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Transvaginal ultrasound (TVUS) represents an accurate and noninvasive technique to investigate endometrial thickness (ET) in the early diagnosis of endometrial cancer (EC). In the literature, for maximum ET there is no consensus on the cutoff value for normal ET in postmenopause for either symptomatic or asymptomatic women. Most patients with EC present with postmenopausal bleeding (PMB) and in these patients is necessary to perform TVUS to evaluate ET as an indicator for endometrial biopsy. On the contrary, if ET is incidentally detected in postmenopausal patients without bleeding, endometrial sampling for a postmenopausal woman without bleeding should not be routinely performed, although it is estimated that up to 15% of EC occurs in women without vaginal bleeding. The aim of our review was to give clinicians necessary and useful knowledge on the role of TVUS and ET for early detection of EC in their daily routine practice. Based on the most important studies in the literature, we summarized that in premenopausal woman with abnormal uterine bleeding, an optimal cutoff for ET has not yet been established. For postmenopausal women with PMB, at low risk, and ET <4 mm, a follow-up scan could be offered, and for women with ET ≥4 mm, office hysteroscopy-guided endometrial sampling is recommended independently of ET results. On the other hand, in postmenopausal women with PMB and at high risk of EC, office hysteroscopy-guided endometrial sampling is necessary. In postmenopausal women without PMB and ET ≥4 mm, arbitrary endometrial sampling is not recommended, but evaluated case by case based on risk factors. In conclusion, there is broad consensus on the importance of TVUS and the need for further investigation based on risk factors of EC.

Over the study period we identified 60 eligible patients; however, 14 were excluded from the final analysis as 10 patients underwent programmed cesarean section, one patient was excluded due to illiteracy and could not receive the informative material and three declined to enter the analysis, leaving a final study population of 46 patients. Population characteristics Non Mother Tongue (n = 20) Mother Tongue(n = 26) p-value Age, mean (SD) 29.5 (24.5—33.5) 29 (27.25—31.75) 0.911 BMI > 30, % (n) 40 (8) 46.2 (12) 0.676 Pre-pregnancy BMI > 30, % (n) 20 (4) 23.1 (6) 0.802 Pre-eclampsy, % (n) 0 (0) 3.8 (10) 0.375 Gestational diabetes, % (n) 15 (3) 23.1 (6) 0.493 Anesthesiology consultation GW, mean (SD) 36.5 (35—37) 37 (36.25—37.75) 0.149 Previous Pregnancy, % (n) 80 (16) 50 (13) 0.036* Spoken Language, %(n) 0.319 Arabic 10 (2) 19 (5) Chinese 15 (3) 19 (5) English 15 (3) 23 (6) French 15 (3) 23 (6) Pungjabi 35 (7) 15 (4) Russian 10 (2) 0 (0) BMI Body Mass Index, GW Gestational week *p-value < 0.05 Patients in the MT group had a higher rate of EA access (53.8%, n = 14) compared to the non-MT group (30%, n = 6), though this difference did not reach statistical significance (p = 0.105). Despite this, the observed trend suggests that providing translated informational materials may positively impact EA access among non-Italian-speaking patients and will serve as the foundation for a prospective controlled study aimed at further evaluating the effectiveness of this intervention. [...]these results, while preliminary, highlight the potential value of multilingual written materials as a low-cost, easily implementable tool to support equitable access to EAL.

