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Objective Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. Methods Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. Results A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17–0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33–3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00–2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001). Conclusion Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Introduction: Endometrial cancer (EC) is the most common gynecological cancer in developed countries. Histological grade (G) and myometrial invasion (MI) are important risk factors, and together with the histological type and other postoperative data establish the risk of lymph node involvement and guide the adjuvant treatments. The objective of this study was to assess the validity of a preoperative stratification model that combines preoperative histological grade and MI as identified by magnetic resonance imaging (MRI) to select candidates for lymph node staging and optimize surgical planning for our patients. Material and methods: It´s an observational retrospective cohort study including 294 patients diagnosed with EC at Donostia University Hospital from January 2012 to December 2017. Preoperative endometrial biopsy, including histological type and grade, preoperative MRI was compared with the definitive histological diagnosis. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the MRI-based diagnosis were calculated. Results: After inclusion and exclusion criteria 242 cases of type I or II EC were analyzed. Our model was found to have a Se of 91.4% (95% CI 83.2-95.8) and a Sp of 90.7% (95% CI 85.2-94.3). Percentage of down staging was 6.2% (15 unnecessary lymphadenectomies) and the upstaging rate was 2.9%. The NPV of the model was very high (95.4%, 95% CI 90.9-97.8). The diagnostic odds ratio for our model was 147.95 (95% CI 52.9-410.5), with a diagnostic accuracy of 91.7% (95% 87.6-94.6). Conclusions: A preoperative strategy that includes the determination of the tumor grade based on an endometrial biopsy and an assessment of MI by MRI is of great help in pre-surgical planning for endometrial cancer surgery, allowing an extra peritoneal approach and optimizing the use of physical and human resources. MRI presents excellent discriminatory power in the detection of MI in EC, with no significant variation by pathological subtype.

Introduction/Background* The aim of this study is to present the final results of the study of dual cervical and fundal injection with ICG in endometrial cancer for sentinel lymph node detection. The hypothesis of this study is that fundal injection does not obviate the infundibulo-pelvic drainage pathway and improves the detection of the aortic sentinel lymph node, making it possible to add aortic mapping to the excellent pelvic mapping achieved by cervical injection. Methodology This is a 6-year (June 2014-December 2020) prospective, observational cohort study with 332 patients evaluated. Inclusion criteria were early endometrial cancer, and low/intermediate or high risk criteria of the ESMO/ESGO/ESTRO 2014. Sentinel lymph node (SLN) biopsy with dual cervical and fundal indocyanine green injection was performed in all cases, associating aorto-caval lymphadenectomy up to the left renal vein in intermediate and high risk cases. Result(s)* Detection rate (DR) was 94%. Pelvic DR, Bilateral Pelvic and Aortic Dr was 91.3%, 70.5% and 67.2%. The DR of all the anatomical areas (left & right pelvic & aortic) was 53.6%. Sentinel node detection improved overall detection by 3%. There were a total of 16.9% positive nodes for macrometastases or low-volume disease, 1 out of 4 isolated lymph node metastases corresponds to the aortic area. Sensitivity was 98.3% (95% CI 91-99.7), specificity 100% (95% CI 98.5-100), NPV 99.6% (95% CI 97.8-99.9) and PPV 100% (95% CI 93.8-100). Conclusion* Dual fundic and cervical injection is a feasible technique, which provides additional mapping of the aortic area and allows improved sentinel node detection rates in endometrial cancer, allowing detection of otherwise missed aortic lymph node involvement, which corresponds to a quarter of stage IIIC, and thus a greater number of cases of lymph node involvement that are not limited to the pelvic area.

Objective The aim of this study was to describe our latest results using dual cervical and fundal indocyanine green injection for detection of sentinel lymph node (SLN) in endometrial cancer. Methods A prospective observational study was conducted between 26 June 2014 and 31 December 2019 with 278 patients that underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed SLN biopsy with dual cervical and fundal indocyanine green injection. All SLNs were processed with an ultrastaging technique. A total of 128 patients also underwent total pelvic and paraaortic lymphadenectomy. Results The detection rates were as follows: 93.5 % (260/278) overall for SLNs; 90.7 % (252/278) overall for pelvic SLNs; 68.0 % (189/278) for bilateral SLNs; 66.9 % (186/278) for paraaortic SLNs, and 2.9 % (8/278) for isolated paraaortic SLNs. We found macroscopic lymph node metastasis in 26 patients (10.0 %) and microdisease in lymph nodes in another 48 patients, raising the overall rate of lymph node involvement to 16.2 %. There was one false negative (negative SLN biopsy but positive lymphadenectomy). Applying the SLN algorithm, the sensitivity of detection was 97.9 % (95 % CI 89.1–99.6), specificity 100 % (95 % CI 98.2–100), negative predictive value 99.5 % (95 % CI 97.4–99.9), and positive predictive value 100 % (95 % CI 92.4–100). Conclusions Dual sentinel node injection is a feasible technique that achieves adequate detection rates. Additionally, this technique allows a high rate of aortic detection, identifying a non-negligible percentage of isolated aortic metastases. Aortic metastases in endometrial cancer are possible and we should not give up actively looking for them.

