International Journal of Gynecological Cancer最新文献

Objective: This study aimed to assess factors contributing to the survival disparity between insured Black and White patients with uterine cancer treated within the same large US health care system.

Methods: This is a retrospective cohort analysis of Black and White patients diagnosed with uterine cancer from 2005 to 2022 while members of a large community-based integrated US health care system. Five domains of factors potentially contributing to survival were characterized: co-morbidities, diagnostic process, treatment, tumor characteristics, and socioeconomic factors. Using logistic regression, propensity scores were calculated and used to sequentially balance Black and White patients for each of these domains, evaluating the effect of balancing each domain on the hazard ratio (HR) for 5-year mortality for Black versus White patients.

Results: Comparing 11,878 White with 2196 Black patients, the HR for 5-year mortality for Black patients, adjusted for baseline characteristics and co-morbidities, was 2.05 (95% confidence interval [CI] 1.79 to 2.33). Substantial reductions in excess mortality were observed after balancing tumor factors, which reduced the HR to 1.31 (95% CI 1.11 to 1.53), and socioeconomic factors, which further reduced the HR to 1.08 (95% CI 0.91 to 1.28). No significant reduction was observed after balancing co-morbidity, diagnostic, or treatment factors.

Conclusions: Among insured patients treated within the same US health care system, Black patients had approximately twice the mortality risk of White patients, with 70.8% of the excess relative risk of death among Black patients being attributable to tumor characteristics, 21.4% attributable to socioeconomic status, and 7.8% un-explained. Co-morbidities, diagnostic efficiency, and treatment quality were not significant contributors relative to other factors. These findings suggest that eliminating disparities in survival between Black and White patients will require development of more effective treatments for high-risk tumor types and interventions that mitigate the negative effects of lower socioeconomic status on health.

Objective: To evaluate the effects of fertility-sparing treatment on reproductive and obstetric outcomes in patients diagnosed with early-stage endometrial cancer or atypical hyperplasia.

Methods: A systematic review and meta-analysis was conducted. Literature was searched across multiple electronic databases. The risk of bias in the included studies was assessed using a modified domain-based methodology. This approach evaluated critical bias domains aligned with established systematic review tools, including selection bias, performance bias, attrition bias, detection bias, and reporting bias. Data were extracted and analyzed using R software, with evaluations of heterogeneity and publication bias.

Results: Six studies comprising 337 patients were included. Progestin-based fertility-sparing treatment achieved a complete response rate of up to 94%, with pregnancy rates as high as 77% in some cohorts. Significant variation was observed across studies, with reported pregnancy rates ranging from 44.9% to 70.7% (He and colleagues, 2022). The pooled relative risk for recurrence/progression was 1.1 (95% confidence interval 0.99 to 1.23), indicating no significantly elevated risk of disease recurrence/progression with fertility-sparing treatment compared with conventional treatment. However, the studies showed a high risk of bias, particularly in randomization processes. Sensitivity analysis indicated that the findings were significantly influenced by a single study.

Conclusions: Fertility-sparing treatment shows favorable reproductive outcomes for women with early-stage endometrial cancer or atypical hyperplasia, with high response and pregnancy rates and no significantly increased risk. However, the significant risk of bias and considerable inter-study heterogeneity warrant cautious interpretation of these results. Future rigorously designed studies are needed to confirm these results and support clinical application.

Objective: Tissue biopsy is an important component of pre-surgical pathologic diagnosis of cancer for treatment planning and clinical research. Core needle biopsy, or Tru-Cut biopsy, was introduced in the 1960s and 1970s but has not yet become routine in gynecologic oncology, and few studies have examined its adequacy or accuracy in this setting. We report our experience of ultrasound-guided core needle biopsy in patients with gynecologic malignancies.

Methods: We conducted a retrospective study of ultrasound-guided core needle biopsy at a single tertiary hospital in Prague, Czech Republic, using electronic medical records of cases between 2010 and 2022. We examined the adequacy of biopsy samples, accuracy relative to surgical pathology specimens, and safety. Ultrasound-guided core needle biopsy was performed using standardized procedures.

