The Soleymani and Collins Obstetric morbidity score (SaCOMS): A quantitative tool for measuring maternal morbidity from complex obstetric surgery such as placenta accreta spectrum (PAS).

It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity.

Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer.

AIM: Compare the surgical complexity and histological accuracy of visual inspection of disease in patients undergoing primary debulking (PDS) versus delayed debulking surgery (DDS) following neo-adjuvant chemotherapy (NACT) for advanced ovarian cancer (AOC). MATERIALS AND METHODS: All patients undergoing PDS or DDS for stage III / IV AOC at a UK cancer centre between January 2014-October 2021 were included. Retrospective data was collected accessing an electronic gynaecological oncology database, operation and histology records. Comparative frequencies of surgical procedures performed were calculated for primary versus delayed cohorts; and correlation between intra-operative suspicion of disease and specimen histology at PDS and DDS compared. RESULTS: N=232. PDS was performed in 45.3% and DDS in 54.7% of patients; achieving complete cytoreduction in 77.2%. Appendicectomy, pelvic and para-aortic nodal dissection were undertaken significantly more often at primary surgery; whilst right diaphragm stripping, pelvic peritonectomy, splenectomy and cholecystectomy were more likely following NACT. We found no variation in bowel resection rates between cohorts. For the majority of specimens, there was no difference in correlation between intra-operative suspicion of disease and final histopathology - with a significantly lower positive predictive value for visual assessment demonstrated only for liver capsule and pelvic peritoneum at DDS. CONCLUSION: NACT does not appear to reduce the complexity of surgery, including rates of bowel resection; nor accuracy of intra-operative visual assessment of disease. We therefore caution against both deferring to NACT to facilitate less radical delayed debulking; and any presumption that macroscopically abnormal tissue at DDS may represent inert post-NACT 'burn-out', mitigating indication for excision. We instead suggest reservation of the neo-adjuvant pathway for patients with poor PS and radiologically-confirmed surgical stopping points; and advocate equivalent and maximal cytoreductive effort to remove all visibly abnormal tissue in both the upfront and delayed surgical settings.

Mixed Endometrial Epithelial Carcinoma: Epidemiology, Treatment and Survival Rates-A 10-Year Retrospective Cohort Study from a Single Institution.

Mixed endometrial carcinoma (MEEC) refers to rare endometrial tumours that are composed of two or more distinct histotypes, at least one of which is serous or clear cell. The aim of this study was to evaluate the epidemiology, treatment outcomes and survival rates of patients with mixed endometrial carcinoma. The medical records of 34 patients diagnosed with MEEC between March 2010 and January 2020 were reviewed retrospectively. Clinicopathological variables and treatment strategies were assessed, and overall survival and disease-free survival rates were evaluated. The histology of endometrioid and serous component was found in 26 (76.5%) patients, followed by serous and clear-cell components (5/34, 14.5%) and mixed endometrioid serous and clear-cell components (3/34, 8.8%). The median age at diagnosis was 70 years (range 52-84), and the median follow-up time was 55 months. The 5-year disease-free survival and the 5-year overall survival were 50.4% and 52.4%, respectively. Advanced disease stage was identified as an independent predictor of inferior disease-free (<0.003) and overall survival (p < 0.001). Except for stage, none of the traditional prognostic factors was associated with disease recurrence or death from disease. MEECs represent rare high-risk endometrial carcinomas with significant diagnostic and treatment challenges. Undoubtedly, the implementation of a molecular analysis can offer further diagnostic and management insights.

The Prognostic Characteristics and Recurrence Patterns of High Grade Endometrioid Endometrial Cancer: A Large Retrospective Analysis of a Tertiary Center.

