INTRODUCTION Palliative care is an important aspect of gynaecological oncology practice. In order to successfully integrate end-of-life (EOL) care in the disease trajectory, it is crucial to incorporate systematic training in subspecialty programmes in gynaecological oncology. We aimed to evaluate the quality of training in palliative care across gynaecological oncology fellows in Europe and to provide a framework to facilitate learning opportunities. METHODS A web-based questionnaire was sent to members of the European Network of Young Gynae-Oncologists (ENYGO). The survey consisted of 36 items covering six domains: respondents' characteristics, quality and quantity of teaching, curriculum achievements, observation and feedback, EOL clinical practice and attitudes about palliative care. RESULTS Of the 703 clinicians enrolled in the study, 142 responded (20.2%). Although the majority worked in university hospitals, only half of them (47%) were in a formal subspecialty programme. The majority of respondents (60%) were trained without a mandatory rotation in palliative care units and considered the quality of EOL care teaching as 'very poor' or 'poor' (57.7%). The majority of respondents (71.6%) did not receive any supervision or feedback at the time of their first consultation on changing the goals of care. CONCLUSION Our study underlines lack of structured teaching and supervision in palliative care contents among European fellows in gynaecological oncology. Broad education of healthcare providers is a key factor to achieve the integration of palliative care in gynaecological oncology practice. Stakeholders like European Society of Gynaecological Oncology/ENYGO play an important role to facilitate educational activities and training programmes targeting to EOL care.

A post-menopausal patient presented with abdominal distention, constipation, and intermittent vomiting. Abdominal ultrasonography and CT showed a cystic pelvic and abdominal mass that contained solid areas ([Figure 1A][1]). Abdominal ultrasonographic features were also suspicious for cancer of the

ObjectiveTo report the results of prophylactic use of intraoperative temporary internal iliac arterial occlusion by Bulldog clamps in patients clinically diagnosed with abnormally invasive placenta. MethodsThis retrospective study included 61 patients diagnosed with FIGO grade 3 abnormally invasive placenta between January 2018 and March 2022. After transfundal incision and fetal delivery, bilateral temporary internal iliac arterial occlusion by Bulldog clamps was performed in all patients. The grades 3b and 3c group underwent cesarean hysterectomy whereas selected cases of grade 3a abnormally invasive placenta underwent fertility-preserving procedures. Preoperative and postoperative findings were compared. ResultsCesarean hysterectomy was performed in 50 (82%) patients and cesarean plus conservative procedures were performed in 11 (18%) patients. Intraoperative blood replacement was not performed in 83.6% of all patients. Mean blood loss was 1.37 & PLUSMN; 0.53 L (range 0.5-2.5) in all patients. Estimated blood loss was significantly higher in cesarean hysterectomy group. There was no statistically significant difference between two groups in terms of peroperative blood replacement, bladder, and ureteral injury. ConclusionProphylactic bilateral temporary internal iliac arterial occlusion by Bulldog clamps should be performed in cases of grade 3 abnormally invasive placenta. Fertility-preserving steps may be undertaken safely in selected cases with this approach.

Aim: Adnexal mass is one of the most common surgical indications in gynecology clinics, and laparoscopy is generally accepted as a gold standard in the management of adnexal mass. Materials and Method: Single incision laparoscopic surgery (SILS) is an evolving endoscopic approach in the era of minimal access surgery. Recently, it has been reported that adnexal mass may also be managed by SILS. In this report, we present 3 symptomatic patients with a huge adnexal mass operated by a single port laparoscopic approach. Results: The mean duration of the operations 95 minutes (range 75-135 minutes). None of the patients converted to laparotomy. All patients discharged on postoperative day 1. None of the patients required readmission to the hospital. Postoperatively all patients were satisfied with their incision and cosmetic results. Conclusion: Single port laparoscopic management can be successfully completed via SILS PortTM in patients with large adnexal masses with better cosmetic outcomes.

