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Nodal status is one of the most important prognostic factors for patients with apparent early stage endometrial cancer. The role of retroperitoneal staging in endometrial cancer is controversial. Nodal status provides useful prognostic data, and allows to tailor the need of postoperative treatments. However, two independent randomized trials showed that the execution of (pelvic) lymphadenectomy increases the risk of having surgery-related complication without improving patients' outcomes. Sentinel node mapping aims to achieve data regarding nodal status without increasing morbidity. Sentinel node mapping is the removal of first (clinically negative) lymph nodes draining the uterus. Several studies suggested that sentinel node mapping is not inferior to lymphadenectomy in identifying patients with nodal disease. More importantly, thorough ultrastaging sentinel node mapping allows the detection of low volume disease (micrometastases and isolated tumor cells), that are not always detectable via conventional pathological examination. Therefore, the adoption of sentinel node mapping guarantees a higher identification of patients with nodal disease than lymphadenectomy. Further evidence is needed to assess the value of various adjuvant strategies in patients with low volume disease and to tailor those treatments also on the basis of the molecular and genomic characterization of endometrial tumors. [ABSTRACT FROM AUTHOR]

To investigate the safety of sentinel node mapping for patients with early-stage cervical cancer undergoing cervical conization plus nodal evaluation. The ETERNITY project is a retrospective, multi-institutional study collecting data of patients with early-stage cervical cancer undergoing fertility-sparing treatment. Here, we compared outcomes related to three methods of nodal assessment: sentinel node mapping (SNM), SNM plus backup lymphadenectomy (SNM + LND); pelvic lymphadenectomy (LND). Charts of 123 patients (with stage IA1-IB1 cervical cancer) were evaluated. Median patients' age was 34 (range, 22–44) years. SNM, SNM + LND, and LND were performed in 32 (26 %), 31 (25.2 %), and 60 (48.8 %) patients, respectively. Overall, eight (6.5 %) patients were diagnosed with positive nodes. Two (3.3 %), three (9.7 %), and three (9.4 %) patients were detected in patients who had LND, SNM + LND, and SNM respectively. Considering the 63 patients undergoing SNM (31 SNM + LND and 32 SNM alone), macrometastases, micrometastases, and isolated tumor cells were detected in four (3.2 %), three (2.4 %), and one (0.8 %) patients, respectively. All patients with positive nodes discontinued the fertility sparing treatment. Other two patients (one (1.7 %) in the LND group and one (3.1 %) in the SNM group) required hysterectomy even after negative nodal evaluation. After a median follow-up of 53.6 (range, 1.3, 158.0) months, nine (7.3 %) and two (1.6 %) patients developed cervical and pelvic nodes recurrences, respectively. Disease-free (p = 0.332, log-rank test) and overall survival (p = 0.769, log-rank test) were similar among groups. In this retrospective experience, SNM upholds long-term oncologic effectiveness of LND, reducing morbidity. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the SLN detection rate in presumed early stage, low- and intermediate-risk endometrial cancers, the incidence of SLN metastases, and the negative predictive value of SLN mapping performed with indocyanine green (ICG). Methods: A systematic review with meta-analyses was conducted. Study inclusion criteria were A) low- and intermediate-risk endometrial cancer, B) the use of ICG per cervical injection; C) a minimum of twenty included patients per study. To assess the negative predictive value of SLN mapping, D) a subsequent lymphadenectomy was an additional inclusion criterion. Results: Fourteen studies were selected, involving 2,117 patients. The overall and bilateral SLN detection rates were 95.6% (95% confidence interval [CI]=92.4%-97.9%) and 76.5% (95% CI=68.1%-84.0%), respectively. The incidence of SLN metastases was 9.6% (95% CI=5.1%-15.2%) in patients with grade 1-2 endometrial cancer and 11.8% (95% CI=8.1%-16.1%) in patients with grade 1-3 endometrial cancer. The negative predictive value of SLN mapping was 100% (95% CI=98.8%-100%) in studies that included grade 1-2 endometrial cancer and 99.2% (95% CI=97.9%-99.9%) in studies that also included grade 3. Conclusion: SLN mapping with ICG is feasible with a high detection rate and negative predictive value in low- and intermediate-risk endometrial cancers. Given the incidence of SLN metastases is approximately 10% in those patients, SLN mapping may lead to stage shifting with potential therapeutic consequences. Given the high negative predictive value with SLN mapping, routine lymphadenectomy should be omitted in low- and intermediaterisk endometrial cancer. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and safety of systematic lymph node dissection (SyLND) at the time of interval debulking surgery (IDS) for advanced epithelial ovarian cancer (AEOC). Methods: Systematic literature review of studies including AEOC patients undergoing SyLND versus selective lymph node dissection (SeLND) or no lymph node dissection (NoLND) after neoadjuvant chemotherapy (NACT). Primary endpoints included progression-free survival (PFS) and overall survival (OS). Secondary endpoints included severe postoperative complications, lymphocele, lymphedema, blood loss, blood transfusions, operative time, and hospital stay. Results: Nine retrospective studies met the eligibility criteria, involving a total of 1,660 patients: 827 (49.8%) SyLND, 490 (29.5%) SeLND, and 343 (20.7%) NoLND. The pooled estimated hazard ratios (HR) for PFS and OS were, respectively, 0.88 (95% confidence interval [CI]=0.65-1.20; p=0.43) and 0.80 (95% CI=0.50-1.30; p=0.37). The pooled estimated odds ratios (ORs) for severe postoperative complications, lymphocele, lymphedema, and blood transfusions were, respectively, 1.83 (95% CI=1.19-2.82; p=0.006), 3.38 (95% CI=1.71-6.70; p<0.001), 7.23 (95% CI=3.40-15.36; p<0.0001), and 1.22 (95% CI=0.50-2.96; p=0.67). Conclusion: Despite the heterogeneity in the study designs, SyLND after NACT failed to demonstrate a significant improvement in PFS and OS and resulted in a higher risk of severe postoperative complications. [ABSTRACT FROM AUTHOR]

