Surgical Staging Research Articles

Analysis of human epidermal growth factor receptor 2 immunohistochemical expression in high-grade endometrial carcinomas and its association with variable clinical outcomes

Background Endometrial tumor represents the sixth most common tumor in women all over the world. HER2/neu protein overexpression was related to tumor cell proliferation and survival pathways in some malignancies. Uterine carcinomas are comparatively rare tumors that overexpress HER2/neu. Studies of the percentages of endometrial adenocarcinomas that overexpress HER2/neu have ranged from 13 to 50% with almost half of that fraction accompanied by gene amplifications. Patients and methods This is a retrospective case series study involving 38 cases diagnosed as endometrial carcinoma from January 2014 to December 2018 with full medical records in Ain Shams University Oncology Hospital and in the Early Cancer Detection Unit at Ain Shams University Hospitals. The study includes pathologically proven high-grade endometrial cancers. Immunohistochemical expression for HER2/neu was scored and analyzed. Results HER2/neu expression was positive in 36.8% of patients. HER2/neu score was negative in 57.9%, score 1 in 5.3%, score 2 in 18.4%, and score 3 in 18.4% of cases. A statistically significant association was found among HER2/neu expression and lymphovascular invasion (P<0.05), lymph node metastasis (P<0.05), distant metastasis (P<0.02), and a highly significant association with FIGO surgical tumor stage (P<0.003). Conclusions Although our results did not reach a significant association among HER2/neu-expressions and total survival, further studies on a larger sample size are recommended to validate its value as a potential predictive marker noted from the positive correlation between its expression and other prognostic factors including lymphovascular invasion, lymph node metastasis, distant metastasis, and FIGO surgical tumor stage.

Single position robot-assisted pedicle screw placement with S2-alar-iliac fixation in lateral decubitus: cadaveric feasibility study and early clinical experience.

Single position lateral fusion with robotic assistance eliminates the need for surgical staging while harnessing the precision of robotic adjuncts. We expand on this technique by demonstrating the technical feasibility of placing bilateral pedicle screws with S2-alar-iliac (S2AI) fixation while in the lateral position. A cadaveric study was performed using 12 human specimens. A retrospective clinical series was also performed for patients who had undergone robot-assisted placement of S2AI screws in lateral decubitus between June 2020 and June 2022. Case demographics, implant placement time, implant size, screw accuracy, and complications were recorded. Early postoperative radiographic outcomes were reported. In the cadaveric series, a total of 126 screws were placed with robotic assistance in 12 cadavers of which 24 screws were S2AI. There were four breaches from pedicle screws and none with S2AI screws for an overall accuracy rate of 96.8%. In the clinical series, four patients (all male, mean age 65.8years) underwent single position lateral surgery with S2AI distal fixation. Mean BMI was 33.6 and mean follow-up was 20.5months. Mean radiographic improvements were lumbar lordosis 12.3 ± 4.7°, sagittal vertical axis 1.5 ± 2.1cm, pelvic tilt 8.5 ± 10.0°, and pelvic incidence-lumbar lordosis mismatch 12.3 ± 4.7°. A total of 42 screws were placed of which eight screws were S2AI. There were two breaches from pedicle screws and none from S2AI screws for an overall accuracy rate of 95.2%. No repositioning or salvage techniques were required for the S2AI screws. We demonstrate here the technical feasibility of single position robot-assisted placement of S2-alar-iliac screws in the lateral decubitus position for single position surgery.

Rolul ganglionului-santinelă în tratamentul actual al cancerului de endometru

Introduction. Endometrial cancer is the most prevailing gynecological malignancy in developed countries, with an incidence rising annually. For years, systematic lymphadenectomy had been the preferred method for staging purposes, but a less aggressive approach, with no negative impact on the oncologic outcomes, is the current trend in endometrial cancer management. In this review, we aim to evaluate the role of sentinel lymph node (SLN) mapping as an eligible alternative to complete pelvic lymphadenectomy in the surgical staging process, as well as its influence on the adjuvant treatment options. Materials and method. We analyzed the leading international guidelines regarding sentinel lymph node mapping in endometrial cancer, published between 2018 and 2023, as well as several studies that met the inclusion criteria, from the PubMed database, to outline the recommended surgical techniques, the algorithm, the accuracy, and the advantages of the SLN sampling procedure compared to pelvic lymphadenectomy. Results. Most international guidelines conclude that SLN sampling is the desirable alternative to systematic lymphadenectomy. However, it is agreed that, in case of failed SLN mapping, the radical option consisting in complete pelvic lymphadenectomy is recommended. As far as high-risk patients are concerned, most of the reviewed studies and guidelines encourage the use of SLN mapping in the treatment of endometrial cancer. Our findings revealed high sensitivity and detection rates of SLN mapping, influenced especially by the type of tracer used, indocyanine green having the best outcomes. Conclusions. Considering the high sensitivity and the low morbidity rates of the procedure, SLN mapping is soon to become a gold standard practice for the surgical staging process of endometrial cancer in many gynecologic oncology centers. Thus, SLN mapping represents a viable alternative to complete pelvic lymphadenectomy, acknowledging the principles of minimally invasive surgery and personalized medicine, without compromising the oncologic outcomes.

