[Delays and pathways for patients with endometriosis in France: A multicenter study]

INTRODUCTION

The diagnosis of endometriosis is often difficult to make, generating a median diagnostic delay ranging from 2 to 10.7years. A study of the care pathway of these patients seems essential in order to evaluate the diagnostic delay of endometriosis in France and the factors related to the diagnostic delay.

METHODS

This is a prospective multicenter study, conducted between 2017 and 2019. A questionnaire concerning their care pathway and their feelings about the diagnosis was distributed to all patients consulting for endometriosis. Statistical analyses were performed using the Kruskal-Wallis, Chi² and Student's t tests.

RESULTS

Fifity-seven of the 84 patients (67.8%) who completed the questionnaire were included in the evaluation of diagnostic delays. The total diagnostic delay was 12years (min 0; max 33) and was comparable between all inclusion cities (P=0.68). Regarding the care pathway according to specialties, the diagnosis of endometriosis was made by gynecologists in 81% of patients versus 19% by general practitioners. The time between the onset of symptoms and the first consultation was significantly shorter in favor of the general practitioner (2years versus 4years, P=0.012). 60% of the patients reported that their symptoms were labelled as "normal" by the physicians and 35% of them considered them normal themselves.

CONCLUSION

Our study showed that the delay in diagnosis in France was still very long and that the mechanisms of the delay in management were multifactorial. Awareness raising and training of health care providers remains one of the major areas to be optimized.

O-276 Reproductive outcomes and fertility-sparing in women with Borderline ovarian tumors

The standard treatment of BOT is defined as a total abdominal hysterectomy and bilateral salpingo-oophorectomy, peritoneal cytology, omentectomy and multiple peritoneal biopsies. These procedures allowed to perform an adequate staging, most of the time no adjuvant treatment is necessary except in case of associated invasive peritoneal implants. The prognosis of BOT is excellent. However, late recurrences (after 5 or 10 years) can be observed. Conservative surgery is defined as preservation of the uterus and at least part of one ovary, in order to preserve fertility. BOT arise in a young population, for whom fertility is a major issue. The global recurrence risk is estimated at 13%. The rate of recurrence is correlated with the type of conservative treatment used (salpingo-oophorectomy or cystectomy) with a higher rate of between 10 and 42% in patients undergoing cystectomy. In the case of bilateral serous BOT, if technically feasible, bilateral cystectomy should be performed to improve pregnancy rates. For serous BOT e cystectomy can be performed (tumour can be bilateral for 20% of these patients) with a close follow up by ultrasound. For mucinous BOT, salpingo-oophorectomy is recommended to avoid rare but at risk invasive recurrence, (these lesions are usually unilateral). A complete evaluation must be performed preoperatively including MRI with evaluation of possible safe functional ovarian tissue and oncofertility consultation to discuss if fertility preservation technique can be proposed before surgery.

The observed pregnancy rates observed after conservative surgery are between 32 and 88%. Different factors can influence fertility rates: type of conservative treatment, age of the patient (with almost a quarter of the live birth occurring after recurrence with no more further event to date, a second fertility-sparing surgery after local borderline recurrence can be proposed in the case of pregnancy project), histologic subtype of the tumour (better with mucinous versus serous), the use of a laparoscopic approach and the use of a 2- or 3-step surgery (initial, restaging, second look).

In spite of conservative management in BOT, some patients will experience infertility. In vitro fertilization (IVF) procedures have not been significantly associated with a specific increase in BOT or ovarian cancer rates.  In vitro data suggest that gonadotropins and/or high dose of estrogens don’t induce a borderline cell cultures proliferation. Analyzing all series reporting IVF and BOT, the pooled estimate for pregnancy was 80% (95% CI: 68–92%). The pooled estimate for recurrence was 23% (95% CI: 6–39%). The rate of recurrence in these women is ‘low’ though this is probably due to the fact that women who are selected as eligible for ART have a better prognosis and more often early-stage BOT. However, there is a real need for fertility preservation expert centers associating oncologists and fertility experts who can evaluate conservative management of BOT along with alternative therapeutic options to preserve fertility as well as ART.

[Feasibility and security of laparoscopic (± robotic) total hysterectomy in outpatient surgery: A French multicenter retrospective study]

OBJECTIVE

To assess the feasibility and safety of total hysterectomy by laparoscopic approach (± robot assisted) in ambulatory.

MATERIALS AND METHODS

French three-center retrospective study including 165 patients who had laparoscopic (± robot assisted) total hysterectomy scheduled as outpatients from January 2016 to December 2020. Clinical and perioperative data were collected. Factors associated with outpatient failure and rehospitalization were evaluated.

