Comparison of Outcomes in Bowel Resections by Gynecologic Oncologists Versus General Surgeons During Maximal Cytoreductive Surgery for Advanced Ovarian Cancer: Gynecologic Oncology Research Investigators Collaboration Study (GORILLA-3006).

BACKGROUND: This report describes the oncologic outcomes for patients with advanced ovarian cancer who had bowel surgery performed by gynecologic oncologists (GOs) and compares the outcomes with those for bowel surgery performed by general surgeons (GSs) during maximal cytoreductive surgery. METHODS: Patients from six academic institutions who had FIGO stage III or IV ovarian cancer and underwent any bowel surgeries during maximal cytoreductive surgery were eligible for the study. The patients were divided into two groups according to whether bowel surgery was performed by a GO or a GS. In both groups, the GOs were mainly involved in extra bowel debulking procedures. Perioperative and survival outcomes were compared between the two groups. RESULTS: The 761 patients in this study included 113 patients who underwent bowel surgery by a GO and 648 who had bowel surgery by a GS. No discernible differences were observed in age, American Society of Anesthesiology (ASA) score, FIGO stage, histologic type, timing of cytoreductive surgery (primary or interval debulking surgery), or complications between the two groups. The GO group exhibited a shorter operation time than the GS group. Kaplan-Meier analysis showed no survival differences between the two groups. In the Cox analysis, non-serous cell types and gross residual diseases were associated with adverse effects on overall survival. However, performance of bowel surgery by a GO did not have an impact on survival. CONCLUSION: Performance of bowel surgery by a GO during maximal cytoreductive surgery is both feasible and safe. These results should be reflected in the training system for GOs regarding bowel surgery, and further research is needed to confirm that GOs can play a more leading role in performing extra-uterine procedures.

Is minimally invasive radical surgery safe for patients with cervical cancer ≤2 cm in size? (MISAFE): Gynecologic Oncology Research Investigators coLLborAtion study (GORILLA-1003).

OBJECTIVE: To identify clinicopathological factors associated with disease recurrence for patients with 2018 FIGO stage IA with lymphovascular invasion to IB1 cervical cancer treated with minimally invasive surgery (MIS). METHODS: A total of 722 patients with cervical cancer between January 2010 and February 2021 were identified. Clinicopathological factors related to disease recurrence were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. To determine prognostic factors for DFS, a Cox proportional hazard regression model was used. RESULTS: Of 722 patients, 49 (6.8%) experienced disease recurrence (37 pelvis, 1 para-aortic lymph node, and 11 peritoneum). Five-year DFS and OS rates were 90.7% and 98.1%, respectively. In multivariate analysis, risk factors associated with disease recurrence were residual disease in the remaining cervix (OR, 3.122; 95% CI, 1.152-8.461; p = 0.025), intracorporeal colpotomy (OR, 3.252; 95% CI, 1.507-7.017; p = 0.003), and positive resection margin (OR, 3.078; 95% CI, 1.031-9.193; p = 0.044). The non-conization group had a higher percentage of stage IB1 (77.4% vs. 64.6%; p = 0.004) and larger tumor (10 mm vs. 7 mm; p < 0.001) than the conization group. Intracorporeal colpotomy and residual disease in the remaining cervix were independent variables associated with disease recurrence in patients undergoing MIS following conization. CONCLUSION: During MIS, patients with cervical cancer ≤2 cm in size can be vulnerable to peritoneal recurrences. Patients diagnosed with invasive cancer through conization often have low-risk pathological features, which may affect their survival outcomes.

Fertility-sparing hormonal treatment in patients with stage I endometrial cancer of grade 2 without myometrial invasion and grade 1-2 with superficial myometrial invasion: Gynecologic Oncology Research Investigators coLLaborAtion study (GORILLA-2001).