NIR-II Fluorescence Imaging for the Detection and Resection of Cancerous Foci and Lymph Nodes in Early-Stage Orthotopic and Advanced-Stage Metastatic Ovarian Cancer Models.

The high mortality rate of ovarian cancer can be primarily attributed to late diagnosis and early lymph node (LN) metastasis. The anatomically deep-located ovaries own intricate anatomical structures and lymphatic drainages that compromise the resolution and sensitivity of near-infrared first-window (NIR-I) fluorescence imaging. Reported NIR-II imaging studies of ovarian cancer focused on late-stage metastasis detection via the intraperitoneal xenograft model. However, given the significant improvement in patient survival associated with early-stage cancer detection, locating tumors that are restricted within the ovary is equally crucial. We obtained the polymer nanoparticles with bright near-infrared-II fluorescence (NIR-II NPs) by nanoprecipitation of DSPE-PEG, one of the ingredients of FDA-approved nanoparticle products, and benzobisthiadiazole, an organic NIR-II dye. The one-step synthesis and safe component lay the groundwork for its clinical translation. Benefiting from the NIR-II emission (∼1060 nm), NIR-II NPs enabled a high signal-to-noise (S/N) ratio (13.4) visualization of early-stage orthotopic ovarian tumors with NIR-II fluorescence imaging for the first time. Imaging with orthotopic xenograft allows a more accurate mimic of human ovarian cancer origin, thereby addressing the dilemma of translating existing nanoprobe preclinical research by providing the nano-bio interactions with early local tumor environments. After PEGylation, the desirable-sized probe (∼80 nm) exhibited high lymphophilicity and relatively extended circulation. NIR-II NPs maintained their accurate detection of orthotopic tumors, tumor-regional LNs, and minuscule (<1 mm) disseminated peritoneal metastases simultaneously (with S/N ratios all above 5) in mice with advanced-stage cancer in real time ∼36 h after systematic delivery. With NIR-II fluorescence guidance, we achieved accurate surgical staging in tumor-bearing mice and complete tumor removal comparable to clinical practice, which provides preclinical data for translating NIR-II fluorescence image-guided surgery.

Impact on peri-implant connective tissue of laser treated versus traditional healing abutments: a human clinical trials

BackgroundDental implant is the principal treatment for edentulism and the healthiness of the peri-implant tissue has a pivotal role for its longterm success. In addition, it has been shown that also the topography of the healing abutment can influence the outcome of the restoration. The objective of this human clinical trial was to assess the impact of a novel laser-treated healing abutment on peri-implant connective tissue and extracellular matrix proteins compared to the conventional machined surface, which served as the control group.MethodsDuring second surgical stage a customized healing abutment were inserted on 30 single dental implants. Healing abutments were realized with two alternated different surface (two side laser-treated surfaces and two side machined surfaces) in order to be considered both as test and control on the same implant and reduce positioning bias. Following the soft tissue healing period (30 ± 7 days) a 5 mm circular biopsy was retrieved. Immuno-histochemical and quantitative real-time PCR (qPCR) analyses were performed on Collagen, Tenascin C, Fibrillin I, Metalloproteinases (MMPs) and their inhibitor (TIMPs). 15 were processed for qPCR, while the other 15 were processed for immunohistochemical analysis. Paired t-test between the two groups were performed. A value of p < 0.05 was considered statistically significant.ResultsResults revealed that the connective tissue facing the laser-treated surface expressed statistically significant lower amount of MMPs (p < 0.05) and higher level of TIMPs 3 (p < 0.05), compared to the tissue surrounding the machined implant, which, in turn expressed also altered level of extracellular matrix protein (Tenascin C, Fibrillin I (p < 0.05)) and Collagen V, that are known to be altered also in peri-implantitis.ConclusionsIn conclusion, the laser-treated surface holds promise in positively influencing wound healing of peri-implant connective tissue. Results demonstrated that topographic nature of the healing abutments can positively influence mucosal wound healing and molecular expression. Previous studies have been demonstrated how laser treatment can rightly influence integrity and functionality of the gingiva epithelium and cell adhesion. Regarding connective tissue different molecular expression demonstrated a different inflammatory pattern between laser treated or machined surfaces where laser treated showed better response. Targeted interventions and preventive measures on peri- implant topography could effectively minimize the risk of peri-implant diseases contributing to the long-term success and durability of restoration. However, new studies are mandatory to better understand this phenomenon and the role of this surface in the peri-implantitis process. Trial registrationThis trial is registered with ClinicalTrials.gov Identifier: (Registration Number: NCT05754970). Registered 06/03/2023, retrospectively registered.

