The association between breast cancer and pregnancy is defined as detecting breast cancer during pregnancy or within one year after delivery. The diagnosis is often difficult and delayed. It is based on clinical examination, radiological exams (ultrasound and/or RM) and biopsy of the suspected lesion. The staging examinations should be performed only if any change in therapeutic decisions or clinical practice could be made or in the presence of a high risk of distant metastases. The treatment includes surgery, radiotherapy, chemotherapy, hormonal therapy and molecular targeted therapy, and it should be as close as possible with the standard protocols of non-pregnant patients and should be discussed with a multidisciplinary team. It is important to start the treatment as soon as possible, with the exception of term pregnant patients, for whom it can be postponed after delivery. The major fetal complications seem to be related to prematurity, and the type of delivery depends on obstetrics indication. The delivery should be planned at least three weeks after the infusion of chemotherapy, and the treatment generally could be restarted one week after the cesarean section and immediately after a vaginal delivery. The apparent poor outcome in pregnant women can be explained by the delayed diagnosis and/or treatment and the biological characteristics of the tumor (often of high grade and triple negative). Finally, when the treatment is planned, reproductive counseling should always be proposed to young patients immediately after diagnosis in order to plan the best fertility preservation strategies

Introduction/Background Incidence of ovarian cancer increases with age and reaches a peak at 70 years. The aim of this study is to analyse the surgical and pharmacological therapies for patients affected by ovarian cancer identifying the best approach based not on the age but on the performance status. Methodology We have conducted a single-center retrospective study. Patients with epithelial and non-epithelial ovarian tumours were included and ranked according to age at diagnosis in group A (≥70 years) and group B (<70 years). For each patient are considered: co-morbidities, performance status, FIGO stage, grading, histotype and treatment. Surgical treatment was differentiated into primary debulking surgery or interval debulking surgery, reporting extension, residual tumour, complications and days of hospitalization. Chemotherapy was administered for 3 or more cycles and the clinical response was evaluated at the end. Results 134 patients were included in the study, 44 (32.8%) in group A and 90 (67.2%) in group B further divided into early and advanced stages. Optimal cytoreduction was achieved in 61.9% of the younger patients and in 36.1% of the older patients (p=0.01), although the surgical extension is not statistically significant different in the two groups. There is good correlation between overall survival and the performance status (p=0.0001), the age at diagnosis (p=0.004), the tumour stage (p=0.03) and the residual tumour (p=0.00001). The residual tumour (OR=2.399; p=0.006) and the performance status (OR=2.50; p=0.0001) resulted as an independent survival prognostic factors according to the multivariate Cox analysis. Conclusion Our data suggest that patients aged ≥70 can tolerate radical surgical treatments in the same way as younger patients without a significant increase in morbidity, so an optimal cytoreduction should be considered the gold standard regardless of age. Therefore, our data underlines the importance of managing these patients within Gynecologic Oncology units equipped with a multidisciplinary team. Disclosure Prof. Paolo Zola has received grants from AstraZeneca, Roche, Tesaro and PharmaMar.

Introduction/Background Endometrial cancer is the fourth neoplasia in the female population with 88 000 new cases annually in Europe. Recently great efforts have been made to modulate treatments based on the risk of relapse. One of the risk factors included in ESGO guidelines is lymphovascular space invasion (LVSI). In patients LR (IA G1), LVSI determines whether to add EBRT when the lymph node status is unknown. In HR group (IAG3-IBG1-2) LVSI is useful to decide if adding EBRT to the BRT or performing just the follow up. Methodology To verify the role of the LVSI in the management of EC, data from 697 patients treated consecutively were collected from hospital databases (01/2011 to 10/2018) in 3 Centres of the Cancer Network of Piemonte and Valle d9Aosta. Results LVSI was found in 285 out of 697 tumours collected (40.9%). Stratifying positive LVSI by centre, we found that 12.3% in centre A, 31.7% in centre B, and 5.5% in centre C were positive in LR EC (286 patients G1-2, IA). 43.3% in centre A, 62.5% in centre B, 10.8% in centre C were positive in HR EC (196 patients IA, G3; IB, G1-G2). In order to analyse these differences within centres, we evaluated the determinants of LVSI with mono and multivariate logistic regression analyses. The factors identified related to LVSI are: risk class LR (OR=2.9) vs HR (OR=7.5 p=0.0001); Type I vs II EC (OR=3.3 p=0.001); surgical approach: LPS without manipulation vs LPS with manipulation (OR=2.1) vs LPT (OR=3.1 p=0.001); number of lymph nodes removed during surgery (<20 vs ≥20 lymph nodes; OR 1.8 p=0.01). Conclusion LVSI, a key factor for the decision of adjuvant treatment, depends on different factors that should be considered in quality control studies. Disclosure Prof. Paolo Zola has received grants from Astrazeneca, Roche, Pharmamar and Tesaro.

