OBJECTIVE:Endometrial cancer surgery has a low risk of specimen fragmentation, but removing large uteri can be challenging. This study aimed to assess whether the use of minilaparotomic incision for specimen retrieval compromises the benefits of minimally invasive surgery in endometrial cancer patients with a large uterus or utero-vaginal discrepancy. METHODS:This is a retrospective multi-institutional study, including endometrial cancer patients with FIGO 2009 clinical stage I-II, undergoing minimally invasive staging surgery (laparoscopic or robot-assisted) followed by minilaparotomic specimen retrieval. A propensity-matched algorithm was used to compare outcomes of minimally invasive staging with open surgery. RESULTS:The study included 45 propensity-matched pairs (90 patients): 45 underwent minimally invasive staging with minilaparotomic specimen retrieval and 45 underwent open staging. Patients undergoing minimally invasive surgery plus trans-abdominal specimen retrieval experienced longer median operative time (95 vs. 85 minutes; p=0.0017), lower blood loss (50 vs. 100 ml; p<0.001), and shorter length of hospital stay (3 vs. 5 days; p<0.001) in comparison to patients undergoing open surgery. No intraoperative complication occurred. No intraoperative transfusions were administered in both cohorts. No statistically significant differences in complications rates were registered between groups (p=0.266). No differences in term of disease-free (p=0.833, log-rank test) and overall (p=0.723, log-rank test) survival was noted between groups. CONCLUSIONS:Transabdominal specimen retrieval does not reduce the benefits of minimally invasive staging in endometrial cancer with large uteri or utero-vaginal disproportion. Uterine size is not a limitation for minimally invasive surgery. Further studies are needed to confirm these results and define the optimal approach.

OBJECTIVE:To evaluate the lymphatic-specific morbidity (specifically, lower extremity lymphedema) associated with laparoscopic management of early-stage endometrial cancer using the sentinel lymph node (SLN) algorithm by type of actual nodal assessment. METHODS:An ambispective study was conducted on consecutive patients surgically treated for apparent early-stage endometrial cancer who underwent laparoscopic staging according to the National Comprehensive Cancer Network SLN algorithm at a single institution from January 2020 to August 2023. Data on patient characteristics, surgical details, and post-operative complications were collected. Lymphedema screening was performed using a validated questionnaire. RESULTS:A total of 239 patients were analyzed, with a questionnaire response rate of 85.4%. The study population was grouped based on actual surgical staging: hysterectomy+SLN (54.8%), hysterectomy+systematic pelvic lymphadenectomy (27.2%), and hysterectomy only (18%). The prevalence of lymphedema was significantly lower in the hysterectomy+SLN group compared with the hysterectomy+systematic pelvic lymphadenectomy group (21.4% vs 44.6%, p=0.003). Multivariable analysis showed a threefold increase in the risk of lymphedema for the hysterectomy+systematic pelvic lymphadenectomy group compared with the hysterectomy+SLN group: OR 3.11 (95% CI 1.47 to 6.58). No significant associations were found between lymphedema and other patient or tumor characteristics. CONCLUSION:In the setting of a laparoscopic approach for early-stage endometrial cancer surgery, SLN mapping is associated with a significant reduction in lymphatic complications compared with a systematic lymph node dissection. Our findings provide additional evidence endorsing the adoption of SLN mapping during minimally invasive surgery for endometrial cancer. This technique ensures comparable diagnostic accuracy and also minimizes complications.