Long-term results of dearterialization and mucopexy for stage II–III hemorrhoids

BACKGROUND:Nowadays, minimally invasive procedures are mainly performed in the treatment of hemorrhoidal diseases. However, the feasibility of using ultrasound navigation for hemorrhoidal artery ligation-rectoanal repair (HAL-RAR) is still discussed because digital palpation of hemorrhoidal arteries for ligation is safe and easy to perform. AIM:To evaluate the long-term results of HAL with mucopexy by digital examination in comparison with traditional HAL-RAR in the surgical treatment stage II–III hemorrhoidal disease. MATERIALS AND METHODS:The controlled randomized trial included 150 patients with stage II–III hemorrhoidal disease. The study group (n=75) included patients who underwent surgery using digital palpation with mucopexy, and in the control group (n=75), the HAL-RAR was used. The primary endpoint was a recurrence of the main symptoms. Secondary endpoints included patient satisfaction and discomfort, pain intensity, prolapse of hemorrhoidal piles, and rectal bleeding. RESULTS:The groups did not differ in sex, age, body mass index, and stage, and symptoms of hemorrhoidal disease. During the 12-month follow-up, no difference in the prolapse of hemorrhoidal piles (p=0.49), patient satisfaction (p=0.95), and discomfort (p=0.67) was found. Periodic bleeding occurred in 5.3% and 17.3% of the patients in the study and control groups, respectively (p=0.037). After 2 months of follow-up, pain recurred in 8 (10.6%) patients in the study group and 22 (29.3%) in the control group (p=0.037). At 18 months follow-up, no difference in patient satisfaction (p=0.95) and discomfort (p=0.89) was noted; however, the rate of hemorrhoidal prolapse was significantly higher in the study group (16.3%) than in the control group (13.5%) (p=0.045), and bleeding was reported in 10.2% and 15.4% of the patients in these groups, respectively (p=0.86). Open hemorrhoidectomy for relapse of hemorrhoidal prolapse was performed in 2 (2.6%) patients in the study group and 4 (5.3%) patients in the control group (p=0.68). CONCLUSION:Ligation of hemorrhoidal arteries in combination with mucopexy without ultrasound guidance is a safe, easy, and reproducible technique, with comparable effectiveness, and long-term results to HAL-RAR. This procedure can be recommended for the surgical treatment of stage II–III hemorrhoids.

Ovarian mucinous adenocarcinoma and false negative frozen pathology: A case report and review of the literature

Introduction: In this case report we discuss the presentation and management of a woman with a large adnexal mass. Case Report: This report describes a 32-year-old year healthy woman who presented with four months of increasing abdominal fullness. Computed tomography (CT) imaging showed a 34 cm fluid-filled left adnexal mass with few thin septations. Tumor markers were within normal limits. She strongly desired minimally invasive surgery in the setting of low concern for malignancy. A mini-laparotomy was performed, purse string sutures were placed through the cyst wall, and fluid was aspirated with minimal spillage. Her left tube and ovary were resected laparoscopically. Intraoperative frozen pathology returned as mucinous cystadenoma with some areas of atypia. Final pathology resulted with Grade 2 mucinous adenocarcinoma and she was taken back to the operating room for a surgical staging procedure. Pathology from her laparoscopic staging surgery was benign. She underwent chemotherapy with carboplatin/paclitaxel for Stage 1C1, Grade 2 mucinous adenocarcinoma of the ovary based on intra-operative spillage. Conclusion: Despite reassuring imaging and tumor markers, particularly in the setting of frozen pathology with low concern for malignancy, final pathology may indicate carcinoma. Although the accuracy of intra-operative frozen pathology is generally high, both gynecologic oncologists and non-oncologic gynecologists should be aware of the limitations of the test and counsel patients that the final pathology may be discordant. Appropriate counseling about the risk of intra-operative spillage and subsequent upstaging is of particular importance.

Self-reported lower extremity lymphedema and quality of life after surgical staging of endometrial carcinoma: A population based cross-sectional study

ObjectivesSentinel lymph node biopsy (SLN) has replaced lymphadenectomy in staging of endometrial carcinoma. The aims of the study were to explore the prevalence of self-reported lymphedema (LEL), identify factors associated with LEL, compare quality of life (QoL) scores using thresholds of clinical importance, and assess correlation between different questionnaires. MethodsWomen who underwent staging for endometrial carcinoma from 2006 to 2021 were invited to complete the Lower Extremity Lymphedema Screening Questionnaire (LELSQ), EORTC QLQ-C30, QLQ-EN24 and EQ-5D-5L. ResultsOf 2156 invited survivors, 61% participated in the study, whereof 1127 were evaluable by LELSQ. The LEL prevalence was 51%, 36% and 40% after lymphadenectomy, SLN and hysterectomy, respectively (p < 0.001). Higher BMI, undergoing lymphadenectomy and receiving adjuvant chemotherapy were associated with LEL; odds ratios 1.07 (95% CI 1.05–1.09), 1.42 (95% CI 1.03–1.97) and 1.43 (95% CI 1.08–1.89) respectively. QoL was lower for women with LEL compared to those without. In women with musculoskeletal complaints the prevalence of LEL was 59%, 50% and 53% after lymphadenectomy, SLN and hysterectomy (p = 0.115), respectively, compared to 39%, 17% and 18% (p < 0.001) in women without musculoskeletal complaints. Spearman's correlation was moderate to strong between the questionnaires. ConclusionSLN implementation is not associated with increased LEL prevalence compared to hysterectomy alone, but is associated with a significantly lower prevalence compared to lymphadenectomy. LEL is associated with lower QoL. Our study demonstrates moderate to strong correlation between self-reported LEL and QoL scores. Available questionnaires may not distinguish between symptoms caused by LEL and musculoskeletal disease.

