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Simple Summary: In situ/microinvasive adenocarcinoma of the uterine cervix represents the majority of cervical glandular lesions and can be treated conservatively. In contrast to squamous lesions, approximately 15–20% of glandular disease may be HPV-negative and therefore associated with a worse prognosis. Furthermore, up to 4% of cases may show recurrence after three years of follow-up. Given the abovementioned risk, knowing the predictive factors of disease recurrence becomes crucial for post-treatment management. In the present study, HPV testing in follow-up was the best predictor for recurrences in women with in situ/microinvasive AC undergoing conservative treatment. So, its use in clinical practice is of pivotal importance. However, attention should be paid to non-high-risk HPV women in follow-up with non-usual-type histopathology, given that it seems to represent a sub-population at increased risk of recurrences. Objective: The present study aimed to assess long-term follow-up outcomes in women with in situ/microinvasive adenocarcinoma (AC) of the uterine cervix treated conservatively. Methods: Retrospective multi-institutional study including women with early glandular lesions and 5-year follow-up undergoing fertility-sparing treatment. Independent variables associated with recurrence were evaluated. Logistic regression analysis and Kaplan–Meier survival analysis with Logrank test were performed. Results: Of 269 women diagnosed with in situ/microinvasive AC, 127 participants underwent conservative treatment. During follow-up, recurrences were found in nine women (7.1%). The only factor associated with recurrence during follow-up was positive high-risk Human Papillomavirus (hr-HPV) testing (odds ratio 6.21, confidence interval 1.47–26.08, p = 0.012). HPV positivity in follow-up showed a recurrence rate of 21.7% against 3.8% in patients who were HPV-negative (p = 0.002, Logrank test). Among women with negative high-risk HPV tests in follow-up, recurrences occurred in 20.0% of non-usual-type histology vs. 2.1% of usual-type cases (p = 0.005). Conclusion: HPV testing in follow-up is of pivotal importance in women with early glandular lesions undergoing conservative treatment, given its recurrence predictive value. However, women who are high-risk HPV-negative in follow-up with non-usual-type histopathology may represent a sub-population at increased risk of recurrences. Further studies should confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: Coronavirus disease 2019 (COVID-19) outbreak has correlated with the disruption of screening activities and diagnostic assessments. Endometrial cancer (EC) is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms. Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of EC patients. Methods: This is a retrospective study involving 54 centers in Italy. We evaluated patterns of presentation and treatment of EC patients before (period 1: March 1, 2019 to February 29, 2020) and during (period 2: April 1, 2020 to March 31, 2021) the COVID-19 outbreak. Results: Medical records of 5,164 EC patients have been retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. Surgery was the mainstay of treatment in both periods (p=0.356). Nodal assessment was omitted in 689 (27.3%) and 484 (21.2%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.7% in period 1 vs. 52.8% in period 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during COVID-19 pandemic (p<0.001). Conclusion: Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic. [ABSTRACT FROM AUTHOR]

SARS-CoV-2 pandemic is continuing to spread. There are growing concerns on the impact of COVID-19 in cancer patients. Several papers reporting recommendations and guidelines are published. But few data on cancer patients affected by COVID-19 are available. This is a retrospective study including all consecutive patients affected by gynecological cancer who developed COVID-19. All patients were treated in an academic setting (in Milan, Lombardy, Italy) between February and March 2020. Overall, 355 patients had active treatment during the study period due to newly diagnosed or recurrent gynecological disease. Among those, 19 (5.3%) patients affected developed COVID-19. All patients were asymptomatic at the time of COVID-19 detection. Six patients were diagnosed before starting planned treatments; while the remaining 13 were diagnosed for COVID-19 after their started their treatments. Considering the first group of six patients, one patient died due to COVID-19 3 days after the diagnosis; while the other patients recovered from COVID-19 after a median of three weeks. The latter group of 13 patients (treatments started) included five patients who underwent surgery and eight patients who underwent chemotherapy. Focusing on five patients who were diagnosed after surgery, we observed that two patients died during postoperative course, while in other two cases prolonged hospitalization was needed. One patient had no issues. Chemotherapy was delayed for the remaining patents without sequelae. Our report highlights that COVID-19 impacts the quality of treatments for cancer patients. Mortality rate is high, especially after surgery. More important, patients under active treatment for cancer are at high risk of developing severe evolution of COVID-19. Prioritizing patients journey during COVID-19 is of paramount importance. • There are growing concerns on the impact of COVID-19 in cancer patients. • COVID-19 is impacting oncologic practice directly and indirectly. • Prioritizing patients journey during COVID-19 is of paramount importance. [ABSTRACT FROM AUTHOR]

