Optimal Interval Debulking Surgery Research Articles

Impact of increased cycles of neoadjuvant chemotherapy on interval debulking surgery outcomes (541)

Impact of increased cycles of neoadjuvant chemotherapy on interval debulking surgery outcomes (541)

Chemotherapy response score as a prognostic tool in advanced-stage endometrial cancer patients treated with neoadjuvant chemotherapy.

e18095 Background: Chemotherapy response score (CRS) applied to omental metastases obtained at the time of interval debulking surgery (IDS) has been used to quantify response to neoadjuvant chemotherapy (NACT) in advanced stage ovarian cancer patients. The score has been correlated with both progression free survival (PFS) and overall survival (OS). This CRS score has not been studied in advanced stage endometrial cancer. The aim of the current study is 1) to apply the CRS to omental and adnexal metastases obtained at IDS of advanced stage endometrial cancer patients and 2) to investigate the association between the CRS score and surgical outcome, PFS and OS. Methods: Patients with clinical stage III-IV endometrial cancer (endometrioid, serous, clear cell, carcinosarcoma) were identified through the endometrial cancer database, billing data and tumor board notes (2003-2019) from the University of Chicago. Patients were included if they received NACT followed by IDS (R0 no gross residual, optimal < 1 cm residual or suboptimal ≥ 1 cm residual disease). Patients who received pre-operative radiotherapy were excluded. Pathology specimens from primary and metastatic sites were reviewed by the study pathologist blinded to clinical outcome. Histologic specimens from the omental and adnexal metastases were assigned a single quantitative score of 1 (no/minimal tumor response), 2 (appreciable tumor response with viable tumor) or 3 (complete/near complete response) using the CRS system as previously described by Bohm et al (JCO 2015; 33:2457-63). Results: A total of 40 patients were available for analysis. Median age 63.5, median BMI 32 kg/m2. There is a significant association between omental CRS and optimal IDS (p = 0.029) but no significant association between the adnexal CRS and optimal IDS (p = 0.145). Cox regression analysis identified CRS omentum [2: HR = 0.095, p = 0.001; 3 HR = 0.088, p = 0.004] and CRS adnexa [2: HR = 0.24, p = 0.007] predictive of PFS. There was not enough evidence to comment on any association between CRS with OS. Conclusions: Omental CRS2, CRS3 are associated with optimal IDS. Omental CRS2, CRS3 and adnexal CRS2 are prognostic for improved PFS in stage III – IV endometrial cancer patients after neoadjuvant chemotherapy. [Table: see text]

1945P - Comparison of 11 circulating miRNAs and CA125 kinetics in ovarian cancer during first line treatment: Data from the randomized CHIVA trial (a GINECO-GCIG study)

