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ObjectivesThe aim of the present article was to discuss currently available evidence on the impact of frailty assessment on adverse postoperative outcomes and survival in patients undergoing surgery for gynecological cancer.MethodsSystematic search of Medline (PubMed) and Embase databases until September 30, 2020. Key inclusion criteria were: (1) randomized or observational studies; (2) patients undergoing non-emergent surgery for gynecological malignancies; (3) preoperative frailty assessment.ResultsThrough the process of evidence acquisition, twelve studies including 85,672 patients were selected and six tools were evaluable: 30-item frailty index, 40-item frailty index, modified frailty index (mFI), John Hopkins Adjusted Clinical Groups index, Fried frailty criteria, Driver’s tool. The prevalence of frailty varied roughly from 6.1% to 60% across different series included. The mFI was the most adopted and predictive instrument. Pooled results underlined that frail patients were more likely to develop 30-day postoperative complications (OR, 4.16; 95% CI, 1.49–11.65; p=0.007), non-home discharge (OR, 4.41; 95% CI, 4.09–4.76; p<0.001), ICU admission (OR:3.99; 95% CI, 3.76–4.24; p<0.001) than the non-frail counterpart. Additionally, frail patients experienced worse oncologic outcomes (disease-free and overall survivals) than non-frail patients.ConclusionsThe present systematic review demonstrated that preoperative frailty assessment among gynecologic oncology patients is essential to predict adverse outcomes and tailor a personalized treatment. The mFI appeared as the most used and feasible tool in daily practice, suggesting that tailored therapeutic strategies should be considered for patients with 3 or more frailty-defining items.

Introduction/BackgroundEndometrial cancer is the most common gynecological malignancy in developed countries.Transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) are widely accepted as imaging tools in preoperative local staging.In this prospective study, we evaluated the diagnostic accuracy of TVUS and MRI for detecting the depth of myometrial invasion and cervical involvement and for measuring tumor volume. We also correlated tumor volume to negative histological prognostic factors.MethodologyWe enrolled women with a histological diagnosis of endometrial carcinoma. The study was conducted from January 2018 to March 2019. All patients were evaluated by TVUS and pelvic MRI with gadolinium, in the absence of any contraindication. We compared the preoperative imaging results with final histopathology.ResultsThe mean age was 63,65±9.79 years. Fifty-four out of the 60 patients resulted suitable for primary surgery. Six patients underwent neoadjuvant chemotherapy for carcinomatosis. Twenty-eight women underwent both TVUS and MRI. The additional 26 patients underwent only TVUS because they were not able to perform MRI.Both TVUS and MRI showed an accuracy of 85.7% for diagnosing presence or absence of myometrial invasion and an accuracy of 100% and 89.3% respectively, for the assessment of deep myometrial infiltration. The accuracy for the cervical involvement was 92.9% and 96.4% for TVUS and MRI respectively. The coefficient of determination (R2) of tumor volume measurement was 0.99, 0.95 and 0.98 using 3-Dimensional (D) TVUS, 2-D TVUS and MRI respectively.A value of tumor volume ≥2 ml showed a positive correlation with negative histological prognostic factors, such as high tumor grade, lymphovascular space involvement (LVSI) and deep myometrial invasion (p<0.05).ConclusionThe accuracy of TVUS and MRI in evaluating deep myometrial invasion, cervical involvement and tumor volume measurement were comparable. A preoperative evaluation of the tumor volume would allow the identification of the patients with a poor prognosis.DisclosureNothing to disclose.

Introduction/BackgroundEndometrial cancer is generally associated with a good prognosis, due to an early diagnosis in stage I and II, 75% and 13% respectively. For advanced-stage disease, the recurrence rate is high and the site of the relapse is heterogeneous with localized or spread peritoneal disease. The treatment strategy is based on site of relapse. For non-localized relapse the chances are limited with a poor prognosis.MethodologyWe reported our experience of three cases with peritoneal spread recurrences, in endometrial cancer patients with advanced stage diagnosis.ResultsThe patients had been underwent to multiple lines of chemotherapy including rechallenging with platinum regimens, pegilated liposomal doxorubicin and taxane, with a progression of disease. These patients came at our Department for abdominal distension and breathing difficulty, CA 125 increased and radiology find (CT scan or US scan) of ascites. In these cases, after paracentesis and a single administration of intraperitoneal chemotherapy based on carboplatin (AUC5) were showed quality of life improvement, reduction of fatigue, improved breathing and reduction of anorexia. No complications occurred.ConclusionAlthough only few cases have been reported, the exceptional results and the absence of side effects observed in these cases, strongly warrant future trials to investigate the role that intraperitoneal chemotherapy can have both as palliative treatment of refractory ascites and as salvage therapy in advanced endometrial cancer.DisclosureAll authors declare that they have no conflict of interest and nothing to disclose.