Objectives Uterine smooth muscle tumors of uncertain malignant potential (STUMP) represent a group of rare and challenging myometrial neoplasms. STUMPs that are followed by a recurrence are biologically low-grade leiomyosarcomas, but using current methods of analysis, this diagnosis cannot be made with certainty until a recurrence has developed. Our objective is to describe ultrasound findings in women with STUMP. Methods We retrospectively evaluated preoperative sonographic data of patients with histopathological STUMP diagnosis between 2014 and 2018 in Turin S. Anna Hospital, a tertiary center. The tumors were characterized on the basis of ultrasound images and ultrasound reports using the terms and definitions of the Morphological Uterus Sonographic Assesment (MUSA) group. Results Thirteen patients with STUMP (19 lesions, of which 17 pure STUMP and 2 STUMP with LMS associated) were identified. Using the MUSA terms and definitions most STUMP were poorly or moderately vascularized (69%) and almost all had both circumferential and intra-lesional flows (82%). Only three (16%) STUMP showed shadowing. Outline were well-defined in sixteen cases (84%). All STUMP had non-uniform echogenicity. Eleven (58%) STUMP were isoechoic, two (11%) hyperechoic and six (31%) had mixed echogenicity. Thirteen (68%) STUMP had microcystic anechoic areas. Over 30% of patients had multiple stumps and almost 80% associated myomas. Conclusions The suspicion of STUMP is supported by the ultrasound finding of a single or multiple lesion, isoechoic or with mixed echogenicity, without shadowing, with regular borders, internal microcystic anechoic areas and vascularization from minimal to high both circumferential and intralesional.

ObjectivesAt present there is no predictive value univocally associated with the success of chemotherapy. Biomarkers produced by ovarian cancer (HE4 and Ca125) could have a good prognostic significance. The aim of this study is to prove the ability of biomarkers to identify patients with the highest risk of not optimal response during the chemotherapy and to predict which patients will most probably develop recurrence of disease.MethodsWe analyzed 78 patients with EOC who underwent surgery in the biennium 2016–2017. All the patients performed chemotherapy after surgery or interval debulking surgery following neoadjuvant therapy. Serum levels of HE4 and Ca125 were measured at the diagnosis and at each cycle of chemotherapy. We established the degree of response to the treatment by CT-scan and the patients were followed up (FU median: 10 months). The parameters PFS and DFS were related to serum levels of biomarkers.ResultsThe average markers values became both negative at the fourth cycle in the patients with good response to chemotherapy. HE4 compared earlier than Ca125. The parameters that best correlated with a long PFS were: negativization of the marker after the third cycle of chemotherapy (HE4: OR 5.5; Ca125: OR 9.1) and biomarker serum levels lower than the mean value in the affected population at the time of diagnosis (HE4: OR 3.4; Ca125: OR 3.7).ConclusionsWe can conclude that the monitoring of HE4 and Ca125 during chemotherapy, especially at the third cycle, is recommended, because their variation is a good prognostic factor.

Introduction/Background In developed countries, endometrial cancer is the fourth most common cancer in women. ESGO guidelines propose appropriate strategies based on risk factors. Lymphadenectomy is a staging procedure and even if it does not seem to have a therapeutic role, it is crucial for tailoring adjuvant therapy. The aim of the study is to verify the reliability of expert transvaginal sonographer (TVS) and frozen section (FS) to assess myometrial infiltration (<50% vs ≥50%) to limit systematic lymphadenectomy where not indicated. Methodology To verify the accuracy of expert TVS and intraoperative frozen section to evaluate myometrial infiltration, 364 consecutive patients affected by EC were prospectively followed in 3 centres of the Oncological Network of Piemonte and Valle d'Aosta from 01/2016 to 10/2018. Definitive pathological report sensitivity, specificity, PPV, NPV, LR + LR- of TVUS and FS are obtained. The results were evaluated overall and by centre. Results TVUS by expert ultra-sonographer has obtained a diagnostic accuracy with sensitivity 76% specificity 73% PPV 66% NPP 82%. The variability observed between hospitals: centre A sensitivity 76% specificity 86% PPV 85% NPP 82%; centre B sensitivity 60% specificity 75% PPV 59% NPP 76%; centre C sensitivity 95% specificity 58% PPV 58% NPP 95%. The overall FS examination has the following values: sensitivity 86% specificity 97% PPV 95% NPP 92%. Stratifying by centres: A sensitivity 91% specificity 96% PPV 95% NPP 93%; B sensitivity 87% specificity 97% PPV 93% NPP 95%; C sensitivity 85% specificity 100% PPV 100% NPP 91%. Patients who add FS to TVUS had a reclassification improvement of 7.5%. Conclusion FS remains the most reliable method in the 'real world' to assess myometrial infiltration and to direct the staging procedures in endometrial cancer. The variability of FS among centres belonging to an oncological network is lower than what observed for TVUS. Disclosure Prof. Paolo Zola has received grants from Astrazeneca, Roche, Pharmamar and Tesaro.

