INTRODUCTION:Sertoli-Leydig cell tumors (SLCTs) are rare, with a challenging diagnosis and management. Herein is our case. CASE REPORT:We report the case of a 14-year-old female patient who presented with secondary amenorrhea with clinical signs of virilization. A pelvic MRI showed a solid-cystic intraperitoneal mass. The patient underwent surgery. A left adnexectomy, along with an omentectomy, peritoneal biopsy, and peritoneal cytology sampling, was performed. The histopathological examination confirmed a Sertoli-Leydig cell tumor of the left ovary. While the majority of the tumor cells were well-differentiated, a focal area contained poorly differentiated cells with high mitotic activity and sarcoma-like features. The case was presented at a multidisciplinary tumor board meeting to assess the potential benefit of adjuvant chemotherapy, given the presence of a poorly differentiated component. However, adjuvant chemotherapy was not recommended. DISCUSSION:SLCTs are rare ovarian neoplasms that predominantly affect individuals of reproductive age. Virilization occurs in up to 60 % of cases. Serum tumor markers can aid in the detection of SLCTs. According to the latest WHO classification, SLCTs are categorized as well-differentiated, moderately differentiated, or poorly differentiated. Surgical resection remains the gold standard treatment, while postoperative chemotherapy is recommended for patients with poor prognostic factors. However, managing SLCTs remains challenging due to the lack of standardized treatment guidelines. Prognosis is primarily determined by tumor stage and degree of differentiation. CONCLUSION:Managing SLCTs remains complex, and further studies are needed to better define treatment guidelines.

PURPOSE:In 2023, the European Society of Gynaecological Oncology (ESGO), jointly with the European Society for Radiotherapy and Oncology (ESTRO) and the European Society of Pathology (ESP), published evidence-based guidelines for the management of patients with cervical cancer. Acknowledging that limitations exist even in high-income countries, some of these established standards of care are not applicable in clinical practice in some areas of the world. Following a global ESGO survey involving 256 clinicians from 57 countries, which pointed out potential limitations, barriers, and missing guidelines, ESGO decided to develop alternative management strategies for situations when optimal resources are unavailable or limited. METHODS:A multi-disciplinary international development group consisting of 22 experts, utilizing feedback from the survey conducted mostly in low- and middle-income regions, identified potential limitations to the standards of care as defined in the updated ESGO-ESTRO-ESP guidelines published in 2023 and suggested alternative approaches. New resource-stratified guidelines on the management of women living with the human immunodeficiency virus have been newly proposed. To ensure a global perspective, the guidelines were reviewed by 188 independent international practitioners from Asia, Africa, Europe, and South, Central, and North America. RESULTS:These resource-stratified guidelines focus on achieving the best patient outcomes, with alternative management strategies based on expert opinions in areas with limited evidence. They should be used as a guide for the next best alternatives in multi-disciplinary care settings such as diagnostics, pathology, surgery, radiotherapy, systemic therapy, palliative care, and follow-up management. CONCLUSION:Efforts should always focus on providing optimal available care. In the absence of key resources, the primary effort should be directed toward consulting and referring patients to other facilities that provide better conditions.

Background Nurses play an essential role in patient care, and nurse-patient relationship are a fundamental aspect of healthcare delivery. Research has indicated that oncology nurses are particularly susceptible to burnout. However, there is limited research on nurse burnout in oncology, particularly in the Arab Muslim world. Objective This study aimed to investigate burnout among oncology nurses and analyze its association with professional and sociodemographic factors. Methods A cross-sectional study was conducted with oncology nurses at the Salah Azaiz Institute. We assessed socio-demographic data, work variables, job satisfaction, and burnout using the Maslach Burnout Inventory. Results Of the nurses surveyed, 78 responded correctly to the questionnaire. The median age of participants was 37 years, with a predominance of females (52.6%). The median duration of oncology work was 11 years. Regarding job satisfaction, 30.8% were somewhat dissatisfied, and 24.4% were not satisfied. The prevalence of burnout was 89.9%, with 73.1% experiencing high levels of emotional exhaustion, 48.7% high levels of depersonalization, and 25.6% a low level of personal accomplishment. Personal medical and psychiatric history, along with job satisfaction, emerged as the strongest predictors of burnout in the multivariate analysis. Conclusion This study highlights the significant prevalence of burnout among nurses in oncology settings. In Tunisia, there is an urgent need to prioritize the psychological well-being of oncology nurses. Preventive strategies should emphasize enhancing working conditions to reduce these risks.

