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Human papillomaviruses (HPV)-related gynecological cancers are a major health care issue, and a leading cause of cancer death in low- and middle-income countries (LMIC). In 2020, the World Health Organization launched a program aimed at cervical cancer elimination, by screening and vaccination strategies. Offering the best possible care to women diagnosed with invasive cancer is a complementary objective. Treatment of cervical cancer as per modern standards is complex and multimodal, mainly relying on surgery, external-beam radiotherapy (+/-chemotherapy) and brachytherapy. In parallel with the pivotal role of multidisciplinary discussion, international societies provide guidance to define the most effective and least toxic anti-cancer strategy, homogenize treatment protocols and provide benchmark quality indicators as a basis for accreditation processes. The challenge is to offer the appropriate diagnostic workup and treatment upfront and to avoid non- evidence-based treatment that consumes resources, impairs quality of life (QoL), and compromises oncological outcome. Various strategies may be applied for improving treatment quality: development of surgical mentorship, companion-training programs and international cooperation. The lack of radiotherapy/brachytherapy facilities is a major concern in LMIC. Reinforcing international support in terms of education, training, research and development and technical cooperation with national projects is required to increase access to minimum requirements but also introduce modern techniques, upgrade radiotherapy/brachytherapy services, and expand access to modern systemic treatments. In countries with robust economies, compliance to standards should also be increased. Integrative cancer care and multidisciplinary approaches are needed to tackle the dual challenge of increasing cure rates while minimizing QoL impairment. Appropriate dimensioning of the resources to avoid harmful treatment delays and access to expert referral centers is also a priority., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: To assess associations between treatment and recurrence-free survival (RFS) among patients with isolated tumor cells (ITCs) in sentinel lymph nodes (SLN) and otherwise stage I/II endometrioid endometrial cancer (EC)., Methods: A multi-institutional retrospective study of patients with SLN ITCs (<200 cells and < 0.2 mm) was performed. Only patients with otherwise stage I/II EC, endometrioid histology, and no evidence of micro-or macrometastases were included. Univariate and multivariable Cox proportional hazard models were used to evaluate associations between treatment, tumor characteristics, and RFS., Results: 175 patients were included. Median follow up time was 31 months. 39% stage IB and 12% stage II disease. 76 (43%) received no adjuvant therapy or vaginal brachytherapy only (NAT/VBT), 21 (12%) had external beam radiation (EBRT), and 78 (45%) received chemotherapy +/- radiation. Patients who received chemotherapy more often had tumors with deep myoinvasion, lymphovascular space invasion (LVSI), and higher grade. Nine (5.1%) patients recurred; 5 distant, 3 retroperitoneal, and 1 vaginal. Extra-vaginal recurrences were similar in patients with or without chemotherapy (5.2% vs 3.8%, p = 0.68). After controlling for stage, LVSI and grade, chemotherapy and EBRT were not associated with RFS (HR = 0.63, 95%CI 0.11-3.52, and HR = 0.90, 95%CI 0.22-3.61, respectively). Type of lymph node dissection and ITC detection method were not associated with RFS., Conclusions: Risk of retroperitoneal and/or distant recurrence is low (4.6%) for patients with stage I/II endometrioid EC and ITCs in SLNs regardless of treatment. Our preliminary data suggests that adjuvant therapy may not be significantly associated with RFS. However, longer follow-up time and a larger sample size are needed before definitive recommendations regarding adjuvant therapy for patients with EC and only ITCs in SLN can be made., Competing Interests: Declaration of Competing Interest Dr. Leitao reports personal fees from JnJ/Ethicon, outside the submitted work; and Dr. Leitao is an ad hoc speaker for Intuitive Surgical, Inc. Dr. Abu-Rustum reports grants from GRAIL, grants from Stryker, outside the submitted work. Dr. Backes reports grants and personal fees from Eisai, grants and personal fees from Merck, grants from Immunogen, grants and personal fees from Clovis, personal fees from Agenus, personal fees from AstraZeneca, personal fees from Genentech, personal fees from GlaxoSmithKline, all outside the submitted work. None of the other authors have a significant conflict of interest related to the current study. Some of the investigators (Felix, Abu-Rustum, Leitao) receive grants for other projects that fund part of their time., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The Silva invasion pattern-based classification system stratifies endocervical adenocarcinomas (ECAs) into 3 categories corresponding to risk of metastasis and recurrence, but has only been evaluated for HPV-associated ECAs of usual type. We examined whether the Silva system is applicable to all endocervical adenocarcinomas, especially those not associated with HPV., Methods: Complete slide sets from 341 surgical specimens of ECA were collected from 7 institutions worldwide. All specimens were associated with clinical records covering at least 5 years of follow-up. Tumors were classified as HPV-associated (HPVA) or not (NHPVA) by both morphology and detection of HPV using in situ hybridization. Recurrence and survival were analyzed by multivariate Mantel-Haenszel methods., Results: Most specimens (292; 85.6%) were HPVA, while 49 (14.3%) were NHPVA. All NHPVAs were Silva pattern C, while 76.0% of HPVAs were pattern C, 14.7% pattern A, and 9.3% pattern B. Including both HPVAs and NHPVAs, lymphovascular invasion (LVI) was detected in 0% of pattern