OBJECTIVE:To investigate whether molecular classification could support individualized selection of patients with grade II endometrioid endometrial cancer for fertility-sparing approaches. METHODS:This is a retrospective multi-institutional study. Data of patients undergoing fertility-sparing treatment with a levonorgestrel intrauterine device (with or without oral hormonal therapy) were retrieved. Surrogate molecular classification was used to categorize patients into 4 classes: (1) POLE-mutated, (2) mismatch repair deficient/microsatellite instability high, (3) p53 abnormal, and (4) no specific molecular profile. RESULTS:Overall, data from 23 patients with grade II endometrioid endometrial cancer starting a fertility-sparing attempt were retrieved. The median patient age was 36 (range; 30-41) years. All patients underwent hysteroscopic-guided endometrial biopsies. Hysteroscopic resection of the tumor was performed in 9 (39.1%) patients. According to surrogate molecular classification, 1 (4.3%), 2 (8.7%), 3 (13.1%), and 17 (73.9%) patients were classified as POLE-mutated, p53 abnormal, mismatch repair deficient/microsatellite instability high, and no specific molecular profile, respectively. Molecular classification was not associated with 6-month response rates (p = .080) nor with best response rates (p = .366). Overall, 7 women attempted to achieve a pregnancy; 3 underwent in vitro fertilization. Three patients achieved a pregnancy (1 first-trimester miscarriage and 2 term live births). A total of 10 (43.4%) patients were diagnosed with progressive disease during hysteroscopic surveillance. Overall, 19 (82.6%) patients required hysterectomy. Three (13%) patients required adjuvant therapy for the presence of locally advanced disease (1 stage II, and 2 stage III). Over a median (range) follow-up of 28.7(8.2-91.1) months, no recurrence or disease-related death occurred. CONCLUSIONS:Less than 10% of women with grade II endometrioid endometrial cancer starting a fertility-sparing attempt achieve a term pregnancy. In our series, molecular classification did not influence response rate. Further collaborative registers are needed.

STUDY QUESTION:Can patients with uterine smooth muscle tumours of uncertain malignant potential (STUMP) be effectively and safely managed with fertility-sparing treatment? SUMMARY ANSWER:This multicentre retrospective study demonstrates that fertility-sparing management for patients diagnosed with STUMP is both feasible and safe. WHAT IS KNOWN ALREADY:Few studies, involving a limited number of patients, have investigated fertility-sparing management for STUMP in women with future pregnancy aspirations. STUDY DESIGN SIZE DURATION:This multicentre retrospective study was conducted in collaboration with 13 Italian institutions specializing in gynaecologic oncology. The primary objective was to evaluate the reproductive outcomes of the included patients, while the secondary objective was to analyse their clinical outcomes. PARTICIPANTS/MATERIALS SETTING METHODS:A total of 106 patients with a histological diagnosis of STUMP who underwent fertility-sparing treatment for uterine tumours were included. Patient data were collected from 13 referral centres across Italy, and reproductive and clinical outcomes were documented during follow-up. The median (range) length of follow-up was 48 (7-191) months. MAIN RESULTS AND THE ROLE OF CHANCE:Of the 106 patients, 47 (44.3%) patients actively tried to conceive after fertility-sparing surgery, and 27 of them (57.4%) achieved a pregnancy. Among the patients trying to conceive, 12 (25.5%) women had more than one pregnancy after surgery for STUMP. At follow-up, 23 (21.7%) out of the 106 women had a recurrence of uterine disease. Furthermore, a higher rate of recurrence was observed among patients who became pregnant (17 out of 27 women (63.0%)) compared with those who did not (6 out of 79 women (7.6%); P < 0.001). Only two cases (1.9%) of malignant relapse were recorded, and one patient with a leiomyosarcoma recurrence died. LIMITATIONS REASONS FOR CAUTION:The primary limitation of this study is the inherent biases associated with its retrospective design. WIDER IMPLICATIONS OF THE FINDINGS:This multicentre retrospective study represents the largest case series to date examining the reproductive and clinical outcomes of patients undergoing conservative treatment for STUMP. The findings suggest that patients can be counselled on the feasibility and safety of fertility-sparing management, which should be considered by clinicians as both safe and effective. STUDY FUNDING/COMPETING INTERESTS:No funding was received, and there are no competing interests. TRIAL REGISTRATION NUMBER:N/A.