Sentinel lymph node mapping (SNM) has gained popularity in managing apparent early-stage endometrial cancer (EC). Here, we evaluated the long-term survival of three different approaches of nodal assessment. This is a multi-institutional retrospective study evaluating long-term outcomes of EC patients having nodal assessment between 01/01/2006 and 12/31/2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm. Overall, 940 patients meeting inclusion criteria were included in the study, of which 174 (18.5%), 187 (19.9%), and 579 (61.6%) underwent SNM, SNM followed by backup lymphadenectomy (LND) and LND alone, respectively. Applying a propensity score matching algorithm (1:1:2) we selected 500 patients, including 125 SNM, 125 SNM/backup LND, and 250 LND. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM/backup LND and LND, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p = 0.750) and overall survival (p = 0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification based on uterine risk factors. Our study highlighted that SNM provides similar long-term oncologic outcomes than LND. • Sentinel node mapping (SNM) allows an accurate detection of nodal involvement. • Low volume disease accounts for about 50% of nodal disease diagnosed with SNM. • Backup lymphadectomy does not improve oncologic outcomes in comparison to SNM alone. [ABSTRACT FROM AUTHOR]

The role of retroperitoneal staging in endometrial cancer is still unclear. Although the prognostic value of lymphadenectomy has been demonstrated no data support the therapeutic value of nodal dissection. Sentinel node mapping represents an evolution of lymphadenectomy. Sentinel node mapping allows a more accurate identification of low-volume diseases (i.e., micrometastasis and isolated tumor cells) that are not always detectable via conventional histopathological evaluation. Adjuvant therapy might play a role in patients with low-volume disease. However, the presence of isolated tumor cells alone seems to not impact outcomes of endometrioid endometrial cancer patients. Hence, the choice to deliver adjuvant therapies has to be tailored based on uterine factors only. The introduction of molecular and genomic profiling would be useful in selecting appropriate surgical and adjuvant treatments. The molecular-integrated risk profile should be integrated in clinical practice to overcome the need of retroperitoneal staging (in case of non-bulky nodes) in patients at low risk. [ABSTRACT FROM AUTHOR]

To predict the overall pathologic response to neoadjuvant chemotherapy (NACT) of patients with locally advanced cervical cancer (LACC) creating a prediction model based on clinical-pathological factors and biomarkers (p53, Bcl1 and Bcl2) and to evaluate the prognostic outcomes of NACT. This is a retrospective study of 88 consecutive patients with LACC who underwent NACT followed by nerve sparing surgery with retroperitoneal lymphadenectomy at National Cancer Institute of Milan, between January 2000 and June 2013. Clinical pathologic data were retrieved from the institutional database. Biomarkers (p53, Bcl1 and Bcl2) were evaluated before and after NACT in the specimen. To investigate their role as predictors of response, we tried several statistical machine learning algorithms. Responders to NACT showed a 5-years survival between 100%(CR) and 85.7%(PR). Clinical factors were the most important predictor of response. Age, BMI and grade represented the most important predictors of response at random forest analysis. Tree-based boosting revealed that after adjusting for other prognostic factors, age, grade, BMI and tumor size were independent predictors of response to NACT, while p53 was moderately related to response to NACT. Area under the curve (crude estimate): 0.871. Whereas Bcl1 and Bcl2, were not predictors for response to NACT. The final logistic regression reported that grade was the only significant predictor of response to NACT. Combined model that included clinical pathologic variables plus p53 cannot predict response to NACT. Despite this, NACT remain a safe treatment in chemosensitive patients avoiding collateral sequelae related to chemo-radiotherapy. [ABSTRACT FROM AUTHOR]