High grade endometrioid endometrial cancer (HGEEC) is a heterogeneous group of tumors with unclear prognostic features. The aim of the present study is to evaluate the independent risk factors for recurrence and mortality and to describe the recurrence patterns of HGEEC. Ninety-six consecutive cases of HGEEC treated with primary surgery in a single Tertiary Center were retrospectively reviewed. Clinicopathological and treatment details were recorded, and all patients were closely followed up. Disease-free, overall and cancer-specific survival rates were 83.8%, 77.8% and 83.6%, respectively. Cervical stromal involvement was independently related to recurrence (HR = 25.67; 95%CI 2.95-223.30; p = 0.003) and cancer-related death (HR = 15.39; 95%CI 1.29-183.43; p = 0.031) after adjusting for other pathological and treatment variables. Recurrence rate was 16%, with 60% of these cases having lung metastases and only one case with single vaginal vault recurrence. 81.81% of the recurrences presented with symptoms and not a single recurrence was diagnosed in routine follow-up clinical examination. In conclusion, the recurrence pattern may suggest that patient-initiated follow-up (PIFU) could be considered a potential alternative to clinical-based follow-up for HGEEC survivors, especially for patients without cervical involvement and after two years from treatment. Additional caution is needed in patients with cervical stromal involvement.

Combined direct hysteroscopic and real-time ultrasound guidance facilitating safe insertion of intra-uterine brachytherapy applicator for locally advanced cervical cancer with significant endocervical stenosis: A novel collaborative approach.

Locally advanced cervical cancer is treated with combined chemoradiation (CCRT) - with the radiotherapy component comprising delivery of both external beam (EBRT) and intra-uterine brachytherapy (IUBT). Following initial pelvic and tumour irradiation via EBRT, secondary tissue fibrosis can obliterate the vagina and / or endocervical canal. 30-88% of women will develop some degree of stenosis, with complete stenosis reported in up to 11% of patients - making accessing the uterine cavity to insert brachytherapy applicators challenging and high risk (Bran et al., 2006). This can result in inadvertent uterine perforation, occurring in 2-10% of cases (Irvin et al., 2002); with subsequent abandonment of both the procedure and proceeding to IUBT to complete treatment. Omission of IUBT confers an at least 10% reduction in overall survival (Karlsson et al., 2017). Whilst ultrasound-guided insertion has been previously described (Van Dyk et al., 2021), we present a surgical video demonstrating a novel technique. We instead utilise a combination of both real-time ultrasound and direct hysteroscopic guidance to achieve successful IUBT applicator insertion following CCRT in a patient with stage IIa1 SCC cervix and previous failed insertion attempt due to complete stenosis of the endocervical canal. We demonstrate how post-radiation changes can be safely navigated - avoiding morbidity from procedural complications and ensuring successful outcome. Our case supports a collaborative approach to complex gynaecological cancer cases; with the combined skills of the oncology, radiology and surgical teams maximising patient safety - and optimising oncological treatment. Use of portable hand-held hysteroscopic devices would increase the feasibility of replicating our described technique in brachytherapy suites, mitigating need for theatre capacity; with MDT discussion central to the planning and staffing of cases.

Bartholin's gland carcinoma-the diagnostic and management challenges of a rare malignancy-a case report and review of current literature.

Background: Bartholin's gland carcinoma (BGC) accounts for approximately 5% of all vulval malignancies-making it an extremely rare malignancy of the female genital tract. It commonly manifests as a painless unilateral mass, near the introitus. BGC more commonly occurs in post-menopausal women. Unfortunately, over half of cases are associated with a missed or delayed diagnosis as it is often mistaken for a Bartholin's gland cyst or abscess. These tumours have a predilection for local and perineural invasion. Magnetic resonance imaging (MRI) is the imaging modality of choice for suspected Bartholin's tumour. Although no current guidance dedicated to the management of BGC exists, the majority of cases are treated by primary excision and bilateral groin node dissection (GND). Chemoradiotherapy has a role in both the adjuvant and palliative setting. BGC are typically associated with more advanced disease at presentation, higher rates of recurrence and poorer prognosis than other vulval cancer sub-types. Case Description: We share a case report of primary BGC-supported by high-quality radiological and surgical images; and further supplemented by a detailed review of current literature. Conclusions: We aim to generate improved clinician awareness of this rare pathology, highlighting the need for vigilance to avoid misdiagnosis and subsequent treatment delay; as well as contribute towards generating consensus on the approach to management of this gynaecological malignancy.

Does the presence of single compared to multiple endometrial polyps alter the risk of cancer in post-menopausal women?

