European Surgical Education and Training in Gynecologic Oncology: The impact of an Accredited Fellowship.

OBJECTIVE: The aim of this study was to understand the current situation of surgical education and training in Europe among members of the European Society of Gynecological Oncology (ESGO) and its impact on the daily surgical practice of those that have completed an accredited fellowship in gynecologic oncology. METHODS: A questionnaire addressing topics of interest in surgical training was designed and sent to ESGO members with surgical experience in gynecologic oncology. The survey was completely confidentially and could be completed in less than 5 minutes. Responses from 349 members from 42 European countries were obtained, which was 38% of the potential target population. The respondents were divided into 2 groups depending on whether they had undergone an official accreditation process. RESULTS: Two thirds of respondents said they had received a good surgical education. However, accredited gynecologists felt that global surgical training was significantly better. Surgical self-confidence among accredited specialists was significantly higher regarding most surgical oncological procedures than it was among their peers without such accreditation. However, the rate of self-assurance in ultraradical operations, and bowel and urinary reconstruction was quite low in both groups. There was a general request for standardizing surgical education across the ESGO area. Respondents demanded further training in laparoscopy, ultraradical procedures, bowel and urinary reconstruction, and postoperative management of complications. Furthermore, they requested the creation of fellowship programs in places where they are not now accredited and the promotion of rotations and exchange in centers of excellence. Finally, respondents want supporting training in disadvantaged countries of the ESGO area. CONCLUSIONS: Specialists in gynecologic oncology that have obtained a formal accreditation received a significantly better surgical education than those that have not. The ESGO responders recognize that their society should lead the standardization of surgical training and promote ways of improving members' surgical skills.

FIGO stage IV epithelial ovarian, fallopian tube and peritoneal cancer revisited.

Epithelial ovarian, fallopian tube and peritoneal cancer (EOC) is the seventh most common cancer diagnosis among women worldwide and shows the highest mortality rate of all gynecologic tumors. Different histological and anatomic spread patterns as well as multiple gene-expression based studies have demonstrated that EOC is indeed a heterogeneous disease. The prognostic factors that best predict the survival in this disease include: age, performance status and patient's comorbidities at the time of diagnosis; tumor biology, histological type, amount of residual tumor after surgery and finally tumor stage as surrogate for pre-operative tumor burden and growth pattern. In the majority of patients, the disease is diagnosed in advanced stage, disseminated intra- and/or extra-abdominally. It is unclear whether this is a consequence of distinct tumor biology, absence of anatomic barriers between ovary and the abdominal cavity, delay of diagnosis and/or the lack of sufficient early detection methods. FIGO stage IV disease, defined as tumor spread outside the abdominal cavity (including malignant pleural effusion) and/or visceral metastases, will be present in 12-33% of the patients at initial diagnosis. Overall, median survival for patients with stage IV disease ranges from 15 to 29months, with an estimated 5-year survival of approximately 20%. Unfortunately, over the past decades the overall survival gain compared to stage III remains disappointing. The current review aims to summarize the current data published in the international literature concerning FIGO stage IV EOC and discusses the published evidence for the clinical management of these patients.

Minimal Macroscopic Residual Disease (0.1-1 cm). Is It Still a Surgical Goal in Advanced Ovarian Cancer?

OBJECTIVE: The objective of this review was to try to determine by searching in the literature what is the survival in patients with advanced ovarian cancer after a primary debulking with minimal macroscopic residual disease (MMRD; 0.1-10 mm). Additionally, this review aimed to explore the survival in patients with residual disease from 0.1 to 0.5 cm. METHODS: A retrospective search was accomplished in the PubMed database looking for all English-language articles published between January 1, 2007 and December 31, 2014, under the following search strategy: "ovarian cancer and cytoreduction" or "ovarian cancer and phase III trial". We selected those articles that contain information on both percentage of MMRD (0.1-1 cm) and median overall survival (OS) in this subset of patients with stage III to stage IV ovarian cancer after primary debulking surgery. RESULTS: Thirteen publications were obtained including information of a total 11,999 patients with stage III to stage IV ovarian cancer. Five thousand thirty-seven patients (42%) had MMRD after the primary debulking (0.1-1 cm). Median overall survival in patients with MMRD was 40 months and disease-free survival (DFS) was 16 months. This group of patients obtained an advantage of 10 months in OS (40 vs 30 m) and 4 months in DFS (16 vs 12 m) compared with the group with suboptimal debulking (P < 0.001). Compared with the group of complete resection, patients with minimal macroscopic residuum showed a significant inferior median OS and DFS of 30 months and 14 months, respectively (OS, 70 vs 40 m; DFS, 30 vs 16 m) (P < 0.001). The group of residual disease of 0.1 to 0.5 cm reached a median survival of 53 months. CONCLUSIONS: Patients with ovarian cancer with MMRD after primary surgery obtain a modest but significant advantage in survival (10 months) over suboptimal patients. Patients with macroscopic residual disease (0.1-0.5 cm) obtain a better survival (53 months) than those with more than 0.5 to 1 cm. We propose that they should be classified as a different prognostic group.

A critical appraisal of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer.