OBJECTIVEThe aim of this study was to report the incidence, severity, and factors associated with femoral nerve injury during gynecologic cancer surgery. METHODSAll patients who underwent abdominal surgery for gynecologic cancer entered the study. A retrospective review of the medical records was carried out for patients operated on from 2003 to April 2011. After this analysis, the use of the Bookwalter retractor was modified and the data were prospectively recorded. RESULTSIn the first period, femoral nerve injury was observed in 11 (2.7%) of 406 patients, occurring with a significantly higher frequency when the Bookwalter retractor was used (5.1% vs 0%, P < 0.01) and when pelvic lymphadenectomy was performed (5.1% vs 0.9%, P < 0.01). The analysis of the 212 patients (52.2%) in the Bookwalter group showed higher frequency of nerve injury in the patients undergoing pelvic lymphadenectomy (7.8% vs 2.0%, P = 0.05). In the second period, femoral nerve injury was observed in 1 (0.7%) of 132 patients operated on and in 1 (2.3%) of 43 patients (32.6%) in the Bookwalter group. When comparing the 2 periods, the lesser use of the Bookwalter retractor and the reduced time of maximal traction of the pelvic blades decreased the nerve injury rate from 2.7% to 0.7% and, in the Bookwalter group, from 5.1% to 2.3%. These results, although not statistically significant, are clinically relevant. CONCLUSIONSFemoral nerve injury during gynecologic cancer surgery was associated with the Bookwalter retractor. The pelvic blades of the retractor may exert a compression on the nerve. The weakened muscles suggest that the nerve compression occurred intrapelvically over the iliacus muscle. Shortening the time of maximal traction of the pelvic blades reduced the incidence of femoral nerve injury. When performing gynecologic surgery with the use of the Bookwalter retractor, care must taken with the placement of the pelvic blades.

Introduction/BackgroundThis video presents the key surgical steps of the laparoscopic removal of bulky pelvic lymph nodes in two different cases of high-grade serous ovarian cancer recurrences.MethodologyTwo patients underwent laparoscopic cytoreduction due to bulky pelvic lymph nodes.The first case refers to a tertiary recurrence of HGSOC, the second one to a secondary relapse.Both patients underwent Interval Debunking Surgery and chemotherapy as first treatment.ResultsLaparoscopic cytoreduction, performed after previous chemotherapy and prior surgery, presents several significant challenges. Tissues appear scarred and fibrotic due to the insults from prior surgeries, making them more adherent and less mobile. Additionally, the anatomical planes can be disrupted due to adhesions or changes in tissue morphology.In the first case we initially attempt a medial approach to the obturator fossa, dissecting the spaces between the external iliac vessels and isolating the pelvic portion of the ureter. The medial approach resulted unfeasible due to the increased tissue consistency and fibrosis. Eventually we attempted a lateral approach between the psoas muscle laterally and the external iliac artery medially.There is also an increased risk of intraoperative complications such as bleeding or damage to nervous structures, as we can see in the second case: the bleeding from external iliac vein injured was stopped by the traction of a silicon strip previously positioned, which surrounded the vessel. Two bulldog hemostatic forceps are positioned upstream and downstream of the lesion in order to allowed the surgeon to suture the vessel.ConclusionSecondary cytoreduction, which is technically more complex compared to upfront surgery, is characterized by the difficulty in opening anatomical spaces, often altered by the outcomes of previous treatments. Tissues appear edematous, fibrotic, and easily prone to bleeding, which may necessitate the use of alternative surgical approaches.DisclosuresThe authors declare that they have no conflict of interest.

Introduction/BackgroundEpithelial ovarian cancer (EOC), notably high-grade serous EOC (HGS-EOC), is a prevalent and lethal cancer in women. Despite the efficacy of initial treatment involving primary surgical cytoreduction and platinum-based chemotherapy, high relapse rates contribute to poor outcomes. This study leverages single-cell RNA-Seq data to delve into gene expression, immune signatures, and pathways, providing insights into the tumor microenvironment (TME) and immune profile of HGS-EOC.MethodologyThe single-cell RNA-Seq patient cohort comprises 35 samples from 15 patients, collected pre and post neoadjuvant chemotherapy (NACT) at specific sites: the primary site (ovary or nearby tissues), omentum (the most invaded membrane), and peritoneum (the second most invaded). The procedure involves dissociating fresh samples, conducting flow cytometry analysis with a panel of antibodies, and employing Illumina Next-Seq 2000 for single-cell RNA sequencing, carried out by co-investigators at Humanitas Clinical Institute, MilanResultsPreliminary results from analyzing a complete patient, encompassing a primary sample pre-NACT and three metastatic sites post-NACT, indicate a higher prevalence of the stromal component in metastatic samples compared to the primary site. Dimensionality reduction techniques and the ESTIMATE package are utilized to assess TME composition, deriving tumor, immune, and stromal scores from gene expression profiles.ConclusionThe findings underscore the pivotal role of the TME, particularly the stromal component, in tumor progression. While these initial results highlight distinctions in cell composition between primary and metastatic sites, further analyses with additional samples are imperative for a comprehensive understanding of cell behavior throughout disease progression.DisclosuresNoneAbstract 483 Figure 1