Objective: To evaluate long-term outcomes after surgery for apparent early-stage ovarian cancer (OC).Methods: Retrospective analysis of women who underwent staging surgery for apparent early-stage OC at a single center in Milan, Italy, from 1990 to 2008, and had a follow-up longer than 10 years (living women with no recurrence). Univariate and multivariate analyses and propensity score matching were carried out.Results: Overall, 182 women underwent radical (n=148, 81.3%) or conservative (n=34, 18.7%) procedures for early-stage OC. Ten-year disease-free and overall survival were 82.9% (n=151) and 87.9% (n=160), respectively. Conservative or radical surgery had similar disease-free (log-rank test, P=0.783) and overall (log-rank test, P=0.783) survival. These data were confirmed after the application of propensity score matching. High-risk features correlated with non-significant worse disease-free survival (P=0.080). In the high-risk group (≥Grade 3 or ≥ Stage IC), type of surgical approach (conservative vs radical) did not affect survival (hazard ratio, 0.81; 95% confidence interval, 0.18-3.56; P=0.781).Conclusion: Women with early-stage OC had encouraging long-term survival. The presence of high-risk disease had detrimental effects on survival, regardless of surgical approach. High-risk disease should not be considered a contraindication to conservative surgery. [ABSTRACT FROM AUTHOR]

Background: Clinical characteristics combined with new biomarkers help discriminate between atypical uterine smooth muscle tumors (AUSMT) and leiomyosarcomas (LMS). Patients and Methods: We retrospectively collected a series of leiomyomas (LM), AUSMT, and LMS. Estrogen receptors (ER), progesterone receptors (PR), p16, Ki-67, and p53 expression were assessed by immunohistochemistry. For AUSMT patients, immunohistochemistry evaluations were performed at the time of diagnosis and at recurrences. Results: A total of 27 cases of AUSMT, 22 LM, and 31 LMS were identified. The expression of ER and PR decreased from LM to LMS (ER+: LM 95.5%, AUSMT 88.9%, LMS 41.9%, p < 0.001; PR+: LM 100%, AUSMT 88.9%, LMS 38.2%, p = 0.002). By contrast, p16 and p53 expression increased (p16+: LM 4.5%, AUSMT 40.7%, LMS 45.2%, p = 0.004; p53: LM 9.1%, AUSMT 33.3%, LMS 58.1%, p = 0.001). At a median follow-up of 33.47 months, 40.7% of patients with AUSMT experienced recurrent disease, 6 patients relapsed as AUSMT and 5 as LMS. In univariate analysis was observed that ER status (p = 0.027) and p53 expression (p = 0.015) predicted risk of relapse. Conclusions: Treatment of AUSMT should be centralized in dedicated centers. International collaborations are needed to optimize research strategy, which may lead to the identification of new useful biomarkers and to improvement in the clinical management of this rare disease. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of hematologic toxicity and leukopenia in locally advanced cervical cancer patients undergoing neoadjuvant chemotherapy (NACT).Study Design: Data of consecutive patients undergoing platinum-based NACT followed by surgery were retrospectively searched in order to evaluate the impact of chemotherapy-related toxicity on survival outcomes. Toxicity was graded per the Common Terminology Criteria for Adverse Events (CTCAEv.4.03). Survival outcomes were evaluated using Kaplan-Meir and Cox hazard models.Results: Overall, 126 patients were included. Among those, 94 (74.6%) patients experienced grade2+ hematologic toxicity; while, grade2+ non-hematologic toxicity occurred in 11 (8.7%) patients. After a median follow-up of 37.1 (inter-quartile range, 12-57.5) months, 21 (16.6%) patients experienced recurrence. Via multivariate analysis, no factor was independently associated with disease-free survival; while a trend toward worse prognosis was observed for patients experiencing grade2+ leukopenia at cycle-3 (HR:3.13 (95%CI: 0.94, 10.3); p=0.06). Similarly, grade2+ leukopenia (HR:9.98 (95%CI: 1.14, 86.6); p=0.03), lymph-node positivity (HR:14.6 (95%CI:1.0, 214.4); p=0.05) and vaginal involvement (HR:5.81 (95%CI:1.43, 23.6); p=0.01) impacted on overall survival, at multivariate analysis. Magnitude of leukopenia correlated with survival (p<0.001).Conclusions: Although, our data have to be confirmed by prospective investigations, the present study shows an association between the occurrence of leukopenia and survival outcomes. NACT-related immunosuppression might reduce the response against the tumor, thus promoting cancer progression. [ABSTRACT FROM AUTHOR]

Objective: The extent to which the observed variation in episiotomy rates can be attributed to individual practitioners is not known. We sought to analyze the contribution of the attending midwife to a risk model for episiotomy.Study Design: We prospectively collected data on 736 consecutive vaginal deliveries in nulliparas at a tertiary maternity hospital. The study measures the impact of the attending midwife on the decision to perform an episiotomy, controlling for a host of patient and clinical characteristics. Midwife effect is evaluated in terms of its overall contribution to the explanatory power of logistic regression model.Results: The overall rate of episiotomy in primiparas was 40.6%. Individual midwife episiotomy rate ranged from 5.6% to 73.9% (p < 0.0001). After controlling for confounding factors with logistic regression, maternal age ≥35 years (OR 1.61, 95%CI: 1.02-2.52), vacuum extraction (OR 26.88, 95%CI: 2.57-280.7), fundal pressure (OR 62.90, 95%CI: 18.39-214.98), second-stage duration (OR 2.24, 95%CI: 1.53-3.28), and the individual midwife were all associated with episiotomy use. The midwife attending the birth and fundal pressure provided the greatest explanatory power of the model.Conclusions: The attending provider adds a significant independent effect to the episiotomy risk model. This has implications for both practice and research in this clinical area. [ABSTRACT FROM AUTHOR]