A, 18.5% of pattern B and 62.6% of pattern C cases (p < 0.001). None of the pattern A or B cases were associated with lymph node metastases (LNM), in contrast to pattern C cases (21.8%). Among patients with Silva pattern C ECA, those with HPVA tumors had a lower recurrence rate and better survival than those with NHPVA; however, when adjusted for stage at diagnosis, the difference in recurrence and mortality was small and not statistically significant., Conclusions: Application of the Silva system is only relevant in HPVA cervical adenocarcinoma., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the changes in prognostic impression and patient management following PET/CT in patients with vulvar and vaginal carcinoma; and to compare PET/CT findings with those of conventional imaging modalities., Methods: We summarized prospectively and retrospectively collected data for 50 consecutive patients from our institution that enrolled in the National Oncologic PET Registry and underwent FDG-PET/CT for a suspected or known primary or recurrent vulvar/vaginal cancer., Results: 54/83 (65%) studies included had a diagnosis of vulvar cancer, and the remaining 29/83 (35%), a diagnosis of vaginal cancer. Following FDG-PET/CT, the physician's prognostic impression changed in 51% of cases. A change in patient management, defined as a change to/from a non-interventional strategy (observation or additional imaging), to/from an interventional strategy (biopsy or treatment), was documented in 36% of studies. The electronic records demonstrated that 95% of the management strategies recorded in the physician questionnaires were implemented as planned. MRI and/or CT were performed within one month of the FDG-PET/CT in 20/83 (24%) and 28/83 (34%) cases, respectively. FDG-PET/CT detected nodes suspicious for metastases on 29/83 (35%) studies performed. MRI and CT detected positive nodes on 6 and 11 studies respectively. Distant metastases were identified in 10 cases imaged with FDG-PET and 5 cases that had additional conventional CT imaging. All suspicious lesions seen on CT were positively identified on PET/CT. In 4 cases, an abnormality identified on PET/CT, was not seen on diagnostic CT., Conclusions: FDG-PET/CT may play an important role in the management of vulvar and vaginal carcinoma., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To determine if extensive upper abdominal surgery (UAS) affected overall survival (OS) in patients left with ≤ 1 cm but visible residual disease after undergoing primary cytoreductive surgery for ovarian cancer. Our secondary objective was to determine if leaving ≤ 1cm but visible residual throughout the small bowel (SB) conferred a worse prognosis., Methods: All stage IIIB-IV ovarian cancer patients who had visible but ≤ 1 cm residual disease at time of primary cytoreductive surgery from 2001 to 2010 were identified. Extensive UAS procedures and residual SB involvement were recorded., Results: The 219 patients identified with ≤1 cm but visible residual disease had a median OS of 51 months. In this cohort, 127 had extensive UAS performed, and 87 had residual disease involving the SB. Univariate OS analysis was performed. There was no significant difference in OS between patients who did or did not have extensive UAS (45 vs. 52 months, P=0.56), or between patients with or without residual SB disease (45 vs. 51 months, P=0.84). Factors that were significantly associated with OS were age, ASA score, family history, and stage., Conclusions: Patients cytoreduced to ≤ 1 cm but visible residual disease who required UAS did not have a worse OS than those who did not require UAS. OS was similar if residual disease involved the SB or not. For ovarian cancer patients with disease not amenable to complete gross resection, extensive surgery should still be considered to achieve ≤ 1 cm but visible residual disease status, including cases where the residual disease involves the SB., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: According to the updated FIGO system, positive peritoneal cytology does not affect endometrial cancer stage. This revision may reduce rates of obtaining cytology, with unclear implications in advanced disease. This study evaluates the significance of positive cytology in stage III (FIGO 2009) endometrial cancer., Methods: Eligible patients received treatment for stage III endometrial cancer at a single institution and had peritoneal cytology performed., Results: Of 196 patients, 58% were ≥ 60 years old, 48% had deep myometrial invasion, 71% lymphovascular invasion, 25% cervical invasion, 37% adnexal involvement, 79% nodal involvement, and 46% aggressive histology. Positive cytology was present in 23% (45/196) and significantly associated with cervical stromal invasion, adnexal involvement, and aggressive histology (P ≤ 0.03). There was no significant difference in rates of lymphadenectomy, chemotherapy, or radiation between negative and positive cytology groups. At a median follow-up of 47 months, the 5-year freedom from relapse was 39% for positive cytology vs. 69% for negative, disease-specific survival 42% vs. 77%, and overall survival 34% vs. 72% (P < 0.001). Positive cytology correlated with higher recurrence rates in the para-aortic nodes and peritoneum (30% vs. 9%, 23% vs. 4%; P ≤ 0.008). When controlling for adverse features including aggressive histology, positive cytology was associated with an increased hazard for relapse (HR 2.3; P = 0.002) and death (HR 2.9; P < 0.001)., Conclusions: In stage III endometrial cancer, positive cytology independently predicts outcome and is associated with distinct relapse patterns. Obtaining peritoneal cytology in stage III endometrial cancer is critical., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine whether the frequency of cases diagnosed with stage IIIC endometrial cancer is affected by the incorporation of a modified surgical lymph node assessment., Methods: Since 2008, we have