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During surgery for advanced epithelial ovarian cancer (EOC), the most important prognostic factor is the absence of residual tumor. Invisible microscopic peritoneal metastasis (mPM) are not removed during surgery and can be responsible of peritoneal recurrences. The aim of this current systematic review is to assess the role of fluorescence in evaluating mPM in EOC. We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. MeSH terms for fluorescence, EOC and peritoneal carcinomatosis were combined and not restricted to the English language. The final search was performed on September 1rst, 2021. The primary outcome was to determine the diagnostic accuracy of fluorescence. We also reviewed the different techniques used. Eighty-seven studies were identified. Of these, 10 were included for analysis. The sensitivity and specificity of fluorescence ranged between 66.7-100% and 54.2-100%, respectively. Most importantly, the negative predictive value (NPV) ranged from 90 to 100% Due to the heterogeneity of the studies, no consensus was reached concerning the optimal use of fluorescence in terms of type of dye, type and timing of injection and imager to use. No adverse event was reported. Fluorescence can safely be used in EOC to evaluate mPM with a high NPV. However, a randomized controlled trial is needed to homogenize current practice.

Resume De nouvelles approches therapeutiques moleculaires ont vu le jour ces dernieres annees pour les cancers gynecologiques avances parmi lesquels les inhibiteurs de poly-ADP-ribose-polymerases (PARPi). Ceux-ci ont demontre une efficacite dans les cancers sereux de haut grade ovarien chez les patientes porteuses de mutation du gene de predisposition aux cancers notamment du sein et de l’ovaire BRCA. Les donnees cliniques et pre cliniques suggerent que l’activite des inhibiteurs de PARPi ne serait pas limitee aux tumeurs mutees BRCA et mettraient en jeu la voie de recombinaison homologue. Ces donnees soulevent la question de l’efficacite des PARPi dans les cancers de l’endometre et du col de l’uterus a des stades avances pour lesquels les options therapeutiques sont aujourd’hui limitees. A l’heure actuelle, il existe peu de donnees disponibles quant a l’activite des PARPi dans les cancers de l’endometre et du col de l’uterus mais certains resultats semblent prometteurs. Nous proposons dans cette revue une synthese des etudes disponibles concernant les PARPi dans le cancer de l’endometre et le cancer du col de l’uterus.

The initial management of early-stage ovarian cancer consists of staging surgery including pelvic and para-aortic lymphadenectomy. The use of the sentinel lymph node (SLN) procedure in this setting may decrease the morbidity associated with this surgery. The objective of this review was to evaluate the feasibility of the SLN procedure in ovarian cancer diagnosed at an early stage by comparing the different techniques used and their accuracy. A systematic literature search was performed on PubMed and ClinicalTrials.gov for articles in English or French about the SLN technique in ovarian cancer. Ten studies were included in the analysis, with a total of 179 patients. The main tracers used were Technetium-99m, indocyanine green, and patent blue, and the most common site of injection was the proper ovarian and unfundibulopelvic ligaments. The overall detection rate was 87.7%. Of the small number of cases of lymph node metastasis reported, the SLN procedure had a sensitivity of 90.9% and a negative predictive value of 98.8%. The sentinel node procedure appears to be feasible and safe and could be reliable in determining the lymph node status of patients with early-stage ovarian cancer.

Background Lymphadenectomy is debated in patients with ovarian cancer. The aim of our study was to evaluate the impact of lymphadenectomy in patients with high-grade serous ovarian cancer receiving neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Methods A retrospective, unicentric study including all patients undergoing NACT and IDS was carried out from 2005 to 2018. Patients with and without lymphadenectomy were compared in terms of recurrence free survival (RFS), overall survival (OS), and complication rates. Results We included 203 patients. Of these, 133 had a lymphadenectomy (65.5%) and 77 had involved nodes (57.9%). Patients without a lymphadenectomy were older, had a more extensive disease and less complete CRS. No differences were noted between the lymphadenectomy and no lymphadenectomy group concerning 2-year RFS (47.4% and 48.6%, p = 0.87, respectively) and 5-year OS (63.2% versus 58.6%, p = 0.41, respectively). Post-operative complications tended to be more frequent in the lymphadenectomy group (18.57% versus 31.58%, p = 0.09). In patients with a lymphadenectomy, survival was significantly altered if the nodes were involved (positive nodes: 2-year RFS 42.5% and 5-year OS 49.4%, negative nodes: 2-year RFS 60.7% and 5-year OS 82.2%, p = 0.03 and p Conclusion Lymphadenectomy during IDS does not improve survival and increases post-operative complications.