Objective: To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer.Methods: This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting.Results: Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p < 0.001, log-rank test) and SNM (p = 0.038, log-rank test) correlated with a lower risk of developing surgery-related events. Independently, open abdominal surgery was associated with an increased risk of developing lymphatic morbidity (OR: 37.4 (95%CI: 4.38, 319.5); p = 0.001).Conclusion: The adoption of the laparoscopic approach and SNM technique were associated with lower 90-day complication rates than open surgery in high-risk endometrial cancer undergoing staging surgery. [ABSTRACT FROM AUTHOR]

The role of nodal dissection in patients with endometrial cancer has been intensively studied in several studies. Historically, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess potential nodal involvement and consequently define the appropriate stage of the tumor. Over the last years, sentinel node biopsy (SLNB) has been introduced as a more targeted alternative to lymph node dissection for lymph node staging and it has become popular among gynecologic oncologists. However, no level A evidence is still available, and several features of the SLNB technique have been matter of discussion among clinicians and a universally accepted methodology is still not currently available. This narrative review aims to summarize the body of knowledge on SLNB to offer the reader a complete picture about the evolution of this technique over the last decades. [ABSTRACT FROM AUTHOR]

Sentinel node mapping (SLN) has replaced lymphadenectomy for staging surgery in apparent early-stage low and intermediate risk endometrial cancer (EC). Only limited data about the adoption of SNM in high risk EC is still available. Here, we evaluate the outcomes of high-risk EC undergoing SNM (with or without back-up lymphadenectomy). This is a multi-institutional international retrospective study, evaluating data of high-risk (FIGO grade 3 endometrioid EC with myometrial invasion >50% and non-endometrioid histology) EC patients undergoing SNM followed by back-up lymphadenectomy and SNM alone. Chart of consecutive 196 patients were evaluated. The study population included 83 and 113 patients with endometrioid and non-endometrioid EC, respectively. SNM alone and SNM followed by back-up lymphadenectomy were performed in 50 and 146 patients, respectively. Among patients having SNM alone, 14 (28%) were diagnosed with nodal disease. In the group of patients undergoing SNM plus back-up lymphadenectomy 34 (23.2%) were diagnosed with nodal disease via SNM. Back-up lymphadenectomy identified 2 (1%) additional patients with nodal disease (in the para-aortic area). Back-up lymphadenectomy allowed to remove adjunctive positive nodes in 16 (11%) patients. After the adoption of propensity-matched algorithm, we observed that patients undergoing SNM plus back-up lymphadenectomy experienced similar disease-free survival (p = 0.416, log-rank test) and overall survival (p = 0.940, log-rank test) than patients undergoing SLN alone. Although the small sample size, and the retrospective study design this study highlighted that type of nodal assessment did not impact survival outcomes in high-risk EC. Theoretically, back-up lymphadenectomy would be useful in improving the removal of positive nodes, but its therapeutic value remains controversial. Further prospective evidence is needed. • Back-up lymphadectomy does not improve disease-free survival of high-risk EC undergoing SNM. • Back-up lymphadectomy does not improve overall survival of high-risk EC undergoing SNM. • Back-up lymphadenectomy increases positive node detection rate by 1%. [ABSTRACT FROM AUTHOR]

Objective: Uterine serous carcinoma (USC) is a rare highly aggressive disease. In the present study, we aimed to investigate the survival implication of the systematic lymphadenectomy in patients who underwent surgery for apparent early-stage USC. Methods: Consecutive patients with apparent early-stage USC surgically treated at six Italian referral cancer centers were analyzed. A comparison was made between patients who underwent retroperitoneal staging including at least pelvic lymphadenectomy "LND" vs. those who underwent hysterectomy alone "NO-LND". Baseline, surgical and oncological outcomes were analyzed. Kaplan- Meier curves were calculated for disease-free survival (DFS) and disease-specific survival (DSS). Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). Results: One hundred forty patients were analyzed, 106 LND and 34 NO-LND. NO-LND group (compared to LND group) included older patients (median age, 73 vs.67 years) and with higher comorbidities (median Charlson Comorbidity Index, 6 vs. 5) (p<0.001). No differences in terms of recurrence rate (LND vs. NO-LND, 33.1% vs. 41.4%; p=0.240) were observed. At Cox regression analysis lymphadenectomy did not significantly influence DFS (HR=0.59; 95% confidence interval [CI]=0.32-1.08; p=0.09), and DSS (HR=0.14; 95% CI=0.02-1.21; multivariable analysis p=0.07). Positive node was independently associated with worse DFS (HR=6.22; 95% CI=3.08-12.60; p<0.001) and DSS (HR=5.51; 95% CI=2.31- 13.10; p<0.001), while adjuvant chemotherapy was associated with improved DFS (HR=0.38; 95% CI=0.17-0.86; p=0.02) and age was independently associated with worse DSS (HR=1.07; 95% CI=1.02-1.13; p<0.001). Conclusions: Although lymphadenectomy did not show survival benefits in patients who underwent surgery for apparent early-stage USC, the presence of lymph node metastasis was the main adverse prognostic factors, supporting the prognostic role of the retroperitoneal staging also in this histological subtype. [ABSTRACT FROM AUTHOR]