To highlight the importance of preoperative assessment of imaging studies to rule out vascular abnormalities involving high bleeding risk in para-aortic lymphadenectomy for gynecological cancer.

Introduction/Background Approximately 10% of patients with intraoperative diagnosis of low risk Endometrial Cancer (EC) will suffer an upstage after the definitive histological evaluation of the piece of hysterectomy and bilateral adnexectomy, We aim to explore the results associated with the performance of pelvic and para-aortic lymphadenectomy as restaging these patients that will require a second surgery, and to compare those with and without Sentinel Node Biopsy (SNB) in the first procedure. Methodology Retrospective cohort study involving 27 patients diagnosed with low-risk EC (ESMO-ESGO-ESTRO criteria) with surgical restaging due to upstage in the final histological result at the Hospital Universitario Donostia from April 2013 to September 2018. Surgical and oncological results were compared between patients who underwent hysterectomy and double adnexectomy without any additional procedure (SNB-) n=17 and those who also had a pelvic and aortic SNB (SNB+) n=10.The main outcome evaluated in the study was intraoperative complications. Secondary outcomes were mean operative time, length of hospital stay, number of nodes obtained, Progression-Free Survival (PFS) and Overall Survival (OS). Results The median duration of restaging surgery was 240 minutes (Q25 - Q75: 180 – 300) in the SNB(-) group, and 300 (Q25 - Q75: 247.5 – 330) minutes in the SNB(+) group, this difference being statistically significant (one-side t-student test, p=0.0295). With regard to intraoperative complications, there were 17.65% vs 40% respectively, all of them vascular, this difference being not significant. There were no statistical differences in length of hospital stay and number of pelvic nodes obtained. PFS and OS in both groups were the same. Conclusion Women with EC who require lymph node restaging due to upstage and have previously undergone sentinel lymph node biopsy have greater surgical difficulty with longer duration of the procedure. The risk of complications is increased.We advise against performing a second re-staging surgery in patients sentinel node biopsy. Disclosures No disclosures.

Introduction/Background Sentinel node in endometrial cancer (EC) is an evolving technique to know the nodal status in a more precise way without the need to perform a complete lymphadenecotomy. The aim of this study was to describe our latest results using dual cervical and fundal indocyanine green (ICG) injection for detection of sentinel lymph node (SLN) in endometrial cancer and results of SLN biopsy. Methodology This is an observational prospective study performed between 26 June 2014 and 31 December 2019, 278 patients underwent laparoscopic surgery for endometrial cancer at Hospital Uniersitario Donostia, in Spain. In all cases, we performed SLN biopsy with dual cervical and fundal ICG injection, looking for pelvic and aortic sentinel node. All SLNs were processed with an ultrastaging technique. A total of 128 patients with Intermediate and High risk EC also underwent total pelvic and paraaortic lymphadenectomy. Results The detection rates were as follows: 93.52% (260/278) overall for SLNs; 90.65% (252/278) overall for pelvic SLNs; 67.99% (189/278) for bilateral SLNs; 66.91% (186/278) for paraaortic SLNs, and 2.88% (8/278) for isolated paraaortic SLNs. We found macroscopic lymph node metastasis in 26 patients (10.03%) and microdisease in lymph nodes in another 48 patients, raising the overall rate of lymph node involvement to 16.19%. There was one false negative (negative SLN biopsy but positive lymphadenectomy). 6.6% of all pelvic and also aortic sentinel nodes were positive for metastasis. Applying the SN algorithm, the sensitivity of detection was 97.9% (95% CI 89.1–99.6), specificity 100% (95% CI 98.2–100), negative predictive value 99.5% (95% CI 97.4–99.9), and positive predictive value 100% (95% CI 92.4–100). Conclusion Dual sentinel node injection is a feasible technique that achieves adequate detection rates. Additionally, this technique allows a high rate of aortic detection, identifying a non-negligible percentage of isolated aortic metastases. Aortic metastases in endometrial cancer are possible and it is necessary to investigate the relevance of its detection. Disclosures No disclosures.

