To drain or not to drain: A propensity score analysis of abdominal drainage after colorectal surgery for endometriosis

AIM

To assess the benefit of prophylactic abdominal drainage (AD) after colorectal surgery for endometriosis.

METHODS

We conducted a retrospective study of 215 patients who underwent colorectal surgery for endometriosis using a mini-invasive approach in our center from February 2019 to July 2023. A propensity score matched (PSM) analysis (1:1 ratio) identified two groups of patients with similar characteristics. Postoperative outcomes were then compared.

RESULTS

In the unmatched cohort, 151 patients (70 %) had AD at the end of surgery and 64 (30 %) did not. Clinical characteristics and surgical procedures were comparable between the groups after PSM. After PSM, AD was associated with a longer hospital stay (p < 0.001) and a greater number of postoperative complications (p = 0.03). There were no differences for readmission, repeat surgery, or severe postoperative complications.

CONCLUSION

In this retrospective cohort of patients undergoing colorectal resection for endometriosis using a mini-invasive approach, prophylactic AD was not found to be beneficial.

Saliva-based microRNA diagnostic signature for the superficial peritoneal endometriosis phenotype

OBJECTIVE

Patients with superficial peritoneal endometriosis (SPE) present with symptoms suggestive of endometriosis but clinical and imaging exams are inconclusive. Consequently, laparoscopy is usually necessary to confirm diagnosis. The present study aimed to evaluate the accuracy of microRNAs (miRNAs) to diagnose patients with SPE from the ENDOmiARN cohort STUDY DESIGN: This prospective study (NCT04728152) included 200 saliva samples obtained between January and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy and/or MRI to confirm the presence of endometriosis. Among the patients with endometriosis, two groups were defined: an SPE phenotype group of patients with peritoneal lesions only, and a non-SPE control group of patients with other endometriosis phenotypes (endometrioma and/or deep endometriosis). Data analysis consisted of two parts: (i) identification of a set of miRNA biomarkers using next-generation sequencing (NGS), and (ii) development of a saliva-based miRNA signature for the SPE phenotype in patients with endometriosis based on a Random Forest (RF) model.

RESULTS

Among the 153 patients with confirmed endometriosis, 10.5 % (n = 16) had an SPE phenotype. Of the 2633 known miRNAs, the feature selection method generated a signature of 89 miRNAs of the SPE phenotype. After validation, the best model, representing the most accurate signature had a 100 % sensitivity, specificity, and AUC.

CONCLUSION

This signature could constitute a new diagnostic strategy to detect the SPE phenotype based on a simple biological test and render diagnostic laparoscopy obsolete. PRéCIS: We generated a saliva-based signature to identify patients with superficial peritoneal endometriosis which is the most challenging form of endometriosis to diagnose and which is often either misdiagnosed or requires invasive laparoscopy.

Correction: Dabi et al. Clues for Improving the Pathophysiology Knowledge for Endometriosis Using Plasma Micro-RNA Expression. Diagnostics 2022, 12, 175

In the original publication [...].

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment

OBJECTIVE

To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP).

METHODS

We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation.

RESULTS

A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency.

CONCLUSION

Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery

OBJECTIVE

To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses.

METHODS

EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended).

RESULTS

The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI95% 0.96-0.98) and was of 92.0 % (484/526) for categorizing lesions with a negative predictive value of 98.1 % (415/423, CI95% 0.96-0.99). Theoretical management using the score would have spared surgery in 229 patients (87.1 %, 229/263) with benign lesions and malignancy would have been missed in 6 borderline and 2 invasive cases. In patients with a presumed benign mass using O-RADS MRI score, recommending surgery for lesions >= 100 mm would miss only 4/77 (4.8 %) malignant adnexal tumors instead of 8 (50 % decrease).

CONCLUSION

The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81 min vs 240 ± 79 min, p = 0.010, and 216 ± 78 min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4 days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

Reasons why it is time to change imaging guidelines on endometriosis

In light of the rising number of patients referred for magnetic resonance imaging (MRI) due to suspected endometriosis and the high expectations of these patients, there is a need for new imaging guidelines to optimally protocol and indicate MRI and transvaginal ultrasonography (TVUS) examinations. This is crucial for accurately addressing the inquiries of gynecologists, encompassing complete mapping and preoperative staging, and facilitating effective communication with patients. In this context, the development of a standardized lexicon, as well as dedicated imaging classifications, is recommended to aid in the comprehensive management of patients. CLINICAL RELEVANCE STATEMENT: The radiologist should use a standardized lexicon and provide a score along with details about the specific compartments affected by endometriosis disease. This helps in offering clearer guidance to the surgeon. KEY POINTS: • An optimal staging is based on the combination of clinical examination, transvaginal US, and MRI. • MRI is able to detect location that is hidden at the beginning of a laparoscopic surgery and thus the need for dedicated MR classifications to correctly stage the disease. • Deep pelvic endometriosis index (dPEI) classification is externally validated and highly correlated with operating time, hospital stay, and postoperative complications.

Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates

OBJECTIVE

The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.

METHODS

49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.

RESULTS

Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).

CONCLUSION

Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

O-RADS MRI to classify adnexal tumors: from clinical problem to daily use

Eighteen to 35% of adnexal masses remain non-classified following ultrasonography, leading to unnecessary surgeries and inappropriate management. This finding led to the conclusion that ultrasonography was insufficient to accurately assess adnexal masses and that a standardized MRI criteria could improve these patients' management. The aim of this work is to present the different steps from the identification of the clinical issue to the daily use of a score and its inclusion in the latest international guidelines. The different steps were the following: (1) preliminary work to formalize the issue, (2) physiopathological analysis and finding dynamic parameters relevant to increase MRI performances, (3) construction and internal validation of a score to predict the nature of the lesion, (4) external multicentric validation (the EURAD study) of the score named O-RADS MRI, and (5) communication and education work to spread its use and inclusion in guidelines. Future steps will include studies at patients' levels and a cost-efficiency analysis. Critical relevance statement We present translating radiological research into a clinical application based on a step-by-step structured and systematic approach methodology to validate MR imaging for the characterization of adnexal mass with the ultimate step of incorporation in the latest worldwide guidelines of the O-RADS MRI reporting system that allows to distinguish benign from malignant ovarian masses with a sensitivity and specificity higher than 90%. Key points • The initial diagnostic test accuracy studies show the limitation of a preoperative assessment of adnexal masses using solely ultrasonography.• The technical developments (DCE/DWI) were investigated with the value of dynamic MRI to accurately predict the nature of benign or malignant lesions to improve management.• The first developing score named ADNEX MR Score was constructed using multiple easily assessed criteria on MRI to classify indeterminate adnexal lesions following ultrasonography.• The multicentric adnexal study externally validated the score creating the O-RADS MR score and leading to its inclusion for daily use in international guidelines.