Objective: To identify predictive factors of recurrence and survival in patients with early-stage epithelial ovarian cancer (eEOC).Methods: We retrospectively searched the medical records of all women undergoing optimal surgical staging for eEOC (stage I-II) at the National Cancer Institute of Milan, Italy, between January 1, 1974, and December 31, 2014.Results: During the study period, 429 patients underwent primary surgery followed by either adjuvant chemotherapy or observation alone for apparent eEOC. In multivariable analysis, International Federation for Gynecology and Obstetrics (FIGO) stage greater than 1 (hazard ratio [HR] 2.49, 95% CI 1.24-4.99) was the only prognostic factor for lower disease-free survival. Multivariate analysis showed that age at diagnosis (HR 1.68, 95% CI 1.14-2.47) and stage (HR 2.29, 95% CI 1.01-6.39) were independent predictive factors for poorer overall survival (OS).Conclusions: FIGO stage is the most important prognostic factor for recurrence and survival in patients with eEOC. Furthermore, age at diagnosis was identified as a factor that negatively influenced OS. Our data for oncologic outcomes are similar to those reported in previous studies. [ABSTRACT FROM AUTHOR]

Objective: Early iatrogenic menopause in gynecological cancer survivors and BRCA mutation (BRCAm) carriers undergoing risk-reducing salpingo-oophorectomy (RRSO) is a major health concern. Hormone replacement therapy (HRT) is the most effective remedy, but remains underused in clinical practice. The Multicenter Italian Trials in Ovarian cancer and gynecologic malignancies (MITO) group promoted a national survey to investigate the knowledge and attitudes of healthcare professionals regarding the prescription of HRT., Methods: The survey consisted of a self-administered, multiple-choice 45-item questionnaire, available online to all MITO members for 2 months starting from January 2022., Results: A total of 61 participants completed the questionnaire (47 out of 180 MITO centers; compliance: 26.1%). Most respondents were female (73.8%), younger than 50 years (65.6%), and gynecologic oncologists (55.7%), working in public general hospitals (49.2%). An 84.4% of specialists actively discuss HRT with patients and 51.0% of patients ask the specialist for an opinion on HRT. The rate of specialists globally in favor of prescribing HRT was 22.9% for ovarian cancer, 49.1% for cervical cancer, and 8.2% for endometrial cancer patients. Most respondents (70.5%) believe HRT is safe for BRCA-mutated patients after RRSO. Nearly 70% of physicians prescribe systemic HRT, while 23.8% prefer local HRT. Most specialists recommend HRT for as long as there is a benefit and generally for up to 5 years., Conclusion: Real-world data suggest that many healthcare professionals still do not easily prescribe HRT for gynecological cancer survivors and BRCA mutation carriers after RRSO. Further efforts are required to implement the use of HRT in clinical practice and to support both clinicians in recommending HRT and patients in accepting it., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2024. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology, and Japan Society of Gynecologic Oncology.)