BackgroundMicroRNAs (miRNAs) are promising biomarkers in ovarian cancer. Their kinetics during treatment might be useful for monitoring disease burden, and guiding treatments in patients treated with neoadjuvant chemotherapy and interval debulking surgery (IDS). MethodsSerial blood samples of patients enrolled in the randomized phase II CHIVA trial, comparing neo-adjuvant carboplatin-paclitaxel +/- nintedanib (NCT01583322), were investigated to assess the kinetics of 11 relevant miRNAs compared to CA125 kinetics, using C-index & survival tests for predictive and prognostic values. MiRNAs were extracted and quantified by qRT-PCR. The selection of the final 11 miRNAs was based on the expression levels found with a large explorative panel of 84 miRNAs in 8 patients, and on the literature: miR-15b-5p, miR-16-5p, miR-20a-5p, miR-21-5p, miR-93-5p, miR-122-5p, miR-150-5p, miR-195-5p, miR-200b-3p, miR-148b-5p and miR-34a-5p. Results756 serial blood samples done every 3 weeks from 119 patients were analyzed for a total of 8172 miRNA assays, and 1299 CA-125 values. About 82% of miRNA concentrations were above the limits of quantification. The time courses of the miRNAs expressions were highly heterogeneous, and were not parallel with the CA-125 time changes. The miRNAs kinetics during treatment were not found associated with disease bulk changes, RECIST tumor response, or cytoreductive surgery outcomes (optimal vs non-optimal IDS). However, for 6 of them (miR-15b-5p; miR-16-5p; miR-20a-5p; miR-21-5p; miR-93-5p; and miR-195-5p), significant increases at disease progressions were found (median 40%). Decreases of miR-34a-5p and miR-93-5p were associated with PFS benefit (13.7 vs 24.8 months; p=0.009) and OS benefits (34.3 months vs Not reached; p<0.001), respectively, using univariate tests. ConclusionsThe longitudinal kinetics of miRNA expressions during neo-adjuvant treatment in ovarian cancer patients were inconsistent, and were not found to be associated with tumor burden changes. Although some prognostic value could be discussed, no predictive value regarding tumor responses or IDS quality could be identified. Clinical trial identificationEudraCT: 2011-006288-23. Legal entity responsible for the studyARCAGY-GINECO. FundingBoehringer Ingelheim. DisclosureI.L. Ray-Coquard: Honoraria (self): AstraZeneca; Honoraria (self): Clovis; Honoraria (self): Tesaro; Honoraria (self): Pharma Mar; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Roche; Advisory / Consultancy: Clovis; Advisory / Consultancy: Tesaro; Advisory / Consultancy: Genmab; Advisory / Consultancy: pharma Mar; Advisory / Consultancy: MSD; Advisory / Consultancy: Pfizer; Research grant / Funding (institution): MSD; Travel / Accommodation / Expenses: AstraZeneca. J. Florence: Advisory / Consultancy: Roche; Advisory / Consultancy: Novartis; Advisory / Consultancy: Pfizer; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Tesaro; Advisory / Consultancy: Ipsen; Advisory / Consultancy: Astellas; Advisory / Consultancy: Bayer; Advisory / Consultancy: BMS; Advisory / Consultancy: Sanofi; Research grant / Funding (institution): BMS; Travel / Accommodation / Expenses: Janssen; Travel / Accommodation / Expenses: AstraZeneca; Travel / Accommodation / Expenses: Ipsen; Travel / Accommodation / Expenses: BMS. A. Lortholary: Honoraria (self): AstraZeneca; Honoraria (self): Tesaro. N. Raban: Travel / Accommodation / Expenses: Roche. G. Ferron: Honoraria (self): Olympus Europe; Advisory / Consultancy: AstraZeneca; Travel / Accommodation / Expenses: Roche. J. Alexandre: Honoraria (self): Roche; Honoraria (self): AstraZeneca; Honoraria (self): Ipsen; Honoraria (self): Novartis; Honoraria (self): PharmaMar; Advisory / Consultancy: Roche; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Novartis; Research grant / Funding (institution): Janssen; Travel / Accommodation / Expenses: Janssen; Travel / Accommodation / Expenses: Novartis. A. Leary: Advisory / Consultancy: Tesaro; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Clovis; Advisory / Consultancy: Gamamab; Advisory / Consultancy: Gridstone; Advisory / Consultancy: Seattle Genetics; Travel / Accommodation / Expenses: Clovis; Travel / Accommodation / Expenses: Tesaro; Travel / Accommodation / Expenses: AstraZeneca. All other authors have declared no conflicts of interest.

Neoadjuvant chemotherapy followed by surgery for advanced-stage endometrial cancer.

Data showing the value of neoadjuvant chemotherapy (nact) followed by interval debulking surgery (ids) in the management of advanced-stage serous endometrial carcinoma (eca) are limited; the aim of the present study was to expand the knowledge about that treatment strategy in patients with advanced eca, including endometrioid eca. Data were collected retrospectively from all patients with advanced-stage eca treated with nact between 2005 and 2014 at 3 oncology referral centres. Primary outcomes were the radiologic response to nact and achievement of optimal or complete ids. Secondary outcomes were recurrence rate and progression-free and overall survival. Of 102 eca cases included, a complete radiologic response was achieved in only 4 cases, with a partial response being achieved in 72% (64% of endometrioid cases, 80% of serous cases). Complete ids was achieved in 62% of the endometrioid cases and in 56% of the serous eca cases, with optimal ids achieved in 31% and 28% of those cases respectively. Survival rates were calculated for all patients with complete and optimal ids; recurrence was observed in 56% and 67% of the cases respectively, and progression-free survival was 18 months and 13 months respectively. Median survival duration was 24 months for endometrioid eca and 28 months for serous eca. For patients with advanced eca who are not suitable for primary debulking, nact followed by ids can be considered regardless of histologic subtype. The treatment options for this group of patients are limited and have to be explored.

