Gynecologic Oncology Research Articles

Universal screening for Lynch syndrome in endometrial cancer diagnoses in Auckland, New Zealand: The initial experience.

Universal mismatch repair immunohistochemistry (MMR IHC) tumour testing in endometrial cancer (EC) for Lynch syndrome (LS) was introduced in Auckland, New Zealand, in January 2017. Identifying patients with LS allows them and their families to access risk reduction strategies. Universal MMR IHC testing aids in the molecular classification of EC and has prognostic and therapeutic implications. We aimed to determine the incidence of LS in women with EC in Auckland, New Zealand, following the introduction of MMR testing and the impact of universal screening on local genetic services. This is a retrospective clinicopathological evaluation of women with a new EC diagnosis referred to the Auckland Gynaecological Oncology Unit from 1/1/17 to 31/12/18. Patient data were extracted from the Gynaecological Oncology Unit database and electronic records, and analysed using descriptive statistics. During the study period, 409 patients were diagnosed with EC, with an over-representation of Pacific Islanders (32.5%). Of these, 82.6% underwent MMR IHC testing, 20% were MMR-deficient (MMRd), and 71% had somatic hypermethylation. The Pacific Islander population had a 64% (odds ratio 0.36, P = 0.005) reduction in the odds of having MMRd tumours compared with Europeans. Of the patients who underwent MMR IHC testing, 5.5% were referred to a genetic clinic for germline testing. LS was confirmed in eight patients (2.3%). LS was diagnosed in 2.3% of patients. There was an over-representation of Pacific Islanders in the EC group but not among those diagnosed with LS.

Role of artificial intelligence applied to ultrasound in gynecology oncology: A systematic review.

The aim of this paper was to explore the role of artificial intelligence (AI) applied to ultrasound imaging in gynecology oncology. Web of Science, PubMed, and Scopus databases were searched. All studies were imported to RAYYAN QCRI software. The overall quality of the included studies was assessed using QUADAS-AI tool. Fifty studies were included, of these 37/50 (74.0%) on ovarian masses or ovarian cancer, 5/50 (10.0%) on endometrial cancer, 5/50 (10.0%) on cervical cancer, and 3/50 (6.0%) on other malignancies. Most studies were at high risk of bias for subject selection (i.e., sample size, source, or scanner model were not specified; data were not derived from open-source datasets; imaging preprocessing was not performed) and index test (AI models was not externally validated) and at low risk of bias for reference standard (i.e., the reference standard correctly classified the target condition) and workflow (i.e., the time between index test and reference standard was reasonable). Most studies presented machine learning models (33/50, 66.0%) for the diagnosis and histopathological correlation of ovarian masses, while others focused on automatic segmentation, reproducibility of radiomics features, improvement of image quality, prediction of therapy resistance, progression-free survival, and genetic mutation. The current evidence supports the role of AI as a complementary clinical and research tool in diagnosis, patient stratification, and prediction of histopathological correlation in gynecological malignancies. For example, the high performance of AI models to discriminate between benign and malignant ovarian masses or to predict their specific histology can improve the diagnostic accuracy of imaging methods.

Does HPV-18 co-infection increase the risk of cervical pathology in individuals with HPV-16?

We aimed to investigate differences between HPV-16 mono- and HPV-16/18 co-infections in terms of cervical dysplasia and invasive cancer. This multicentre, retrospective study spanned from December 2017 to December 2020, involving women who visited gynaecological oncology clinics for colposcopy with either HPV-16 or HPV-16/18 positivity. A total of 736 patients, 670 in Group 1 (HPV-16 positivity) and 66 in Group 2 (HPV-16/18 positivity), were compared for the presence of CIN2+ lesions detected by colposcopic biopsy or endocervical curettage (ECC). Exclusions included hysterectomized patients, those with prior gynaecological cancers, and patients with HPV positivity other than types 16 and 18. Among the included patients, 42.4% had a diagnosis of CIN2+ lesions. The cytology results demonstrated abnormal findings in 45.3% in Group 1 and 42.2% in Group 2, with no significant difference between the groups. ECC revealed CIN2+ lesion in 49 (8.7%) patients in group 1, while only 1 (1.7%) patient had CIN2+ lesion in group 2. There was no difference between 2 groups in terms of ECC result (p = 0.052). In group 1, 289 (43.1%) patients had CIN2+ lesion, while 23 (34.8%) patients had CIN2+ lesions in group 2. There was no difference between group 1 and 2 in terms of diagnosis of CIN2+ lesions (p = 0.19). This multicentre retrospective study found no significant differences between HPV-16 mono- and HPV-16/18 co-infections regarding cervical pathologies. Larger studies are needed to validate and further explore these findings.