Introduction Advanced epithelial ovarian cancer (EOC) is associated with high mortality and often managed first with neoadjuvant chemotherapy (NACT) followed by debulking surgery. Laparoscopic surgery with or without robotic assistance (Minimally Invasive Surgery (MIS)) may represent a beneficial option for these patients. The objective of this literature review is to clarify the place of MIS in the management of advanced EOC for selected patients. Method Pubmed, Cochrane and Clinicaltrials.gov online databases were used for this review, to select English or French published articles. Results We selected 11 original articles published between 2015 and 2020, 6 of which compared MIS and laparotomy. Among these 11 studies, 8 were retrospective cohorts, 2 were phase II trials, and one was a case-control study. In total, there were 3721 patients, of which 854 (23%) were treated with MIS. The robotic assistance was used with 224 patients (26%) of those MIS patients.Looking specifically at MIS patients, the laparoconversion rate was 9.5%, the rate of complete resection (CC-0) was 83.4%. Finally, the MIS complication rate was 1% intraoperatively and 12% postoperatively. The rate of complete resection, postoperative complication, as well as overall survival (OS) were comparable between patients treated with MIS or laparotomy. One study found an improved disease-free survival (DFS) in MIS versus laparotomy (18 months versus 12 months; p=0,027). Conclusion MIS seems feasible, effective, and reliable in comparison to laparotomy for the completion of cytoreductive surgery after NACT without compromising oncological safety. Prospective randomized controlled trials are needed to confirm the role of MIS in advanced EOC.

Introduction The benefit of a systematic lymphadenectomy is still debated in patients undergoing neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in ovarian cancer (OC). The objective of this study was to evaluate the predictive value of the pre-NACT and post-NACT CT in predicting definitive histological lymph node involvement. The prognostic value of a positive node on the CT was also assessed. Materiel and methods A retrospective, unicentric cohort study was performed including all patients with ovarian cancer who underwent NACT and IDS with a lymphadenectomy between 2005 and 2018. CT were analyzed blinded to pathology, and nodes with small axis ≥ 10 mm on CT were considered positive. Sensitivity (Se), specificity (Sp), and negative (NPV) and positive predictive values (PPV) and their CI95% were calculated. The 2-year recurrence free survival (RFS) and 5-year overall survival (OS) was compared. Results 158 patients were included, among which 92 (58%) had histologically positive lymph nodes. CT had a Se, Sp, NPV and PPV of 35%, 82%, 47% and 73% before NACT and 20%, 97%, 47% and 91% after NACT, respectively. Patients with nodes considered positive had a non-significant lower 2-year RFS and 5-year OS on the pre-NACT and post-NACT CT. Patients at ‘high risk’ (nodes stayed positive on the CT or became positive after NACT) also had a non-significant lower 2-year RFS and 5-year OS. Conclusion Presence of enlarged lymph nodes on CT is a weak indicator of lymph node involvement in patients with advanced ovarian cancer undergoing NACT. However, it could be used to assess prognosis.

Resume Les nouvelles recommandations europeennes concernant la prise en charge des patientes presentant un cancer de l’endometre ont ete publiees debut 2021. Ces recommandations sont conjointes aux trois societes savantes europeennes d’oncologie gynecologique (ESGO), de radiotherapie et d’oncologie (ESTRO) et d’anatomo-pathologie (ESP). Au nom de la Societe Francaise d’Oncologie Gynecologique (SFOG), nous souhaitons apporter a la connaissance du lectorat francophone les principales mesures pour la prise en charge des patientes qui representent une avancee par rapport aux recommandations de 2016. Les nouvelles recommandations europeennes concernant la prise en charge des patientes presentant un cancer de l’endometre insistent sur la generalisation de la recherche d’une instabilite des microsatellites (MSI) ou de l’analyse immunohistochimique des proteines du systeme MMR pour toutes les patientes. Aussi, la classification en 4 groupes a risque pronostic integre les donnees de l’analyse moleculaire (p53, MSI, POLE) pour guider la prise en charge chirurgicale initiale ainsi que les modalites du traitement adjuvant. La procedure du ganglion sentinelle au vert d’indocyanine est par ailleurs devenue la technique de reference pour la stadification ganglionnaire des stades FIGO I et II quel que soit le type histologique. On rappelle que la prise en charge doit etre assuree dans un etablissement specialise par une equipe specialisee dans la prise en charge des cancers gynecologiques, en particulier pour les patientes a haut risque et/ou presentant un cancer avance.

