Treatment Of Gynecologic Cancers Research Articles

PARP inhibition and immune modulation: scientific rationale and perspectives for the treatment of gynecologic cancers.

Poly[adenosine diphosphate (ADP) ribose]polymerase (PARP) has multifaceted roles in the maintenance of genomic integrity, deoxyribonucleic acid (DNA) repair and replication, and the maintenance of immune-system homeostasis. PARP inhibitors are an attractive oncologic therapy, causing direct cancer cell cytotoxicity by propagating DNA damage and indirectly, by various mechanisms of immunostimulation, including activation of the cGAS/STING pathway, paracrine stimulation of dendritic cells, increased T-cell infiltration, and upregulation of death-ligand receptors to increase susceptibility to natural-killer-cell killing. However, these immunostimulatory effects are counterbalanced by PARPi-mediated upregulation of programmed cell-death-ligand 1 (PD-L1), which leads to immunosuppression. Combining PARP inhibition with immune-checkpoint blockade seeks to exploit the immune stimulatory effects of PARP inhibition while negating the immunosuppressive effects of PD-L1 upregulation.

Effects of Treatment Environment and Intensive Nursing Intervention on Gynecological Oncology Patients

Objective: To assess effects of treatment environment and intensive nursing intervention on gynecological oncology patients. Methods: 108 patients diagnosed as gynecological oncology from July 2015 to July 2018. They were randomly assigned to control group and intervention group, the participant had the different nursing measure and new treatment environment in two groups. We collected the result that included quality of life, pain level, immune function and participants characteristics by completing questionnaires, collecting medical records and flow cytometer. In addition, the participants were asked to complete the questionnaires, such as Short Form-36 (SF-36) and Self-report questionnaires. We use flow cytometer (FCM) to assess immunity function of patient. Result: The participants of intervention group had higher increasing in CD8+ (19.88±2.40 vs 17.32±2.88). Additionally, most participants had mild pain in treatment process [30 (50.66%) & 42 (73.24%)] and few participants had severe pain. In addition, few participants had severe pain, very few participants had very pain experience and painless experience in treatment process. In four domains of quality of life, all participants were improved in all domains. Conclusion: Treatment environment and intensive nursing intervention improve the outcome of gynecologic cancer treatment. But the improvement was not significant in the treatment process.

The Therapeutic Effects of Goreisan, a Traditional Japanese Herbal Medicine, on Lower-Limb Lymphedema after Lymphadenectomy in Gynecologic Malignancies: A Case Series Study.

Background Lower-limb lymphedema (LLL) is a chronic and progressive complication of gynecologic cancer treatment, including pelvic lymphadenectomy. This study aims to investigate the therapeutic effect of goreisan, a traditional Japanese medicine, which has been used for hydrostatic modulation on patients with LLL. Methods Patients diagnosed with LLL in our hospital in 2018 were included and principally treated with complex decongestive therapy (CDT), including elastic clothing and lymph drainage. The patients who received a combination therapy of CDT and goreisan (CDT-G group) were prescribed goreisan extract granules, with a dose of 7.5 g per os daily in three doses. Patients who were not prescribed goreisan received CDT alone (CDT group). The severity of lymphedema was evaluated by the estimated limb volume calculated by limb circumferences and the ratio of extracellular water (ECW) to total body water (TBW). Results Nineteen women with LLL after pelvic lymphadenectomy were included in the study. The number of patients in the CDT and CDT-G groups was 8 and 11, respectively. There were no statistically significant differences between the CDT and CDT-G groups in terms of patient characteristics and severity of LLL before treatment. Reduction in ECW/TBW in the CDT-G group (in the whole body and the affected lower limb) after the intervention was significantly more remarkable than that in the CDT group. Conclusions Goreisan-based Japanese herbal therapy may be effective in patients with LLL after retroperitoneal lymphadenectomy.

IMRT and brachytherapy comparison in gynaecological cancer treatment: thinking over dosimetry and radiobiology.

