarelli D, Pasciuto T, Zannoni GF, Fagotti A, Scambia G. Sentinel-node biopsy in apparent early stage ovarian cancer: final results of a prospective multicentre study (SELLY). Eur J Cancer 2024; 196:113435. [PMID: 38006759 DOI: 10.1016/j.ejca.2023.113435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/27/2023]
Abstract
AIM To evaluate the sensitivity and specificity of sentinel-lymph-node mapping compared with the gold standard of systematic lymphadenectomy in detecting lymph node metastasis in apparent early stage ovarian cancer. METHODS Multicenter, prospective, phase II trial, conducted in seven centers from March 2018 to July 2022. Patients with presumed stage I-II epithelial ovarian cancer planned for surgical staging were eligible. Patients received injection of indocyanine green in the infundibulo-pelvic and, when feasible, utero-ovarian ligaments and sentinel lymph node biopsy followed by pelvic and para-aortic lymphadenectomy was performed. Histopathological examination of all nodes was performed including ultra-staging protocol for the sentinel lymph node. RESULTS 174 patients were enrolled and 169 (97.1 %) received study interventions. 99 (58.6 %) patients had successful mapping of at least one sentinel lymph node and 15 (15.1 %) of them had positive nodes. Of these, 11 of 15 (73.3 %) had a correct identification of the disease in the sentinel lymph node; 7 of 11 (63.6 %) required ultra-staging protocol to detect nodal metastasis. Four (26.7 %) patients with node-positive disease had a negative sentinel-lymph-node (sensitivity 73.3 % and specificity 100.0 %). CONCLUSIONS In a multicenter setting, identifying sentinel-lymph nodes in apparent early stage epithelial ovarian cancer did not reach the expected sensitivity: 1 of 4 patients might have metastatic lymphatic disease unrecognized by sentinel-lymph-node biopsy. Nevertheless, 35.0 % of node positive patients was identified only thanks to ultra-staging protocol on sentinel-lymph-nodes.
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Affiliation(s)
- Camilla Nero
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Di Berardino
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Sillano
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Medicine - University of Udine, Udine, Italy; Clinic of Obstetrics and Gynecology, "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Francesco Cosentino
- Dipartimento di medicina e scienze della salute "V. Tiberio" Università degli studi del Molise UNIMOL, Italy; Dipartimento di Oncologia Gemelli Molise Hospital, Italy
| | - Virginia Vargiu
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pierandrea De Iaco
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Anna Myriam Perrone
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Uccella
- AOUI-Università di Verona, Obstetrics and Gynecology Department, Verona, Italy
| | - Fabio Ghezzi
- University of Insubria, Obstetrics and Gynecology Unit, Varese, Italy
| | - Luigi Carlo Turco
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giacomo Corrado
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Diana Giannarelli
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Tina Pasciuto
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gian Franco Zannoni
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per le Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Yang C, Zhang T, Gong A, Shi C. Influence of lymphadenectomy on survival and recurrence in patients with early-stage epithelial ovarian cancer: a meta-analysis. BMC Womens Health 2023; 23:474. [PMID: 37667358 PMCID: PMC10478186 DOI: 10.1186/s12905-023-02615-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the effectiveness of lymphadenectomy on survival and recurrence in patients with early-stage epithelial ovarian cancer (eEOC). METHODS Relevant studies were searched from four online databases. Hazard ratios (HRs) with 95% confidence intervals (CIs) or risk ratios (RRs) with 95% CIs were used to evaluate the effects of lymphadenectomy on overall survival (OS), progression-free survival (PFS), and recurrence rates. A subgroup analysis was performed to explore the sources of heterogeneity, followed by sensitivity and publication bias assessments. RESULTS Fourteen articles involving 22,178 subjects were included. Meta-analysis revealed that lymphadenectomy was significantly associated with improved OS (HR = 0.72; 95% CI:0.61, 0.84; P < 0.001), improved PFS (HR = 0.74; 95% CI: 0.67, 0.80; P < 0.001), and reduced recurrence rates (RR = 0.72; 95% CI: 0.60, 0.85; P < 0.001). Subgroup analysis showed that factors including area, histology, and source of the control group were significantly related to improved OS and PFS in patients with eEOC. Sensitivity analysis showed that the combined results were stable and reliable, and no significant publication bias was observed. CONCLUSIONS Patients with eEOC can benefit from lymphadenectomy, with improved survival outcomes (OS and PFS) and a lower recurrence rate.
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Affiliation(s)
- Chenchen Yang
- Department of Emergency, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, 223300, Jiangsu, China
| | - Ting Zhang
- Department of Obstetrics and Gynecology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huanghe Road West,, Huai'an, 223300, Jiangsu, China
| | - Aifeng Gong
- Department of General Practice, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, 223300, Jiangsu, China
| | - Can Shi
- Department of Obstetrics and Gynecology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huanghe Road West,, Huai'an, 223300, Jiangsu, China.