increasingly utilized a modified nodal assessment using an algorithm that incorporates SLN mapping. For this analysis, we identified all cases of newly diagnosed endometrial cancers undergoing a minimally invasive staging procedure not requiring conversion to laparotomy from 1/1/08 to 12/31/10. Procedures were categorized as standard, modified, and hysterectomy only. Differences were based on time period: 2008 (Y1), 2009 (Y2), and 2010 (Y3). Appropriate statistical tests were used., Results: We identified a total of 507 cases. The distribution of cases was 143 (Y1), 190 (Y2), and 174 (Y3). Tumor grade (P=0.05) and high-risk histologies (P=0.8) did not differ during the 3 time periods. A standard staging procedure was performed in the following cases: Y1 (93/143; 65%), Y2 (66/166; 35%), and Y3 (40/164; 23%) (P<0.001). Median operative times were as follows: Y1 (218 min), Y2 (198 min), and Y3 (176.5 min) (P<0.001). The median numbers of total lymph nodes removed among cases with at least 1 node retrieved were: Y1 (20); Y2 (10); Y3 (7) (P<0.001). Cases diagnosed as stage IIIC were as follows: Y1 (10/143; 7%), Y2 (15/166; 7.9%), and Y3 (13/164; 7.5%) (P=1.0)., Conclusions: The incorporation of a modified staging approach utilizing the SLN mapping algorithm reduces the need for standard lymphadenectomy and does not appear to adversely affect the rate of stage IIIC detection., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To report the reproductive outcomes of patients undergoing fertility-preserving radical trachelectomy (RT) for the treatment of early-stage cervical cancer., Methods: We analyzed data from our institution's first 105 patients who underwent attempted fertility-sparing surgery with radical trachelectomy, pelvic lymphadenectomy, and cerclage from November 2001 to October 2010., Results: Of the 105 patients who underwent attempted RT, 77 (73%) did not require a conversion to radical hysterectomy or postoperative treatment. The median age was 32 (range, 25-38 years). Most patients (75%) had stage IB1 disease. Sixty-six patients (63%) were nulliparous. Thirty-five women were actively attempting conception 6 months after surgery, and 23 (66%) women were successful in conceiving: there were 20 live births, 3 elective terminations, and 4 spontaneous miscarriages. Four patients had 2 pregnancies each; all delivered their second pregnancy between 32 and 36 weeks. Cerclage erosion through the vaginal wall occurred in 6 cases and was treated by transvaginal removal of protruding suture material. One of these patients experienced a second trimester miscarriage., Conclusions: The majority of women who attempted to conceive after radical trachelectomy were successful, and most of their pregnancies resulted in full-term births. Assisted reproduction played an important role in select women. Cerclage likely contributed to a post-trachelectomy uterine ability to carry a pregnancy to the third trimester. The second post-trachelectomy pregnancy appears to be at higher risk for preterm delivery than the first pregnancy., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: Evaluate prognostic significance of low volume disease detected in sentinel nodes (SN) of patients with early stages cervical cancer. Although pathologic ultrastaging of SN allows for identification of low volume disease, including micro-metastasis and isolated tumor cells (ITC), in up to 15% of cases, prognostic significance of these findings is unknown., Methods: A total of 645 records from 8 centers were retrospectively reviewed. Enrolled in our study were patients with early-stage cervical cancer who had undergone surgical treatment including SN biopsy followed by pelvic lymphadenectomy and pathologic ultrastaging of SN., Results: Macrometastasis, micrometastasis, and ITC were detected by SN ultrastaging in 14.7%, 10.1%, and 4.5% patients respectively. False negativity of SN ultrastaging reached 2.8%. The presence of ITC was not associated with significant risk, both for recurrence free survival and overall survival. Overall survival was significantly reduced in patients with macrometastasis and micrometastasis; hazard ratio for overall survival reached 6.85 (95% CI, 2.59-18.05) and 6.86 (95% CI, 2.09-22.61) respectively. Presence of micrometastasis was an independent prognostic factor for overall survival in a multivariable model., Conclusion: Presence of micrometastasis in SN in patients with early stage cervical cancer was associated with significant reduction of overall survival, which was equivalent to patients with macrometastasis. No prognostic significance was found for ITC. These data highlight the importance of SN biopsy and pathologic ultrastaging for the management of cervical cancer., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to determine the incidence of invasive cancer in ovarian masses diagnosed as borderline tumor (BT) at the time of frozen section., Methods: We performed a retrospective review of all patients diagnosed with ovarian BT on frozen section (FS) at our institution between 2000 and 2010. Clinical and pathologic data were extracted. Univariate and multivariate analyses were performed using standard two-sided statistical tests., Results: A total of 120 patients were identified, of which 104 (86.7%) had BT on frozen section that was confirmed on final pathology. In 15 (12.5%) patients, BT was diagnosed on FS but was reclassified as invasive cancer on final pathology. One patient (0.8%) had BT on FS but benign pathology on final diagnosis. Histologies included serous in 79 (65.8%), seromucinous in 13 (10.8%), mucinous in 21 (17.5), endometrioid in 5 (4.2%), and clear cell in 2 (1.7%) patients. Reclassification of pathologic diagnosis was related to histologic subtype, but only for endometrioid and clear cell tumors (P<0.001). The rate of invasive cancer for serous micropapillary tumors on frozen section was 42.8% compared with 2.8% for serous non-micropapillary tumors (P<0.001). Tumor size >8 cm was associated with a 22.4% incidence of invasive cancer on final pathology compared to 3.2% in tumors ≤ 8 cm (P=0.004)., Conclusion: Comprehensive surgical staging can be considered in BT >8 cm in diameter, as well as those with micropapillary serous, endometrioid, and clear cell histology diagnosed at the time of frozen section analysis., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The hereditary basis of endometrial cancer is apparent in young women with endometrial cancer. The objective of this study was to examine risk factors and outcomes in patients 40 years of age and younger with endometrial cancer., Methods: We performed a retrospective cohort study of patients aged 40 years or less who were diagnosed with endometrial carcinoma between 1/93 and 5/08. Clinical and pathologic data were extracted from medical records. Paraffin-embedded slides from hysterectomy specimens were obtained and DNA mismatch repair (MMR) immunohistochemistry was performed. Cases were analyzed according to the presence of DNA MMR protein defects. Standard two-sided statistical tests were performed., Results: Of the 56 identified patients, the median age was 36 years (range, 24-40). The majority of the endometrial carcinomas were of endometrioid histology (91%), stage I (71%), and FIGO grade 1 (59%). Abnormal DNA MMR was found in 9 cases (16%). Cases with abnormal DNA MMR had lower body mass index (BMI) (P=0.05), and had a family history suggestive of Lynch syndrome (P=0.001). Tumors were more likely to have advanced stage disease (P<0.001), be high grade (P<0.001), have deep myometrial invasion (P<0.001), and have lymphovascular invasion (P=0.002). Cases with abnormal DNA MMR had significantly worse overall survival (P=0.028) and progression-free survival (P=0.042)., Conclusions: Endometrial cancer is rare in women aged 40 years or less. In this group of patients, loss of DNA MMR was associated with lower BMI, worse clinicopathologic factors, and worse outcome. These results may have implications when young women diagnosed with endometrial cancer are counseled regarding prognosis., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: The international acceptance of a universal classification system for radical hysterectomy is one of the important challenges in gynecologic oncology. The recently published classification system by Querleu and Morrow is a relevant proposal that has been well received by the professional community. However, it does not include a description of parametrial resection in three dimensions, which mostly determines post-operative morbidity., Methods: The intention of this follow-up paper was to further develop the classification system based on the four proposed types of radical hysterectomy (A-D) into a three-dimensional model using standard anatomical landmarks for definition of resection margins in longitudinal and transverse dimensions and demonstrate it on pictures., Results: Resection margins were defined in longitudinal and transverse dimensions for each suggested type of radical hysterectomy on all three parts of the parametria. Besides precise description using stable anatomical landmarks, all resection lines have been shown on intra-operative photographs., Conclusion: Four types of radical hysteretomy can be precisely defined on a three-dimensional anatomical template, including nerve sparing procedure. Our paper should contribute to better standardization (including nomenclature) of the radical hysterectomy, enhancing harmonization of clinical practice in gynecological oncology., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To compare the incidence of metastatic cancer cells in sentinel lymph nodes (SLN) vs. non-sentinel nodes in patients who had lymphatic mapping for endometrial cancer and to determine the contribution of metastases detected on ultrastaging to the overall nodal metastasis rate., Methods: All patients who underwent lymphatic mapping for endometrial cancer were reviewed. Cervical injection of blue dye was used in all cases. Sentinel nodes were examined by routine hematoxylin and eosin (H&E), and if negative, by standardized institutional pathology protocol that included additional sections and immunohistochemistry (IHC)., Results: Between 09/2005 and 03/2010, 266 patients with endometrial cancer underwent lymphatic mapping. Sentinel node identification was successful in 223 (84%) cases. Positive nodes were diagnosed in 32/266 (12%) patients. Of those, 8/266 patients (3%) had the metastasis detected only by additional section or IHC as part of SLN ultrastaging. Excluding the 8 cases with positive SLN on ultrastaging only, 24/801 (2.99%) SLN and 30/2698 (1.11%) non-SLN were positive for metastatic disease (p=0.0003)., Conclusion: Using a cervical injection for mapping, metastatic cells from endometrial cancer are three times as likely to be detected in SLN than in the non-sentinel nodes. This finding strongly supports the concept of lymphatic mapping in endometrial cancer to fine tune the nodal dissection topography. By adding SLN mapping to our current surgical staging procedures we may increase the likelihood of detecting metastatic cancer cells in regional lymph nodes. An additional benefit of incorporating pathologic ultrastaging of SLN is the detection of micrometastasis, which may be the only evidence of extrauterine spread., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to identify clinicopathologic features that are associated with an increased risk of recurrence for borderline ovarian tumors (BOT)., Methods: We performed a retrospective review of all patients treated for BOT at our institution from 1979 to 2008. Progression-free survival (PFS) was defined as the time of diagnosis to time of recurrence/death or last follow-up. The Kaplan-Meier method was used to calculate the PFS rate and the Wilcoxon-Gehan test was performed to identify prognostic factors., Results: A total of 266 