Introduction Sentinel lymph node biopsy (SLN) helps define lymph node status, a major prognostic factor in vulvar cancer. The aim of the current systematic review was to assess the use of indocyanine green (ICG) coupled with near-infrared (NIR) fluorescence imaging in SLN mapping in vulvar cancer in terms of technique used, feasibility and accuracy. Data sources We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov , Embase, Cochrane Library, and Web of Science databases. MeSH terms for SLN, ICG and vulvar cancer were combined and restricted to the English language. The final search was performed on May 28, 2020. The primary outcome was to determine if the use of ICG alone in detecting SLN in women with vulvar cancer is as accurate as the gold standard dual labeling technique. Results Of the 34 studies initially identified, 13 were included for analysis. The SLN detection rate with ICG and NIR fluorescence ranged from 89.7 to 100%. No studies demonstrated the superiority of other detection techniques compared to ICG and NIR imaging. Lower SLN detection rates were found in studies with the most metastatic lymph nodes. No consensus was reached concerning the optimal use of ICG in terms of: injection timing or site; concentrations or volume of ICG; or use of human serum albumin or hybrid tracer. No adverse events were reported. Conclusion ICG for SLN mapping appears to be safe in women with vulvar cancer with a detection rate similar to the current techniques. A large prospective randomized controlled study with optimization of the technique is necessary to homogenize current practice and determine the true value of ICG in vulvar cancer. PROSPERO ID CRD42020178261.

Resumen El cancer de endometrio (CE) es el cancer ginecologico mas frecuente, tanto en Francia como en el resto de los paises occidentales. El diagnostico se suele establecer en un contexto de metrorragias posmenopausicas, despues de realizar una biopsia de endometrio. Despues de la menopausia, se debe investigar cualquier metrorragia o un grosor endometrial superior a 4 mm. La histologia, la exploracion fisica y las imagenes obtenidas por resonancia magnetica permiten determinar los grupos con riesgo de recidiva, asi como las modalidades del tratamiento inicial, a menudo quirurgico. La histerectomia con anexectomia bilateral es la intervencion de referencia, completada segun los casos por una exploracion ganglionar. El examen definitivo de las piezas operatorias permite redefinir los grupos en funcion del riesgo de recidiva, de acuerdo con los criterios establecidos en 2009 por la European Society for Medical Oncology, asi como la indicacion de los tratamientos adyuvantes (radioterapia, braquiterapia, quimioterapia). Es necesario saber identificar a las familias que presentan un riesgo genetico de CE (sindrome de Lynch) para adaptar su vigilancia, asi como a las pacientes aptas para una estrategia de preservacion de la fertilidad. la vigilancia es clinica. En la actualidad, son varias las lineas terapeuticas en desarrollo: antiangiogenicos, terapias dirigidas (via de senalizacion PI3K-AKT-mTOR), inmunoterapias (tumor con inestabilidad de los microsatelites). Con estas terapias, deberia mejorar el pronostico de las pacientes que presentan un CE.

Objective To assess the diagnostic and prognostic characteristics of borderline ovarian tumours (BOTs) detected during pregnancy, and to establish an inventory of French practices. Materials and methods A retrospective multi-centre case study of 14 patients treated for BOTs, diagnosed during pregnancy between 2005 and 2017, in five French pelvic cancerology expert centres, including data on clinical characteristics, histological tumour characteristics, surgical procedure, adjuvant treatments, follow-up and fertility. Results The mean age of patients was 29.3 [standard deviation (SD) 6.2] years. Most BOTs were diagnosed on ultrasonography in the first trimester (85.7 %), and most of these cases (78.5 %) also underwent magnetic resonance imaging to confirm the diagnosis (true positives 54.5 %). Most patients underwent surgery during pregnancy (57 %), with complete staging surgery in two cases (14.3 %). Laparoscopy was performed more frequently than other procedures (50 %), and unilateral adnexectomy was more common than cystectomy (57.5 %). Tumour size influenced the surgical approach significantly (mean size 7.5 cm for laparoscopy, 11.9 cm for laparoconversion, 14 cm for primary laparotomy; P = 0.08), but the type of resection did not. Most patients were initially diagnosed with International Federation of Gynecology and Obstetrics stage IA (92.8 %) tumours, but many were upstaged after complete restaging surgery (57.1 %). Most BOTs were serous (50 %), two cases had a micropapillary component (28.5 %), and one case had a micro-invasive implant. BOTs were bilateral in two cases (14.2 %). Mean follow-up was 31.4 (SD 14.8) months. Recurrent lesions occurred in two patients (14.2 %) and no deaths have been recorded to date among the study population. Conclusion BOTs remain rare, but this study – despite its small sample size – supports the hypothesis that BOTs during pregnancy have potentially aggressive characteristics.