RESULTS

The outpatient success rate was 92.7%. Factors associated with outpatient failure were incision time>13:00, large volume of blood loss, intraoperative complications with Oslo score≥2, uterine weight≥250g, indication for benign pathology, and robot-assisted approach. Among patients managed as outpatients, 7.2% were rehospitalized at a mean of 10 days from surgery. The factors associated with rehospitalization were the use of an effective antiaggregant or anticoagulant treatment and the use of intraoperative adhesiolysis. Four patients (2.6%) underwent revision surgery.

CONCLUSION

Minimally invasive hysterectomy can be performed as an outpatient procedure even in cases of malignant pathology. Age and body mass index are not associated with an increased risk of failure or re-hospitalization within one month.

[Management of HPV-induced cervical lesions in immunosuppressed patients - Review of the literature]

INTRODUCTION

Current French recommendations for the management of cervical lesions related to human papilloma virus (HPV) infection are limited to general population. Patients who are immunocompromised appear to be at increased risk of induced HPV lesions. The objective of this review is to summarize the various existing data about risk of induced HPV lesions in immunocompromised patients to specify the management.

METHODS

The Medline database was searched through the Pubmed portal, as well as the recommendations of various international learned societies.

RESULTS

Situations with an increased risk are regardless of treatment: Human Immunodeficiency Virus (HIV) infection, transplants, lupus. Patients with chronic inflammatory bowel disease (IBD) and rheumatoid arthritis are at increased risk only when immunosuppressive therapy is required. Screening for dysplasic intraepithelial lesions in HIV+ patients should be more sustained than in the general population. Due to lack of data, recommendations for other conditions have been extrapolated from the management of HIV+ patients. HPV vaccination is effective in these populations, particularly at times when the immune system is the most effective.

DISCUSSION

Identified immunocompromised populations are at higher risk of induced HPV lesions due to an incomplete immune response and should be screened on a sustained basis. In addition, HPV vaccination should be encouraged.

[What's new in the management of endometrial cancer? Update on the new European recommendations for 2021]

The new European guidelines for the management of patients with endometrial cancer were published in early 2021. These recommendations are joint to the three European Learned Societies of Gynecologic Oncology (ESGO), Radiation Therapy and Oncology (ESTRO) and Anatomical Pathology (ESP). On behalf of the French Society of Gynecologic Oncology (SFOG), we wish to bring to the knowledge of the French-speaking readership the main measures for the management of patients which represent an advance compared to the 2016 recommendations. The new European recommendations for the management of patients with endometrial cancer emphasize the generalization of micro-satellite instability (MSI) or immunohistochemical analysis of MMR system proteins for all patients. Also, the classification into 4 prognostic risk groups integrates data from molecular analysis (p53, MSI, POLE) to guide initial surgical management as well as adjuvant treatment modalities. The indocyanine green sentinel node procedure has also become the reference technique for FIGO I and II lymph node staging regardless of histological type. It should be remembered that management should be provided in a specialized institution by a team specialized in the management of gynecological cancers, particularly for high-risk and/or advanced cancer patients.

Borderline ovarian tumors: Guidelines from the French national college of obstetricians and gynecologists (CNGOF)

It is recommended to classify Borderline Ovarian Tumors (BOTs) according to the WHO classification. Transvaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended to perform a pelvic MRI (Grade A) with a score for malignancy (ADNEX MR/O-RADS) (Grade C) included in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being BOT (Grade C). It is recommended to evaluate serum levels of HE4 and CA125 and to use the ROMA score for the diagnosis of indeterminate ovarian mass on imaging (grade A). If there is a suspicion of a mucinous BOT on imaging, serum levels of CA 19-9 may be proposed (Grade C). For Early Stages (ES) of BOT, if surgery without risk of tumor rupture is possible, laparoscopy with protected extraction is recommended over laparotomy (Grade C). For treatment of a bilateral serous ES BOT with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended where possible (Grade B). For mucinous BOTs with a treatment strategy of fertility and/or endocrine function preservation, unilateral salpingo-oophorectomy is recommended (grade C). For mucinous BOTs treated by initial cystectomy, unilateral salpingo-oophorectomy is recommended (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). For ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only in case of a macroscopically pathological appendix (Grade C). Restaging surgery is recommended in cases of serous BOTs with micropapillary architecture and an incomplete abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended for mucinous BOTs after initial cystectomy or in cases where the appendix was not examined (Grade C). If restaging surgery is decided for ES BOTs, the following procedures should be performed: peritoneal washing (grade C), omentectomy (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix and appendectomy in case of a pathological macroscopic appearance (grade C) as well as unilateral salpingo-oophorectomy in case of a mucinous BOT initially treated by cystectomy (grade C). In advanced stages (AS) of BOT, it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). For AS BOT in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed (Grade C). Restaging surgery aimed at removing all lesions, not performed initially, is recommended for AS BOTs (Grade C). After treatment, follow-up for a duration greater than 5 years is recommended due to the median recurrence time of BOTs (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). If the determination of tumor markers is normal preoperatively, the routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of an initial elevation in serum CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In case of conservative treatment, it is recommended to use transvaginal and transabdominal ultrasound during follow up of a treated BOT (Grade B). In the event of a BOT recurrence in a woman of childbearing age, a second conservative treatment may be proposed (Grade C). A consultation with a physician specialized in Assisted Reproductive Technique (ART) should be offered in the case of BOTs in women of childbearing age (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). In the case of optimally treated BOT, there is no evidence to contraindicate the use of ART. The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After management of mucinous BOT, for women under 45 years, given the benefit of Hormonal Replacement Therapy (HRT) on cardiovascular and bone risks, and the lack of hormone sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). Over 45 years of age, HRT can be prescribed in case of a climacteric syndrome after individual benefit to risk assessment (Grade C).

