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Objective: Our aim was to present the surgical technique of robotic radical trachelectomy (RRT) for early-stage squamous cell cervical cancer in women with a desire to preserve fertility., Design: A surgical case to illustrate the entire surgical technique of RRT and sentinel lymph node dissection. Institutional Review Board approval was not required for this video presentation., Setting: University hospital., Interventions: A 30-year-old patient with one child and no medical history. Pap smear and cervical biopsy were in favor of high-grade squamous intraepithelial lesion, and a conization procedure allowed the diagnosis of a 15 mm squamous cell carcinoma (International Federation of Gynecology and Obstetrics [FIGO] 1B1). An RRT was performed to preserve the fertility of this young patient, after bilateral sentinel lymph node dissection to ensure the absence of nodal metastasis. The trachelectomy specimen was negative at final pathology examination and the disease was confirmed as stage 1B1 (FIGO 2018). There were no surgical complications and no adjuvant treatment was indicated. Fertility-sparing surgery is acceptable for women of childbearing age who want to become pregnant., Conclusion: Minimally invasive surgery is safe, effective, and particularly adapted for women who wish to preserve their fertility without compromising oncological outcomes.1 - 2 This option may be safely proposed in expert centers for tumors smaller than 2 cm, with primary vaginal closure, and without use of a uterine manipulator.3 Complete information about oncological and obstetrical outcomes is mandatory and patients should agree to comply with a close follow-up protocol., (© 2021. Society of Surgical Oncology.)

Background: Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting., - Methods: Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model., Results: The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers., Conclusion: The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH., Clinical Trial Registration: NCT02523612.

Background: The prognosis for patients with endometrial cancer (EC) peritoneal carcinomatosis (PC) recurrence has received little study. This study aimed to determine specific risk factors and prognosis of EC with PC recurrence (PCR) versus no PC recurrence (NPCR)., Methods: Data of all patients with EC who received primary surgical treatment between January 2000 and February 2017 were abstracted from the French FRANCOGYN Research Group database. Clinical and pathologic variables were compared between the two groups (PCR vs. NPCR). Multivariate analysis was performed to define prognostic factors for peritoneal recurrence. Overall survivals (OS) of patients after recurrence were compared using the Kaplan-Meier method., Results: The study analyzed 1466 patients, and 257 of these patients (17.5%) had recurrence. At presentation, 63 of these patients had PC. International Federation of Gynecology and Obstetrics (FIGO) stages 3 and 4 disease were significantly associated with PCR versus NPCR (odds ratio 2.24; 95% confidence interval 1.23-4.07; p = 0.008). The death rate for the patients with PC was 47.6%, with a median survival of 12 months after diagnosis of recurrence. According to the histologic subtype, OS was 29 months (Q1-Q3, 13-NA) for endometrioid carcinomas, 7.5 months (Q1-Q3, 4-15) for serous carcinomas, and 10 months (Q1-Q3, 5-15) for clear cell carcinomas. Chemotherapy for treatment of PCR was associated with improved OS after recurrence (OSAR; p = 0.0025)., Conclusion: An initial advanced stage of EC is a risk factor for PCR. For women with PCR, a diagnosis of type 1 EC recurrence more than 12 months after the initial treatment and management of PCR with chemotherapy is associated with improved OSAR. Prospective studies are needed to determine the precise optimal management required in this clinical situation and to assess the relevance of biomarkers to predict the risk of PCR for EC patients.

Background: Surgical management of borderline ovarian tumors (BOTs) is similar to that of ovarian cancer apart from lymphadenectomy. However, the complete procedure including peritoneal washing, infracolic omentectomy and random peritoneal biopsies remains a subject of controversy especially in presumed early stage BOTs. To evaluate the prognostic value of complete surgical staging on recurrence rates, recurrence free (RFS) and overall survival (OS) in a multicentre cohort of BOTs., Methods: This retrospective multicentre study included 428 patients with BOTs diagnosed from January 1980 to December 2008. Survival estimates were based on Kaplan-Meier calculations and RFS defined as the time from the date of surgery to the date of recurrence., Results: The median time of follow-up was 94.9 months (range: 60.00-207.3). The overall recurrence rate was 23.8 %. There was no difference in 5-year RFS between patients with and without complete surgical staging 78.1 % (95 % CI 68.9-88.6) and 70.9 % (95 % CI 64.6-77.8), (p = 0.0806). In the whole cohort, 5-year OS was higher for patients with complete surgical staging 98.4 % (95 % CI 96.8-1.0) and 93.8 % (95 % CI 88.1-1), (p = 0.0182) but this difference was not significant for patients with FIGO stage I 98.6 % (95 % CI 96.7-1) and 92.7 % (95 % CI 83.4-1.0), p = 0.1275, respectively., Conclusions: Complete staging surgery should be considered as a cornerstone treatment for patients with advanced stage BOT but not for those with stage I disease.

