Treatment strategies in patients with gynecological sarcoma: Results of the prospective intergroup real-world registry for gynecological sarcoma in Germany (REGSA-NOGGO RU1).

OBJECTIVE: Gynecological sarcomas account for 3% of all gynecological malignancies and are associated with a poor prognosis. Due to the rarity and heterogeneity of gynecological sarcomas there is still no consensus on optimal therapeutic strategies. This study's objective was to describe the treatment strategies used in patients with gynecological sarcomas in the primary course of disease. METHODS: The German prospective registry for gynecological sarcoma (REGSA) is the largest registry for gynecological sarcomas in Germany, Austria and Switzerland. Primary inclusion criteria for REGSA are histological diagnosis of sarcoma of the female genital tract, sarcoma of the breast or uterine smooth muscle tumors of uncertain malignant potential (STUMP). We evaluated data of the REGSA registry on therapeutic strategies used for primary treatment from August 2015 to February 2021. RESULTS: A total of 723 patients from 120 centers were included. Data on therapeutic strategies for primary treatment were available in 605 cases. Overall, 580 (95.9%) patients underwent primary surgery, 472 (81.4%) of whom underwent only hysterectomy. Morcellation was reported in 11.4% (n=54) of all hysterectomies. A total of 42.8% (n=202) had no further surgical interventions, whereas an additional salpingo-ophorectomy was performed in 54% (n=255) of patients. An additional lymphadenectomy was performed in 12.7% (n=60), an omentectomy in 9.5% (n=45) and intestinal resection in 6.1% (n=29) of all patients. Among 448 patients with available information, 21.4% (n=96) received chemo- or targeted therapies, more commonly as single-agent treatment than as drug combinations. Information about anti-hormonal treatment was available for 423 patients, among which 42 (9.9%) received anti-hormonal treatment, 23 (54.8%) of whom with low-grade endometrial stroma sarcomas. For radiotherapy, data of 437 patients were available, among which 29 (6.6%) patients underwent radiotherapy. CONCLUSION: Our study showed that treatment of patients with gynecologic sarcomas is heterogeneous. Further trials are needed along with more information on treatment modalities, therapy response and patient-reported outcomes to implement new treatment strategies.

Role of the Cardiophrenic Lymph Node Status After Neoadjuvant Chemotherapy in Primary Advanced Ovarian Cancer.

BACKGROUND/AIM: This study investigated the cardiophrenic lymph node (CPLN) status before and after neoadjuvant chemotherapy (NACT), as its presence seems to have a rather prognostic significance in patients with advanced ovarian cancer. PATIENTS AND METHODS: The baseline computed tomography scans of 66 patients with advanced ovarian cancer primary treated with NACT between March 2015 and June 2020 were reviewed. A CPLN enlargement was defined as ≥5 mm. RESULTS: 44% (n=29) of the patients had enlarged CPLNs; 10.7% (n=3) showed a complete response, 71.4% (n=20) a partial response, and 17.9% (n=5) a stable disease after NACT. There was no significant difference between the response to NACT measured according to the status of CPLN compared to other biomarkers in the CPLN group. CONCLUSION: Patients with CPLN enlargement have a tendency to an impaired prognosis. The response of CPLN to NACT was comparable to the response of established biomarkers, adding a monitoring function to the CPLN.

LION-PAW (lymphadenectomy in ovarian neoplasm) sexual function assessment: a prospective sub-study of the LION trial.

