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Background Lymphatic mapping and sentinel lymph node (SLN) biopsy have been proposed as a safer and less morbid approach than full lymphadenectomy for patients with early endometrial cancer (EC), through either cervical or corporeal dye injection. 1 – 4 The advantage of mini-laparoscopy is a further reduction in the overall surgical trauma for the patient. This video aims to show the feasibility of SLN biopsy using a 3-mm mini-laparoscopic approach. Methods A 56-year-old woman with grade 2 endometrioid EC underwent mini-laparoscopic pelvic SLN detection plus extrafascial total hysterectomy and bilateral salpingo-oophorectomy (TLH-BSO). A two-sided superficial and deep cervical injection of indocyanine green (2 mL diluted to 1.25 mg/mL) was used for inoculation before the procedure. A 5.8-mm 0° optical camera with a near-infrared high-intensity light source for detection of fluorescence imaging was inserted through the umbilicus. Two ancillary 3-mm trocars were inserted suprapubically. The procedure was accomplished using only 3-mm instruments. Results Neither intraoperative complications nor conversion to conventional laparoscopy or open surgery occurred. The operative time was 60 min, and the estimated blood loss was 50 mL. SLN was detected bilaterally, and removal of the two identified nodes was achieved through meticulous dissection and preservation of the surrounding structures followed by TLH-BSO. No postoperative complications were registered, and the patient was discharged 24 h after surgery. An SLN ultrastaging exam was negative, and the final pathology showed a International Federation of Gynaecology and Obstetrics (FIGO) stage 1A G2 EC with a 2/21-mm myometrial invasion. Conclusion Mini-laparoscopic SLN detection plus TLH-BSO is a feasible procedure that guarantees minimal surgical trauma to selected patients with early EC.

ObjectivesTo evaluate the impact of preoperative diagnosis of malignancy on survival in patients surgically treated for apparent early-stage uterine leiomyosarcoma (ULMS).MethodsData of consecutive patients who underwent total hysterectomy at Del Ponte Hospital, (Varese-Italy) between January 2000 and December 2019 were retrieved. Only cases with histologically proven ULMS at final diagnosis were included and stratified according with the preoperative finding of malignancy into: ‘Suspicious ULMS’ vs. ‘unexpected ULMS’. Demographic, pathologic and surgical-related characteristics were compared. Survivals curves were estimated with Kaplan-Meier methods and predictors of recurrence were investigated.ResultsOverall 36 patients ULMS were included, 24 and 12 ‘unexpected ULMS’ and ‘suspicious ULMS’, respectively. No significant differences between the groups in terms of baseline characteristics and surgical approach (minimally-invasive approach: 3, 25% vs. 15, 62.5%, p=0.08) were found. The morcellation of the uterus was less likely performed in patients in ‘suspicious ULMS’ (18, 33% vs.14, 58.33%; p=0.005). The survival analysis did not show statistical differences between the groups. No differences in survival (DFS (log-rank=0.28) and OS (log-rank=0.78).Details on recurrence are reported (table 1). No predictors of relapse were found, including uterine morcellation (41.67% vs. 66.67%, p=0.15).Abstract EPV141/#627 Table 1ConclusionsPatients undergoing hysterectomy for ULMS have poor prognosis regardless the surgical approach. In our population, preoperative suspicious of malignancy did not influence survival outcomes and morcellation did not seem to have a detrimental effect on recurrence rate.Larger studies are warranted to confirm our findings.

ObjectivesTo evaluate the rate of lymphatic-related morbidity among patients undergoing surgical staging for apparent early-stage ovarian cancer (EOC) and to report the specific patients’ lymphatic complications.MethodsData of consecutive patients who underwent surgical staging for EOC between 01/2002 and 12/2018 were analyzed. A self-reported validated 13-item lymphedema screening questionnaire was sent to evaluate specific lymphatic complications. Patients were stratified by the performance retroperitoneal staging into two groups: fully pelvic and aortic lymphadenectomy performed (LND) vs. no retroperitoneal staging (NO-LND). Patients who had conservative treatment were included in the study. The analysis focused only on women who answered the specific questionnaire. Patients lost at follow-up and those who reported peripheral vascular disease at the time of surgery were excluded.ResultsDuring the study period 140 patients were treated; according to the inclusion/exclusion criteria 107 represented our study population. Baseline characteristics such as age, BMI, Charlson Comorbidity Index (CCI) and surgical approach did not significantly differ between the groups. Patients in LND group (compared to NO-LND) had a higher rate of specific lymphatic complications (26.6% vs. 0%, p <0.01). The performance of lymphadenectomy significantly impacted the subjective lymphatic-related morbidity (score >5).Abstract EPV219/#581 Table 1ConclusionsOur study confirms a high correlation between the performance of LND and specific lymphatic morbidity in patients undergoing surgical staging for EOC. The dedicated 13-item screening questionnaire might be a useful tool to categorize patients’ perception of lymphatic-related complications, including lower extremity lymphedema.