OBJECTIVE: To evaluate the relative rates of malignancy in women with single and multiple polyps presenting to a UK Cancer Centre with postmenopausal bleeding (PMB). STUDY DESIGN: A retrospective review of patients treated at Royal Derby Hospital (RDH) for PMB who underwent outpatient hysteroscopy based on ultrasonographic suspicion of endometrial polyps between May 2014 to December 2019. The main outcome measure was the rates of precancerous and malignant histology for single or multiple polyps. The secondary outcomes assessed the influence of risk factors on the rates of malignancy within the single and multiple polyps groups. RESULTS: The study population was 851 women of which 533 were in the single polyp group and 318 in the multiple polyps group. The multiple polyps group (mean age 65.2 years) was older compared to the single polyp group (mean age 62.1 years), P = 0.0001. Elevated rates of cancer was driven most significantly by endometrioid cancer in the multiple polyps compared to single polyp group, with rates of 50/314 (16 %) and 28/512 (5.5 %) respectively, P=< 0.00001. For rarer histologies there was no significant difference between the proportion of serous, carcinosarcomas and clear cell cancers between those with single compared to multiple polyps (P > 0.05). Significantly more endometrial hyperplasia with atypia (AEH) was found in the multiple polyps compared to single polyp group, with rates of 18/314 (5.7 %) and 15/512 (2.9 %) respectively, P = 0.046. CONCLUSION: Our study found increased rates of endometrioid cancer and its precursor, AEH within the multiple polyps compared to the single polyps groups. Future risk predicting algorithms should consider incorporating single and multiple polyps as part of their risk model.

Does the character of the hospital of primary management influence outcomes in patients treated for presumed early stage endometrial cancer and atypical endometrial hyperplasia: a comparison of outcomes from a cancer unit and cancer centre.

A retrospective study from 2015 to 2020 comparing overall survival (OS) outcomes of a cancer unit and centre for presumed early stage endometrial cancers is presented. Cancer centres manage these presumed early endometrial cancer (EC) in situations of complex co-morbidities, surgical challenges as well as their own local unit patients. Our analysis compares 138 patients at KMH (unit) and 282 patients at RDH (centre) on OS, patient demographics, grading histology and final histology. Patients with presumed early stage EC can be reassured regarding no difference in OS between the cancer unit and centre management (p = .05). However, rates of minimal access surgery were higher at the cancer centre compared to the unit (93.2% versus 68.1%). The rates of upstaged disease were 4% and 8.8% at the cancer unit and centre respectively (p = .096). Sentinel node biopsy and genomic assessment may change future thresholds for centre-level management due to rates of upstaged disease.Impact StatementWhat is already known on this subject? Presumed lower risk endometrial cancers (endometrioid grades 1 and 2) have a rate of occult nodal involvement of only 1.4%. The BGCS does not recommend lymphadenectomy for low-risk endometrial cancers. These low-risk endometrial cancers should be managed with a hysterectomy and bilateral salpingo-ophrectomy via minimal access surgery. In view of the low rates of occult nodal involvement in low-risk endometrial cancer, surgery can be offered at a cancer unit.What do the results of this study add? Our study demonstrates there is no disadvantage in overall survival in the surgical management of presumed low-risk endometrial cancers at cancer units and centres. However, cancer centres have higher rates of minimal access to surgery despite managing a more elderly population. Our rates of upstaged disease of 4% and 8.8% at the cancer unit and centre indicate a potential benefit of pelvic lymph node assessment.What are the implications of these findings for clinical practice and/or further research? Sentinel lymph node biopsy does not have the surgical morbidity associated with systematic lymph node dissection. Therefore, when applied to presumed early stage endometrial cancer, there are potential changes in the threshold for centre-level management to improve overall survival.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival.

INTRODUCTION: Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined. MATERIALS AND METHODS: Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed. RESULTS: 42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes. CONCLUSION: Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

FARGO-360: a multi-disciplinary survey of practice and perspectives on provision of care for patients with frailty presenting with gynecological cancers in the UK and Ireland.