Abstract Background Sex cord-stromal tumors with annular tubules are a rare tumor accounting for less than 1% of all ovarian malignancies. However, they are characterized by very late recurrence, which can be as late as 30 years after diagnosis and treatment. Case presentation A 16-year-old female Caucasian patient was treated in our department for a stage IA ovarian sex cord-stromal tumors with annular tubules. She underwent a left salpingo-oophorectomy and ipsilateral pelvic node biopsy with no adjuvant treatment. She was seen for amenorrhea after being lost to follow up for 16 years. The diagnosis of recurrence was made by radiology and the elevation of serum inhibin B level. The patient underwent resection of the tumor, left segmental colectomy, and paraaortic lymphadenectomy because the mass was massively adherent to the left mesocolon. Histology confirmed the diagnosis with no metastatic lymph nodes. No adjuvant therapy was indicated. The patient was lost to follow-up again for 4 years and re-presented for amenorrhea. Serum inhibin B level was high. A second recurrence was suggested, and the patient underwent a laparoscopic surgery. We performed left pelvic and paraaortic lymphadenectomy, and 3 months after surgery the patient was pregnant. Conclusion Sex cord-stromal tumors with annular tubules is a slow-growing ovarian tumor with a high potential for recurrence and metastasis. Surgery is the mainstay of treatment. Due to the rarity of these tumors, they are often unsuspected and thus incompletely staged before primary surgery; the diagnosis is made by histological examination. The prognosis of these patients is unknown, and they require long-term follow-up.

Introduction/Background Borderline ovarian tumors account for 15 to 20% of ovarian tumors. Prognostic factors of recurrence include the stage of the disease, presence of peritoneal implants, micropapillary pattern, microinvasion and intra-epithelial carcinoma. Fertility sparing constitutes a major therapeutic issue in young patients that leads to conservative surgical treatment in specific cases. Methodology We conducted a retrospective descriptive study including patients treated at our Institute for Borderline ovarian tumor who underwent conservative surgical treatment from 2003 to 2018. Results Nine patients were included in our study. The median age was 33 years. Three patients were nulliparous. Given to the age, conservative treatment was indicated in all these patients. Cystectomy without ovariectomy was indicated in 5 of the 9 women, which was within the margin of tumor resection on definitive anatomopathic examination in 3 of the 5 women.In contrast, given the impossibility of ovarian conservation, total annexectomy was carried out in 4 of all these women. All of patients were followed regularly postoperatively, three had a carcinomatous transformation as an ovarian adenocarcinoma at an average interval of 18 months. Among these three patients, a single one presented intra-peritoneal metastases, requiring radical surgical treatment and adjuvant chemotherapy with 6 cures of Carbo-Taxol, with a good tolerance and a complete response. Moreover, one patient had a recurrence on the contralateral ovary as a Borderline mucinous ovarian tumor. For the remaining four women, after a median follow-up of 35 months, one patient fell spontaneously pregnant during follow-up, three patients were in complete remission at 16 months. Conclusion Borderline ovary tumors usually occur in young patients, which makes conservative treatment advisable if possible, but this always comes with a risk of recurrence and/or carcinomatous transformation, especially if the conservative surgical procedure was a cystectomy instead of a total annexectomy, and even more so if the resection margins were tumoral. Disclosures All authors declare that they have no conflicts of interest.