OBJECTIVES: To evaluate oncologic and pregnancy outcomes of fertility-sparing treatment (FST) using progestin in patients with stage I grade 2 endometrioid endometrial cancer (EC) without myometrial invasion (MI) or grade 1-2 with superficial MI. METHODS: Multicenter data of patients with stage I grade 2 EC without MI or grade 1-2 EC with superficial MI, who received FST between 2005 and 2021, were analyzed. Cox regression analysis identified independent factors for progressive disease (PD) during the FST. RESULTS: Altogether, 54 patients received FST [medroxyprogesterone acetate (500-1000 mg) in 44, megestrol acetate (40-800 mg) in 10] with concurrent levonorgestrel-releasing intrauterine devices use in 31. With median time to achieve a complete response (CR) of 10 (3-24) months, 39 patients (72.2%) achieved CR. Of the 15 patients who attempted to conceive after achieving CR, 7 (46.7%) became pregnant (2 abortions, 5 live births). During a median FST duration of 6 (3-12) months, nine patients (16.6%) were diagnosed with PD. Fifteen (38.5%) experienced recurrence with a median recurrence-free survival of 23 (3-101) months. In the multivariable analysis, tumor size before FST ≥2 cm (HR 5.456, 95% CI 1.34 to 22.14; p = 0.018) was significantly associated with a high PD rate during FST. CONCLUSION: The overall response rate to FST was promising, however, the PD rate was significant during the first 12 months of FST. Therefore, performing thorough endometrial biopsy and imaging studies is essential to strictly evaluate the extent of the disease every 3 months from FST initiation.

Optimum selection criteria for secondary cytoreductive surgery in patients with recurrent epithelial ovarian cancer: A multicenter study from the Gynecologic Oncology Research Investigators coLLaborAtion group (GORILLA-3001).

BACKGROUND: To identify those most likely to benefit from secondary cytoreductive surgery (SCS), we evaluated the survival outcomes and factors predictive of prognosis in patients with recurrent ovarian cancer. METHODS: We retrospectively reviewed the medical records of patients with recurrent ovarian cancer treated at five high-volume Korean hospitals between 2010 and 2021. Recurrence characteristics, treatment methods, and potential predictors of survival were compared between the chemotherapy and surgery groups. RESULTS: Among all 670 patients, 88.1% had initial stage III/IV disease, and 215 (32.1%) underwent SCS. Among patients who underwent SCS, only those who achieved complete resection exhibited improved survival. Even in patients with residual disease < 1 cm after SCS, we observed no significant survival benefit (p = 0.942). In the multivariate Cox analysis, residual disease at primary surgery, progression-free interval, recurrence sites (≤3 regions or limited carcinomatosis), ascites, and SCS were significant predictors of survival. Meanwhile, the only factor predictive of complete resection after SCS was recurrence sites (p < 0.001). CONCLUSIONS: The benefits of SCS appear to be exclusive to cases of complete resection. We propose limited regional platinum-sensitive recurrence (≤3 regions or limited carcinomatosis) without ascites as the optimum selection criteria for SCS.

Significance of cholecystectomy in cytoreductive surgery for advanced ovarian cancer.

BACKGROUND: There have been no studies concerning the complications or benefits of cholecystectomy in ovarian cancer. In this study, we aimed to evaluate the outcomes of cholecystectomy performed during various time periods of the disease course and suggest a management strategy for cholecystectomy in ovarian cancer. METHODS: We retrospectively reviewed the medical records of patients with advanced ovarian cancer who underwent cholecystectomy during the cytoreductive surgery from 2009 to 2020. Cholecystectomy was primarily indicated when the gallbladder and surrounding structures were considered to have metastatic tumor invasion. If the final pathologic results showed free of malignant tumor, patients were placed into the no-infiltration group. Clinical outcomes including the recurrence rate and complications were analyzed. RESULTS: A total of 62 patients underwent cholecystectomy, 48 of whom (77.4%) underwent cholecystectomy during primary or interval debulking surgery, whereas 14 (22.6%) underwent cholecystectomy during the follow-up period (five with benign disease and 9 with disease recurrence). Among the patients, 32 (51.6%) patients were included in the no-infiltration group in the final pathology. There were no complications observed in the no-infiltration group (n = 32). Seven (78%) of the nine patients who received cholecystectomy for disease recurrence had metastatic disease in the porta-hepatis or lesser sac at the time of primary surgery. However, no recurrent lesions were observed around the porta-hepatis in patients who received cholecystectomy during primary treatment. CONCLUSION: Considering the safety of the procedure, as well as the risk of disease recurrence or cholecystitis, a cholecystectomy can be offered to patients with ovarian cancer who have metastatic lesions around the gallbladder and porta-hepatis at the time of primary surgery.