Introduction/BackgroundPostpartum hemorrhage (PPH) is an important cause of maternal morbidity and mortality, and is associated with 25% of peripartum maternal deaths worldwide [1]. Placenta accreta spectrum (PAS) is a severe risk factor for PPH[2]. PAS have become one of the most important iatrogenic public health problems today. The incidence changes between 0.3% and 6.7% [3]. The risk may be 11% with one prior cesarean section, 40% with two and 60% with three or more[4]. Maternal morbidity ranges from 24% to 67% [5]. Many institutions worldwide rely on gynecologic oncologists in the surgical management of PAS [6]. Gynecologic oncology associations have not yet taken an active step in determining the standardized surgical steps, developing guidelines and spreading it. Here we propose a useful technique and present results on 61 patients diagnosed with PAS.Methodology61 patients with preoperative radiologic and intraoperative diagnosis of PAS was included. Defined surgical technique by the same multidisciplinary team lead by gynecologic oncologists was performed in each case. The steps of the technique were as follows: Midline incision Transfundal extraction of the fetus Identification of retroperitoneal landmarks Bulldog clamp attachment to the internal iliac artery Bladder dissection Hysterectomy and cuff closure Complication management (repair of the bladder or other ureteral injury) Pre- and postsurgical parameters, estimated blood loss (EBL) (mL), blood transfusion requirement >5 units of packed red cells, and visceral injuries were recorded.ResultsIntraoperative blood replacement was not performed in 83.6%. Postoperative blood transfusion was performed in 8.2% of the patients. Ureteral injury occurred in 9.8% and bladder injury occurred in 11.5% (table 1).ConclusionOur society should define and spread new techniques and guidelines for this life-threatening condition in which we are the ones commonly relied on in many settings worldwide.DisclosuresGynecologic oncologists should be proactively involved in the management of PAS.

Purpose/Objective(s) Treatment planning for locally advanced non-small cell lung cancer (NSCLC) has always been challenging due to the variabilities of the planning target volume (PTV) and competing constraints of organs at risk such as lung, cord, esophagus, and heart. We share our experience in developing a fully automatic treatment planning solution for NSCLC. Materials/Methods Automated plans for NSCLC radiotherapy patients with static IMRT fields were designed using an in-house-developed automated planning system named Expedited Constrained Hierarchical Optimization (ECHO) which is integrated into the treatment planning system (TPS) using API scripting. ECHO does not use TPS optimization algorithms, but utilizes TPS leaf sequencing and final dose calculation. ECHO applies advanced optimization tools (such as hierarchical constrained optimization, convex approximations and Lagrangian methods) to produce Pareto optimal plans that meet clinical constraints and improve desired clinical objectives as much as possible. ECHO optimization parameters were tuned with 29 NSCLC patients and validated retrospectively using 113 NSCLC patients treated with prescription doses including conventional (1.8Gy-2Gy x 25-35 fractions) and hypofractionation (2.75Gy-4Gy x 10-20 fractions). Clinically treated plans were created manually using either static IMRT or VMAT. Automated plans were created using static IMRT fields with beam templates based on the location of PTV within the lung. Dosimetric metrics were evaluated with respect to tumor coverage and normal tissue sparing. Results PTV sizes ranged from 64cc to 2297cc (median 292cc). Median planning time for ECHO was 23 minutes (range: 8min-78min). Both manual and ECHO plans met all established clinical criteria. Compared with manual plans, ECHO plans produced significantly improved and more consistent PTV coverage and better sparing of esophagus, heart and cord while maintaining similar lung doses (Table 1). Conclusion An automated and clinical-criteria-driven treatment planning system has been validated and clinically implemented in our institution for NSCLC radiotherapy. Use of automation improves efficiency, plan consistency and quality for NSCLC treatment planning.

Uterine leiomyosarcoma is a rare malignant tumor arising from the myometrium, which accounts for nearly 2–5% of all uterine malignancies. Chromosomal rearrangement may be the underlying oncogenetic mechanism. Uterine leiomyomas are the most common solid pelvic tumors in women of reproductive age.