patients were identified. The median age was 43 years (range, 15-94 years). The majority of patients (68.4%) had FIGO stage I disease and serous histology (73.7%). Only 23 (8.6%) patients developed recurrent disease. The median PFS was 19 years and the median follow-up was 4 years. Abnormal baseline CA-125 (>35 U/ml), advanced stage, age at diagnosis, and invasive implants were associated with decreased PFS. Of the 196 patients with serous BOT, those with a micropapillary pattern had a 3-year PFS of 75.9% (95%CI, 55.6-87.8) compared with 94.3% (95% CI, 88.4-97.3) for patients without micropapillary pattern (P<0.001)., Conclusion: Age at diagnosis, an elevated preoperative CA-125, invasive implants, and micropapillary histology were clinical factors associated with increased risk of recurrence in women with BOT. Including these clinicopathologic features will likely identify patients at higher risk for recurrence, for whom development of new treatment strategies would be appropriate., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: Traditionally we have relied mainly on final FIGO stage to estimate overall oncologic outcome in endometrial cancer patients. However, it is well known that other patient factors may play equally important roles in outcome. Our objective was to develop a clinically useful nomogram in the hope of providing a more individualized and accurate estimation of overall survival (OS) following primary therapy., Methods: Using a prospectively maintained endometrial cancer database, 1735 patients treated between 1993 and 2008 were analyzed. Characteristics known to predict OS were collected. For each patient, points were assigned to each of these 5 variables. A total score was calculated. The association between each predictor and the outcome was assessed by multivariable modeling. The corresponding 3-year OS probabilities were then determined from the nomogram., Results: The median age was 62 years (range, 25-96). Final grade included: G1 (471), G2 (622), G3 (634), and missing (8). Stage included: IA (501), IB (590), IC (141), IIA (36), IIB (75), IIIA (116), IIIB (6), IIIC (135), IVA (7), and IVB (128). Histology included: adenocarcinoma (1376), carcinosarcoma (100), clear cell (62), and serous (197). Median follow-up for survivors was 29.2 months (0-162.2 months). Concordance probability estimator for the nomogram is 0.746+/-0.011., Conclusion: We developed a nomogram based on 5 easily available clinical characteristics to predict OS with a high concordance probability. This nomogram incorporates other individualized patient variables beyond FIGO stage to more accurately predict outcome. This new tool may be useful to clinicians in assessing patient risk when deciding on follow-up strategies.

Background: Pelvic lymphadenectomy is an integral component of gynecologic cancer surgery, yet there is a lack of standardization in the terminology used, the extent of the procedure, and the definition of anatomic landmarks. This lack of standardization if corrected will likely facilitate a more clear communication and analysis of outcomes from various institutions, and reduce confusion to trainees about the procedure being performed., Methods: We summarize the anatomic data concerning pelvic lymphatic drainage; describe the procedure based on clearly defined anatomic landmarks; and finally propose a new classification system to facilitate standardization, communication, and comparison of results. The accompanying video demonstrates the anatomic landmarks., Results: We list and define four commonly used terms related to pelvic lymph node harvesting: sentinel node mapping, excision of bulky nodes, pelvic lymph node sampling, and systematic pelvic lymphadenectomy. We list the five specific anatomic regions of the pelvic lymphatic basin: external iliac, obturator, internal iliac, common iliac, and presacral. We highlight the important neural structures located in regions of the pelvic lymphadenectomy: genitofemoral nerve, obturator nerve, cranial part of the lumbosacral plexus, hypogastric plexus, and splanchnic nerves. Finally, we propose a new, four-part classification system of types of pelvic lymph node dissection., Conclusion: In this report and video, we demonstrate anatomy and offer a new classification system for pelvic lymphadenectomy.

Objectives: To analyze progression-free (PFS) and overall survival (OS) in patients with small cell neuroendocrine carcinoma of the cervix (SCNEC), and to determine whether platinum-based combination chemotherapy is beneficial for this population., Methods: We performed a retrospective analysis of all patients with SCNEC who were treated at our institution between 1/1990 and 2/2007. Patients were excluded if pathologic diagnosis was not confirmed at our institution. Standard statistical methods were utilized., Results: Seventeen patients met inclusion criteria. The estimated 3-year PFS and OS rates for the entire group were 22% and 30%, respectively. Median time to progression was 9.1 months. Extent of disease was the only significant prognostic factor. Median OS for patients with early stage disease (IA1-IB2) was 31.2 months and 6.4 months for patients with advanced stage disease (IIB-IV, P=0.034). In the early-stage disease group, the 3-year distant recurrence-free survival rate was 83% for patients who received chemotherapy and 0% for patients who did not receive chemotherapy as part of their initial treatment (P=0.025). The estimated 3-year OS rate was 83% for patients who received and 20% for patients who did not receive chemotherapy as part of their initial treatment (P=0.36)., Conclusion: Given the rarity of SCNEC this retrospective analysis is limited by a small number of patients. However, the natural history of this rare disease is akin to small cell lung cancer and the prognosis is poor due to the tumor's propensity for distant spread. The treatment should conform to the treatment of small cell lung cancer.