Background: The goal, methods, and results of surgery for growing teratoma syndrome (GTS) in men after testicular cancer have been well described. The main surgical challenge relates to the need for vascular or thoracic procedures. But little is known about GTS in women, particularly regarding the optimal management of intraabdominal disease. This study aimed to evaluate the surgical management and outcomes (recurrences and fertility) for a large series of ovarian GTS., Methods: This study retrospectively analyzed patients treated for an ovarian immature teratoma (IT) who subsequently experienced abdominal GTS requiring surgery., Results: Between 1983 and 2014, 196 cases of IT were referred to the authors' institution or treated there, and 38 patients (19 %) subsequently experienced a GTS, including 10 cases of gliomatosis peritonei (containing exclusively pure mature glial tissue). The median age at diagnosis was 26 years (range 8-41 years), and the mean delay between IT and GTS diagnosis was 7 months (range 3-84 months). Surgical resection included peritonectomy (n = 22), diaphragmatic peritoneal resection (n = 14), bowel resection (n = 8), and splenectomy (n = 5). Conservative surgery was possible for 20 patients. Complete cytoreductive surgery was achieved for 25 patients. The mean follow-up period was 73 months (range 3-263 months). At least one recurrence developed for 10 patients (in the form of mature disease in all, and 8 of these patients had an initial complete resection. Five patients had a pregnancy. One patient died of complications from the disease (pulmonary embolism in a patient with bowel obstruction)., Conclusions: The overall prognosis of abdominal GTS is good. The surgical procedures for GTS are similar to those used in debulking surgery for epithelial cancer. Whenever technically possible, a conservative surgery should be performed because spontaneous fertility is possible. Recurrent GTS is frequent even after complete surgery.

Background: When any atypical feature is identified on a percutaneous biopsy specimen of a suspicious breast lesion, surgical excision is mandatory, leading to unnecessary surgeries in 70-90% of the cases. The purpose of this study was to develop a model to predict the presence of cancer at surgery that would be applicable to all atypical lesions., Methods: We collected complete clinical, radiological, and double-reading histological data concerning all patients with a diagnosis of a pure atypical lesion on image-guided biopsy performed at the One-Stop Breast Care Unit between 2004 and 2011., Results: Among the 204 eligible patients, 49 cancers (24%) had been diagnosed at definitive surgery (20 ductal carcinoma in situ, 20 invasive ductal, and 9 invasive lobular carcinoma). The univariate analysis retrieved age (p=0.03), the focus size in mm (p=0.02), the number of biopsy cores (p=0.02), the disappearance of radiological anomalies after biopsy (p=0.05), the mean number of atypical foci (p=0.05) and the percentage of atypical lobules and ducts for lobular neoplasia (p=0.04) as factors associated with cancer at surgery, whereas neither Ki67 nor ALDH1 expression was significantly correlated. The final most informative nomogram comprised information on patient age, the disappearance of radiological anomalies after biopsy and a focus size>15 mm. For the optimal threshold (risk of cancer=21%), sensitivity, specificity, positive predictive value, and negative predictive value were 78, 66, 36, and 90%, respectively., Conclusions: After validation, this model could help to identify a subset of patients with premalignant disease who could be spared surgery.

Purpose: To examine the feasibility and to report the results of laparoscopic radical hysterectomy (LRH) after initial uterovaginal brachytherapy (BT) for stage IB1 cervical cancer., Methods: We retrospectively reviewed patients at 2 comprehensive cancer centers who underwent initial BT followed 6-8 weeks later by LRH and lymph node dissection., Results: Between 2003 and 2010, a total of 162 patients underwent LRH. The procedure was feasible via this approach in 160 cases (98.8%) (2 conversions to laparotomy). Eight perioperative complications occurred. Nineteen patients had nodal involvement. Peri- or postoperative ureteral morbidity occurred in 10 patients (6%). Twenty-four patients (15%) experienced postoperative dysuria. Histologically, only 9 patients had residual cervical disease ≥5 mm, and only 1 patient had parametrial lymphovascular space involvement (associated with nodal spread). No patient had vaginal disease or involved surgical margins. After a median follow-up of 39 (range 3-118) months, 9 patients experienced relapse. Five-year overall survival was 95% (range 88.2-97.9%)., Conclusions: Radical hysterectomy using a laparoscopic approach is feasible and reproducible after initial BT for stage IB1 cervical cancer and is associated with excellent survival. Morbidity is close to that reported in patients treated with up-front surgery. In this large series, the morbidity associated with parametrial dissection and the fact that parametrial spread was observed in only 0.6% of the patients suggest that a simple extrafascial hysterectomy is perhaps sufficient in this context; the rate of urinary tract morbidity would then be reduced.