BackgroundThe role of radiotherapy and brachytherapy in the management of locally advanced cervical and endometrial cancer is well established. However, in some cases, intracavitary brachytherapy (ICBRT) is not recommended or cannot be carried out. We aimed to investigate whether external-beam irradiation delivered by means of intensity-modulated radiation therapy (IMRT) might replace ICBRT in gynaecological cancer when the standard ICBRT boost delivering cannot be administered for technical or clinical reasons.Materials and methodsFifteen already delivered treatments for gynaecological cancer patients were analysed. The treatments were performed through 3-dimensional conformal radiotherapy (3D-CRT) to the whole-pelvis up to the dose of 45–50.4 Gy followed by a boost dose administered with ICBRT in high-dose-rate or pulsed-dose-rate modality. For each patient, IMRT plans were elaborated to mimic the ICBRT. We analysed the ICBRT boost versus IMRT boost in terms of dosimetric and radiobiological aspects.ResultsMean conformity index value calculated on boost volume was 0.73 for ICBRT and 0.97 for IMRT. Mean conformation number was 0.24 for ICBRT boost and 0.78 for IMRT boost. Mean normal tissue complication probability (NTCP) values for 3D-CRT plus ICBRT and for IMRT (pelvis plus boost) were, respectively, 28% and 5% for rectum; 1.5% and 0.1% for urinary bladder and 8.9% and 6.1% for bowel.ConclusionsOur findings suggest that IMRT may represent a viable alternative in delivering the boost in patients diagnosed with gynaecological cancer not amenable to ICBRT.

Correlation Among Anxiety, Depression, and Quality of Life in Women With Gynecologic Cancer

Anxiety and depression are common emotional distresses experienced by women during gynecologic cancer treatment. These often have dangerous effects on physical and mental health and may impact quality of life (QoL). To investigate the factors influencing anxiety, depression, social support, and QoL in women with gynecologic cancer. This was a cross-sectional correlational study. A total of 111 women with gynecologic cancer receiving treatment at a medical center in central Taiwan were selected as subjects using convenience sampling. A demographic characteristics questionnaire, the World Health Organization Quality of Life-Brief-Taiwan version (WHOQOL-BREF-Taiwan version) questionnaire, the International Support Evaluation List (ISEL), and the Hospital Anxiety and Depression Scale (HADS) were used for data collection. Of the 111 subjects, 41.4% and 24.3% had tendencies for anxiety and depression, respectively, and a moderate QoL score (mean = 3.46; SD = 0.73). The physical health domain had the highest mean QoL score (14.93; SD = 2.24), followed by environmental health (14.76; SD = 1.97), social relationships (14.13; SD = 2.33), and psychological health (13.92; SD = 2.44). Anxiety, depression, marital status, and social support respectively explained 18.5%-37.0% of the total variation in QoL scores. Of the four QoL domains examined in this study, anxiety was the most significant predictor of QoL. It is recommended that healthcare professionals strengthen the early assessment of anxiety, depression, and social support in women with gynecologic cancer. In addition, sensitivity towards emotional status should be increased in these cases. Healthcare professionals should provide care, support, and timely completion of referrals. Finally, psychological and social support and related interventions should be provided based on patient needs in order to maintain QoL.

Intraoperative near infrared fluorescence for detecting sentinel lymph nodes in the robotic surgical approach of endometrial cancer

In recent years sentinel lymph node (SLN) mapping has emerged as an attractive investigational approach for the treatment of gynecological cancers, and in particular, endometrial cancer (EC). In fact, radical lymphadenectomy may have no therapeutic benefit in patients with early-stage EC who have low probability of lymph nodes involvement; subsequently, SLN mapping may decrease unnecessary lymph node dissections. In recent years, the number of minimally invasive procedures for gynecologic oncology has increased, with robotic procedures rising remarkably. Robotic SLN evaluation by intraoperative near infrared fluorescence (INIF) imaging system (Firefly™, Intuitive Surgical Inc., Sunnyvale, CA, USA) is an innovative surgical tool, which allows for a rapid conversion from the normal robotic view to that for detecting fluorescent indocyanine green (ICG). The aim of this video is to describe the use of this tool and technical outcomes of SLN dissection during our single-center experience in the robotic surgical approach of patients with early endometrial cancer.