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Yu H, Wang J, Wu B, li J, Chen R. Prognostic significance and risk factors for pelvic and para-aortic lymph node metastasis in type I and type II ovarian cancer: a large population-based database analysis. J Ovarian Res 2023; 16:28. [PMID: 36717897 PMCID: PMC9885671 DOI: 10.1186/s13048-023-01102-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/14/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To compare the prognosis of lymphatic metastasis in type I and type II epithelial ovarian cancer (OC) and to identify the risk factors for pelvic lymph node metastases (PLNs) and para-aortic lymph node metastases (PALNs). METHODS Patients diagnosed with epithelial OC were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were estimated. The Cox proportional hazards regression model was used to identify independent predictors of survival. RESULTS A total of 11,275 patients with OC were enrolled, including 31.2% with type I and 68.8% with type II. Type II and high tumour stage were risk factors for lymph node involvement (p < 0.05). The overall rate of lymph node metastasis in type I was 11.8%, and that in type II was 36.7%. In the type I group, the lymph node metastasis rates in stages T1, T2, T3 and TXM1 were 3.2%, 14.5%, 40.4% and 50.0%, respectively. In the type II group, these rates were 6.4%, 20.4%, 54.1% and 61.1%, respectively. Age and tumour size had little effect on lymph node metastasis, and grade 3 was not always a risk factor. For the type I group, the 10-year CSS rates of LN(-), PLN( +), PALN( +), and PLN + PALN( +) were 80.6%, 46.6%, 36.3%, and 32.3%, respectively. The prognosis of PLN ( +) was better than that of PALN ( +) in the type I group (p > 0.05). For the type II group, the 10-year CSS rates of LN(-), PLN( +), PALN( +), and PLN + PALN( +) were 55.6%, 18.5%, 25.7%, and 18.2%, respectively. PALN ( +) had a significantly better prognosis than PLN ( +) in the type II group (p < 0.05). CONCLUSIONS The clinical characteristics and prognoses of patients with type I and type II OC differed greatly. Patients with type II and higher tumour stages had poorer prognoses. Type I with PALN metastasis and type II with PLN metastasis indicated a worse prognosis. Patients with stage TI did not require lymph node dissection, especially in the type I group.
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Affiliation(s)
- Hailin Yu
- grid.8547.e0000 0001 0125 2443Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jieyu Wang
- grid.8547.e0000 0001 0125 2443Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Beibei Wu
- grid.8547.e0000 0001 0125 2443Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jun li
- grid.8547.e0000 0001 0125 2443Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Ruifang Chen
- grid.8547.e0000 0001 0125 2443Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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Imterat M, Bizzarri N, Fruscio R, Perrone AM, Traut A, du Bois A, Rosati A, Ferrari D, De Iaco P, Ataseven B, Ergasti R, Volontè S, Tesei M, Heitz F, Perri MT, Concin N, Fanfani F, Scambia G, Fagotti A, Harter P. Impact of substage and histologic type in stage I ovarian carcinoma survival: a multicenter retrospective observational study. Int J Gynecol Cancer 2023; 33:42-49. [PMID: 36104079 DOI: 10.1136/ijgc-2022-003745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE This international study aimed to investigate the impact of substage, histological type and other prognostic factors on long-term survival for stage I ovarian carcinoma. METHODS Our study was a retrospective multicenter cohort study that included patients with the International Federation of Gynecology and Obstetrics (FIGO) stage I (IA-IC3) ovarian carcinoma treated at four European referral centers in Germany and Italy. Using Kaplan-Meier survival curves we compared overall and disease-free survival between the different stage I groups. RESULTS A total of 1115 patients were included. Of these, 48.4% (n=540) were in stage IA, 6.6% (n=73) stage IB, and 45% (n=502) stage IC, of the latter substage IC1, 54% (n=271), substage IC2, 31.5% (n=158), and substage IC3, 14.5% (n=73). Five-year overall and disease-free survival rates for the entire cohort were 94% and 86%, respectively, with no difference between stage IA and IB. However, there was a significantly better overall and disease-free survival for stage IA as compared with stage IC (p=0.007 and p<0.001, respectively). Multivariate analysis revealed incomplete/fertility-sparing staging (HR 1.95; 95% CI 1.27 to 2.99, and HR 3.54; 95% CI 1.83 to 6.86, respectively), and stage IC (HR 2.47; 95% CI 1.63 to 3.75) as independent risk factors for inferior disease-free survival, while low-grade endometrioid (HR 0.42; 95% CI 0.25 to 0.72) and low-grade mucinous (HR 0.17; 95% CI 0.06 to 0.44) histology had superior disease-free survival. Considering overall survival, stage IC (HR 2.41; 95% CI 1.45 to 4.01) and older age (HR 2.41; 95% CI 1.46 to 3.95) were independent risk factors. CONCLUSION Although stage I ovarian carcinoma exhibited excellent outcomes, the prognosis of patients with stage IA differs significantly compared with stage IC. Sub-optimal staging as an indicator for quality of care, and tumor biology defined by histology (low-grade endometrioid/mucinous) independently impact disease-free survival.
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Affiliation(s)
- Majdi Imterat
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany
| | - Nicolò Bizzarri
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Robert Fruscio
- Clinic of Obstetrics and Gynecology, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Anna Myriam Perrone
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alexander Traut
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany
| | - Andreas du Bois
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany
| | - Andrea Rosati
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Debora Ferrari
- Clinic of Obstetrics and Gynecology, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Pierandrea De Iaco
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Emilia-Romagna, Italy
| | - Beyhan Ataseven
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany.,Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Raffaella Ergasti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Silvia Volontè
- Clinic of Obstetrics and Gynecology, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Marco Tesei
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Emilia-Romagna, Italy
| | - Florian Heitz
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany.,Department for Gynecology with the Center for Oncologic Surgery Charité Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maria Teresa Perri
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Nicole Concin
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany
| | - Francesco Fanfani
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Anna Fagotti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy
| | - Philipp Harter
- Department of Gynecology and Gynecologic Oncology, Evangelische Kliniken Essen-Mitte, Huyssens-Stiftung, Essen, Nordrhein-Westfalen, Germany
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