[FRANCOGYN group: A brief history]

OBJECTIVES

Describing the constitution of the FRANCOGYN group (a national French research group in Oncological and Gynecological Surgery) and present its current and future development.

METHODS

Literature review using PUBMed database with the keyword "FRANCOGYN".

OBJECTIVES

Describing the constitution of the FRANCOGYN group (a national French research group in Oncological and Gynecological Surgery) and present its current and future development.

RESULTS

The FRANCOGYN group was formed in December 2015, bringing together over the years more than 17 gynecological and oncological surgical department in France. The group carries out clinical research on gynecological pelvic cancers by constituting retrospective cohorts. Its legitimacy allows it to lead or co-lead the drafting of recommendations for clinical practice in the field of gynecological cancers. It now offers prospective randomized research funded by national grants.

CONCLUSION

The FRANCOGYN network allows us to propose a national reflection on the surgical management of pelvic cancers in women, resulting in numerous international reference publications.

Adherence to ESGO guidelines and impact on survival in obese patients with endometrial cancer: a multicentric retrospective study

OBJECTIVES

Obesity is known to be both a major risk factor for endometrial cancer and associated with surgical complexity. Therefore, the management of patients with obesity is a challenge for surgeons and oncologists. The aim of this study is to assess the adherence to European Society of Gynaecological Oncology (ESGO) guidelines in morbidly obese patients (body mass index (BMI) >40 kg/m2). The secondary objectives were the impact on overall survival and recurrence-free survival.

METHODS

All the patients who were treated for an endometrial cancer in the 11 cancer institutes of the FRANCOGYN group were included and classified into three weight groups: morbid (BMI >40 kg/m2), obese (BMI 30-40), and normal or overweight (BMI <30). Adherence to guidelines was evaluated for surgical management, lymph node staging, and adjuvant therapies.

RESULTS

In total, 2375 patients were included: 1330 in the normal or overweight group, 763 in the obese group, and 282 in the morbid group. The surgical management of the morbid group was in accordance with the guidelines in only 30% of cases, compared with 44% for the obese group and 48% for the normal or overweight group (p<0.001); this was largely because of a lack of lymph node staging. Morbid group patients were more likely to receive the recommended adjuvant therapy (61%) than the obese group (52%) or the normal or overweight group (46%) (p<0.001). Weight had no impact on overall survival (p=0.6) and morbid group patients had better recurrence-free survival (p=0.04).

CONCLUSION

Adherence to international guidelines for surgical management is significantly lower in morbid group patients, especially for lymph node staging. However, morbidly obese patients had more often the adequate adjuvant therapies. Morbid group patients had a better recurrence-free survival likely because of better prognosis tumors.

Changes in hospital consumption of opioid and non-opioid analgesics after colorectal endometriosis surgery

The aim of this study was to analyze postoperative consumption of analgesics during hospitalization following colorectal surgery for endometriosis. We conducted a retrospective study at Tenon University Hospital, Paris, France from February 2019 to December 2021. One hundred sixty-two patients underwent colorectal surgery: eighty-nine (55%) by robotic and seventy-three (45%) by conventional laparoscopy. The type of procedure had an impact on acetaminophen and nefopam consumed per day: consumption for colorectal shaving, discoid resection, and segmental resection was, respectively, 2(0.5), 2.1(0.6), 2.4(0.6) g/day (p = 10-3), and 25(7), 30(14), 31(11) mg/day (p = 0.03). The total amount of tramadol consumed was greater following robotic surgery compared with conventional laparoscopy (322(222) mg vs 242(292) mg, p = 0.04). We observed a switch in analgesic consumption over the years: tramadol was used by 70% of patients in 2019 but only by 7.1% in 2021 (p < 10-3); conversely, ketoprofen was not used in 2019, but was consumed by 57% of patients in 2021 (p < 10-3). A history of abdominal surgery (OR = 0.37 (0.16-0.78, p = 0.011) and having surgery in 2020 rather than in 2019 (OR = 0.10 (0.04-0.24, p < 10-3)) and in 2021 than in 2019 (OR = 0.08 (0.03-0.20, p < 10-3)) were the only variables independently associated with the risk of opioid use. We found that neither clinical characteristics nor intraoperative findings had an impact on opioid consumption in this setting, and that it was possible to rapidly modify in-hospital analgesic consumption modalities by significantly reducing opioid consumption in favor of NSAIDS or nefopam.

O-RADS scoring system for adnexal lesions: Diagnostic performance on TVUS performed by an expert sonographer and MRI

RATIONALE AND OBJECTIVE

To determine the diagnostic performance of transvaginal ultrasound (TVUS) performed by an US specialist and MRI based on the O-RADS scoring system.

MATERIALS AND METHODS

Between March 5th 2013 and December 31st 2021, 227 patients, referred to our center, underwent TVUS and pelvic MRI for characterization of an adnexal lesion proven by surgery or two years of negative follow-up. All lesions were classified according to O-RADS US and O-RADS MRI risk scoring systems. Imaging data were then correlated with histopathological diagnosis or negative follow-up for 2 years.

RESULTS

The prevalence of malignancy was 11.1%. Sensitivity of O-RADS US / O-RADS MRI were respectively of 83.3%/83.3% and specificity was 73.2%/92.9% (p < 0.001). O-RADS MRI was more accurate than O-RADS US even when performed by an US specialist (p < 0.001). When MRI was used after US, 51 lesions were reclassified correctly by MRI and only 4 lesions incorrectly reclassified. Most of the lesions (49/51) rated O-RADS US 4 or 5 and reclassified correctly by MRI were benign, mainly including cystadenomas or cystadenofibromas. Only 4 lesions were misclassified by MRI but correctly classified by ultrasound.

CONCLUSION

Our study suggests that MR imaging has equally high sensitivity but higher specificity than TVUS for the characterization of adnexal lesions based on O-RADS scoring system. MRI should be the recommended second-line technique when a mass is discovered during TVUS and is rated O-RADS 4 and 5 over than TVUS by an US specialist.