Resumen La linfadenectomia lumboaortica (LLA) o vaciamiento ganglionar lumboaortico es una tecnica dirigida a extirpar el tejido ganglionar a nivel laterocavo, precavo, interaortocavo, preaortico, lateroaortico supra e inframesenterico y del promontorio. En muchos casos, si las condiciones especificas de la paciente lo permiten, esta intervencion se puede efectuar por laparoscopia (reestadificacion del cancer de ovario en estadio precoz, estadificacion preterapeutica en el cancer de cuello de utero). Sin embargo, en caso de carcinomatosis, si la intervencion esta indicada, el estandar sigue siendo la laparotomia. En ginecologia, en ausencia de contraindicaciones debidas a caracteristicas propias de las pacientes, esta intervencion esta indicada en el cancer de ovario en estadio precoz (excepto en los tumores mucinosos) y avanzado, en la estadificacion del cancer de cuello de utero avanzado (por laparoscopia) y en algunos canceres de endometrio con riesgo de extension lumboaortica. Este tipo de cirugia requiere determinados conocimientos tecnicos, sobre todo en caso de adenopatias voluminosas o fijas, con un equipo sanitario y de anestesia entrenado para controlar los posibles riesgos vasculares.

International audience; IntroductionIn France, participation in the organized breast cancer screening program remains insufficient. A personalized approach adapted to the risk factors for breast cancer (RBC) should make screening more efficient. A RBC evaluation consultation would therefore make it possible to personalize this screening. Here we report our initial experience.Material and methodThis is a prospective study on women who were seen at the RBC evaluation consultation and analyzing: their profile, their risk assessed according to Tyrer Cuzick model (TC) ± Mammorisk© (MMR), the existence of an indication of oncogenetic consultation (Eisinger and Manchester score), their satisfaction and the recommended monitoring.ResultsAmong the women who had had a TCS and/or MMR evaluation of SCR (n = 153), 76 (50%) had a high risk (n = 67) or a very high risk (n = 9). Almost half (47%) had a possible (15%) or certain (32%) indication to an oncogenetic consultation. Regarding this consultation, 98% of women were satisfied or very satisfied. In total, 60% of women had a change in screening methods.ConclusionThis RBC evaluation consultation satisfies women and for a majority of them, modifies their methods of breast cancer screening.; IntroductionL’adhésion en France au programme de dépistage organisé du cancer du sein demeure insuffisante. Une approche personnalisée adaptée aux facteurs de risque de cancer du sein (RCS) permettrait une meilleure efficience du dépistage. Une consultation d’évaluation du RCS permettrait donc de personnaliser ce dépistage. Nous rapportons ici notre expérience initiale.Matériel et méthodeIl s’agit d’une étude prospective portant sur les femmes ayant été vues à la consultation d’évaluation du RCS et analysant : leur profil, leur risque évalué selon les modèles de Tyrer Cuzick (TC) ± Mammorisk© (MMR), l’existence d’une indication de consultation d’oncogénétique (scores d’Eisinger et de Manchester), leur satisfaction et la surveillance préconisée.RésultatsParmi les femmes ayant eu une évaluation du RCS par le modèle TC et/ou MMR (n = 153), 76 (50 %) avaient un risque élevé (n = 67) ou très élevé (n = 9). Près de la moitié (47 %) avait une indication possible (15 %) ou certaine (32 %) à une consultation d’oncogénétique. Concernant cette consultation, 98 % des femmes étaient satisfaites ou très satisfaites. Au total, 60 % des femmes ont eu un changement des modalités de surveillance.ConclusionCette consultation d’évaluation du RCS satisfait les femmes et pour une majorité d’entre elles, modifie les modalités de leur surveillance mammaire.

INTRODUCTION: Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period. MATERIAL AND METHOD: Recommendations based on the consensus conference model. RESULTS: In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies. CONCLUSION: During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