Objective: To report on our initial experience with radical vaginal trachelectomy for patients with early-stage cervical cancer., Methods: Data on patients undergoing radical vaginal trachelectomy with pelvic lymphadenectomy from 11/01 to 12/06 were collected in a prospective database., Results: Forty-three women with early-stage cervical cancer were operated on with the intent of fertility preservation with radical vaginal trachelectomy. Median age was 31 years (range, 20-40 years). FIGO stage for the group was: IB1, 28; IA2, 7; IA1 with lymphovascular invasion, 8. Histologic type included: squamous, 24; adenocarcinoma, 16; adenosquamous, 3. Parity for the group was: nullipara, 35; one child, 7; two children, 1. Median BMI was 24 kg/m2 (range, 19-42 kg/m2). Two patients (5%) underwent completion hysterectomy due to extensive endocervical disease. The median OR time was 330 min (range, 220-480 min). Median pelvic lymph node count was 25 (range, 9-52). Median hospital stay was 3 days (range, 3-7 days). Four patients (9%) required a second intervention for a perioperative complication. Five patients (12%) underwent adjuvant chemoradiation for pathologic risk factors determined on final pathology. Eleven (79%) of 14 women who were trying to get pregnant were able to conceive. Four (36%) required assisted reproductive techniques to conceive. Four patients delivered by cesarean section after 35 weeks and four patients are currently pregnant. With a median follow-up of 21 months in patients treated with trachelectomy alone, we have had one recurrence., Conclusions: Radical vaginal trachelectomy can be incorporated into gynecologic oncology practices and appears to be a reasonable option for patients with early cervical cancer who desire to maintain their fertility. It should be discussed with candidate patients during preoperative consultation.

Objective: Recent studies have suggested that the definition of optimal cytoreduction for advanced EOC should be changed from the current Gynecologic Oncology Group threshold of < or =1 cm residual disease to no gross residual disease owing to improved survival of patients (pts) rendered macroscopically disease-free. The objective of this study was to analyze survival rates at very specific residual disease diameters to determine the optimal goal of primary cytoreduction for bulky stage IIIC EOC., Methods: A prospectively kept database was used to identify and review the records of all pts with Stage IIIC EOC who underwent primary cytoreductive surgery at our institution between January 1989 and December 2003. To analyze a homogeneous cohort of cases, we excluded pts with stage IIIC disease based on nodal metastasis alone (without bulky abdominal tumor), fallopian tube or primary peritoneal carcinomas, and borderline tumors. Standard statistical analyses were utilized., Results: The study cohort included 465 pts. The median age was 60 years (range, 25-87), and the median follow-up was 38 months (range, 1-199). Univariate and multivariate analyses, which included various prognostic factors, identified amount of residual disease as a significant prognostic factor (P < 0.001). Median overall survival in relation to the 5 residual disease categories was: no gross residual, 106 months; gross < or =0.5 cm, 66 months; 0.6-1.0 cm, 48 months; 1-2 cm, 33 months; >2 cm, 34 months. Statistical comparison between the 5 residual disease categories revealed 3 distinct groups with significantly different survival rates (P < 0.01). These 3 groups were: (1) no gross residual; (2) gross < or =1 cm residual; and (3) >1 cm residual. Although the difference in survival did not reach statistical significance, within the gross < or =1 cm residual group, there was a trend toward improved survival in pts left with smaller volume, < or =0.5 cm residual compared with those with 0.6-1.0 cm residual (P = 0.06)., Conclusion: Our data suggest that removal of all evidence of macroscopic disease is associated with prolonged survival and should be the goal of primary cytoreductive surgery. If complete gross resection is not feasible, however, cytoreduction to as minimal residual tumor as possible should be the focus of cytoreductive efforts, as each incremental decrease in residual disease below 1 cm may be associated with an incremental improvement in overall survival.

Objectives: The aims of this study were to estimate the 5-year breast cancer risk in indigent women presenting to the gynecology clinic at a public hospital and to determine whether routine use of the computerized Gail model for screening in this population identifies individuals at increased risk., Methods: A prospective study was performed over 1-year period (7/99-7/00) of women presenting to the gynecology and gynecologic oncology clinics at a public hospital. All women ages 35-60 years with no personal history of breast cancer were offered testing utilizing the computerized Gail model provided by the National Cancer Institute. Age, race, age at menarche, age at first live birth, number of first-degree relatives with breast cancer, number of breast biopsies, and number of breast biopsies diagnosed as atypical hyperplasia were documented. A calculated 5-year risk > or =1.67% was considered high-risk., Results: In all, 319 women enrolled, 121 (38%) with a history of gynecologic cancer and 198 (62%) without. The mean age was 46.9 years (range 35-60), and 28 (8.8%) patients had at least one first-degree relative with breast cancer. Ethnicity included 206 (65%) African American, 52 (16%) Caucasian, 45 (14%) Hispanic, and 16 (5%) oriental. Eight (2.5%) women had a 5-year risk > or =1.67%. The mean 5-year risk for all patients was 0.68% (0.55% for African American versus 0.90% for Caucasian/other, P < 0.001)., Conclusion: Estimating 5-year breast cancer risk using the Gail model in indigent women may identify individuals at increased risk. Compared to other patients, African American women appeared to have a lower estimated 5-year risk according to the currently available model. The routine utilization of the Gail model deserves further investigation in the indigent minority population., (Copyright 2001 Academic Press.)