Pharmacogenomic analysis of patient-derived tumor cells in gynecologic cancers

BackgroundGynecologic malignancy is one of the leading causes of mortality in female adults worldwide. Comprehensive genomic analysis has revealed a list of molecular aberrations that are essential to tumorigenesis, progression, and metastasis of gynecologic tumors. However, targeting such alterations has frequently led to treatment failures due to underlying genomic complexity and simultaneous activation of various tumor cell survival pathway molecules. A compilation of molecular characterization of tumors with pharmacological drug response is the next step toward clinical application of patient-tailored treatment regimens.ResultsToward this goal, we establish a library of 139 gynecologic tumors including epithelial ovarian cancers (EOCs), cervical, endometrial tumors, and uterine sarcomas that are genomically and/or pharmacologically annotated and explore dynamic pharmacogenomic associations against 37 molecularly targeted drugs. We discover lineage-specific drug sensitivities based on subcategorization of gynecologic tumors and identify TP53 mutation as a molecular determinant that elicits therapeutic response to poly (ADP-Ribose) polymerase (PARP) inhibitor. We further identify transcriptome expression of inhibitor of DNA biding 2 (ID2) as a potential predictive biomarker for treatment response to olaparib.ConclusionsTogether, our results demonstrate the potential utility of rapid drug screening combined with genomic profiling for precision treatment of gynecologic cancers.

Genomic and Molecular Abnormalities in Gynecologic Clear Cell Carcinoma.

Gynecologic clear cell carcinoma is a rare histology, accounting for ~5% of all ovarian and endometrial cancers in the United States. Compared to other types of gynecologic cancer, they are generally less responsive to standard therapy and have an overall worse prognosis. In addition, mounting evidence suggests that the landscape of genetic and molecular abnormalities observed in these tumors is distinct from other cancers that arise from the same sites of origin. On a molecular level, these tumors characteristically display upregulation of the PI3K-AKT-mTOR and RAS-RAF-MAPK signaling axes, frequent loss of ARID1a, and overexpression of MDM2. Evidence also suggests that these tumors are more likely to express programmed death ligand 1 or demonstrate microsatellite instability than other gynecologic cancers. Despite these important differences, there has been relatively little investigation into histology-specific treatment of clear cell gynecologic cancers, representing an opportunity for new drug development. In this article, we review the unique genetic and molecular features of gynecologic clear cell cancers with an emphasis on potential therapeutic targets. The results of completed studies of treatment for clear cell carcinoma are also presented. We conclude with a discussion of ongoing clinical trials and potential avenues for future study.

Feasibility of precision cancer medicine in advanced gynaecologic cancers

Abstract Background Advanced gynecologic cancers have a poor prognosis and constitute a major challenge for adequate treatment strategies. By analyzing and targeting molecular alterations, precision cancer medicine (PCM) may be a viable option for the treatment of advanced gynecologic cancers. Methods In this single center, real-world retrospective analysis of our PCM platform, we describe the molecular profiling of 72 patients diagnosed with different types of metastasized BTC. Tumor samples of the patients were examined by a 162-gene next-generation sequencing (NGS) panel, immunohistochemistry (IHC), fluorescence in situ hybridization (FISH) and RNA fusion panel. Results In total, we identified 209 molecular aberrations in 72 patients. The ten most frequently alterations were TP53 (n = 42), KRAS (n = 14), PIK3CA (n = 11), PIK3R1 (n = 9), ATR (n = 8), PTEN (n = 8), BRCA1 (n = 6), NF1 (n = 4), NOTCH1 (n = 4), POLE (n = 4) that make up together over half of the molecular alterations (52.6%). BRAF mutations and gene fusions each were observed in two patients. 21 patients were found to have only one mutation and 44 patients had more than one mutation. No mutations were detected in 7 patients. IHC detected expression of p-mTOR and EGFR in 58 and 53 patients, respectively. In over two-thirds (n = 51) of the 72 patients, a targeted therapy was suggested, based on the identified genetic mutations. The most frequently recommended specific treatment was the combination of everolimus with exemestan (n = 19). The median turnaround time from biopsy to discussion in our multidisciplinary tumor board was 20 days. The median turnaround time from biopsy to therapy initiation was 26 days. Conclusions Based on our observations, it seems that PCM might be a feasible treatment approach for advanced gynecologic cancers with limited treatment options. Legal entity responsible for the study Medical University of Vienna. Funding Has not received any funding. Disclosure H. Taghizadeh: Travel / Accommodation / Expenses: Roche. All other authors have declared no conflicts of interest.

Physical Activity: Impact on Survival in Gynecologic Cancer.