Robotic Surgery in Gynecologic Oncology—A Bibliometric Study

Study ObjectiveTo characterize robotic surgery publications in gynecologic oncology, and to identify factors associated with high citation metrics. DesignA cross-sectional study SettingOriginal articles on robotic surgery in gynecologic oncology. PatientsNo patients involved. InterventionsRobotic surgeries in gynecologic oncology. Measurements and Main ResultsWe performed PubMed Medical Subject Headings search for original articles on robotic surgery in gynecologic oncology. We analyzed citation scores and income level of country of publication, as well as factors associated with high citation metrics. Overall, 566 studies during 2005 to 2023 were included. Of those 292, 51.6% were from North America, and 182 32.2% from Europe. The leading tumor site studied was endometrial cancer (57.4%). The majority (87.6%) of studies were retrospective and 13 (2.3%) were randomized controlled trials. Most studies (94.2%) originated in high-income countries. Articles from middle-income countries had lower citations per year as compared to high-income countries (median 1.6 vs 2.5, p =.002) and were published in lower-impact factor journals (median 2.6 vs 4.3, p < .001) when compared with high-income countries. Cervical cancer studies had higher representation in middle-income countries than in high-income countries (48.5% vs 18.4%, p < .001). In a multivariable regression analysis, journal's impact factor [aOR 95% CI 1.26 (1.12–1.40)], cervical cancer topic [aOR 95% CI 3.0 (1.58–5.91)], and North American publications [aOR 95% CI 2.07 (1.08–3.97)] were independently associated with higher number of citations per year. ConclusionThe majority of robotic surgery research in gynecologic oncology is retrospective and from high-income countries. Middle-income countries are not as frequently cited and are predominantly in lower-impact factor journals.

#HashtagThis – Everything you need to know about launching your gynecologic oncology social media research career: A report from Gynecologic Oncology Reports and Society of Gynecologic Oncology Education Committee

On February 6th, 2024, Gynecologic Oncology Reports and the Society of Gynecologic Oncology Education Committee co-hosted a webinar about ways to use social media for career enhancement and for dissemination of research. During the discussion, we reviewed:i.how to identify one’s goals, target audience, and select a social media platform.ii.how to navigate the negatives of social media.iii.how to develop one’s online academic brand.iv.how to use social media for academic promotion and career advancement.v.how to use social media as a research tool.vi.how to use visual tools to bring attention to one’s research.The objective of this report is to review the literature on social media in oncology and review the webinar presentation.

Assessing The Safety of Laparoscopic Surgery in Treating of Adenocarcinoma Endometrial Cancer

In recent years, there has been a growing preference for laparoscopic surgery. Insufficient data exists on the safety of laparoscopy in endometrial cancer. The objective of this study was to assess and compare the perioperative and oncologic results of laparoscopic and laparotomic. staging surgery in patients diagnosed with adenocarcinoma endometrial cancer. The study aimed to evaluate the safety and effectiveness of laparoscopic surgery in this specific patient group. A retrospective analysis was conducted on the data of 250 patients who had surgical staging for adenocarcinoma endometrial cancer at the gynecologic oncology department of a government hospital from 2018 to 2023. A comparison was made between the laparoscopy and laparotomy groups in terms of demographic, histopathologic, perioperative, and oncologic parameters. An additional assessment was conducted on a subset of individuals who had a body mass index greater than 30. The demographic and histopathologic parameters of the two groups were comparable, however laparoscopic surgery demonstrated a much higher level of effectiveness in terms of perioperative outcomes. The laparotomy group had a much greater number of excised and metastatic lymph nodes. However, this difference did not have an impact on the oncologic outcomes, such as recurrence and survival rates. Both groups had similar results in this regard. The results of the subgroup with a BMI more than 30 were consistent with those of the entire population. The intraoperative problems encountered during the laparoscopic procedure were effectively resolved. Laparoscopic surgery is considered superior to laparotomy and, depending on the surgeon's expertise, it can be safely used for surgical staging of adenocarcinoma endometrial cancer.

Complex obstetrical surgery: building a team and defining roles

As the number of placenta accreta spectrum (PAS) cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetricians-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries (CD) and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process whereby key personnel within departments of obstetrics and gynecology are identified, and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the CD complexity level can be matched to specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is twofold: first, to return cases with higher levels of surgical complexity back to obstetricians, and second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.

P-742 In-vitro fertilization outcomes after laparoscopic repair of cesarean scar defect