Serum CA125 levels predict outcome of interval debulking surgery after neoadjuvant chemotherapy in patients with advanced ovarian cancer

ObjectiveTo evaluate the correlation between the changes of serum CA125 level and the outcome of interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) in patients with advanced epithelial ovarian cancer (EOC). MethodsA retrospective review for 62 patients with FIGO stage III or IV EOC treated with NACT-IDS was conducted. Demographic data, clinical characters, pathological features and prognosis were collected. Continuous variables were evaluated by Student's t-test or Mann–Whitney U test. Categorical variables were evaluated by chi square test or Fisher's exact test as appropriate for category size. Standard univariate analyses and multivariable analysis with logistic regression were performed to identify independent predictor of optimal IDS. Kaplan-Meier method was used to analyze the prognosis. ResultsNo statistical difference was found on serum CA125 levels between suboptimal (n = 34)IDS and optimal (n = 28) IDS either before NACT (median levels: 1552.2 U/mL and 1715.5 U/mL, p = 0.453) or before IDS (median levels: 27.25 U/mL and 26.4 U/mL, p = 0.713). Those with optimal IDS achieved longer progression free survival (PFS) and overall survival (OS) than those with suboptimal IDS (median PFS: 22 and 13.5 months, p < 0.001; median OS: 33.5 and 21 months, p = 0.005). Eighteen of 31 patients (58.1%) with serum CA125 declines ≥0.95828 achieved optimal IDS compared to 10 of the 31 patients (32.3%) with serum CA125 declines <0.95828 (p = 0.041). Standard univariate analyses and multivariable analysis showed that serum CA125 declines ≥0.95828 could be an independent predictor of optimal IDS. ConclusionPatients who underwent optimal IDS have better prognosis compare to suboptimal IDS. The changes of serum CA125 after neoadjuvant chemotherapy might predict optimal interval debulking surgery in patients with advanced epithelial ovarian cancer.

The efficacy of systematic lymph node dissection in advanced epithelial ovarian cancer during interval debulking surgery performed after neoadjuvant chemotherapy.

The therapeutic role of systematic lymph node dissection (LND) remains unclear in advanced epithelial ovarian cancer (EOC), especially during interval debulking surgery (IDS) performed after neoadjuvant chemotherapy (NAC). We analyzed the therapeutic and prognostic roles of systematic LND in advanced EOC patients. Data from consecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV disease, who underwent optimal IDS (<1cm) after NAC, were obtained via a retrospective chart review. Patients were classified into a lymph node sampling (LNS; node count <20) group and an LND (node count ≥20) group. Among 133 study patients, 65 and 68 underwent LND and LNS, respectively, during IDS. Overall survival (OS) was significantly better in the LND group than in the LNS group. In subgroup analysis with negative lymphadenopathy on preoperative imaging, progression-free survival (PFS) and OS were significantly better in the LND group than in the LNS group. Follow-up of subsequent recurrences showed significantly lower nodal and peritoneal recurrence rates among patients who underwent LND. Multivariate analysis identified LND as an independent prognostic factor for PFS and OS. Systematic LND may have therapeutic value in advanced EOC patients treated with NAC and IDS.

The number of cycles of neoadjuvant chemotherapy is associated with prognosis of stage IIIc–IV high-grade serous ovarian cancer