Sentinel lymph node mapping in the modern management of gynaecological malignancy

Key content Sentinel lymph node (SLN) biopsy is an alternative to systematic lymphadenectomy in the surgical staging of gynaecological malignancy. It is recommended in the management of vulval cancer and is increasingly used in endometrial and cervical cancer. SLN failed mapping algorithms require that side‐specific lymphadenectomy should be performed in the case of failed mapping, and that suspicious lymph nodes are removed. Ultrastaging protocols improve detection of lymph‐node metastasis and should be used for the pathological processing of SLNs. Learning objectives To understand the rationale, use and evidence for SLN biopsy in women with vulval, cervical and endometrial malignancy. To appreciate the concepts behind the technical performance of SLN biopsy. To understand the pathological processing of SLN samples and the implications this may have for the interpretation of results and adjuvant therapy. Ethical issues How to manage adjuvant therapy decisions in the context of micrometastases or isolated tumour cells in positive pelvic SLNs in cervical or endometrial cancer when the evidence‐base is limited.

Comparison of oncological outcomes between sentinel lymph node biopsy and complete lymphadenectomy for endometrial cancer.

Sentinel lymph node (SLN) mapping allows node-negative patients to be spared from the surgical comorbidities associated with total lymphadenectomy. This study aimed to evaluate the oncological outcomes of SLN biopsy versus complete lymph node dissection in patients with early-stage endometrial carcinoma. Retrospective analyses were performed in patients with pathologically confirmed endometrioid endometrial carcinoma, who underwent minimally invasive surgical staging with SLN biopsy or complete lymph node dissection at Yonsei Cancer Center between 2015 and 2019. A total of 301 patients were included in this study. Eighty-two patients underwent SLN biopsy, while 219 underwent complete lymph node dissection. There were no significant differences in patient characteristics between the two groups. In terms of operative characteristics, the SLN biopsy-only group had a significantly shorter surgical duration (p < 0.001) than the lymphadenectomy group. The mean follow-up period was 41.4 months. There were no differences in progression-free survival (PFS) and overall survival (OS) between the two groups (SLN biopsy vs. complete lymph node dissection; p = 0.798 and 0.301, respectively). Multivariate analysis revealed that SLN biopsy was not an independent prognostic factor for PFS or OS. Our results showed that SLN biopsy provided oncological outcomes similar to those of lymphadenectomy.

Minimally Invasive Staging of Early-Stage Epithelial Ovarian Cancer versus Open Surgery in Terms of Feasibility and Safety: A Systematic Review and Meta-Analysis.

Epithelial ovarian cancer is women's fourth most common oncological cause of death. One of the main prognostic factors in ovarian cancer is the tumor stage. For instance, surgical staging of the disease is focal when choosing the best therapeutic option for each case. Although open surgery is the prevalent approach for staging and treating ovarian cancer, the use of minimally invasive surgery (MIS) has found recent application in staging or restaging cases of early disease. Our work compares oncological outcomes after MIS staging for FIGO I epithelial ovarian cancer with the laparotomic approach. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations, we systematically searched the Pub Med and Scopus databases in February 2023. No temporal nor geographical limitation was made. We included the articles containing data about Disease-Free Survival (DFS) and Overall Survival (OS), Recurrence Rates (RR), and Upstaging Rates (UpR). We used comparative studies for the meta-analysis. After the database search and article selection, 19 works matched the inclusion criteria for the systematic review. Eleven of these were comparative studies between MIS and Open Surgical Staging (OSS) approaches for ovarian cancer staging and were included in the meta-analysis. The meta-analysis did not show a statistically significant difference between the MIS and the OSS group concerning DFS, OS, and RR. Only Upstaging Rate ≥ FIGO Stage II was statistically significative higher in the OSS group. Likewise, MIS is confirmed to be an approach with a lower profile of surgical complications. In conclusion, our study did not show one approach to be safer than the other. However, the lack of dedicated studies limits the evidence of our study. For instance, we recommend adequately selecting the specimen, minimizing the risk of spillage, and optimizing surgical staging.