Purpose: Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node involvement at initial assessment. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging., Methods: Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement., Results: A total of 125 LACC patients (stage IB2-IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (n = 117) or laparotomy (n = 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases., Conclusions: Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.

Background: To determine the prognosis and prognostic factors in a large series of mucinous borderline tumors of the ovary (MBOT)., Materials and Methods: A retrospective review of patients with MBOT treated or referred to our institution. Three inclusion criteria were defined: (1) centralized histological review by our expert pathologist, (2) exclusion of peritoneal pseudomyxoma and any synchronous malignant tumor in the abdominal cavity, and (3) available data on the management and outcomes of patients., Results: From 1997 to 2004, 97 patients fulfilled inclusion criteria (95 stage I and 2 stage II disease). Of these, 9 patients had endocervical-like subtypes, 8 patients had stromal microinvasion, and 24 had intraepithelial carcinoma. Radical and conservative surgeries were performed, respectively, in 28 and 69 patients. After a median follow-up of 48 months, 13 patients had developed 14 recurrences: 7 were borderline and 7 were invasive lesions. The probability of recurrence in the form of carcinoma 5 and 10 years after the diagnosis was, respectively, 9 and 13%. The only prognostic factor for recurrence attaining statistical significance was the use of a cystectomy (compared with other surgeries relative risk [RR] = 5.6; P = 0.003; compared with salpingo-oophorectomy RR = 5.5; P = 0.012)., Conclusions: In the present series of 97 MBOT, mainly early-stage disease and excluding peritoneal pseudomyxoma, the cumulative risk of recurrence in the form of invasive carcinoma at 10 years was 13%. MBOT do not appear to be such a "safe" disease. The only prognostic factor for recurrence was the use of a cystectomy, suggesting that a salpingo-oophorectomy should be preferred in cases of conservative treatment.

Objective: The aim of this study was to assess the outcomes of patients treated conservatively for a serous borderline ovarian tumor with micropapillary patterns (SBOT-MP)., Methods: Retrospective study collecting cases of conservative treatment of SBOT-MP. There are 15 patients treated with conservative management for a stage I (n = 8) or III (n = 7) SBOT-MP. Eight patients underwent a unilateral salpingo-oophorectomy with a contralateral cystectomy, three a unilateral salpingo-oophorectomy, two a cystectomy, and two a bilateral cystectomy. Four patients had stromal microinvasion associated with MP at histological examination of the ovarian tumor. Noninvasive implants were observed in eight patients and invasive implants in one. Three patients had residual disease <1 cm on the peritoneum. One patient received adjuvant chemotherapy., Results: After a median interval of 63 months (range, 18-120 months), 11 recurrences were observed: six of them exclusively on the ovary, three exclusively on the peritoneum (invasive peritoneal disease in one), and two on the ovary and peritoneum. One of the last two patients succumbed to the recurrence (under the form of invasive adenocarcinoma). The other patients were actually disease free. Five patients achieved eight spontaneous pregnancies., Conclusion: This study demonstrates that spontaneous pregnancies can be achieved after conservative treatment of SBOT-MP. Nevertheless, as 2/3 of patients had bilateral ovarian involvement at the time of initial management, the recurrence rate is high. However, making definitive conclusions about the safety of conservative surgery is limited by the small sample size. So, further studies are warranted to evaluate conservative management of advanced-stage disease.

Background: The prognosis for patients who develop a recurrence after fertility-sparing surgery for epithelial ovarian cancer (EOC) remains unclear. This is the first study to evaluate survival in patients who have developed a recurrence in this context., Methods: The outcomes of relapsed patients reported in the literature in the four main series of fertility-sparing surgery for EOC were reviewed and updated (where feasible)., Results: Twenty-three of the 166 patients in the series were reported to have recurrent disease. The site of the recurrence was the peritoneum (+/- remaining ovary) in 17 patients, and distant in six patients. Twelve patients died of recurrent disease, two are still alive with persistent disease, eight are disease-free, and one is alive but her exact status is not known. Among eight patients (34%) with an isolated recurrence on the remaining ovary, two died and one was lost to follow-up., Conclusion: In this carefully monitored population, including systematic radiological examinations, the rate of isolated recurrences on the spared ovary is low. Recurrence in these patients carries a poor prognosis. Such results suggest that initial selection of candidates for fertility-sparing surgery should be carefully defined to reduce the rate of recurrences that carry a poor prognosis.

