Survival in pregnancy-associated breast cancer patients compared to non-pregnant controls.

BACKGROUND: Pregnancy-associated breast cancer (PABC) is a rare entity whose prognosis has previously been studied and is subject to controversy. METHODS: Survival of patients with PABC diagnosed between 2009 and 2021 with breast cancer during pregnancy or until 1 year after childbirth was compared with non-pregnant patients with breast cancer from the same period at La Paz University Hospital. Cox proportional hazards regression was used to compare disease-free (DFS) and overall (OS) survival between the groups, adjusting for grade and pathologic stage. RESULTS: Among the 89 included patients with breast cancer, 34 were diagnosed during pregnancy, and 55 were not pregnant. The pregnant patients were more likely to have grade 3 tumors (61.3% vs 37%, p = 0.023) and an advanced stage (pathologic stage III-IV: 44.1% vs 17.6%, p = 0.008). Median follow-up was 47 months for the pregnant group and 46 months for the control group. After adjustments for tumor grade and pathologic stage, OS was comparable between the groups (HR 2.03; 95% CI 0.61 to 6.79; P = 0.25). CONCLUSIONS: The outcome of women diagnosed with PABC is comparable to young non-pregnant controls. However, it should be taken into account that PABC has a more aggressive phenotype.

Identification of miR-30c-5p microRNA in Serum as a Candidate Biomarker to Diagnose Endometriosis.

The diagnosis of endometriosis by laparoscopy is delayed until advanced stages. In recent years, microRNAs have emerged as novel biomarkers for different diseases. These molecules are small non-coding RNA sequences involved in the regulation of gene expression and can be detected in peripheral blood. Our aim was to identify candidate serum microRNAs associated with endometriosis and their role as minimally invasive biomarkers. Serum samples were obtained from 159 women, of whom 77 were diagnosed with endometriosis by laparoscopy and 82 were healthy women. First, a preliminary study identified 29 differentially expressed microRNAs between the two study groups. Next, nine of the differentially expressed microRNAs in the preliminary analysis were evaluated in a new cohort of 67 women with endometriosis and 72 healthy women. Upon validation by quantitative real-time PCR technique, the circulating level of miR-30c-5p was significantly higher in the endometriosis group compared with the healthy women group. The area under the curve value of miR-30c-5p was 0.8437, demonstrating its diagnostic potential even when serum samples registered an acceptable limit of hemolysis. Dysregulation of this microRNA was associated with molecular pathways related to cancer and neuronal processes. We concluded that miR-30c-5p is a potential minimally invasive biomarker of endometriosis, with higher expression in the group of women with endometriosis diagnosed by laparoscopy.

Molecular Signature of Endometrial Cancer with Coexistent Adenomyosis: A Multicentric Exploratory Analysis.

Adenomyosis has been associated with better survival outcomes in women with endometrial cancer. However, although the endometrial cancer patients' risk stratification has been revolutionized by molecular findings, the impact of the molecular signature on the favorable prognosis of endometrial cancer patients with coexistent adenomyosis is unknown. The aim of our study was to compare the prevalence of molecular groups at poor and intermediate prognosis between endometrial cancer patients with and without coexistent adenomyosis. A multicentric, observational, retrospective, cohort study was performed to assess the differences in the prevalence of p53-abnormal expression (p53-abn) and mismatch repair protein-deficient expression (MMR-d) signatures between endometrial cancer patients with and without coexistent adenomyosis. A total of 147 endometrial cancer patients were included in the study: 38 in the adenomyosis group and 109 in the no adenomyosis group. A total of 37 patients showed the MMR-d signature (12 in the adenomyosis group and 25 in the no adenomyosis group), while 12 showed the p53-abn signature (3 in the adenomyosis group and 9 in the no adenomyosis group). No significant difference was found in the prevalence of p53-abn (p = 1.000) and MMR-d (p = 0.2880) signatures between endometrial cancer patients with and without coexistent adenomyosis. In conclusion, the molecular signature does not appear to explain the better prognosis associated with coexistent adenomyosis in endometrial cancer patients. Further investigation of these findings is necessary through future larger studies.