OBJECTIVE:This study aimed to describe the patterns of adjuvant therapy use within the SUCCOR cohort, a large retrospective analysis comparing disease-free survival following minimally invasive versus open surgery in early-stage cervical cancer. Furthermore, to assess the factors associated with the indication for adjuvant radiotherapy after radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB (≤4cm) cervical cancer. METHODS:A retrospective analysis was performed using the SUCCOR study database. We investigated patients with FIGO 2009 stage IB1, node-negative cervical cancer at final pathology. Univariate and multi-variable logistic regression were performed to determine factors associated with the administration of adjuvant radiation therapy. RESULTS:The study included a total of 572 patients. Of these, 340 patients (59.4%) did not receive adjuvant radiotherapy, including 45 (13.2%) who met the Sedlis criteria. Conversely, among the 232 patients (40.6%) who received adjuvant radiotherapy, 132 (56.9%) did not meet Sedlis criteria. In the univariate logistic regression, factors associated with adjuvant radiotherapy included tumor size >2 cm (p< .001), lymphovascular space invasion (p < .001) and a tumor grade G3 (vs G1-G2, p .01). Furthermore, the probability of receiving adjuvant radiotherapy was higher for patients with deep stromal invasion (p < .001), and with intermediate stromal invasion (p < .001) in comparison to those with superficial stromal invasion. At multiple logistic regression, open approach (odds ratio [OR] 1.63, p =.01) and G3 tumor grade (OR 1.64, p= .01) were independently associated with the administration of adjuvant radiotherapy. In addition, the presence of Sedlis criteria was associated with a 4 times higher probability of having adjuvant radiotherapy (OR 4.44, p < .001). CONCLUSIONS:While the Sedlis criteria should guide post-operative radiotherapy administration, we observed a significant variation in post-operative adjuvant treatment among institutions involved in the SUCCOR study. A call for a standardized recommendation of adjuvant radiation therapy is needed.

OBJECTIVE:Limited prospective data are available on the outcomes and performance of sentinel node mapping (SNM) in patients with endometrial cancer (EC). This study aimed to describe the surgical outcomes related to laparoscopic staging and the performance of SNM in patients with apparent early-stage EC. METHODS:This is a secondary analysis of a prospective single-arm study focusing on predictors of nodal disease in apparent early-stage EC. This analysis focused on 90-day surgical outcomes of patients undergoing laparoscopic surgery, including hysterectomy, bilateral salpingo-oophorectomy and SNM. RESULTS:Overall, 210 patients were evaluated: 178 (84.8 %) patients had endometrioid EC and 32 (15.2 %) patients had non-endometrioid EC. No conversions to open surgery were reported at the time of SNM. Two (1 %) patients converted to open surgery for completion of hysterectomy. Unilateral mapping was achieved in all patients (n = 210, 100 %), with a bilateral pelvic detection rate of 93.8 % (n = 197). Sentinel nodes in the para-aortic area were detected in 19 patients (9 %). The majority of sentinel nodes were located in the external iliac area (55.7 % on the right side and 58.6 % on the left side), followed by the obturator area (26.1 % on the right side and 22.9 % on the left side) and internal iliac area (11.9 % on the right side and 8.1 % on the left side). Overall, 41 patients (19.5 %) had positive nodes detected, with low-volume disease observed in 21 (10 %) patients. Eight (3.8 %) patients had moderate (grade 2) 90-day complications. Three (1.4 %) patients had severe (grade 3) 90-day complications. CONCLUSIONS:Laparoscopic surgical staging for apparent early-stage endometrial cancer is safe and effective. Long-term data are needed to assess oncological outcomes.

OBJECTIVE:To assess 5-year oncologic outcomes of apparent early-stage high-intermediate and high-risk endometrial cancer undergoing sentinel node mapping versus systematic lymphadenectomy. METHODS:This is a multi-institutional retrospective, propensity-matched study evaluating data of high-intermediate and high-risk endometrial cancer (according to ESGO/ESTRO/ESP guidelines) undergoing sentinel node mapping versus systematic pelvic lymphadenectomy (with and without para-aortic lymphadenectomy). Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard methods. RESULTS:Overall, the charts of 242 patients with high-intermediate and high-risk endometrial cancer were retrieved. Data on 73 (30.1%) patients undergoing hysterectomy plus sentinel node mapping were analyzed. Forty-two (57.5%) and 31 (42.5%) patients were classified in the high-intermediate and high-risk groups, respectively. Unilateral sentinel node mapping was achieved in all patients. Bilateral mapping was achieved in 67 (91.7%) patients. Three (4.1%) patients had site-specific lymphadenectomy (two pelvic areas only and one pelvic plus para-aortic area), while adjunctive nodal dissection was omitted in the hemipelvis of the other three (4.1%) patients. Sentinel nodes were detected in the para-aortic area in eight (10.9%) patients. Twenty-four (32.8%) patients were diagnosed with nodal disease. A propensity-score matching was used to compare the aforementioned group of patients undergoing sentinel node mapping with a group of patients undergoing lymphadenectomy. Seventy patient pairs were selected (70 having sentinel node mapping vs. 70 having lymphadenectomy). Patients undergoing sentinel node mapping experienced similar 5-year disease-free survival (HR: 1.233; 95%CI: 0.6217 to 2.444; p = 0.547, log-rank test) and 5-year overall survival (HR: 1.505; 95%CI: 0.6752 to 3.355; p = 0.256, log-rank test) than patients undergoing lymphadenectomy. CONCLUSIONS:Sentinel node mapping does not negatively impact 5-year outcomes of high-intermediate and high-risk endometrial cancer. Further prospective studies are warranted.

