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

OBJECTIVE

To assess 5-year oncologic outcomes of apparent early-stage high-intermediate and high-risk endometrial cancer undergoing sentinel node mapping versus systematic lymphadenectomy.

METHODS

This is a multi-institutional retrospective, propensity-matched study evaluating data of high-intermediate and high-risk endometrial cancer (according to ESGO/ESTRO/ESP guidelines) undergoing sentinel node mapping versus systematic pelvic lymphadenectomy (with and without para-aortic lymphadenectomy). Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard methods.

RESULTS

Overall, the charts of 242 patients with high-intermediate and high-risk endometrial cancer were retrieved. Data on 73 (30.1%) patients undergoing hysterectomy plus sentinel node mapping were analyzed. Forty-two (57.5%) and 31 (42.5%) patients were classified in the high-intermediate and high-risk groups, respectively. Unilateral sentinel node mapping was achieved in all patients. Bilateral mapping was achieved in 67 (91.7%) patients. Three (4.1%) patients had site-specific lymphadenectomy (two pelvic areas only and one pelvic plus para-aortic area), while adjunctive nodal dissection was omitted in the hemipelvis of the other three (4.1%) patients. Sentinel nodes were detected in the para-aortic area in eight (10.9%) patients. Twenty-four (32.8%) patients were diagnosed with nodal disease. A propensity-score matching was used to compare the aforementioned group of patients undergoing sentinel node mapping with a group of patients undergoing lymphadenectomy. Seventy patient pairs were selected (70 having sentinel node mapping vs. 70 having lymphadenectomy). Patients undergoing sentinel node mapping experienced similar 5-year disease-free survival (HR: 1.233; 95%CI: 0.6217 to 2.444; p = 0.547, log-rank test) and 5-year overall survival (HR: 1.505; 95%CI: 0.6752 to 3.355; p = 0.256, log-rank test) than patients undergoing lymphadenectomy.

CONCLUSIONS

Sentinel node mapping does not negatively impact 5-year outcomes of high-intermediate and high-risk endometrial cancer. Further prospective studies are warranted.

Consensus on surgical technique for sentinel lymph node dissection in cervical cancer

OBJECTIVE

The purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer.

METHODS

A 26 question survey was emailed to international expert gynecological oncology surgeons. A two-step modified Delphi method was used to establish consensus. After a first round of online survey, the questions were amended and a second round, along with semistructured interviews was performed. Consensus was defined using a 70% cut-off for agreement.

RESULTS

Twenty-five of 38 (65.8%) experts responded to the first and second rounds of the online survey. Agreement ≥70% was reached for 13 (50.0%) questions in the first round and for 15 (57.7%) in the final round. Consensus agreement identified 15 recommended, three optional, and five not recommended steps. Experts agreed on the following recommended procedures: use of indocyanine green as a tracer; superficial (with or without deep) injection at 3 and 9 o'clock; injection at the margins of uninvolved mucosa avoiding vaginal fornices; grasping the cervix with forceps only in part of the cervix is free of tumor; use of a minimally invasive approach for SLN biopsy in the case of simple trachelectomy/conization; identification of the ureter, obliterated umbilical artery, and external iliac vessels before SLN excision; commencing the dissection at the level of the uterine artery and continuing laterally; and completing dissection in one hemi-pelvis before proceeding to the contralateral side. Consensus was also reached in recommending against injection at 6 and 12 o'clock, and injection directly into the tumor in cases of the tumor completely replacing the cervix; against removal of nodes through port without protective maneuvers; absence of an ultrastaging protocol; and against modifying tracer concentration at the time of re-injection after mapping failure.

CONCLUSION

Recommended, optional, and not recommended steps of SLN dissection in cervical cancer have been identified based on consensus among international experts. These represent a surgical guide that may be used by surgeons in clinical trials and for quality assurance in routine practice.

Assessment of sentinel Lymph node mapping with different volumes of Indocyanine green in early-stage ENdometrial cancer: the ALIEN study

OBJECTIVE

To evaluate the impact of different volumes of indocyanine green (ICG) on the detection rate and bilateral mapping of sentinel lymph nodes in patients with apparent uterine-confined endometrial cancer.

METHODS

All patients who underwent surgical staging with sentinel node mapping in six reference centers were included. Two different protocols of ICG intracervical injection were used: (1) 2 mL group: total volume of 2 mL injected superficially; (2) 4 mL group: total volume of 4 mL, 2 mL deeply and 2 mL superficially. Logistic regression was used to analyze factors that could influence dye migration and detection rates. A sensitivity analysis was carried out to determine how independent variables could affect the sentinel node detection rate.

RESULTS

Of 442 eligible patients, 352 were analyzed (172 in the 2 mL group and 180 in the 4 mL group). The bilateral detection rates of the 2 mL and 4 mL groups were 84.9% and 86.1%, respectively (p=0.76). The overall detection rate was higher with a volume of 4 mL than with 2 mL (97.8% vs 92.4%, respectively; p=0.024). In the univariate analysis the rate of bilateral mapping fell from 87.5% to 73.5% when the International Federation of Gynecology and Obstetrics (FIGO) 2009 tumor stage was >IB (p=0.018). In the multivariate analysis, for both overall and bilateral detection rates a statistically significant difference emerged for the volume of ICG injected and FIGO 2009 stage >IB. Increasing body mass index was associated with worse overall detection rates on univariate analysis (p=0.0006), and significantly decreased from 97% to 91% when the body mass index exceeded 30 kg/m2 (p=0.05).

CONCLUSIONS

In patients with early-stage endometrial cancer, a volume of 2 mL ICG does not seem to compromise the bilateral detection of sentinel lymph nodes. In women with obesity and FIGO 2009 stage >IB, a 4 mL injection should be preferred.

Statement of the AGO Kommission Ovar, AGO Study Group, NOGGO, AGO Austria, Swiss AGO, BGOG, CEEGOG, GEICO, and SFOG regarding the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in epithelial ovarian cancer

An international joint statement about the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer was published in 2016, warning about the uncritical use of HIPEC outside controlled studies. This statement has now been updated after the most recent literature was reviewed by the participating study groups and societies. HIPEC became a treatment option in patients with advanced colon cancer after positive results of a randomized trial comparing surgery and HIPEC versus palliative treatment alone. Although this trial did not compare the added value of HIPEC to surgery alone, HIPEC for the treatment of peritoneal metastases was in the subsequent years generalized to many other cancer types associated with peritoneal carcinomatosis including epithelial ovarian cancer (EOC). In the meantime, new evidence from prospective randomized trials specifically for EOC-patients emerged, with however contradicting results and several quality aspects that made the interpretation of their findings critical. Moreover, three additional trials in colorectal cancer failed to confirm the previously presumed survival benefit through the implementation of HIPEC in peritoneally disseminated colorectal cancers. Based on a still unclear and inconsistent landscape, the authors conclude that HIPEC should remain within the remit of clinical trials for EOC-patients. Available evidence is not yet sufficient to justify its broad endorsement into the routine clinical practice.

Real-World Data Assessing the Impact of Lymphovascular Space Invasion on the Diagnostic Performance of Sentinel Lymph Node Mapping in Endometrial Cancer

BACKGROUND

SLN mapping has emerged as a standard of care in endometrial cancer due to its high sensitivity and significant reduction in morbidity. Although lymphovascular space invasion (LVSI) is a known risk factor for lymph node metastasis and recurrence, evidence on the reliability of SLN mapping in LVSI-positive patients is scarce. The aim of this study was to determine the impact of LVSI on the diagnostic performance of SLN mapping.

METHODS

This retrospective cohort study included patients with endometrial cancer who underwent primary surgical treatment at the Bern University Hospital, Switzerland, between 2012 and 2022.