ABSTRACTObjectiveTransvaginal sonography (TVS) and serum biomarkers are used widely in clinical practice to triage women with adnexal masses, but the effectiveness of current biomarkers is weak. The aim of this study was to determine the best method of diagnosing patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: (1) the International Ovarian Tumor Analysis group's simple rules (SR) for interpretation of TVS with subjective assessment (SA) by an experienced ultrasound operator when TVS results are inconclusive (referred to hereafter as SR ± SA), (2) SR ± SA and cancer antigen 125 (CA 125), (3) SR ± SA and human epididymis protein 4 (HE4) and (4) SR ± SA and the risk of malignancy algorithm (ROMA). Our main hypothesis was that the addition of the biomarkers to SR ± SA could improve triaging of these patients in terms of diagnostic accuracy (i.e. malignant vs benign). As secondary analyses, we estimated the cost effectiveness of the four strategies and the diagnostic accuracy of SR ± SA at the study hospitals.MethodsBetween February 2013 and January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S. Anna and Mauriziano Hospitals in Turin were enrolled in this multicenter prospective cohort study. Preoperative TVS was performed and preoperative CA 125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies and the cost of each strategy was calculated.ResultsA total of 391 patients were included in the analysis: 57% (n = 221) were premenopausal and 43% (n = 170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients and thus did not require SA; the overall performance of SR ± SA showed a sensitivity of 82%, specificity of 92% and positive and negative predictive values and positive and negative likelihood ratios of 74%, 95%, 10.5 and 0.19, respectively. In premenopausal women, mean cost among the four triage strategies varied from €36.41 for SR ± SA to €70.12 for SR ± SA + ROMA. The addition of biomarkers to SR ± SA showed no diagnostic advantage compared with SR ± SA alone and was more costly. Among postmenopausal women, mean cost among the four triage strategies varied from €39.52 for SR ± SA to €73.23 for SR ± SA + ROMA. Among these women, SR ± SA + CA 125 and SR ± SA + ROMA had a higher sensitivity (both 92% (95% CI, 85–99%)) than SR ± SA (81% (95% CI, 71–91%)), but SR ± SA had a higher specificity (84% (95% CI, 77–91%)). SR ± SA + CA 125 and SR ± SA + ROMA improved diagnostic accuracy, each diagnosing a third more malignant adnexal masses. In postmenopausal women, compared with SR ± SA alone, SR ± SA + CA 125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13.00, while the extra cost for SR ± SA + ROMA was €33.71, with a comparable gain, in terms of NRI, as that of SR ± SA + CA 125.ConclusionsIn our study sample, SR ± SA seems to be the best strategy to triage women with adnexal masses for surgical management. Among postmenopausal women, SR ± SA + CA 125 increased the NRI at a reasonable extra cost. Our data do not justify the use of HE4 and ROMA in the initial triage of women with adnexal masses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

OBJECTIVETo evaluate the outcome of vaginal intraepithelial neoplasia (VaIN) treatment with CO2 laser vaporization in terms of local recurrence and progression to vaginal carcinoma. Additionally, the authors investigated the predictive factors for first recurrence.MATERIALS AND METHODSThe medical records of all patients treated for VaIN with CO2 laser vaporization at Sant'Anna Hospital in Turin (1995-2012), were retrospectively reviewed. A univariate logistic model was applied to evaluate selected clinical features as predictive factors for recurrence. A multivariate logistic regression analysis was then carried out including significant risk factors after univariate analysis (p < 0.05).RESULTSThe analysis included 285 out of 302 patients. Seventy-one (25%) women relapsed; of these 24 VaIN 1 (22%), 37 VaIN 2 (27%), and ten VaIN 3 (26%). The median time to the first recurrence was 5.2 months (1.4-127.8) for VaIN 1, 6.6 months (1-85.2) for VaIN 2, and 3.6 months (1.2-62) for VaIN 3. Sixty-one out of 71 patients were retreated with CO2 laser vaporization. At the last follow-up visit, 273 (96%) women were free from VaIN. No patients progressed to vaginal carcinoma. The multivariate model showed a higher risk of VaIN recurrence in the case of previous hysterectomy (HR 3.3, 95% CI 1.7-6.3, p < 0.001) and concomitant H-SIL on the Pap smear (HR 1.9, 95% CI 1.2-3.1, p = 0.008).CONCLUSIONCO2 laser vaporization is an effective low impact treatment for VaIN. Despite this, VaIN recur, in particular in cases of previous hysterectomy and concomitant H-SIL on the Pap smear. An intensive follow-up is proposed for women with a high risk of VaIN relapse.