Objective: The goal of this work was to compare characteristics and survival of cervical cancer patients at adjacent public and university hospitals to define the effects of poverty and ethnicity on disease., Methods: A retrospective chart review was conducted of cervical cancer patients managed by gynecologic oncologists at two adjacent urban hospitals between 1992 and 1998. Continuous variables were compared by t test, categorical variables by chi(2), and survival by the Kaplan-Meier and log-rank methods., Results: In all, 372 patients were identified, with 209 (56%) at the public hospital and 163 (44%) at the adjacent university hospital. Ethnic distribution differed between the two hospitals: 100 (52%) versus 46 (28%) African-American, 56 (29%) versus 13 (8%) Hispanic, 31 (16%) versus 96 (60%) Caucasian, and 5 (3%) versus 6 (4%) other (P < 0.001). In addition, public hospital patients presented with more advanced cancers (stages II--IV) than those managed at the university hospital, 96 (48%) versus 53 (34%) (P = 0.008), and squamous cancers were more common at the public hospital, 154 (89%) versus 120 (76%) (P = 0.03). However, with a median follow-up of 17 months, stage-adjusted survival did not differ between the two institutions., Conclusions: The higher proportions of advanced and squamous cervical cancers encountered at the public hospital likely reflect suboptimal screening. Equal access to gynecologic oncologists eliminated disparities in stage-adjusted survival. Efforts at earlier diagnosis should be directed at indigent, especially minority women., (Copyright 2001 Academic Press.)

Objectives: The goals of this work were to describe the compliance with and acute hematologic toxic effects of chemoradiation for cervical cancer in indigent women and to explore the likelihood that chemoradiation is effective outside research settings. We hypothesized that if compliance and toxicity are not limiting in this high-risk group of patients, the effectiveness of chemoradiation for cervical cancer in community settings is likely to mirror the efficacy demonstrated in clinical trials., Methods: This study is a retrospective review of prospectively maintained data on women with newly diagnosed cervical cancer treated with chemoradiation between August 1998 and August 2000. Cisplatin was given weekly at 40 mg/m(2) to a maximum of six courses. A WBC count <3000/mm(3) resulted in cancellation of cisplatin but not radiation, and patients were transfused for hemoglobin <9 g/dl. Statistical analysis was performed using the t test, chi(2) test, and Fisher's exact test., Results: In all, 19 of 65 patients treated (29.2%) missed at least one chemotherapy cycle, with 10 (15.4%) due to missed appointments, 8 (12.3%) due to a low WBC count, and 1 due to increased creatinine. Nineteen patients (29.2%) received RBC transfusion during chemoradiation, and two (3%) had platelets <75,000/mm(3). Noncompliant patients had a lower mean total point A dose (7986 cGy vs 8413 cGy, P = 0.04) and longer overall treatment duration (79 days vs 51 days, P < 0.001). No patient had a fatal hematologic complication., Conclusion: Nearly a third of the indigent women treated with chemoradiation for cervical cancer do not complete the prescribed treatment, and a similar number require blood transfusions. In indigent and minority women, the effectiveness of chemoradiation protocols may not mirror the efficacy obtained in clinical trials., (Copyright 2001 Academic Press.)

Objective: The objective of this study was to determine the impact of pretreatment tests on staging and management for women with bulky or clinically evident metastatic cervical cancer., Methods: Demographics and findings of clinic pelvic examination (PE), examination under anesthesia (EUA), chest x ray (CXR), abdominopelvic computed tomography (CT), and intravenous urography (IVU) were reviewed for women with primary, untreated cervical cancers either > or =4 cm or with extracervical disease apparent on PE or CXR evaluated between July 1, 1994, and March 31, 1999. Stage was assigned according to standards of the International Federation of Gynecology and Obstetrics., Results: In 133 women studied, tumor diameter averaged 4. 9 cm on PE and 5.7 cm at EUA (P = 0.0005). Of 92 women undergoing both PE and EUA, 30 (33%) had size discrepancies of more than 1 cm. Compared with EUA, PE had sensitivity, specificity, and positive and negative predictive values, respectively, of 65, 89, 79, and 81% for vaginal disease, 74, 91, 95, and 63% for parametrial disease, and 57, 90, 60, and 89% for sidewall fixation. CXR was abnormal in 5 (4%). IVU showed ureteral dilation in 20 (22%) of 90 women, while CT showed dilation in 34 (28%) of 123 women. CT also showed pelvic lymphadenopathy in 22 (18%) women and paraaortic lymphadenopathy in 12 (10%). Bladder biopsies showed malignancy in 8 (8%), including one transitional cell carcinoma of the bladder. Proctoscopy failed to reveal metastatic cervical cancer., Conclusions: CXR and EUA with cystoscopy are important to the accurate staging and treatment of bulky or clinically metastatic cervical cancers, while proctoscopy is rarely useful. CT predicts ureteral obstruction well, and its greater information yield may justify its higher cost compared with IVU., (Copyright 2000 Academic Press.)