Abstract Study question Does laparoscopic repair of cesarean scar defect improve in-vitro fertilization (IVF) outcomes? Summary answer Laparoscopic (LSC) repair of cesarean scar defect (CSD) should selectively indicated to patients experiencing repetitive pregnancy failure or having an increased depth of niche What is known already Cesarean section (CS) rate has markedly from 7% in 1990 to an estimated 29% of all births by 2030. CSD, also known as isthmocele or uterine niche, has emerged as a cause of secondary infertility, frequently encountered with recurrent implantation failures and cycle cancellations because of the endometrial fluid collection both in endometrium and uterine lower segment of cesarean scar. Study design, size, duration This is a retrospective study encompassing total of 62 patients. With 50 patients undergoing expectant management, 12 undergoing LSC repair of CSD at a single IVF center from 2019 to 2023. Primary outcomes included the clinical pregnancy rate and time to pregnancy, while secondary outcomes were the depth of CSD and residual myometrial thickness. Of the 72 patients, 68 patients underwent frozen embryo transfer. Participants/materials, setting, methods Patients with secondary infertility who had experienced more than two instances of implantation failure or cycle cancellation due to endometrial fluid collection were included. Laparoscopic repair of CSD was performed by a single gynecologic oncologist in accordance with the physician’s preference and patient consent. For patients in expectant management, diagnostic hysteroscopy and endometrial fluid suction were conducted prior to embryo transfer. Main results and the role of chance The age, BMI, gravidity, parity, or the number of previous cesarean section showed no statistical differences between the expectant management and the LSC repair group. The uterine position, either anteflexion was similar across groups. (all p value &amp;gt;0.05). Both the clinical pregnancy rate and live birth rate did not significantly differ between the expectant management group and the LSC repair group (26.0% vs 50.0%, p = 0.149, and 32.0% vs 60.0%, p = 0.149, respectively). The mean time to pregnancy was 7.38 months in the expectant management group and 9.80 months in LSC repair group, showed no significant difference (p = 0.240). Correlation analysis revealed a significantly moderate correlation between the initial depth of CSD and the depth of CSD at embryo transfer with clinical pregnancy (r = -0.424, P = 0.001). Furthermore, our data indicated that the CSD depth at embryo transfer was significantly impacted on clinical pregnancy outcomes from the multivariate regression logistic analysis (OR = 0.522, 95% CI [0.332 – 0.823]). Limitations, reasons for caution This study is retrospectively designed and including small sample size, caution is required in interpreting the findings. Wider implications of the findings This study suggests that the depth of niche influences clinical pregnancy outcomes. Laparoscopic repair may offer a viable treatment option who have experienced multiple failed cycles and increased depth of niche. Future studies with larger population studies may further indicate the LSC repair based on the depth of CSD. Trial registration number not applicable

Use of social media for academic and professional purposes by gynecologic oncologists

ObjectiveTo investigate the prevalence and patterns of social media use among gynecologic oncologists for professional and academic purposes.MethodsA prospective online survey between November and December 2022 targeted gynecologic oncology practitioners...

Effects of patient-based self-assessed fatigue intervention on early postoperative ambulation following gynaecological oncology surgery: a randomised controlled non-inferiority trial

ObjectivesTo assess the impact of a patient-based self-assessed fatigue intervention aimed at promoting early postoperative ambulation.DesignProspective randomised controlled trial.SettingSingle-centre, conducted at the Obstetrics and Gynaecology Department of the Xiangyang Central...

Clinicopathological Characteristics of Multiple Primary Malignancies Involving Female Genital Tract at a Tertiary Cancer Institute of Northeast India

ABSTRACT Background: The term “Multiple Primary Malignant Neoplasms (MPMNs)” refers to two or more unrelated primary malignant neoplasms that originate from single or different organs and occur in one patient. MPMNs have been divided into synchronous and metachronous based on time duration after first malignancy. Materials and Methods: This was a hospital-based retrospective study conducted at a tertiary cancer institute in Northeast India. Clinicopathological factors of patients with multiple primary malignancies with at least one female genital tract malignancy attending the gynecological oncology outpatient department were observed. Those with ambiguous status of primary malignancy and incomplete treatment of first primary malignancy were excluded from the study. Results: A total of 57 patients with MPMN, including one case of triple primary malignancy, were included in the study. 59.18% of cases had metachronous, and 40.81% had synchronous malignancies. The median time to the development of second primary malignancy was 60 months. Among the first diagnosed malignancies, cervix was the most common site (26.5%), followed by endometrium (20.4%) and ovary (14.28%), whereas ovarian malignancy was more commonly diagnosed second malignancy (38.77%), followed by endometrium (14.28%) and cervix (10.2%). In an analysis of synchronous malignancies, the most common genital tract involvement was seen with endometrium and ovary, with a predominance of low-grade endometrioid histology in 75% of cases. Conclusions: As the cancer survivor population continues to increase in future, these patients must be comprehensively evaluated on follow-up, and a cognizance of prior treatment taken should be kept. In addition, it is vital that the clinicians keep a lookout for high-risk population in which genetic testing may be beneficial.

Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study.

The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups. This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection. A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups. Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.

Prediction of nonresectability using the updated Predictive Index value model assessed by imaging and surgery in tubo-ovarian cancer: a prospective multicenter ISAAC study