Gastrointestinal/genitourinary perforation and fistula formation with or without bevacizumab in patients with previously irradiated recurrent cervical cancer: a Korean multicenter retrospective study of the Gynecologic Oncology Research Investigators Collaboration (GORILLA) group (GORILLA-1001).

BACKGROUND: This study aims to evaluate the incidence of and identify risk factors for gastrointestinal (GI) and genitourinary (GU) fistula or perforation formation with or without bevacizumab in patients with recurrent cervical cancer who underwent pelvic radiation therapy (RT). METHODS: Medical records of patients with recurrent cervical cancer who previously underwent pelvic RT between 2007 and 2020 were retrospectively reviewed. Clinicopathological factors were compared between groups that are stratified according to: 1) fistula/perforation (+) versus (-); and 2) bevacizumab plus conventional chemotherapy (BC) versus chemotherapy alone (C). Univariate and multivariate regression analyses were performed to identify risk factors for fistula/perforation. Overall survival (OS) was compared between the different groups. RESULTS: Of 219 participants, fistula/perforation of any grade occurred in 36 patients (16.4%); 27 fistulas and 9 perforations. Bevacizumab was more frequently used in Bevacizumab was more frequently used ( +) group than fistula/perforation (-) group (p = 0.015). Multivariate analysis showed that bevacizumab administration was the only independent risk factor for fistula or perforation (HR, 3.27; 95% CI, 1.18-9.10; P = 0.023). F/P was observed more frequently in women receiving BC (n = 144) than those receiving C (n = 75) (20.8% vs. 8.0%; P = 0.019). During median follow-up of 33.7 months (1.2-185.6 months), no significant OS difference was observed between fistula/perforation ( +) vs. (-) (hazards ratio [HR], 1.78; median 84.2 months [95% CI, 59.3-109.0] vs. 129.5 months [95% CI, 114.1-144.9]; P = 0.065) or BC vs. C (HR, 1.03; median 119.8 months [95% CI, 97.3-142.3] vs. 115.7 months [95% CI, 96.0-135.4]; P = 0.928). CONCLUSIONS: This study suggests that incorporation of bevacizumab in chemotherapy regimens for treating recurrent cervical cancer in patients who underwent pelvic RT incurs considerable risk for GI/GU fistula or perforation. There were no other independent risk factors for developing GI/GU fistula or perforation in this study population.

Treatment outcomes and complications in FIGO stage IIIC and IVB endometrioid endometrial cancer patients presenting as nodal spreads following systematic lymphadenectomy and adjuvant therapy.

OBJECTIVE: To evaluate the treatment outcomes and complications of patients with FIGO stage IIIC and IVB endometrioid endometrial cancer (EC) presenting primarily as nodal spreads following systematic lymphadenectomy and adjuvant therapy. MATERIAL AND METHODS: Forty-four FIGO stage IIIC and IVB endometrioid EC patients between July 2003 and March 2020 received staging procedures including systematic lymphadenectomy. The survival outcomes and late treatment-related complications were compared between adjuvant chemoradiation-based group and chemotherapy-based group. RESULTS: Of the 44 patients, 16 (36.4%) had stage IIIC1, 26 (59.1%) had stage IIIC2, and 2 (4.5%) had stage IVB disease. The median follow-up time was 54 months (range, 10-185 months). There was no statistical difference in mortality between the microscopic and macroscopic nodal groups (6.2% vs 4.3%, p > 0.999). Eleven patients (25.0%) and 33 patients (75.0%) received adjuvant chemoradiation and chemotherapy, respectively. The 5-year disease-free and overall survival rates were not different between the two groups (disease-free survival, 81.8% vs 82.1%, p = 0.743; overall survival, 90.9% vs 95.8%, p = 0.537). The incidence rates of grade 2 lymphedema (36.4% vs 9.1%, p = 0.032) and grade 2/3 gastrointestinal complications (36.4% vs 0.0%, p < 0.001) were higher in the chemoradiation-based group than those in the chemotherapy-based group. CONCLUSIONS: Systematic lymphadenectomy and adjuvant chemotherapy might be the preferred treatment for FIGO stage IIIC and IVB endometrioid EC patients presenting as nodal spreads given that no difference in patient survival was found, but a higher incidence of treatment-related complications was observed in the chemoradiation-based group.