Introduction Approximately 10 % of patients with an intra-operative diagnosis of low-risk endometrial cancer (EC) will be upstaged after a definitive histological evaluation of hysterectomy and bilateral adnexectomy samples. This study aimed to explore the results associated with the performance of pelvic and para-aortic lymphadenectomy for restaging after upstaging/upgrading these patients, and to compare those who underwent sentinel lymph node biopsy (SNB) in the first procedure with those who did not. Materials and methods This retrospective cohort study included 27 patients diagnosed with low-risk EC (based on the criteria of the European Society of Medical Oncology/European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology), who underwent surgical laparoscopic restaging due to upstaging based on the final histological result at Hospital Universitario Donostia from April 2013 to September 2018. Surgical and oncological results were compared between patients who underwent hysterectomy and double adnexectomy without any additional procedures (SNB-; n = 17) and patients who also underwent pelvica n = 10). The main outcome evaluated in the study was intra-operative complications. Secondary outcomes were mean operative time, length of hospital stay, number of nodes obtained, progression-free survival (PFS) and overall survival (OS). Results The median duration of restaging surgery was 240 [interquartile range (IQR) 180–300) min in the SNB(−) group and 300 (IQR 247.5–330) min in the SNB(+) group; this difference was significant (one-sided Student’s t-test, p = 0.0295). With regard to intra-operative complications, there were 17.65 % and 40 % in the SNB(−) and SNB(+) groups, respectively, all of which were vascular; this difference was not significant. There were no significant difference in the length of hospital stay, number of pelvic nodes obtained, PFS or OS between the groups. Conclusion Women with EC who require lymph node restaging due to upstaging, and have previously undergone SNB, experience more surgical complications and a longer operative time. The authors advise against performing second restaging surgery in these patients.

PurposeThe aim of this study was describe a novel sentinel lymph node (SLN) tracer injection procedure featuring dual cervical and fundal indocyanine green (ICG) injection for endometrial cancer and results of SLN biopsy.MethodsBetween June 26, 2014 and October 31, 2016, 111 patients underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed SLN biopsy with dual cervical and fundal ICG injection. All SLNs were processed with an ultrastaging technique. A total of 69 patients also underwent total pelvic and paraaortic lymphadenectomy.ResultsThe detection rates were as follows: 92.79% (103/111) overall for SLNs; 89.19% (99/111) overall for pelvic SLNs; 61.26% (68/111) for bilateral SLNs; 59.46% (66/111) for paraaortic SLNs, and 4% (4/111) for isolated paraaortic SLNs. We found macroscopic lymph node metastasis in 11 patients (9.9%) and microdisease in lymph nodes in another 10 patients, raising the overall rate of lymph node involvement to 18.92%. There was 1 false-negative (negative SLN biopsy but positive aortic lymphadenectomy) and another positive case in 1 undetected SLN. The sensitivity of detection was 94.44%, specificity 100%, negative predictive value 97.83%, and negative likelihood ratio 0.06 for intermediate and high-risk endometrial cancer groups.ConclusionsThe SLN biopsy with both cervical and fundal ICG injection offers good overall detection rates and improved mapping of the aortic area. The SLN ultrastaging increases the number of nodes considered positive.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer FREE http://orcid.org/0000-0002-1908-3251Luis Chiva1, Vanna Zanagnolo2, Denis Querleu3, Nerea Martin- Calvo4, Juan Arévalo-Serrano5, Mihai Emil Căpîlna6, Anna Fagotti7, Ali Kucukmetin8, Constantijne Mom9, Galina Chakalova10, Shamistan Aliyev11, Mario Malzoni12, http://orcid.org/0000- 0001-5809-3535Fabrice Narducci13, Octavio Arencibia14, Francesco Raspagliesi15, Tayfun Toptas16, David Cibula17, Dilyara Kaidarova18, http://orcid.org/0000-0001-6763-9720Mehmet Mutlu Meydanli19, Mariana Tavares20, Dmytro Golub21, http://orcid.org/0000-0003-3140-4772Anna Myriam Perrone22, Robert Poka23, Dimitrios Tsolakidis24, Goran Vujić25, http://orcid.org/0000-0001-8935- 0311Marcin A Jedryka26, Petra L M Zusterzeel27, Jogchum Jan Beltman28, Frederic Goffin29, Dimitrios Haidopoulos30, Herman Haller31, Robert Jach32, Iryna Yezhova33, Igor Berlev34, Margarida Bernardino35, Rasiah Bharathan36, Maximilian Lanner37, Minna M Maenpaa38, http://orcid.org/0000-0002-4403-3707Vladyslav Sukhin39, Jean-Guillaume Feron40, Robert Fruscio41, 42, Kersti Kukk43, Jordi Ponce44, Jose Angel Minguez45, http://orcid.org/0000-0002-9618- 5606Daniel Vázquez-Vicente45, Teresa Castellanos45, Enrique Chacon46 and http://orcid.org/0000-0002-9700-0853Juan Luis Alcazar47 On behalf of the SUCCOR study Group Author affiliations Abstract Background Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse. Methods We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group. Results Mean age was 48.3 years (range ; 23–83) while the mean BMI was 25.7 kg/m2 (range ; 15–49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07 ; 95% CI, 1.35 to 3.15 ; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45 ; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76 ; 95% CI, 1.75 to 4.33 ; P