Management of borderline ovarian tumours during pregnancy: Results of a French multi-centre study

OBJECTIVE

To assess the diagnostic and prognostic characteristics of borderline ovarian tumours (BOTs) detected during pregnancy, and to establish an inventory of French practices.

MATERIALS AND METHODS

A retrospective multi-centre case study of 14 patients treated for BOTs, diagnosed during pregnancy between 2005 and 2017, in five French pelvic cancerology expert centres, including data on clinical characteristics, histological tumour characteristics, surgical procedure, adjuvant treatments, follow-up and fertility.

RESULTS

The mean age of patients was 29.3 [standard deviation (SD) 6.2] years. Most BOTs were diagnosed on ultrasonography in the first trimester (85.7 %), and most of these cases (78.5 %) also underwent magnetic resonance imaging to confirm the diagnosis (true positives 54.5 %). Most patients underwent surgery during pregnancy (57 %), with complete staging surgery in two cases (14.3 %). Laparoscopy was performed more frequently than other procedures (50 %), and unilateral adnexectomy was more common than cystectomy (57.5 %). Tumour size influenced the surgical approach significantly (mean size 7.5 cm for laparoscopy, 11.9 cm for laparoconversion, 14 cm for primary laparotomy; P = 0.08), but the type of resection did not. Most patients were initially diagnosed with International Federation of Gynecology and Obstetrics stage IA (92.8 %) tumours, but many were upstaged after complete restaging surgery (57.1 %). Most BOTs were serous (50 %), two cases had a micropapillary component (28.5 %), and one case had a micro-invasive implant. BOTs were bilateral in two cases (14.2 %). Mean follow-up was 31.4 (SD 14.8) months. Recurrent lesions occurred in two patients (14.2 %) and no deaths have been recorded to date among the study population.

CONCLUSION

BOTs remain rare, but this study - despite its small sample size - supports the hypothesis that BOTs during pregnancy have potentially aggressive characteristics.

Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms

PURPOSE

The objective of this study was to evaluate the efficacy of fractional CO₂ laser to manage vulvar and vaginal symptoms of Genitourinary Syndrome of Menopause (GSM) in postmenopausal women.

METHODS

All postmenopausal women with symptoms of GSM undergoing fractional CO₂ laser treatment in our centers were asked to fill out a validated quality of life questionnaire (Global Quality of Life Questionnaire), Visual Analog Scale (VAS) for symptoms, a questionnaire on overall discomfort related to pelvic floor symptoms, and the Female Sexual Function Index (FSFI) at several points: before each session (three sessions at monthly intervals) and one 3 months after treatment completion. Statistical analysis compared pre-therapy data and data at 3 months of treatment.

RESULTS

Forty-six women were included with a mean age of 57.3 years (± 11.1 years). A significant improvement was demonstrated in vaginal dryness (p = 6.34 10^-6) and for symptoms of stress urinary incontinence (p = 0.043). Among sexually active patients, there was a significant improvement in the degree of symptom discomfort affecting their satisfaction (p = 0.007), dyspareunia (p = 0.001) and sensitivity during sexual intercourse (p = 0.001). Significantly, more women were able to achieve (p = 0.026) and maintain (p = 0.018) lubrication during intercourse.

CONCLUSION

CO₂ laser treatment seems to improve the quality of life and sexual health of patients as well as GSM symptoms at 3 months of treatment; long-term reevaluation is necessary to demonstrate that improvement persists over time.

Prognostic Value and Risk Factors of Peritoneal Carcinomatosis Recurrence for Patients with Endometrial Cancer: A Multicenter Study from the FRANCOGYN Group

BACKGROUND

The prognosis for patients with endometrial cancer (EC) peritoneal carcinomatosis (PC) recurrence has received little study. This study aimed to determine specific risk factors and prognosis of EC with PC recurrence (PCR) versus no PC recurrence (NPCR).

METHODS

Data of all patients with EC who received primary surgical treatment between January 2000 and February 2017 were abstracted from the French FRANCOGYN Research Group database. Clinical and pathologic variables were compared between the two groups (PCR vs. NPCR). Multivariate analysis was performed to define prognostic factors for peritoneal recurrence. Overall survivals (OS) of patients after recurrence were compared using the Kaplan-Meier method.