ObjectivesTo evaluate a correlation between pre-surgical condition as predictor of overall, severe complications and 90 days mortality in patients undergoing cytoreductive surgery for advanced ovarian cancer.MethodsConsecutive patients affected by advanced ovarian cancer who have undergone cytoreduction surgery were considered for the study. Patients’ characteristics’ and surgical data were recorded. Modified Frailty Index (mFI) was evaluated. Higher mFI scores indicated more severe comorbidities. Postoperative complications were evaluated and graded according to Accordion score. Logistic regression was used to evaluate the associations between clinical and surgical variables and severe or overall complications.Results263 patients were included. 86 patients developed at least one complication: 70 (26.6%) of these reported mild complications, 13 (4.9%) developed severe complications, 3(1.1%) died within 90 days from surgery. At multivariate analysis logistic regression mFI>3 (OR: 1.67, CI 95% 1.08–2.81;p=0.05) the complexity of surgical procedures performed (OR: 4.15, CI 95% 2.38–7.23; p<0.001) were independent predictors of overall complications, while BMI>30 (OR: 5.13, CI 95%:1.15–22.92, p=0.03), mFI>3 (OR:2.45,CI95%:1.06–5.67;p=0.04),high complexity surgery executed (OR:12.31,CI95%:3.08–47.74;p<0.001) were independent predictors of severe complications.ConclusionsmFI and high complexity surgery are predictive of Severe and Overall Complications. Patients’ pre-operative care profile evaluation may guide specialists in reducing, preventing and managing complications correctly. mFI seems to be effective in identify high-risk patients and represent a valuable tool to help health professionals in providing risk counseling and discussion of management for women undergoing surgery for gynecologic cancer.

Introduction/BackgroundThis study aimed to define the role of combination of preoperative PET/CT scan and SLN biopsy for detection of nodal metastasis in Endometrial Cancer (EC) patients.MethodologyAll patients affected by EC prospectively collected from January 2014 to August 2016 underwent PET/CT scan and SLN mapping using indocyanine green (ICG) as tracer. Patients with suspicious lymph nodes at FDG-PET/CT underwent selective pelvic lymphadenectomy. In case of undetectable SNL, no further lymphadenectomy was performed if PET/CT scan was negative. Basic descriptive statistics were used to describe outcomes.ResultsA total of 83 patients were enrolled in the study. PET/CT scan was suggestive of nodal involvement in 15 patients. SLN were detected bilaterally in 78% of patients. Detection rate was influenced by patient’ BMI and learning curve. Five patients were node positive: of these all had hyper metabolic nodes at PET/CT scan, in 1 patient SLN was not detected. Ten out of 15 patients, with suspicious nodal at PET/CT scan, was node negative. After a median follow up of 24 months (range 14–45) all patients are alive. Four patients experienced recurrent disease. No nodal relapse was recorded.ConclusionLymphatic mapping with sentinel node biopsy is able to reduce morbidity associated with pelvic lymphadenectomy. Detection rate is strongly improved with learning curve and reduced in morbidly obese patients. PET/CT scan shows high sensitivity for nodal metastasis but moderate specificity and may help to avoid nodal dissection in patients with sentinel node failure.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

Radical hysterectomy and plus pelvic node dissection are the primary methods of treatment for patients with early stage cervical cancer. During the last decade, growing evidence has supported the adoption of a minimally invasive approach. Retrospective data suggested that minimally invasive surgery improves perioperative outcomes, without neglecting long-term oncologic outcomes. In 2018, the guidelines from the European Society of Gynaecological Oncology stated that a “minimally invasive approach is favored” in comparison with open surgery. However, the phase III, randomized Laparoscopic Approach to Cervical Cancer (LACC) trial questioned the safety of the minimally invasive approach. The LACC trial highlighted that the execution of minimally invasive radical hysterectomy correlates with an increased risk of recurrence and death. After its publication, other retrospective studies investigated this issue, with differing results. Recent evidence suggested that robotic-assisted surgery is not associated with an increased risk of worse oncologic outcomes. The phase III randomized Robotic-assisted Approach to Cervical Cancer (RACC) and the Robotic Versus Open Hysterectomy Surgery in Cervix Cancer (ROCC) trials will clarify the pros and cons of performing a robotic-assisted radical hysterectomy (with tumor containment before colpotomy) in early stage cervical cancer.