Impact of the Covid-19 pandemic on the management of gynecologic cancer: a Spanish survey. Observational, multicenter study.

BACKGROUND: The SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) pandemic changed the distribution of healthcare resources, leading in many cases to the suspension of all non-essential treatments and procedures and representing a challenge for medical professionals. The objective of this study was to evaluate whether clinical protocols in gynecologic oncology care were modified as a result of the pandemic and to assess surgeons' perceptions regarding the management of gynecologic cancers". METHODS: Data were collected through an anonymous and voluntary survey sent via email to healthcare professionals in the field of gynecologic oncology in Spain. RESULTS: A total of 75 gynecologic oncologists completed the online survey. Of these, 93.2% (69) reported working in public hospitals and 62.5% (45) in tertiary care hospitals. 97.3% (71) were affiliated with hospitals treating patients infected with SARS-CoV-2. 85.1% (63) of the respondents expressed concern about the SARS-CoV-2 pandemic and 52.1% (38) indicated that the pandemic impacted the diagnostic and therapeutic quality of care for oncology patients. SARS-CoV-2 nasopharyngeal swab PCR (Polymerase Chain Reaction) testing was always performed before surgical interventions by 97.3% (71), being considered a best practice in triage by 94.4% (68). 87.5% (63) reported no change in the type of surgical approach during the pandemic. 62.5% (45) experienced limitations in accessing special personal protective equipment for SARS-CoV-2. An impact on the follow-up of patients with gynecologic cancers due to the pandemic was reported by 70.4% (50). CONCLUSIONS: Most of the Spanish gynecologic oncologists who responded to our survey reported that the SARS-CoV-2 pandemic had affected their clinical practice. The primary measures implemented were an increase in telemedicine, restricting outpatient visits to high-risk or symptomatic patients and the use of SARS-CoV-2 screening prior to surgery. No major changes in the surgical approach or management of the treatment of ovarian, endometrial or cervical cancer during the pandemic were reported.

Evaluation of Immune Infiltrates in Ovarian Endometriosis and Endometriosis-Associated Ovarian Cancer: Relationship with Histological and Clinical Features.

BACKGROUND: the association between ovarian endometriosis (OE) and endometriosis-associated ovarian cancer (EAOC) is extensively documented, and misfunction of the immune system might be involved. The primary objective of this study was to identify and compare the spatial distribution of tumour-infiltrating lymphocytes (TILs) and tumour-associated macrophages (TAMs) in OE and EAOC. Secondary objectives included the analysis of the relationship between immunosuppressive populations and T-cell exhaustion markers in both groups. METHODS: TILs (CD3, CD4, and CD8) and macrophages (CD163) were assessed by immunochemistry. Exhaustion markers (PD-1, TIM3, CD39, and FOXP3) and their relationship with tumour-associated macrophages (CD163) were assessed by immunofluorescence on paraffin-embedded samples from n = 43 OE and n = 54 EAOC patients. RESULTS: we observed a predominantly intraepithelial CD3+ distribution in OE but both an intraepithelial and stromal pattern in EAOC (p < 0.001). TILs were more abundant in OE (p < 0.001), but higher TILs significantly correlated with a longer overall survival and disease-free survival in EAOC (p < 0.05). CD39 and FOXP3 significantly correlated with each other and CD163 (p < 0.05) at the epithelial level in moderate/intense CD4 EAOC, whereas in moderate/intense CD8+, PD-1+ and TIM3+ significantly correlated (p = 0.009). Finally, T-cell exhaustion markers FOXP3-CD39 were decreased and PD-1-TIM3 were significantly increased in EAOC (p < 0.05). CONCLUSIONS: the dysregulation of TILs, TAMs, and T-cell exhaustion might play a role in the malignization of OE to EAOC.