No consensus exists on the number of chemotherapy cycles to be administered before and after interval debulking surgery (IDS) in patients with advanced stage epithelial ovarian cancer. The present study aims to explore the optimal number of cycles of neoadjuvant chemotherapy (NAC) and post-operation chemotherapy to treat the International Federation of Gynecology and Obstetrics stage IIIc-IV high-grade serous ovarian cancer (HG-SOC). A total of 129 IIIc-IV stage HG-SOC cases were retrospectively analyzed. Cases were comprised of patients who underwent NAC followed by IDS and who achieved clinical complete response (CCR) at the end of primary therapy. Patients were recruited from the Jiangsu Institute of Cancer Research between 1993 and 2013. Optimal IDS-associated factors were explored with logistic regression. The association between progression-free survival (PFS), overall survival (OS) duration, and covariates was assessed by Cox proportional hazards model and log-rank test. The median number of NAC cycle was 3 (range 1-8). CA-125 decreasing kinetics (p=0.01) was independently associated with optimal IDS. CA-125 decreasing kinetics, optimal IDS, and NAC cycles was independently associated with OS (p<0.01, p<0.01, p=0.03, respectively) and PFS (p<0.01, p<0.01, p=0.04, respectively). The PFS of patients who underwent≥5 NAC cycles was shorter than those of patients who underwent<5 NAC cycles (12.3 versus 17.2months). The PFS and OS of patients who underwent<5 cycles of adjuvant chemotherapy post-IDS were shorter than those of patients who underwent≥5 cycles (14.2 and 20.3 versus 21.2 and 28.8months). NAC cycles, CA-125 decreasing kinetics, and optimal debulking are independently associated with the prognosis of patients with advanced stage HG-SOC who underwent NAC/IDS and achieved CCR. The number of administered NAC cycles should not exceed 4.

Ascites regression following neoadjuvant chemotherapy in prediction of treatment outcome among stage IIIc to IV high-grade serous ovarian cancer.

BackgroundNo consensus exists on the outcome-related factors of interval debulking surgery (IDS) in patients with advanced high-grade serous ovarian cancer (HG-SOC) who underwent neoadjuvant chemotherapy (NAC). This study aimed to explore the optimal timing for IDS and the prognosis-associated factors of International Federation of Gynecology and Obstetrics stage IIIc to IV HG-SOC patients.MethodsA total of 160 IIIc to IV stage HG-SOC patients were retrospectively analyzed. Patients with large volume ascites underwent NAC and subsequent IDS from the Jiangsu Institute of Cancer Research between 1993 and 2013. The outcome of IDS-associated factors was explored by logistic regression. To predict IDS outcome, the potential values of serum CA-125 levels and CA-125 decreasing kinetics were determined by the receiver operating characteristic curve. The associations between survival durations and covariates were assessed by Cox proportional hazards model and log-rank test.ResultsOptimal IDS was achieved in 80.6% of HG-SOC patients who underwent NAC. Multivariate analyses revealed that ascites regression (p = 0.01), serum CA-125 level (p = 0.02), and CA-125 decreasing kinetics (p = 0.01) were independent optimal IDS predictors. CA-125 decreasing kinetics, IDS outcome, and ascites volume were independently associated with overall survival (OS) (p = 0.04, p < 0.01, p = 0.03, respectively) and progression-free survival (PFS) (p < 0.01, p < 0.01, p = 0.02, respectively). Patients who exhibited disappearance of ascites (<500 ml) had longer PFS (19.7 months vs.14.9 months) and OS (32.1 months vs. 26.0 months) than patients who exhibited residual ascites (≥500 ml). Subsets with higher CA-125 decreasing kinetics (≥2.2) had longer PFS (21.4 months vs.13.1 months) and OS (29.6 months vs.26.8 months) than counterparts (kinetics < 2.2).ConclusionsAscites regression and CA-125 decreasing kinetics were independently associated with surgical outcome and prognosis in advanced HG-SOC patients who underwent NAC.

The Impact of Percent Reduction in CA-125 Levels on Prediction of the Extent of Interval Cytoreduction and Outcome in Patients With Advanced-Stage Cancer of Müllerian Origin Treated With Neoadjuvant Chemotherapy.