Human papillomavirus (HPV) is the most common sexually transmitted infection. The implementation of primary prevention aims to reduce the burden of HPV infection and HPV-related disease. However, HPV-related diseases are still a concern, even in high-income countries. Approximately 570 000 new cervical cancer cases are diagnosed in Italy every year. Prophylactic HPV vaccines have been developed to minimize the spread of HPV. Growing evidence supports the administration of HPV vaccines (even just one dose) in reducing the prevalence of HPV infection and HPV-related disease including cancers. HPV vaccines are characterized by a high level of efficacy (>95%) in women who are naïve to HPV; however, they do not increase clearance in patients with ongoing HPV infection. With more than 200 million doses administered to date, HPV vaccines are considered to be safe and effective at preventing HPV-related infections and cancers. In this review we aim to review the current evidence regarding HPV vaccination and to describe trends in HPV vaccination coverage in Italy. In Italy, vaccination against HPV has been included in the National Immunization Plan (NIP) since 2007-2008. Using data abstracted from the Italian Ministry of Health, we analyzed changes in HPV vaccination coverage. We observed that HPV vaccines are underutilized and coverage rates are decreasing. Looking at the target population (females and males aged 11-12 years) in Italy, a decrease in coverage rates was observed. A call for action, improved HPV awareness, and education are the key elements to enhance the widespread adoption of HPV vaccination., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study was to analyze the oncological outcome of stage I malignant ovarian germ cell tumors patients included in the MITO-9 study to identify those who might be recommended routine surveillance alone after complete surgical staging., Methods: MITO-9 was a prospective observational study analyzing data collected between January 2013 and December 2019. Three groups were identified: group A included 13 patients stage IA dysgerminoma and IAG1 immature teratoma; group B included 29 patients with stage IB-C dysgerminomas, IA-C G2-G3 immature teratomas and stage IA mixed malignant ovarian germ cell tumors and yolk sac tumors; and group C included five patients (two patients with stage IC1 and one patient with stage IC2 yolk sac tumors and two patients with mixed-stage IC2 malignant ovarian germ cell tumors)., Results: A total of 47 patients with stage I conservatively treated malignant ovarian germ cell tumors were analyzed. Two patients in group B were excluded from the routine surveillance alone group due to positive surgical restaging. Therefore, a total of 45 patients were included in the study. Median follow-up was 46.2 months (range; 6-83). In total, 14 of 45 patients (31.1%) received chemotherapy, while 31 (68.9%%) underwent surveillance alone. One patient in group A, with stage IA dysgerminoma had a relapse, successfully managed with conservative surgery and chemotherapy. None of the patients in group B and C relapsed. All patients were alive at completion of the study. Overall, among 31 patients (68.9%) who underwent surveillance alone, only one patient relapsed but was treated successfully., Conclusions: Our data showed that close surveillance alone could be an alternative option to avoid adjuvant chemotherapy in properly staged IB-C dysgerminomas, IA-IC G2-G3 immature teratomas, and IA mixed malignant ovarian germ cell tumors with yolk sac tumor component., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Cervical cancer prevention guidelines include Human Papillomavirus (HPV) test, cytology, and HPV-16/18 typing for triage to determine the risk of cervical intraepithelial neoplasia (CIN) grade 3 as the best proxy of cervical cancer risk. In doing that, they do not consider how age can modify the type-specific risk of CIN3. The present study aimed to evaluate the age-related distribution of HPV genotypes affecting the risk-assessment in cervical cancer screening programs: non-screening-type-HPV and non-HPV-16/18 in unvaccinated women with CIN3., Methods: Retrospective multi-institutional study, including HPV genotyped women with CIN3 on cone histology treated between 2014 and 2019. The sample was divided into three categories of age: <30, 30-44, ≥45. HPV genotypes were grouped in non-screening-type-HPV (not-including genotypes 16/18/31/33/35/39/45/51/52/56/58/59/66/68) and non-HPV-16/18. Associations and trends between different age-groups and HPV genotypes were measured., Results: 1332 women were analyzed. Non-screening-type-HPV CIN3 were 73 (5.5%). Non-HPV-16/18 were found in 417 participants (31.3%). Women over 45 associated with non-screening-type HPV [odds ratio (OR) = 1.87, 95% confidence interval (CI) 1.07-3.25; p = 0.027]. Non-screening-type-HPV prevalence increased significantly with age (3.9% vs 5.1% vs 9.0%, p = 0.016). Women under 30 showed a lower rate of non-HPV-16/18 (OR = 0.65, 95% CI 0.47-0.89; p = 0.007). There was a positive trend with age of non-HPV-16/18 CIN3 (23.6% vs 32.1% vs 38.0%, p = 0.0004)., Conclusion: The proportion of CIN3 lesions unrelated to genotypes detected by primary screening tests increased with age. This implies that age probably modifies the risk of CIN3 and possibly of cancer associated with HPV types. The risk-based recommendation should take into consideration age to define the management of HPV positive women., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Objective: To investigate the factors associated with poorer oncologic outcomes in patients undergoing laparoscopic radical hysterectomy (LRH) for early stage cervical cancer., Design: Multicenter retrospective study., Setting: Three gynecologic oncology referral centers., Patients: Patients with International Federation of Gynecology and Obstetrics 2009 stage IA (positive lymphovascular space invasion)-IB1 cervical cancer between January 2006 and June 2018., Interventions: LRH (Piver type II-III hysterectomies). Lymph-node dissection was accomplished according to the tumor characteristics., Measurements and Main Results: Surgical and oncologic outcomes were analyzed. Overall, 186 patients met the inclusion criteria, 16 (8.6%) experienced a recurrence, and 9 (4.8%) died of the disease (median follow-up period 37.9 months). Surgery-related complications did not influence disease-free survival. All the recurrences (16/16; 100%) occurred in patients with stage IB1 disease (p = .02), and 15 (93.7%) in cases involving tumors ≥2 cm. No association between positive lymph node and recurrence was detected (p =.82). Patients who had a preoperative diagnosis through conization (93; 50%) had a significantly lower rate of recurrence than those who underwent cervical biopsy (93; 50%): 1/93 (1.1%) vs 15/93 (16.1%); p <.001). The subanalysis of patients with International Federation of Gynecology and Obstetrics stage IB1 cervical cancer showed that patients undergoing preoperative conization (vs cervical biopsy) were less likely to experience a recurrence (odds ratio 0.09; 95% confidence interval 0.01-0.55)., Conclusion: We confirmed that LRH was associated with a recurrence rate similar to that reported in the Laparoscopic Approach to Cervical Cancer trial. Tumor size ≥2 cm represents the most important risk factor influencing disease-free survival. However, we found that preoperative conization plays a potentially protective role in patients with an IB1 tumor., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Coronavirus disease 2019 (COVID-19) has caused rapid and drastic changes in cancer management. The Italian Society of Gynecology and Obstetrics (SIGO), and the Multicenter Italian Trials in Ovarian cancer and gynecologic malignancies (MITO) promoted a national survey aiming to evaluate the impact of COVID-19 on clinical activity of gynecologist oncologists and to assess the implementation of containment measures against COVID-19 diffusion., Methods: The survey consisted of a self-administered, anonymous, online questionnaire. The survey was sent via email to all the members of the SIGO, and MITO groups on April 7, 2020, and was closed on April 20, 2020., Results: Overall, 604 participants completed the questionnaire with a response-rate of 70%. The results of this survey suggest that gynecologic oncology units had set a proactive approach to COVID-19 outbreak. Triage methods were adopted in order to minimize in-hospital diffusion of COVID-19. Only 38% of gynecologic surgeons were concerned about COVID-19 outbreak. Although 73% of the participants stated that COVID-19 has not significantly modified their everyday practice, 21% declared a decrease of the use of laparoscopy in favor of open surgery (19%). However, less than 50% of surgeons adopted specific protection against COVID-19. Additionally, responders suggested to delay cancer treatment (10%-15%), and to perform less radical surgical procedures (20%-25%) during COVID-19 pandemic., Conclusions: National guidelines should be implemented to further promote the safety of patients and health care providers. International cooperation is of paramount importance, as heavily affected nations can serve as an example to find out ways to safely preserve clinical activity during the COVID-19 outbreak., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2020. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology.)