OBJECTIVES: Frailty has been associated with worse cancer-related outcomes for people with gynecological cancers. However, the lack of clear guidance on how to assess and modify frailty prior to instigating active treatments has the potential to lead to large variations in practice and outcomes. This study aimed to evaluate current practice and perspectives of healthcare practitioners on the provision of care for patients with frailty and a gynecological cancer. METHODS: Data were collected via a questionnaire-based survey distributed by the Audit and Research in Gynecological Oncology (ARGO) collaborative to healthcare professionals who identified as working with patients with gynecological malignancies in the United Kingdom (UK) or Ireland. Study data were collected using REDCap software hosted at the University of Manchester. Responses were collected over a 16 week period between January and April 2021. RESULTS: A total of 206 healthcare professionals (30 anesthetists (14.6%), 30 pre-operative nurses (14.6%), 51 surgeons (24.8%), 34 cancer specialist nurses (16.5%), 21 medical/clinical oncologists (10.2%), 25 physiotherapists/occupational therapists (12.1%) and 15 dieticians (7.3%)) completed the survey. The respondents worked at 19 hospital trusts across the UK and Ireland. Frailty scoring was not routinely performed in 63% of care settings, yet the majority of practitioners reported modifying their practice when providing and deciding on care for patients with frailty. Only 16% of organizations surveyed had a dedicated pathway for assessment and management of patients with frailty. A total of 37% of respondents reported access to prehabilitation services, 79% to enhanced recovery, and 27% to community rehabilitation teams. CONCLUSION: Practitioners from all groups surveyed considered that appropriate training, dedicated pathways for optimization, frailty specific performance indicators and evidence that frailty scoring had an impact on clinical outcomes and patient experience could all help to improve care for frail patients.

Lactate Is a Reliable Predictor of ICU Length of Stay Following Ultra-radical Ovarian Cancer Surgery.

BACKGROUND/AIM: With a greater proportion of women with advanced ovarian cancer (AOC) successfully undergoing radical cytoreductive surgery, the demand on peri-operative resources - including intensive care (ICU) beds - is also on the rise. Extended post-operative ICU length of stay (LOS) confers increased patient morbidity and mortality. Several variables associated with prolonged ICU LOS following AOC surgery have been identified. We aimed to evaluate the predictive value of serum lactate levels. PATIENTS AND METHODS: All patients undergoing ultra-radical surgery for AOC in a large cancer centre over a 34-month period between 2018-2021 were identified via the institution tumour registry. Data were collected retrospectively via electronic care and operating records; biochemistry, radiology, and histopathology databases. RESULTS: In total, 63 patients were identified. Elevated intra-operative serum lactate levels were associated with significantly longer length of ICU post-operative stay. Longer time for hyperlactaemia to normalise following surgery also conferred significantly longer ICU, high dependency and total hospital LOS. Greater blood loss, higher surgical complexity and peritoneal carcinomatosis score, and longer operating time were associated with higher - and persistently elevated - peri-operative lactate levels. CONCLUSION: Serum lactate in the context of ultra-radical surgery for AOC represents an accessible and inexpensive marker with potential to not only reliably predict LOS, but also to serve as a dynamic prompt for early targeted intervention. Early recognition and correction of hyperlactaemia following AOC may reduce ICU LOS limiting both the resource pressure and patient morbidity/mortality sequelae.

Transdiaphragmatic resection of enlarged cardiophrenic lymph node during interval debulking surgery for advanced ovarian cancer.

Surgery in advanced ovarian malignancy is indicated when complete debulking can be achieved. In patients with disease above the diaphragm, achieving R0 can present a surgical challenge and bring into question the feasibility of surgery (Soleymani majd et al., 2016, Pinelli et al., 2019). We present a surgical video demonstrating the technique of cardiophrenic lymph node dissection in advanced ovarian malignancy. Following type 3 liver mobilisation, the diaphragm is stripped and muscle opened to gain access to the thoracic cavity. Transdiaphragmatic assessment of the cardiophrenic lymph node bundle is performed. A bulky node - correlating with pre-operative radiology - is removed using an advanced energy device, maintaining the surrounding lung parenchyma and underlying pericardium safely in view throughout. The diaphragmatic is closed using a loop non-absorbable suture and placing continuous, locking sutures (Addley et al., 2021). We demonstrate that the presence of cardiophrenic lymphadenopathy is not an obstacle to complete debulking. By employing a trans-diaphragmatic technique to gain thoracic access, involved cardio-phrenic nodes - and hence all visible disease - can be surgically excised, successfully achieving R0 status and offering patients optimal prognosis.