BACKGROUND: There is limited information about the impact of radical surgery including pelvic and para-aortic lymphadenectomy and subsequent platinum-based chemotherapy on sexuality in patients with advanced ovarian cancer. OBJECTIVE: To evaluate the impact of radical surgery including pelvic and para-aortic lymphadenectomy and subsequent platinum-based chemotherapy on sexuality in patients with advanced ovarian cancer as a sub-protocol of the prospectively randomized LION trial. METHODS: The Sexual Activity Questionnaire was applied to assess sexual function according to its sub-scales activity, pleasure, and discomfort. The 'orgasm' sub-scale from the Female Sexual Function Index was also added. The questionnaire was administered in combination with the EORTC QLQ-C30 questionnaire at baseline prior surgery, after 6, 12, and 24 months. The primary endpoint was changes in sexual function. RESULTS: Overall, 495 patients received the questionnaires. 254 (51%) responded at baseline. Of these, 55 (22%) patients were sexually active, 182 (72%) were sexually inactive, and for 17 (7%) patients' data were not available. There was a total of 55/495 (11%) patients at 6 months, 139 (28%) patients at 12 months, and 81 (16%) patients at 24 months. Median age was 60.5 years (range 21.4-75.8). At baseline, sexually active responders were significantly younger (median age 51.5 years,) than sexually inactive responders (median age 61.8 years) and tended to have a better performance status. Discomfort evaluated as dryness of the vagina and pain during sexual intercourse was significantly worse at 12 months than at baseline (p<0.001); however, the surgical variable, lymphadenectomy, did not have any impact on this. The orgasm sub-scale showed diverging results with a deterioration from baseline to 12 months in the lymphadenectomy group compared with the no-lymphadenectomy group (p=0.02). CONCLUSION: The majority of patients were sexually inactive; however, in those who were sexually active, pain during intercourse was worse at 12 months. In addition, the orgasm sub-scale demonstrated worse results in patients who underwent complete lymphadenectomy. The study suggests that surgery in the retroperitoneal space may influence sexual function.

The Impact of Age on the Prognosis of Vulvar Cancer.

INTRODUCTION: Younger women are particularly affected by the increase in the incidence of vulvar cancer. The purpose of this study was to investigate how clinical characteristics differ depending on the patient´s age and what role the age of initial diagnosis plays in the prognosis. Patients andMethods: Included patients were divided into groups aged below or above 50 years. The disease-free survival (DFS) was calculated and a multivariate discriminant analysis was conducted. RESULTS: Of the 300 patients, 79 were ≤50 years and 221 were >50 years. The median age was 64 years (19-96 years). There were no differences between the groups regarding lymph node (LN) status and distant metastasis, but T1 tumours were more frequent in patients ≤50 years (77% vs. 62%, p = 0.02). The DFS only differed between the groups when there were no LN metastases. The nodal status was the predominant prognostic factor for the DFS regardless of age. In node-free patients, the 5-year DFS was 49% for the ≤50 years group and 89% for the >50 years group (p = 0.008), whereas there was no difference if a LN was involved. CONCLUSION: In node-free patients, the risk for recurrence is lower for patients older than 50 years.

Prognostic significance of Sugarbaker's peritoneal cancer index for the operability of ovarian carcinoma.

INTRODUCTION: This study aimed to investigate Sugarbaker's peritoneal cancer index (PCI) as a prognostic indicator for the resectability of ovarian carcinoma (OC), as depicted in the study using the completeness of cytoreduction score (CCS).Currently, the intraoperative assessment of operability in OC surgery is primarily a subjective measurement that is dependent on the surgeon. METHODS: The retrospective data from 98 patients with OC International Federation of Gynecology and Obstetrics (FIGO) III to IV who had received surgery between January 2010 and December 2011 were analyzed. The PCI and the CCS were determined retrospectively using surgical reports, histological findings, and intraoperative photographic documentation. Receiver operating characteristic curves and ordinal regression were applied to evaluate the predictability of CCS using the PCI. RESULTS: Of 98 patients, 80 (81.6%) were staged FIGO III and 18 (18.4%) FIGO IV. A statistically significant correlation was demonstrated between the PCI and CCS (P < 0.01). A receiver operating characteristic curve with an area under the curve of 0.839 demonstrated the high precision in discrimination with which the PCI could predict the CCS. Using ordinal regression, it was possible to estimate the probabilities of achieving CCS 0, CCS 1, CCS 2, or CCS 3 for a given PCI (pseudo R(2) according to Cox and Snell 0.428, Nagelkerke 0.476, and McFadden 0.244). CONCLUSIONS: The PCI more precisely defined the heterogeneous group of patients with OC FIGO III. The PCI provided objectivity and reproducibility, and it seems to be a possible prognostic indicator for OC resectability.

Exenteration in the treatment of Stage III/IV vulvar cancer.