Comparison of posterior rectal dissection techniques during rectosigmoid colon resection as part of cytoreductive surgery in patients with epithelial ovarian cancer: Close rectal dissection versus total mesorectal excision.

OBJECTIVE: The aim of this study was to evaluate the clinical outcomes of close rectal dissection (CRD) compared with those of total mesorectal excision (TME) as the posterior rectal dissection procedure during rectosigmoid colectomy performed as part of cytoreductive surgery in patients with epithelial ovarian cancer. METHODS: We retrospectively reviewed the medical records of 163 patients who underwent posterior rectal dissection for rectosigmoid resection, including low anterior resection or subtotal colectomy, as part of ovarian cancer surgery from 2006 to 2018. The TME technique was mainly performed by colorectal surgeons, and the CRD technique preserving the mesorectal tissue was performed by an experienced gynecologic oncology surgeon. The patients were divided into the TME group and the CRD group, and their clinical outcomes were analyzed. RESULTS: A total of 163 patients with ovarian cancer underwent rectosigmoid colon resection. Among the patients, 87 (53.4%) underwent CRD and 76 (46.6%) underwent TME as the posterior rectal dissection technique. The disease severity according to FIGO stage (p = .390) and the residual disease status (p = .412) were not statistically different between the 2 groups. However, the postoperative incidences of anastomotic leakage (p = .045) and prolonged ileus (>7 days, p = .055) were higher in the TME group. The pelvic recurrence rate and progression-free survival did not differ between the 2 groups (p = .663 and .790, respectively). CONCLUSIONS: Considering the perioperative outcomes, CRD may be an alternative technique for rectal dissection in ovarian cancer with less perioperative morbidity and equivalent oncologic outcomes.

Perioperative outcomes of extensive bowel resection during cytoreductive surgery in patients with advanced ovarian cancer.

BACKGROUND AND OBJECTIVES: To achieve optimal cytoreduction, extensive bowel resections are sometimes required in patients with advanced ovarian cancer. Few studies have focused on the extent or number of resections of bowel surgeries and their feasibility. METHODS: We retrospectively reviewed the medical records of patients with advanced ovarian cancer who underwent bowel surgery as part of debulking procedures at Ajou University Hospital from 2006 to 2018. Patients who received extensive bowel resections (two-segment resections or subtotal colectomy) were identified, and their perioperative outcomes were evaluated. RESULTS: A total of 172 patients underwent bowel surgery. Of them, 128 (74.4%) underwent one-segment bowel resection, 25 (14.5%) underwent two-segment bowel resections, and 19 (11.1%) underwent subtotal colectomy. Although the operative time, transfusion rate, and postoperative bleeding events were higher in patients who underwent extensive bowel resection, the rates of perioperative complications were not significantly higher in this group. Anastomotic leakage occurred in two (1.5%) patients in the one-segment resection group, one (4.2%) patient in the multiple resection group, and two (10.5%) patients in the subtotal colectomy group. CONCLUSIONS: Multiple bowel resections (up to two segments) are feasible and can be safely performed with an acceptable complication rate in patients with advanced ovarian cancer.

Risk factors for septic adverse events and their impact on survival in advanced ovarian cancer patients treated with neoadjuvant chemotherapy and interval debulking surgery.

OBJECTIVES: The aim of this study was to analyze risk factors for septic complications during adjuvant chemotherapy and their impact on survival in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). METHODS: We retrospectively reviewed the medical records of 69 patients with advanced epithelial ovarian cancer from 2004 to 2017. All patients underwent three cycles of NACT followed by IDS and adjuvant chemotherapy. We identified grade 3 or 4 hematologic complications and severe adverse events accompanied by neutropenia, including sepsis or septic shock, that occurred during treatment. Clinicopathologic data including demographic factors, preoperative medical conditions, surgical procedures, and survival times were evaluated. RESULTS: Of 69 patients, 27 (39.1%), 6 (8.8%), and 2 (2.9%) patients experienced grade 3 or 4 neutropenia, anemia, and thrombocytopenia, respectively, during NACT. Thirteen patients (18.8%) had a neutropenic fever with sepsis and 2 patients (2.9%) died of septic shock during adjuvant chemotherapy. Concurrent medical disease, splenectomy during IDS, and anemia or thrombocytopenia during NACT were significant risk factors for septic adverse events. In multivariate analysis, anemia (hemoglobin < 8 g/dL, p = 0.004) during NACT was the only significant factor associated with septic adverse events during adjuvant chemotherapy. Although there was no significant difference in progression-free survival, overall survival was significantly shorter in patients with septic adverse events (median, 82.3 vs. 17.3 months, p = 0.007). CONCLUSIONS: Grade 3 anemia during NACT may be an early indicator for septic adverse events during adjuvant chemotherapy. Considering the adverse impact on survival, scheme and dose of adjuvant chemotherapy should be tailored, and careful follow-up evaluation should be ensured in this patient group.