RESULTS

The study analyzed 1466 patients, and 257 of these patients (17.5%) had recurrence. At presentation, 63 of these patients had PC. International Federation of Gynecology and Obstetrics (FIGO) stages 3 and 4 disease were significantly associated with PCR versus NPCR (odds ratio 2.24; 95% confidence interval 1.23-4.07; p = 0.008). The death rate for the patients with PC was 47.6%, with a median survival of 12 months after diagnosis of recurrence. According to the histologic subtype, OS was 29 months (Q1-Q3, 13-NA) for endometrioid carcinomas, 7.5 months (Q1-Q3, 4-15) for serous carcinomas, and 10 months (Q1-Q3, 5-15) for clear cell carcinomas. Chemotherapy for treatment of PCR was associated with improved OS after recurrence (OSAR; p = 0.0025).

CONCLUSION

An initial advanced stage of EC is a risk factor for PCR. For women with PCR, a diagnosis of type 1 EC recurrence more than 12 months after the initial treatment and management of PCR with chemotherapy is associated with improved OSAR. Prospective studies are needed to determine the precise optimal management required in this clinical situation and to assess the relevance of biomarkers to predict the risk of PCR for EC patients.

Prognostic factors of overall survival for patients with FIGO stage IIIc or IVa ovarian cancer treated with neo-adjuvant chemotherapy followed by interval debulking surgery: A multicenter cohort analysis from the FRANCOGYN study group

INTRODUCTION

The aim of this study was to identify prognostic factors of overall survival in patients with FIGO stage IIIc or IVa ovarian cancer (OC) treated by neo-adjuvant chemotherapy (NAC) followed by interval debulking surgery.

MATERIALS AND METHODS

Data from 483 patients with ovarian cancer were retrospectively collected, from January 1, 2000 to December 31, 2016, from the FRANCOGYN database, regrouping data from 11 centers specialized in ovarian cancer treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analysis were performed to define prognostic factors of overall survival.

RESULTS

The median overall survival was 52 after a median follow up of 30 months. After univariate analysis, factors significantly associated with decreased overall survival were; no pelvic and/or para-aortic lymphadenectomy (p = 0.002), residual disease (CC1/CC2/CC3) after surgery (p < 0.001), positive cytology after NAC (p < 0.001), omental disease after NAC (p = 0.002), no pathologic complete response (pCR) (p = 0.002). In multivariate analysis, factors significantly associated with decreased overall survival were; residual disease after surgery (HR = 1.93; CI95% (1.16-3.21), p = 0.01) and positive cytology after NAC (HR = 1.59; CI95% (1.01-2.55), p = 0.05). Patients with no residual disease after surgery had a median overall survival of 64 months versus 35 months for patients with residual disease. Patients with negative cytology after NAC had a median overall survival of 71 months versus 43 months for patients with positive cytology after NAC.

CONCLUSION

In this first and largest French based retrospective study, complete cytoreductive surgery in ovarian cancer remains the main prognostic factor of overall survival.

[Guidelines for surgical management of gynaecological cancer during pandemic COVID-19 period - FRANCOGYN group for the CNGOF]

INTRODUCTION

Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period.

MATERIAL AND METHOD

Recommendations based on the consensus conference model.

RESULTS

In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies.

CONCLUSION

During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Therapeutic Management of Early Stages]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning early stage borderline ovarian tumors (BOT).

METHODS

Bibliographical search in French and English languages by consultation of Pubmed, Cochrane, Embase, and international databases.