Introduction/Background Sentinel lymph node biopsy (SLNB) in endometrial cancer is not standardized yet. Multiple studies have been published using different tracers and injection sites. Most autors prefer cervix injection because of its simplicity, reproducibility and high detection rate, despite detecting few sentinel lymph nodes (GC) in the aortic area. We present our data on location of GCs injecting the green indocyanine tracer (ICG) into both the cervix and uterine fundus in order to increase the detection of GC in the aortic area. Methodology We included 207 patients intervened from 2014 to 2018. We injected 2 ml of ICG into the uterine fundus through the cervix and another 4 ml in the cervix, 2 ml at 9 o’clock and 2 ml at 3 o´clock. Then we locate and selectively biopsy the GC, first in the aortic area, after in the pelvic area. We established 10 aortic zones (laterocavo, precavo, interaortocavo, preaortic and lateroaortic, at supramesenteric and inframesenteric zones) and 11 pelvic zones (common iliac, external iliac, interiac, obturator, and pararectal at right and left hemipelvis and also presacral zone). We consider as positive GC macrometastases, micrometastases or isolated tumor cells. Results We found 822 GC, 525 pelvic (64%) and 297 aortic (36%). Detection rate was 89.9%, 65.7% and 64.3% for unilateral pelvic, bilateral pelvic and aortic respectively. Of the 60 positive GC, 38 were pelvic and 22 aortic. 7.3% of GC were positive, similar in both areas (7.24% and 7.4%). Conclusion We found less GC in the aortic than pelvic area, even injecting the tracer also in the uterine fundus. However, the percentage of positive GCs in both areas was similar. These data reaffirm the importance of studying the aortic area when performing BGC in endometrial cancer and also injecting the tracer in the uterine fundus to obtain significant detection rates. Disclosure Nothing to disclose.

Introduction/Background Lymph node involvement is the most important prognostic factor in endometrial cancer. Identifying predictive factors of involvement prior to surgery would help us to plan the surgery and even avoid lymphadenectomy in low risk patients. The aim of this study is to analyze the pre- and post-surgery correlation of these predictive factors and their association with lymph node involvement. Methodology Prospective cohort study including 207 patients with endometrial cancer at Donostia University Hospital (June 2014 - December 2018). Inclusion criteria was indication for primary surgery. Pre-surgery variables to study were histology (Endometroid subtype defined as type I and the rest as type II) and tumor grade (G1, G2 and G3) determined in preoperative endometrial biopsy, size and myometrial infiltration (MI) Results The correlation was very high for the size (rho 0.98) (figure 1), high for the IM (rho 0.66) and the G (rho 0.66). The last one, became very high eliminating the G2 (rho 0.85). For histology, the correlation was moderate (rho 0.54). All factors were associated with lymph node involvement (table 2). Best predictive model was constructed by a multivariate regression combining the LVSI (OR 2.4 CI 95% 1.0– 5.6), ≥50% myometrial infiltration (OR 6.0 CI 95% 2.5–14.3) and type II histology (OR 3.5 CI 95% 1.2–9.9). Finally, we assessed the diagnostic output of tumor size for lymph node involvement using the ROC curve and its area under the curve was 0.68. (Figure 2). Conclusion Studied predictive factors have good pre- and post-surgery correlation. All are associated with lymph node involvement. The best model to predict lymph node involvement is the one that includes MI, histology and LVSI. Disclosure Nothing to disclose.