Resume Objectifs Editer, par le College national des gynecologues et obstetriciens francais (CNGOF), des recommandations fondees sur les preuves disponibles dans la litterature pour la prise en charge des tumeurs frontieres de l’ovaire (TFO) de stade precoce. Methodes Recherche bibliographique en langue francaise et anglaise effectuee par consultation des bases de donnees Pubmed, Cochrane, Embase et des recommandations internationales. Resultats Dans la prise en charge chirurgicale des TFO a un stade precoce, si une chirurgie sans risque de rupture tumorale avec extraction protegee des pieces operatoires est possible, la voie cœlioscopique est recommandee par rapport a la laparotomie (Grade C). Dans les TFO, il est recommande de prendre toutes les dispositions pour eviter la rupture tumorale, y compris la decision peroperatoire de laparoconversion (Grade C). Dans les TFO, une extraction de la piece operatoire a l’aide d’un sac endoscopique est recommandee (Grade C). En cas de TFO de stade precoce, uni- ou bilaterale, suspectee a l’imagerie preoperatoire chez une patiente menopausee et/ou sans de desir de preservation de fertilite et/ou de la fonction endocrine, il est recommande de realiser une annexectomie bilaterale (Grade B). En cas de TFO de stade precoce sereuse bilaterale avec desir de preservation de la fertilite et/ou de la fonction endocrine, il est recommande de realiser une kystectomie bilaterale dans la mesure du possible (Grade B). En cas de TFO de stade precoce mucineuse avec desir de preservation de la fertilite et/ou de la fonction endocrine, il est recommande de realiser une annexectomie unilaterale (Grade C). En cas de TFO de stade precoce endometrioide avec desir de preservation de la fertilite et/ou de la fonction endocrine, il n’est pas possible d’etablir une recommandation de choix de traitement entre kystectomie et annexectomie unilaterale. En cas de TFO de stade precoce mucineuse a l’analyse histologique definitive chez une femme ayant eu une kystectomie initiale, avec ou sans desir de preservation de la fertilite et/ou de la fonction endocrine, une reprise chirurgicale pour une annexectomie unilaterale est recommandee (Grade C). En cas de TFO de stade precoce sereuse a l’analyse histologique definitive chez une femme ayant eu une kystectomie initiale, avec desir de preservation de la fertilite et/ou de la fonction endocrine, il n’est pas recommande de reprise chirurgicale pour annexectomie en l’absence de lesion suspecte residuelle lors de la chirurgie et/ou a l’imagerie postoperatoire (echographie par referent ou IRM pelvienne) (Grade C). Une omentectomie est recommandee afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est diagnostiquee a l’examen extemporane ou suspectee sur les elements radiologiques preoperatoires (Grade B). Il n’existe pas de donnees dans la litterature permettant de recommander le type d’omentectomie a realiser. Si une chirurgie de restadification est decidee pour une TFO a un stade presume precoce, une omentectomie est recommandee (Grade B). Des biopsies peritoneales multiples sont recommandees afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est diagnostiquee a l’examen extemporane ou suspectee sur les elements radiologiques preoperatoires (Grade C). En cas de chirurgie de restadification pour une TFO a un stade presume precoce, l’exploration de la cavite abdominale doit etre complete et des biopsies peritoneales doivent etre realisees sur les zones suspectes ou de facon systematique (Grade C). Une cytologie peritoneale premiere est recommandee afin de realiser une stadification initiale chirurgicale complete lorsqu’une TFO est suspectee sur les elements radiologiques preoperatoires (Grade C). En cas de chirurgie de restadification pour une TFO a un stade presume precoce, une cytologie peritoneale premiere est recommandee (Grade C). Concernant les TFO sereuses ou mucineuses de stade precoce, il n’est pas recommande de realiser une hysterectomie a titre systematique (Grade C). Concernant les TFO de stade precoce de type endometrioide, et en l’absence de desir de conserver la fertilite, il est recommande de realiser une hysterectomie en chirurgie initiale ou si une chirurgie de restadification est indiquee (Grade C). Concernant les TFO de stade precoce de type endometrioide, en cas de desir de preservation de la fertilite, l’uterus peut etre conserve sous reserve d’une bonne evaluation de l’endometre par imagerie et prelevement endometrial (Grade C). Concernant les TFO de stade precoce, quel que soit le type histologique, il est recommande d’evaluer l’aspect macroscopique de l’appendice lors de la chirurgie (initiale ou de restadification si indiquee) (Grade B). Concernant les TFO de stade precoce, quel que soit le type histologique, il est recommande de ne realiser une appendicectomie qu’en cas d’aspect macroscopiquement pathologique de l’appendice (Grade C). Concernant les TFO de stade precoce, quel que soit le type histologique, la lymphadenectomie pelvienne et/ou lombo-aortique n’est pas recommandee dans le cadre d’une chirurgie initiale ou d’une chirurgie de restadification (Grade C). En cas de TFO diagnostiquee sur histologie definitive, l’indication de chirurgie de restadification doit etre discutee en Reunion de Concertation Pluridisciplinaire. Pour les TFO presumees de stade precoce, il est recommande de privilegier la voie cœlioscopique pour realiser une chirurgie de restadification (Grade C). Une chirurgie de restadification est recommandee en cas de TFO sereuse avec aspect micropapillaire et une inspection de la cavite abdominale non satisfaisante lors de la chirurgie initiale (Grade C). Une chirurgie de restadification est recommandee en cas de TFO mucineuse si seule une kystectomie a ete realisee ou que l’appendice n’a pas ete visualise, il sera alors realise une annexectomie unilaterale (Grade C). Si une chirurgie de restadification est decidee dans la prise en charge d’une TFO presumee de stade precoce, les gestes a realiser sont les suivants : une cytologie peritoneale (Grade C), une omentectomie (il n’existe pas de donnees dans la litterature permettant de recommander le type d’omentectomie a realiser) (Grade B), une exploration complete de la cavite abdominale avec biopsies peritoneales sur les zones suspectes ou de facon systematique (Grade C), la visualisation de l’appendice ± l’appendicectomie en cas d’aspect macroscopique pathologique (Grade C), une annexectomie unilaterale en cas de TFO mucineuse (Grade C).