Outcomes for patients with high-risk endometrial cancer undergoing sentinel lymph node assessment versus full lymphadenectomy

ObjectiveThe objective of this study was to determine the progression free survival (PFS) and overall survival (OS) among patients with high-risk endometrial cancer (EC) who underwent sentinel lymph node (SLN) mapping and dissection compared to patients who underwent pelvic +/− para-aortic lymphadenectomy (LND). MethodsPatients with newly diagnosed high-risk EC were identified. Inclusion criteria included patients who underwent primary surgical management from January 1, 2014 to September 1, 2020 at our institution. Patients were categorized into either the SLN or LND group based on their method of planned lymph node assessment. Patients in the SLN group had dye injected followed by successful bilateral lymph node mapping, retrieval, and processing per our institutional protocol. Clinicopathological and follow-up data were extracted from patient's medical records. The t-test or Mann-Whitney test was used to compare continuous variables and Chi-squared or Fisher's exact test were used for categorical variables. Progression-free survival (PFS) was calculated from the date of initial surgery to the date of progression, death, or last follow-up. Overall survival (OS) was calculated from the date of surgical staging to the date of death or last follow-up. Three-year PFS and OS were calculated using the Kaplan-Meier method, and the log-rank test was used to compare cohorts. Multivariable Cox regression models were used to assess the relationship between nodal assessment cohort and OS/PFS while adjusting for age, adjuvant therapy, and surgical approach. A result was considered statistically significant at the p < 0.05 level of significance and all statistical analysis was done using SAS version 9.4 (SAS Institute, Cary, NC). ResultsOut of 674 patients diagnosed with EC during the study period, 189 were diagnosed with high-risk EC based on our criteria. Forty-six (23.7%) patients underwent SLN assessment and 143 (73.7%) underwent LND. No difference was observed between the two groups in regards to age, histology, stage, body mass index, tumors myometrial invasion, lymphovascular space invasion, or peritoneal washing positivity. Patients in the SLN group underwent robotic-assisted procedures more frequently than those in the LND group (p < 0.0001). The three-year PFS rate was 71.1% (95% CI 51.3–84.0%) in the SLN group and 71.3% (95% CI 62.0–78.6%) in the LND group (p = 0.91). The unadjusted hazard ratio (HR) for recurrence in the SLN versus LND group was 1.11 (95% CI 0.56–2.18; p = 0.77), and after adjusting for age, adjuvant therapy, and surgical approach, the HR for recurrence was 1.04 (95% CI 0.47–2.30, p = 0.91). The three-year OS rate was 81.1% (95% CI 51.1–93.7%) in the SLN group and 95.1% (95% CI 89.4–97.8%) in the LND group (p = 0.009). Although the unadjusted HR for death was 3.74 in the SLN vs LND group (95% CI 1.39–10.09; p = 0.009), when adjusted for age, adjuvant therapy, and surgical approach, it was no longer significant with a HR of 2.90 (95% CI 0.94–8.95, p = 0.06). ConclusionsThere was no difference in three-year PFS in patients diagnosed with high-risk EC who underwent SLN evaluation compared to those who underwent full LND in our cohort. The SLN group did experience shorter unadjusted OS; however, when adjusting for age, adjuvant therapy and surgical approach, there was no difference OS in patients who underwent SLN compared to LND.

CARD30: Variability of Operator’s Physiologic and Motion Patterns in the Surgical Environment

Introduction: During a cardiac surgery, continuous interaction occurs between the surgeon and the environment. We analyzed these interactions and their correlation with surgical stages. Methods: Recorded data included a volunteer surgeon’s physiologic data: heart rate (HR), O2 saturation (SAT), and physical data included environmental noise level in decibel (dB), hand motions quaternion data for navigation of hands in 3D space during the surgery. Results: During the surgery, surgeon’s mean HR was 71/min (62-92), the mean SAT was 98.7% (96-99%) and the mean noise level was 67 dB (61-84). The quaternion data showed a rotation angle of the surgeon’s arm in 3D space from 40-180 degrees, (Figure 1). The highest HR was recorded just prior to removal of the aortic cross-clamp until coming off cardiopulmonary bypass. A single drop in SAT to 96% was recorded during the chest opening, correlating with electrocautery use. The average noise level was 67 dB, comparable to a vacuum cleaner noise, about 20dB louder than a typical office noise level. Some noise peaks were followed by HR increase. The longest low-noise period was during the cardiopulmonary bypass when most alarms were off. Hands motion analysis showed that there are certain periods of the operation with sharp changes in the orientation angle corresponding to various surgical stages. The slight variations refer to microsurgery when the arm is almost static, and fingers and/or wrist do the necessary rotations and the wider motions represent actions such as chest closure. Conclusion: This study represents the complex interactions between human and the surroundings during a surgery. The inputs from various sources have the potential to affect surgeon’s physiologic state and are recognizable as a pattern which could be easily studied for prediction of surgical conduct in tools such as artificial intelligence, or for design and improvement of future surgical technologies to improve patient outcome.Figure 1. Data Recorded During the Surgery, (Horizontal axis represents the surgical time)