Impact of Ovarian Endometrioma and Surgery on Reproductive Outcomes: A Single-Center Spanish Cohort Study.

Anti-Müllerian hormone (AMH) and antral follicular count (AFC) decrease in women with ovarian endometrioma (OMA) and in vitro fertilization (IVF). In addition, these parameters drop even further when women with OMA undergo surgery. In this study, the primary aim was to compare the reproductive variables in IVF-treated women with and without endometriosis. The secondary aim was to explore if the reproductive variables were modified by endometrioma surgery. In this retrospective study, 244 women undergoing IVF were enrolled at the Hospital Universitario La Paz (Madrid, Spain). Women were categorized as OMA not surgically treated (OMA; n = 124), OMA with surgery (OMA + S; n = 55), and women with infertility issues not related to OMA (control; n = 65). Demographic and clinical variables, including age, body mass index (BMI), and reproductive (AMH, AFC, number of extracted oocytes, and transferred embryos) and obstetrical data (biochemical pregnancy and fetal heart rate at 6 weeks) were collected. Adjusted logistic regression models were built to evaluate reproductive and pregnancy outcomes. The models showed that women with OMA (with and without surgery) had significantly decreased levels of AMH and AFC and numbers of cycles and C + D embryos. Women with OMA + S had similar rates of pregnancy to women in the control group. However, women with OMA had lower biochemical pregnancy than controls (aOR = 0.08 [0.01; 0.50]; p-value = 0.025). OMA surgery seems to improve pregnancy outcomes, at least until 6 weeks of gestation. However, it is important to counsel the patients about surgery expectations due to the fact that endometrioma itself reduces the quality of oocytes.

Application of Deep Learning Model in the Sonographic Diagnosis of Uterine Adenomyosis.

BACKGROUND: This study aims to evaluate the diagnostic performance of Deep Learning (DL) machine for the detection of adenomyosis on uterine ultrasonographic images and compare it to intermediate ultrasound skilled trainees. METHODS: Prospective observational study were conducted between 1 and 30 April 2022. Transvaginal ultrasound (TVUS) diagnosis of adenomyosis was investigated by an experienced sonographer on 100 fertile-age patients. Videoclips of the uterine corpus were recorded and sequential ultrasound images were extracted. Intermediate ultrasound-skilled trainees and DL machine were asked to make a diagnosis reviewing uterine images. We evaluated and compared the accuracy, sensitivity, positive predictive value, F1-score, specificity and negative predictive value of the DL model and the trainees for adenomyosis diagnosis. RESULTS: Accuracy of DL and intermediate ultrasound-skilled trainees for the diagnosis of adenomyosis were 0.51 (95% CI, 0.48-0.54) and 0.70 (95% CI, 0.60-0.79), respectively. Sensitivity, specificity and F1-score of DL were 0.43 (95% CI, 0.38-0.48), 0.82 (95% CI, 0.79-0.85) and 0.46 (0.42-0.50), respectively, whereas intermediate ultrasound-skilled trainees had sensitivity of 0.72 (95% CI, 0.52-0.86), specificity of 0.69 (95% CI, 0.58-0.79) and F1-score of 0.55 (95% CI, 0.43-0.66). CONCLUSIONS: In this preliminary study DL model showed a lower accuracy but a higher specificity in diagnosing adenomyosis on ultrasonographic images compared to intermediate-skilled trainees.

Impact of pattern of recurrence on post-relapse survival according to surgical timing in patients with advanced ovarian cancer.