ObjectivesTo evaluate oncological outcomes and predictors of recurrence in patients undergoing laparoscopic treatment for apparent early stage cervical cancer (CC).MethodsA single-centre retrospective study was conducted among patients who had radical surgery for FIGO stage (2009) IA (positive LVSI) – IB1 at Women’s and Children Hospital of Varese (Italy) between January 2006 and December 2018. Radical hysterectomy (Querleu and Morrow B-C1 Classification) with or without lymph node dissection according with tumour characteristics. Surgical and oncological outcomes were analysed.ResultsAmong 90 patients who met the inclusion criteria, 12 (13.3%) had recurrent disease (6 vault, 6 pelvis, 3 abdominal, 2 distant, 1 other), and 6 (6.7%) died of disease over the follow-up period (median follow-up 38.2 months). Surgical-related outcomes did not influence survival. Stage of disease has been found to be the main predictor of recurrence (p=0.03), while no association between positive lymph node and relapse was detected. Patients who had preoperative biopsy had a significant higher rate of recurrence in comparison to those undergoing conization (83.33% vs 16.67%, p=0.01). After stratification by tumour size, patients with stage IB1 CC undergoing preoperative conization had 0.37 relative risk of recurrence compared to those undergoing cervical biopsy (16.67% vs 38.89%, p=0.14).Abstract 156 Figure 1ConclusionsPreoperative conization might play a crucial role for patients undergoing laparoscopic treatment for early stage CC. Further studies are warranted to confirm our finding.

Introduction/Background*Sentinel node mapping (SNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate the long-term survival of three different approaches of nodal assessment in low, intermediate, and high-risk EC.MethodologyThis is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years of follow-up) of EC patients having nodal assessment between 2006 and 2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm.Result(s)*Charts of 940 patients were evaluated: 174 (18.5%), 187 (19.9%), and 579 (61.6%) having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Applying a propensity score matching algorithm (1:1:2) we selected 500 patients: 125 SNM vs. 125 SNM plus backup lymphadenectomy vs. 250 lymphadenectomy. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease (7 and 12 patients with micrometastasis and isolated tumor cells). The mean (SD) follow-up time was 62 (±11) months. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p=0.750) and overall survival (p=0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification on the basis of uterine risk factors.Conclusion*Our study highlighted that SNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultrastaging and the role of molecular/genomic profiling.

Introduction/BackgroundSeveral studies have demonstrated the feasibility and role of cardiophrenic lymph nodes (CPLNs) resection during primary debulking surgery (PDS) for stage IV ovarian cancer (OC). However, no studies, to date, investigated the role of CPLNs removal during interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT).MethodologyA retrospective analysis of consecutive stage IV OC patients who underwent NACT followed by IDS with CPLNs resection from July 2017 to June 2018. CPLNs sized >7 mm on the short axis at pre-operative CT-scan were considered for excision if optimal complete resection could be achieved.ResultsA total of 21 ovarian cancer stage IV patients treated with NACT followed by IDS were identified. Seven (33.3%) patients underwent CPLNs resection. A partial response to NACT by RECIST criteria was observed in 5 of 7 patients (71%) while 2 cases had stable disease (29%). Complete cytoreduction without residual disease was achieved in 5 cases (71%) while in two cases (29%) optimal cytoreduction was performed. All patients underwent full-thickness right diaphragmatic resection and pleurectomy. All excised CPLNs were found in the right side of the lower anterior mediastinum. Intra-operative surgical complications occurred in one patient. One patient (14%) had a major postoperative complication (Clavien-Dindo 3). Two cases of postoperative cardiac arrhythmia were observed. The final histological examination of the CPLNs revealed metastatic disease in 4 (57%) of 7 patients.ConclusionCPLNs removal after NACT for stage IV OC is safe and necessary to achieve a complete resection in the context of IDS after NACT.DisclosureNothing to disclose.Abstract EP956 Table 1Demographic characteristics, response to treatment and tumour details of patients who underwent CPLN

Introduction/BackgroundFollowing the results of LACC trial, laparoscopic treatment for early stage cervical cancer has become matter of debate. In the present investigation we aimed to evaluate predictors of recurrence after laparoscopic surgery for early stage cervical cancer (CC).MethodologyA multi-centre retrospective study was conducted among patients who underwent laparoscopic radical surgery for FIGO 2009 stage IA (positive LVSI) - IB1 at three referral gynecologic oncology centers, between January 2006 and June 2018. All patients had radical hysterectomy (B-C1) with or without lymph node dissection according with tumour characteristics. Surgical and oncological outcomes were analysed.ResultsAmong 186 patients who met the inclusion criteria, 16 (8,6%) experienced recurrence (6 vault, 9 pelvis, 5 abdominal, 3 distant, 7 multiple), and 9 (4.8%) died of disease over the follow-up period (median follow-up 38.0 months). Surgical-related complications did not influence survival outcomes. All the recurrences occurred in stage Ib1 disease, which has been found to be the main predictor of recurrence (p=0.02), while no association between positive lymph node and relapse was detected. Patients who had preoperative conization (93, 50%) had a significant lower rate of recurrence compared to those who had biopsy (93, 50%) (1/93, 1,1% vs. 15/93: 16,1% p=0.0003). After stratification by FIGO stage, patients with Ib1 tumor undergoing conization had significant favourable DFS compared to those who had only biopsy (p=0.012).ConclusionPreoperative conization might play a crucial role in patients undergoing laparoscopic treatment for early stage CC. Further studies are warranted to strength our finding.DisclosureNothing to disclose.Abstract P16 Figure 1Analysis of consecutive patients laparoscopically treated for Stage Ia1 (LVSI+) - Ib1 CCAbstract P16 Figure 2Survival outcomes and pattern of recurrence of the study population