Rates of surgical site infections and length of stay following major gynecologic oncology surgery for patients on federally funded insurance: A 6-month retrospective cohort.

e18627 Background: An estimated 94,000 women have newly diagnosed gynecologic cancer annually–with rates increasing over the last 20 years. The incidence of gynecologic cancers is known to vary by insurance status; more specifically, uninsured or federally insured women are more likely to have advanced-stage disease at the time of diagnosis and worse overall survival compared to privately insured women. Surgical site infections (SSIs) complicate up to 4% of hysterectomies in the United States. Other post-operative sequelae, such as wound dehiscence and 30-day readmission, further complicate the post-surgical course. We sought to determine differences in postoperative outcomes for patients with private and federally-funded insurance plans, such as SSI, length of hospital stay, and 30-day wound dehiscence, and 30 all-cause readmission following gynecologic oncologic surgery. Methods: We conducted a retrospective cohort study from a large metropolitan academic health system between January 1st, 2022, to June 30th, 2022. The study population included adult women who received gynecologic oncologic surgery–surgical staging or interval cytoreduction. Postoperative complications were compared to national rates from the National Surgical Quality Improvement Project (NSQIP) database. Trends were analyzed using chi-squared analysis and a two-sample t-test. Results: Over our 6-month study period, 233 patients underwent gynecologic oncologic surgery. Robotic-assisted hysterectomies were the most common (27.89%, n = 65), followed by total abdominal hysterectomies (21%, n = 49), laparoscopic hysterectomies (7.72%, n = 18), and supracervical hysterectomies (3%, n = 7). More patients required bilateral salpingo-oophorectomy (63.51%, n = 148) compared to unilateral procedures (9.87%, n = 23). Although most patients had private insurance (73.39%, n = 171), 26.1% had federally-funded health plans (n = 62)–Medicaid and Medicare. Rates of wound dehiscence were higher than the NSQIP rate of 1% among our cohort (3%, n = 7). Although there was a high rate of 30-day readmission (9.44%, n = 22) compared to NSQIP rate of 6.1%, the incidence of SSI was fewer than the NSQIP rate of 4% (3.86%, n = 9). Upon intersectional analysis, patients with federal insurance plans had higher rates of SSI (n = 5, p &lt; 0.05). Specifically, Medicare patients had a longer average length of stay at 2.64 days (p &lt; 0.05) compared to a study average of 1.76 days. Conclusions: Patients with federal insurance had longer hospital stays and higher rates of SSI compared to those with private plans. There was no difference in 30-day wound dehiscence or 30-day all-cause readmission between study populations. More studies are needed to risk-stratify patients by insurance type before gynecologic oncology surgery to improve postoperative outcomes further.

Clinicopathological characteristics of endometrial carcinomas according to DNA mismatch repair protein status

DNA mismatch repair protein deficiency (MMRd) in endometrial carcinoma is associated with the risk of Lynch syndrome and response to immune checkpoint inhibitors. It is also related to microsatellite instability and corresponds to a molecular subtype of endometrial tumor with an unclear prognosis. Here, we evaluated the clinicopathological characteristics and prognosis of 312 consecutive endometrial carcinoma cases submitted to complete surgical staging at a single institution. We compared MMRd and mismatch repair protein–proficient (MMRp) tumors and examined the effects of the MMR protein loss type (MLH1/PMS2 vs. MSH2/MSH6) and influence of L1CAM and p53 expression. The median follow-up period was 54.5 (range, 0–120.5) months. No difference was observed between MMRd [n = 166 (37.2%)] and MMRp [n = 196 (62.8%)] cases in terms of age, body mass index, FIGO stage, tumor grade, tumor size, depth of myometrial infiltration, or lymph node metastasis. More MMRd than MMRp tumors had endometrioid histology (87.9% vs. 75.5%) and despite MMRd had more lymphovascular space invasion (LVSI; 27.2% vs. 16.9%), they presented fewer recurrences and no difference in lymph node metastasis and disease-related death. Relative to those with MLH1/MSH6 loss, tumors with MSH2/MSH6 loss were diagnosed at earlier FIGO stages, were smaller, and had less ≥50% myometrial invasion, LVSI and lymph node metastasis. Outcomes, however, did not differ between these groups. L1CAM positivity and mutation-type p53 expression were more common in MMRp than in MMRd tumors and did not differ between the MLH1/PMS2 and MSH2/MSH6 loss groups. In the entire cohort, L1CAM and mutation p53 expression were associated with worse prognosis, but only non-endometrioid histology, FIGO stage III/IV, and deep myometrial infiltration were significant predictors. In the subgroup of endometrioid carcinomas, only FIGO stage III/IV was associated with poor outcomes. The risk of lymph node metastasis was associated with tumor size, non-endometrioid histology, and multifocal LVSI. For MMRd tumors, only tumor size and myometrial invasion depth were predictive of lymph node involvement. In our cohort, MMRd tumors were associated with greater recurrence-free, but not overall, survival. The precise identification of MMRd status, present in a substantial proportion of endometrial cancer cases, is a challenge to be overcome for proper patient management. MMRd status serves as a marker for Lynch syndrome, and a significant number of these tumors are high risk and candidate to immunotherapy.