BackgroundA laparoscopy-based scoring system was developed by Fagotti et al (Fagotti or Predictive Index Value (PIV)score) based on the intraoperative presence or absence of carcinomatosis on predefined sites. Later, the authors updated the PIV score calculated only in the absence of one or both absolute criteria of non-resectability (mesenteric retraction and miliary carcinomatosis of the small bowel) (updated PIV model). ObjectiveThe aim was to demonstrate the non-inferiority of ultrasound to other imaging methods (contrast enhanced computed tomography (CT) and whole-body diffusion-weighted (WB DWI)/MRI) in predicting non-resectable tumor (defined as residual disease>1 cm) using the updated PIV model in patients with tubo-ovarian cancer. The agreement between imaging and intraoperative findings as a reference was also calculated. Study designThis was a European prospective multicenter observational study. We included patients with suspected tubo-ovarian carcinoma who underwent preoperative staging and prediction of non-resectability at ultrasound, CT, WB-DWI/MRI and surgical exploration. The predictors of non-resectability were suspicious mesenteric retraction and/or miliary carcinomatosis of the small bowel or if absent, a PIV>8 (updated PIV model). The PIV score ranges from 0 to 12 according to the presence of disease in six predefined intra-abdominal sites (great omentum, liver surface, lesser omentum/stomach/spleen, parietal peritoneum, diaphragms, bowel serosa/mesentery). The reference standard was surgical outcome, in terms of residual disease>1 cm, assessed by laparoscopy and/or laparotomy. The area under the receiver operating characteristic curve (AUC) to assess the performance of the methods in predicting non-resectability was reported. Concordance between index tests at detection of disease at six predefined sites and intraoperative exploration as reference standard was also calculated using Cohen’s kappa. ResultsThe study was between 2018 and 2022 in five European gynecological oncology centers. Data from 242 patients having both mandatory index tests (ultrasound and CT) were analyzed. 145/242 (59.9%) patients had no macroscopic residual tumor after surgery (R0) (5/145 laparoscopy and 140/145 laparotomy) and 17/242 (7.0%) had residual tumor ≤1cm (R1) (laparotomy). In 80/242 patients (33.1%), the residual tumor was >1 cm (R2), 30 of them underwent laparotomy and maximum surgery was carried out and 50/80 underwent laparoscopy and cytoreduction was not feasible in all of them.After excluding 18/242 (7.4%) patients operated on but not eligible for extensive surgery, the predictive performance of three imaging methods was analyzed in 167 women. The AUCs of all methods in discriminating between resectable and non-resectable tumor was 0.80 for ultrasound, 0.76 for CT, 0.71 for WB-DWI/MRI and 0.90 for surgical exploration. Ultrasound had the highest agreement (Cohen’s kappa ranging from 0.59 to 0.79) compared to CT and WB-DWI/MRI to assess all parameters included in the updated PIV model. ConclusionsUltrasound showed non-inferiority to CT and to WB-DWI/MRI in discriminating between resectable and non-resectable tumor using the updated PIV model. Ultrasound had the best agreement between imaging and intraoperative findings in the assessment of parameters included in the updated PIV model. Ultrasound is an acceptable method to assess abdominal disease and predict non-resectability in patients with tubo-ovarian cancer in the hands of specially trained ultrasound examiners.

Clinician- and Patient-Directed Communication Strategies for Patients With Cancer at High Mortality Risk

Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur infrequently for patients with cancer. Behavioral economic implementation strategies (nudges) directed at clinicians and/or patients may increase SIC completion. To test the independent and combined effects of clinician and patient nudges on SIC completion. A 2 × 2 factorial, cluster randomized trial was conducted from September 7, 2021, to March 11, 2022, at oncology clinics across 4 hospitals and 6 community sites within a large academic health system in Pennsylvania and New Jersey among 163 medical and gynecologic oncology clinicians and 4450 patients with cancer at high risk of mortality (≥10% risk of 180-day mortality). Clinician clusters and patients were independently randomized to receive usual care vs nudges, resulting in 4 arms: (1) active control, operating for 2 years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk; (2) clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates; (3) patient nudge only, consisting of active control plus a preclinic electronic communication designed to prime patients for SICs; and (4) combined clinician and patient nudges. The primary outcome was a documented SIC in the electronic health record within 6 months of a participant's first clinic visit after randomization. Analysis was performed on an intent-to-treat basis at the patient level. The study accrued 4450 patients (median age, 67 years [IQR, 59-75 years]; 2352 women [52.9%]) seen by 163 clinicians, randomized to active control (n = 1004), clinician nudge (n = 1179), patient nudge (n = 997), or combined nudges (n = 1270). Overall patient-level rates of 6-month SIC completion were 11.2% for the active control arm (112 of 1004), 11.5% for the clinician nudge arm (136 of 1179), 11.5% for the patient nudge arm (115 of 997), and 14.1% for the combined nudge arm (179 of 1270). Compared with active control, the combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55 [95% CI, 1.00-2.40]; P = .049), whereas the clinician nudge (HR, 0.95 [95% CI, 0.64-1.41; P = .79) and patient nudge (HR, 0.99 [95% CI, 0.73-1.33]; P = .93) were not. In this cluster randomized trial, nudges combining clinician peer comparisons with patient priming questionnaires were associated with a marginal increase in documented SICs compared with an active control. Combining clinician- and patient-directed nudges may help to promote SICs in routine cancer care. ClinicalTrials.gov Identifier: NCT04867850.