OBJECTIVES AND METHODS: Vulvar carcinomas are rare genital malignancies. While advanced primary cancer chemoradiation is often preferred over pelvic exenteration (PE), PE is often the only therapy available in cases of recurrence. In a retrospective study, we analyzed predictive factors and outcomes of patients who underwent exenteration for vulvar cancer in our department during the past 10 years. RESULTS: We identified 27 patients; 9 of them suffered from primary disease, and 18 had experienced a recurrence. A total of 18 patients presented with stage FIGO III, and 9 patients presented with stage IV. In 10 patients, the disease had spread to the inguinal lymph nodes, and in 3 patients, it had also spread to the pelvic nodes. At the end of surgery, all patients were macroscopically tumor free, which was confirmed microscopically in 20 patients (74%, R0), with the other 7 patients having microscopic tumor remnants. For all patients, median time of survival was 37 months, the five-year survival rate (5YSR) was 62%, and the overall survival (OS) was 59%. Patients with tumor-free lymph nodes had an OS of 76% and a 5YSR of 83% vs. 40% and 36%, respectively, for patients with tumorous spread to the nodes (p=0.03). The 5YSR correlated to the degree of resection (R0 vs. R1, 74% vs. 21%, p=0.01). CONCLUSION: PE is a therapeutic option in advanced primary or relapsed vulvar carcinoma, offering median- to long-term survival for many patients. Carcinomatous spread to regional lymph nodes and complete resection are the most important prognostic factors.

Exenteration as a primary treatment for locally advanced cervical cancer: long-term results and prognostic factors.

OBJECTIVE: Whereas pelvic exenteration is an established therapy for the treatment of recurrent cervical carcinoma, it is not often performed for primary locally advanced cervical cancer (LACC). STUDY DESIGN: This retrospective study analyzed survival data and prognostic factors of 35 patients with LACC who were treated by pelvic exenteration. RESULTS: After surgery, 33 patients (97%) were macroscopically free of tumor. In 20 patients, pelvic lymph nodes (LN) were involved, and in 6 of these, metastatic tissue had reached the paraaortal nodes. Overall, the patients' mean 5 year survival was 43%, and the median survival time was 30 months; these values ranged from 15% to 70% and from 15 to 44 months, respectively, depending on LN involvement (P=.006). Pelvic LN involvement was the only significant factor for overall survival found in the multivariate analysis (P=.02). CONCLUSION: In LACC with free LNs and no distant metastases, pelvic exenteration has good long-term results.

Preoperative assessment of complete tumour resection by magnetic resonance imaging in patients undergoing pelvic exenteration.

OBJECTIVES: To evaluate whether preoperative magnetic resonance imaging (MRI) allows prediction of complete tumour resection in patients planned for pelvic exenteration (PE). STUDY DESIGN: Data of all patients treated by PE at a gynaecologic cancer centre between 6/1999 and 5/2005 were studied retrospectively. Preoperative MRI scans were re-analysed blindly with respect to invasion of neighbouring organs, muscular pelvic side wall, vessels and lymph nodes by an experienced team of radiologist and gynaecologic oncologist, finally also giving estimation whether complete removal of tumour would be feasible. RESULTS: 43 patients were identified: all of them underwent PE. The histopathological investigation of the exenteration specimen demonstrated microscopic complete resection status in 20 cases (46.5%). None of the investigated parameter showed a correlation to complete resection of tumour. Sensitivity for final microscopic results relative to preoperative prediction by radiographic findings was 85%, specificity was 52%. The positive predictive value for tumour-free status was 60% (17/28), the negative 80% (12/15). CONCLUSIONS: Preoperative MRI cannot predict the surgical outcome with sufficient accuracy, hence on its own is inappropriate for prediction of complete tumour resection and final histological margin status in patients undergoing PE.

Pelvic cyst: renal or ovarian?

Ovarian cyst is a common gynecologic finding. Renal cysts develop in 15% of women older than 70 years, and nephroptosis in 20% of the population, primarily in women. Herein, we review these conditions and present a case in which the patient had a cystic kidney in combination with nephroptosis. At vaginal ultrasound performed with the patient in an upright position, the kidney slid down into the pelvis, thus imitating an ovarian mass. At laparoscopy, the patient was positioned head down, and the kidney, lying near the diaphragm, was not seen.