Aim: During the last years, the role of sentinel lymph node mapping (SLNM) for endometrial cancer (EC) surgical treatment has increased in popularity. However, several controversies remain about different technical steps of SLNM. Thus, a randomised control trial was designed to compare cervical (CI) and hysteroscopic (HI) indocyanine green (ICG) injection for SLNM of newly diagnosed EC undergoing surgical staging. The primary end-point of the study was to compare these two techniques in terms of para-aortic detection rate., Methods: Patients with apparent stage I or II histologically confirmed EC undergoing surgery were included in the study. This randomised trial distinguished patients in two study groups according to two different techniques of ICG SLNM: CI versus HI injection. Patients who met the inclusion criteria were randomly assigned to CI or HI injection in a 1:1 ratio. The central randomisation system allocated patient randomisation numbers sequentially in the order in which the patients were enrolled. This randomised trial was not blinded for either patients or the surgeons., Results: From March 2017 until April 2019, a total of 165 patients were randomised in this study: 85 (51.5%) in the CI group and 80 (48.5%) in the HI group. After randomisation, 14 (8.5%) patients were excluded from the study. Finally, 151 patients were included in the analysis: 82 (54.3%) in the CI group and 69 (45.7%) in the HI group. Hysteroscopy injection shows an ability to detect Sentinel nodes (SNLs) in the para-aortic area of about 10% greater compared with CI injection, although this difference did not reach statistical significance. The HI technique was superior in detecting isolated para-aortic SLNs (5.8% Versus 0%). The CI injection was correlated with higher SLN detection rates at the pelvic level compared with HI injection. Pelvic and overall detection was higher in the CI group., Conclusions: The present study supports the adoption of CI instead of HI injection because the former allows better identification of sentinel nodes (especially in the pelvic area). Detection of SLN in the para-aortic area was slightly higher in patients receiving a HI injection, but the difference with the CI route was not statistically significant., Competing Interests: Conflict of interest statement The authors declare no competing interests., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To investigate whether primary conization might overcome the risk of local dissemination in patients undergoing laparoscopic radical hysterectomy., Methods: Consecutive data of 262 patients with early stage cervical cancer were retrieved: 88 women had conization followed by radical hysterectomy. A propensity-matched comparison (1:1) was carried out in order to compare laparoscopy and open surgery. Accumulating data highlighted that minimally invasive surgery has been associated with higher recurrence rates and worse overall survival than open surgery in women with early stage cervical cancer., Results: Data of 35 paired patients (total 70 patients) were analyzed. No between-group differences in baseline, disease, and pathological variables were observed. Patients undergoing laparoscopy correlated with lower blood loss (50 [range 30-100] vs 150 [range 50-500] mL; P<0.001) and shorter length of stay (3 ± 0.8 vs 5.4 ± 1.4 days; P<0.001) compared to open surgery. One local recurrence was observed per group (P=1.00). Type of surgical approach did not influence site of recurrence (P=1.00) or survival outcomes, in terms of 10-year disease-free (P=0.549, log-rank test) and overall survivals (P=0.615, log-rank test)., Conclusions: The data show that primary conization might overcome the risk of local recurrence after laparoscopic radical hysterectomy in early stage cervical cancer. Further prospective evidence is needed., (© 2020 International Federation of Gynecology and Obstetrics.)