Introduction/Background We describe the cases of recurrence in endometrial carcinoma with sentinel lymph node biopsy (SLNB) study and analyze possible factors associated with recurrence. Methodology Retrospective cohort study of patients with recurrent endometrial carcinoma in whom SLNB was performed between 2012-2018. Hysterectomy, double adnexectomy and SLNB were performed by laparoscopy in stages IA G1-G2; while in stages IA G3 and above, we added pelvic and para-aortic lymphadenectomy. Factors that may associate with recurrence were analyzed: high tumor grade (G3), lymphovascular space invasion (LVSI), myometrial infiltration (MI) >50% and positive SLNB. Kaplan-Meier curves, long-rank test and Cox regression were used for statistical analysis. Results We followed 159 patients. Recurrence rate was 7.5%. Mean age was 68.4 years (SD=10.5), BMI 29.4 (SD=4.9) and tumor size 41.2 mm (SD=15.2). Of the 12 recurrences, 6 were serous (50%), 4 endometrioid (33.3%) and 2 clear cell subtype (16.7%). 9 were G3 (75%), in 4 patients (33.3%) MI was >50% and 5 (41.7%) had LVSI. 3 (25%) and 2 (16.7%) patients had positive pelvic and aortic SLNB respectively. In terms of location of the recurrence, 7 (58.3%) were vaginal and 2 (16.6%) abdominal. The rest were peritoneal, pulmonary and hepatic. The mean number of months until recurrence was 12.6 (SD=9.6) and the median was of 9 months [95% CI; 7.3-10.7]. 83% relapsed within the first year of postoperative follow-up (SD=0.11)and none recurred after 2 years. No association was found between lower survival and none of the prognostic factors marked. Conclusion Recurrence rate of endometrial cancer intervened in SLNB study was 7.5%, being mostly serous adenocarcinoma or G3. 83% recurred within the first year of postoperative control. No association was found between lower survival and none of the possible factors indicated. Disclosure Nothing to disclose.

Study objective To describe our technique for excision of the pre-caval and laterocaval nodes using an extraperitoneal approach. This technique was developed to make the dissection and excision of the less accessible nodes in an easier and safer way by minimizing the risk of great vessels injury and bleeding. Design Step-by-step description of the surgical procedure using video (Canadian Task Force classification III). Setting The procedure was performed at a teaching hospital, Hospital Universitario Donostia (Spain). Patients A 52-year-old woman with a body mass index of 33 underwent endoscopic extraperitoneal paraaortic lymphadenectomy for advanced high grade cervical adenocarcinoma FIGO IIB. Interventions The patient underwent an endoscopic extraperitoneal para-aortic lymphadenectomy. An anatomical dissection is being performed being the upper limit of the dissection the left renal vein. Focus of the video involves the challenging dissection of the right nodes. Measurements and main results Firstly we complete a dissection of all the anatomical aortic limits until the renal vein and exeresis of aortic nodes. A plane just above the cava vein is carefully developed by pushing all the lymph nodes to the roof of the dissection. Special care must be taken close to the aortic bifurcation due to the perforating vessels that can be found more frequently in this location. Once all this space is dissected, nodes attached to the roof are easily pushed down. It is useful to use a clip in the upper part, close to the renal vein, to prevent lymphorrhea. Nodes are excised in four blocks, supramesenteric and inframesenteric aortic and precaval nodes. The proximity to the peritoneal roof and the chance for a peritoneal hole and loss of pneumoperitoneum can be less problematic if the right dissection is performed at the end of the procedure. Conclusion A complete para-aortic retroperitoneal dissection can be achieved with this extraperitoneal approach. Benefits of this technique are based on the absence of the bowel or other intraperitoneal structures invading the operative field given the barrier-free nature of the retroperitoneal space. Despite the challenge of the access to the right nodes in a retroperitoneal paraaortic lymphadenectomy they can be successfully excised reaching the renal vein including obese patients.