Patient reported opioid usage following vulvar surgery in gynecologic oncology

BackgroundThere remains a paucity of data for vulvar surgery outcomes in gynecologic oncology in the era of Enhanced Recovery After Surgery (ERAS) ®. As such, the primary objective is to assess the impact of patient and procedural factors on patient reported postoperative opioid usage following vulvar surgery. Secondary objective is to create a tailored opioid prescribing algorithm for this population. MethodsA retrospective cohort study was performed of patients who underwent vulvar surgery for a gynecologic malignancy between 3/2019–7/2022. Covariates of interest included a history of risk factors for opioid usage, age, anatomic location of the vulvar resection, radicality of surgery, groin dissection, use of postoperative non-steroidal anti-inflammatory drugs (NSAIDs), and complications. Logistic regression models evaluated the effects that sociodemographic characteristics and procedural factors have on opioid usage. Linear regression models were created to determine prescribing guidelines. ResultsA total of 100 patients were included. Following surgery, 35 patients (35 %) were not sent home with an opioid prescription, 39 patients (39 %) reported using at least one opioid pill from their prescription, and 26 patients (26 %) reported not using any opioid pills from their prescription. In the regression models, patient age (p < 0.006) had a significant impact on opioid use, while all other factors did not. Contraindications to NSAIDs did not have a statistically significant impact (p = 0.1) but was deemed clinically meaningful and included in the final model. Proposed opioid prescribing guidelines were created. ConclusionIn conclusion, most patients after vulvar surgery require little to no opioids. Identifiable preoperative factors can aid providers to manage postoperative pain while minimizing unnecessary opioid prescriptions.

Timeliness and Completeness of Endometrial Cancer Pathology Reports Before and After the FIGO 2023 Endometrial Cancer Staging Guidelines Update

Introduction: Uterine cancer is the most common gynecologic malignancy among women in the United States with an estimated 66,200 new cases and 13,030 deaths in 2023.1 These cancers are divided into endometrial adenocarcinomas (EAC) and uterine sarcomas. In 2013, the Cancer Genome Atlas (TCGA) proposed four new molecular classifications based on genome and exome sequencing of EACs including POLE-mutant, mismatch repair deficiency (MMRd), p53 abnormal, and no specific molecular profile (NSMP).4 In June of 2023, the International Federation of Gynecology and Obstetrics (FIGO) published an updated staging system for uterine cancer to incorporate these molecular indices along with the traditional anatomical distribution of disease and histology used in older FIGO staging guidelines.5 The primary objective of this project was to analyze the timeliness and completeness of pathology reports and IHC staining of patients who underwent hysterectomies for uterine cancer at Detroit Medical Center from October 2022 – December 2023. Methods: Patients were identified from the list of patients presented at the Karmanos Cancer Insitute’s (KCI) Gynecologic Oncology Tumor Board. Given the June publication timing of the FIGO 2023 staging guidelines, this served as the intervention for the study. The pre-intervention group consists of surgical cases from October 2022 through June 2023, and the post-intervention group consists of cases from July 2023-December 2023. Differences in time from surgery to pathology report, surgery to IHC result, pathology report to IHC result as well as completeness of IHC results were compared pre- and post-intervention. Because neither group was normally distributed, a MannWhitney-U test was used to calculate P-value. IHC result completeness pre- and post-intervention was calculated using a Fisher exact test. Results: A total of 106 cases were included, of which 67 were preintervention (63%) and 39 were postintervention. The median number of days from surgery to final pathology report was statistically significant (p=0.003) between the groups. The median number of days from pathology report to IHC result was not a statistically significant difference (p=0.19). The median number of days from surgery to completed IHC also not statistically significant. In terms of IHC staining, there was a statistically significant difference in the number of specimens pre- and post-intervention for p53 (p=0.004) and HER2 (p=0.04). There was no change in the MMR and MSI testing between the two groups. Conclusions: Following the implementation of the FIGO 2023 staging guidelines in June of 2023, there was a significant decrease in the time from surgery to finalized pathology report and a significant change in the completeness of staining for p53 and HER2 on hysterectomy specimens. By finalizing the results of both pathology and IHC for endometrial cancer specimens in a timelier manner, patients can be informed of their diagnosis sooner. Additionally, with a complete pathologic and molecular diagnosis, our gynecologic oncologists can also more efficiently and effectively communicate within a multidisciplinary team of providers including radiation oncology and genetic counseling colleagues to formulate a treatment plan.