OBJECTIVE: Our study aimed to evaluate the association between timing of cytoreductive surgery and pattern of presentation of the first recurrence in patients with advanced ovarian cancer. We also aimed to assess the impact of the pattern of recurrence on post-relapse overall survival according to surgical timing. METHODS: This retrospective multicenter study evaluated patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV ovarian cancer. Patients had undergone either primary debulking surgery, early interval debulking surgery after 3-4 cycles of neoadjuvant chemotherapy, or delayed debulking surgery after 6 cycles, with minimal or no residual disease, between January 2008 and December 2015. Survival analyses were conducted using the Log-rank test and the Cox model. Cumulative incidences of the different patterns of recurrence were estimated using a competing risks methodology. RESULTS: A total of 549 patients were included: 175 (31.9%) patients had primary, 224 (40.8%) early interval, and 150 (27.3%) delayed debulking surgery. The cumulative incidence of peritoneal recurrences at 2 years was higher with increasing neoadjuvant cycles (24.4%, 30.9% and 39.2%; p=0.019). For pleural or pulmonary recurrences, it was higher after early interval surgery (9.9%, 13.0% and 4.1%; p=0.022). Median post-relapse overall survival was 33.5 months (95% confidence interval (CI) (24.3 to 44.2)), 26.8 months (95% CI (22.8 to 32.6)), and 24.5 months (95% CI (18.6 to 29.4)) for primary, early interval, and delayed debulking surgery groups, respectively (p=0.025). The pattern of recurrence in a lymph node (hazard ratio (HR) 0.42, 95% CI (0.27 to 0.64)), delayed surgery (HR 1.53, 95% CI (1.11 to 2.13)) and time to first recurrence (HR 0.95, 95% CI (0.93 to 0.96)) were associated with post-relapse overall survival. For primary and early interval surgery, lymph node recurrences were associated with significantly longer post-relapse overall survival. CONCLUSIONS: The pattern of first recurrence was associated with timing of surgery, with peritoneal recurrences being more frequent with the increasing number of cycles of neoadjuvant chemotherapy. Lymph node recurrences were associated with better prognosis, having higher post-relapse overall survival. This improved prognosis of lymphatic recurrences was not observed in patients who underwent delayed surgery.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases.

PURPOSE: The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI). METHODS: A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections. RESULTS: The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy. CONCLUSION: In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Quality of Life in Women after Deep Endometriosis Surgery: Comparison with Spanish Standardized Values.

The quality of life (QoL) of women who have been surgically treated for endometriosis may be severely impaired. Therefore, QoL can be a determining factor in the recovery of these patients. The aims of this study were to evaluate if the QoL of women surgically treated for deep endometriosis differs from a healthy age-matched population from Catalonia (Spain) and to analyze the QoL of these women considering concomitant events. This is an observational cross-sectional study, where 112 women (between 18 and 48 years old), with endometriosis treated by surgery at Hospital Universitario La Paz (Madrid, Spain), were enrolled to assess the QoL using the second version of the 12-item short form (SF-12) questionnaire. The QoL in these women were tested against a reference population of healthy women using a standardized one-sample comparison method. In addition, the QoL was compared according to the pathophysiology and type of surgery. In women with endometriosis, the physical health component, but not mental health component, was positively correlated with age (r = 0.19; p-Value = 0.048). In addition, physical (20.3 ± 29.2) and social functions (29.7 ± 38.3) and the overall physical health component (37.8 ± 19.4) were significantly lower than the reference population. On the contrary, the body pain (64.1 ± 41.2), emotional role (62.5 ± 42.2), mental health (54.4 ± 26.0), vitality (59.3 ± 31.2), and the overall mental health component (59.4 ± 26.6) had significantly higher scores than the reference. The anatomical compartment of endometriosis, reintervention, bowel nodule resection, and fertility preservation did not show statistical differences in QoL. Women with deep endometriosis had worse physical and social functions, and the overall physical health, compared to the norm in Spanish women. Bodily pain, emotional role, vitality, and the overall mental health improved. These areas could be considered protective factors in this disease. Considering the importance of QoL in adjustments in mental and physical health, it would be necessary to improve these areas of QoL in women surgically treated for deep endometriosis.