New class of RNA biomarker for endometriosis diagnosis: The potential of salivary piRNA expression

OBJECTIVES

In contrast to miRNA expression, little attention has been given to piwiRNA (piRNA) expression among endometriosis patients. The aim of the present study was to explore the human piRNAome and to investigate a potential piRNA saliva-based diagnostic signature for endometriosis.

METHODS

Data from the prospective "ENDOmiRNA" study (ClinicalTrials.gov Identifier: NCT04728152) were used. Saliva samples from 200 patients were analyzed in order to evaluate human piRNA expression using the piRNA bank. Next Generation Sequencing (NGS), barcoding of unique molecular identifiers and both Artificial Intelligence (AI) and machine learning (ML) were used. For each piRNA, sensitivity, specificity, and ROC AUC values were calculated for the diagnosis of endometriosis.

RESULTS

201 piRNAs were identified, none had an AUC ≥ 0.70, and only three piRNAs (piR-004153, piR001918, piR-020401) had an AUC between ≥ 0.6 and < 0.70. Seven were differentially expressed: piR-004153, piR-001918, piR-020401, piR-012864, piR-017716, piR-020326 and piR-016904. The respective correlation and accuracy to diagnose endometriosis according to the F1-score, sensitivity, specificity, and AUC ranged from 0 to 0.862 %, 0-0.961 %, 0.085-1, and 0.425-0.618. A correlation was observed between the patients' age (≥35 years) and piR-004153 (p = 0.002) and piR-017716 (p = 0.030). Among the 201 piRNAs, four were differentially expressed in patients with and without hormonal treatment: piR-004153 (p = 0.015), piR-020401 (p = 0.001), piR-012864 (p = 0.036) and piR-017716 (p = 0.009).

CONCLUSION

Our results support the link between piRNAs and endometriosis physiopathology and establish its utility as a potential diagnostic biomarker using saliva samples. Per se, piRNA expression should be analyzed along with the clinical status of a patient.

Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study

OBJECTIVE

Evaluation of the management by first brachytherapy followed by radical hysterectomy (Wertheim type) compared to radical hysterectomy alone (Wertheim type) for the treatment of IB2 cervical cancer.

METHODS

Data from women with histologically proven FIGO stage IB2 cervical cancer treated between April 1996 and December 2016 were retrospectively abstracted from twelve French institutions with prospectively maintained databases.

RESULTS

Of the 211 patients with FIGO stage IB2 cervical cancer without lymph node involvement included, 136 had surgical treatment only and 75 had pelvic lymph node staging and brachytherapy followed by surgery. The surgery-only group had significantly more adjuvant treatment (29 vs. 3; p = 0.0002). A complete response was identified in 61 patients (81%) in the brachytherapy group. Postoperative complications were comparable (63,2% vs. 72%, p = 0,19) and consisted mainly of urinary (36vs. 27) and digestive (31 vs 22) complications and lymphoceles (4 vs. 1). Brachytherapy had no benefit in terms of progression-free survival (p = 0.14) or overall survival (p = 0.59). However, for tumors of between 20 and 30 mm, preoperative brachytherapy improved recurrence-free survival (p = 0.0095) but not overall survival (p = 0.41). This difference was not observed for larger tumors in terms of either recurrence-free survival (p = 0.55) or overall survival (p = 0.95).

CONCLUSION

Our study found that preoperative brachytherapy had no benefit for stage IB2 cervical cancers in terms of recurrence-free survival or overall survival. For tumor sizes between 2 and 3 cm, brachytherapy improves progression-free survival mainly by reducing pelvic recurrences without improving overall survival.

Prognostic impact of cytoreductive surgery conducted with primary intent, versus cytoreductive surgery after neoadjuvant chemotherapy, in the management of patients with advanced epithelial ovarian cancers: a multicentre, propensity score-matched study from the FRANCOGYN group

OBJECTIVE

To compare survival and morbidity rates between primary cytoreductive surgery (pCRS) and interval cytoreductive surgery (iCRS) for epithelial ovarian cancer (EOC), using a propensity score.

DESIGN

We conducted a propensity score-matched cohort study, using data from the FRANCOGYN cohort.

SETTING

Retrospective, multicentre study of data from patients followed in 15 French department specialized in the treatment of ovarian cancer.

SAMPLE

Patients included were those with International Federation of Gynaecology and Obstetrics (FIGO) stage III or IV EOC, with peritoneal carcinomatosis, having undergone CRS.

METHODS

The propensity score was designed using pre-therapeutic variables associated with both treatment allocation and overall survival (OS).

MAIN OUTCOME MEASURES

The primary outcome was OS. Secondary outcomes included recurrence-free survival (RFS), quality of CRS and other variables related to surgical morbidity.

RESULTS

A total of 513 patients were included. Among these, 334 could be matched, forming 167 pairs. No difference in OS was found (hazard ratio, HR = 0.8, p = 0.32). There was also no difference in RFS (median = 26 months in both groups) nor in the rate of CRS leaving no macroscopic residual disease (pCRS 85%, iCRS 81.4%, p = 0.76). The rates of gastrointestinal tract resections, stoma, postoperative complications and hospital stay were significantly higher in the pCRS group.

CONCLUSIONS

Analysis of groups of patients made comparable by propensity score matching showed no difference in survival, but lower postoperative morbidity in patients treated with iCRS.

ENDOGRADE: A four level classification to rate surgical complexity in endometriosis

OBJECTIVES

We studied a post operative classification of surgical complexity in endometriosis.

STUDY DESIGN

Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels.

RESULTS

Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively.

CONCLUSION

ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.

Validation of a Salivary miRNA Signature of Endometriosis - Interim Data

Salivary miRNA Signature of EndometriosisThis interim analysis of the prospective, multicenter, external validation ENDOmiRNA Saliva Test study, confirms the diagnostic performance and reproducibility of the saliva miRNA signature for endometriosis. At a population prevalence of ∼80%, the miRNA signature had a sensitivity of 96.2%, specificity of 95.1%, and area under the curve of 0.96.

Resolution of Pain after Percutaneous Image-Guided Cryoablation of Extraperitoneal Endometriosis

PURPOSE

To retrospectively evaluate the relief of pain after percutaneous image-guided cryoablation of symptomatic extraperitoneal endometriosis (EE).