To investigate trends in prevalence of various human papillomavirus types in order to assess the unmet clinical needs for women affected by human papillomavirus-related disease. Data of consecutive 15 138 patients undergoing human papillomavirus DNA testing from 1998 to 2018 were retrospectively identified. Human papillomavirus types were classified at high-risk according to the classification of the International Agency for Research on Cancer. The International Agency for Research on Cancer included seven human papillomavirus types covered by nine-valent vaccine and five not yet covered by any available vaccines. Overall, 4159 (65.3%), 1500 (23.5%) and 714 (11.2%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. At least one high-risk human papillomavirus type(s) was detected in 1241 patients with genital dysplasia: 832 (67.1%), 291 (23.4%) and 118 (9.5%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. Over the twenty-year study period, the number of human papillomavirus types not covered by nine-valent vaccine increased dramatically (from 4 to 16%; P < 0.001, P for trend). Similarly, looking at patients with genital dysplasia, high-risk human papillomavirus types not covered by nine-valent vaccine increased from 3 to 13% (P < 0.001, P for trend). Our data highlight that human papillomavirus types covered by nine-valent vaccine represent are the main types associated with genital dysplasia. However, over the study period, we observed an increasing prevalence of confections and high-risk human papillomavirus types not covered by the nine-valent vaccine, thus suggesting the need of developing more complete vaccines against human papillomavirus.

Objective: Recent evidence has suggested that laparoscopic radical hysterectomy is associated with an increased risk of recurrence in comparison with open abdominal radical hysterectomy. The aim of our study was to identify patterns of recurrence after laparoscopic and open abdominal radical hysterectomy for cervical cancer., Methods: This a retrospective multi-institutional study evaluating patients with recurrent cervical cancer after laparoscopic and open abdominal surgery performed between January 1990 and December 2018. Inclusion criteria were: age ≥18 years old, radical hysterectomy (type B or type C), no recurrent disease, and clinical follow-up >30 days. The primary endpoint was to evaluate patterns of first recurrence following laparoscopic and open abdominal radical hysterectomy. The secondary endpoint was to estimate the effect of the primary surgical approach (laparoscopy and open surgery) in post-recurrence survival outcomes (event-free survival and overall survival). In order to reduce possible confounding factors, we applied a propensity-matching algorithm. Survival outcomes were estimated using the Kaplan-Meier model., Results: A total of 1058 patients were included in the analysis (823 underwent open abdominal radical hysterectomy and 235 patients underwent laparoscopic radical hysterectomy). The study included 117 (14.2%) and 35 (14.9%) patients who developed recurrent cervical cancer after open or laparoscopic surgery, respectively. Applying a propensity matched comparison (1:2), we reduced the population to 105 patients (35 vs 70 patients with recurrence after laparoscopic and open radical hysterectomy). Median follow-up time was 39.1 (range 4-221) months and 32.3 (range 4-124) months for patients undergoing open and laparoscopic surgery, respectively. Patients undergoing laparoscopic radical hysterectomy had shorter progression-free survival than patients undergoing open abdominal surgery (HR 1.98, 95% CI 1.32 to 2.97; p=0.005). Patients undergoing laparoscopic radical hysterectomy were more likely to develop intrapelvic recurrences (74% vs 34%; p<0.001) and peritoneal carcinomatosis (17% vs 1%; p=0.005) than patients undergoing open surgery., Conclusions: Patients undergoing laparoscopic radical hysterectomy are at higher risk of developing intrapelvic recurrences and peritoneal carcinomatosis. Further evidence is needed in order to corroborate our findings., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The widespread introduction of screening methods allow to identify cervical dysplasia before having invasive cancer. The risk of developing cervical dysplasia persistence/ recurrence following conization represent a major health issue. Although several studies tried to identify predictors for cervical dysplasia persistence/recurrence, no previous study has been conducted to develop a risk calculator. The current study aimed to identify predictors of cervical dysplasia persistence/recurrence among women undergoing primary conization. We aimed to build nomograms estimating the risk of developing cervical dysplasia recurrence. Data of consecutive women with diagnosis of high-risk human papillomavirus (HPV) undergoing conization were retrospectively evaluated (1503 patients). The risk of developing cervical dysplasia persistence/recurrence was assessed with Kaplan-Meier and Cox's hazard models. Additionally, two nomograms were built to estimate likelihood of cervical dysplasia recurrence: the first based on baseline and operative parameters and the second focusing on type-specific HPV detected. The performance of the above nomograms was assessed using concordance index. A total of 1503 patients were analyzed. After a mean (SD) follow-up of 48.6 ( ± 17.5) months, 84 (5.6%) patients required secondary conization. By multivariate analysis, HIV infection [hazard ratio (HR): 7.78; 95% confidence interval (CI): 2.77-21.81; P < 0.001], positive margins (HR: 26.2; 95% CI: 14.1-48.71; P < 0.001) and persistence of HPV (HR: 6.82; 95% CI: 4.15-11.21; P < 0.001) correlated with cervical intraepithelial neoplasia 2+ persistence/recurrence. The importance of those variables was corroborated by our first nomogram. The second nomogram suggested the impact of type-specific HPV infection in predicting cervical dysplasia persistence/ recurrence. HPV16, HPV18, HPV33, HPV35 and HPV45 were the HPV types most commonly associated with cervical dysplasia persistence/recurrence. The concordance index was greater than 0.70 for both nomograms, thus suggesting the reproducibility of our models. We developed the first two nomograms predicting this risk. The findings of this study require external validation. Once validated our data might be useful to plan a tailored postoperative surveillance of women receiving primary conization.