• Sentinel node mapping allows a more accurate identification of patients with nodal disease compared to lymphadenectomy. • Patients having sentinel node mapping experience similar outcomes than patients having lymphadenectomy. • Even in high-risk group sentinel node mapping ensures the oncologic safety of lymphadenectomy. [ABSTRACT FROM AUTHOR]

To evaluate the long-term outcomes of young early stage cervical cancer patients wishing to preserve their childbearing potential. Data of young (aged <40 years) patients with early stage cervical cancer were prospectively collected. All patients with stage IA2, IB1 and IB2 cervical cancer were included; they have cervical conization and pelvic node dissection performed via minimally invasive surgery. Survival outcomes were assessed with the Kaplan-Meier model. Overall, 32 patients met the inclusion criteria. Mean (SD) age of the population included was 33 (±4). According to the FIGO 2018 staging system, the stage of disease was IA2, IB1 and IB2 in 9 (28%), 21 (66%) and 2 (6%) cases, respectively. All patients included had cervical conization and laparoscopic pelvic node assessment, including systematic pelvic lymphadenectomy (N = 30, 94%) and sentinel node mapping (N = 2, 6%). In six (19%) patients the planned conservative treatment was discontinued. Median follow-up was 75 (range, 12–184) months. No recurrent disease was diagnosed among patients undergoing conservative treatment; while 2 out of 6 patients having definitive surgical or radiotherapy treatments developed recurrent disease. Five-year disease free and overall survivals were 94% and 97%, respectively. Considering reproductive outcomes, 11 (69%) out of 16 patients who attempted to conceive got pregnant. Cervical conization and pelvic nodes assessment could be considered a valid treatment modality for early-stage cervical cancer patients who are wishing to preserve their childbearing potential. • Cervical conization plus lymph node dissection is a valuable option for early-stage stage cervical cancer. • About 20% for patients initially submitted to fertility sparing procedure required radical treatments. • In case of negative margins, cervical conization guarantees a good local disease control rate. [ABSTRACT FROM AUTHOR]

Sentinel node mapping is increasingly being utilized for endometrial cancer staging. However, only limited evidence supporting the adoption of sentinel node mapping instead of conventional lymphadenectomy is still available. Here, we aimed to review the current evidence comparing sentinel node mapping and lymphadenectomy in endometrial cancer staging. This systematic review was registered in the International Prospective Register of Systematic Reviews. Six comparative studies were included. Overall, 3536 patients were included: 1249 (35.3%) and 2287 (64.7%), undergoing sentinel node mapping and lymphadenectomy, respectively. Pooled data suggested that positive pelvic nodes were detected in 184 out of 1249 (14.7%) patients having sentinel node mapping and 228 out of 2287 (9.9%) patients having lymphadenectomy (OR: 2.03; (95%CI: 1.30 to 3.18); p = 0.002). No difference in detection of positive nodes located in the paraaortic was observed (OR: 93 (95%CI: 0.39 to 2.18); p = 0.86). Overall recurrence rate was 4.3% and 7.3% after sentinel node mapping and lymphadenectomy, respectively (OR: 0.90 (95%CI: 0.58 to 1.38); p = 0.63). Similarly, nodal recurrences were statistically similar between groups (1.2% vs. 1.7%; OR: 1.51 (95%CI: 0.70 to 3.29); p = 0.29). In conclusion, our meta-analysis underlines that sentinel node mapping is non-inferior to standard lymphadenectomy in term of detection of paraaortic nodal involvement and recurrence rates (any site and nodal recurrence); while, focusing on the ability to detect positive pelvic nodes, sentinel node mapping could be consider superior to lymphadenectomy. Further randomized studies are needed to asses long term effectiveness of sentinel node mapping. • Sentinel node mapping allows an accurate identification of nodal disease in the pelvic area in comparison to lymphadenectomy. • Sentinel node mapping is non inferior to lymphadenectomy in terms of para-aortic detection rate. • Sentinel node mapping does not increase nodal-specific recurrence. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the role of full lymphadenectomy in patients with isolated nodal recurrence of ovarian cancer.Methods: In a retrospective study, the data of women undergoing secondary cytoreduction at the National Cancer Institute, Milan, Italy, between January 1, 2001, and December 31, 2015, were collected and patients with isolated nodal recurrence were identified. Factors predicting for disease-free interval (DFI) and overall survival were estimated using Kaplan-Meier survival analysis and Cox regression analysis.Results: Of the 199 consecutive patients whose data were collected, isolated nodal recurrence (defined as the presence of lymphatic disease) was observed in 35 women. Among this study cohort, lymphadenectomy and bulky node removal were performed in 11 (31%) and 24 (69%) patients, respectively. Women who underwent lymphadenectomy experienced better DFI compared with those who had bulky node removal only (median 21 and 12 months, respectively; P=0.019), and lymphadenectomy, but not bulky node removal, significantly improved rates of DFI (P=0.043). No factors were independently associated with overall survival; however, a trend toward an improved overall survival rate was observed in patients undergoing complete resection at the time of primary surgery (P=0.055).Conclusion: Lymphadenectomy at the time of secondary cytoreduction improved DFI but did not have a significant effect on overall survival. [ABSTRACT FROM AUTHOR]