The coronavirus disease 2019 (COVID-19) outbreak spread to over 100 countries with a total of 100,000 cases during the first week of March 2020. Health care workers, as those on the frontline of the COVID-19 pandemic, are more susceptible to infection. Inadequate related knowledge and preventive behaviors among health care workers might lead to delayed treatment and result in the rapid spread of the infection. Therefore, this study evaluated the knowledge of health care workers with regard to COVID-19. A cross-sectional study was conducted from June 10–18, 2020. Participants were general practitioners, specialists, and nurses working at the forefront of the pandemic. Their knowledge, preventive behaviors, and risk perceptions concerning COVID-19 were evaluated using an online questionnaire created by our medical specialists. The questionnaire consisted of 29, 5, and 4 items about COVID-19 knowledge, preventive behaviors, and risk perceptions, respectively. A total of 251 health care workers completed the questionnaire. The mean age of the participants was 33.88±8.72 years old, and the sample consisted of 68 males (27.08%) and 183 females (72.91%). While there was no difference between the percentage of correct answers given by female and male participants to knowledge-based questions (p>0.05), the percentage of correct answers to the questions on preventive behaviors was significantly higher in female participants than in males (p<0.001). The overall average percentages of correct responses were 91.66% for knowledge-based questions and 85.96% for preventive behavior questions. The scores for knowledge-based questions were higher for medical specialists, whereas nurses scored higher on preventive behavior questions. Government hospital staff showed a significant difference in preventive behaviors compared to that of university hospitals (p<0.05). In addition, there was a positive correlation between knowledge scores and preventive behaviors. Although all the participants (100%) knew that contracting COVID-19 can lead to death, only 66.93% of them were willing to get vaccinated themselves. The knowledge level of health care workers concerning COVID-19 was above 90%, but the level of competence in terms of preventive behaviors was found to be low, especially in males.

ObjectiveThis study aimed to analyze the prognostic factors for overall and progression-free survival in patients with vulvar cancer.MethodsThis international, multicenter, retrospective study included 2453 patients diagnosed with vulvar cancer at 100 different institutions. Inclusion criteria were institutional review board approval from each collaborating center, pathologic diagnosis of invasive carcinoma of the vulva, and primary treatment performed at the participating center. Patients with intraepithelial neoplasia or primary treatment at non-participating centers were excluded. Global survival analysis and squamous cell histology subanalysis was performed.ResultsAfter excluding patients due to incomplete data entry, 1727 patients treated for vulvar cancer between January 2001 and December 2005 were registered for analysis (1535 squamous, 42 melanomas, 38 Paget’s disease and 112 other histologic types). Melanomas had the worse prognosis (p=0.02). In squamous vulvar tumors, independent factors for increase in local recurrence of vulvar cancer were: no prior radiotherapy (p<0.001) or chemotherapy (p=0.006), and for distant recurrence were the number of positive inguinal nodes (p=0.025), and not having undergone lymphadenectomy (p=0.03) or radiotherapy (p<0.001), with a HR of 1.1 (95% CI 1.2 to 1.21), 2.9 (95% CI 1.4 to 6.1), and 3.1 (95% CI 1.7 to 5.7), respectively. Number of positive nodes (p=0.008), FIGO stage (p<0.001), adjuvant chemotherapy (p=0.001), tumor resection margins (p=0.045), and stromal invasion >5 mm (p=0.001) were correlated with poor overall survival, and large case volume (≥9 vs <9 cases per year) correlated with more favorable overall survival (p=0.05).ConclusionsAdvanced patient age, number of positive inguinal lymph nodes, and lack of adjuvant treatment are significantly associated with a higher risk of relapse in patients with squamous cell vulvar cancer. Case volume per treating institution, FIGO stage, and stromal invasion appear to impact overall survival significantly. Future prospective trials are warranted to establish these prognostic factors for vulvar cancer.

