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ObjectivesClear cell (CC) carcinomas are a type 2 endometrial carcinomascharacterized by their rarity (2%) and their aggressive behavior.MethodsThis was a retrospective study including 9 cases of CC, recorded at the Salah Azaiez Institute over a period of 16 years (2000–2015). Clinical, pathological and evolutionary data were analyzed.ResultsThe mean age was 70 years [50–73]. All patients underwent curative resection by laparotomy.Extra-facial hysterectomy was performed in 8 cases and radical hysterectomy in 1 case. Lymph node surgery was performed in all of our patients.Patients were classified according to FIGO 2009: 33.3% were classified stage I, 22.2% stage II, 22.2% stage III and 22.2% stage IV.Lymphovascular space invasion was found in 44.4% of the cases. The median number of retiredlymph node and involved were 10 [1–32] and 2 [1–14], respectively.Two patients received adjuvant chemotherapy, 4patients received adjuvant radiotherapy and vaginal brachytherapy was performed in 5 patients.Median follow-up was 28 months (5–129). The 5-years overall survival were 48.6%.Excluding one patient lost of view after the end of the treatment, 3 patients were in clinical remission, 2 patients were in a progression of their disease, and relapses occurred in the three remain patients.ConclusionsEndometrial CC are an aggressive histological subtype with particular clinical and pathological features leading to a high rate of recurrence and death.

OBJECTIVELaparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy. METHODSBetween August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator. RESULTSA total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2–86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1–288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery. CONCLUSIONThe combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

OBJECTIVEThe aim of this retrospective study was to assess the surgical and oncological outcome of 3 different surgical approaches (laparotomy, laparoscopy, and robotic surgery) in the treatment of early-stage cervical cancer International Federation of Gynecology and Obstetrics (FIGO) stage IB1. METHODSAll patients with a histologically confirmed diagnosis of early-stage cervical cancer, FIGO stage IB1, who underwent abdominal radical hysterectomy (ARH), laparoscopic radical hysterectomy, or robotic radical hysterectomy with or without pelvic and aortic lymphadenectomy were included in the study. A review of the literature was conducted. RESULTSThree hundred forty-one patients, between January 2001 and December 2016, were included in this study101 patients were submitted to ARH, 152 to laparoscopic radical hysterectomy, and 88 to robotic radical hysterectomy. In 97% and 11.5% of cases, bilateral pelvic and aortic lymph node dissections were performed, respectively. The 3 groups were similar in regard to clinical characteristics. Compared with ARH, the minimally invasive surgery group was safer in terms of estimated blood loss, transfusion rates, and hospital stay. Above all, robotic surgery was equivalent to laparoscopy in terms of intraoperative and postoperative complications, hospital stay, conversions, and reintervention. On the other hand, robotic surgery had better outcomes compared with laparoscopy in terms of transfusion rates and was equivalent to abdominal surgery and laparoscopy in regard to oncological outcomes. CONCLUSIONSOur study confirmed that minimally invasive surgery (laparoscopy or robotics) was as adequate and effective as abdominal surgery in terms of surgical and oncological outcomes in the surgical treatment of EEC FIGO stage IB1.

Objective The aim of this study was to describe, from a historical perspective, the relevance, resilience and outcomes of vaginal hysterectomy (VH) in gynecology in the age of technological scenario. Methods The authors searched records from January 2011 to January 2021 on the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library) for combinations of the terms “vaginal hysterectomy,” “outcomes” AND “history”; and before that period, if the search had historical relevance. Inclusion criteria: randomized clinical trials; hysterectomy performed for benign gynecological conditions; and VH outcomes compared with Abdominal Hysterectomy (AH), Laparoscopic Hysterectomy (LH) or Robotic Hysterectomy (RH). Results The VH combines sequences of reproducible techniques which have been developed over the years to safely and effectively overcome the limitations of difficult cases of vaginal extirpation from the uterus. Conclusion The authors support endoscopic surgical approaches in complex surgery for benign indications, urogynecology, and gynecologic oncology when appropriate. However, what makes the gynecological surgeon different from the general surgeon is the vaginal access. It is essential to continue to train residents in vaginal surgical skills and provide safe and cost-effective patient care. The art of technology is the resilience of keeping only the patient at the center of innovation.

Background One of the most important principles in modern cervical cancer surgery is the concept of tailoring surgical radicality. In practice, this means abandoning the “one-fits-all” concept in favor of tailored operations. The term “radical hysterectomy” is used to describe many different procedures, each with a different degree of radicality. Anatomic structures are subjected to artificial dissection artifacts, as well as different interpretations and nomenclatures. This study aimed to refine and standardize the principles and descriptions of the different classes of radical hysterectomy as defined in the Querleu–Morrow classification and to propose its universal applicability. Methods All three authors independently examined the current literature and undertook a critical assessment of the original classification. Images and pathologic slides demonstrating different types of radical hysterectomy were examined to document a consensual vision of the anatomy. The Cibula 3-D concept also was included in this update. Results The Querleu–Morrow classification is based on the lateral extent of resection. Four types of radical hysterectomy are described, including a limited number of subtypes when necessary. Two major objectives remain constant: excision of central tumor with clear margins and removal of any potential sites of nodal metastasis. Conclusion Studies evaluating radicality in the surgical management of cervical cancer should be based on precise, universally accepted descriptions. The authors’ updated classification presents standardized, universally applicable descriptions of different types of hysterectomies performed worldwide, categorized according to degree of radicality, independently of theoretical considerations.