Does age matter? An ovarian cancer cohort from a single, urban, academic institution.

e17599 Background: While it is well established that age of diagnosis impacts survival in patients with certain types of cancer including breast, colon and prostate, this has yet to be explored in ovarian cancer. The aim of this study was to examine age of diagnosis of ovarian cancer in relation to oncologic treatment, prognosis, and surgical outcomes. Methods: All patients diagnosed with ovarian cancer between the dates of January 1, 2014 and December 31, 2022 who underwent surgical staging at a single institution were identified. Clinicopathological and follow-up data were extracted from patient’s medical record. The survival analysis of time from diagnosis to recurrence or death was accomplished using the Kaplan-Meier method, categorical data were analyzed using Fisher’s exact test and continuous data were compared using Wilcoxon-rank sum test. A result was considered statistically significant at the p &lt; 0.05 level of significance. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Results: There were 401 patients who were diagnosed with ovarian cancer during our study period, ranging from 22 to 90 years old. In our cohort, 89 patients (22%) were diagnosed at or before 50 years old and 309 (78%) after 50 years old. When compared to older patients, patients aged less than 50 years at diagnosis were less likely to be White (36 vs. 56%, p &lt; 0.0001), more likely to have private insurance (66 vs. 33%, p &lt; 0.0001), less likely to have high grade serous tumors (42 vs. 73%, p &lt; 0.0001), less likely to have disease stage 3 or 4 (44 vs. 72%), and more likely to receive surgery as primary treatment compared to NACT, regardless of stage (88 vs. 61%, p &lt; 0.0001). Post-operative day of discharge was significantly different between early-diagnosis and later-diagnosis groups (p = 0.02). When age at diagnosis was divided into ≤50 years, 51-70 years, and &gt; 70 years groups, there was not enough evidence to conclude that overall survival differed between the three groups (p = 0.17). The younger cohort was found to have significantly longer recurrence-free survival (RFS) compared to older patients (median time to recurrence or death 92 vs. 28 months, p = 0.007). When age at diagnosis was divided into ≤50 years, 51-70 years, and &gt; 70 years groups, patients in the ≤50 years group were found to have significantly longer RFS compared to patients in the 51-70 years group (p = 0.01) and compared to patients in the &gt; 70 years group (p = 0.01). Once adjusting for stage, however, there was no significant association between age of diagnosis and RFS. Conclusions: In our cohort, patients younger or equal to 50 years old were more likely to have surgery as their primary treatment modality regardless of stage and were more likely to be discharged on an earlier day compared to older patients. Patients less or equal to 50 years old were more likely to be diagnosed at an earlier stage and therefore experience overall longer RFS.

Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage ovarian cancer: A prospective multicentre study (SELLY).

e17579 Background: Comprehensive surgical staging of early epithelial ovarian cancer includes systematic paraaortic and bilateral pelvic lymphadenectomy but its therapeutic role is controversial and it is associated with potential severe morbidity. The feasibility of sentinel lymph-node (SLN) identification in early stage ovarian cancer has been shown only. We did a prospective multicenter study to assess the feasibility, detection rate and diagnostic accuracy of the SLN procedure in predicting the pathological pelvic-node status in patients with early stage ovarian cancer. Methods: This is a phase II single arm study (EUDRACT 2019-001088-58) including patients with presumed stage I-II epithelial ovarian cancer planned for immediate or delayed minimally-invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green (ICG) solution. The pelvic and lumbo-aortic retroperitoneum is then accessed and inspected to identify and remove SLNs. Staging is then completed including systematic pelvic and para-aortic lymphadenectomy and an histopathological examination of all nodes is performed. The primary endpoint was estimation of the sensitivity and sensibility of SLN in predicting nodal status. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (i.e. the maximum marginal error) d=5%, a type I error α = 0.05, a sample size of 141 patients is needed to test the general hypothesis (i.e. to answer whether SLN(s) identified with ICG can accurately predict nodal status at histology of patients with apparently early EOC). Assuming a drop-out rate of 20%, a total of 176 patients will be enrolled in the study. Results: One-hundred and seventy-six patients were included with a drop-out rate of 22%. Sentinel node was identified in 102 patients (detection rate, 58%, [95% CI: 51-65]). There were no clinical differences between patients with successful or unsuccessful mapping. Both the infundibolopelvic ligament and the legamentum ovarii proprium were injected in 29.0% of cases. Twenty-one patients had positive nodes and 71% of them showed successful mapping. Among the latter, a negative sentinel node was identified in 3 patients (Sensitivity 78.6% [95% CI: 57-100]; Specificity 100%; Accuracy 97% [95% CI: 94-100]; PPV 100%; NPV 96,6% [95% CI: 93-100]). Twenty-two (12.5%) intra- and 25 (14.2%) postoperative complications occurred (12 G1; 9 G2; 2 G3, 2 G4). Clinical trial information: EUCTR2019-001088-58 .