INTRODUCTION:Infectious affections are the most frequent post-operative complications, the rate have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (FN) and pelvic organ necrosis. There is no well-codified treatment.CASE PRESENTATION:A 42-year-old female patient, was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. Two months after surgery, the patient presented with fever. Abdominal CT scan revealed a recto-vaginal fistula. The patient underwent a surgical evacuation of the collection and a bypass colostomy. Post-operative period was marked by the occurrence of an extensive necrosis to pelvic organs and medial left leg's thigh compartments muscles. She also presented a thrombosis of the left external iliac vein and artery. Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required and a ligature of the left external iliac vessels. Then she received palliative treatment.she died one month after surgery because of multivisceral failure due to sepsis.CONCLUSION:Necrotizing fasciitis is extremely rare and serious condition, the diagnosis is clinical and radiological, CT scan is helpful for the. There are predisposing factors such as diabetes, neoadjuvant radiotherapy or chemotherapy. The prognosis can be improved with rapid management and appropriate medical and surgical excisions of necrotic tissue, and antibiotic therapy adapted to the suspected germs, essentially anaerobic ones.

Introduction/Background Concurrent chemoradiotherapy(CCRT) is the standard-of-care treatment for locally advanced cervical cancer(LACC) and complete response(CR) is achieved in 70%–90% of patients. Surgery after CR is still debated .Is definitive CCRT recommended in our population? Methodology We retrospectively reviewed the clinical record of 22 patients treated for LACC by definitive CCRT between 2011 and 2021. Results The mean age of patients at diagnosis was 55.5 years old . Patients were staged as stage IB3, IIA, IIB, III to stage IV in 9.1%, 13.6%, 36.4%, 31.7% and 9.1% of cases respectively. All subjects received CCRT followed by brachytherapy. Response after CRRT, evaluated by a magnetic resonance imaging (MRI) and cervical biopsy, was complete in all cases. Six patients presented with a loco-regional relapse (LRR) respectively on pelvic lymph nodes (3cases), uterine cervix (2cases), and on the vagina. The relapses occurred in the first 18 months in 5 cases. One patient had a late LRR after 45 months of follow-up. Three of them underwent surgery with an R0 resection while the other ones received palliative chemotherapy. One patient presented after 13 months of follow-up with bone metastasis that was treated by exclusive external radiotherapy. Clinical factors correlated with LRR were pelvic nodal status on MRI (p<0.01), bladder involvement on MRI (p<0.035) and clinical tumor stage (p<0.047). However age, tumor size, histological type and the presence of lympho-vascular invasion were not significantly related to the risk of LRL . The average duration of follow-up was 27.05 months. The 2-year OS rate was 76.4% visualized in Kaplan–Meier curves; however, the disease-free survival rate was about 85.9% for all cases in 2 years. Conclusion To date no study has attested of a significantly improved OS and DFS after completion surgery. A prospective randomized trial is mandatory to compare the two approaches and to evaluate the morbidity and survival outcome. Disclosures The authors have nothing to disclose.

The Institute Salah Azaiez has been the Public AntiCancer Center in Tunisia since March 20, 1969. It has thus offered over 50 years of cancer care to our population. The center comprises 10 departments: Surgical Oncology, otorhinolaryngology, Medical Oncology, Radiation Oncology, Nuclear Medicine, Histology, Immunohistocytology, Diagnostic Radiology, Biology, and Epidemiology. Like every anticancer center, the decisionmaking process is made in a multidisciplinary meeting, known in our institution as a committee. One of those committees is dedicated to gynecologic malignancy. It is known as “Committee 06” and has been working since March 1969 (Figure 1) to help improve care. Since that date Committee 06 through its leading members has been a cornerstone in the field of gynecologic malignancies, with multiple roles in establishing and promoting standard of care. As part of its role promoting the best standard of care for Tunisian patients, Committee 06 members have produced the first countryspecific guidelines (Figure 2) for gynecologic cancers based on the international state of the art. As a team we have worked to adapt these international standards to our reality. This has helped in terms of recognizing and addressing our limitations and focusing on what we need to do to maintain our health system at a viable, highquality level. Since 2011 and the Arab Spring, approximately 4000 women per year have had surgery for various tumor types. Each year approximately 60 women had access to radical hysterectomies for cervical cancer. One hundred others had hysterectomies mainly for endometrial cancer and also earlystage cervical cancers. More than 60% of women diagnosed with ovarian cancer underwent optimal to complete cytoreductive surgery. Since 1969, a mean of 20 cases has been discussed per committee meeting. In addition to its role in decisionmaking, the committee through its members has worked to improve and homogenize women’s health care. Committee 06 members have been collecting and analyzing data from these patients, and comparing it to the existing international data. The aim has been to offer the best care possible for our patients. Despite being mostly retrospective, this data has been a vital tool in developing our standard of care. In 2018, Committee 06 started an early feasibility study to evaluate the safety and efficacy of dual tracer sentinel lymph nodes in stage I endometrial cancer. For Tunisan health care to keep pace with the standards of more developed countries in terms of endometrial Figure 1 The O6 Committee meeting.