RESULTS

Considering management of early stage BOT, if surgery is possible without a risk of tumor rupture, the laparoscopic approach is recommended compared to laparotomy (Grade C). In BOT, it is recommended to take all the measures to avoid tumor rupture, including the peroperative decision of laparoconversion (Grade C). In BOT, extraction of the surgical specimen using an endoscopic bag is recommended (Grade C). In case of early stage, uni or bilateral BOT, suspected in preoperative imaging in a postmenopausal patient, bilateral adnexectomy is recommended (Grade B). In cases of bilateral BOT and desire of fertility preservation, a bilateral cystectomy is recommended (Grade B). In case of mucinous BOT and desire of fertility preservation, it is recommended to perform a unilateral adnexectomy (Grade C). In case of endometrioid BOT and desire of fertility preservation, it is not possible to establish a recommendation of treatment choice between cystectomy and unilateral adnexectomy. In case of mucinous BOT at definitive histological analysis in a woman of childbearing age who had an initial cystectomy, surgical revision for unilateral adnexectomy is recommended (Grade C). In the case of serous BOT with definitive histological analysis in a woman of childbearing age who has had an initial cystectomy, it is not recommended to repeat surgery for adnexectomy in the absence of residual suspicious lesion during initial surgery and/or on postoperative imaging (referent ultrasound or pelvic MRI) (Grade C). An omentectomy is recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous analysis or suspected on preoperative radiological elements (Grade B). There is no data in the literature to recommend the type of omentectomy to be performed. If restaging surgery is decided for a presumed early stage BOT, an omentectomy is recommended (Grade B). Multiple peritoneal biopsies are recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous or suspected on preoperative radiological elements (Grade C). In case of restaging surgery for a presumed early stage BOT, exploration of the abdominal cavity should be complete and peritoneal biopsies should be performed on suspicious areas or systematically (Grade C). A primary peritoneal cytology is recommended in order to achieve complete initial surgical staging when BOT is suspected on preoperative radiological elements (Grade C). In case of restaging surgery for presumed early stage BOT, a first peritoneal cytology is recommended (Grade C). For early serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (Grade C). For early stage endometrioid BOT, and in the absence of a desire to maintain fertility, hysterectomy is recommended for initial surgery or if restaging surgery is indicated (Grade C). For endometrioid-type early stage BOT, if there is a desire for fertility preservation, the uterus may be retained subject to good evaluation of the endometrium by imaging and endometrial sampling (Grade C). In case of surgery (initial or restaging if indicated) for early stage BOT, it is recommended to evaluate the macroscopic appearance of the appendix (Grade B). In case of surgery (initial or restaging if indicated) for early stage BOT, appendectomy is recommended only in case of macroscopically pathological appearance of the appendix (Grade C). Pelvic and lumbar aortic lymphadenectomy is not recommended for initial surgery or restaging surgery for early stage BOT regardless of histologic type (Grade C). In case of BOT diagnosed on definitive histology, the indication of restaging surgery should be discussed in Multidisciplinary Collaborative Meeting. For presumed early stage BOT, it is recommended to use the laparoscopic approach to perform restaging surgery (Grade C). Restaging surgery is recommended for serous BOT with micropapillary appearance and unsatisfactory abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended in case of mucinous BOT if only a cystectomy has been performed or the appendix has not been visualized, then a unilateral adnexectomy will be performed (Grade C). If a restaging surgery is decided in the management of a presumed early stage BOT, the actions to be carried out are as follows: a peritoneal cytology (Grade C), an omentectomy (there is no data in the literature recommending the type of omentectomy to be performed) (Grade B), a complete exploration of the abdominal cavity with peritoneal biopsies on suspect areas or systematically (Grade C), visualization of the appendix± the appendectomy in case of pathological macroscopic appearance (Grade C), unilateral adnexectomy in case of mucinous TFO (Grade C).

[For which patients could we consider de-escalation in the management of ductal carcinomas in situ?]

Ductal carcinomas in situ (DCIS) of the breast account for 85% to 90% of breast cancer in situ. Current recommendations for the management of DCIS in France are based on surgical excision of the lesions, lumpectomy in healthy margins (margins of excision≥2mm) or mastectomy in case of extensive lesions. Radiation therapy is recommended after conservative surgical treatment. However, it seems relevant for some patients to discuss the benefit of a therapeutic de-escalation. Indeed, it has been reported that radiotherapy has no major impact on overall survival and that its interest could be discussed in the low-risk situations of invasive recurrence for which surgery alone could be sufficient, subject to sufficient margins. These questions call for the precise definition of low risk populations and to clarify the importance of taking into account decision support tools and new molecular markers. The place of scores like that of the University of Southern California - Van Nuys, and that of genomic tests such as the Oncotype test© DX DCIS (DCIS score) need to be specified. The expected results of several prospective studies could go in the direction of a significant therapeutic de-escalation for the management of DCIS in the years to come. In the meantime, however, it is advisable to remain cautious and the inclusion of patients in clinical trials should be favored.

[HPV testing in the screening and follow-up of patients with cervical high-grade squamous intraepithelial lesions]

OBJECTIVES

To evaluate the value of high-risk HPV (HR HPV) testing in screening and post-treatment follow-up of high-grade squamous intraepithelial cervical lesions (HSIL).

METHODS

A systematic review of the literature from 2000 to 2019 was conducted including the following keywords: "human papilloma virus", "HPV testing", "cervical squamous intraepithelial lesion", "cervical cancer".

RESULT

Numerous recent randomized studies and meta-analyzes have concordant results in favor of HR HPV superiority over cervical smear in the screening and post-treatment monitoring of HSIL. In screening, the sensitivity of the HR HPV tests is 63% to 98% whereas that of the cervical smear is only 38% to 65% for the detection of HSIL+ (HSIL and invasive cancers). A negative HR HPV test is associated with less than 5% risk of LIEHG+at 6 years. In addition, after removal of a LIEHG, HR HPV tests have a sensitivity>90% and specificity>80% to predict treatment failure. After surgicale exision, a negative HR HPV test is associated with a risk of failure<2% (negative predictive value of 98%), and 12-25% if it is positive.