RESULTS

LVSI was present in 22% of patients and was significantly associated with lymph node metastasis (p < 0.001) and recurrence (p < 0.001). In node-negative patients with only SLN mapping performed, LVSI was an independent predictor of recurrence during multivariable Cox regression analysis (p = 0.036). The negative predictive value of SLN mapping was 91.5% and was significantly lower in tumors with LVSI (75.0%) compared to LVSI-negative tumors (95.6%, p = 0.004).

CONCLUSION

The presence of LVSI was significantly associated with worse oncological outcomes. LVSI was an independent predictor of recurrence in node-negative patients with only SLN mapping performed. Furthermore, the negative predictive value of SLN mapping was significantly lower in LVSI-positive tumors.

Is Diastasis Recti Abdominis Rehabilitation after Childbirth Able to Prevent the Onset of Stress Urinary Incontinence? A Case-Control Study

Background and Objectives: Pelvic floor muscle training (PFMT) represent the first-line approach to pelvic floor dysfunctions (PFDs). Recently, studies have shown a synergy between the pelvic floor and abdominal muscles, hypothesizing that the anatomical and functional integrity of the abdominal wall plays a role in the prevention of pelvic floor disorders. Some studies have shown a significant correlation between diastasis recti abdominis (DRA) and stress urinary incontinence (SUI). Nevertheless, the evidence reported in the literature is controversial and based on low-quality data. The aim of the study is to clarify whether DRA-specific abdominal rehabilitation is needed in women with SUI after childbirth. Materials and Methods: All consecutive women who had at least one delivery and complained of symptoms of pure SUI that were urodynamically proven were considered for the study. The group of symptomatic patients was compared with a series of consecutive women, identified during the same study period, without any symptoms of SUI. In both groups, we measured the inter-rectal distance (IRD) with an ultrasound scanner above and below the navel. Results: A total of 102 women eligible for the study group and 100 women who did not report any symptoms of SUI were enrolled. The inter-rectal distance above the umbilicus showed no significant difference between the two groups (2.12 ± 0.98 vs. 2.1 ± 0.77; p = 0.94). In contrast, the data from the sub-umbilical measurements showed a significant difference. Surprisingly, the asymptomatic group showed significantly greater (0.98 ± 0.9 vs. 1.33 ± 0.87 p-value: 0.009) IRD compared to the symptomatic group. Conclusions: The study shows that DRA is not a risk factor for SUI in women after childbirth. Therefore, specific abdominal wall rehabilitation after childbirth does not seem to be indicated.

Risk of congenital malformation after first trimester mRNA COVID-19 vaccine exposure in pregnancy: the COVI-PREG prospective cohort

OBJECTIVES

This study aimed to evaluate the risk of congenital malformation among pregnant women exposed to the mRNA COVID-19 vaccines during the first trimester of pregnancy, which is a developmental period where the foetus is at risk of teratogenicity.

METHODS

Pregnant women were prospectively enrolled from March 2021 to March 2022, at the time of COVID-19 vaccination. Pregnant women exposed to at least one dose of mRNA COVID-19 vaccine from conception to 11 weeks of gestations and 6 days were compared with pregnant women exposed to the vaccine from 12 weeks to the end of pregnancy. The primary outcome was a confirmed congenital malformation at birth.

RESULTS

A total of 1450 pregnant women were enrolled including 124 in the first trimester and 1326 in the second and third trimester. The overall proportion of congenital malformation was 0.81% (n = 1/124; 95% CI: 0.02-4.41) and 0.83% (n = 11/1326; 95% CI: 0.41-1.48) among pregnant exposed to the COVID-19 vaccine during the first and second/third trimester, respectively. First trimester exposure was not associated with a higher risk of congenital malformation with a relative risk of 0.89 (95% CI: 0.12-6.80) with no significant changes after adjustment through exploratory analysis.

CONCLUSIONS

Pregnant women exposed to mRNA COVID-19 vaccine before 12 weeks of gestation did not have an increased risk of congenital malformation compared with women exposed outside the teratogenic window. Because vaccination is safe and effective, emphasis must be placed on promoting vaccination during pregnancy.

Whole-Body Composition Features by Computed Tomography in Ovarian Cancer: Pilot Data on Survival Correlations

BACKGROUND

The primary objective of this study was to assess the associations of computed tomography (CT)-based whole-body composition values with overall survival (OS) and progression-free survival (PFS) in epithelial ovarian cancer (EOC) patients. The secondary objective was the association of body composition with chemotherapy-related toxicity.

METHODS

Thirty-four patients (median age 64.9 years; interquartile range 55.4-75.4) with EOC and thorax and abdomen CT scans were included. Clinical data recorded: age; weight; height; stage; chemotherapy-related toxicity; and date of last contact, progression and death. Automatic extraction of body composition values was performed by dedicated software. Sarcopenia was defined according to predefined cutoffs. Statistical analysis included univariate tests to investigate associations of sarcopenia and body composition with chemotoxicity. Association of body composition parameters and OS/PFS was evaluated by log-rank test and Cox proportional hazard model. Multivariate models were adjusted for FIGO stage and/or age at diagnosis.

RESULTS

We found significant associations of skeletal muscle volume with OS (p = 0.04) and PFS (p = 0.04); intramuscular fat volume with PFS (p = 0.03); and visceral adipose tissue, epicardial and paracardial fat with PFS (p = 0.04, 0.01 and 0.02, respectively). We found no significant associations between body composition parameters and chemotherapy-related toxicity.

CONCLUSIONS

In this exploratory study, we found significant associations of whole-body composition parameters with OS and PFS. These results open a window to the possibility to perform body composition profiling without approximate estimations.

The Risk of Recurrence in Endometrial Cancer Patients with Low-Volume Metastasis in the Sentinel Lymph Nodes: A Retrospective Multi-Institutional Study

The aim of this study was to assess the impact of low-volume metastasis (LVM) on disease-free survival (DFS) in women with apparent early-stage endometrial cancer (EC) who underwent sentinel lymph node (SLN) mapping. Patients with pre-operative early-stage EC were retrospectively collected from an international collaboration including 13 referring institutions. A total of 1428 patients were included in this analysis. One hundred and eighty-six patients (13%) had lymph node involvement. Fifty-nine percent of positive SLN exhibited micrometastases, 26.9% micrometastases, and 14% isolated tumor cells. Seventeen patients with positive lymph nodes did not receive any adjuvant therapy. At a median follow-up of 33.3 months, the disease had recurred in 114 women (8%). Patients with micrometastases in the lymph nodes had a worse prognosis of disease-free survival compared to patients with negative nodes or LVM. The rate of recurrence was significantly higher for women with micrometastases than those with low-volume metastases (HR = 2.61; p = 0.01). The administration of adjuvant treatment in patients with LVM, without uterine risk factors, remains a matter of debate and requires further evaluation.

Hysteropexy and Anterior Vaginal Native Tissue Repair in Women with Anterior and Central Compartment Prolapse: A Long Term Follow-Up

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than −1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Surgical Outcomes and Complications of Laparoscopic Hysterectomy for Endometriosis: a multicentric cohort study

STUDY OBJECTIVE

To investigate the postoperative morbidity of laparoscopic hysterectomy (LH) for endometriosis/adenomyosis in terms of operative outcomes and complications.

DESIGN

Retrospective multicentric cohort study.

SETTING

Eight European minimally invasive referral centers.

PATIENTS

Data from 995 patients with pathologically confirmed endometriosis and/or adenomyosis who underwent LH without concomitant urological and/or gastroenterological procedures from January 2010 to December 2020.