examination. Management of vulvar neoplasms depends on histopathologic type and ranges from wedge resection with or without lymph node biopsy or dissection, to radiation therapy with chemo-or immunotherapy. Overall survival

Introduction/Background Adenocarcinoma of the uterine cervix is not as common as squamous cell carcinoma. It accounts for 10–25% of all cervical cancers, yet this rate has been increasing over the past few decades. Uterine cervix adenocarcinoma is a very heterogeneous disease, with different histological subtypes, having an affinity for lymphoid, ovarian, and distant metastases, and a poorer prognosis compared to squamous cell carcinoma. Methodology We conducted a retrospective descriptive study including patients followed and treated for adenocarcinoma of cervix at the Salah Azaiez institute over a period of 20 years from 2004 to 2020. Results Sixty-eight female patients were included in our study. The mean age was 58.19±13 years ranging from 35 to 86 years. HPV infection was documented in 13% of cases. Clinically, the tumor size varied between 1 and 6 cm, parametrium's invasion was estimated in 46% of cases. Concerning histological subtypes, endocervical adenocarcinoma was the most frequent subtype, occurring in 41.5% of cases, followed by mucinous adenocarcinoma (23.1%), clear cell adenocarcinoma (15.8%), Adenosquamous carcinoma (11.8%), and finally, the endometrioid subtype (7.4%). Only two cases of mesonephric adenocarcinoma were reported. The most frequent FIGO stages were IIB (27,9%) and IIIC1 (14,7%). Seventy-one percent of patients underwent neoadjuvant radiotherapy associated to chemotherapy and 61% had brachytherapy. After neoadjuvant treatment, 31% had partial response, 0.7% had no response and 4 patients progressed. Subsequently, 70.6% of patients underwent surgery, type colpo hysterectomy and pelvic lymphadenectomy in 50% of cases. After a median follow-up of 90 months, only 35% of our patients are alive with no sign of recurrence. Conclusion Adenocarcinoma of the uterine cervix is a very heterogenous disease, including different histological subtypes. Current guidelines recommend the same management approach as for squamous cell carcinoma; however, adenocarcinoma has been associated with a poorer prognosis and a higher likelihood of distant recurrence. Disclosures None

In another department, a 65-year-old patient underwent hysterectomy for a bleeding myoma. The final histology was concordant with leiomyosarcoma. After 8 months she consulted again after she had fecaluria. An abdomino-pelvic CT showed a vaginal cuff relapse invading the ileum and bladder, with the

Introduction/Background Large cell neuroendocrine carcinoma (LCNEC) is a rare subtype of cervical cancer that accounts for approximately 2–5% of all cervical cancer cases. LCNEC is characterized by a high degree of aggressiveness, early metastasis, and poor prognosis. Methodology In this abstract, we present three cases of Large cell neuroendocrine carcinoma, each with a unique clinical presentation. Results Case 1: A 50-year-old woman presented with abnormal vaginal bleeding and pelvic pain. Further investigation revealed a large tumor in the cervix. A biopsy confirmed the diagnosis of LCNEC. The patient underwent Neoadjuvant chemotherapy and brachytherapy, but developed metastases to the lungs and liver within six months of initial diagnosis. Case 2: A 51-year-old woman presented with postmenopausal bleeding and was diagnosed with LCNEC on biopsy. Further imaging studies showed the presence of metastases to the lymph nodes and liver. The patient was treated with chemotherapy and radiotherapy, but succumbed to the disease after 18 months. Case 3: A 47-year-old woman presented with recurrent vaginal bleeding and was diagnosed with LCNEC on biopsy. Further evaluation revealed metastases to the lungs, liver and bones. The patient underwent chemotherapy, but unfortunately experienced disease progression and passed away within a year of initial diagnosis. Conclusion LCNEC is a rare and aggressive subtype of cervical cancer that poses significant challenges in diagnosis and management. The prognosis for patients with NECC is poor, with a high risk of recurrence and metastasis. While surgery and lymphadenectomy have been found to significantly impact survival rates, chemotherapy and radiotherapy appear to have little to no effect on prognosis. Disclosures All authors declare that they have no conflicts of interest.