MATERIAL AND METHODS

From 2017 to 2022, cryoablation of EE was performed at a single institution on a total of 47 lesions in 42 consecutive patients (median age, 37 years; interquartile range [IQR], 33-39.5 years). Patient and procedural characteristics were reviewed retrospectively. Tolerance and outcomes in terms of pain and patient satisfaction were evaluated.

RESULTS

The median follow-up duration was 13.5 months (IQR, 1.1-37.7 months) after cryoablation. The median pain-free survival rate was 93.8% (95% confidence interval [CI], 77.3-98.4) at 6 months and 82.7% (95% CI, 58.8-93.5) after 12 months. Pain decreased from a median of 8/10 (IQR, 7-9) on the visual analog scale to 0/10 (IQR, 0-1) at the last follow-up (P < .0001). The median Patient Global Impression of Change score recorded at the last follow-up was 1/7 (IQR, 1-2). The efficacy rate of cryoablation to avoid secondary surgery was 92.8% (39/42) per patient and 93.6% (44/47) per nodule treated. Four patients (9.5%, 4/42) experienced an adverse event in the days following the procedure, and 1 patient (2%) experienced a severe adverse event.

CONCLUSIONS

Percutaneous cryoablation is safe and effective in significantly reducing pain and obtaining local control of EE.

Value of non-coding RNAs to assess lymph node status in cervical cancer

Cervical cancer (CC) is the fourth cancer in women and is the leading cause of cancer death in 42 countries. Lymph node metastasis is a determinant prognostic factor, as underlined in the latest FIGO classification. However, assessment of lymph node status remains difficult, despite the progress of imaging such as PET-CT and MRI. In the specific setting of CC, all data underlined the need for new biomarkers easily available to assess lymph node status. Previous studies have underlined the potential value of ncRNA expression in gynecological cancers. In this review, we aimed to evaluate the contribution of ncRNAs in tissue and biofluid samples to determine lymph node status in CC with potential impact on both surgical and adjuvant therapies. In tissue samples, our analysis found that there are arguments to support the role of ncRNAs in physiopathology, differential diagnosis from normal tissue, preinvasive and invasive tumors. In biofluids, despite small studies especially concerning miRNAs expression, promising data opens up new avenue to establish a non-invasive signature for lymph node status as well as a tool to predict response to neo- and adjuvant therapies, thus improving management algorithm of patients with CC.

Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score

Importance

Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key.

Objective

To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort.

Design, Setting, and Participants

In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022.

Intervention

Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score.

Main outcomes and measures

Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction.

Results

The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86).

Conclusions and Relevance

The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

Saliva microRNA signature to diagnose endometriosis: A cost-effectiveness evaluation of the Endotest®

OBJECTIVE

To evaluate a saliva diagnostic test (Endotest®) for endometriosis compared with the conventional algorithm.

DESIGN

A cost-effectiveness analysis with a decision-tree model based on literature data.

SETTING

France.

POPULATION

Women with chronic pelvic pain.

METHODS

Strategy I is the French algorithm, representing the comparator. For strategy II, all patients have an Endotest®. For strategy III, patients undergo ultrasonography to detect endometrioma and patients with no endometrioma detected have an Endotest®. For strategy IV, patients with no endometrioma detected on ultrasonography undergo pelvic magnetic resonance imaging (MRI) to detect endometrioma and/or deep endometriosis. An Endotest® is then performed for patients with a negative result on MRI.

MAIN OUTCOMES MEASURES

Costs and accuracy rates and incremental cost-effectiveness ratios (ICERs). Three analyses were performed with an Endotest® priced at €500, €750, and €1000. Probabilistic sensitivity analysis was conducted with Monte Carlo simulations.

RESULTS

With an Endotest® priced at €750, the cost per correctly diagnosed case was €1542, €990, €919 and €1000, respectively, for strategies I, II, III and IV. Strategy I was dominated by all other strategies. Strategies IV, III and II were, respectively, preferred for a willingness-to-pay threshold below €473, between €473 and €4670, and beyond €4670 per correctly diagnosed case. At a price of €500 per Endotest®, strategy I was dominated by all other strategies. At €1000, the ICERs of strategies II and III were €724 and €387 per correctly diagnosed case, respectively, compared with strategy I.

CONCLUSION

The present study demonstrates the value of the Endotest® from an economic perspective.

Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group

PURPOSE

The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.

How to optimize MRI breast protocol? The value of combined analysis of ultrafast and diffusion-weighted MRI sequences

PURPOSE

The purpose of this retrospective study was to demonstrate the validity of early enhancement criteria on ultrafast magnetic resonance imaging (MRI) sequence to predict malignancy in a large population, and the benefit of diffusion-weighted imaging (DWI) to improve the performance of breast MRI.

MATERIAL AND METHODS

Women who underwent breast MRI examination between April 2018 and September 2020 and further breast biopsy were retrospectively included. Two readers quoted the different conventional features and classified the lesion according to the BI-RADS classification based on the conventional protocol. Then, the readers checked for the presence of early enhancement (≤ 30 s) on ultrafast sequence and the presence of an apparent diffusion coefficient (ADC) ≥ 1.5 × 10^-3 mm²/s to classify the lesions based on morphology and these two functional criteria only.

RESULTS

Two hundred fifty-seven women (median age: 51 years; range: 16-92 years) with 436 lesions (157 benign, 11 borderline and 268 malignant) were included. A MRI protocol plus two simple functional features, early enhancement (≤ 30 s) and an ADC value ≥ 1.5 × 10^-3 mm²/s, had a greater accuracy than the conventional protocol to distinguish benign from malignant breast lesions with or without ADC value (P = 0.01 and P = 0.001, respectively) on MRI, mainly due to better classification of benign lesions (increased specificity) with increasing diagnostic confidence of 3.7% and 7.8% respectively.

CONCLUSION

BI-RADS analysis based on a simple short MRI protocol plus early enhancement on ultrafast sequence and ADC value has a greaterr diagnostic accuracy than a conventional protocol and may avoid unnecessary biopsy.