International audience; Objective: To assess the surgical management and survival of severely obese patients with high-risk endometrial cancer.Materials and methods: Data from 269 patients with high-risk endometrial cancer who were treated between 2001 and 2018 were collected from a multicenter database (11 centers). We classified the patients according to their BMI and compared outcomes in two groups: a normal weight group of women with a BMI < 25 kg/m2, and a severe obesity group of women with a BMI ≥ 35 kg/m2. The groups were compared for epidemiologic, pathologic, management, relapse-free survival (RFS) and overall survival (OS) elements.Results: Patients in the severe obesity group were younger (64 years vs. 68 years, p < 0.05) and had more comorbidities (hypertension, diabetes). They also had more locally advanced tumors and pelvic lymph node involvement (47% vs 24%, p < 0.05). The severely obese patients were less likely to undergo recommended surgical staging, with fewer lumbar aortic dissections than women of normal weight (23% vs 36%, p < 0.05) and fewer pelvic sentinel lymph node biopsies (26.5% vs 12.1%, p < 0.05). No difference in RFS or OS were observed between the two groups.Conclusion: Patients with severe obesity and high-risk endometrial cancer have more locally advanced tumors, and are less likely to be managed according to surgical recommendations. However, RFS and OS do not seem to be affected.

Resumen La incidencia de las displasias durante el embarazo esta estimada en un 1%, y la del cancer del cuello uterino, en una de cada 10.000. El inicio del embarazo constituye un momento ideal para realizar un frotis cervicouterino (FCU) si no se realizo recientemente y para sensibilizar a las pacientes en la necesidad de efectuar esta deteccion precoz. Para las lesiones de neoplasia intraepitelial, en ausencia de sospecha de invasion en la colposcopia, el tratamiento puede diferirse al posparto, siempre bajo una estricta vigilancia. Para las lesiones invasivas, el estudio debe completarse con una resonancia magnetica (RM) lumbopelvica para definir mejor el tamano de la lesion. El tratamiento depende del subtipo histologico, del estadio de la lesion, de la afectacion ganglionar, siempre que se puedan obtener estos datos (linfadenectomia pelvica por via laparoscopica hasta las 20-24 semanas de amenorrea [SA] para los tumores menores de 4 cm o por RM en caso de termino del embarazo mas avanzado), y del termino del embarazo. La pareja debe saber que el embarazo por si mismo no cambia el pronostico del tumor. Para estos tumores invasivos, el objetivo consiste en aplicar el tratamiento mas parecido al de las pacientes no embarazadas y, si es posible, mantener la gestacion. El tratamiento debe basarse en un acuerdo multidisciplinario que incluya a los oncologos con experiencia en el tratamiento de los canceres durante el embarazo. El College National des Gynecologues Obstetriciens Francais (CNGOF) establecio una serie de recomendaciones en 2008 para las lesiones precancerosas y cancerosas diagnosticadas durante el embarazo, y el Institut National du Cancer (INCa) publico en 2016 recomendaciones relacionadas con el tratamiento de los FCU anormales. Este articulo esta basado en estas recomendaciones, y ofrece los datos mas recientes de la literatura.