Quality of life and low anterior resection syndrome before and after deep endometriosis surgery.

PURPOSE: Deep endometriosis (DE) is defined by the presence of ectopic endometrial glands, with rectal involvement ranging from 5.3 to 12%. The prevalence of low anterior resection-like syndrome (LARS) in patients with DE, how it affects quality of life (QoL), and its evolution after surgery is unclear. The objective of this study was to assess the gastrointestinal functional outcomes and QoL in patients who underwent surgery for DE. PATIENTS AND METHODS: A prospective study was conducted from 2017 to 2019, recruiting patients who underwent DE surgery with and without rectal resection. Patients completed LARS and SF-36 questionnaires before, at 6 months and at 1 year after surgery. RESULTS: Eighty-two patients were enrolled. Rectal segmental resection was required in 16 (19.5%) patients, shaving in 16 (19.5%) and discoid resection in 8 (9.8%). All 8 domains of the SF-36 questionnaire showed improvement during follow-up, reflecting improved QoL after surgery (p ≤ 0.05) in all patients. Mean LARS scores for patients without rectal surgery were 7.5 ± 10.4 before and 13.7 ± 14.2 1 year after surgery; rectal surgery was 13.6 ± 13.6 and 14.6 ± 13.1, respectively (p = 0.17). No significant differences were found in the rectal surgery patients' postoperative LARS score among the 3 rectal DE surgical techniques (p = 0.97), and the SF-36 scores improved independent of the technique performed. CONCLUSIONS: Patients with DE present a LARS-like syndrome before surgery that does not appear to be negatively affected after rectal surgery, independent of the technique performed. Rectal surgery improves the QoL of patients with DE patients as measured by the SF-36 questionnaire at 1 year of follow-up.

Surgeons' workload assessment during indocyanine-assisted deep endometriosis surgery using the surgery task load index: The impact of the learning curve.

Objective: Assess the surgeons' workload during deep endometriosis surgery after ureteral ICG. Design: Prospective, consecutive, comparative, single-center study. Population: 41 patients enrolled to deep endometriosis surgery with ureteral ICG from January 2019 to July 2021 at La Paz University Hospital. Methods: Patients were divided into 2 groups: patients operated during the learning curve of ureteral ICG instillation and patients operated after the technique was implemented and routinely performed. After surgery, the SURG-TLX form was completed by the surgeons. We evaluated whether a workload reduction occurred. Main outcomes measures: Surgeon's workload was measured using the SURG-TLX form, obtaining the total workload and 6 different dimensions (distractions, temporal demands, task complexity, mental demands, situational stress and physical demands). Results: A significant positive correlation was found between surgical complexity and situational stress (p = 0.04). Mental demands (p = 0.021), physical demands (p = 0.03), and total workload (p = 0.025) were significantly lower when the technique was routinely performed. The mental demand, physical demands, and total workload perceived by the surgeons at the beginning of the implementation was higher (68 [39-72], 27 [11-46.5], 229 [163-240], respectively) than in the latter ones (40 [9-63], 11.5 [0-32.8], 152 [133.3-213.8], respectively). Distractions appeared to be higher in the latter surgeries (8.5 [0-27.8]) than in the first surgeries (0 [0-7]; p = 0.057). Conclusions: Ureter ICG instillation prior to DE surgery significantly reduces the mental and physical demands and total workload of the surgeons in DE surgeries after overcoming the learning curve. Distractions appear to increase as surgical stress decreases.

Survival impact of histological response to neoadjuvant chemotherapy according to number of cycles in patients with advanced ovarian cancer.