Primary Malignant Melanoma of the Cervix with Rapidly Progressing Metastases

Introduction: Mucosal melanomas only account for 0.03% of newly diagnosed cancer cases. Female genital tract melanomas account for only 3% of all melanomas, with melanoma of the cervix accounting for less than 3% of all female genital tract melanomas. It is difficult to understand how mucosal melanomas arise as the pathogenesis is still unknown. The incidence of cutaneous melanoma has greatly increased over the years whereas the incidence of mucosal melanomas has stayed relatively steady. Given the rarity of melanoma of the cervix, a standard of care treatment has not been established. Based on the limited cases that have previously been treated, the first option is surgery for early stage melanomas with adjuvant radiation therapy indicated in some cases. The use of systemic chemotherapy is still controversial as it has not been shown to prevent metastases. Case Report: A 66-year-old postmenopausal female presented with heavy vaginal bleeding. A transvaginal ultrasound showed a complex cystic structure in the cervix and she was referred to gynecologic oncology. She was up to date on her pap smears, and they have always been normal. Patient was found to have a fungating 4 x 5 cm mass in the upper vagina and pathology demonstrated poorly differentiated malignant neoplasm. The patient was diagnosed with FIGO Stage IIA2 cervical cancer. Patient’s initial PET/CT demonstrated hypermetabolic area in the cervix consistent with known cervical carcinoma with no other uptake in the uterus. Weekly chemosensitization with cisplatin and external beam radiation was initiated. On clinical examination after treatment by the gynecologic oncologist, visible disease was seen confined to the cervix. An MRI of the pelvis showed response with the suspected tumor limited to the cervical stroma in the anterior and lateral portion of the cervix with no definitive parametrial tumor and no evidence of nodal metastasis. Second opinion from pathology review was received and results showed poorly differentiated malignant neoplasm immunohistochemically consistent with “melanoma”. After 25 fractions of daily radiotherapy with weekly cisplatin, patient underwent exploratory laparotomy for radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node sampling. Final pathology of the uterus and cervix showed invasive poorly differentiated melanoma with deepest invasion of melanoma measuring 8mm and negative surgical margins. All lymph nodes removed during surgery were negative for malignancy. Adjuvant Pembrolizumab was started at this time. Two months postoperatively, the patient underwent CT surveillance again due to new onset chest wall and axillary nodules varying in size from 2-4 cm. Right chest wall axilla biopsy pathology was consistent with melanoma. At this time Pembrolizumab was discontinued and the patient was transitioned to Nivolumab and Ipilimumab 19 days after discontinuing Pembrolizumab. Four months postoperatively, additional CT scans were performed showing widespread metastatic disease in the lungs, chest wall, liver, peritoneum, retroperitoneum and left eye. Patient underwent left frontal craniotomy with tumor resection, and pathology was consistent with metastatic melanoma. Subsequent to craniotomy, the patient underwent three treatments with stereotactic radiosurgery. Despite treatment, six months postoperatively, the patient’s symptoms continued to progress with slurred speech, generalized weakness and abdominal pain. Ultimately, the patient passed away nine months after the diagnosis and four months after a combination of external beam radiotherapy, surgery, and vaginal brachytherapy. Discussion: Melanoma of the cervix is a rare type of cervical cancer with poor prognosis. Globally, 5-year survival is 18.8% for stage I, 11.1% for stage II, and 0% for stages III–IV. It has been shown that median overall survival time decreases with increasing FIGO stage. Risk factors have not been identified for gynecologic melanomas or most other mucosal melanomas. Pembrolizumab is most effective for cutaneous melanomas, however, has been shown to prolong progression free survival in mucosal melanomas. The median overall survival is significantly shorter for patients with mucosal melanoma (11.3 months) as compared to patients with a cutaneous primary (23.5 months). Primary malignant melanoma of the cervix (PMMC) remains a rare tumor and the prognosis is generally poor. Radical hysterectomy, chemoradiation, and immunotherapy have all been utilized in the treatment of PMMC. Further investigation of primary melanoma of the cervix is necessary to formulate a standard of care treatment.