(1) Background: In 2018 FIGO reclassified tumors confined to the cervix larger than 4 cm as stage IB3. Although concurrent CTRT has been the standard of care and surgery the alternative, optimal management remains controversial due to the lack of direct comparison between surgery and CTRT. (2) Methods: This prospective observational study investigated the efficacy, safety and oncologic outcomes of nerve-sparing laparoscopic radical hysterectomy (nsLRH) for FIGO stage IB3 cervical cancer patients (IB3). From 2009 to 2023, IB3 patients underwent laparoscopic pelvic lymphadenectomies with frozen section analysis, followed by a nsLRH if the lymph nodes were tumor-free. No uterine manipulator was used and the vaginal cuff was sealed before retrieving the specimen. Intermediate-risk patients were under close observation without adjuvant therapy. Outcomes were monitored until 2023. (3) Results: During the study period, 74 IB3 patients were treated. Sixty-eight (91.9%) underwent a nsLRH. A complete resection with negative margins was achieved in all cases. At a median of 68 months of follow-up, the disease-free survival (DFS) rate was 89.7% and the overall survival (OS) rate was 93.1%. The overall complication rate was 23.5% and there were no grade 4–5 complications. (4) Conclusions: In patients with IB3 cervical cancer, a nsLRH is safe and effective. While awaiting the results from ongoing randomized trials, these findings support nsLRH as a viable treatment.

Introduction/BackgroundThis video shows a laparoscopic en-bloc resection of the pelvis with rectosigmoid resection and termino-terminal anastomosis in a 75-year-old patient affected by advanced ovarian carcinoma. The patient was discussed at our tumor board with a CT scan showing a solid pelvic mass (approximately 12x8x8 cm) upper abdominal and diaphragmatic disease. The findings were later confirmed at exploratory laparoscopy when a decision was made to perform up-front surgery.The patient was recruited to the ULTRA-LAP trial (NCT05862740) and underwent up-front laparoscopic debulking.MethodologyThe procedure begins with the exposure of the retroperitoneum. Subsequently, the pararectal, paravesical, and presacral spaces are developed. The uterine artery and infundibulo-pelvic ligament are identified and ligated bilaterally. The mesentery is opened and the proximal sigmoid-rectum colon is sectioned using a 60 mm Endo-GIA™ stapler. The presacral space is developed until a level caudal to the tumor. Peritonectomy of the bladder is completed and the vesicovaginal space is reached and anterior colpotomy is performed. Recto-vaginal septum is developed, meso rectum is sealed and sectioned, the distal end of the rectum is transected with an Endo-GIA™ again. The pelvic organs are removed through the vagina inside an endo-bag without the need for a service mini-laparotomy. Also through the vagina the proximal part of the colon is exposed to insert the anvil and suture over a purse string suture. The procedure concludes with the creation of a trans-anal termino-terminal anastomosis using an ECHELON™ circular stapler.ResultsNo protective ileostomy was performed. Bowel opening occurred on the fifth postoperative day, and the patient was discharged on the thirteenth postoperative day.ConclusionIn selected patients, minimally invasive surgery can be employed in primary cytoreductive surgery for advanced ovarian carcinoma, improving postoperative outcomes for the patient without compromising surgical radicality.DisclosuresNo.