Physical activity has many important health benefits. There is also growing evidence that physical activity plays a role in the prevention and prognosis of multiple cancers, including gynecologic malignancies. Despite the many benefits of physical activity, the number of individuals meeting physical activity recommendations remains low. To examine the role that physical activity plays in the prevention, treatment, and prognosis of gynecologic malignancies and to review the feasibility of physical activity interventions among gynecologic cancer survivors. A PubMed search was performed using relevant terms to identify journal articles related to the proposed subject. The websites of multiple national and international organizations were also used to obtain up-to-date guidelines and recommendations. Physical activity appears to decrease the risk of ovarian, endometrial, and cervical cancer, with the strongest evidence of this association seen in endometrial cancer. Although the literature is scarce, participation in physical activity is feasible during active treatment for gynecologic cancers and may decrease symptom burden and increase chemotherapy completion rates. Gynecologic cancer survivors are motivated to increase physical activity, and lifestyle intervention programs are feasible and well received among this population. Health care providers caring for women with gynecologic malignancies must counsel patients regarding the importance of physical activity. This should include a discussion of the health benefits and, specifically, the cancer-related benefits. A personalized approach to physical activity intervention is essential.

Early clinical experience with varian halcyon V2 linear accelerator: Dual-isocenter IMRT planning and delivery with portal dosimetry for gynecological cancer treatments.

PurposeVarian Halcyon linear accelerator version 2 (The Halcyon 2.0) was recently released with new upgraded features. The aim of this study was to report our clinical experience with Halcyon 2.0 for a dual‐isocenter intensity‐modulated radiation therapy (IMRT) planning and delivery for gynecological cancer patients and examine the feasibility of in vivo portal dosimetry.MethodsTwelve gynecological cancer patients were treated with extended‐field IMRT technique using two isocenters on Halcyon 2.0 to treat pelvis and pelvic/or para‐aortic nodes region. The prescription dose was 45 Gy in 25 fractions (fxs) with simultaneous integrated boost (SIB) dose of 55 or 57.5 Gy in 25 fxs to involved nodes. All treatment plans, pretreatment patient‐specific QA and treatment delivery records including daily in vivo portal dosimetry were retrospectively reviewed. For in vivo daily portal dosimetry analysis, each fraction was compared to the reference baseline (1st fraction) using gamma analysis criteria of 4 %/4 mm with 90% of total pixels in the portal image planar dose.ResultsAll 12 extended‐field IMRT plans met the planning criteria and delivered as planned (a total of 300 fractions). Conformity Index (CI) for the primary target was achieved with the range of 0.99–1.14. For organs at risks, most were well within the dose volume criteria. Treatment delivery time was from 5.0 to 6.5 min. Interfractional in vivo dose variation exceeded gamma analysis threshold for 8 fractions out of total 300 (2.7%). These eight fractions were found to have a relatively large difference in small bowel filling and SSD change at the isocenter compared to the baseline.ConclusionHalcyon 2.0 is effective to create complex extended‐field IMRT plans using two isocenters with efficient delivery. Also Halcyon in vivo dosimetry is feasible for daily treatment monitoring for organ motion, internal or external anatomy, and body weight which could further lead to adaptive radiation therapy.

Anticholinergic burden of long-term medication is an independent risk factor for the development of postoperative delirium: A clinical trial.

Postoperative delirium (POD) is a common complication after surgery. We sought to determine the association between preoperative anticholinergic load calculated using the anticholinergic drug scale (ADS) and POD in cancer patients over 65 years of age. A retrospective sub-investigation of a randomised controlled interventional trial. Two tertiary university hospitals. Overall, patients aged 65 years and older scheduled for surgical treatment of gastrointestinary, genitourinary or gynaecological cancers. The primary outcome was the interaction between anticholinergic drug scale and occurrence of postoperative delirium. Patient clinical parameters and ADS scores were assessed preoperatively. POD screening was conducted for a total of 7 days following surgery using validated measures. Independent associations between ADS and POD were assessed using multivariate logistical regression analyses. A total of 651 patients (mean age, 71.8 years; 68.5% males) were included. Of those, 66 patients (10.1%) developed POD. The ADS score was independently associated with the occurrence of POD (higher ADS per point OR 1.496; 95% CI 1.09-2.05; p = 0.01). Additionally, age (per year OR 1.06; CI 95% CI 1.01-1.11; p = 0.03) and ASA state (OR 2.16; 95% CI 1.22-3.83; p = 0.01), as well as stay on ICU (yes vs. no OR 2.8; 95% CI 1.57-4.998; p < 0.01), were independently associated with POD. ADS assessment according to chronic medication use is a cost-effective, non-invasive method of identifying elderly cancer patients at risk for POD. www.clinicaltrials.gov. Identifier NCT01278537. Ethics: IRB of Charité University-Medicine Berlin, Germany; EA2/241/08.