Primary Malignant Melanoma of the Cervix with Rapidly Progressing Metastases

Introduction: Mucosal melanomas only account for 0.03% of newly diagnosed cancer cases. Female genital tract melanomas account for only 3% of all melanomas, with melanoma of the cervix accounting for less than 3% of all female genital tract melanomas. It is difficult to understand how mucosal melanomas arise as the pathogenesis is still unknown. The incidence of cutaneous melanoma has greatly increased over the years whereas the incidence of mucosal melanomas has stayed relatively steady. Given the rarity of melanoma of the cervix, a standard of care treatment has not been established. Based on the limited cases that have previously been treated, the first option is surgery for early stage melanomas with adjuvant radiation therapy indicated in some cases. The use of systemic chemotherapy is still controversial as it has not been shown to prevent metastases. Case Report: A 66-year-old postmenopausal female presented with heavy vaginal bleeding. A transvaginal ultrasound showed a complex cystic structure in the cervix and she was referred to gynecologic oncology. She was up to date on her pap smears, and they have always been normal. Patient was found to have a fungating 4 x 5 cm mass in the upper vagina and pathology demonstrated poorly differentiated malignant neoplasm. The patient was diagnosed with FIGO Stage IIA2 cervical cancer. Patient’s initial PET/CT demonstrated hypermetabolic area in the cervix consistent with known cervical carcinoma with no other uptake in the uterus. Weekly chemosensitization with cisplatin and external beam radiation was initiated. On clinical examination after treatment by the gynecologic oncologist, visible disease was seen confined to the cervix. An MRI of the pelvis showed response with the suspected tumor limited to the cervical stroma in the anterior and lateral portion of the cervix with no definitive parametrial tumor and no evidence of nodal metastasis. Second opinion from pathology review was received and results showed poorly differentiated malignant neoplasm immunohistochemically consistent with “melanoma”. After 25 fractions of daily radiotherapy with weekly cisplatin, patient underwent exploratory laparotomy for radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node sampling. Final pathology of the uterus and cervix showed invasive poorly differentiated melanoma with deepest invasion of melanoma measuring 8mm and negative surgical margins. All lymph nodes removed during surgery were negative for malignancy. Adjuvant Pembrolizumab was started at this time. Two months postoperatively, the patient underwent CT surveillance again due to new onset chest wall and axillary nodules varying in size from 2-4 cm. Right chest wall axilla biopsy pathology was consistent with melanoma. At this time Pembrolizumab was discontinued and the patient was transitioned to Nivolumab and Ipilimumab 19 days after discontinuing Pembrolizumab. Four months postoperatively, additional CT scans were performed showing widespread metastatic disease in the lungs, chest wall, liver, peritoneum, retroperitoneum and left eye. Patient underwent left frontal craniotomy with tumor resection, and pathology was consistent with metastatic melanoma. Subsequent to craniotomy, the patient underwent three treatments with stereotactic radiosurgery. Despite treatment, six months postoperatively, the patient’s symptoms continued to progress with slurred speech, generalized weakness and abdominal pain. Ultimately, the patient passed away nine months after the diagnosis and four months after a combination of external beam radiotherapy, surgery, and vaginal brachytherapy. Discussion: Melanoma of the cervix is a rare type of cervical cancer with poor prognosis. Globally, 5-year survival is 18.8% for stage I, 11.1% for stage II, and 0% for stages III–IV. It has been shown that median overall survival time decreases with increasing FIGO stage. Risk factors have not been identified for gynecologic melanomas or most other mucosal melanomas. Pembrolizumab is most effective for cutaneous melanomas, however, has been shown to prolong progression free survival in mucosal melanomas. The median overall survival is significantly shorter for patients with mucosal melanoma (11.3 months) as compared to patients with a cutaneous primary (23.5 months). Primary malignant melanoma of the cervix (PMMC) remains a rare tumor and the prognosis is generally poor. Radical hysterectomy, chemoradiation, and immunotherapy have all been utilized in the treatment of PMMC. Further investigation of primary melanoma of the cervix is necessary to formulate a standard of care treatment.

A Rare Case of Bilateral Retroperitoneal Ovaries: A Case Report and Review of the Literature

Introduction: Retroperitoneal gynecologic tumors and cysts are rare. They are often asymptomatic or present similarly to their intraperitoneal counterpart with vague abdominal discomfort and distention. Our literature review revealed that many retroperitoneal cysts are found intraoperatively due to their benign predominance consistent with their ultrasound findings. The rarity of retroperitoneal gynecologic tumors and cysts creates uncertainty regarding the best practice management for general gynecologists caught off guard by their location when found intraoperatively. Rarer still are retroperitoneal ovaries. There are few cases of retroperitoneal ovary displacement in the literature, most often associated with female neonatal incarcerated inguinal hernia repair surgery. We found one case report involving an intraoperatively found retroperitoneal ovarian cystadenofibroma in a patient with a hernia repair performed in infancy. To our knowledge, there are no bilateral retroperitoneal ovaries described in the literature. Objective: To report a rare case of bilateral retroperitoneal ovaries in an 11 year old female. Methods: Case report. Results: We present an 11-year-old female with a past medical history of Dandy-Walker malformation and hydrocephalus status post ventriculoperitoneal (VP) shunt with six laparoscopic VP shunt revisions who endorsed hirsutism and irregular, heavy, and painful menstrual periods. Her family history is significant for polycystic ovarian syndrome (PCOS), endometriosis, and Lynch syndrome. Physical exam revealed mild abdominal distention and lower abdominal tenderness. She had an elevated estradiol, luteinizing hormone (LH), and total and free testosterone. Normally, an elevated estradiol causes a negative feedback response that results in a low LH. Due to these abnormal results, a pelvic ultrasound was ordered to rule out a potential estrogen secreting ovarian tumor. Ultrasound revealed a large anechoic structure in the left adnexa not definitively separated from the ovary measuring 13.0 x 7.7 x 10.7 cm. Radiologic differential diagnosis included large simple cyst, hemorrhagic cyst, and serous neoplasm. A referral to an adolescent gynecologist was made where the patient presented five months later with 25-pound weight gain, constipation, and a hard belly. Repeat ultrasound was consistent with a left ovarian simple cyst with an increased size measuring 16.78 x 12.58 x 8.66 cm as well as a new finding consistent with a right ovarian simple cyst measuring 4.96 x 4.48 x 3.61 cm. Due to her history of severe abdominal adhesions secondary to multiple laparoscopic VP shunt revisions, likely endometriosis, and large ovarian cyst, she was referred to a gynecologic oncologist where she was consented for robotic assisted bilateral ovarian cystectomy and lysis of adhesions. In the operating room, extensive pelvic adhesions were lysed to reveal bilateral retroperitoneal ovaries. The right cyst was drained of clear fluid, revealing no internal complexity, and was completely excised. Persistent pelvic adhesions and cyst size prolonged the time required to excise the left ovarian cyst wall. Once open, papillary excrescences were seen inside the cyst raising concern for a borderline ovarian tumor. The decision was made to remove the cyst wall in its entirety regardless of increased risk of ovarian function compromise. Restoration of normal anatomy was not attainable, and her bilateral ovaries remained embedded in the side walls and superior to the iliac vessels. Pathology revealed a benign 8 cm right paratubal cyst and a benign 18 cm left serous cystadenoma with papillary excrescences. Conclusions: Pelvic anatomy can be greatly distorted secondary to prior abdominal surgeries or certain pathologies including endometriosis and congenital abnormalities. Ultrasound cannot easily discriminate between intraperitoneal and retroperitoneal ovarian cysts but is often the only preoperative imaging obtained prior to cystectomy. Thus, many retroperitoneal cysts are found intraoperatively resulting in diagnostic and therapeutic challenges. Therefore, general gynecologists must be aware of risk factors associated with abnormal pelvic anatomy and prepared to request intraoperative consultation if needed to ensure optimized patient care and safety.