Endometrial cancer (EC) represents the most common gynecological neoplasm in developed countries. Surgery is the mainstay of treatment for EC. Although EC is characterized by a high prevalence several features regarding its management are still unclear. In particular the execution of lymphadenectomy is controversial. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. In the present review we discuss the emerging role of sentinel node mapping in EC. In addition, we discussed how type of tracers utilized and site of injection impacted on sentinel node detection rates. Future perspective regarding EC management are also discussed. [ABSTRACT FROM AUTHOR]

Objective To estimate the prevalence of lymph node involvement in early-stage epithelial ovarian cancer in order to assess the prognostic value of lymph node dissection. Methods Data of consecutive patients undergoing staging for early-stage epithelial ovarian cancer were retrospectively evaluated. Logistic regression and a nomogram-based analysis were used to assess the risk of lymph node involvement. Results Overall, 290 patients were included. All patients had lymph node dissection including pelvic and para-aortic lymphadenectomy. Forty-two (14.5%) patients were upstaged due to lymph node metastatic disease. Pelvic and para-aortic nodal metastases were observed in 22 (7.6%) and 42 (14.5%) patients. Lymph node involvement was observed in 18/95 (18.9%), 1/37 (2.7%), 4/29 (13.8%), 11/63 (17.4%), 3/41 (7.3%) and 5/24 (20.8%) patients with high-grade serous, low-grade-serous, endometrioid G1, endometrioid G2&3, clear cell and undifferentiated, histology, respectively ( p = 0.12, Chi-square test). We observed that high-grade serous histology was associated with an increased risk of pelvic node involvement; while, histology rather than low-grade serous and bilateral tumors were independently associated with para-aortic lymph node involvement ( p < 0.05). Nomograms displaying the risk of nodal involvement in the pelvic and para-aortic areas were built. High-grade serous histology and bilateral tumors are the main characteristics suggesting lymph node positivity. Conclusions Our data suggested that high-grade serous and bilateral early-stage epithelial ovarian cancer are at high risk of having disease harboring in the lymphatic tissues of both pelvic and para-aortic area. After receiving external validation, our data will help to identify patients deserving comprehensive retroperitoneal staging. [ABSTRACT FROM AUTHOR]

Objective To evaluate how the introduction of robotic-assisted surgery affects treatment-related morbidity and cost of endometrial cancer (EC) staging. Methods We retrospectively reviewed the records of consecutive patients with stage I–III EC undergoing surgical staging between 2007 and 2012 at our institution. Costs (from surgery to 30 days after surgery) were set based on the Medicare cost-to-charge ratio for each year and inflated to 2014 values. Inverse probability weighting (IPW) was used to decrease the allocation bias when comparing outcomes between surgical groups. Results We focused our analysis on the 251 EC patients who had robotic-assisted surgery and the 384 who had open staging. During the study period, the use of robotic-assisted surgery increased and open staging decreased ( P < 0.001). Correcting group imbalances by using IPW methodology, we observed that patients undergoing robotic-assisted staging had a significantly lower postoperative complication rate, lower blood transfusion rate, longer median operating time, shorter median length of stay, and lower readmission rate than patients undergoing open staging (all P < 0.001). Overall 30-day costs were similar between the 2 groups, with robotic-assisted surgery having significantly higher median operating room costs ($2820 difference; P < 0.001) but lower median room and board costs ($2929 difference; P < 0.001) than open surgery. Increasing experience with robotic-assisted staging was significantly associated with a decrease in median operating time ( P = 0.002) and length of stay ( P = 0.003). Conclusions The implementation of robotic-assisted surgery for EC staging improves patient outcomes. It provides women the benefits of minimally invasive surgery without increasing costs and potentially improves patient turnover. [ABSTRACT FROM AUTHOR]