A Suggested Modification to FIGO Stage IV Epithelial Ovarian Cancer

International Federation of Gynecology and Obstetrics (FIGO) staging classification for stage IV epithelial ovarian cancer (EOC) separates stages IVA (pleural effusion) and IVB (parenchymal and/or extra-abdominal lymph node metastases). We aimed to evaluate its prognostic impact and to compare survival according to the initial metastatic location. We conducted a multicenter study between 2000 and 2020, including patients with a FIGO stage IV EOC. Primary endpoint was overall survival (OS). The secondary endpoints were progression-free survival (PFS) and recurrence rates. We included 307 patients: 98 (32%) had FIGO stage IVA and 209 (68%) had FIGO stage IVB. The median OS and PFS of stage IVA patients were significantly lower than those of stage IVB patients (31 versus 45 months (p = 0.02) and 18 versus 25 months (p = 0.01), respectively). Recurrence rate was higher in stage IVA than IVB patients (65% versus 47% (p = 0.004)). Initial pleural involvement was a poor prognostic factor with a median OS of 35 months versus 49 months for patients without initial pleural involvement (p = 0.024). Patients with FIGO stage IVA had a worse prognosis than patients with FIGO stage IVB EOC. Pleural involvement appears to be relevant for predicting survival. We suggest a modification of the current FIGO staging classification.

Endometrial cancer of the very elderly: Management and survival in the Francogyn population

INTRODUCTION

We aimed to describe management and survival of patients with endometrial cancer (EC) ≥80 years to identify poor prognosis criteria.

METHODS

We collected clinical, histologic, surgical and follow-up data for patients with EC ≥ 80 years included in a multicenter French cohort (FRANCOGYN) who underwent primary surgical treatment from 1999 to 2019. The outcomes were overall survival (OS) and disease-free survival (DFS). We performed a descriptive analysis then a survival time analysis and comparison using the Kaplan Meier method and log-rank test.

RESULTS

Of the 1647 patients with EC who received treatment during the study period, 184 (11.17%) were ≥80 years. The mean age was 84 years (±3.34). Thirty-three patients (25.4%) died during the follow-up period and 26 relapsed (18.4%). Forty-nine patients were lost to follow-up (27.37%). The median follow-up time was 15.3 months (4.9-28.8). The median OS and DFS was 16.4 months (6.3-24.9) and 13.6 months (4.5-26.6), respectively. Eighty-three patients received adjuvant therapy (45.11%), out of 95 who had a formal or relative indication. Four patients received adjuvant chemotherapy (2.6%), out of 61 who had a formal or relative indication. Inappropriate or underuse of chemotherapy was significantly associated with a lower median OS of 12.6 months [3.73-24] versus 17.3 months [7.93-41.77] when performed appropriately (HR = 4.14, CI 95% [1.62-10.56]), and a lower median DFS of 10.83 months [3.73-24] versus 17.3 months [7.93-28.5] (HR = 9.04, CI 95% [2.04-40.12]).

CONCLUSION

Our results suggest that very elderly patients with EC should receive adjuvant chemotherapy according to the standard care guidelines.

Endometriosis-associated infertility diagnosis based on saliva microRNA signatures

RESEARCH QUESTION

Can a saliva-based miRNA signature for endometriosis-associated infertility be designed and validated by analysing the human miRNome?

DESIGN

The prospective ENDOmiARN study (NCT04728152) included 200 saliva samples obtained between January 2021 and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy, magnetic resonance imaging, or both. Patients diagnosed with endometriosis were allocated to one of two groups according to their fertility status. Data analysis consisted of identifying a set of miRNA biomarkers using next-generation sequencing, and development of a saliva-based miRNA signature of infertility among patients with endometriosis based on a random forest model.

RESULTS

Among the 153 patients diagnosed with endometriosis, 24% (n = 36) were infertile and 76% (n = 117) were fertile. Small RNA-sequencing of the 153 saliva samples yielded approximately 3712 M raw sequencing reads (from ∼13.7 M to ∼39.3 M reads/sample). Of the 2561 known miRNAs, the feature selection method generated a signature of 34 miRNAs linked to endometriosis-associated infertility. After validation, the most accurate signature model had a sensitivity, specificity and area under the curve of 100%.

CONCLUSION

A saliva-based miRNA signature for endometriosis-associated infertility is reported. Although the results still require external validation before using the signature in routine practice, this non-invasive tool is likely to have a major effect on care provided to women with endometriosis.

Accuracy of combined physical examination, transvaginal ultrasonography, and magnetic resonance imaging to diagnose deep endometriosis

OBJECTIVES

To assess the ability of physical examination (PE), transvaginal ultrasonography (TVUS), and magnetic resonance imaging (MRI) alone and combined to diagnose deep infiltrating endometriosis (DIE).

DESIGN

We retrospectively queried our pelvic MRI database to identify women who underwent PE, TVUS, and pelvic MRI for DIE up to 12 months before surgery between January 1, 2016 and August 31, 2020. The presence of uterosacral ligaments (USL), vaginal, rectosigmoid (RS), parametrial, or sacrorectogenital septum (lateral) DIE shown by PE, TVUS, and MRI were correlated with surgical and histological findings.

SETTING

Academic hospital.

PATIENT(S)

We included 178 patients.

INTERVENTION(S)

Clinical and imaging evaluation of women who were diagnosed at surgery with deep pelvic endometriosis.

MAIN OUTCOME MEASURE(S)

The sensitivity, specificity, positive and negative predictive values, and accuracy of each technique separately and combined were assessed for each location. When the 3 techniques were combined, 2 models were tested as follows: all 3 techniques positive and concordant; and ≥2 techniques positive and concordant.

RESULT(S)

The prevalence of USL, vaginal, RS, and lateral DIE were 94.4%, 20.2%, 34.3%, and 32.6%, respectively. In addition, MRI was more sensitive than PE, TVUS or any combination to detect DIE. Moreover, MRI and model B were the most accurate for detecting USL and RS locations with an accuracy of 90.4% and 82.6%, a sensitivity of 91.1% and 50%, and a specificity of 77.8% and 90.9%, respectively. Model B was the most accurate for the vaginal location with an accuracy, sensitivity, and specificity of 82.6%, 50%, and 90.9%, respectively. Finally, MRI was more accurate than any combination for identifying a lateral location with an accuracy, sensitivity, and specificity of 75.1%, 36%, and 93.8%, respectively.

CONCLUSION(S)

A combination of PE, TVUS, and MRI was more accurate than each technique separately to diagnose DIE because of the equally high sensitivity of each, as well as the high specificity of PE and TVUS.