Study Objective To determine the importance of a dual (cervical and fundal) indocyanine green (ICG) injection and thorough dissection for the detection of sentinel lymph nodes (SLNs). Design Description and step-by-step demonstration of the surgical procedure using video (Canadian Task Force classification III). Setting Hospital Universitario Donostia, San Sebastian, Spain. Patients A 60-year-old woman with a diagnosis of IAG1 endometrial adenocarcinoma (EC). Interventions The patient received a cervical and transcervical fundal ICG injection for para-aortic and pelvic SLN detection in the setting of a research protocol, followed by a total hysterectomy and bilateral salpingo-oophorectomy with a frozen section of the uterus as a standard approach [1] . Institutional Review Board approval was obtained for the research protocol of this study. Measurements and Main Results Dual ICG injection [2] adds the benefit of a cervical injection (that best evaluates the pelvic region [3] ) to the fundal injection, with better spread to the lumboaortic pathway [4] so as not to lose the aortic drainage and aortic SLN, whose relevance is still discussed due to its low incidence of metastasis [5] . This search does not add to the associated morbidity but is associated with increased operative time. For pelvic SLN dissection, patience and good training are key; the surgeon must always be on the lookout for uncommon pathways if no SLN is detected in the classical areas. The final histological classification was upgraded to a grade IIIC2 (ie, micrometastasis in the aortic and pelvic-right pararectal space) EC, 3 cm G1 with no lymphovascular invasion. Conclusion Dual ICG injection allows comprehensive mapping not only of pelvic SLNs, but also of para-aortic SLNs, in EC, maximizing the identification of all possible affected areas. Nonetheless, the relevance of its added benefit requires further evaluation.

ResumenObjetivoEvaluar el impacto de una intervención multifactorial para promover la desprescripción de tratamientos con bisfosfonatos de duración superior a 5 años (BF5a) en la Comarca Gipuzkoa y compararlo con la intervención estándar en el resto de las organizaciones de servicios (OS) de Osakidetza.MétodosEstudio de evaluación del impacto de dos intervenciones con medida de resultados antes y después, con un seguimiento de 8 meses. Se incluyeron todos los pacientes de Osakidetza que en julio de 2013 tenían un tratamiento activo con BF5a (prescripción electrónica). La intervención estándar (9 OS) consistió en el envío de un documento de consenso sobre desprescripción de BF5a y en facilitar los identificadores de pacientes con BF5a para su revisión por el médico de atención primaria. La intervención multifactorial (Comarca Gipuzkoa) incluyó, además, un consenso local con los especialistas de referencia y sesiones de formación en los centros de salud.ResultadosSe incluyeron 18.725 pacientes, el 94,7% mujeres. Con la intervención estándar, los porcentajes de desprescripción oscilaron entre el 26,4% (C. Bilbao) y el 49,4% (C. Araba), siendo del 37,2% en su conjunto. Con la intervención multifactorial la desprescripción fue del 44,6%, un 7,4% superior a la estándar (p

To evaluate the impact of a multifactorial intervention to promote bisphosphonate deprescription after over 5 years of use (BF5y) in a health care organisation (HCO) in Gipuzkoa (Spain) and to compare it with the standard intervention in other HCOs in the Basque Health Service-Osakidetza.An 8-month follow-up study (results from before and after) to assess the impact of two interventions. All patients from Osakidetza receiving BF5y treatment (electronic prescription) in July 2013 were included. The standard intervention (9 HCOs) consisted of mailing a consensus statement on BF5y deprescribing and facilitating patient identifiers with BF5y prescription for review by the primary care physician. The multifactorial intervention (Gipuzkoa) also included a local consensus with leading specialists and training sessions in health centres.18,725 patients were included; 94.7% were women. Standard intervention deprescribing rates ranged from 26.4% (Bilbao) to 49.4% (Araba), being 37.2% overall. The multifactorial intervention deprescribing rate was 44.6%, 7.4% (p0.0001; 95% confidence interval [95%CI]: 5.4-9.4) higher than standard intervention. Changes to other treatments were less common with the multifactorial intervention, with a difference of 3.7% (p0.0001; 95%CI: -2.2 to -5.2).Standard and multifactorial interventions are very effective in reducing unnecessary treatments with bisphosphonates. The multifactorial intervention is more effective than the standard one, although more complex to implement.

The cornerstone of treatment for advanced cervical cancer is chemotherapy and concomitant radiotherapy, extending the radiation field to the paraaortic area if affected nodes are present in the upper abdomen. The sensitivity of available imaging techniques, including Positron Emission Tomography (PET), is low, with an inadmissible false negative rate. Surgical staging is the best way to assess nodal status. Moreover there are some reports that suggest therapeutic benefit of paraaortic lymphadenectomy in cervical cancer. The uncertainty regarding survival impact of pre-treatment para-aortic lymph node assessment results in different treatment alternatives, in many cases depending on locally available resources or surgeonstraining in advanced laparoscopic procedures. As far as better sensitivity is achieved, a paraaortic lymphadenectomy should be offered preferably via retroperitoneal route until renal vein by MIS (either laparoscopy or robotics) whenever available.