Background: Acute lower extremity paralysis secondary to lumbosacral plexopathy is a rare but severe complication that may follow pelvic radiotherapy for cervical cancer., Case: A 49-year-old female with newly diagnosed stage IIIB cervical cancer developed progressive bilateral lower extremity paralysis and pelvic pain only 10 weeks following completion of radiation therapy for cervical cancer with no evidence of metastasis or progression of disease. Her bladder and bowel function were not affected. Following extensive workup, the most likely etiology was presumed radiation-induced lumbosacral plexopathy., Conclusion: Although metastatic carcinoma is more commonly the reason for progressive lower extremity weakness with pelvic pain in women with advanced cervical cancer, radiation-induced lumbosacral plexopathy, a rare but devastating complication, may be the cause. Diagnosis is by exclusion., (Copyright 1999 Academic Press.)

Objective: The objective of our study was to describe the accuracy of intraoperative frozen-section diagnosis of carcinoma metastatic to the adnexa in women with a history of breast or colorectal carcinoma., Methods: We conducted a retrospective chart review of all patients with a history of breast or colorectal carcinoma who developed histologically proven pelvic or abdominal metastases between 1988 and 1995. In those patients whose final histologic review revealed carcinoma metastatic to the adnexa, the accuracy of the intraoperative frozen-section diagnosis of the adnexal tumor was compared to the final diagnosis., Results: Forty-three patients were identified and in 36 patients the frozen section was obtained from the adnexa. Twenty-one patients (58.3%) had metastatic breast carcinoma and 15 (41.7%) had metastatic colorectal carcinoma to the adnexa. Carcinoma in the adnexa was correctly diagnosed by frozen section in 35 of 36 patients (97.2%). Metastatic carcinoma was identified at frozen section in 17 of 21 patients (81%) with metastatic breast cancer and 13 of 15 patients (86.7%) with metastatic colorectal cancer. In 3 of 21 patients (14.3%) with metastatic breast cancer and in 2 of 15 patients (13.3%) with metastatic colorectal cancer, the frozen-section diagnosis was carcinoma of uncertain origin. One patient had a false-negative frozen section because the small focus of metastatic breast cancer was not sampled at the time of frozen section., Conclusion: Intraoperative frozen-section evaluation correctly diagnosed carcinoma in the adnexa in 97% of patients, and in over 80% of cases, the carcinoma was diagnosed as being metastatic in origin., (Copyright 1999 Academic Press.)

Objective: The role of surgical resection of metastatic breast cancer to the abdomen and pelvis is controversial. The objective of this study is to describe the characteristics, surgical management, and outcome of women with a history of breast adenocarcinoma who developed abdominal or pelvic metastases during follow-up., Methods: We retrospectively reviewed the medical records of 40 female patients with documented invasive breast cancer who were referred to the Gynecology Service between 1986 and 1995 and were found to have metachronous abdominal and/or pelvic metastases., Results: The median patient age at exploration by the Gynecology Service was 53.5 years (range 27-79 years), and the median interval from breast cancer diagnosis to exploration was 80 months (range 9-264 months). The majority of patients, 32 (80%), had a preoperative diagnosis of a new pelvic mass or suspected abdominal carcinomatosis. With a median follow-up of 14.2 months following the diagnosis of abdominal or pelvic metastasis, the median survival for all patients was 24.1 months. Patients who had no gross residual disease in the abdomen or pelvis after surgery had a median survival of 41.6 months, which did not significantly differ from those with gross residual < or =2 cm (16.1 months) or >2 cm (18.4 months) (P = 0.624)., Conclusion: Metachronous abdominal and pelvic metastases from breast cancer may appear many years following initial diagnosis and are often operated on by gynecologists because of their clinical presentation. Surgical resection may be indicated in some symptomatic patients; however, the survival advantage of surgical cytoreduction remains to be determined.

We retrospectively reviewed the medical records of 21 patients with advanced epithelial ovarian carcinoma treated with intravenous chemotherapy in an attempt to restore intestinal function following small-bowel obstruction. All patients had a drainage gastrostomy tube placed for palliation of vomiting, and 11 patients received concomitant total parenteral nutrition (TPN). Eight (38%) patients were treated with single-agent paclitaxel, 7 (33%) received platinum-based regimens, and 6 (29%) received other second-line chemotherapy. The median survival for all patients post-gastrostomy tube placement was 84 days. The median survival for patients with recurrent ovarian cancer who received salvage chemotherapy and TPN was 89 days, longer than for patients who received salvage chemotherapy alone (71 days) (P = 0.031). Two of three patients with newly diagnosed ovarian cancer and concomitant bowel obstruction had sufficient temporary response from chemotherapy with resolution of obstruction and removal of the gastrostomy tube. Chemotherapy was ineffective in restoring bowel function in heavily pretreated patients with recurrent disease.