Akt-Activated Endothelium Increases Cancer Cell Proliferation and Resistance to Treatment in Ovarian Cancer Cell Organoids

Ovarian cancer (OC) is a heterogeneous disease characterized by its late diagnosis (FIGO stages III and IV) and the importance of abdominal metastases often observed at diagnosis. Detached ovarian cancer cells (OCCs) float in ascites and form multicellular spheroids. Here, we developed endothelial cell (EC)-based 3D spheroids to better represent in vivo conditions. When co-cultured in 3D conditions, ECs and OCCs formed organized tumor angiospheres with a core of ECs surrounded by proliferating OCCs. We established that Akt and Notch3/Jagged1 pathways played a role in angiosphere formation and peritoneum invasion. In patients' ascites we found angiosphere-like structures and demonstrated in patients' specimens that tumoral EC displayed Akt activation, which supports the importance of Akt activation in ECs in OC. Additionally, we demonstrated the importance of FGF2, Pentraxin 3 (PTX3), PD-ECGF and TIMP-1 in angiosphere organization. Finally, we confirmed the role of Notch3/Jagged1 in OCC-EC crosstalk relating to OCC proliferation and during peritoneal invasion. Our results support the use of multicellular spheroids to better model tumoral and stromal interaction. Such models could help decipher the complex pathways playing critical roles in metastasis spread and predict tumor response to chemotherapy or anti-angiogenic treatment.

Overview of non-coding RNAs in breast cancers

Breast cancer in women is the second most common cancer and the fifth leading cause of cancer death worldwide. Although earlier diagnosis and detection of breast cancer has resulted in lower mortality rates, further advances in prevention, detection, and treatment are needed to improve outcomes and survival for women with breast cancer as well as to offer a personalized therapeutic approach. It is now well-established that non-coding RNAs (ncRNAs) represent 98% of the transcriptome but in-depth knowledge about their involvement in the regulation of gene expression is lacking. A growing body of research indicates that ncRNAs are essential for tumorigenesis by regulating the expression of tumour-related genes. In this review, we focus on their implication in breast cancer genesis but also report the latest knowledge of their theragnostic and therapeutic role. We highlight the need for accurate quantification of circulating ncRNAs which is determinant to develop reliable biomarkers. Further studies are mandatory to finally enter the era of personalized medicine for women with breast cancer.

A Bioinformatics Approach to MicroRNA-Sequencing Analysis Based on Human Saliva Samples of Patients with Endometriosis

Endometriosis, defined by the presence of endometrium-like tissue outside the uterus, affects 2–10% of the female population, i.e., around 190 million women, worldwide. The aim of the prospective ENDO-miRNA study was to develop a bioinformatics approach for microRNA-sequencing analysis of 200 saliva samples for miRNAome expression and to test its diagnostic accuracy for endometriosis. Among the 200 patients, 76.5% (n = 153) had confirmed endometriosis and 23.5% (n = 47) had no endometriosis (controls). Small RNA-seq of 200 saliva samples yielded ~4642 M raw sequencing reads (from ~13.7 M to ~39.3 M reads/sample). The number of expressed miRNAs ranged from 1250 (outlier) to 2561 per sample. Some 2561 miRNAs were found to be differentially expressed in the saliva samples of patients with endometriosis compared with the control patients. Among these, 1.17% (n = 30) were up- or downregulated. Among these, the F1-score, sensitivity, specificity, and AUC ranged from 11–86.8%, 5.8–97.4%, 10.6–100%, and 39.3–69.2%, respectively. Here, we report a bioinformatic approach to saliva miRNA sequencing and analysis. We underline the advantages of using saliva over blood in terms of ease of collection, reproducibility, stability, safety, non-invasiveness. This report describes the whole saliva transcriptome to make miRNA quantification a validated, standardized, and reliable technique for routine use. The methodology could be applied to build a saliva signature of endometriosis.

[Imagerie dans les cancers de l'ovaire]

IMAGING OF OVARIAN CANCERS Imaging of ovarian lesions is based on the triptych: pelvic ultrasound with Doppler, magnetic resonance imaging (MRI) and computed tomography (CT). Endovaginal pelvic ultrasound is the first-line examination; tools are available to help with its interpretation (IOTA group rules, O-RADS US classification). When an ovarian mass is detected on ultrasound and if its characterization is «undetermined» or complex, MRI with perfusion sequences is used to clarify the criteria. Finally, a thoraco- abdominopelvic CT scan is necessary for extension assessment in the case of ovarian cancer, in particular to look for peritoneal carcinosis and to anticipate surgical difficulties.

[Préservation de la fertilité avant traitement d'un cancer de l'ovaire]

FERTILITY PRESERVATION BEFORE OVARIAN MALIGNANCY TREATMENT While most ovarian epithelial malignancies affect postmenopausal women, 12% occur in reproductive age patients. In addition, borderline ovarian tumors and rare non epithelial ovarian tumors are diagnosed in young patients as well. The prognosis of early-stage epithelial tumors, non-epithelial and frontier tumors is good. Increased knowledge in this specific field now allows the development of fertility preservation strategies. They include conservative surgery when applicable, associated with oocyte and / or ovarian tissue cryopreservation. Indications remain limited, and any decision must be validated by a multidisciplinary expert committee. The different strategies depend on specific tumoral or genetic context.

Stimulation Duration in Patients with Early Oocyte Maturation Triggering Criteria Does Not Impact IVF-ICSI Outcomes

Results from studies reporting the optimal stimulation duration of IVF-ICSI cycles are inconsistent. The aim of this study was to determine whether, in the presence of early ovulation-triggering criteria, prolonged ovarian stimulation modified the chances of a live birth. This cross-sectional study included 312 women presenting triggering criteria beginning from D8 of ovarian stimulation. Among the 312 women included in the study, 135 were triggered for ovulation before D9 (D ≤ nine group) and 177 after D9 (D > nine group). The issues of fresh +/− frozen embryo transfers were taken into consideration. Cumulative clinical pregnancy and live-birth rates after fresh +/− frozen embryo transfers were similar in both groups (37% versus 46.9%, p = 0.10 and 19.3% versus 28.2%, p = 0.09, respectively). No patient characteristics were found to be predictive of a live birth depending on the day of ovulation trigger. Postponing of ovulation trigger did not impact pregnancy or live-birth rates in early responders. A patient’s clinical characteristics should not influence the decision process of ovulation trigger day in early responders. Further prospective studies should be conducted to support these findings.