A study of clinicopathologic factors as indicators for early prediction of suboptimal debulking surgery after neoadjuvant chemotherapy in advanced ovarian cancer.

AIM: This study aimed to evaluate early clinicopathologic factors predicting gross residual disease after neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer. METHODS: We analyzed clinicopathologic data of 68 patients with ovarian cancer who were treated with neoadjuvant chemotherapy followed by interval debulking surgery (NAC-IDS) between March 2006 and December 2016. All the patients received three cycles of NAC followed IDS. We evaluated all possible clinicopathologic characteristics, including reduction rates of serum CA-125 after each NAC and seven initial abdominopelvic computed tomography (CT) findings related to disease severity. RESULTS: After IDS, no gross residual disease was found in 46 (67.6%) patients and 22 (33.4%) patients had gross residual disease. Multivariate analysis identified that reduction rate of CA-125 after 2nd NAC, body mass index (BMI) and small bowel lesion in the initial CT findings were significantly associated with gross residual disease after IDS (P = 0.005, 0.030, 0.001, respectively). The optimal cutoff value predicting gross residual disease were less than 50% of CA-125 reduction rate after 2nd NAC and low BMI (<23 kg/m2 ). The combined receiver operating characteristic curve analysis of these factors showed good performance for predicting gross residual disease after IDS (area under the curve = 0.845). CONCLUSION: A model using small bowel mesentery involvement on CT, BMI (<23 kg/m2 ) and less than 50% reduction of the initial CA-125 level after the 2nd NAC is highly predictive of gross residual disease after IDS in advanced ovarian cancer patients. These results may be helpful in further treatment planning and patients counseling.

Treatment outcomes in patients with FIGO stage IB-IIA cervical cancer and a focally disrupted cervical stromal ring on magnetic resonance imaging: A propensity score matching study.

OBJECTIVE: The aim of this study was to compare treatment outcomes of primary concurrent chemoradiation therapy (CCRT) versus radical hysterectomy (RH) followed by adjuvant RT or CCRT in patients with FIGO stage IB-IIA cervical cancer with focal disruption of the cervical stromal ring on magnetic resonance imaging (MRI). METHODS: We retrospectively analyzed the clinicopathological data of 156 patients with FIGO stage IB-IIA cervical cancer showing a focal disruption of the stromal ring on MRI between March 2000 and March 2015. Treatment outcomes were compared between the RT-based (n=54) group and RH-based group (n=54) after propensity score matching of each of the patients using a logistic regression model, including age, tumor size on MRI, pelvic lymph node enlargement on MRI, and histology. RESULTS: Five-year disease-free survival rate was 83.1% for the RT-based group and 77.4% for the RH-based group (p=0.228). Five-year disease-specific survival rate was 84.3% for the RT-based group and 83.5% for the RH-based group (p=0.434). Incidence rates of late grade 3 genitourinary adverse reactions (14.8% vs. 0.0%, p=0.006) were significantly higher in the RH-based group than those in the RT-based group. CONCLUSIONS: Primary CCRT might be the preferred treatment for FIGO stage IB-IIA cervical cancer patients with focal disruption of cervical stromal ring on MRI given that no difference in patient's survival was found, but higher incidence of treatment-related complications was observed in the RH-based group. Also, primary radical surgery should be done more cautiously in these patients.

Preoperative nomogram for prediction of microscopic parametrial infiltration in patients with FIGO stage IB cervical cancer treated with radical hysterectomy.