Objective: We have investigated outcomes of women presenting with recurrent high-grade vaginal intra-epithelial neoplasia., Methods: Data of consecutive women diagnosed with recurrent high-grade vaginal intra-epithelial neoplasia after primary treatment(s) were retrieved. Risk of developing new recurrence over the time was assessed using Kaplan-Meier and Cox models., Results: Data of 117 women were available for the analysis. At primary diagnosis, 41 (35%), 4 (3.4%) and 72 (61.6%) patients had had laser, pure surgical and medical treatments, respectively. Secondary treatments included: laser ablation and medical treatment in 95 (81.2%) and 22 (18.8%) cases, respectively. After a mean (standard deviation) follow-up of 72.3 (±39.5) months, 37 (31.6%) out of the entire cohort of 117 patients developed a second recurrence. Median time to recurrence was 20 (range,5-42) months. Patients with recurrent high-grade vaginal intra-epithelial neoplasia undergoing medical treatments were at higher risk of developing a second recurrence in comparison to women having laser treatment (p=0.013, log-rank test). After we corrected our results for type of treatment used for recurrent disease, we observed that the execution of primary laser treatment was independently associated with a lower risk of developing new recurrences (hazard ratio [HR]=0.46; 95% confidence interval [CI]=0.21-0.99; p=0.050). The other variable that is independently associated with a new recurrence is the persistent infection from HPV16 or 18 (HR=3.87; 95% CI=1.15-13.0; p=0.028)., Conclusion: Patients with recurrent high-grade vaginal intra-epithelial neoplasia are at high risk of developing new recurrences. Our data underline that the choice of primary treatment might have an impact of further outcomes., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2019. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology.)

Background: Several techniques for vaginal reconstruction after pelvic exenteration such as myocutaneous and myoperitoneal flaps are available. However, the use of a myofascial flap has not been previously described. Thus, the objective of this article is to present our experience of vaginal reconstruction with rectus abdominis myofascial (RAMF) flap., Methods: Between May 2008 and March 2017, 16 patients underwent anterior, posterior, or total pelvic exenteration with RAMF flap vaginal reconstruction. Patient records were systematically reviewed; demographic, clinic and pathologic, operative details, flap-related and non-flap-related complications, and risk factors for wound healing are reported. Quality of life and sexual function were also investigated., Results: Eleven (68.8%) of 16 patients died during the follow-up (29.1 ± 25 months), whereas 5 (31.3%) are still alive. Early complications were reported in 7 patients (43.8%), with 2 (12.5%) flap-related and 5 (31.3%) non-flap-related complications. Similarly, late complications were reported in 5 patients (31.3%), with 2 (12.5%) flap-related and 3 (18.8%) non-flap-related complications. Quality of life measured by SF-36 (Survey Short Form 36) significantly improved at 12-month follow-up in comparison with baseline (physical component summary 31.5 ± 4.8 vs 26.8 ± 2.9; P = 0.027; mental component summary 29.5 ± 6.0 vs 25.9 ± 2.0; P = 0.042)., Conclusions: This study demonstrates for the first time that RAMF flap vaginal reconstruction after pelvic exenteration is an efficacious and safe technique. Furthermore, it is associated with a significant improvement of quality of life and sexual function in those women who had sexual intercourse before surgery.

Objective: Pelvic exenteration for recurrent gynecological malignancies is characterized by a high rate of severe complications. Factors predictive of morbidity, readmission, and cost were analyzed., Methods: Data of consecutive patients undergoing pelvic exenteration between January 2007 and December 2016 were prospectively evaluated., Results: Fifty-eight patients were included in the analysis. Anterior, posterior, and total exenterations were executed in 39 (67%), 9 (16%), and 10 (17%) patients, respectively. Ten (15.5%) severe complications occurred: 8 (20.5%), 0 (0%), and 1 (10%) after anterior, posterior, and total exenterations, respectively. Radiotherapy dosage, time between radiotherapy and surgery, and previous administration of chemotherapy did not influence 90-day complications and readmission. At multivariable analysis, albumin levels less than 3.5 g/dL (odds ratio, 16.2 [95% confidence interval, 2.85-92.8]; P = 0.002) and history of deep vein thrombosis (odds ratio, 9.6 [95% confidence interval, 0.93-98.2]; P = 0.057) were associated with 90-day morbidity. Low albumin levels independently correlated with readmission (P = 0.011). The occurrence of 90-day postoperative complications and readmission increased costs of a median of +12,500 and +6000 euros, respectively (P < 0.05)., Conclusions: Preoperative patient selection is a key point for the reduction of postoperative complications after pelvic exenteration. Further prospective studies are warranted to improve patient selection.