CONCLUSIONS

HR HPV tests are effective, allowing early detection of LIEHG+ identification of low-risk women in case of negative test, and a prediction of the risk of failure after treatment.

[Microscopic peritoneal metastases of epithelial ovarian cancers. Clinical relevance, diagnostic and therapeutic tools]

Understanding the biology and progression mechanisms of peritoneal metastases in ovarian epithelial cancers (EOC) is important because peritoneal carcinomatosis is present or will occur during surveillance of a majority of patients. Despite the clinical remission achieved after complete macroscopic cytoreductive surgery and platinum-based chemotherapy, 60% of patients will develop peritoneal recurrence. This suggests that microscopic lesions, which are not eradicated by surgery may be present and may participate in the mechanisms leading to peritoneal recurrence. This paper discusses current available data on microscopic peritoneal metastases, their diagnosis and their treatment. We reviewed all publications dealing with microscopic peritoneal metastases of EOC between 1980 and 2017. The most recent and most relevant publications dealing with the treatment modalities of these metastases were selected. Peritoneal and epiploic microscopic localizations would occur in 1.2 to 15.1% of cases at early-stage and are not treated during conventional surgery. They could represent a potential therapeutic target. Local treatments (intraperitoneal chemotherapy, photodynamic therapy, fluorescence-guided surgery) seem to be necessary in addition to surgery and chemotherapy and may help reduce the risk of peritoneal recurrence. The place of these treatments in the management of EOC remains to be defined by subsequent researches.

Patterns of care and the survival of elderly patients with high-risk endometrial cancer: A case-control study from the FRANCOGYN group

BACKGROUND

The standard of care of endometrial cancer involves complex procedures such as pelvic and para-aortic lymphadenectomy and omentectomy, particularly for high-risk endometrial cancer. Few data are available about these complex surgical procedures and adjuvant therapy in elderly women. We aim to examine treatment and survival of elderly women diagnosed with high-risk endometrial cancer.

STUDY DESIGN

We performed a case-control study of women diagnosed between 2001 and 2013 with high-risk endometrial cancers. Women older than 70 years (n = 198) were compared with patients <70 years (n = 198) after matching on high-risk for recurrence and LVSI status.

RESULTS

Elderly patients had lymphadenectomies less frequently compared with younger patients (76% vs 96%, p < 0.001) and no adjuvant treatment more frequently (17% vs 8%, p = 0.005) due to less chemotherapy being administered (23% vs 46%, p < 0.001). The 3-year DFS, CSS and OS of patients ≥70 years was 52% (43-61), 81% (74-88) and 61% (53-70), respectively. These were significantly lower than the 3-year DFS, CSS, and OS of younger patients, which was 75% (68-82) (p < 0.001), 92% (87-96) (p < 0.008) and 75% (69-82) (p = 0.018), respectively. Cox proportional hazard models found that elderly women had 57% increased risk of recurrence (hazard ratio 1.57, 95% CI 1.04-2.39) compared with younger patients.

CONCLUSION

Although we found an independently significant lower DFS in elderly patients with high-risk endometrial cancer when compared with young patients, elderly women are less likely to be treated with lymphadenectomy and chemotherapy. Specific guidelines for management of elderly patients with high-risk endometrial cancer are required to improve their prognosis.

First-trimester determination of fetal gender by ultrasound: measurement of the ano-genital distance

INTRODUCTION

Early ultrasound fetal sex determination is of obvious interest, particularly in the context of X-linked diseases. In the human, the anogenital distance, i.e., the distance between the caudal end and the base of the genital tubercule is sexually dimorphic. This difference is apparent from 11 weeks of gestation. The aim of this prospective study was to evaluate the accuracy of anogenital distance measurement during the first trimester ultrasound in the early determination of fetal gender.

MATERIALS AND METHODS

Fetal gender was assessed by ultrasound in 310 singleton pregnancies at 11-14 weeks of gestation. The optimal cut-off was determined by the minimal p-value technic and validated using bootstrap simulation.

RESULTS

310 women were included. A cut-off of 4.8mm was determined to predict male (≥4.8mm) or female (<4.8mm) fetuses. Sex was correctly determined for 87% of the males and 89% of the females. The inter-observer variability was excellent.

CONCLUSION

This study presents a new sonographic sign for early fetal sex determination that has not been previously explored. It appears to be an accurate tool but it requires further validation in larger series.

[Clinical practice guidelines: Benign breast tumor--Aims, methods and organization]

Conversely to breast cancer, few data and guidelines are available to explore and manage benign breast disorders. Therefore, the Collège national des gynécologues et obstétriciens français (CNGOF - French College of Gynaecologists and Obstetricians) decided to establish clinical practice guidelines for benign breast tumour (BBT). CNGOF appointed a committee with responsibility for selecting experts, compiling questions and summarizing the recommendations. The summary of valid scientific data for each question analyzed by the experts included a level of evidence, based on the quality of the data available and defined accordingly rating scheme developed by the Haute Autorité de santé (French National Authority for Health).