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013–2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference = 1

Introduction/Background Human papillomavirus (HPV) is one of the most common sexually transmitted diseases, worldwide. In most cases, HPV correlates with transient infections, but its persistence can lead to precancerous and cancerous lesions in various districts. To date, no data supports the execution of vaccination after hysterectomy for high-grade cervical intraepithelial neoplasia (CIN2+) and early-stage cervical cancer (CC). We aim to evaluate the potential effect of vaccination after hysterectomy for high-grade cervical intraepithelial neoplasia and early-stage cervical cancer Methodology This is a multi-center retrospective study evaluating data of women who develop lower genital tract dysplasia (including anal, vulvar and vaginal intra-epithelial neoplasia) after having hysterectomy for CIN2+ and FIGO stage IA1- IB1 CC Results Overall, charts for 77 patients who developed lower genital tract dysplasia were collected.The study population included 62 (80.5%) and 15 (19.5%) patients with CIN2+ and early-stage CC, respectively. The median (range) time between hysterectomy and diagnosis of develop lower genital tract dysplasia was 38 (range, 14–62) months. HPV types covered by the nonavalent HPV vaccination would potentially cover 94.8% of the development of lower genital tract dysplasia.Restricting the analysis to the 18 patients with available HPV data at the time of hysterectomy, the beneficial effect of nonvalent vaccination was 89%. However, considering that patients with persistent HPV types (with the same HPV types at the time of hysterectomy and who developed lower genital tract dysplasia) would not benefit from vaccination, we estimated the potential protective effect of vaccination to be 67% (12 out of 18 patients; four patients had a persistent infection for the same HPV types). Conclusion Our retrospective analysis supported the adoption of HPV vaccination in patients having treatment for HPV-related disease.Even in the absence of the uterine cervix, HPV vaccination would protect against develop lower genital tract dysplasia.Further prospective studies have to confirm our preliminary research. Disclosures None.

Introduction/Background To assess 5-year oncologic outcomes of apparent early-stage high-intermediate and high-risk endometrial cancer undergoing sentinel node mapping and systematic lymphadenectomy. Methodology This is a multi-institutional retrospective, propensity-matched study evaluating data of high-intermediate and high-risk endometrial cancer (according to ESGO/ESTRO/ESP guidelines) undergoing sentinel node mapping and systematic pelvic lymphadenectomy with and without para-aortic lymphadenectomy. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard methods. Results The charts of 242 patients with high-intermediate and high-risk endometrial cancer were retrieved. Overall, 73 (30.1%) patients undergoing hysterectomy plus sentinel node mapping met the inclusion criteria. Forty-two (57.5%) and 31 (42.5%) patients were classified in the high-intermediate and high-risk groups, respectively. Unilateral sentinel node mapping was achieved in all patients. Bilateral mapping was achieved in 67 (91.7%) patients. Three (4.1%) patients had site-specific lymphadenectomy (two pelvic areas only and one pelvic plus para-aortic area). In comparison, adjunctive nodal dissection was omitted in the hemipelvis of the other three (4.1%) patients. Sentinel nodes were detected in the para-aortic area in eight (10.9%) patients. Twenty-four (32.8%) patients were diagnosed with nodal disease. A propensity-score matching was used to compare patients undergoing sentinel node mapping with patients undergoing lymphadenectomy. Seventy patient pairs were selected (70 with sentinel node mapping vs. 70 with lymphadenectomy). Patients undergoing sentinel node mapping experienced similar 5-year disease-free survival (HR: 1.233; 95%CI: 0.6217 to 2.444; p=0.547, log-rank test) and 5-year overall survival (HR: 1.505; 95%CI: 0.6752 to 3.355; p=0.256, log-rank test) than patients undergoing lymphadenectomy (figure 1). Conclusion Sentinel node mapping does not negatively impact 5-year outcomes of high-intermediate and high-risk endometrial cancer. Further prospective studies are warranted Disclosures The Authors declare no conflicts of interest. No funding sources supported this investigation.