This review aimed to provide an overview of single-port laparoscopic surgery and related literature. Based on previous reviews on endometrial cancer, we focused on the benefit of single-port laparoscopic surgery in endometrium cancer. Endometrial cancer is the most common gynecological cancer and can be treated with laparoscopic surgery without negatively affecting the oncological outcome. Single-port laparoscopic surgery is a recently emerging endoscopic technique, and it was shown that endometrial cancer could be staged using this method. Research shows that endometrial staging with SILS is a feasible strategy that might become a common alternative to the conventional laparoscopic technique. In the future, this novel technique might take on a prominent role in advancing the evolution of minimally invasive gynecologic oncology surgery.

OBJECTIVE:To report the perioperative outcomes of 200 patients with gynecologic cancer who underwent surgery during the Novel Coronavirus Disease (COVID-19) pandemic and the safety of surgical approach. METHODS:Data of patients operated between March 10 and May 20, 2020, were collected retrospectively. Data were statistically analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows v. SP21.0. RESULTS:Data of 200 patients were included. Their mean age was 56 years. Of the patients, 54% (n=108), 27.5% (n=55), 12.5% (n=25), and 2% (n=4) were diagnosed as having endometrial, ovarian, cervical, and vulvar cancer, respectively. Of them, 98% underwent non-emergent surgery. A minimally invasive surgical approach was used in 18%. Stage 1 cancer was found in 68% of patients. Surgeons reported COVID-related changes in 10% of the cases. The rate of postoperative complications was 12%. Only two patients had cough and suspected pneumonic lesions on thoracic computed tomography postoperatively, but neither was positive for COVID-19 on polymerase chain reaction testing. CONCLUSION:Based on the present findings, it is thought that gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to the measures. Postponement or non-surgical management should only be considered in patients with documented infection. Gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to measures. Only 1% of patients developed COVID-19-related symptoms during the postoperative follow-up period.

Objectives: Mycoplasma hominis (M.hominis) infections are sexually transmitted and usually associated with urogenital and respiratory diseases. The aim of our study was to (i) detect M. hominis in the vaginal and urine samples of sexually active women using three different detection methods and (ii) to determine the antimicrobial susceptibility and recurrence after the treatment. Methods: Both vaginal and urine samples were collected from 110 sexually active women at the Obstetrics and Gynecology Clinic, Baskent University Ankara Hospital, Turkey, between March 2015 and February 2016. The presence of M. hominis in the vaginal and urine samples was detected by in vitro culture, two biochemical diagnostics kits (Mycoplasma IES (Autobio, China) and Mycoplasma IST-2 (BioMerieux, France) and PCR. The antibiotic susceptibility of each sample was tested using the kits. The women positive for M. hominis were treated either singly or along with their sexual partners by tetracycline. Results: M. hominis was detected in 72 of 220 (32.7%) samples (both vaginal and urine). Of which 37 showed contrary results with two different kits and then were confirmed by PCR. In 13 samples the IES kit identified M. hominis missed by IST-2, and in 8 samples the MIST-2 kit identified M. hominis missed by IES, while both kits missed 6 samples that were agar culture positive for M. hominis." The highest susceptibility rate was observed against pristinamycin (100%), followed by 91%, 83%, and 75% for doxycycline, tetracycline, and josamycin, respectively. Twenty-five patients treated with tetracycline were followed after one month. The recurrence of M. hominis was not observed in any of the 18 cases where both sexual partners were treated but recurred in 5 of the 7 singly treated women. Conclusions: The rate of M. hominis detection was significantly higher in the vaginal samples compared to the urine samples. The probability of detecting M. hominis by IST-2 kit was 1.18 times less than IES kit (p < 0.001). When the relationship between the samples was examined, the difference between IES and IST-2 for detecting M. hominis was statistically significant (p < 0.01). Antibiotic susceptibility tests indicated that the tetracycline group of antibiotics was effective in eliminating M. hominis when given to both the sexual partners.