Introduction Paratesticular rhabdomyosarcoma is a rare and aggressive mesenchymal tumor, accounting for only 7% of all rhabdomyosarcomas. It is mainly encountered in children and adolescents. The standard treatment consists of radical orchidectomy with negative surgical margins. However, chemotherapy is recommended to control retroperitoneal micrometastasis. The place of surgery for progressive retroperitoneal lymph node metastases remains controversial. We present a case of paratesticular rhabdomyosarcoma with progressive retroperitoneal lymph node metastases treated with surgery. Case report We report a case of a 17-year-old North African male with no particular medical history who presented with a left scrotal mass that had been evolving for several months. Beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase were normal. Scrotal ultrasonography revealed the presence of a 6 cm heterogeneous hypoechogenic tissular mass with cystic areas adherent to the left scrotal wall, which was thickened in some places and vascularized by color Doppler. It exerted a mass effect on the homolateral testicle, which was of average volume. The thoracic–abdominal–pelvic computed tomography scan showed the presence of suspicious paraaortic lymph nodes. The most voluminous one measured 16 × 23 mm 2 . A left orchidectomy was performed. The final pathology report revealed an 8 cm paratesticular rhabdomyosarcoma of the embryonic type that displaced the testicle without invading it. Without going beyond it, it infiltrated the epididymis, the rete testis, and the albuginea. The surgical margin at the level of the spermatic cord was free. The patient had adjuvant chemotherapy (ifosfamide, vincristine, and dactinomycin). The patient had a challenging paraaortic lymph node dissection since the mass enlaced the left ureter and renal vessels. On histological examination, the paraaortic lymph nodes were metastatic. Conclusion Rhabdomyosarcoma is an aggressive malignancy with high metastatic potential. Therefore, only an accurate diagnosis and early treatment can ensure better survival. Surgery in expert hands seems to be a good option for progressive retroperitoneal nodes. However, further studies are needed to determine the place of surgery in this setting.

Objectives The distinction of ovarian Mucinous Borderline Tumors (MBT) from carcinomas remains the greatest challenge for pathologists. The aim of the work was to assess concordance between the response of extemporaneous examination (EE) and the final diagnosis of MBT. Methods Our study was retrospective including 37 cases of primary ovarian MBT, diagnosed at the Pathology Department of Salah Azaiez Institute from 1992 to 2019. We included in our study all patients who presented with a primary MBT on a surgical specimen and who had an EE of the tumor. Results The EE showed a borderline tumor in 27 cases (the exact diagnosis), a benign tumor in six cases, and a carcinoma in one case. In two cases, it was necessary to wait for the final result after inclusion in paraffin. Finally, in one case, the EE could not be concluded due to extensive necrosis. The EE/definitive examination concordance rate was about 73%. Conclusions The EE is a valuable aid in guiding the therapeutic decision, but it is difficult due to the bulky and heterogeneous nature of these tumours. According to the literature, the concordance between the EE and the final diagnosis of borderline tumors varies from 44 to 70%. This examination is quite effective in excluding the diagnosis of benign tumor and often responds that the tumor is 'at least' borderline.