To investigate the role of CA-125 percent reduction after neoadjuvant chemotherapy in predicting the extent of the interval debulking surgery (IDS) and outcomes in patients with advanced-stage müllerian carcinoma. Patients who received neoadjuvant chemotherapy for advanced-stage müllerian carcinoma from 2000 to 2013 were identified. Percent reduction in CA-125 was categorized into 2 groups: ≥ 90% (CA ≥ 90%) and <90% (CA < 90%) reduction from prechemotherapy to preoperative CA-125. Of the 115 patients identified, 73% had CA ≥ 90% and 27% had CA < 90%. Optimal and complete IDS were achieved in 87% and 38%, respectively. Compared with the CA < 90% group, the CA ≥ 90% group was more likely to have complete IDS (P = 0.035), less likely to have a bowel resection (P < 0.001), and more likely to have no viable tumor/microscopic disease with treatment effect (P < 0.001). No difference in overall survival (OS; P = 0.81) and progression-free survival (PFS; P = 0.60) was noted between the groups. In multivariable analysis, CA ≥ 90% was not a predictor of PFS (hazard ratio [HR], 1.08; 95% confidence interval [CI], 0.65-1.79; P = 0.77) or OS (HR, 1.45; 95% CI, 0.73-2.9; P = 0.29). Patients with preoperative CA-125 < 20 had significantly longer OS (P = 0.05) and PFS (P = 0.005) than did those with preoperative CA-125 ≥ 20. In multivariable analysis, preoperative CA-125 < 20 was a predictor of PFS (HR, 0.37; 95% CI, 0.20-0.66; P < 0.001) but not OS (HR, 0.64; 95% CI, 0.34-1.21; P = 0.17). A reduction in CA-125 of at least 90% is associated with complete IDS, favorable pathologic response, and fewer bowel resections. A preoperative CA-125 < 20 suggests improved outcome. These findings are helpful for treatment planning and patient counseling.

1013 - Predicting Factors of Secondary Resection after Neoadjuvant Chemotherapy in Locally Advanced Epithelial Ovarian Cancers. a Retrospective Study of 82 Cases

ABSTRACT Objective The aims of our study were to assess the rate of optimal interval debulking surgery (IDS) and the potential predictors of chemotherapy responsiveness in patients treated with neoadjuvant chemotherapy(NACT). Methods We present a retrospective study including 82 EOC cases (stage IIIC or IV) collected in the medical oncology department of Farhat Hached Hospital-Sousse (Tunisia) during a period of 9 years (from 2002 to 2010). All patients received NACT followed by a clinical, radiological and biological assessment. Results The mean age of our patients was 54.5 years (27-80 years). Stage IIIC represented 69.5% of all cases and stage IV 30.5% (8 cases with pleural metastases, 14 cases with liver metastases, and 3 with pleural and liver metastases). CA-125 serum level was normal in only 7 cases. All patients received a mean number of 5 cycles of platinum-based NACT associated with paclitaxel in 78% of cases. Twenty seven patients achieved complete clinical response (CCR), 28 a partial clinical response (PCR) and 17 cases have disease progression. In 46/82 pts(56%), serum CA-125 was normalized after NACT. Ten patients achieved a radiological CR. Radiological PR was noted in 44 cases, while 19 patients had radiological disease progression. The rate of secondary resection was 51% (61.4% for stage IIIC and 28% for stage IV). Thirty one patients (74%) had an optimal IDS. We observed 9 pathological complete responses (pCR). Secondary optimal resection was significantly correlated to CA-125 serum level at the end of NACT (p = 0.001) and the quality of radiological response (CR or PR) (p = 0.001). Overall survival was 28.4 months, significantly better in cases of clinical or radiological complete response(p = 0.001) and in patients with optimal IDS (p = 0.01). pCR was associated with higher survival but without significant value (p = 0.08). In multivariate analysis, the parameters predicting a prolonged survival were: radiological complete or partial response (p = 0.05), optimal surgery (p = 0.001) and pCR (p = 0.03). Conclusion In initially unresectable EOC, NACT platinum-based chemotherapy followed by IDS is a therapeutic alternative leading to a higher rate of optimal surgery with an improvement of survival. Pre-operative CA-125 serum level as well as the radiological response appeared to be good predictors of secondary R0 surgery and tumor chemosensitivity. Disclosure All authors have declared no conflicts of interest.