Background: The aim of this study was to determine the influence of the different histological subtypes (serous versus non-serous) on the location of nodal metastases in patients undergoing pelvic and para-aortic lymphadenectomies during the initial management of epithelial ovarian tumors., Methods: We carried out a retrospective analysis of data concerning patients fulfilling the following inclusion criteria: (1) an epithelial ovarian tumor; (2) a complete pelvic and bilateral para-aortic lymphadenectomy up to the level of the left renal vein; (3) surgical procedures including lymphadenectomies performed before adjuvant chemotherapy; and (4) a description of the distribution of positive nodes removed between pelvic and para-aortic areas. Patients were classified into two groups according to the histological subtypes: serous (group 1) and non-serous (group 2) tumors., Results: Of patients treated between 1989 and 2005, 148 fulfilled the inclusion criteria: 73 had a serous tumor and 75 a non-serous tumor. Positive nodes were observed in 70 (47%) patients-47 (64%) in group 1 and 23 (31%) in group 2 (P < 0.05). But the distribution of involved nodes between pelvic and para-aortic areas in patients with positive nodes was not statistically different between the two groups. In both groups, the most common site for positive nodes in the para-aortic area was the left para-aortic group: 74% in group 1 and 61% in group 2 (NS)., Conclusions: This series suggests that the histological subtype has no impact on the distribution of positive nodes in pelvic and para-aortic areas in patients with epithelial ovarian tumors.

Background: Pelvic radiation therapy with concomitant chemotherapy (PCRT) is the standard treatment of stage IB2/II cervical carcinoma. The impact of concomitant chemotherapy on positive para-aortic nodes (PA+), however, remains unknown. The aim of this study was twofold: to evaluate the rate of histological PA+ after PCRT and to determine the survival of patients with PA+., Methods: Patients fulfilling the following inclusion criteria were studied: (1) stage IB2/II cervical carcinoma, (2) histological subtype: squamous cell, adenocarcinoma or an adenosquamous tumor, (3) exclusion of patients with radiological PA+ (CT scan/MRI), (4) pelvic external radiation therapy of 45 Gy with concomitant chemotherapy (cisplatin 40 mg/m2/week) + utero-vaginal brachytherapy, and (5) completion surgery after the end of PCRT including at least a para-aortic lymphadenectomy., Results: Seventy-three patients (16 stage IB2, 57 stage II) treated between 1998 and 2004 fulfilled all the inclusion criteria. PA+ after PCRT were observed in 13 patients (18%) with a median of five (range, 2-22) positive nodes. Overall and disease-free survival at 24 months in patients with PA+ was 40% and 17%. Only two patients with PA+ are currently alive and in remission., Conclusions: The rate of PA+ remains high after PCRT in patients treated for stage IB2/II cervical carcinoma. Furthermore, the survival rate of patients with PA+ is very low. These important results suggest that detection of PA + at the time of completion surgery (after PCRT) is not beneficial for improving survival.

Background: The aim was to study the prognosis for and survival of patients treated with combined therapy (including surgical resection) for nodal recurrences from epithelial ovarian cancer (EOC)., Methods: This was a retrospective study of a group of 12 patients with a recurrence from EOC, a priori, exclusively located in lymph node(s). All patients underwent surgical resection of nodal metastases, followed by adjuvant therapy., Results: The median age of patients was 51 (range, 42-71) years. The initial disease stages were as follows: stage IA, n = 5; stage IIA, n = 1; and stage IIIC, n = 6. The median interval between the end of initial treatment and the nodal relapse was 21 (range, 6-72) months. The recurrence was located in the abdominal nodes in 10 patients (pelvic and/or para-aortic area) and was extra-pelvic in one patient, and the last patient had concomitant para-aortic and supraclavicular nodal involvement. Ten patients received postoperative chemotherapy and two had radiation therapy (one patient received both treatments). Eight patients relapsed and four did not. To date, three patients have died of the disease, three are alive with persistent disease, and six are alive and disease-free (including two patients who were treated by surgical resection after relapses twice in abdominal nodes). Five-year overall survival from the time of treatment of recurrent disease is 71% (confidence interval, 41%-90%)., Conclusions: The prognosis of patients with an a priori isolated nodal recurrence from EOC was good in this group of treated with surgical resection followed by chemoradiation or radiation therapy. This finding argues in favor of proposing surgical resection in such patients.