Patients' and physicians' expectations differ significantly during the follow-up period after completion of primary treatment of gynecological or breast cancer

Patients' and physicians' expectations differ significantly during the follow-up period after completion of primary treatment of gynecological or breast cancer

Noninvasive Prediction of Lymph Node Status for Patients with Early-Stage Cervical Cancer Based on Radiomics Features from Ultrasound Images

To investigate the feasibility of a noninvasive detection of lymph node metastasis (LNM) for early-stage cervical cancer (ECC) patients with radiomics methods based on the textural features from ultrasound images. One hundred seventy-two ECC patients between January 2014 and September 2018 with pathologically confirmed lymph node status (LNS) and preoperative ultrasound images were retrospectively reviewed. Regions of interest (ROIs) were delineated by a senior radiologist in the ultrasound images. LIFEx was applied to extract textural features for radiomics study. Least absolute shrinkage and selection operator (LASSO) regression was applied for dimension reduction and for selection of key features. A multivariable logistic regression analysis was adopted to build the radiomics signature. The Mann–Whitney U test was applied to investigate the correlation between radiomics and LNS for both training and validation cohorts. Receiver operating characteristic (ROC) curves were applied to evaluate the accuracy of the radiomics prediction models. A total of 152 radiomics features were extracted from ultrasound images, in which 6 features were significantly associated with LNS (p < 0.05). The radiomics signatures demonstrated a good discrimination between patients with LNM and non-LNM groups. The best radiomics performance model achieved an area under the curve (AUC) of 0.79 (95% confidence interval (CI), 0.71–0.88) in the training cohort and 0.77 (95% CI, 0.65–0.88) in the validation cohort. The feasibility of radiomics features from ultrasound images for the prediction of LNM in ECC was investigated. This noninvasive prediction method may be used to facilitate preoperative identification of LNS in patients with ECC. • Few studied had investigated the feasibility of radiomics based on ultrasound images for cervical cancer, even though it is the most common practice for gynecological cancer diagnosis and treatment. • The radiomics signatures based on ultrasound images demonstrated a good discrimination between patients with and without lymph node metastasis with an area under the curve (AUC) of 0.79 and 0.77 in the training and validation cohorts, respectively. • The radiomics model based on preoperative ultrasound images has the potential ability to predict lymph node status noninvasively in patients with early-state cervical cancer, so as to reduce the impact of invasive examination and to optimize the treatment choices.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting.

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

Current Possibilities of Gynecologic Cancer Treatment with the Use of Immune Checkpoint Inhibitors.

Despite the ongoing progress in cancer research, the global cancer burden has increased to 18.1 million new cases and 9.6 million deaths in 2018. Gynecological cancers, such as ovarian, endometrial, and cervical cancers, considerably contribute to global cancer burden, leading to $5,862.6, $2,945.7, and $1,543.9 million of annual costs of cancer care, respectively. Thus, the development of effective therapies against gynecological cancers is still a largely unmet medical need. One of the novel therapeutic approaches is to induce anti-cancer immunity by the inhibition of the immune checkpoint pathways using monoclonal antibodies. The molecular targets for monoclonal antibodies are cytotoxic T lymphocyte-associated protein-4 (CTLA-4), programmed cell death protein-1 (PD-1), and programmed death-ligand 1 (PD-L1). The rationale for the use of immune checkpoint inhibitors in patients with gynecological cancers was based on the immunohistological studies showing high expression levels of PD-1 and PD-L1 in those cancers. Currently available immune checkpoint inhibitors include nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, and ipilimumab. The efficacy and safety of these inhibitors, used as monotherapy and with combination with chemotherapy, is being currently evaluated in several clinical studies. As the results are promising, more clinical trials are being planned, which may lead to the development of efficient therapies for gynecological cancer patients.