[Common benign breast tumors including fibroadenoma, phyllodes tumors, and papillary lesions: Guidelines]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning common benign breast tumors: fibroadenoma (FA), phyllodes breast tumors (PBT), and papillary lesions (BPL).

METHODS

Bibliographical search in French and English languages by consultation of PubMed, Cochrane and international databases.

RESULTS

In case of percutaneous biopsy diagnosis of FA, clinico-radiologic and pathologic discordance or complex FA or proliferative lesions or atypia with FA, a family history of cancer, it seems legitimate to discuss management in a multidisciplinary meeting. When surgery is proposed for FA, periareolar compared to direct incision is associated with more insensitive nipple but better aesthetic results (LE4). When surgery is proposed for FA, indirect incision is preferable for better cosmetic results (Grade C). Techniques of percutaneous destruction or resection can be used (Grade C). The WHO classification distinguishes three categories of phyllodes tumors (PBT): benign (grade 1), borderline (grade 2) and malignant (grade 3). For grade 1 PBT, the risk of local recurrence after surgical excision increases when PBT lesion is in contact with surgical limits (not in sano). After in sano resection, there is no correlation between margin size and the risk of recurrence (LE4). For grade 2 PBT, local recurrence after surgical excision increases for margins under 10mm margins (LE4). For grade 1-2 PBT, in sano excision is recommended. For grade 2 PBT, 10-mm margins are recommended (Grade C). No lymph node evaluation or neither systematic mastectomy is recommended (Grade C). Breast papillary lesion (BPL) without atypia, complete resection of radiologic signal is recommended (Grade C). For BPL with atypia, complete excisional surgery is recommended (Grade C).

Just how accurate are the major risk stratification systems for early-stage endometrial cancer?

BACKGROUND

To compare the accuracy of five major risk stratification systems (RSS) in classifying the risk of recurrence and nodal metastases in early-stage endometrial cancer (EC).

METHODS

Data of 553 patients with early-stage EC were abstracted from a prospective multicentre database between January 2001 and December 2012. The following RSS were identified in a PubMed literature search and included the Post Operative Radiation Therapy in Endometrial Carcinoma (PORTEC-1), the Gynecologic Oncology Group (GOG)-99, the Survival effect of para-aortic lymphadenectomy (SEPAL), the ESMO and the ESMO-modified classifications. The accuracy of each RSS was evaluated in terms of recurrence-free survival (RFS) and nodal metastases according to discrimination.

RESULTS

Overall, the ESMO -modified RSS provided the highest discrimination for both RFS and for nodal metastases with a concordance index (C-index) of 0.73 (95% CI, 0.70-0.76) and an area under the curve (AUC) of 0.80 (0.78-0.72), respectively. The other RSS performed as follows: the PORTEC1, GOG-99, SEPAL, ESMO classifications gave a C-index of 0.68 (0.66-0.70), 0.65 (0.63-0.67), 0.66 (0.63-0.69), 0.71 (0.68-0.74), respectively, for RFS and an AUC of 0.69 (0.66-0.72), 0.69 (0.67-0.71), 0.68 (0.66-0.70), 0.70 (0.68-0.72), respectively, for node metastases.

CONCLUSIONS

None of the five major RSS showed high accuracy in stratifying the risk of recurrence or nodal metastases in patients with early-stage EC, although the ESMO-modified classification emerged as having the highest power of discrimination for both parameters. Therefore, there is a need to revisit existing RSS using additional tools such as biological markers to better stratify risk for these patients.

Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review

AIM

Endometriosis affects from 10% to 15% of women of childbearing age and 20% of these women have deep infiltrating endometriosis (DIE). The goal of this review was to assess the impact of various locations of DIE on spontaneous fertility and the benefit of surgery and Medically Assisted Reproduction (MAR) (in vitro fertilization and intrauterine insemination) on fertility outcomes.

METHODS

MEDLINE search for articles on fertility in women with DIE published between 1990 and April 2013 using the following terms: "deep infiltrative endometriosis", "colorectal", "bowel", "rectovaginal", "uterosacral", "vaginal", "bladder" and "fertility" or "infertility". Twenty-nine articles reporting fertility outcomes in 2730 women with DIE were analysed.

RESULTS

Among the women with DIE and no bowel involvement (N.=1295), no preoperative data on spontaneous pregnancy rate (PR) were available. The postoperative spontaneous PR rate in these women was 50.5% (95% Confidence Interval [CI] =46.8-54.1) and overall PR (spontaneous pregnancies and after MAR) was 68.3% (95% CI=64.9-71.7). No evaluation of fertility outcome according to locations of DIE was feasible. For women with DIE with bowel involvement without surgical management (N.=115), PR after MAR was 29%; 95% CI=20.7-37.4). For those with bowel involvement who were surgically managed (N.=1320), postoperative spontaneous PR was 28.6% (95% CI=25-32.3) and overall postoperative PR was 46.9% (95% CI=42.9-50.9).