BackgroundScreening for anal cancer (squamous cell carcinoma of the anus, SCCA) prevention is suggested is target high risk populations. Since access to such screening is still limited, men who have sex with men (MSM) are often prioritized given their very high risk of this neoplasm. Following current guidelines, women living with HIV should also undergo screening for SCCA prevention starting at age 45 as well as women NLH based on their history of genital histopathology.Material and MethodsHere we present retrospective data on a cohort of 52 women (7 LWH and 45 NLH) that underwent screening with anal cytology, anal HPV test for high risk HPV genotypes (HR-HPV) identification and high resolution anoscopy (HRA).Women LWH were referred for screening by their Infectious Diseases practitioners, while women NLH were directly referred by their Gynecologists following screening for HPV related genital lesions.High grade lesions were treated with electrocautery.Continuous variables are reported as median values.ResultsMedian age of women LWH was 51±10, while median age of women NLH was 44±11 (p=0.52). All participants LWH showed undetectable HIV RNA, median CD4 count was 742±201 cells/uL.No differences were observed between the two groups in regard to smoking habit (14.3% vs. 38.4%; p=0.22), BMI (26.1±3 vs. 23.8±2; p=0.73) and HPV vaccination rate (42.8% vs. 31.7%; p=0.56).The presence of cervical HR-HPV infection was detected in 57.1% of participants LWH and 50% of women NLH (p=0.56). Similarly, prevalence of anal HR-HPV infection was comparable between women LWH and women NLH (85.7% vs. 77.7%; p=0.15), while, on the other hand, anal HPV16 was more frequently observed in women LWH (57.1% vs. 35.7%; p=0.02).A higher prevalence of HSIL was observed among women LWH in respect to women NLH (87.5% vs. 40%; p=0.02).Recurrence of treated HSIL was similar between the groups, while onset of metachronous lesions during follow-up was more frequent among women LWH (33.3% vs. 11.1%; p=0.06).ConclusionsAccess to screening for SCCA prevention is limited, thus a strict compliance to guidelines indications should be warranted to maximize prevention in high risk populations besides MSM.

Background/Objectives: Laparoscopic gynecologic surgery is widely utilized due to its minimally invasive nature. Postoperative discomfort, including intra-abdominal and referred shoulder pain, remains a challenge. This study evaluates the impact of deep neuromuscular blockade (NMB) reversed with sugammadex compared to moderate NMB reversed with neostigmine on postoperative pain, recovery, and surgical conditions in patients undergoing laparoscopic hysterectomy. Methods: This double-blind, randomized controlled trial included 228 patients undergoing laparoscopic hysterectomy under standardized pneumoperitoneum pressure (12 mmHg). Participants were randomized into two groups: deep NMB with sugammadex (SUG) and moderate NMB with neostigmine (NEO). Primary outcomes included postoperative pain (NRS) and neuromuscular recovery time (TOF ratio ≥ 0.9). Secondary outcomes were surgical conditions, surgeon satisfaction, extubation and recovery times, incidence of postoperative nausea and vomiting (PONV), and analgesic consumption. Results: The SUG group exhibited lower pain scores up to 24 h compared to the NEO group (p < 0.05). Pain reductions remained statistically significant up to 6 h postoperatively after Bonferroni correction, while differences beyond this time were not significant after adjustment. Neuromuscular recovery was markedly faster in the SUG group (147.58 ± 82.26 s vs. 488.02 ± 223.07 s, p < 0.05). Patients in the SUG group had shorter extubation (ΔT1), awakening (ΔT2), and recovery room transfer times (ΔT3). PONV was significantly lower in the SUG group. Deep NMB did not contribute to the improvement of surgical workspace conditions. Conclusions: Deep NMB with sugammadex enhances postoperative pain control and accelerates neuromuscular recovery in laparoscopic hysterectomy. These findings support the adoption of deep NMB with sugammadex as a valid anesthetic approach in laparoscopic hysterectomy procedures.