INTERVENTIONS

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Demographic patients' characteristics, surgical outcomes, and intraoperative and postoperative complications were evaluated. We considered major postoperative surgical-related complications any grade 2 or more events (Clavien-Dindo score) that occurred within 30 days from surgery. Univariate analysis and multivariable models fit with logistic regression were used to estimate the adjusted odds ratio (OR) and corresponding 95% CI for major complications. Median age at surgery was 44 years (28-54) and about half of them (505, 50.7%) were on medical treatment (estro-progestins, progestin or GnRh-analogues) at the time of surgery. In association with LH, posterior adhesiolysis was performed in 387 (38,9%) cases and deep nodule resection in 302 (30,0%). Intraoperative complications occurred in 3% of the patients and major postoperative complications were registered in 93 (9.3%). The multivariable analysis showed an inverse correlation between the occurrence of Clavien-Dindo >2 complications and age (OR 0.94, 95%CI 0.90-0.99), while previous surgery for endometriosis (OR 1.62, 95%CI 1.01-2.60) and intraoperative complications (OR 6.49, 95%CI 2.65-16.87) were found as predictors of major events. Medical treatment at the time of surgery has emerged as a protective factor (OR 0.50, 95%CI 0.31-0.81).

CONCLUSION

LH for endometriosis/adenomyosis is associated with non-negligible morbidity. Knowing the factors associated with higher risks of complications might be used for risk stratification and could help clinicians during preoperative counseling. The administration of estro-progestin or progesterone preoperatively might reduce the risks of postoperative complications following surgery.

Abstract OT3-12-01: Immunological predictors of nodal response in breast cancer patients undergoing neoadjuvant therapy

Immunological predictors of nodal response in breast cancer patients undergoing neoadjuvant therapy Maria Luisa Gasparri1, Ilary Ruscito2, Filippo Bellati2, Fabio Corsi3, Rosa Di Micco4, Oreste D. Gentilini4, Thorsten Kuehn5, Andrea Papadia1, Donatella Caserta2, Lorenzo Rossi6, Arianna Calcinotto7 1 Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, Switzerland 2 Department of Medical and Surgical Science and Translational Medicine, Sapienza University of Rome, Azienda Ospedaliera Sant’Andrea, Rome, Italy 3 Breast Unit, Department of Surgery, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, Milan, Italy 4 Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy 5 Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany 6 Oncology Institute of Southern Switzerland, Bellinzona, Switzerland 7 Cancer Immunotherapy lab, IOR Institute of Oncology Research, Bellinzona, Switzerland Background: Almost 20% of breast cancer patients present at diagnosis with clinically positive nodes. Most of these patients undergo neoadjuvant therapy in order to de-escalate the axillary surgery in case of response (sentinel lymph node biopsy, targeted axillary dissection or targeted axillary dissection, instead of an axillary lymphadenectomy). The conversion from positive to negative nodes after neoadjuvant therpy is expected in approximately the 60% of the cases, depending by tumor subtypes. Several models have been proposed with the goal of identifying predictors of nodal response prior to neoadjuvant treatment. The immune system plays a pivotal role in cancer invasion and progression. Its role in treatment response is currently under investigation in several settings. Primary endpoint: to identify a preoperative immune profiling of breast cancer patients with nodal involvement at diagnosis and to correlate the immune changes after neoadjuvant therapy with the nodal response (macrometastases, micrometastasis, isolated tumor cells, complete response). Trial design: It is an international prospective cohort study including breast cancer patients undergoing standard neoadjuvant therapy, who present initially with biopsy-proven axillary lymph node metastasis. Ten immune markers will be analyzed using immunohistochemistry and tissue microarray in primary tumor and nodal tissue samples (tumor associated neutrophils, CD4 lymphocytes, CD8 lymphocytes, T regulatory cells, Macrophages, Follicular dendritic cells(DC), plasmocytoid DC, interdigitant DC, mature DC, Lysosomal associated membrane protein 3). The tissue analysis will be performed on the biopsy collected at diagnosis (prior to neoadjuvant therapy) and during the axillary surgery (after neoadjuvant therapy). Target accrual/sample size: 210 patients Statistical analysis: To compare the distribution of immune cells according to the state of lymph node metastasis, Student’s t test will be performed. Pearson’s chi-square test will be used to evaluate the correlation between immune profile and nodal response, based on clinic-pathological features. Odds ratios (ORs) and 95% confidence intervals (CIs) will be calculated using logistic regression analysis. Multivariable analysis will be performed using the multivariable logistic regression model. Logistic regression models will be used to identify the clinical, pathologic and immunological variables associated with the nodal response. P-values less than 0.05 will be considered significant. Analyses will be performed using Microsoft IBM SPSS® version 20.0 for Mac. Current status: Recruitment has not started yet. Contact information: marialuisa.gasparri@eoc.ch

Citation Format: Maria Luisa Gasparri, Ilary Ruscito, Filippo Bellati, Fabio Corsi, Rosa Di Micco, Oreste Davide Gentilini, Thorsten Kuehn, Andrea Papadia, Donatella Caserta, Lorenzo Rossi, Arianna Calcinotto. Immunological predictors of nodal response in breast cancer patients undergoing neoadjuvant therapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-12-01.

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

OBJECTIVE

To compare outcomes after hysterectomy and hysterectomy plus sentinel node mapping (SNM) in endometrial cancer (EC) patients.

MATERIALS AND METHODS

This is a retrospective study, collecting data of EC patients treated between 2006 and 2016 in nine referral centers.

RESULTS

The study population included 398 (69.5%) and 174 (30.5%) patients having hysterectomy and hysterectomy plus SNM. As the results of the adoption of a propensity-score matched analysis, we selected two homogeneous cohort of patients (150 having hysterectomy only vs. 150 having hysterectomy plus SNM). The SNM group had a longer operative time, but did not correlate with length of hospital stay and estimated blood loss. Overall severe complication rates were similar between groups (0.7% in the hysterectomy group vs. 1.3% in the hysterectomy plus SNM group; p = 0.561). No lymphatic-specific complication occurred. Overall, 12.6% of patients having SNM were diagnosed with disease harboring in their lymph nodes. Adjuvant therapy administration rate was similar between groups. Considering patients having SNM, 4% of patients received adjuvant therapy on the basis of nodal status alone; all the other patients received adjuvant therapy also on the basis of uterine risk factors. Five-year disease-free (p = 0.720) and overall (p = 0.632) survival was not influenced by surgical approach.

CONCLUSIONS

Hysterectomy (with or without SNM) is a safe and effective method for managing EC patients. Potentially, these data support the omission of side specific lymphadenectomy in case of unsuccessful mapping. Further evidence is warranted in to confirm the role SNM in the era of molecular/genomic profiling.

O-RADS MRI: A Systematic Review and Meta-Analysis of Diagnostic Performance and Category-wise Malignancy Rates

Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) MRI lexicon, which is based on the ADNEX MR scoring system. Purpose To perform a systematic review and meta-analysis of the diagnostic performance of pelvic MRI interpreted using the ADNEX or O-RADS MRI stratification systems to characterize US-indeterminate adnexal lesions and of the category-wise malignancy rates. Materials and Methods A systematic literature search from May 2013 (publication of the ADNEX MR score) to September 2022 was performed. Studies reporting the use of pelvic MRI interpreted with the ADNEX or O-RADS MRI systems to characterize US-indeterminate adnexal lesions, with pathologic examination and/or follow-up as the reference standard, were included. Summary estimates of diagnostic performance were obtained with the bivariate random-effects model, while category-wise summary malignancy rates of O-RADS MRI 2, 3, 4, and 5 lesions were obtained with a random-effects model. Effects of covariates on heterogeneity and diagnostic performance were investigated through meta-regression. Results Thirteen study parts from 12 studies (3731 women, 4520 adnexal lesions) met the inclusion criteria. Diagnostic performance meta-analysis for 4012 lesions found a 92% summary sensitivity (95% CI: 88, 95) and a 91% summary specificity (95% CI: 89, 93). The meta-analysis of malignancy rates for 3641 lesions showed summary malignancy rates of 0.1% (95% CI: 0, 1) among O-RADS MRI 2 lesions, 6% (95% CI: 3, 9) among O-RADS MRI 3 lesions, 60% (95% CI: 52, 67) among O-RADS MRI 4 lesions, and 96% (95% CI: 92, 99) among O-RADS MRI 5 lesions. Conclusion Pelvic MRI interpreted with the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI lexicon had high diagnostic performance for the characterization of US-indeterminate adnexal lesions. Summary estimates of malignancy rates in the O-RADS MRI 4 and O-RADS MRI 5 categories were higher than predicted ones. © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Lee and Kang in this issue.