Results: A total of 690 core needle biopsy procedures were evaluated (456 in newly diagnosed cases and 234 in recurrent cases), including 16 repeat procedures, in 674 patients. The 3 most common biopsy sites were ovary (29.3%), carcinomatosis (17.4%), and indeterminate pelvic mass (10.2%). Most (85.9%) biopsies retrieved 3 tissue samples. Core needle biopsy was adequate to establish a diagnosis in 622 of 690 cases (90.1%), and repeat core needle biopsy yielded an additional 16 adequate samples (2.3%). The adequacy rate was highest for ovarian biopsies (96.6%) and lowest for uterine body biopsies (83.3%). Pathologic assessment of core needle biopsy agreed with surgical specimens in 263 of 273 patients who underwent surgery, with an accuracy rate of 96.3%. There was no clear correlation between inaccurate biopsy results and final histotypes. Complications occurred in 9 of 690 core needle biopsy procedures (1.3%), including 6 cases of intra-procedural bleeding (3 required hospitalization), 2 cases of infection, and 1 case of a psychogenic reaction (non-epileptic seizure).

Conclusions: Ultrasound-guided core needle biopsy is an accurate, well-tolerated technique that provides reliable diagnostic tissue in gynecologic oncology and may be considered a preferred approach for initial evaluation and confirmation of disease.

Objective: To evaluate NK6 homeobox 1 (NKX6.1) promoter methylation in cervical lesions and its association with human papillomavirus (HPV)16/18 infection, histological sub-type, and patient outcomes using clinical and bioinformatic data.

Methods: A total of 207 cervical tissue samples, including cervicitis (n = 22), cervical intraepithelial neoplasia grade 3 (n = 20), adenocarcinoma in situ (n = 6), adenocarcinoma (n = 59), and squamous cell carcinoma (n = 100), were analyzed by methylation-specific polymerase chain reaction and bisulfite sequencing. HPV genotyping was performed with the INNO-LiPA assay. The Cancer Genome Atlas data (n = 309) were examined for methylation at 27 cytosine-phosphate-guanine sites and their association with overall survival.

Results: NKX6.1 promoter methylation was detected in 26.6% of cervical samples and was significantly associated with neoplastic lesions, particularly squamous sub-types (p = .002), with comparable frequencies in cervical intraepithelial neoplasia 3. Logistic regression confirmed that NKX6.1 methylation and HPV16/18 infection were independently associated with squamous cell carcinoma. The Cancer Genome Atlas analysis revealed 11 cytosine-phosphate-guanine sites within NKX6.1 significantly correlated with overall survival, with loci, such as cg12401926 and cg18297736 linked to poorer outcomes. These prognostic effects were locus-specific and not observed when global methylation was considered.

Conclusion: NKX6.1 promoter methylation represents an early event in cervical carcinogenesis and is associated with squamous histology. Although global methylation showed no prognostic relevance, site-specific cytosine-phosphate-guanine methylation patterns demonstrated significant survival associations, supporting NKX6.1 as a potential locus-dependent prognostic biomarker in cervical cancer.

Objective: To assess risk factors for long-term recurrence of vulvar high-grade squamous intra-epithelial lesions (vulvar HSIL) and other high-risk human papillomavirus-related genital dysplasia after primary treatment with imiquimod or surgery.

Methods: This was a long-term follow-up of the PITVIN trial (Clinicaltrials.gov identifier: NCT01861535), a multi-center, randomized, phase 3 non-inferiority clinical study of topical imiquimod versus surgery for vulvar HSIL. Number of recurrent vulvar HSIL or other HSIL and related treatment types were assessed. The relationship between initial study treatment, patient characteristics, primary response (quick versus slow) to imiquimod, and pre-treatment immune infiltrates in recurrent and non-recurrent HSIL were analyzed.