MicroRNome analysis generates a blood-based signature for endometriosis

Endometriosis, characterized by endometrial-like tissue outside the uterus, is thought to affect 2–10% of women of reproductive age: representing about 190 million women worldwide. Numerous studies have evaluated the diagnostic value of blood biomarkers but with disappointing results. Thus, the gold standard for diagnosing endometriosis remains laparoscopy. We performed a prospective trial, the ENDO-miRNA study, using both Artificial Intelligence (AI) and Machine Learning (ML), to analyze the current human miRNome to differentiate between patients with and without endometriosis, and to develop a blood-based microRNA (miRNA) diagnostic signature for endometriosis. Here, we present the first blood-based diagnostic signature obtained from a combination of two robust and disruptive technologies merging the intrinsic quality of miRNAs to condense the endometriosis phenotype (and its heterogeneity) with the modeling power of AI. The most accurate signature provides a sensitivity, specificity, and Area Under the Curve (AUC) of 96.8%, 100%, and 98.4%, respectively, and is sufficiently robust and reproducible to replace the gold standard of diagnostic surgery. Such a diagnostic approach for this debilitating disorder could impact recommendations from national and international learned societies.

Feasibility, Safety and Impact of (18F)-FDG PET/CT in patients with pregnancy-associated cancer: experience of the French CALG (Cancer Associé à La Grossesse) network

BACKGROUND

The incidence of pregnancy-associated cancers has been increasing for decades. (18F)-FDG Positron Emission Tomography (PET)/Computed Tomography (CT) imaging has become a golden standard in the staging of many malignant diseases. The aims of the current study were to evaluate the feasibility, safety and impact of (18F)-FDG PET/CT performed during pregnancy.

MATERIAL AND METHODS

A retrospective analysis from the prospective database of the Cancer Associé à La Grossesse (CALG) network (Tenon Hospital, France) including patients who underwent (18F)-FDG PET/CT during their pregnancy between 2015 and 2020.

RESULTS

Of the 536 patients for whom advice from the CALG network was requested during the study period, 359 were diagnosed with cancer during pregnancy. Study population was composed of 63 (17.5%) patients who underwent (18F)-FDG PET/CT. Most cancers were diagnosed during the second trimester. Seventy-five percent were diagnosed with breast cancer, mostly locally advanced invasive ductal carcinomas. Median term of pregnancy at PET/CT was 24.8 weeks of gestation. Twelve (19%), 24 (38.1%) and 22 (34.9%) patients underwent the exam during the 1st, 2nd and 3rd trimester, respectively. (18F)-FDG PET/CT resulted in stage modification for 38 (60.3%) of the patients (28 with more extensive lymph node involvement and 10 with metastatic disease) with subsequently/accordingly modified first-line medical treatment. Fifty patients gave birth to healthy newborns. Two patients had a medical termination of pregnancy, five had a medical abortion, one neonatal death occurred in a patient with severe preeclampsia (unrelated to (18F)-FDG PET/CT). The data of 46 children were available at 6 months, 29 at 12 months, and 15 at 24 months. No cases of mental retardation, childhood cancer, or malformation were reported within 2 years.

CONCLUSION

(18F)-FDG PET/CT has a major impact on the management of pregnancy-associated cancers and does not appear to cause fetal side effects suggesting that the exam is feasible during pregnancy as maternal benefits outweigh fetal risks.

Surgical Determinants of Post Operative Pain in Patients Undergoing Laparoscopic Adnexectomy

Objective: The objective of our study was to determine the main surgical factors associated with postoperative pains in patients undergoing adnexectomy.Material and Methods: Patients that underwent adnexectomy in two French Gynecological centers between July, 2018 and March, 2020 were prospectively included and retrospectively analyzed. The main pre and per operative surgical factors were analyzed to assess their impact on immediate postoperative pain. Analgesic consumption was recorded for each patient and pain was evaluated using the validated numeric rating scale (ranging between 0 and 10).Results: One hundred and seventeen patients underwent laparoscopic adnexectomy. Eighty-four patients (72%) experienced either no or minor postoperative pain (NRS ≤ 2). Seventeen patients (14.5%) required strong opioids (subcutaneous morphine injection) in the immediate postoperative period. The only two parameters that had a significant impact on immediate postoperative pain were the realization of a fascia closure and the duration of pneumoperitoneum longer than 60 minutes. Pneumoperitoneum pressure and size of ports were not significantly correlated with postoperative pain.Conclusion: Fascia closure and increased surgical time were significantly associated with immediate postoperative pain and the need for strong opioids consumption. Surgical training to limit prolonged surgeries should be strongly emphasized to lower postoperative pain and limit opioids consumption.

Impact of vulvar reconstruction on the accuracy of a nomogram for predicting local recurrence after surgery for vulvar cancer

BACKGROUND DATA

Vulvar carcinoma is a rare disease accounting for 3%-5% of all gynaecological cancers. Although surgery is the standard treatment at an early stage, the outcomes are highly correlated with clear resection margins. Therefore, surgical defects can be important and require reconstruction. The aim of this study was to evaluate vulvar reconstructions using a previously validated nomogram predicting the risk of local recurrence at 2 years.

METHODS

Patients who underwent surgery for vulvar cancer between 1998 and 2017 were extracted from eight FRANCOGYN centres. We estimated the probability of local recurrence at 2 years using a previously validated nomogram and compared it with actual relapse in patients with or without vulvar reconstruction. Patients were clustered into tiertiles according to their nomogram score: low-, intermediate-, and high-risk for local relapse probability.

RESULTS

We reviewed 254 patients, of whom 49 underwent immediate vulvar reconstruction. The predicted and actual probability of two-year local relapse were 20.1% and 15.7%, respectively, with a concordance index of 0.75. In the low- and intermediate-risk groups, the difference between predicted and observed recurrence was less than 10% in patients with or without vulvar reconstruction. For the high-risk group, the difference reached 25% and observed recurrence probability was lower in patients who underwent vulvar plasty compared with those who did not (20.0% vs. 36.2%, respectively). Local recurrence-free survival rates following vulvar reconstruction were comparable at two years (82.1% vs. 84.8%, respectively, p = 0.26).

CONCLUSION

Vulvar reconstruction after surgical resection for vulvar cancer is safe. Vulvar reconstruction should be considered in aggressive cases to decrease local recurrence.