OBJECTIVE: We sought to evaluate the impact of chemotherapy response score according to the number of cycles of neoadjuvant chemotherapy, on disease-free survival and overall survival, in patients with advanced epithelial ovarian cancer ineligible for primary debulking surgery. METHODS: This multicenter retrospective study included patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV epithelial ovarian cancer who underwent 3-4 or 6 cycles of a platinum and taxane-based neoadjuvant chemotherapy, followed by complete cytoreduction surgery (CC-0) or cytoreduction to minimal residual disease (CC-1), between January 2008 and December 2015, in four institutions. Disease-free survival and overall survival were assessed according to the histological response to chemotherapy defined by the validated chemotherapy response score. RESULTS: A total of 365 patients were included: 219 (60.0%) received 3-4 cycles of neoadjuvant chemotherapy, and 146 (40.0%) had 6 cycles of neoadjuvant chemotherapy before cytoreductive surgery. There were no significant differences in early relapses, disease-free survival, and overall survival according to the number of neoadjuvant chemotherapy cycles. However, regardless of the number cycles of neoadjuvant chemotherapy, persistent extensive histological disease (chemotherapy response score 1-2) was significantly associated with a higher peritoneal cancer index, minimal residual disease (CC-1), and early relapses. Median disease-free survival in patients with complete or near-complete response (score 3) was 28.3 months (95% CI 21.6 to 36.8), whereas it was 16.3 months in patients with chemotherapy response score 1-2 (95% CI 14.7 to 18.0, p<0.001). CONCLUSION: In our cohort, the number of neoadjuvant chemotherapy cycles was not associated with disease-free survival or overall survival. Chemotherapy response score 3 improved oncological outcome regardless of the number of neoadjuvant chemotherapy cycles.

Deep Learning to Measure the Intensity of Indocyanine Green in Endometriosis Surgeries with Intestinal Resection.

Endometriosis is a gynecological pathology that affects between 6 and 15% of women of childbearing age. One of the manifestations is intestinal deep infiltrating endometriosis. This condition may force patients to resort to surgical treatment, often ending in resection. The level of blood perfusion at the anastomosis is crucial for its outcome, for this reason, indocyanine green (ICG), a fluorochrome that green stains the structures where it is present, is injected during surgery. This study proposes a novel method based on deep learning algorithms for quantifying the level of blood perfusion in anastomosis. Firstly, with a deep learning algorithm based on the U-Net, models capable of automatically segmenting the intestine from the surgical videos were generated. Secondly, blood perfusion level, from the already segmented video frames, was quantified. The frames were characterized using textures, precisely nine first- and second-order statistics, and then two experiments were carried out. In the first experiment, the differences in the perfusion between the two-anastomosis parts were determined, and in the second, it was verified that the ICG variation could be captured through the textures. The best model when segmenting has an accuracy of 0.92 and a dice coefficient of 0.96. It is concluded that segmentation of the bowel using the U-Net was successful, and the textures are appropriate descriptors for characterization of the blood perfusion in the images where ICG is present. This might help to predict whether postoperative complications will occur during surgery, enabling clinicians to act on this information.

Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer.

Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women's age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women's age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.

The effect of major postoperative complications on recurrence and long-term survival after cytoreductive surgery for ovarian cancer.

OBJECTIVE: To assess the impact on survival of major postoperative complications and to identify the factors associated with these complications in patients with advanced ovarian cancer after cytoreductive surgery. METHODS: We designed a retrospective multicenter study collecting data from patients with IIIC-IV FIGO Stage ovarian cancer who had undergone either primary debulking surgery (PDS), early interval debulking surgery (IDS) after 3-4 cycles of neoadjuvant chemotherapy, or delayed debulking surgery (DDS) after 6 cycles, with minimal or no residual disease, from January 2008 to December 2015. Univariable and multivariable analyses were conducted to identify factors associated with major surgical complications (≥Grade 3). We assessed disease-free survival (DFS) and overall survival (OS) rates according to the occurrence of major postoperative complications. RESULTS: 549 women were included. The overall rate of major surgical complications was 22.4%. Patients who underwent PDS had a higher rate of major complications (28.6%) than patients who underwent either early IDS (23.2%) or DDS (14.0%). Multivariable analysis revealed that extensive peritonectomy and surgical timing were associated with the occurrence of major complications. Median DFS and OS were 16.9 months (95%CI = [13.7-18.4]) and 48.0 months (95%CI = [37.2-73.1]) for the group of patients with major complications, and 20.1 months (95%CI = [18.6-22.4]) and 56.7 months (95%CI = [51.2-70.4]) for the group without major complications. Multivariable analysis revealed that major surgical complications were significantly associated with DFS, but not with OS. CONCLUSIONS: Patients who experienced major surgical complications had reduced DFS, compared with patients without major morbidity. Extensive peritonectomy and surgical timing were predictive factors of postoperative morbidity.