Adamantinoma: metastatic disease masquerading as a gynaecological malignancy.

Adamantinoma is a rare low-grade malignancy of the appendicular skeleton with unclear histogenesis. We present the case of a 65-year-old woman with known recurrent and metastatic right tibial disease despite clear resection margins. On further investigation, a positron emission tomography-CT scan identified a primary breast lesion and an 11 cm mass in the right iliac fossa of suspected ovarian malignancy amenable to surgical resection. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and resection of a retroperitoneal mass arising from the pelvic sidewall encompassing the iliac vasculature. The patient made an uneventful recovery with histology confirming disease metastasising to the pelvis. Currently, clinical management guidelines are not available. We present an overview of adamantinoma and highlight a previously undocumented gynaecological oncology surgical approach to this novel disease location. Regarding metastases, we acknowledge the challenges of investigation pertaining to disease site and origin as well as a paucity of recommendations for surveillance and follow-up.

Aggressive anaplastic ovarian carcinoma in a young nulliparous patient.

Ovarian tumours harbouring foci of anaplastic carcinoma are extremely rare. With just a handful of cases reported in the literature, understanding of the disease and optimal management remains limited. A 38-year-old woman was referred to the gynaeoncologists with a multiloculated complex ovarian mass. High-grade mucinous ovarian carcinoma with mural nodules of anaplastic carcinoma was found on biopsy. Furthermore, an umbilical Sister Mary Joseph nodule signalled advanced metastatic disease. The patient underwent primary debulking surgery and was referred for adjuvant chemotherapy. High-quality radiological and surgical images are included to illustrate the approach taken to preoperative diagnosis and described surgical technique. Our case demonstrates the aggressive and rapidly progressive nature of mucinous ovarian carcinoma bearing anaplastic components. Sharing experience of such cases generates awareness and highlights the need for early detection and thorough investigations to guide subsequent management.

Primary diaphragmatic closure following diaphragmatic resection and cardiophrenic lymph node dissection during interval debulking surgery for advanced ovarian malignancy.

•Gaining trans-diaphragmatic access to thoracic cavity during de-bulking laparotomy.•Assessment and dissection of bulky cardiophrenic lymph nodes to achieve optimal cytoreduction.•Technique for primary closure of diaphragm following radical resection.

Rectovaginal extragastrointestinal stromal tumour (EGIST): an additional entity to be considered in the differential diagnosis of tumours of the rectovaginal septum.

Gastrointestinal stromal tumours (GISTs) are rare - and rectovaginal extragastrointestinal stromal tumours (RV-EGISTs) even rarer. We share a case of RV-EGIST, complemented by high-quality radiological and surgical images. A review of current literature pertaining to RV-EGIST is also included. Our case report highlights the diagnostic challenge presented by extragastrointestinal stromal tumours. Differentiated from overlapping pathologies only by targeted application of immunohistopathology and cytogenetics, the inclusion of RV-EGIST in the differential diagnosis of a rectovaginal tumour is essential to making this correct diagnosis. Primary surgery is the treatment of choice for RV-EGIST if complete cytoreduction can be achieved, combined with adjuvant tyrosine kinase inhibitor (TKI) therapy for those with high-risk features to further reduce rates of future recurrence.

The modified radical peripartum cesarean hysterectomy (Soleymani-Alazzam-Collins technique): a systematic, safe procedure for the management of severe placenta accreta spectrum.