Body composition as a predictor of chemotherapy-related toxicity in ovarian cancer patients: A systematic review

OBJECTIVES

The main objective of this systematic review was to examine the literature evaluating association of image-based body composition with chemotherapy-related toxicity in ovarian cancer patients. A secondary objective was to evaluate the different definitions of sarcopenia across studies.

METHODS

This systematic review was conducted according to the PRISMA-DTA statement and the protocol was registered on Prospero. A comprehensive literature search of 3 electronic databases was performed by two authors. For each eligible article, information was collected concerning the clinical setting; basic study data; population characteristics; technical aspects; body composition features; chemotherapy drugs administered; association of body composition values and toxicities. The overall quality of the included studies was critically evaluated.

RESULTS

After the initial retrieval of 812 articles, the systematic review included 6 articles (5/6 studies were retrospective; one was prospective). The number of patients ranged between 69 and 239; mean/median age ranged between 55 and 65 years; the percentage of sarcopenic patients ranged between 25% and 54%. The cut-off values to define sarcopenia and the vertebral levels for evaluation of body composition were different. Five studies included chemotherapy based on carboplatin and paclitaxel, 1 included chemotherapy based on pegylated liposomal doxorubicin. Among the studies including carboplatin and paclitaxel, 3/5 demonstrated an association with toxicity, whereas 2/5 did not. Altogether, 4/6 papers demonstrated an association between the body composition values and the development of chemotherapy-related toxicities.

CONCLUSIONS

There is a wide variability of results about the association of body composition and chemotherapy-related toxicity in ovarian cancer patients. Therefore further studies, possibly including a comprehensive assessment of body compartments and where the definition of body composition cut-offs is constant, are warranted to better understand this association.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022337753, identifier (CRD42022337753).

Pathological processing of sentinel lymph nodes in endometrial carcinoma - routine aspects of grossing, ultra-staging, and surgico-pathological parameters in a series of 833 lymph nodes

Sentinel lymph nodes are widely accepted in the treatment of endometrial carcinoma. Whereas surgical aspects are well studied, the pathological work-up in terms of grossing, frozen section, and the so-called ultra-staging is still a matter of debate. This results in conflicting national or center-based recommendations. In a series of consecutive 833 sentinel lymph nodes from 206 patients in endometrial carcinomas, we compared three different grossing techniques and the use of frozen section in terms of anatomy, detection rates, and survival. In total, 42 macro-metastases, 6 micro-metastases, and 25 nodes with isolated tumor cells were found. Lymph nodes affected at least with micro-metastasis were about 0.5cm enlarged. Detection rates in lamellation technique increased with a step of 5.9% to 8.3% in comparison to bi-valved or complete embedding. The lamellation technique presented with a slight beneficial prognosis in pN0 subgroup (OS, p=0.05), which besides size effects might be attributed to trimming loss. In frozen section, this effect was less pronounced than expected (OS, p=0.56). Ultra-staging only revealed additional micro-metastases and isolated tumor cells. Exclusively, macro-metastases showed poor survival (p<0.001). In multivariate analysis, T-stage, subtype, and lympho-vascular invasion status outperformed this staging parameter significantly. Grossing of sentinel lymph nodes is the most essential step with evidence to prefer lamellation in 2 mm steps. Step sectioning should consider widely spaced protocols to exclude macro-metastases. Frozen sections might add value to the intra-operative assessment of endometrial carcinoma in selected cases. The excellent biological behavior of cases with isolated tumor cells might question the routine application of pan-cytokeratin as ultra-staging method.

The added value of SLN mapping with indocyanine green in low- and intermediate-risk endometrial cancer management: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to assess the SLN detection rate in presumed early stage, low- and intermediate-risk endometrial cancers, the incidence of SLN metastases, and the negative predictive value of SLN mapping performed with indocyanine green (ICG).

METHODS

A systematic review with meta-analyses was conducted. Study inclusion criteria were A) low- and intermediate-risk endometrial cancer, B) the use of ICG per cervical injection; C) a minimum of twenty included patients per study. To assess the negative predictive value of SLN mapping, D) a subsequent lymphadenectomy was an additional inclusion criterion.

RESULTS

Fourteen studies were selected, involving 2,117 patients. The overall and bilateral SLN detection rates were 95.6% (95% confidence interval [CI]=92.4%-97.9%) and 76.5% (95% CI=68.1%-84.0%), respectively. The incidence of SLN metastases was 9.6% (95% CI=5.1%-15.2%) in patients with grade 1-2 endometrial cancer and 11.8% (95% CI=8.1%-16.1%) in patients with grade 1-3 endometrial cancer. The negative predictive value of SLN mapping was 100% (95% CI=98.8%-100%) in studies that included grade 1-2 endometrial cancer and 99.2% (95% CI=97.9%-99.9%) in studies that also included grade 3.

CONCLUSION

SLN mapping with ICG is feasible with a high detection rate and negative predictive value in low- and intermediate-risk endometrial cancers. Given the incidence of SLN metastases is approximately 10% in those patients, SLN mapping may lead to stage shifting with potential therapeutic consequences. Given the high negative predictive value with SLN mapping, routine lymphadenectomy should be omitted in low- and intermediate-risk endometrial cancer.

Evaluating long-term outcomes of three approaches to retroperitoneal staging in endometrial cancer

OBJECTIVE

Sentinel lymph node mapping (SNM) has gained popularity in managing apparent early-stage endometrial cancer (EC). Here, we evaluated the long-term survival of three different approaches of nodal assessment.

METHODS

This is a multi-institutional retrospective study evaluating long-term outcomes of EC patients having nodal assessment between 01/01/2006 and 12/31/2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm.

RESULTS

Overall, 940 patients meeting inclusion criteria were included in the study, of which 174 (18.5%), 187 (19.9%), and 579 (61.6%) underwent SNM, SNM followed by backup lymphadenectomy (LND) and LND alone, respectively. Applying a propensity score matching algorithm (1:1:2) we selected 500 patients, including 125 SNM, 125 SNM/backup LND, and 250 LND. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM/backup LND and LND, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p = 0.750) and overall survival (p = 0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification based on uterine risk factors.

CONCLUSION

Our study highlighted that SNM provides similar long-term oncologic outcomes than LND.

The subjective and objective very long-term outcomes of TVT in the COVID era: A 20-year follow-up

Introduction and hypothesis

Few studies in literature have assessed the long-term durability and mesh-related complications of mid-urethral slings (MUSs). The aim of this study is to assess the efficacy and safety of retro-pubic tension-free vaginal tape (TVT) 20 years after implantation for the treatment of female stress urinary incontinence (SUI).

Methods

A prospective observational study was conducted in two urogynaecologic units in two countries. All the patients involved were consecutive women with urodynamically proven pure SUI treated by TVT. The patients underwent preoperative clinical and urodynamic evaluations. Subjective outcomes, objective outcomes and adverse events were recorded during the follow-up period.

Results

Fifty-two patients underwent a TVT surgical procedure. Twenty years after surgery, 32 out of 36 patients (88.8%) declared themselves cured (p = 0.98). Similarly, 33 out of these 36 patients (91.7%) were objectively cured (p = 0.98). No significant deterioration of subjective and objective cure rates was observed over time (p for trend 0.50 and 0.48). Fifteen of the 36 patients (41.6%) at the 20-year follow-up reported the onset of de novo overactive bladder (OAB) (p = 0.004). No significant vaginal bladder or urethral erosion or de novo dyspareunia was recorded and no patient required tape release or resection during this period. The cause of death of seven out of ten women who died in the last year of the follow-up period was coronavirus disease 19 (COVID 19).