Role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery: a systematic review.

BACKGROUND: Our aim was to review the current knowledge of the role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery. MATERIAL AND METHODS: A computer-based systematic review was performed from 2000 to 2020. All articles describing the use of indocyanine green (ICG) applied to bowel assessments in gynecology or endometriosis surgery were considered for review. RESULTS: ICG is an effective tool for assessing bowel vascularization, potentially preventing anastomotic leakage and recto-vaginal fistula and can therefore be useful for endometriosis surgery or bowel assessment in gynecological oncology procedures. Real-time characterization of the hypovascular pattern of endometriotic nodules has been associated with a larger nodule size and lower microvessel density, helping surgeons choose the best transecting line and the most appropriate technique. ICG angiography allows for a laparoscopic and intrarectal bowel assessment, which can act as a double check of bowel perfusion, enabling the assessment of mucosa vascularization. ICG fluorescence can guide intraoperative decision-making after intestinal anastomosis, discoid resection, and rectal shaving, preventing anastomotic leakage and postoperative recto-vaginal fistula in low anterior resections. CONCLUSIONS: ICG angiography provides a better intestinal assessment. Larger, prospective, randomized controlled studies are needed to validate the technique and confirm these encouraging results.

Prognostic markers of inflammation in endometrioid and clear cell ovarian cancer.

OBJECTIVES: Cancer-related systemic inflammation has been associated with prognosis in multiple cancer types. Conversely, local inflammation, which is characterized by dense intratumoral immune infiltrates, is a favorable predictor of survival outcome. However, these survival associations are not well established in ovarian cancer, particularly in the less frequent endometrioid and clear cell endometriosis associated histotypes. METHODS: This retrospective study included 119 patients (63 endometrioid and 56 clear cell ovarian carcinomas). We performed a comprehensive survival association analysis of both systemic (neutrophil-to-lymphocyte ratio or presence of endometriosis) and local inflammation markers (CD3+ and CD8+ tumor infiltrating lymphocytes) using multivariate Cox proportional hazards models that account for confounding factors. RESULTS: Medium to high levels of intraepithelial CD8+ tumor infiltrating lymphocytes are associated with longer survival in endometrioid ovarian cancer (p=0.04). In addition, we found that intraepithelial CD8+ tumor infiltrating lymphocytes are prognostic in clear cell ovarian cancer (p=0.02), and that intraepithelial CD3+ tumor infiltrating lymphocytes are also associated with improved outcome (p=0.02). Furthermore, intratumoral CD3+ and CD8+ tumor infiltrating lymphocytes showed improved prognosis in the endometrioid subtype (p<0.1). No prognostic value was observed for systemic immune markers. CONCLUSIONS: In this study, patients with endometrioid and clear cell ovarian cancer with moderate to high CD8+ and CD3+ intraepithelial tumor infiltrating lymphocytes had longer overall survival. Higher expression of intratumoral CD3+ and CD8+ tumor infiltrating lymphocytes also showed an improved outcome in endometrioid ovarian cancer. In contrast, systemic inflammation, evaluated by neutrophil-to-lymphocyte ratio or presence of endometriosis, did not have a prognostic impact in these histologic subtypes.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study.

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.