Introduction/Background Locally advanced cervical cancer is treated with Radio-chemotherapy and brachytherapy. Therefore; a pre-treatment para-aortic lymph node assessment is important for disease staging and therapeutic implications. Our study aimed to analyze the Tunisian experience of laparoscopic lymphadenectomy for patients with locally advanced cervical cancer. Methodology We reported 29 patients with locally advanced cervical cancer who underwent laparoscopic lymphadenectomy at our Institute between 2016 and 2022. Results The mean age was 44 years. Patients were staged IIIC1 in 48.2%, 2.,5% were IIB, 6.9% were IVA, 6.9% IB1, 6.9% IB3 and 2.8% were IIA2. CT scan and MRI showed suspicious pelvic lymph nodes in 65.5% and suspicious para-aortic lymph nodes in 17.9% of cases. All patients underwent para-aortic lymph node dissection after a mean time of 6 days. Our technique was 68.9% Transperitoneal and 31.O1% extraperitoneal. The mean time duration was 2:37Hours. There was no per-operative or postoperative complications. One patient had a blood transfusion The mean time of hospital stay was 2 days. Pathological examination found a mean number of 9Nodes (range 2–22 removed lymph nodes). There was 32.17% of invaded lymph nodes. sensitivity and specificity were respectively 100% and 83.3%, and VPP was 33.3%. All patients had radiochemotherapy for their cervical cancer. Conclusion Pre-treatment laparoscopic staging surgery plays an important role in the treatment and the decision of the radiation field. Although imaging modalities are improving, the current gold standard for determining lymph node status is surgical sampling mainly in developing countries with difficult access to PET-CT.

Introduction/Background We aim to correlate serum CA 125 values after chemotherapy with clinical findings during second-look surgery. Methodology This study was conducted on twenty-five patients with epithelial ovarian cancers undergoing second-look operations in our hospital between 2019 and 2021. Results The average age of the patients was 59, 2 years. Twenty-one cases of stage III (84%) and 4 cases of stage VI (16%) high serous ovarian carcinoma. The CA125 level before chemotherapy was high in all cases with a mean rate of 932, 8 UI/ml. All the patients underwent multiple courses of neoadjuvant chemotherapy. The evaluation of response was clinically, radiologically, and biologically. Eight patients who had negative second-look findings gave normal serum CA125 levels. Of the 17 patients who were positive in second-look surgery, 10 had normal CA125 levels with a false negative rate of 58, 8%. Of the patients with normal CA125 levels at the time of operation, those with persistent disease had higher mean CA125 levels (22, 21 UI/ml) than those with no disease detected (12, 2 UI/ml). All the seven patients with elevated CA125 serum levels were positive in their second-look. 70% of patients with residual tumors having the greatest diameter less than or equal to 2 cm had normal CA125 with a mean value of 21 u/ml. 42% of patients with tumors having the greatest diameter greater than 2 cm had normal CA125, while all the 8 patients with no macroscopic tumor during surgery had normal CA125 level. These results show that the residual tumor size found in the second-look was related to the serum CA125 level. Conclusion As CA125 levels within normal limits gave more false negatives, the necessity of second-look surgery can not be judged by serum CA125 assay though elevated CA125 levels do predict the presence of tumor.

Introduction/Background Breast cancer is the most prevalent type of cancer in women. Invasive papillary carcinoma (IPC) is a rare pathological type that accounts for around 3% to 6% of all invasive breast cancers. It is linked to an increased risk of axillary lymph node metastases and lymphovascular invasion. Local recurrence seems to be more frequent. Methodology Data of 70 patients were reviewed retrospectively. Thirty of them were included in our study between 2004 and 2022, Results All of the patients were female, with a mean age of 62. The right breast was the most affected. The tumor was largely situated in the outerupper quadrant. In 76 percent of cases, a breast lump and an axillary lymph node were found, with 20 percent of cases being metastatic. The tumor was classified as T2N1M0 in 50% of cases. ultrasound examination showed a cystic or solidocystic appearance In the majority of cases. The mean histological tumor size was 26 mm. Immunohistochemical studies revealed the positivity of hormonal receptor in 73% and the negativity of HER in all cases. Age, lymphovascular invasion, and tumor necrosis were all significantly correlated to the recurrence-free and overall survival. Local recurrence was observed in 6% of patients. Five-year recurrence-free survival and overall survival rates were 87 and 88 percent, respectively. Conclusion IPC is characterized by aggressive clinicopathologic features. Their prognosis is thouht to be poorer than other breast malignancies such as invasive ductal carcinoma. However our study showed high rates of survival and low incidence of recurrence