Conclusions

The 20-year results of this study showed that TVT is a highly effective and safe option for the treatment of SUI. The impact of COVID 19 on the mortality rate of elderly women has drastically reduced the number of eligible patients for future evaluations in our region.

Low placental weight and altered metabolic scaling after severe acute respiratory syndrome coronavirus type 2 infection during pregnancy: a prospective multicentric study

Objectives

A higher risk of adverse pregnancy outcomes is associated with SARS-CoV-2 infection; this could be partially explained by an altered placental function. Because histopathology is often unspecific, we aimed to assess placental weight, birthweight/placental weight (b/p) ratio, and the metabolic scaling exponent ß, an indicator of normal fetal-placental growth, to analyze placental function.

Methods

We included 153 singleton pregnancies with SARS-CoV-2–positive PCR result who delivered at three referring hospitals in Switzerland. Placental weight and b/p ratio were compared to published reference charts. Logistic regression analysis investigated the role of time of infection and other confounding factors on placental weight. The scaling exponent β was compared to the reference value of 0.75.

Results

Placental weight was inferior or equal to the tenth centile in 42.5% (65 of 153) and to the third centile in 19% (29 of 153) of the cases. The risk of low placental weight was not influenced by the trimester in which infection occurred. The b/p ratio was >50th centile in 80.4% (123 of 153) of the cases. The incidence of foetal growth restriction, preeclampsia, and gestational diabetes was 11.8% (18 of 153), 3.3% (5 of 153), and 19.6% (30 of 153). Linear regression modelling revealed a pathologic metabolic scaling exponent β of 0.871 ± 0.064 (R² = 0.56).

Discussion

SARS-CoV-2 infection during pregnancy was associated with a higher incidence of low placental weight, an increased b/p ratio, and an abnormal scaling exponent β in our cohort. This could be particularly relevant for the still controversial issue of an increased stillbirth rate in SARS-CoV-2 infection during pregnancy. In this regard, intensified foetal surveillance should be mandatory in these pregnancies.

Cytologic presentation of ovarian large cell carcinoma with rhabdoid features detected on peritoneal washing. Report of one case with cyto-histologic correlation and previously undescribed inactivating SMARCA-4 mutations

The SMARCA subgroup of genes belongs to the SWI1/SNF1 family, responsible for chromatin remodeling and repair within the nucleosome. The SMARCA4 gene is located on chromosome 19p13 and encodes the BRG1 (BRAhMA) protein. We report the cytological and histological findings in one case of large cell SMARCA4 deficient ovarian carcinoma with positive peritoneal washing in a 69-year-old woman. The neoplastic cells were present as singly lying or perivascular clusters and showed medium or large size, round to oval hyperchromatic nuclei, and scarce to moderate cytoplasms. Molecular pathology investigations performed on the ovarian surgical sample found two previously undescribed mutations in the SMARCA4 gene and additional mutations in the CTNNB1 (Beta Catenin gene) and in PIK3CA. To our knowledge, this case probably represents the third cytologic report of this variant of ovarian carcinoma and the first one with molecular pathologic study.

Ovarian reserve of women with and without BRCA pathogenic variants: A systematic review and meta-analysis

INTRODUCTION

Preliminary clinical evidence suggests a detrimental effect of pathogenic variants of BRCA1 and 2 genes on fertility outcome. This meta-analysis evaluates whether women carrying BRCA mutations (BRCAm) have decreased ovarian reserve, in terms of Anti-Muellerian Hormone (AMH), compared to women without BRCAm (wild-type).

MATERIAL AND METHODS

Systematic searches of PubMed, Medline, Scopus, Embase, Science Direct and the Cochrane Library from inception until July 2020 were conducted. All studies comparing AMH level in fertile age women, with and without BRCA pathogenic variants were considered. Sub-analyses were performed according to age, presence of breast cancer, and type of mutation.

RESULTS

Among 64 studies, 10 series were included. For the entire cohort, a trend of reduced AMH level were found between BRCAm carriers and women without pathogenic variants. BRCAm carriers aged 41-years or younger had lower AMH levels compared to 41-years or younger wild type women (OR: 0.73 [95%CI-1.12;-0.35]; p = 0.0002). This finding was confirmed for BRCA1m carriers (OR: 1 [95%CI-1.96;-0.05]; p = 0.004) whereas no difference was observed between BRCA2m carriers and wild type women. The same analysis on breast cancer patients with and without BRCAm achieved the same results.

CONCLUSION

Young BRCA1m carriers seem to have lower AMH level compared with wild type women and therefore a potential decreased ovarian reserve.

Is it time to leave Multi- for Single-port laparoscopy in benign gynecologic surgery? A systematic review of randomized clinical trials

INTRODUCTION

Conventionally, laparoscopic surgery in gynecology requires multiple accesses in the abdominal cavity. Laparo-Endoscopic Single-Site surgery (LESS) is a more recent technique consisting in a laparoscopy in which the abdominal cavity is reached by a single umbilical incision. The aim of this systematic review is to summarize and comment the benefits and drawbacks in benign gynecological surgeries, including hysterectomy, myomectomy, and adnexal surgery, by LESS and conventional Multi-Port Laparoscopy (MPL), respectively.

EVIDENCE ACQUISITION

A systematic review following the Preferred Reporting Items for Systematic reviews and Randomized Control Trials (PRISMA) was performed by researching articles in PubMed, Medline, Web of Science, and Cochrane library. The terms searched were "single port laparoscopy" or "laparo-endoscopic single site surgery" or "single site laparoscopy" or "single-incision laparoscopic surgery" and "hysterectomy", or "myomectomy", or "adnexal surgery". Only randomized-controlled trials (RCTs) comparing LESS and MPL in benign gynecology were included.

EVIDENCE SYNTHESIS

Thirteen RCTs including 1088 women undergoing gynecological surgery for benign disease through LESS versus MPL were included in the analysis of which 620 underwent hysterectomy, 154 myomectomy, 314 adnexal surgery. LESS approach was performed in 531/1088 (48.8%) procedures. All studies compared the surgical outcomes for length of operative time, hemoglobin drop, length of hospitalization, rate of conversion, post-operative pain, intra and post-operative complications. For hysterectomy, a longer operating time and a higher conversion rate were shown in the LESS group, but no significant differences were found for the other outcomes. For myomectomy, the only significant difference was found for a higher conversion rate in the LESS group. For adnexal surgery, no significant differences were found. Globally there was no difference in pain based on the Visual Analog Scale score. Cosmetic outcome was reported in 6/13 of the studies included, 4/6 demonstrated a superior cosmetic satisfaction in the LESS group.

CONCLUSIONS

Despite cosmetic result is intuitively the main advantage for LESS technique, current evidence does not seem to demonstrate a clear superiority of LESS compared to MPL in benign gynecological surgery.

Factors predicting morbidity in surgically-staged high-risk endometrial cancer patients

OBJECTIVE

To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer.

METHODS

This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting.

RESULTS

Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p < 0.001, log-rank test) and SNM (p = 0.038, log-rank test) correlated with a lower risk of developing surgery-related events. Independently, open abdominal surgery was associated with an increased risk of developing lymphatic morbidity (OR: 37.4 (95%CI: 4.38, 319.5); p = 0.001).

CONCLUSION

The adoption of the laparoscopic approach and SNM technique were associated with lower 90-day complication rates than open surgery in high-risk endometrial cancer undergoing staging surgery.

Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials

Simple Summary

Axillary dissection is a highly mobile procedure with severe lymphatic consequences. The off-label application of fibrin sealants in the axilla, with the sole aim to eliminate dead space and to provoke sealing of the disrupted lymphatic vessels at the end of axillary dissection, is an experimental procedure to reduce lymphatic morbidity. The aim of our systematic review and meta-analysis is to investigate the effects of fibrin sealants on lymphatic morbidity after axillary dissection. Our results show that this experimental procedure is able to decrease the total axillary drainage output, the number of days before the axillary drainage is removed, and the length of hospital stay. However, no effects on the occurrence rate of axillary lymphocele or on the surgical site complications rate were demonstrated

Abstract

Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.

Exploratory Study of the Clinical Value of Near-Infrared Sentinel Lymph Node Mapping With Indocyanine Green in Vulvar Cancer Patients

Background

This study aimed to evaluate the clinical value of indocyanine green sentinel lymph node (SLN) mapping in patients with vulvar cancer. The conventional procedure of SLN mapping in vulvar cancer includes peritumoral injection of technetium-99m nanocolloid before surgery and intraoperative injection of a blue dye. However, these techniques harbor some limitations. Near-infrared fluorescence imaging with indocyanine green has gained popularity in SLN mapping in different types of cancer.

Methods

We analyzed retrospectively vulvar cancer patients at our institution between 2013 and 2020 undergoing indocyanine green SLN mapping by applying video telescope operating microscope system technology.

Results

64 groins of 34 patients were analyzed. In 53 groins we used technetium-99m nanocolloid, in four patent blue, and in five both techniques, additionally to indocyanine green for SLN detection. In total, 120 SLNs were identified and removed. The SLN detection rate of indocyanine green was comparable to technetium-99m nanocolloid (p=.143) and higher than patent blue (p=.003). The best results were achieved using a combination of ICG and technetium-99m nanocolloid (detection rate of 96.9%). SLN detection rates of indocyanine green were significantly higher in patients with positive lymph nodes (p=.035) and lymphatic space invasion (p=.004) compared to technetium-99m nanocolloid.

Conclusion

Indocyanine green SLN mapping in vulvar cancer is feasible and safe, with reasonable detection rates. Due to its easy application and few side effects, it offers a sound alternative to the conventional SLN mapping techniques in vulvar cancer. In patients with lymph node metastasis, indocyanine green even outperformed technetium-99m nanocolloid in terms of detection rate.

From systematic lymphadenectomy to sentinel lymph node mapping: a review on transitions and current practices in endometrial cancer staging

Endometrial cancer care has undergone major changes in the past 30 years. In 1988, staging transitioned from clinical to surgical. Moreover, the surgical approach of choice is no longer open surgery, but minimally invasive surgery. An improvement in terms of nodal evaluation followed. Full systematic lymphadenectomy has been continuously replaced by sentinel lymph node mapping. Although sentinel lymph node mapping with a cervical injection of indocyanine green dye is rapidly gaining clinical acceptance, we lack consistent recommendations on a well-defined procedure that accurately and indolently assesses the lymph node status. Such recommendations are indispensable, as nodal status is the most important predictive factor of survival and is essential for tailoring adjuvant treatment to the risk of recurrence. This paper focuses on transitions in endometrial cancer care and highlights current data on sentinel lymph node mapping in endometrial cancer. We demonstrate that sentinel lymph node mapping is a safe and accurate strategy for nodal status evaluation with appropriate sensitivity, false-negative rate and negative predictive value in high- as well as low-risk settings. Furthermore, we elaborate on type and dose of tracer, site of injection, number of sentinel lymph nodes to be removed, sentinel lymph node mapping learning curve, operation mode and sentinel lymph node ultrastaging. In the future, guidelines with consistent recommendations on the above outlined features of sentinel lymph node mapping should be established to allow for a uniform and wide-spread application of the sentinel lymph node mapping procedure.

The Clinical and Pathological Profile of BRCA1 Gene Methylated Breast Cancer Women: A Meta-Analysis

BACKGROUND

DNA aberrant hypermethylation is the major cause of transcriptional silencing of the breast cancer gene 1 (BRCA1) gene in sporadic breast cancer patients. The aim of the present meta-analysis was to analyze all available studies reporting clinical characteristics of BRCA1 gene hypermethylated breast cancer in women, and to pool the results to provide a unique clinical profile of this cancer population.

METHODS

On September 2020, a systematic literature search was performed. Data were retrieved from PubMed, MEDLINE, and Scopus by searching the terms: "BRCA*" AND "methyl*" AND "breast". All studies evaluating the association between BRCA1 methylation status and breast cancer patients' clinicopathological features were considered for inclusion.

RESULTS

465 studies were retrieved. Thirty (6.4%) studies including 3985 patients met all selection criteria. The pooled analysis data revealed a significant correlation between BRCA1 gene hypermethylation and advanced breast cancer disease stage (OR = 0.75: 95% CI: 0.58-0.97; p = 0.03, fixed effects model), lymph nodes involvement (OR = 1.22: 95% CI: 1.01-1.48; p = 0.04, fixed effects model), and pre-menopausal status (OR = 1.34: 95% CI: 1.08-1.66; p = 0.008, fixed effects model). No association could be found between BRCA1 hypermethylation and tumor histology (OR = 0.78: 95% CI: 0.59-1.03; p = 0.08, fixed effects model), tumor grading (OR = 0.78: 95% CI :0.46-1.32; p = 0.36, fixed effects model), and breast cancer molecular classification (OR = 1.59: 95% CI: 0.68-3.72; p = 0.29, random effects model).

CONCLUSIONS

hypermethylation of the BRCA1 gene significantly correlates with advanced breast cancer disease, lymph nodes involvement, and pre-menopausal cancer onset.

Abstract OT-23-02: Volumetric analysis of the pectoralis major muscle as preoperative tool to select patients undergoing pre-pectoral versus sub-pectoral implant based breast reconstruction after risk reducing mastectomy

Background: Proper patient selection is crucial to maximize aestethic outcome in breast reconstructive surgery. No specific patients selection criteria have been developed to choose between prepectoral versus subpectoral implant-based reconstruction. A quantitative tool able to determine the pectoralis muscle individual characteristics might be helpful to discriminate a priori the patients who will experience better aesthetic outcome and less complications following a pre-pectoral versus a sub-pectoral approach. Preoperative pectoralis muscle assessment may optimize patients’ selection for the breast reconstructive technique. Trial design: This is a multicentric trial in which, patients candidated to risk reducing mastectomy fulfilling inclusion criteria, will undergo a preoperative MRI prior to randomization to pre-pectoral versus sub-pectoral implant placement in immediate breast reconstruction. Volumetric analysis of the pectoralis major muscle (cm2) and measurement of the subcutaneous adipose tissue in the breast region, will be performed to assess anatomic characteristics of the pectoralis muscle using a sagittal T1 fat suppressed sequence. The volume of the pectoralis muscle will be calculated by measuring differences in density with the MRI. In all patients, the pectoralis muscle area on the left and right side will be determined separately and the two values will be averaged. The volumetric assessment will be performed by two expert radiologists. BREAST-Q© questionnaire will be completed by each patient prior to surgery and at the follow up evaluations. Breast reconstruction will be performed immediately after nipple-sparing mastectomy (Arm 1: breast implant placed above the pectoralis major muscle (pre-pectoral); Arm 2: breast implant placed below the pectoralis major muscle (sub-pectoral)). Number of revisional surgeries, explantations, infections, seromas, flap necrosis, will be compared between two groups and correlated with MRI pectoralis muscle volume. Post-operative follow-up evaluations at 6 and 12-months to assess capsular contracture and BREAST-Q changes will be performed. Eligibility criteria:

Inclusion criteria:

•Female patient•Ages 18-60•Patients undergoing risk reducing mastectomy with immediate implant-based reconstruction •Signed informed consent

Exclusion Criteria:

•Prior chest wall irradiation •Patients with a contraindication to immediate breast reconstruction.•Patients with history of smoking, •BMI&gt; 40, •D cup breast size•grade III ptosis

Aims: To identify variables measured at preoperative MRI pectoralis muscle’s volumetric analysis that correlate with aesthetic outcome and complication rate in pre-pectoral versus sub-pectoral implant based reconstruction.