OBJECTIVE: This study aimed to establish a nomogram to predict microscopic parametrial infiltration (PMI) by combining preoperative clinicopathologic factors in FIGO stage IB cervical cancer patients treated by radical hysterectomy (RH). METHODS: We retrospectively analyzed clinicopathologic data of 298 patients with FIGO stage IB cervical cancer treated by RH between February 2000 and March 2015. The nomogram was developed based on multivariate logistic regression analysis of preoperative clinicopathologic data. The accuracy and discriminative ability of the nomogram were evaluated by a concordance index and calibration curve. The low-risk group was predefined as having a predicted probability of PMI <10%. RESULTS: Multivariate analysis identified diameter-based tumor volume and disruption of the cervical stromal ring on magnetic resonance imaging, serum squamous cell carcinoma antigen level, and menopausal status as independent prognostic factors associated with PMI. The concordance index of the nomogram was 0.940 (95% CI, 0.908-0.967), and calibration plots revealed good agreement between the observed probabilities and nomogram-predicted probabilities (Hosmer Lemeshow test, p=0.574). The nomogram classified 200 out of 298 patients (67.1%) as low risk. In the low-risk group, the predicted probability of PMI was 3.5% and the actual PMI rate was 2.5% (5 out of 200). CONCLUSIONS: We developed a preoperative nomogram predicting microscopic PMI in surgically treated FIGO stage IB cervical cancer patients. The probabilities derived from this nomogram may have the potential to provide valuable guidance for physicians regarding the primary management of FIGO stage IB cervical cancer patients.

Value of endocervical margin and high-risk human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia, adenocarcinoma in situ, and microinvasive carcinoma of the uterine cervix.

OBJECTIVE: The aim of this study was to analyze clinico-pathologic factors and the optimal cut-off value of high-risk human papillomavirus (HR-HPV) viral load for predicting high-grade residual/recurrent disease after the conization in cervical intraepithelial neoplasia (CIN 2-3), adenocarcinoma in situ (AIS), and microinvasive carcinoma of the uterine cervix (MICA). METHODS: We retrospectively reviewed data from 701 patients with CIN 2-3, AIS, and MICA who underwent conization between September 2003 and June 2012. Receiver-operating characteristic curve analysis was used to find out the cut-off value of HR-HPV viral load for predicting residual/recurrent disease. Clinico-pathologic variables, including resection margin and HR-HPV status, were evaluated as possible predictors of residual/recurrent disease. RESULTS: At a cut-off value of 1.16 RLU/CO for post-cone HR-HPV viral load, the sensitivity was 88.2% and the specificity was 98.3%. Multivariate analysis demonstrated that post-cone cytology (p=0.001, OR=83.808, 95% CI=6.688-1050.232), endocervical margin status (p<0.001, OR=80.478, 95% CI=7.421-872.732), and post-cone HR-HPV status (p<0.001, OR=79.660, 95% CI=8.539-743.129) were significantly associated with residual/recurrent disease. The post-cone HR-HPV positivity was observed more in the patients who showed positive endocervical margin than in the patients with positive ectocervical margin (32.6% vs. 5.3%, p=0.002). CONCLUSIONS: Follow-up using liquid based cytology in combination with HR-HPV test at 12 months after the conization, and not the early HR-HPV test, might be acceptable. Post-cone endocervical margin status combined with post-cone HR-HPV test is critical for predicting residual/recurrent disease and clinical management.

A predictive model for lymph node metastasis using tumor location in presumed early-stage endometrioid endometrial cancer patients.

OBJECTIVE: The aim of this study was to identify high- and low-risk subgroups of patients with lymph node (LN) metastasis in presumed early-stage endometrioid endometrial cancer (EC) patients. METHODS: Clinicopathologic data of presumed early-stage endometrioid EC patients (n=361) treated with lymphadenectomy between March 2000 and July 2022 were analyzed. None of the patient had definite evidence of LN metastasis in a preoperative magnetic resonance imaging (MRI). A received operating characteristic curve analysis was conducted to define the sensitivity and specificity for the combined preoperative risk factors for LN metastasis, which was determined by multivariate analysis. RESULTS: Nineteen patients (5.3%) had LN metastasis. Multivariate analysis identified cervical stromal invasion on MRI (odds ratio [OR]=4.386; 95% confidence interval [CI]=1.020-18.852; p=0.047), cornual location of tumor on MRI (OR=36.208; 95% CI=7.902-165.913; p<0.001), and lower uterine segment/isthmic location of tumor on MRI (OR=8.454; 95% CI=1.567-45.610; p=0.013) as independent prognostic factors associated with LN metastasis. Patients were categorized into low- and high-risk groups according to risk criteria. Significant differences in the rates of LN metastasis were observed between the two groups (0.4% vs. 22.2%, p<0.001). CONCLUSION: Approximately 95% of presumed early-stage endometrioid EC patients did not have LN metastasis. A model using tumor location was significantly correlated with the risk of LN metastasis. Even in presumed early-stage endometrioid EC patients, therefore, tumor location should be investigated to determine whether to perform LN assessment.