979P - Predictive and Prognostic Role of Survivin and P53 Expression in Patients with Advanced Ovarian Cancer Treated with Neoadjuvant Chemotherapy

ABSTRACT Background Qualification of patients with advanced ovarian cancer (AOC) to treatment with primary or interval debulking surgery (IDS) is the subject of controversy. The aim of this study was to assess the expressions of selected proteins of apoptosis to the effects of neoadjuvant chemotherapy (NAC) in patients with AOC. Material and methods We evaluated 60 consecutive patients with AOS (FIGO stage IIIC-IV) treated with NAC, retrospectively. Formalin-fixed, paraffin-embedded tissue specimens were immunohistochemically stained for expression of p53 and survivin in patients given platinum-based NAC undergoing IDS. The expression of survivin was adopted dichotomization by the median expression of the protein found total score (TS) equals 2. For low expression of survivin was TS ≤ 2, while high total score TS> 2 The positive and negative expression of p53 were used to dichotomization study group. Results Median age of 60 patients was 60 years. The optimal IDS was achieved in 69.1% (38/55). We observed significant difference in the percentage of stained nuclei (PS, p = 0.0002), the intensity of staining (IS, p = 0.0003) and TS (p = 0.0001) by comparing the expression of survivin in tumor tissue taken before and after NAC. The expression of p53 in tumor tissue before and after NAC was observed and significant difference was in PS, (p = 0.0424). There were no statistically significant difference in IS and the TS. Expression of survivin and p53 was not related to the results of IDS. Survivin expression was a prognostic factor in AOC patients treated with NAC (p = 0.0484). Expression of survivin and p53 proteins was not a predictor factor in AOC patients. Adverse factors affecting the PFS for AOC patients treated with NAC were: lack of optimal IDS and the lack of an objective response by RECIST criteria (respectively HR was 3.93 (95% CI, 2.07-7.46, p Conclusions High expression of survivin is a useful prognostic factor in patients treated with neoadjuvant chemotherapy for advanced ovarian cancer. This effect is more significant in patients with positive expression of p53. Disclosure All authors have declared no conflicts of interest.

CA125 as a predictive marker for optimal interval debulking surgery in advanced ovarian cancer.

e15543 Background: Neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS) is an accepted treatment for patients with advanced ovarian cancer. It is unclear, however, whether achieving optimal IDS can be predicted by preoperative analysis using imaging (CT and MRI) or by measuring cancer antigen (CA) 125 levels. The aim of the present study was to assess whether CA125 values can be used to identify patients who are candidates for optimal IDS following NAC for advanced ovarian cancer. Methods: Eighty-one women diagnosed with ovarian cancer (6 FIGO IIIA and 75 IIIC) between 1995 and 2010, with serum CA125 levels greater than 40 IU/mL prior to NAC that underwent NAC followed by IDS, were retrospectively evaluated. After each NAC, CA 125 levels were measured and CA125 regression rates ([pre first NAC CA125 – pre each NAC CA125]/pre first NAC CA125) were calculated. Optimal IDS was defined as the largest volume of residual disease less than 1 cm in the maximal dimension. The ability of CA12...

Neoadjuvant chemotherapy followed by interval debulking surgery in patients with serous endometrial cancer with transperitoneal spread (stage IV): a new preferred treatment?

Background:To investigate the value of neoadjuvant chemotherapy (NACT), followed by interval debulking surgery (IDS), in endometrial cancer with transperitoneal spread (stage IV).Methods:Patients with endometrial cancer with transperitoneal spread, as determined by laparoscopy (±pleural effusion), were treated with NACT. Efficacy was determined according to the Response Evaluation Criteria in Solid Tumors, residual tumour at IDS and histopathological assessment of tumour regression.Results:A total of 30 patients (median age: 65 years; range:44–81 years) received 3–4 cycles of NACT (83% paclitaxel/carboplatin). Histopathological subtypes were as follows: serous (90%), clear cell (3%) and endometrioid (6%) carcinoma. Response according to RECIST was as follows: 2 (7%) complete remission, 20 (67%) partial remission, 6 (20%) stable disease and 2 (7%) progressive disease (PD). Patients with PD were not operated upon. A total of 24 patients (80%) had optimal cytoreduction (R ⩽1 cm), of whom 22 (92%) were without residual tumour. Four patients were considered inoperable and were excluded from further analysis. The median progression-free survival and overall survival times were 13 and 23 months, respectively.Histopathological features of chemoresponse in both uterus and omentum were related to a better PFS (P=0.017, hazard ratio (HR) =0.785) and overall survival (P=0.014, HR=0.707). In particular, the absence of tumour infiltration and necrosis were associated with prognosis.Conclusion:The use of NACT resulted in a high rate (80%) of optimal IDS for the treatment of endometrial cancer with transperitoneal spread.