Introduction/BackgroundElderly ovarian cancer (OC) patients are more likely to be managed suboptimally and experience worse clinical outcomes as a result. Strategies to improve outcomes in this patients are lacking.MethodologyRetrospective analysis for consecutive patients with advanced stage OC (IIIC–IV) who were managed in Oxford University Hospital between January 2016 and July 2018 were analysed. All patients underwent neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) according to our institution protocol. We divided the patients into two groups: an ‘older group’ (age ≥70 years) (Group 1) and a ‘younger group’ (age <70 years) (Group 2). The primary outcome of the study was the assessment of peri-operative morbidity amongst the two groups.ResultsA total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), of which 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS when compared to younger patients (39% vs. 19%, p=0.03). Elderly patients were more frequently subjected to Cardiopulmonary Exercise Testing (CPET) as part of their pre-operative assessment (63% vs. 27%, p=0.002). For those who underwent IDS; optimal/complete resection was achieved in all patients in Group 1 (100%) and in 97% of patients in Group 2. With the exception of higher postoperative cardiac arrhythmias in Group 1 (11% vs. 1%, p=0.04), no significant differences in 30-day morbidity were observed. No 90-day death in both groups was registered.ConclusionOlder age should not preclude clinicians from offering ultra-radical resection, for patients with advanced OC who underwent careful preoperative assessment. In our series, elderly patients received the same treatment with similar outcomes to the younger group. CPET has an important role and clinicians should be encouraged to use it more frequently especially when ultraradical surgery is postponed.DisclosureNothing to disclose.

ObjectivesSentinel node mapping (SNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate the long-term survival of three different approaches of nodal assessment in low, intermediate, and high-risk EC.MethodsThis is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years of follow-up) of EC patients having nodal assessment between 2006 and 2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm.ResultsCharts of 940 patients were evaluated: 174 (18.5%), 187 (19.9%), and 579 (61.6%) having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Applying a propensity score matching algorithm (1:1:2) we selected 500 patients: 125 SNM vs. 125 SNM plus backup lymphadenectomy vs. 250 lymphadenectomy. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease (7 and 12 patients with micrometastasis and isolated tumor cells). The mean (SD) follow-up time was 62 (±11) months. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p=0.750) and overall survival (p=0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification on the basis of uterine risk factors.ConclusionsSNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultrastaging and the role of molecular/genomic profiling

Introduction/Background*In the last decade, sentinel lymph node mapping (SLNM) has gained a central role in endometrial cancer (EC) surgical staging. However, different technical steps of SLNM still remain object of discussione. Terofere, a randomized control trial (RCT) was conducted to compare cervical and hysteroscopic indocyanine green (ICG) injection for SLNM of newly diagnosed EC undergoing surgical staging. The prima-ry endpoint of the study was to compare these two techniques in term of para-aortic detection rate.MethodologyThis RCT included women with apparent stage I or II histologically confirmed endometrial cancer undergoing surgery were included in the study. Two groups were distinguished according to two different techniques of indocyanine green (ICG) sentinel lymph node mapping (SLNM): cervical versus hysteroscopic injection. This randomized trial was not blinded for both the patients and the surgeons.Result(s)*Since March 2017 until April 2019, 165 patients were randomized: 85 (51.5%) in the cervical group and 80 (48.5%) in the hysteroscopic group. After randomization, 14 (8.5%) patients were excluded from the study. Finally, 151 patients were included in the analysis: 82 (54.3%) in the cervical group and 69 (45.7%) in the hysteroscopic group. Hysteroscopy injection demonstrated a 10% higher accuracy to detect SNLs in the paraaortic area compared to cervical injection, although this difference did not reach statistical significance. The hysteroscopic technique was better in detecting isolated SLN para-aortic (5.8% vs 0%). Cervical injection was correlated with higher SLN detection rates at pelvic level compared to hysteroscopic injection. Pelvic and overall detection was superior in the cervical group.Conclusion*The current study suggests the use of cervical injection rather than hysteroscopic injection due to its better identification of sentinel nodes (particularly in the pelvic area). Although, detection of SLN in the para-aortic area was slightly superior in patients undergoing a hysteroscopic injection, no significant difference with cervical injection was detected.