Vulvar cancer is a rare disease, which represents 4% of gynecological tumors with an incidence of 0.5 to 1.5 per 100,000 women per year in France. Vulvar cancers are induced in 30 to 69% of cases by the presence of papillomavirus (HPV), in particular HPV 16 and 18, and can also occur in an inflammatory context. The diagnosis is made by histological examination of a vulvar biopsy. The histological subtype is a squamous cell carcinoma in 90% of cases. The 5-year survival of patients with vulvar cancer ranges from 86% for localized stages (FIGO I and II) to 57% for advanced stages (FIGO III and IVA), and 17% in case of metastatic disease (FIGO IVB). The treatment of vulvar cancer is mainly surgical, but radiotherapy and chemotherapy have become more important in recent years. Management has evolved into a personalized multidisciplinary approach, where each therapeutic decision must be discussed in a multidisciplinary consultation meeting. Surgical excision with tumor- free margins is central in the management of early stages. The indication for radiotherapy and brachytherapy should be discussed in the event that the excisional margins are positive in early stages. Radiotherapy is indicated in cases of lymph node involvement or in a neoadjuvant situation if the tumor is not immediately resectable. In this situation, it can be associated with chemotherapy. Chemotherapy alone is the treatment of diseases that are metastatic at the time of diagnosis.

No consensus exists regarding the management of recurrent pelvic organ prolapse (POP). The aim of this study was to evaluate robot-assisted laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse (POP), and to investigate postoperative outcomes.We conducted a single-center retrospective study including 10 consecutive patients who underwent a robot-assisted sacrocolpopexy for symptomatic POP recurrence from February 2017 to December 2019. Recurrence rates and patient satisfaction, measured by the Pelvic Floor Impact Questionnaire (PFIQ-7) were recorded.Median age was 57 years (IQR: 54-67). No intraoperative complications were reported. The median hospital stay after surgery was 2 nights (IQR: 1-4). Two patients (20%) experienced early recurrence: at 1 month for one and at 4.5 months for the other. The median follow-up for the remaining eight patients was 18 months (IQR: 12-23). Among the recurrence-free patients, the median PFIQ-7 score was 11.4 at 12 months.Robot-assisted sacrocolpopexy is feasible and safe for the management of POP recurrence, with a high patient satisfaction.

A multimodal approach to promoting recovery from surgery was first described by Henrik Kehlet in 1995. This approach has since been significantly developed and refined, and is now referred to as Enhanced Recovery in Surgery (ERS). The goal of ERS is to enable a patient to regain his/her pre-surgery physical and psychological state after a surgical procedure - notably by reducing the stress and the inflammatory response inevitably triggered by surgery. ERS protocols include anesthesia-related items (such as reducing the use of morphine) and surgical items (such as the use of minimally invasive routes, and limiting the postoperative use of drains and probes). Each step is essential - from patient information, education and adherence during the preoperative phase to involvement of the family circle and the attending physician with a view to early discharge. The term ERS corresponds to a set of principles for optimizing pre-, per- and postoperative care, the aim of which is to improve the post-operative course and the patient's experience by decreasing per- and postoperative complications and accelerating a return to the patient's pre-operative physical and psychological state. The use of ERS protocols is associated with a lower complication rate and a shorter hospital stay, regardless of the patient's age and comorbidities.

Epithelial ovarian cancer (EOC) is the most lethal of all gynecological cancers. Despite excellent responses to standard treatment in approximately 70% of patients, most of them will relapse within 5 years of initial treatment and many of them will develop chemotherapy-resistant disease. It is then important to find other means of treatment for these patients such as immunotherapy or targeted therapy. To understand immunotherapy, it is important to explain the dynamic interplay between cancer and the immune system. Compared to traditional tumor therapies, immunotherapy acts primarily on the immune system or the tumor microenvironment but not directly on the tumor cells, and it may also promote synergistic anti-tumor actions as part of a combined treatment. The aim of this narrative review is to provide a basic understanding of immunotherapy the interest of this treatment in EOC, and to present the main ongoing studies that could change patient management in the future.

Genitourinary syndrome of menopause (GSM) brings together a collection of signs including vaginal dryness, burning sensation and itching discomfort as well as deterioration of sexual health, dysuria, urgenturia and repeated urinary infections and may be responsible for a significant impairment of quality of life in symptomatic postmenopausal women. The management of GSM therefore represents a public health issue. Systemic or local hormonal treatments are frequently offered, as well as non-hormonal treatments. The existence of contraindications to hormonal treatments and the constraints of using local treatments lead us to propose other therapeutic options. CO2 LASER is now part of the therapeutic arsenal for the treatment of vaginal dryness in the context of GSM. There is a growing interest in this technique, especially for women who have a contraindication to hormonal therapy, as it is a globally effective, long-acting alternative with very little adverse effect. Current evidence suggests that this tool could provide a quality of life benefit to many patients with minimal side effect exposure, if used in the respect of its indications and implementation protocols. However, clinical data based on high-level therapeutic trials remain absolutely essential for this treatment to be validated and recommended by health professionals.