A Rare Case of Bilateral Retroperitoneal Ovaries: A Case Report and Review of the Literature

Introduction: Retroperitoneal gynecologic tumors and cysts are rare. They are often asymptomatic or present similarly to their intraperitoneal counterpart with vague abdominal discomfort and distention. Our literature review revealed that many retroperitoneal cysts are found intraoperatively due to their benign predominance consistent with their ultrasound findings. The rarity of retroperitoneal gynecologic tumors and cysts creates uncertainty regarding the best practice management for general gynecologists caught off guard by their location when found intraoperatively. Rarer still are retroperitoneal ovaries. There are few cases of retroperitoneal ovary displacement in the literature, most often associated with female neonatal incarcerated inguinal hernia repair surgery. We found one case report involving an intraoperatively found retroperitoneal ovarian cystadenofibroma in a patient with a hernia repair performed in infancy. To our knowledge, there are no bilateral retroperitoneal ovaries described in the literature. Objective: To report a rare case of bilateral retroperitoneal ovaries in an 11 year old female. Methods: Case report. Results: We present an 11-year-old female with a past medical history of Dandy-Walker malformation and hydrocephalus status post ventriculoperitoneal (VP) shunt with six laparoscopic VP shunt revisions who endorsed hirsutism and irregular, heavy, and painful menstrual periods. Her family history is significant for polycystic ovarian syndrome (PCOS), endometriosis, and Lynch syndrome. Physical exam revealed mild abdominal distention and lower abdominal tenderness. She had an elevated estradiol, luteinizing hormone (LH), and total and free testosterone. Normally, an elevated estradiol causes a negative feedback response that results in a low LH. Due to these abnormal results, a pelvic ultrasound was ordered to rule out a potential estrogen secreting ovarian tumor. Ultrasound revealed a large anechoic structure in the left adnexa not definitively separated from the ovary measuring 13.0 x 7.7 x 10.7 cm. Radiologic differential diagnosis included large simple cyst, hemorrhagic cyst, and serous neoplasm. A referral to an adolescent gynecologist was made where the patient presented five months later with 25-pound weight gain, constipation, and a hard belly. Repeat ultrasound was consistent with a left ovarian simple cyst with an increased size measuring 16.78 x 12.58 x 8.66 cm as well as a new finding consistent with a right ovarian simple cyst measuring 4.96 x 4.48 x 3.61 cm. Due to her history of severe abdominal adhesions secondary to multiple laparoscopic VP shunt revisions, likely endometriosis, and large ovarian cyst, she was referred to a gynecologic oncologist where she was consented for robotic assisted bilateral ovarian cystectomy and lysis of adhesions. In the operating room, extensive pelvic adhesions were lysed to reveal bilateral retroperitoneal ovaries. The right cyst was drained of clear fluid, revealing no internal complexity, and was completely excised. Persistent pelvic adhesions and cyst size prolonged the time required to excise the left ovarian cyst wall. Once open, papillary excrescences were seen inside the cyst raising concern for a borderline ovarian tumor. The decision was made to remove the cyst wall in its entirety regardless of increased risk of ovarian function compromise. Restoration of normal anatomy was not attainable, and her bilateral ovaries remained embedded in the side walls and superior to the iliac vessels. Pathology revealed a benign 8 cm right paratubal cyst and a benign 18 cm left serous cystadenoma with papillary excrescences. Conclusions: Pelvic anatomy can be greatly distorted secondary to prior abdominal surgeries or certain pathologies including endometriosis and congenital abnormalities. Ultrasound cannot easily discriminate between intraperitoneal and retroperitoneal ovarian cysts but is often the only preoperative imaging obtained prior to cystectomy. Thus, many retroperitoneal cysts are found intraoperatively resulting in diagnostic and therapeutic challenges. Therefore, general gynecologists must be aware of risk factors associated with abnormal pelvic anatomy and prepared to request intraoperative consultation if needed to ensure optimized patient care and safety.