Results: Long-term clinical data was available for 87 patients (42 imiquimod, 45 surgery) of the 107 patients included in the original intention-to-treat analysis. Mean follow-up time was 70 months (standard deviation ±24). Among the 80 patients with per-protocol treatment in the initial study, recurrent vulvar HSIL was diagnosed in 33% (12/36) after imiquimod and in 20% (9/44) after surgery (p =.20). Baseline recurrence status, age, and smoking were not associated with vulvar HSIL recurrence. Within the imiquimod study group, patients with an initial slow or partial response to imiquimod experienced recurrent HSIL lesions in 54% (7/13), and patients with an initial quick response in 22% (5/23) of cases (p =.05). Recurrent vulvar HSILs showed significantly higher initial intra-epithelial infiltration of cluster of differentiation 33+ immature monocytes compared with non-recurrent lesions (p =.04), suggesting tumor-mediated immunosuppression. In the intention-to-treat population, 21% (18/87) developed cervical HSIL (n = 9), vaginal HSIL (n = 3), anal HSIL (n = 3), cervical cancer (n = 1), anal cancer (n = 1) and vulvar cancer (n = 1) during long-term follow-up.

Conclusions: Topical imiquimod and surgical treatment of vulvar HSIL are effective in long-term follow-up, with recurrences occurring in 20% to 33% of patients within 5 years. Initial slow or partial treatment response to imiquimod and the composition of pre-treatment immune infiltrates may be predictors of an increased long-term recurrence risk.

Objective: Body mass index (BMI) has been associated with length of stay and post-operative complications; however, minimally invasive surgery has been proposed to mitigate this. Using real-world data of patients undergoing minimally invasive surgery for uterine cancer, we investigated the association between BMI and length of stay. Among patients discharged the same day, we explored post-operative complications associated with BMI.

Methods: This was a National Surgical Quality Improvement Program retrospective cohort study including patients who underwent minimally invasive surgery for uterine cancer from 2013 to 2022. We performed a multi-variable Poisson regression to assess the association between BMI and length of stay, adjusting for a priori selected patient-level factors. In patients discharged the same day after surgery, we performed multi-variable linear regression to assess associations between BMI and the following post-operative complications: wound disruption, blood transfusion, surgical site infections, urinary tract infection, pneumonia, sepsis, deep vein thrombosis, pulmonary embolism, renal insufficiency, myocardial infarction, stroke/cerebrovascular accident, and re-admission, return to the operating room, and death within 30 days.

Results: A total of 33,307 patients were included. Their median BMI was 34.2 kg/m² (interquartile range [IQR] 12.88) and median length of stay was 1 day (IQR 1). Length of stay increased by approximately 0.5 hours per 5 kg/m² (per BMI obesity class categorization). In total, 9186 patients (27.6%) were discharged the same day after their minimally invasive surgery for uterine cancer, and in this cohort, no association between BMI and any post-operative complications were found.

Conclusions: In patients undergoing minimally invasive surgery for uterine cancer, BMI was not associated with a clinically significant increase in length of stay, and in those discharged the same day, BMI was not associated with post-operative complications. Minimally invasive surgery for uterine cancer should be considered standard of care regardless of patient BMI, and same-day discharge for patients with elevated BMI is safe.

Objective: Clear cell endometrial cancer is a rare, aggressive sub-type with a poor prognosis. Due to its low incidence, treatment strategies are often extrapolated from other high-risk histologies. Optimal adjuvant treatment following primary surgery for advanced clear cell endometrial cancer is unclear. This meta-analysis compares radiotherapy-containing strategies with chemotherapy alone in the adjuvant setting.

Methods: We conducted a systematic literature review (Medline, Cochrane CENTRAL, Embase, and Web of Science) of studies evaluating first-line adjuvant treatment for advanced clear cell endometrial cancer. Inclusion criteria were: English language; full peer-reviewed manuscript; International Federation of Gynecology and Obstetrics 2009 stage III/IV clear cell patients receiving adjuvant chemotherapy and/or radiotherapy after primary surgery (staging or cytoreductive); and overall survival data specific to this cohort. Studies reporting overall survival estimates comparing treatment groups in advanced clear cell endometrial cancer patients were included. A random-effects model was used to estimate the overall survival hazard ratio (HR) and 95% confidence interval (CI), pooled using the generic inverse-variance method with adjusted weights.