Statistical methods: The assumption of distributional normality will be tested using the Shapiro-Wilk test. Comparisons of two variables will be carried out using the Wilcoxon test for paired groups and the Mann-Whitney test for unpaired groups.

Present accrual and target accrual: The trial has been submitted for IRB approval at the ethical commission of Italian Switzerland. Recruitment has not started yet. With an enrollment ratio of 1:1, fifty patients (25 per arm) need to be recruited to ensure a power of 80% with a two sides alpha error of 0.05.

Contact information: marialuisa.gasparri@eoc.ch

Citation Format: Maria Luisa Gasparri, Thorsten Kuehn, Isabel Rubio, Philip Poortmans, Diana Lueftner, Orit Kaidar-Pearson, Beat Thuerlimann, Yves Harder, Daniel Schmauss, Francesco Meani, Claudia Rauh, Michael David Mueller, Malgorzata Banys-Paluchowski, Andrea Papadia, Valerio Vitale, Stefania Rizzo, Oreste Davide Gentilini. Volumetric analysis of the pectoralis major muscle as preoperative tool to select patients undergoing pre-pectoral versus sub-pectoral implant based breast reconstruction after risk reducing mastectomy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-23-02.

Impact of clinical factors and surgical outcome on long-term survival in high-grade serous ovarian cancer: a multicenter analysis

INTRODUCTION

Long-term survivors of ovarian cancer are a unique group of patients in whom prognostic factors for long-term survival have been poorly described. Such factors may provide information for a more personalized therapeutic approach. The objective of this study is to determine further characteristics of long-term survivors with high-grade serous ovarian cancer.

METHODS

Long-term survivors were defined as patients living longer than 8 years after first diagnosis and were recruited within seven high volume centers across Europe from November 1988 to November 2008. The control group included patients with high-grade serous ovarian cancer with less than 5 years' survival identified from the systematic 'Tumorbank ovarian cancer' database. A subanalysis of Charité patients only was performed separately for in-depth analysis of tumor dissemination. Propensity score matching with nearest-neighbor caliper width was used to match long-term survivors and the control group regarding age, FIGO stage, and residual tumor.

RESULTS

A total of 276 patients with high-grade serous ovarian cancer were included, divided into 131 long-term survivors and 145 control group patients. After propensity score matching and multivariable adjustment, platinum sensitivity (p=0.002) was an independent favorable prognostic factor whereas recurrence (p<0.001) and ascites (p=0.021) were independent detrimental predictors for long-term survival. Significantly more long-term survivors tested positive for mutation in the BRCA1 gene than the BRCA2 gene (p=0.016). Intraoperatively, these patients had less tumor involvement of the upper abdomen at initial surgery (p=0.024). Complexity of surgery and surgical techniques were similar in both cohorts.

CONCLUSION

Platinum sensitivity constitutes a favorable factor for long-term survival whereas tumor involvement of the upper abdomen, ascites, and recurrence have a negative impact. Based on clinical estimation, long-term survival is associated with combinations of clinical, surgical, and molecular factors.

Computed Tomography Based Radiomics as a Predictor of Survival in Ovarian Cancer Patients: A Systematic Review

Simple Summary

Ovarian cancer represents the most lethal gynecological malignancy. Since many new drugs have been recently introduced as adjunctive treatments for this pathology, an early prediction of outcome might be helpful to further improve outcomes. Radiomics represents a recent advancement, relying on extraction of quantitative features from imaging examinations. Indeed, clinical images, such as computed tomography images, may contain quantitative information, reflecting the underlying pathophysiology of a tumoral tissue. Radiomic analyses can be performed in tumor regions and metastatic lesions, as well as in normal tissues. The radiomic process relies on quantitative features, usually extracted by dedicated software, and then culminates in analysis and model building, according to a defined clinical question. This systematic review aims to evaluate association between radiomics based on computed tomography images and survival (in terms of overall survival and progression free survival) in ovarian cancer patients.

Abstract

The objective of this systematic review was to assess the results of radiomics for prediction of overall survival (OS) and progression free survival (PFS) in ovarian cancer (OC) patients. A secondary objective was to evaluate the findings of papers that based their analyses on inter-site heterogeneity. This systematic review was conducted according to the PRISMA statement. After the initial retrieval of 145 articles, the final systematic review comprised six articles. Association between radiomic features and OS was evaluated in 3/6 studies (50%); all articles showed a significant association between radiomic features and OS. Association with PFS was evaluated in 5/6 (83%) articles; the period of follow-up ranged between six and 36 months. All the articles showed significant association between radiomic models and PFS. Inter-site textural features were used for analysis in 2/6 (33%) articles. They demonstrated that high levels of inter-site textural heterogeneity were significantly associated with incomplete surgical resection in breast cancer gene-negative patients, and that lower heterogeneity was associated with complete resectability. There were some differences among papers in methodology; for example, only 3/6 (50%) articles included validation cohorts. In conclusion, radiomic models have demonstrated promising results as predictors of survival in OC patients, although larger studies are needed to allow clinical applicability.

Sentinel node mapping vs. sentinel node mapping plus back-up lymphadenectomy in high-risk endometrial cancer patients: Results from a multi-institutional study

OBJECTIVE

Sentinel node mapping (SLN) has replaced lymphadenectomy for staging surgery in apparent early-stage low and intermediate risk endometrial cancer (EC). Only limited data about the adoption of SNM in high risk EC is still available. Here, we evaluate the outcomes of high-risk EC undergoing SNM (with or without back-up lymphadenectomy).

METHODS

This is a multi-institutional international retrospective study, evaluating data of high-risk (FIGO grade 3 endometrioid EC with myometrial invasion >50% and non-endometrioid histology) EC patients undergoing SNM followed by back-up lymphadenectomy and SNM alone.

RESULTS

Chart of consecutive 196 patients were evaluated. The study population included 83 and 113 patients with endometrioid and non-endometrioid EC, respectively. SNM alone and SNM followed by back-up lymphadenectomy were performed in 50 and 146 patients, respectively. Among patients having SNM alone, 14 (28%) were diagnosed with nodal disease. In the group of patients undergoing SNM plus back-up lymphadenectomy 34 (23.2%) were diagnosed with nodal disease via SNM. Back-up lymphadenectomy identified 2 (1%) additional patients with nodal disease (in the para-aortic area). Back-up lymphadenectomy allowed to remove adjunctive positive nodes in 16 (11%) patients. After the adoption of propensity-matched algorithm, we observed that patients undergoing SNM plus back-up lymphadenectomy experienced similar disease-free survival (p = 0.416, log-rank test) and overall survival (p = 0.940, log-rank test) than patients undergoing SLN alone.

CONCLUSIONS

Although the small sample size, and the retrospective study design this study highlighted that type of nodal assessment did not impact survival outcomes in high-risk EC. Theoretically, back-up lymphadenectomy would be useful in improving the removal of positive nodes, but its therapeutic value remains controversial. Further prospective evidence is needed.

The impact of low-volume metastasis on disease-free survival of women with early-stage cervical cancer

PURPOSE

We aimed to assess the impact of low-volume metastasis (micrometastasis and isolated tumor cells) on disease-free survival (DFS) of women with early-stage cervical cancer.

METHODS

Women with clinically suspected stage 1A-IB2 (FIGO 2018 classification) disease who underwent retroperitoneal nodal staging between October 2010 and April 2018, were retrospectively analyzed. The group of women who had undergone lymphadenectomy and standard node pathologic analysis (H&E group), were compared to the group undergoing sentinel node mapping (SLN) and ultrastaging with or without lymphadenectomy (ultrastaging group). At a median follow-up of 45 months, the DFS curves were analyzed.