This review aims to provide a comprehensive description of surgical approaches for the management of uterine sarcomas. Uterine sarcomas are rare uterine neoplasms. Frequently, diagnosis is made after hysterectomy or myomectomy scheduled for presumed benign leiomyomas. The gold standard for surgical treatment of uterine sarcomas is hysterectomy with bilateral salpingo-oophorectomy. It is possible to adopt a fertility-sparing approach for those patients who wish to maintain their fertility. The role of pelvic lymphadenectomy is controversial; in fact, removal of lymph nodes is only recommended in the case of radiological suspicion of nodal involvement. Use of a morcellator is associated with increased risk of total recurrence, intra-abdominal recurrence and death. Advanced disease management should be customized based on the patient's performance status given the uncertain role of adjuvant chemotherapy. Treatment of advanced or recurrent disease remains a subject of debate, but surgery is the best approach in terms of morbidity and mortality. There are few options for management of these uterine tumours, and further studies are needed to clarify the diagnostic and therapeutic pathways of patients with a first diagnosis of uterine sarcoma and patients with relapse of uterine sarcoma. No specific evidence supports the adoption of adjuvant therapy in uterine-confined disease, and molecular/genomic profiling may be useful to identify patients at risk of recurrence. [ABSTRACT FROM AUTHOR]

Objectives: Sentinel node mapping (SNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate the long-term survival of the three different approaches of nodal assessment in low, intermediate, and high-risk EC. Methods: This is a multi-institutional retrospective study evaluating long-term outcomes (at least three years of follow-up) of EC patients having nodal assessment between 2006 and 2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm. Results: Charts of 940 patients were evaluated, with 174 (18.5%), 187 (19.9%), and 579 (61.6%) having SNM, SNM followed by backup lym- phadenectomy and lymphadenectomy, respectively. Applying a propensity score matching algorithm (1:1:2), we selected 500 patients: 125 SNM versus 125 SNM plus backup lymphadenectomy versus 250 lymphadenectomies. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease (seven and 12 patients with micrometastasis and isolated tumor cells). The mean (SD) follow-up time was 62 (±11) months. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p=0.750) and overall survival (p=0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification on the basis of uterine risk factors. Conclusions: Our study highlighted that SNM provides similar longterm oncologic outcomes to lymphadenectomy. Further evidence is warranted to assess the prognostic value of low volume disease detected by ultrastaging and the role of molecular/genomic profiling. [ABSTRACT FROM AUTHOR]

The role of adopting PET/CT and its cost-effectiveness in the context of sentinel node mapping have to be further validated into prospective trials. As observed for CT scan [[8]], in high-risk patients PET/CT would be useful in identify gross intra-abdominal disease and suspected nodes, thus tailoring surgical plans. Accumulating data suggested that sentinel node mapping improves detection rate of positive nodes in comparison to lymphadenectomy, thanks to the application of ultrastaging on sentinel nodes harvested. [Extracted from the article]

Study Objective To investigate if low-dose aspirin influences the risk of bleeding and hemorrhagic complications during minimally invasive surgical staging for endometrial cancer. Design Retrospective study (Canadian Task Force classification II-2.) Setting University teaching hospital. Patients Three hundred seventeen endometrial cancer patients undergoing laparoscopic staging. Interventions Laparoscopic surgical staging included total laparoscopic hysterectomy plus bilateral salpingo-oophorectomy ± retroperitoneal staging. Measurement and Main Results Forty-three (14%) low-dose aspirin users were compared with 274 (86%) nonaspirin users. Aspirin-treated patients were older than patients in the control group (71 [range, 50-85] vs 64 [range, 27-92] years old, p < .001). No between-group differences in intraoperative bleeding (p = .32), hemoglobin drop (p = .91), transfusions (p = .09), and hemorrhagic complications rate (p = .58) were recorded. Aspirin users had a lower lymphadenectomy rate in comparison with patients in the control group (p = .001). However, according to a subanalysis of patients undergoing retroperitoneal staging (20 aspirin users vs 200 patients in the control group), no differences in bleeding (p = .53), hemorrhagic complications (p = 1.0), or transfusion rate (p = .25) were observed. Conclusion Low-dose aspirin does not influence the risk of bleeding and hemorrhagic complications in endometrial cancer patients undergoing minimally invasive staging. Hence, the choice to continue or cease the use of low-dose aspirin should be guided only by perioperative cardiovascular risk stratification. [ABSTRACT FROM AUTHOR]