OBJECTIVE: Our objective was to review the published experiences of the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer with a focus on survival outcomes. METHODS: A search of the PubMed database (2008-2014) for articles specifically addressing the topic "HIPEC and ovarian cancer" was performed. We found a total of 22 publications that included 1450 patients. A final group of eleven studies (248 patients with advanced ovarian cancer) and eight publications (499 patients with recurrent sensitive ovarian cancer) that included information about survival were reviewed. RESULTS: Among patients with primary ovarian cancer who were treated with primary debulking and HIPEC, the weighted median overall survival was 37.3 months (range 27-78), the median disease-free survival was 14.4 months (range 12-30), and the 5-yr-survival rate was 40% (range 28-72). In the recurrent cohort, the overall survival after HIPEC was 36.5 months (range 23-62), and the median disease-free survival was 20.2 months (range 11-29). The rates of severe morbidity were 25 and 19% in the primary and recurrent groups, respectively. CONCLUSION: Although randomized trials are ongoing, the recently published retrospective data regarding the use of HIPEC for primary advanced and for recurrent ovarian cancer do not indicate any apparent advantage of this treatment in terms of the survival outcomes in these patients. Therefore, HIPEC cannot be considered a standard treatment and should not be offered outside of clinical trials.

Ovarian low-grade serous carcinoma: a comprehensive update.

Ovarian low-grade serous ovarian carcinoma (OvLGSCa) comprises a minority within the heterogeneous group of ovarian carcinomas. Despite biological differences with their high-grade serous counterparts, current treatment guidelines do not distinguish between these two entities. OvLGSCas are characterized by an indolent clinical course. They usually develop from serous tumors of low malignant potential, although they can also arise de novo. When compared with patients with ovarian high grade serous carcinoma (OvHGSCa) patients with OvLGSCa are younger and have better survival outcomes. Current clinical and treatment data available for OvLGSCa come from retrospective studies, suggesting that optimal cytoreductive surgery remains the cornerstone in treatment, whereas chemotherapy has a limited role. Molecular studies have revealed the preponderance of the RAS-RAF-MAPK signaling pathway in the pathogenesis of OvLGSCa, thereby representing an attractive therapeutic target for patients affected by this disease. Improved clinical trial designs and international collaboration are required to optimally address the unmet medical treatment needs of patients affected by this disease.

Ileal orthotopic neobladder after pelvic exenteration for cervical cancer.

OBJECTIVE: We aimed to describe our preliminary experience in creating an ileal orthotopic urinary conduit in patients with a history of pelvic irradiation undergoing pelvic exenteration for recurrent cervical cancer and to evaluate the feasibility, complication rates, and outcomes of this procedure. METHODS: A retrospective chart review was performed in all 6 patients who underwent ileal orthotopic neobladder creation at our institution between January 2005 and March 2008. Main outcome measures were surgical complications, continence rate, neobladder function, and oncologic outcome. RESULTS: The mean patient age was 46.6 years (range, 38-61). Four patients underwent anterior exenteration and 2 total pelvic exenterations. There were no intraoperative complications. The median operative time was 456 min (range, 372-600). The median time to create the orthotopic urinary conduit was 70 min (range, 55-90). Three patients had postoperative neobladder anastomotic leak. Two of them had this complication successfully managed conservatively and 1 surgically. Daytime urinary continence was good or satisfactory in 4 of 6 patients. Nighttime urinary continence was good or satisfactory in 3 of 6 patients. All patients reported being satisfied with their decision to undergo this procedure. Median follow-up time was 20.5 months (range, 6-34). At last visit, 3 patients were alive without evidence of disease, 1 was alive with stable retroperitoneal disease, and 2 had died of disease recurrence after exenteration. CONCLUSIONS: Ileal orthotopic neobladder creation in patients undergoing exenteration for recurrent cervical cancer is feasible after radiation. The rate of urinary continence is acceptable.

Surgical treatment of recurrent cervical cancer: state of the art and new achievements.

This article review the current situation of the exenterative procedures as part of the treatment of recurrent cervical cancer after radiation. Pelvic exenteration has been proven the only curative choice of treatment in selected cases of this clinical situation. A review of historical and recent published series have shown an increase of 5-y survival from 30 to 42 %. Almost one out of two patients will suffer complications of some kind, and one out of three will have a severe complication with pelvic exenteration. During the past sixty years, a number of outstanding improvements have been achieved - not only in surgical outcomes, but also in quality of life - owing to new reconstructive approaches. Women facing an exenterative procedure must be counseled carefully about the risks and long-term concerns related to the procedure. Each should undergo a comprehensive evaluation to make sure there is no evidence of unresectable or metastatic disease that would make her an unsuitable candidate for exenteration.

The current role of neoadjuvant chemotherapy in the management of cervical carcinoma.

The role of neoadjuvant chemotherapy (NACT) in cervical cancer has been a matter of investigation over the last 20 years. A systematic review and meta-analysis of individual patient data (IPD) demonstrated that NACT followed by surgery is superior to radiotherapy alone in terms of overall survival. However, in spite of the results of the meta-analysis, NACT has not been adopted as the new standard of care. In the present paper, we review the reasons why NACT is still considered an investigational approach in cervical cancer.