Sexual Function, Quality of Life, and Experiences of Women with Ovarian Cancer: A Mixed-Methods Study.

IntroductionOvarian cancer impacts approximately 1 in 75 women. Sexual health is receiving increasing attention as a critical aspect of gynecologic cancer treatment and a component of quality of life. Therefore, investigating how women with ovarian cancer experience and express sexuality is an important area of inquiry.AimsTo evaluate how women with ovarian cancer experience and express sexuality, a major determinant of quality of life, in the context of their illness.MethodsIn a mixed-methods approach, 6 validated self-report questionnaires (n = 64) and an in-depth focus group (n = 3) were used to gather data.ResultsThe quantitative phase of the study showed that women with ovarian cancer have a poorer quality of life and higher rates of sexual dysfunction and sexual distress compared with published norms from the general population. They also have lower levels of relationship satisfaction and increased rates of depression. The qualitative phase of the study revealed 6 themes: (i) changes to relationship satisfaction; (ii) sexual difficulties; (iii) challenges with body image; (iv) gaps in communication with healthcare providers; (v) feelings of guilt, grief, resentment, anxiety, and fear; and (vi) strategies used for coping.ConclusionsOvarian cancer impacts women’s lives beyond mere survival, including their sexual function and quality of life. Healthcare providers are urged to prepare women with ovarian cancer for these challenges and offer information and resources to help improve their quality of life and sexuality.Fischer OJ, Marguerie M, Brotto LA. Sexual Function, Quality of Life, and Experiences of Women with Ovarian Cancer: A Mixed-Methods Study. Sex Med 2019;7:530–539.

Early Clinical Experience with Varian Halcyon V2 Linear Accelerator: Dual -Isocenter IMRT Planning and Delivery with Portal Dosimetry for Gynecological Cancer Treatments

A linear accelerator was recently released with new upgraded features. One of new features is to allow treatment length > 28cm using multiple- isocenters (maximum of 36cm in superior and inferior directions). As one of the first users of Halcyon V2, we report our clinical experience with Halcyon V2 for a dual - isocenter IMRT planning and delivery for gynecological cancer patients and examine the feasibility of in-vivo portal dosimetry. Eight extended field IMRT plans for gynecological cancer patients were generated with a treatment planning system using two isocenters to treat pelvis and pelvic/or para-aortic nodes region. Auto feathering technique was employed to split fields between isocenters during IMRT optimization. The prescription dose was 45Gy in 25 fractions (fxs) with simultaneous integrated boost (SIB) dose of 55Gy or 57.5 Gy in 25 fxs to involved nodes. All treatment plans, pre-treatment patient specific QA and treatment delivery records including daily in-vivo portal dosimetry were retrospectively reviewed. For in-vivo daily portal dosimetry analysis, each fraction was compared to the reference baseline (1st fraction) using gamma analysis criteria of 4%/4mm with 90% of total pixels in the portal image planar dose. All 8 extended field IMRT plans met the planning criteria and delivered as planned (a total of 200 fractions). Conformity Index (CI) for the primary target was achieved with the range of 0.99-1.14. For organs at risks, most were well within the dose volume criteria. Treatment delivery took from 5.0 to 6.5 minutes. All 8 cases passed pre-treatment QA using gamma analysis criteria of 3%/2mm with 95 % of total pixels. Interfractional in-vivo dose variation exceeded gamma analysis threshold for 8 fractions out of total 200 (4%). Those 8 fractions were found to have relatively large difference in small bowel filling or motion and SSD change at the isocenter compared to the baseline. Halcyon V2 is effective to create complex extended field IMRT plans using dual isocenters with efficient delivery. Also Halcyon in-vivo dosimetry is feasible for daily treatment monitoring for possible (or significant) changes of organ motion, internal or external anatomy and weight which could further lead to adaptive radiation therapy.

Laterally extended endopelvic resection with external iliac vessels resection and crossover ileofemoral bypass

Involvement of major pelvic vessels is one of the traditional contraindications of surgical treatment for recurrent gynecologic cancers. In our experience, ligation of the external iliac vein is also feasible...

Prediction of early discharge after gynaecological oncology surgery within ERAS.

Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2days). This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures). 230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR 0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR 0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]). The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.