We report a case report regarding the eradication of isolated lymph-nodal para-aortic recurrence in the aortic region down the left renal vein (LRV) in a patient treated two years earlier in another hospital for a FIGO stage IC2 high-grade serous ovarian carcinoma with a video showing the para-aortic space after eradication of the metastatic tissue. A 66 year-old woman was admitted 24 months after the initial surgical procedure for an increased Ca 125 level and CT scan that revealed a 3 cm para-aortic infrarenal lymph-nodal recurrence that was confirmed by PET/CT scan. A secondary cytoreductive surgery (SCS) with a para-aortic lymph-nodal dissection of the tissue down the LRV and radical omentectomy were performed: during the cytoreduction, the right hemicolon was mobilized. The anterior surface of the inferior vena cava (IVC), aorta and LRV were exposed. The metastatic lymph nodes were detected in the para-ortic space down the proximal part of the LRV and eradicated; an en bloc infrarenal lymph-node dissection from the aortocaval region was performed. The operative time during the surgical procedure was 212 min with a blood loss of 120 mL. No intra- and postoperative complications, including ureteral or vascular injury or renal dysfunction, occurred. At histological examination, three dissected lymph nodes were positive for metastasis, and the patient was discharged five days after laparotomy without side effects and underwent chemotherapy 3 weeks later; after a follow-up of 42 months, no recurrence was detected. In conclusion, secondary debulking surgery can be considered a safe and effective therapeutic option for the management of recurrences, although long-term follow-ups are necessary to evaluate the overall oncologic outcomes of this procedure. [ABSTRACT FROM AUTHOR]

Objective Fertility-sparing surgery (FSS) is a strategy often considered in young patients with low-grade (G1-2) early-stage epithelial ovarian cancer (eEOC), while is still controversial in high-risk patients. We investigated the role of FSS in low and high-risk eEOC patients undergoing comprehensive surgical staging. Methods We analyzed data from patients operated for an eEOC from 1975 to 2011, focusing on patients submitted to FSS. Seventy patients out of 307 with eEOC were identified. Patients underwent FSS were compared with 237 patients underwent radical-comprehensive-staging (RCS) in the same period. Disease free (DFS) and overall (OS) survivals were evaluated using Kaplan-Meier and Cox models. Results Overall, 307 patients had surgery for eEOC: 70 (22.8%) and 237 (77.2%) women had FSS and RCS, respectively. At univariate analysis, the execution of FSS not influenced DFS (HR:1.06 (95%CI: 0.56,2.02); p = 0.84) and OS (HR:1.94 (95%CI: 0.75,4.98); p = 0.16). Stage of disease was the only factor correlating with DFS (HR:4.73; 95%CI: 2.01,11.11; p < 0.001). Independently, increased age (HR per 1-unit of age:1.06 (95%CI: 1.03,1.11); p < 0.001) and high risk disease (HR:3.26; 95%CI: 1.23,8.62; p = 0.01) remained associated with worse OS. Focusing on the high risk group (stage IAG3 or more) we observed that type of surgery (FSS v. RCS) did not influence DFS (p = 0.77, log-rank test) and OS (p = 0.08, log-rank test). Conclusions FSS upholds oncologic effectiveness of RCS, preserving reproductive and endocrine functions. FSS does not increase risk of recurrence among high risk eEOC patients. Further prospective studies on this issue are warranted to improve patients' care. [ABSTRACT FROM AUTHOR]

Objective To determine if a sentinel lymph node (SLN) mapping algorithm will detect metastatic nodal disease in patients with intermediate −/high-risk endometrial carcinoma. Methods Patients were identified and surgically staged at two collaborating institutions. The historical cohort (2004–2008) at one institution included patients undergoing complete pelvic and paraaortic lymphadenectomy to the renal veins (LND cohort). At the second institution an SLN mapping algorithm, including pathologic ultra-staging, was performed (2006–2013) (SLN cohort). Intermediate-risk was defined as endometrioid histology (any grade), ≥ 50% myometrial invasion; high-risk as serous or clear cell histology (any myometrial invasion). Patients with gross peritoneal disease were excluded. Isolated tumor cells, micro-metastases, and macro-metastases were considered node-positive. Results We identified 210 patients in the LND cohort, 202 in the SLN cohort. Nodal assessment was performed for most patients. In the intermediate-risk group, stage IIIC disease was diagnosed in 30/107 (28.0%) (LND), 29/82 (35.4%) (SLN) ( P = 0.28). In the high-risk group, stage IIIC disease was diagnosed in 20/103 (19.4%) (LND), 26 (21.7%) (SLN) ( P = 0.68). Paraaortic lymph node (LN) assessment was performed significantly more often in intermediate −/high-risk groups in the LND cohort ( P < 0.001). In the intermediate-risk group, paraaortic LN metastases were detected in 20/96 (20.8%) (LND) vs. 3/28 (10.7%) (SLN) ( P = 0.23). In the high-risk group, paraaortic LN metastases were detected in 13/82 (15.9%) (LND) and 10/56 (17.9%) (SLN) (%, P = 0.76). Conclusions SLN mapping algorithm provides similar detection rates of stage IIIC endometrial cancer. The SLN algorithm does not compromise overall detection compared to standard LND. [ABSTRACT FROM AUTHOR]