Introduction/BackgroundThe contribution of surgery to ovarian cancer (OC) is witnessed by the undisputed prognostic significance of the complete resection (CR), regardless of the initial treatment modality. It is therefore justified that gynecologic oncologists strive to increase CR rate to the highest possible. Alongside this, the effort has been to reduce the surgical morbidity by introducing the use of laparoscopy to complete the whole surgical debulking.A non-randomized prospective phase I-II clinical trial (ULTRA-LAP) (ClinicalTrials.gov NCT05862740) to test safety, side effects and efficacy of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV OC was performed. The pilot study was designed to identify which OC patients are suitable to undergo L-VPD.MethodologyFrom March 2016 all consecutive patients with OC underwent exploratory laparoscopy (EXL). Patients whose disease was deemed amenable for a complete resection (CR) based on imaging and EXL underwent VPD. In all patients, a consistent attempt was made at completing L-VPD.ResultsIn the study period, 208 OC patients underwent EXL: 121 underwent interval VPD and 87 up-front VPD. Overall, 158 patients had VPD by laparotomy (75.9%) and 50 (24.1%) had L-VPD, of which 34 patients as interval (iL-VPD) and 16 as up-front (uL-VPD). Intra- and post-operative morbidity were very low in the L-VPD group. CR rate was 98% in L-VPD group and 94% in VPD. The most common reason for conversion was diaphragmatic disease extending dorsally.ConclusionIn the pilot study, L-VPD was completed in 24,1% of OC. Initial analysis supports the feasibility of L-VPD in 2 groups of OC: those with no gross disease at interval surgery and those with gross visible disease at upfront or interval surgery, but limited to: pelvis (including recto-sigmoid), gastro colic omentum, peritoneum and diaphragm, the latter not requiring dorsal liver mobilization. Both groups had 100% feasibility and have been thus forth recruited to ULTRA-LAP.DisclosuresNone

Immunotherapy, particularly the use of immune checkpoint inhibitors (ICIs), has shown limited efficacy in treating ovarian cancer (OC), possibly due to diverse T cell infiltration patterns in the tumor microenvironment. This review explores how neoadjuvant chemotherapy (NACT) impacts the immune landscape of OC, focusing on tumor-infiltrating lymphocytes (TILs), PD-1/PD-L1 expression, and their clinical implications. A comprehensive literature search across four databases yielded nine relevant studies. These studies evaluated stromal (sTILs) and intra-epithelial (ieTILs) TILs before and after NACT. sTIL responses varied, impacting prognostic outcomes, and ieTILs increased in some patients without clear survival associations. PD-L1 expression after NACT correlated with improved overall survival (OS), and increases in granzyme B+ and PD-1 correlated with longer progression-free survival (PFS). Remarkably, reduced FoxP3+ TILs post-NACT correlated with better prognosis. NACT often increases sTIL/ieTIL and CD8+ subpopulations, but their correlation with improved PFS and OS varies. Upregulation of co-inhibitory molecules, notably PD-L1, suggests an immunosuppressive response to chemotherapy. Ongoing trials exploring neoadjuvant ICIs and chemotherapy offer promise for advancing OC treatment. Standardized measurements assessing TIL density, location, and heterogeneity are crucial for addressing genetic complexity and immunological heterogeneity in OC.

Ovarian cancer (OC) has the highest mortality rate of all gynecological malignancies due to the high prevalence of advanced stages of diagnosis and the high rate of recurrence. Furthermore, the heterogeneity of OC tumors contributes to the rapid development of resistance to conventional chemotherapy. In recent years, in order to overcome these problems, targeted therapies have been introduced in various types of tumors, including gynecological cancer. However, the lack of predictive biomarkers showing different clinical benefits limits the effectiveness of these therapies. This requires the development of preclinical models that can replicate the histological and molecular characteristics of OC subtypes. In this scenario, organoids become an important preclinical model for personalized medicine. In fact, patient-derived organoids (PDO) recapture tumor heterogeneity with the possibility of performing drug screening. However, to best reproduce the patient’s characteristics, it is necessary to develop a specific extracellular matrix (ECM) and introduce a tumor microenvironment (TME), which both represent an actual object of study to improve drug screening, particularly when used in targeted therapy and immunotherapy to guide therapeutic decisions. In this review, we summarize the current state of the art for the screening of PDOs, ECM, TME, and drugs in the setting of OC, as well as discussing the clinical implications and future perspectives for the research of OC organoids.