Influence of the COVID-19 pandemic on the timing of surgical triage, tumor stage, and therapy of patients with colon carcinoma

PurposeWith the onset of the COVID pandemic in Germany in March 2020, far-reaching restrictions were imposed that limited medical access for patients. Screening examinations such as colonoscopies were greatly reduced in number. As rapid surgical triage after diagnosis is prognostic, our hypothesis was that pandemic-related delays would increase the proportion of advanced colon cancers with an overall sicker patient population.MethodsA total of 204 patients with initial diagnosis of colon cancer were analyzed in this retrospective single-center study between 03/01/2018 and 03/01/2022. Control group (111 patients, pre-COVID-19) and the study group (93 patients, during COVID-19) were compared in terms of tumor stages, surgical therapy, complications, and delays in the clinical setting. The data were presented either as absolute numbers or as median for constant data.ResultsA trend towards more advanced tumor stages (T4a p = 0.067) and a significant increase of emergency surgeries (p = 0.016) with higher rates of ileus and perforation (p = 0.004) as well as discontinuity resections (p = 0.049) during the pandemic could be observed. Delays in surgical triage after endoscopic diagnosis were seen during the 2nd lockdown (02/11/20–26/12/20; p = 0.031).ConclusionIn summary, the results suggest delayed treatment during the COVID-19 pandemic, with the infection pattern of COVID appearing to have a major impact on the time between endoscopic diagnosis and surgical triage/surgery. Adequate care of colon cancer patients is possible even during a pandemic, but it is important to focus on structured screening and tight diagnosis to treatment schedules in order to prevent secondary pandemic victims.

Management of large paravaginal hematomas with the Zhukovsky vaginal catheter.

To ameliorate the treatment of large paravaginal hematomas postpartum using the Zhukovsky vaginal catheter. A retrospective, controlled study including puerperas with large paravaginal hematomas. To assess the effectiveness of the proposed treatment, a group of patients underwent traditional obstetric surgery. A second group of puerperas underwent an integrated approach: the surgical stage (pararectal incision) and the application of the Zhukovsky vaginal catheter. The effectiveness of treatment was assessed according to the following criteria: blood loss volume and hospital admission time. In total, 30 puerperas were included in the study; 15 in each treatment group. Large paravaginal hematomas were reported most often in primiparas (50.0%), in 36.7% were combined with rupture of the vagina and the cervix, and in 10.0% of cases an episiotomy was performed during delivery. In 40.0% of primiparas, the blood loss volume was more than 1000 mL, whereas in multiparous and in multiple pregnancies, blood loss did not exceed 1000 mL (r = -0.49; P = 0.022). In 25.0% of puerperas with a blood loss of up to 1000 mL there were no obstetric injuries; in the group with a blood loss of more than 1000 mL, 83.3% of patients had obstetric injuries. An integrated approach reduced the blood loss volume (r = -0.22; P = 0.29), compared with the traditional surgery, and reduced the hospital admission time from 12 (11.5; 13.5) days to 9 (7.5; 10.0) days (P < 0.001). In patients with large paravaginal hematomas treated by an integrated approach we reported a decrease in bleeding, less risk of postoperative complications, and a reduction in the time of the hospital stay.

Этапная реконструктивно-пластическая хирургия при дефекте нижнего века после удаления базалиомы

Purpose. Evaluation of the effectiveness of multi-staged plastic and reconstructive rehabilitation of the patient with a large lower eyelid defect after the excision of basal cell carcinoma. Material and methods. The patient L., 75 years old, was treated with postoperative coloboma of the lower eyelid, lagophthalmos of the right eye after removal of the eyelid basal cell carcinoma, applied to the S.N. Fyodorov Eye Microsurgery Federal State Institution in Moscow. She underwent a multi-stage reconstructive plastic treatment in order to restore the anatomy and function of the lower eyelid, eliminate the cosmetic defect. Results and discussion. As a result of the first surgical stage, we were able to restore the skin defect using a free skin flap from the upper eyelid of the left eye. The second stage of treatment allowed us to restore the function of the lower eyelid by eliminating the artificial ankyloblepharone created earlier. The consequence of performing the following stages of surgery was the filling of the lack of the mucous membrane of the lower eyelid, the creation of the correct ratio and position of the cutaneous and conjunctival layers of the eyelid, the elimination of lagophthalmos and the restoration of anatomical and functional characteristics of the eyelid. Conclusion. As a result of multi-stage surgical treatment, the anatomical and functional integrity of the lower eyelid was achieved, prevented the loss of visual functions, achieved a satisfactory cosmetic effect, and also improved the patient's quality of life. Keywords: basal cell carcinoma, lower eyelid, staged plastic and reconstructive surgery