Objectives To analyze detection-rate(DR) and diagnostic-accuracy (A) of sentinel-nodes(SLNs) mapping following hysteroscopic-injection of tracer. To compare DR and A between tracers: ICG and Tc99m. Methods Evaluation of endometrial-cancer patients who underwent SLNs mapping after hysteroscopic-peritumoral-injection of tracer ± lymphadenectomy. Analysis of DR (overall-bilateral-aortic) and A in the entire cohort and comparison between tracers. Results 202 procedures were performed from January/2005 to February/2017. Mean age:60 years (28–82); mean BMI: 26.8 kg/m 2 (15–47). In 133 cases (65.8%) hysterectomy and mapping procedure were performed laparoscopically. The overall-DR of the technique was 93.2% (179/192) (10 cases were excluded: 9 for technical-equipment failure; 1 for vagal reaction). Bilateral pelvic mapping was found in 59.7% of cases (107/179) and was more frequent in the ICG group (72.8% vs 53.3%; p: 0.012). In 50.8% of cases (91/179) SLNs were mapped both in pelvic and aortic nodes, and in 5 cases (2.8%) only in the aortic area. The mean number of detected SLNs was 3.7 (1–8). 22 patients (12.3%) had nodal involvement: 10-(45.5%)-macrometastases; 5-(22.7%)-micrometastases; 7-(31.8%)-ITCs. In 6 cases (27.3%) only aortic nodes were positive; in 5 cases (22.7%) both pelvic and aortic nodes and in 11 cases (50%) only pelvic nodes were involved. Three false-negative results were found, all in the Tc99m group. All had isolated aortic metastases with negative pelvic nodes. Overall-sensitivity was 86.4% (95%CI: 68.4–100) and overall-negative-predictive-value (NPV) was 96.4% (95%CI 86.7–100). No differences in terms of overall-DR, overall-sensitivity and overall-NPV were found between the two tracers. Conclusions Hysteroscopic-injection of tracer for SLNs mapping in endometrial cancer is as accurate as cervical injection with a higher DR in the aortic area. ICG improves bilateral-DR. Further investigation is warranted on this topic. [ABSTRACT FROM AUTHOR]

Objectives To assess clinicopathologic outcomes between two nodal assessment approaches in patients with endometrioid endometrial carcinoma and limited myoinvasion. Methods Patients with endometrial cancer at two institutions were reviewed. At one institution, a complete pelvic and para-aortic lymphadenectomy to the renal veins was performed in select cases deemed at risk for nodal metastasis due to grade 3 cancer and/or primary tumor diameter > 2 cm (LND cohort). This is a historic approach at this institution. At the other institution, a sentinel lymph node mapping algorithm was used per institutional protocol (SLN cohort). Low risk was defined as endometrioid adenocarcinoma with myometrial invasion < 50%. Macrometastasis, micrometastasis, and isolated tumor cells were all considered node-positive. Results Of 1135 cases identified, 642 (57%) were managed with an SLN approach and 493 (43%) with an LND approach. Pelvic nodes (PLNs) were removed in 93% and 58% of patients, respectively (P < 0.001); para-aortic nodes (PANs) were removed in 14.5% and 50% of patients, respectively (P < 0.001). Median number of PLNs removed was 6 and 34, respectively; median number of PANs removed was 5 and 16, respectively (both P < 0.001). Metastasis to PLNs was detected in 5.1% and 2.6% of patients, respectively (P = 0.03), and to PANs in 0.8% and 1.0%, respectively (P = 0.75). The 3-year disease-free survival rates were 94.9% (95% CI, 92.4–97.5) and 96.8% (95% CI, 95.2–98.5), respectively. Conclusions Our findings support the use of either strategy for endometrial cancer staging, with no apparent detriment in adhering to the SLN algorithm. The clinical significance of disease detected on ultrastaging and the role of adjuvant therapy is yet to be determined. [ABSTRACT FROM AUTHOR]