There are various surgical approaches of hysterectomy for benign indications. This study aimed to compare vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) with respect to their complications and operative outcomes. We selected randomised controlled trials that compared VH with LH for benign gynaecological indications. We included studies published after January 2000 in the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library). The primary outcome was comparison of the complication rate. The secondary outcomes were comparisons of operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and duration of recuperation. We used Review Manager 5.3 software to perform the meta-analysis. Eighteen studies of 1618 patients met the inclusion criteria. The meta-analysis showed no differences in overall complications, intraoperative conversion, postoperative pain on the day of surgery and at 48 h, length of hospital stay and recuperation time between VH and LH. VH was associated with a shorter operating time and lower postoperative pain at 24 h than LH. When both surgical approaches are feasible, VH should remain the surgery of choice for benign hysterectomy.

BackgroundEndometrial intraepithelial neoplasia (EIN) is a monoclonal proliferation of endometrial glands that can progress to endometrial carcinoma (EC). Squamous metaplasia (SM) is a common morphologic feature of EIN associated with β-catenin protein alterations. Patients with high-risk endometrial cancer (copy-number high) have frequent TP53 gene mutations and worse outcomes. This study evaluates the prognostic significance of SM, β-catenin, and p53 expression in EIN.MethodsThis retrospective study included patients with biopsy-proven EIN, subsequent hysterectomy, and evaluable tissue. Hematoxylin and Eosin (H&E) slides were reviewed to characterize SM; β-catenin and p53 expression were evaluated by immunohistochemistry (IHC).Results88 cases met inclusion criteria. On biopsy specimen, 11.4% (10/88) of patients had associated SM, and 2.3% (2/88) had abnormal p53 staining. 80% (8/10) of patients with SM had positive staining for β-catenin versus 2.6% (2/78) of patients lacking SM (p < 0.001) (figure 1). 34.1% (30/88) of patients were diagnosed with EC on subsequent hysterectomy. SM, β-catenin, and p53 expression on biopsy specimen were not correlated with a finding of neoplasia on subsequent hysterectomy (EC or EIN) (p = 0.427, p = 0.104, and p = 0.583, respectively).Abstract 146 Figure 1Biopsies from patients with EIN were evaluated via H&E. IHC was used to evaluate beta-catenin nuclear staining and p53 overexpression or null expression. Abbreviations: BCAT+, beta-catenin positive expression; WT, wild-type)ConclusionsOur findings confirm the association between SM and β-catenin abnormalities. Although rare, abnormal p53 IHC in EIN is concerning and may represent a precursor to copy-number high EC. Although these findings demonstrate molecular abnormalities within EIN, β-catenin and p53 expression do not reliably predict cancer diagnosis on final hysterectomy specimen.

Objectives The choriocarcinoma is the most frequent and chemo-sensitive of the malignant gestational trophoblastic tumors. The main management challenge in young patients is to balance a fertility-sparing therapy with good survival rates and quality of life. The aim of this work is to evaluate the fertility of young women with choriocarcinoma after a fertility-sparing strategy. Methods We conducted a retrospective study of a prospective mono-centric database over a 20 year period (2000–2019) in the Tunisian Central Cancer Registry, the department of gynecology and Obstetrics, and the reproductive medicine unit in Farhat Hached Teaching Hospital in Sousse Tunisia. We collected all the pathology established cases of choriocarcinoma diagnosed in women under 40. Results The cohort of 30 women included 18 (60%) who had a fertility-sparing therapeutic strategy and 12 (40%) who underwent hysterectomy ( all cases before 2010). There was no statistical difference between the fertility-sparing management group and the hysterectomy group in OS and DFS (respectively, P=0.09 and P=0.14). Among the fertility-sparing management group, 16 patients reported a pregnancy desire in the year following the diagnosis and stopped contraception in order to conceive. Twelve pregnancies in 5 patients were recorded with 4 live births. Conclusions The use of less-toxic chemotherapy protocols is a good option when dealing with fertility sparing strategy in managing choriocarcinoma in young women especially that the recommended standards have shifted to no surgery.

ObjectiveTo evaluate conservative treatment in patients with a diagnosis of adenocarcinoma in situ (AIS) patients in Southern Brazil.Methods/MaterialsA retrospective cohort study of patients diagnosed with AIS between 2002 and 2019. Clinical characteristics and pathologic information including specimen volume, margin status, treatment type, pregnancy and oncologic outcomes were collected.ResultsThe mean age was 39.7 years (SD ± 9.4). The initial treatment performed was loop electrosurgical excision procedure (LEEP) in seven (21,2%) participants, cold-knife-cone (CKC) in 26 (78.8%). After the conization, 18 women underwent conservative management, three patients (3/18) became pregnant once and another two patients (2/18) went to hysterectomy in the follow-up. Residual lesion was noted in 7 (41%) hysterectomy specimens, with 2 cases of adenocarcinoma. In our study, an inverse association was found between the volume of the surgical specimen (in mm3) in the LEEP procedure (p = 0.033) and the positive surgical margin (p = 0.012). There was no association between the treatment performed, the volume of the surgical specimen, and recurrence with negative or positive margins (p> 0.05).Abstract 247 Table 1ConclusionConservative treatment is an option in the treatment of AIS, for patients who desire fertility-sparing treatment. Conservative management with LEEP is associated with higher positive margin rates than CKC, however outcomes were similar when margins are negative. The specimen volume was not associated with recurrence.