Prognosis of triple-negative breast cancer associated with pregnancy: A propensity score-matched analysis from the French CALG (Cancer Associé à la Grossesse) network

Introduction

Triple-negative (TN) breast cancer represents one third of pregnancy-associated breast cancers (PABC). The aims of the current study were to describe oncological and obstetrical outcomes of patients with TN-PABC and to compare their prognosis with TN-non-PABC patients using a propensity score.

Materials and methods

Between January 2005 and December 2020, data of patients with histologically proven TN-PABC were collected and compared with data of TN-non-PABC patients under the age of 46 years diagnosed during the same period using a propensity score (PS).

Results

After PS matching (tumor size and lymph node involvement),there were 59 patients in each group. The median follow-up was 14 months (IQR 4.8–40.1) for the TN-PABC group and 60 months (IQR 30.7–101.4) for the TN-non-PABC group. Eight recurrences occurred in the TN-PABC group and 10 in the TN-non-PABC group (adjusted OR (AOR) = 0.60 (0.21–1.60), HR (Cox adjusted model- AHR) = 1.25 (0.53–2.94)). Two patients died in the TN-PABC group, and six in the TN-non-PABC group with an AOR = 0.23 (0.03–1.01) and an AHR = 0.58 (0.12–2.69). All the patients diagnosed during the second (n = 17) and third trimesters (n = 28) continued their pregnancies, with a median term at delivery of 38 WG (IQR 36–39). All patients gave birth to healthy newborns.

Conclusion

Although the TN subtype is associated with poor prognosis in pregnant patients due to advanced stage at diagnosis and high lymph node involvement, our PS-matched case-control study showed that pregnancy per se does not worsen the prognosis in terms of recurrence-free and overall survival.

•

Triple-negative breast cancer are associated with poor prognosis.

•

Breast cancers occurring during pregnancy differ from those occurring in the post-partum period.

•

Pregnancy per se does not worsen the prognosis in triple-negative breast cancer.

Salivary MicroRNA Signature for Diagnosis of Endometriosis

BACKGROUND

Endometriosis diagnosis constitutes a considerable economic burden for the healthcare system with diagnostic tools often inconclusive with insufficient accuracy. We sought to analyze the human miRNAome to define a saliva-based diagnostic miRNA signature for endometriosis.

METHODS

We performed a prospective ENDO-miRNA study involving 200 saliva samples obtained from 200 women with chronic pelvic pain suggestive of endometriosis collected between January and June 2021. The study consisted of two parts: (i) identification of a biomarker based on genome-wide miRNA expression profiling by small RNA sequencing using next-generation sequencing (NGS) and (ii) development of a saliva-based miRNA diagnostic signature according to expression and accuracy profiling using a Random Forest algorithm.

RESULTS

Among the 200 patients, 76.5% (n = 153) were diagnosed with endometriosis and 23.5% (n = 47) without (controls). Small RNA-seq of 200 saliva samples yielded ~4642 M raw sequencing reads (from ~13.7 M to ~39.3 M reads/sample). Quantification of the filtered reads and identification of known miRNAs yielded ~190 M sequences that were mapped to 2561 known miRNAs. Of the 2561 known miRNAs, the feature selection with Random Forest algorithm generated after internally cross validation a saliva signature of endometriosis composed of 109 miRNAs. The respective sensitivity, specificity, and AUC for the diagnostic miRNA signature were 96.7%, 100%, and 98.3%.

CONCLUSIONS

The ENDO-miRNA study is the first prospective study to report a saliva-based diagnostic miRNA signature for endometriosis. This could contribute to improving early diagnosis by means of a non-invasive tool easily available in any healthcare system.

Clues for Improving the Pathophysiology Knowledge for Endometriosis Using Serum Micro-RNA Expression

The pathophysiology of endometriosis remains poorly understood. The aim of the present study was to investigate functions and pathways associated with the various miRNAs differentially expressed in patients with endometriosis. Plasma samples of the 200 patients from the prospective "ENDO-miRNA" study were analyzed and all known human miRNAs were sequenced. For each miRNA, sensitivity, specificity, and ROC AUC values were calculated for the diagnosis of endometriosis. miRNAs with an AUC ≥ 0.6 were selected for further analysis. A comprehensive review of recent articles from the PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases was performed to identify functions and pathways associated with the selected miRNAs. In total, 2633 miRNAs were found in the patients with endometriosis. Among the 57 miRNAs with an AUC ≥ 0.6: 20 had never been reported before; one (miR-124-3p) had previously been observed in endometriosis; and the remaining 36 had been reported in benign and malignant disorders. miR-124-3p is involved in ectopic endometrial cell proliferation and invasion and plays a role in the following pathways: mTOR, STAT3, PI3K/Akt, NF-κB, ERK, PLGF-ROS, FGF2-FGFR, MAPK, GSK3B/β-catenin. Most of the remaining 36 miRNAs are involved in carcinogenesis through cell proliferation, apoptosis, and invasion. The three main pathways involved are Wnt/β-catenin, PI3K/Akt, and NF-KB. Our results provide evidence of the relation between the miRNA profiles of patients with endometriosis and various signaling pathways implicated in its pathophysiology.

Machine learning algorithms as new screening approach for patients with endometriosis

Endometriosis—a systemic and chronic condition occurring in women of childbearing age—is a highly enigmatic disease with unresolved questions. While multiple biomarkers, genomic analysis, questionnaires, and imaging techniques have been advocated as screening and triage tests for endometriosis to replace diagnostic laparoscopy, none have been implemented routinely in clinical practice. We investigated the use of machine learning algorithms (MLA) in the diagnosis and screening of endometriosis based on 16 key clinical and patient-based symptom features. The sensitivity, specificity, F1-score and AUCs of the MLA to diagnose endometriosis in the training and validation sets varied from 0.82 to 1, 0–0.8, 0–0.88, 0.5–0.89, and from 0.91 to 0.95, 0.66–0.92, 0.77–0.92, respectively. Our data suggest that MLA could be a promising screening test for general practitioners, gynecologists, and other front-line health care providers. Introducing MLA in this setting represents a paradigm change in clinical practice as it could replace diagnostic laparoscopy. Furthermore, this patient-based screening tool empowers patients with endometriosis to self-identify potential symptoms and initiate dialogue with physicians about diagnosis and treatment, and hence contribute to shared decision making.