CONCLUSION

For women with DIE without bowel involvement, surgery alone offers a high spontaneous PR. For those with bowel involvement, the low spontaneous and relatively high overall PR suggests the potential benefit of combining surgery and MAR.

A clue towards improving the European Society of Medical Oncology risk group classification in apparent early stage endometrial cancer? Impact of lymphovascular space invasion

Background:

Lymphovascular space invasion (LVSI) is one of the most important predictors of nodal involvement and recurrence in early stage endometrial cancer (EC). Despite its demonstrated prognostic value, LVSI has not been incorporated into the European Society of Medical Oncology (ESMO) classification. The aim of this prospective multicentre database study is to investigate whether it may improve the accuracy of the ESMO classification in predicting the recurrence risk.

Methods:

Data of 496 patients with apparent early-stage EC who received primary surgical treatment between January 2001 and December 2012 were abstracted from prospective multicentre database. A modified ESMO classification including six risk groups was created after inclusion of the LVSI status in the ESMO classification. The primary end point was the recurrence accuracy comparison between the ESMO and the modified ESMO classifications with respect to the area under the receiver operating characteristic curve (AUC).

Results:

The recurrence rate in the whole population was 16.1%. The median follow-up and recurrence time were 31 (range: 1–152) and 27 (range: 1–134) months, respectively. Considering the ESMO modified classification, the recurrence rates were 8.2% (8 out of 98), 23.1% (15 out of 65), 25.9% (15 out of 58), and 45.1% (28 out of 62) for intermediate risk/LVSI−, intermediate risk/LVSI+, high risk/LVSI−, and high risk/LVSI+, respectively (P<0.001). In the low risk group, LVSI status was not discriminant as only 7.0% (14 out of 213) had LVSI+. The staging accuracy according to AUC criteria for ESMO and ESMO modified classifications were of 0.71 (95% CI: 0.68–0.74) and 0.74 (95% CI: 0.71–0.77), respectively.

Conclusions:

The current modified classification could be helpful to better define indications for nodal staging and adjuvant therapy, especially for patients with intermediate risk EC.

An external validation study of nomograms designed to predict isolated loco-regional and distant endometrial cancer recurrences: how applicable are they?

Background:

To externally validate and assess the robustness of two nomograms to predict the recurrence risk of women with endometrial cancer (EC).

Methods:

Using an independent, multicentre external patient cohort we assessed the discrimination and calibration of two nomograms – the 3-year isolated loco-regional (ILRR) and distant (DR) recurrence nomograms – in women with surgically treated stage I–III EC.

Results:

Two hundred and seventy one eligible women were identified from two university hospital databases and the Senti-Endo trial. The median follow-up and initial recurrence time were 38.1 (range: 12–69) and 22.0 (range: 8.3–55) months, respectively. The overall recurrence rate was 13.8% (37 out of 271). Predictive accuracy according to the discrimination was 0.69 (95% CI, 0.58–0.79) and 0.66 (95% CI, 0.60–0.71) for the 3-year ILRR and DR nomograms, respectively. The correspondence between observed recurrence rate and the nomogram predictions suggests a moderate calibration of the nomograms in the validation cohort.

Conclusion:

The nomograms were externally validated and shown to be partly generalisable to a new and independent patient population. The tools need to be improved by including information on the lymph node status and adjuvant therapies.

[Impact of sentinel node technique on the survival in patients with vulvar cancer: analysis of the Surveillance, Epidemiology, and End Results (SEER) database]

OBJECTIVES

Vulvar cancer is usually treated with vulvectomy and bilateral groin lymphadenectomy, which result in serious morbidities while only 30% of patients have positive nodes. The sentinel node technique has good sensitivity and specificity for detecting lymph node involvement while minimizing postoperative morbidity. The aim of this study was to evaluate the specific and overall survival impact of sentinel lymph node procedure versus inguinofemoral lymphadenectomy in patients with vulvar cancer.

PATIENTS AND METHODS

This is a retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database on patients with vulvar squamous cell carcinoma, T1 or T2 stage, metastatis-free, followed between 2004 and 2008.

RESULTS

One thousand and thirty eight patients had a systematic groin lymphadenectomy and 56 a sentinel node technique (including 22 with an associated lymphadenectomy because of a positive sentinel node). There is no significant difference in overall or specific survival between the two groups. In multivariate analysis, age, T stage and nodal status are prognostic factors for overall and specific mortality (P<0.05).

DISCUSSION AND CONCLUSION

Sentinel node technique is not associated with an excess risk of mortality or recurrence.