Results: The search yielded 5421 results, of which 6 met the inclusion criteria. 1 article included 2 independent cohorts, resulting in 7 studies included in the meta-analysis. A total of 1266 patients received adjuvant chemotherapy alone, and 531 patients received adjuvant chemoradiotherapy or radiotherapy only. The pooled HR from 7 studies was 0.63 (95% CI 0.53 to 0.74), corresponding to a 37% reduction in the risk of death for patients receiving adjuvant chemoradiotherapy or radiotherapy compared with chemotherapy alone. The results were consistent across the studies, with no evidence of heterogeneity (p =.89).

Conclusions: Adjuvant chemoradiotherapy or radiotherapy was associated with improved overall survival in advanced clear cell endometrial cancer compared with chemotherapy alone. These findings support prospective validation and define the optimal integration of radiotherapy in this setting.

The role of systematic pelvic and para-aortic lymphadenectomy in presumed early-stage ovarian cancer remains controversial due to the lack of high-quality prospective evidence. No therapeutic benefit has been confirmed for systematic lymphadenectomy during surgical staging for apparent early-stage ovarian cancer. Lymphadenectomy may improve progression-free survival but has demonstrated no impact on overall survival, except for clear cell ovarian cancer, where a potential survival benefit has been suggested in retrospective studies. Systematic lymphadenectomy retains a diagnostic role in identifying occult nodal metastases (9% to 30% across series) undetected on pre-operative imaging or intra-operative assessment. The decision to perform lymphadenectomy should be individualized based on several factors, including histological sub-type, tumor grade, stage, and biomarker profile. Key considerations include the anticipated risk of lymph node metastasis, the opportunity to tailor adjuvant treatment by either omitting chemotherapy or offering maintenance targeted therapy, peri-operative morbidity, long-term sequelae impacting quality of life (eg, lower limb lymphedema), and cost-effectiveness. Systematic lymphadenectomy is guideline-recommended for high-grade tumors, including high-grade serous, high-grade endometrioid, and clear cell histologies, whereas it can be omitted in low-grade endometrioid and expansile mucinous sub-types. Its significance in low-grade serous and infiltrative mucinous ovarian cancers remains unclear, although guidelines frequently advocate for lymphadenectomy in these cases. To optimize patient selection, large-scale prospective studies with proper stratification by histotype and molecular profile are required. Emerging approaches to lymph node assessment, such as sentinel lymph node biopsy, artificial intelligence-assisted pre-operative imaging, and liquid biopsy, hold promise for improving staging accuracy.

Introduction: The Enhanced Recovery After Surgery pathway has transformed peri-operative care in gynecologic surgery through multi-disciplinary, evidence-based protocols. However, real-world adherence to and interpretation of specific Enhanced Recovery After Surgery elements remain heterogeneous, with ongoing discussion about their feasibility and clinical relevance. During the 2025 Enhanced Recovery After Surgery World Congress in Turin, Italy, a rapid-fire debate session addressed 4 "hot topics" in gynecologic Enhanced Recovery After Surgery implementation.

Glycemic control: Peri-operative dysglycemia is associated with worse surgical outcomes, although the evidence favors a targeted rather than universal screening strategy. Universal hemoglobin A1c testing was considered impractical, with screening recommended for patients with diabetes, obesity, or cardiovascular disease to balance safety and oncologic timeliness.

Regional analgesia: Although transversus abdominis plane blocks reduce opioid use and prolong analgesia, multi-layer wound infiltration remains a pragmatic and cost-effective alternative, especially in low-resource settings where expertise or ultrasound guidance is limited.

Venous thromboembolism prophylaxis: In light of the overall risk profile and low bleeding rates, many patients undergoing laparotomy for adnexal masses are likely to benefit from pharmacologic prophylaxis. Development of gynecology-specific risk models remains an unmet research priority.

Normothermia: Structured multi-disciplinary warming bundles can significantly reduce peri-operative hypothermia, but implementation must remain flexible to accommodate different institutional resources and thresholds.

Conclusions: The 2025 Enhanced Recovery After Surgery World Congress debates reinforced that the evolution of Enhanced Recovery After Surgery in gynecologic surgery depends less on discovering new interventions than on refining, validating, and implementing existing evidence. Individualized standardization-adapting Enhanced Recovery After Surgery principles to patient and resource variability-remains the cornerstone of enhanced recovery progress.