Objective: We aimed to compare surgical outcomes and postoperative complications among different hysterectomy approaches such as total abdominal hysterectomy, vaginal hysterectomy, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy. Study Design: This retrospective, single institution, case control study was carried out at the Obstetrics and Gynecology Department of Baskent University in Ankara, Turkey. We evaluated 86 consecutive patients who underwent hysterectomy for benign gynecological conditions. Results: A total of 86 women underwent hysterectomy: 20 (23.3%) total abdominal hysterectomy, 20 (23.3%) vaginal hysterectomy, 27 (31.3%) multiport access laparoscopic hysterectomy, and 19 (22.1%) single-port access laparoscopic hysterectomy using a transumbilical single-port system. There was no significant difference in uterine size between groups (Z=5.705; p=0.127). A statistically significant (p<0.001) difference in operation time (duration of surgery) was observed among the following groups. The duration of surgery for the multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups was similar, with these two laparoscopic procedures requiring significantly more time than total abdominal hysterectomy and vaginal hysterectomy procedures. There was no statistically significant difference in between hemoglobin levels before and after operation between groups. There was no statistically significant difference between groups in intraoperative and postoperative complications. Six patients experienced complications, one intraoperative and five postoperative. Intraoperative complication was ureter injury in single-port access laparoscopic hysterectomy group. The postoperative complication rate was 5.8% (5 cases) in 86 patients. Perirectal abscess in one patient and wound infection in two patients occurred in total abdominal hysterectomy group (15%). Urinary tract infection in one patient and vaginal cuff cellulitis in one patient occurred in vaginal hysterectomy group (4%). No complications were reported in multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups. Post-surgery, all patients who underwent single-port access laparoscopic hysterectomy reported that they were satisfied with their incision and cosmetic results. Conclusions: When technically feasible, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy may be performed instead f total abdominal hysterectomy because of rapid recovery and shorter hospitalization however there are longer operating time.

Sentinel lymph node (SLN) is the first node to receive the drainage directly from a tumor. Detection and pathological examination of the SLN is an important oncological procedure that minimizes morbidity related to extensive nodal dissection. SLN biopsy was first reported in 1960 but took approximately 40 years to come into general practice following reports of good outcomes in patients with melanoma. After many years of observation and research on its use in various malignancies SLN biopsy has become the standard surgical treatment in patients with malignant melanoma, breast, vulvar, and cervical cancers. Along with the introduction of new technologies, such as the fluorescent dyes indocyanine green (ICG) and near-infrared fluorescence (NIR), and pathologic ultrastaging, SLN detection rate has increased and false-negative rate has decreased. This literature review aimed to present an overview of the basic concepts and clinical aspects of SLN biopsy in the light of the current research.

Objectives To assess the survival of patients who have received an operation for recurrent cervical and endometrial cancer and to determine prognostic variables for improved oncologic outcome. Methods A retrospective multicenter analysis of the medical records of 518 patients with cervical (N = 288) or endometrial cancer (N = 230) who underwent surgery for disease recurrence and who had completed at least 1 year of follow-up. Results The median survival reached 57 months for patients with cervical cancer and 113 months for patients with endometrial cancer after surgical treatment of recurrence (p = 0.036). Histological sub-type had a significant impact on overall survival, with the best outcome in endometrial endometrioid cancer (121 months), followed by cervical squamous cell carcinoma, cervical adenocarcinoma, or other types of endometrial cancer (81 vs 35 vs 35 months; p<0.001). The site of recurrence did not significantly influence survival in cervical or in endometrial cancer. Cancer stage at first diagnosis, tumor grade, lymph node status at recurrence, progression-free interval after first diagnosis, and free resection margins were associated with improved overall survival on univariate analysis. On multivariate analysis, the stage at first diagnosis and resection margins were significant independent predictive parameters of an improved oncologic outcome. Conclusion Long-term survival can be achieved via secondary cytoreductive surgery in selected patients with recurrent cervical and endometrial cancer. An excellent outcome is possible even if the recurrence site is located in the lymph nodes. The possibility of achieving complete resection should be the main criterion for patient selection.