RESULTS

Overall, 573 patients were revised (272 in the H&E group and 302 in the ultrastaging group). Eighty-five patients presented lymph node metastasis (32 in H&E, 53 in ultrastaging). Ultrastaging protocol increased the rate of low-volume metastasis by 5.6%. Twenty patients showed exclusive micrometastasis or ITC's. Seventy-three recurrences occurred (35 in H&E, 38 in ultrastaging). Only 1 out of 53 patients in the ultrastaging group (1.9%) presented with micrometastasis recurred. The 3-year disease-free survival was 89% for the H&E group, and 88% for the ultrastaging group, respectively (p = 0.175).

CONCLUSION

Ultrastaging analysis allowed increasing the detection of low volume metastasis in women with early-stage cervical cancer. However, the type of nodal staging did not have an impact on patients' 3-year disease-free survival.

Biological Impact of Unilateral Oophorectomy: Does the Number of Ovaries Really Matter?

Although unilateral oophorectomies are performed more often than bilateral ones in women of reproductive age, their clinical consequences have been less intensively investigated. Experimental models in animals have shown that compensatory mechanisms occur after a unilateral oophorectomy (UO). This review aims to summarize the available evidence on the biological effects of unilateral oophorectomy on women. Evaluated outcomes include age at onset of menopause, risk of cardiovascular and neurological disease, risk of mortality and fertility outcome after spontaneous conception or in vitro fertilization (IVF). Results were compared with findings reported after bilateral oophorectomy and/or ovarian excision and/or women with intact ovaries. An electronic database search was performed using PubMed and Scopus, followed by a manual search to identify controlled studies that compared women after UO with women with two intact ovaries. In particular, a systematic review of fertility outcomes after IVF was performed, and the data were summarized in a table. Women who underwent UO had a similar age at menopause and similar clinical pregnancy rate compared to women with two ovaries. However, decreased ovarian reserve affecting the quantity but not the quality of the ovarian pool after IVF was observed in the UO group. Furthermore, an increased risk of neurological disease and even an increased risk of mortality was observed in women with single ovary. These data need to be confirmed by further studies, and a plausible mechanism of action must be identified. At present, patients who undergo UO can be reassured with regard to their reproductive potential and their age at onset of menopause.

Update in native tissue vaginal vault prolapse repair

The lifetime risk of women for undergoing surgery for pelvic organ prolapse (POP) is estimated to be 11-19%, and 30% of these women will require subsequent reoperation over time. Following hysterectomy, 3.6 per 1,000 person-years need surgical correction of prolapse, and in two-thirds of these cases multi-compartment prolapse is present. In the last decades, vaginally synthetic meshes were widely used in pelvic reconstructive surgery. However, after the decision of the Food and Drug Administration in 2019 to stop selling all surgical mesh devices for transvaginal prolapse repair, native tissue (NT) vaginal repair seems to regain an important role in pelvic reconstructive surgery. In the literature, various surgical techniques have been described for apical repair, but the best surgical approach is still to be proven. This paper analyzes the current evidence from recent literature on NT vaginal vault prolapse (VVP) repair, with special focus on the safety and efficacy of the various vaginal techniques.

What is this vaginal bulge? An atypical case of vaginal paraurethral leiomyoma. A case report and literature systematic review

AIM

Vaginal paraurethral leiomyomas are uncommon benign tumors of the female genitourinary tract. We report a case of anterior vaginal paraurethral leiomyoma. Furthermore, we performed a systematic review of the literature to provide information that can help the physicians in the diagnosis and management of women with this rare pathology.

METHODS

A case of anterior vaginal paraurethral leiomyoma in 53-year-old, primiparous, caucasian woman with history of pelvic pressure, vaginal bulging and overactive bladder symptoms, was described. Furthermore, a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed between January 1, 2000 to Dec 30, 2019. Only articles that reported cases of vaginal or paraurethral leiomyoma (b) case series and case reports with literature review were included.

RESULTS

we screened a total 2281 records; 70 articles published from 2000 to 2019 were included.

CONCLUSION

Vaginal paraurethral leiomyoma is a rare benign tumor of the vagina with a wide spectrum of symptoms and good prognosis. The recurrence and transformation into malignant condition are rare. Histopathological examination is the gold standard for diagnosis, but MRI and US can be help to define the size and localization of the tumor. Management requires surgical vaginal excision in the majority of cases; however, abdominal approach could be considered when it is large and located high in the vagina.

Preoperative Conization and Risk of Recurrence in Patients Undergoing Laparoscopic Radical Hysterectomy for Early Stage Cervical Cancer: A Multicenter Study

STUDY OBJECTIVE

To investigate the factors associated with poorer oncologic outcomes in patients undergoing laparoscopic radical hysterectomy (LRH) for early stage cervical cancer.

DESIGN

Multicenter retrospective study.

SETTING

Three gynecologic oncology referral centers.

PATIENTS

Patients with International Federation of Gynecology and Obstetrics 2009 stage IA (positive lymphovascular space invasion)-IB1 cervical cancer between January 2006 and June 2018.

INTERVENTIONS

LRH (Piver type II-III hysterectomies). Lymph-node dissection was accomplished according to the tumor characteristics.

MEASUREMENTS AND MAIN RESULTS

Surgical and oncologic outcomes were analyzed. Overall, 186 patients met the inclusion criteria, 16 (8.6%) experienced a recurrence, and 9 (4.8%) died of the disease (median follow-up period 37.9 months). Surgery-related complications did not influence disease-free survival. All the recurrences (16/16; 100%) occurred in patients with stage IB1 disease (p = .02), and 15 (93.7%) in cases involving tumors ≥2 cm. No association between positive lymph node and recurrence was detected (p =.82). Patients who had a preoperative diagnosis through conization (93; 50%) had a significantly lower rate of recurrence than those who underwent cervical biopsy (93; 50%): 1/93 (1.1%) vs 15/93 (16.1%); p <.001). The subanalysis of patients with International Federation of Gynecology and Obstetrics stage IB1 cervical cancer showed that patients undergoing preoperative conization (vs cervical biopsy) were less likely to experience a recurrence (odds ratio 0.09; 95% confidence interval 0.01-0.55).

CONCLUSION

We confirmed that LRH was associated with a recurrence rate similar to that reported in the Laparoscopic Approach to Cervical Cancer trial. Tumor size ≥2 cm represents the most important risk factor influencing disease-free survival. However, we found that preoperative conization plays a potentially protective role in patients with an IB1 tumor.

Unilateral versus bilateral lymph-nodal metastases and oncologic outcome in vulvar cancer patients

PURPOSE

To evaluate the difference in oncologic outcome between vulvar cancer patients with uni- and bilateral inguino-femoral lymph nodal involvement and to identify factors affecting their oncologic outcome MATERIALS AND METHODS: Patients who underwent inguino-femoral lymphadenectomy for vulvar cancer were classified into three groups according to their lymph nodal status at the histology analysis (negative, positive one side, positive bilaterally). PFS and OS survival were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to analyze factors predicting overall survival and progression-free survival. Multivariable models were used for variables reporting a p value ≤ 0.1 at the univariate analysis. p values ≤ 0.05 were considered statistically significant.

RESULTS

One hundred and forty-six patients were considered for the analysis. Patients with bilaterally negative lymph nodes had significantly longer PFS and OS as compared to patients with unilateral and bilateral involvement. Patients with unilateral lymph nodal involvement had better PFS than patients with bilateral lymph nodal involvement. Among these patients, the difference in the OS approached but did not reach statistical significance. At the multivariate analysis, the tumor size affected PFS and lymph nodal involvement affected OS.

CONCLUSION

Vulvar cancer patients with bilateral positive lymph nodes have worse oncologic outcome as compared to patients with unilateral lymph nodal involvement; similarly, patients with unilateral lymph nodal involvement have worse oncological outcome as compared to patients with bilateral negative lymph nodes. Furthermore, tumor size and lymph nodal status are independent factors predicting recurrence rate and overall survival, respectively.