Sentinel lymph node mapping versus sentinel lymph node mapping with systematic lymphadenectomy in endometrial cancer: an open-label, non-inferiority, randomized trial (ALICE trial)

BACKGROUND

Growing evidence suggest that sentinel lymph node (SLN) biopsy in endometrial cancer accurately detects lymph node metastasis. However, prospective randomized trials addressing the oncological outcomes of SLN biopsy in endometrial cancer without lymphadenectomy are lacking.

PRIMARY OBJECTIVES

The present study aims to confirm that SLN biopsy without systematic node dissection does not negatively impact oncological outcomes.

STUDY HYPOTHESIS

We hypothesized that there is no survival benefit in adding systematic lymphadenectomy to sentinel node mapping for endometrial cancer staging. Additionally, we aim to evaluate morbidity and impact in quality of life (QoL) after forgoing systematic lymphadenectomy.

TRIAL DESIGN

This is a collaborative, multicenter, open-label, non-inferiority, randomized trial. After total hysterectomy, bilateral salpingo-oophorectomy and SLN biopsy, patients will be randomized (1:1) into: (a) no further lymph node dissection or (b) systematic pelvic and para-aortic lymphadenectomy.

MAJOR INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria are patients with high-grade histologies (endometrioid G3, serous, clear cell, and carcinosarcoma), endometrioid G1 or G2 with imaging concerning for myometrial invasion of ≥50% or cervical invasion, clinically suitable to undergo systematic lymphadenectomy.

PRIMARY ENDPOINTS

The primary objective is to compare 3-year disease-free survival and the secondary objectives are 5-year overall survival, morbidity, incidence of lower limb lymphedema, and QoL after SLN mapping ± systematic lymphadenectomy in high-intermediate and high-risk endometrial cancer.

SAMPLE SIZE

178 participants will be randomized in this study with an estimated date for completing accrual of December 2024 and presenting results in 2027.

TRIAL REGISTRATION NUMBER

NCT03366051.

PROPER-PRehabilitatiOn Plus Enhanced Recovery after surgery versus enhanced recovery after surgery in gynecologic oncology: a randomized clinical trial

BACKGROUND

Prehabilitation is a process that occurs before surgery and aims to improve patient functional capacity and enhance surgical recovery. This process includes medical, nutritional, physical, and psychological interventions that may reduce the duration of hospital stay and provide postoperative physical benefits.

PRIMARY OBJECTIVE

To evaluate the impact of a prehabilitation program on postoperative recovery time for patients who will undergo gynecological surgery following the Enhanced Recovery After Surgery (ERAS) guidelines.

STUDY HYPOTHESIS

A multidisciplinary, preoperative prehabilitation program for patients who will undergo gynecological surgery leads to a reduction in the length of hospital stay and improves patient functional capacity.

TRIAL DESIGN

Prospective, interventionist, and randomized controlled trial in a 1:1 ratio, open to multidisciplinary team and patients, blinded to surgeons and anesthesiologists. The control group will undergo ERAS standard preoperative care while the intervention group will have ERAS standard preoperative care plus prehabilitation.

MAJOR INCLUSION CRITERIA

Patients scheduled to undergo gynecologic surgery performed by laparotomy with a preoperative schedule that allows prehabilitation intervention for 2 to 3 weeks.

PRIMARY ENDPOINT

To compare time between surgery and the day the patient is ready for discharge in patients who underwent the prehabilitation process versus those who did not. Readiness for discharge is defined as the ability to take care of one's-self, to walk alone, and to ingest at least 75% of daily recommended calorie intake.

SAMPLE SIZE

194 participants ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: At present, 30 patients have been recruited. Accrual should be completed by 2023-24.

TRIAL REGISTRATION

The study is approved by the IBCC - São Camilo Oncologia ethics committee (reference number 4.256.553) and is registered at clinicaltrials.gov (NCT04596800).

Hyperbaric oxygen therapy as adjuvant for treating wound complications after extensive resection for vulvar malignancy

INTRODUCTION

Necrosis, wound breakdown, and infection represent major complications associated with radical vulvectomy. We aimed to analyze the feasibility of hyperbaric oxygen (HBO₂) therapy as an adjunctive treatment for such complications.

METHODS

We performed a retrospective analysis of the medical records, clinical charts, and operative records of vulvar cancer patients who underwent hyperbaric oxygen therapy after extensive surgical resection in our institute between 2012 and 2016, with a comparison of the clinical outcomes of patients with similar surgical procedures andsevere wound complications who did not undergo HBO₂.

RESULTS

A total of 16 patients were included in the study. In the subgroup treated with HBO₂, seven patients were identified. Two patients had primary surgery, while five had recurrent surgery (of these, two had previously undergone radiation therapy). Six patients received reconstructive flaps (five myocutaneous and onefasciocutaneous), while one patient had primary suture. Dehiscence, ischemia and necrosis were estimated to cover 30%-80% of the surgical surface area. Surgical debridement was performed in six patients. Daily 90-minute sessions in the hyperbaric chamber were performed at a pressure of 2.2 atmospheres absolute, with partial oxygen pressure of 1672 mbar. Infection control and satisfactory healing were achieved using 10-61 sessions. All patients in the subgroup who did not receive HBO₂ required surgical debridement due to partial or near-total flap necrosis, with two reconstructive interventions required.

CONCLUSIONS

Hyperbaric oxygen therapy was an efficient adjuvant for wound healing and infection control in managing wound complications after extensive vulvar resections.

High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up

Human papillomavirus (HPV) causes cervical, vulvar, and vaginal cancers, precancerous dysplasia, and genital warts. We report data for the longest efficacy evaluation to date of a prophylactic HPV vaccine. In total, 552 women (16–23 years) were enrolled in a randomised, placebo-controlled study of a quadrivalent HPV 6/11/16/18 L1 virus-like-particle vaccine with vaccination at months 0, 2, and 6. At regular intervals through 3 years, subjects underwent gynaecologic examination, cervicovaginal sampling for HPV DNA, serum anti-HPV testing, and Pap testing, with follow-up biopsy as indicated. A subset of 241 subjects underwent two further years of follow-up. At 5 years post enrolment, the combined incidence of HPV 6/11/16/18-related persistent infection or disease was reduced in vaccine-recipients by 96% (two cases vaccine versus 46 placebo). There were no cases of HPV 6/11/16/18-related precancerous cervical dysplasia or genital warts in vaccine recipients, and six cases in placebo recipients (efficacy=100%; 95% CI:12–100%). Through 5 years, vaccine-induced anti-HPV geometric mean titres remained at or above those following natural infection. In conclusion, a prophylactic quadrivalent HPV vaccine was effective through 5 years for prevention of persistent infection and disease caused by HPV 6/11/16/18. This duration supports vaccination of adolescents and young adults, which is expected to greatly reduce the burden of cervical and genital cancers, precancerous dysplasia, and genital warts.