Effect of high-dose polymeric nanoparticle micellar paclitaxel on improved progression-free survival in patients with optimally resected stage III or IV high-grade carcinoma of the ovary: a prospective cohort study with historical controls.

Introduction: We evaluated the effect of high-dose polymeric nanoparticle micellar paclitaxel (PM-Pac) on survival in patients with stage III-IV high-grade serous ovarian cancer (HGSC) who underwent upfront surgery. Methods: We prospectively recruited the patients who received PM-Pac (280 mg/m2) and carboplatin at an area under the curve (AUC) of 5 (cohort 1) in two tertiary centers between October 2015 and June 2019. As historical controls, we retrospectively collected data on those who received paclitaxel (175 mg/m2) and carboplatin (AUC 5; cohort 2) or paclitaxel (175 mg/m2), carboplatin (AUC 5) and bevacizumab (15 mg/kg; cohort 3). Results: A total of 128 patients were divided into cohorts 1 (n=49, 38.3%), 2 (n=53, 41.4%), and 3 (n=26, 20.3%). Cohort 1 showed better progression-free survival (PFS) than cohort 2 in all patients and those treated with optimal debulking surgery (ODS; median, 35.5 vs. 28.1 and 35.5 vs. 28.9 months; p ≤ 0.01) despite no difference in PFS between cohorts 1 and 3 and between cohorts 2 and 3. In particular, stage III disease was a favorable factor for PFS, whereas cohort 2 was related to worse PFS (adjusted hazard ratios, 0.456 and 1.834; 95% confidence interval, 0.263 - 0.790 and 1.061 - 3.171), showing no difference in PFS between cohorts 1 and 3 in those treated with ODS. Conclusion: High-dose PM-Pac improved PFS compared to conventional chemotherapy, and the change of paclitaxel to PM-Pac had as much effect on PFS as the addition of bevacizumab in patients with stage III-IV HGSC who underwent ODS.

Clinical guidelines for ovarian cancer: the Korean Society of Gynecologic Oncology guidelines.

Since the latest practice guidelines for ovarian cancer were developed by the Korean Society of Gynecologic Oncology (KSGO) in 2021, many studies have examined the efficacy and safety of various treatments for epithelial ovarian cancer (EOC). Therefore, the need to develop recommendations for EOC treatments has been raised. This study searched the literature using 4 key items and the Population, Intervention, Comparison, and Outcome: the efficacy and safety of poly-ADP ribose polymerase inhibitors in newly diagnosed advanced EOC; the efficacy and safety of intraperitoneal plus intravenous chemotherapy in optimally debulked advanced EOC; the efficacy and safety of secondary cytoreductive surgery in platinum-sensitive recurrent ovarian cancer; and the efficacy and safety of the addition of bevacizumab to platinum-based chemotherapy in first platinum-sensitive recurrent EOC patients who received prior bevacizumab. The evidence for these recommendations, according to each key question, was evaluated using a systematic review and meta-analysis. The committee of ovarian cancer of the KSGO developed updated guidelines for treatments of EOC.

Lymphadenectomy in clinically early epithelial ovarian cancer and survival analysis (LILAC): a Gynecologic Oncology Research Investigators Collaboration (GORILLA-3002) retrospective study.