BACKGROUND: The prevalence of placenta accreta spectrum is rising worldwide. The severe end of the spectrum where the placenta has invaded other organs is fortunately rare, however, few surgical techniques for such a complex hysterectomy have been described in the literature. OBJECTIVE: This study aimed to describe a stepwise, systematic technique for radical cesarean hysterectomy for placenta accreta spectrum to investigate outcomes for women with severe, invasive placenta accreta spectrum who were hysterectomized using this technique. STUDY DESIGN: This was a retrospective cohort study undertaken at a large UK tertiary referral center. A total of 24 cases of elective primary cesarean hysterectomy with a confirmed intrapartum diagnosis of severe percreta (Federation of Gynecology and Obstetrics grades 3b and 3c) were identified between 2011 and 2020. Among those cases, 16 had standard care (surgical technique dependent on surgeon's preference), and 8 had a radical peripartum hysterectomy using the Soleymani-Alazzam-Collins technique as described. Nonparametric testing was used because of sample size. RESULTS: The Soleymani-Alazzam-Collins technique resulted in significantly less blood loss (P=.032), more transverse incisions (P=.009), and less intensive care unit admissions (P=.046). Furthermore, there was no significant difference in theater time. CONCLUSION: The Soleymani-Alazzam-Collins technique demonstrated a significant improvement in outcomes for women with severe placenta accreta spectrum, without increasing surgical time.

Laparoscopic resection of single site pelvic side wall recurrence 6 years after stage IIIc high grade serous primary peritoneal cancer.

The findings of the DESKTOP 3 (Du Bois et al., 2017) ​study advocate secondary cytoreduction in patients with disease relapse of ovarian or peritoneal malignancy meeting specified criteria. We present a surgical video demonstrating the technique of laparoscopic resection of single site pelvic side wall recurrence 6 years after stage IIIc high grade serous primary peritoneal cancer. In 2014, our patient underwent 3 cycles of neo-adjuvant Cisplatin/Paclitaxel, followed by interval debulking surgery - achieving R0 - for stage IIIc high grade serous primary peritoneal carcinoma. Six years later, at aged 81 years, routine surveillance identified a rising CA 125 level of 91. CT imaging confirmed single site recurrence, reporting an isolated enlarged (3.5 × 2 cm) external iliac lymph node. Given the prolonged disease-free interval, absence of ascites, resectability of recurrent disease and fitness for surgery - secondary cytoreduction was undertaken. Our surgical video demonstrates gaining laparoscopic retroperitoneal access and the subsequent development of the lateral pelvic spaces to facilitate safe excision of disease relapse with a clear surgical margin, Our surgical video demonstrates the feasibility of minimal access surgery for single site recurrence of peritoneal carcinoma, highlighting the importance of understanding and exposing pelvic sidewall anatomy to enable safe and adequate resection - systematically identifying and preserving the ureter, iliac vessels and obturator nerve.

Malignant struma ovarii: surgical, histopathological and survival outcomes for thyroid-type carcinoma of struma ovarii with recommendations for standardising multi-modal management. A retrospective case series sharing the experience of a single institution over 10 years.

PURPOSE: Struma ovarii is rare, accounting for 0.3-1% of ovarian tumours. Malignant transformation may occur, most often into papillary thyroid carcinoma. There is a paucity of data pertaining to malignant struma ovarii. This paper shares a decade of experience of a single institution in the management of this rare ovarian cancer, exploring the characteristics of this tumour and suggesting a standardised approach to treatment and follow-up. METHODS: All patients treated for malignant struma ovarii within a large cancer centre over one decade were identified and data collected retrospectively on presentation, diagnosis, management, follow-up and survival outcomes. A literature review was also undertaken. RESULTS: Eleven cases of malignant struma ovarii were managed in the Oxford Cancer Centre between 2010 and 2019, 6 of which were of papillary thyroid carcinoma sub-type. No cases were correctly diagnosed pre-operatively. All patients had stage I disease and were managed surgically-but with variation in radicality. Patients identified as high-risk based on final histopathology underwent additional thyroidectomy and radio-active iodine ablation therapy. One case of synchronous malignancy of the thyroid gland proper was identified. No disease recurrence occurred. CONCLUSION: Malignant struma ovarii present a diagnostic challenge. Multi-disciplinary team (MDT) input is essential. Unilateral salpingo-oophrectomy may be adequate if stage I; reserving more radical surgery for advanced disease. Histopathological risk-stratification should be used to identify those most likely to benefit from adjuvant thyroid-targeting therapies. Patients require follow-up, anticipating an overall good prognosis.