Objective: To evaluate the efficacy of topical vaginal estrogens in comparison to hyaluronic acid for the treatment of de novo dyspareunia in women using hormonal oral contraceptive (COC)., Study Design: Consecutive sexually active women using COC and complaining of de novo dyspareunia were enrolled in the study. Two attending physicians were involved in the study: the first, prescribed a 12-week vaginal estrogenic therapy with estriol 50 μg/g gel twice a week (group 1) and the second a hyaluronic acid vaginal gel therapy once a day (group 2). We evaluated dyspareunia levels using visual analogic scale (VAS) and sexual function using Female Sexual Function Index (FSFI). Vaginal atrophy was graded per the vaginal maturation index (VM)., Results: Overall, 31 women were enrolled. Seventeen and 14 patients were allocated in group 1 and 2, respectively. In both groups, after the topical therapy, dyspareunia, sexual function and VM were significantly improved. However, patients in group 1 experienced a significantly lower score of dyspareunia than patients in the group 2 (2 (1-7) vs. 4 (2-7); p=0.02). Additionally, women in the group 1 had higher FSFI (29.20 (24.60-34.50) vs. 28.10 (23.60-36.50); p=0.04) scores and VM (73.80 (±8.78) vs. 64.50 (±12.75); p=0.003) values in comparison to the patients in group 2., Conclusions: Our study showed that vaginal supplementation with estriol 50 μg/g gel or with hyaluronic acid could reduce the de novo dyspareunia related to COC. In this cluster of patients, both treatments improve sexuality. However, estriol 50 μg/g gel appears to be significantly more effective in comparison with hyaluronic acid., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Older age is a relevant risk factor for developing endometrial cancer (EC) and has been traditionally regarded as a relative contraindication to laparoscopy. Our aim was to analyze the safety and effectiveness of laparoscopic staging in older women with EC., Methods: Consecutive women aged 75 years or older who underwent laparoscopic staging for EC between May 2002 and October 2012 were compared with consecutive women aged 75 years or older who underwent abdominal staging before the adoption of the laparoscopic approach in our institution. Postoperative complications were graded according to the Accordion Severity Grading System., Results: Fifty-nine women aged 75 years or older who underwent laparoscopy were compared with a cohort of 66 women aged 75 years or older who underwent open staging before the incorporation of laparoscopy. Demographic and disease characteristics, as well as the Charlson comorbidity index, were balanced between groups. Women who underwent laparoscopy had similar operative time (P = 0.14), lower blood loss (P = 0.005), and shorter length of stay (P < 0.001) in comparison with women who underwent open surgical operation. Overall, women who underwent laparoscopy experienced less postoperative complications than women in the control group (P < 0.001). In addition, focusing only on complications grade 3 or higher, we observed a trend toward decreased complication rates in the laparoscopic group (P = 0.06). No differences in survival outcomes (including time of recurrence, site of recurrence, disease-free survival, and overall survival) were recorded (P > 0.05)., Conclusions: Our findings suggest that EC patients older than 75 years may benefit from minimally invasive surgical operation and should not be denied laparoscopy based on mere chronological age.

Objective: The aim of this study was to analyze temporal trends in adoption of laparoscopy in a cohort of older women (> or =70 y) undergoing gynecologic abdominal procedures and to assess operative outcomes compared with those of open procedures., Methods: A prospective entered database was queried for all women aged 70 years or older undergoing surgery at our department during a 9-year period. Surgical outcomes were compared according to the type of surgical approach (laparoscopy vs open) and assessed over time., Results: Two-hundred thirty-one women were identified. Of these, 116 underwent laparoscopic procedures, and 115 had open abdominal surgery. The study groups were similar with regard to demographics and preoperative variables. Conversion to laparotomy due to intervening complications occurred in one case (0.9%). Among women with early-stage gynecologic malignancies, overall and postoperative complications were lower in the laparoscopy group than in the open surgery group. Estimated blood loss and hospital stay were lower in the laparoscopy group than in the open surgery group, for both benign and malignant conditions. The annual proportion of laparoscopic cases has increased significantly during the study period from 12% in 2001 to 79.3% in 2007 (P for trend < 0.0001). No difference was found in operative time, number of lymph nodes harvested, and complication rates, when data of subsequent time periods were compared., Conclusions: Older women who undergo laparoscopy have a significantly shorter hospitalization and fewer complications compared with older women who undergo open surgery. Laparoscopy should be considered in all women in whom a gynecologic abdominal procedure is planned regardless of age.