OBJECTIVE: This study aimed to evaluate the therapeutic role of lymphadenectomy in patients surgically treated for clinically early-stage epithelial ovarian cancer (EOC). METHODS: This retrospective, multicenter study included patients with clinically early-stage EOC based on preoperative abdominal-pelvic computed tomography or magnetic resonance imaging findings between 2007 and 2021. Oncologic outcomes and perioperative complications were compared between the lymphadenectomy and non-lymphadenectomy groups. Independent prognostic factors were determined using Cox regression analysis. Disease-free survival (DFS) was the primary outcome. Overall survival (OS) and perioperative outcomes were the secondary outcomes. RESULTS: In total, 586 patients (lymphadenectomy group, n=453 [77.3%]; non-lymphadenectomy groups, n=133 [22.7%]) were eligible. After surgical staging, upstaging was identified based on the presence of lymph node metastasis in 14 (3.1%) of 453 patients. No significant difference was found in the 5-year DFS (88.9% vs. 83.4%, p=0.203) and 5-year OS (97.2% vs. 97.7%, p=0.895) between the two groups. Using multivariable analysis, lymphadenectomy was not significantly associated with DFS or OS. However, using subgroup analysis, the lymphadenectomy group with serous histology had higher 5-year DFS rates than did the non-lymphadenectomy group (86.5% vs. 74.4%, p=0.048; adjusted hazard ratio=0.281; 95% confidence interval=0.107-0.735; p=0.010). The lymphadenectomy group had longer operating time (p<0.001), higher estimated blood loss (p<0.001), and higher perioperative complication rate (p=0.004) than did the non-lymphadenectomy group. CONCLUSION: In patients with clinically early-stage EOC with serous histology, lymphadenectomy was associated with survival benefits. Considering its potential harm, lymphadenectomy should be performed according to histologic subtype and subsequent chemotherapy in patients with clinically early-stage EOC. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0007309.

Major clinical research advances in gynecologic cancer in 2023: a tumultuous year for endometrial cancer.

In the 2023 series, we summarized the major clinical research advances in gynecologic oncology based on communications at the conference of Asian Society of Gynecologic Oncology Review Course. The review consisted of 1) Endometrial cancer: immune checkpoint inhibitor, antibody drug conjugates (ADCs), selective inhibitor of nuclear export, CDK4/6 inhibitors WEE1 inhibitor, poly (ADP-ribose) polymerase (PARP) inhibitors. 2) Cervical cancer: surgery in low-risk early-stage cervical cancer, therapy for locally advanced stage and advanced, metastatic, or recurrent setting; and 3) Ovarian cancer: immunotherapy, triplet therapies using immune checkpoint inhibitors along with antiangiogenic agents and PARP inhibitors, and ADCs. In 2023, the field of endometrial cancer treatment witnessed a landmark year, marked by several practice-changing outcomes with immune checkpoint inhibitors and the reliable efficacy of PARP inhibitors and ADCs.

Spillage and displacement of indocyanine green-stained tissues from uterine cervix to pelvic peritoneum: A proof of concept study for colpotomy approach in minimally invasive surgery.

OBJECTIVE: To analyze peritoneal spillage and displacement of indocyanine green (ICG)-stained tissues from uterine cervix to pelvis during intracorporeal/vaginal colpotomy in laparoscopic-assisted hysterectomy. MATERIALS AND METHODS: Eleven patients undergoing laparoscopic-assisted hysterectomy were included. One patient with an incidental diagnosis of endometrial cancer was excluded. Of the 10 patients, five underwent intracorporeal colpotomy (IC) and five received vaginal colpotomy (VC) during laparoscopic-assisted hysterectomy. Approximately 5 cm of resected round ligament from each patient was stained with ICG and cut to 1.0 × 1.0 cm in size. Four to five fragments of ICG-stained tissues were placed and sutured on the uterine cervix before colpotomy. During and after colpotomy, serial pictures under white and fluorescence light were taken to document peritoneal spillage and displacement of ICG-stained tissues to the pelvic peritoneum. RESULTS: Peritoneal spillage of ICG occurred in the entire IC group. Displacement of ICG-stained tissues from uterine cervix to pelvic peritoneum were visualized in three (60%) patients undergoing IC. In the five patients who received VC, peritoneal spillage of ICG and displacement of ICG-stained tissue to pelvic peritoneum did not occur. There were no perioperative complications. CONCLUSIONS: IC in minimally invasive radical hysterectomy should not be performed because peritoneal spillage of ICG and displacement of ICG-stained tissues from uterine cervix to pelvis frequently occurs during IC. Therefore, specific measures to prevent tumor exposure during colpotomy should be implemented in cervical cancer patients.