Obesity is a major public health problem. Pregnant women are also affected by this epidemic. In pregnant women, obesity increases obstetric and neonatal complications, and is associated with alterations in the quality of labor that could be explained by reduced myometrial contractility. This leads to an increase in the rate of caesarean sections and postpartum haemorrhages in this population at risk. Adipokines, hormones secreted by adipose tissue, may have a role in altering the myometrial contractility. Weight loss in these patients is based on dietary management and on physical activity, which could be a way to improve adipokines action and uterine contractility. The objective of this literature review was to review current knowledge about the role of adipokines on uterine contractility in obese pregnant women and to assess the interest of sport in improving contractility and in reducing obstetric complications in these women.

Resume La comprehension de la biologie et des mecanismes de progression des metastases peritoneales des cancers epitheliaux de l’ovaire (CEO) est importante car la carcinose peritoneale est presente ou surviendra au cours de la surveillance d’une majorite des patientes. Malgre la remission clinique obtenue apres chirurgie de cytoreduction macroscopiquement complete et chimiotherapie a base de sel de platine, 60 % des patientes developpent une recidive peritoneale. Cela suggere que des lesions microscopiques, qui ne sont pas eradiquees par la chirurgie peuvent etre presentes et pourraient participer aux mecanismes conduisant a la recidive peritoneale. Cet article discute des donnees disponibles concernant les metastases peritoneales microscopiques, leur diagnostic et leur traitement. Nous avons examine toutes les publications traitant des metastases peritoneales microscopiques des CEO entre 1980 et 2017. Les publications les plus recentes et jugees les plus pertinentes traitant des modalites de traitements de ces metastases ont ete selectionnees. Les localisations microscopiques peritoneales et epiploiques seraient presentes dans 1,2 a 15,1 % des cas a un stade precoce. Ces atteintes ne sont pas traitees lors de la chirurgie et pourraient representer une cible therapeutique. Les traitements locaux (chimiotherapie intraperitoneale, therapie photodynamique, chirurgie guidee par la fluorescence) semblent necessaires en complement de la chirurgie et de la chimiotherapie et pourraient contribuer a diminuer le risque de recidive peritoneale. La place de ces traitements dans la prise en charge des CEO reste a definir par des recherches ulterieures.

Regarding extraperitoneal para-aortic lymphadenectomy, installation is key when performed with the assistance of the Da Vinci Xi robotic system. We developed a step-by-step guide, from patient installation to placement of the trocars to patient cart docking, to perform in the efficient and safest installation possible this procedure. The operation does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The benefits of robotic surgery in this indication are comparable to those of the standard laparoscopic approach. Those benefits imply a precise knowledge of the management and installation of the da Vinci Xi robotic system.

Introduction The coronavirus SARS-CoV-2 (COVID-19) pandemic has put tremendous pressure on the French healthcare system. Almost all hospital departments have had to profoundly modify their activity to cope with the crisis. In this context, the surgical management of cancers has been a topic of debate as care strategies were tailored to avoid any delay in treatment that could be detrimental to patient wellbeing while being careful not to overload intensive care units. The primary objective of this study was to observe changes in the surgical management of pelvic cancers during the COVID-19 pandemic in France. Material and Methods This study analyzed data from the prospective multi-center cohort study conducted by the French Society for Pelvic and Gynecological Surgery (SCGP) with methodological support from the French (FRANCOGYN) Group. All members of the SCGP received by e-mail a link allowing them to include patients who were scheduled to undergo gynecological carcinologic surgery between March 16th 2020 and May 11th 2020. Demographic data, the characteristics of cancers and the impact of the crisis in terms of changes to the usual recommended coarse of care were collected. Results A total of 181 patients with a median age 63 years were included in the cohort. In total, 31 patients had cervical cancer, 76 patients had endometrial cancer, 52 patients had ovarian or tubal cancer, 5 patients had a borderline tumor of the ovary, and 17 patients had vulvar cancer. During the study period, the care strategy was changed for 49 (27%) patients with postponed for 35 (19.3%) patients, and canceled for 7 (3.9%) patients. Surgical treatment was maintained for 139 (76.8%) patients. Management with neoadjuvant chemotherapy was offered to 19 (10,5%) patients and a change in surgical choice was made for 5 (2,8%) patients. In total, 8 (4,4%) patients tested positive for COVID-19. Data also shows a greater number of therapeutic changes in cases of ovarian cancer as well as a cancelation of a lumbo-aortic lymphadenectomy in one patient with cervical cancer. Hospital consultants estimated a direct detrimental impact of the COVID-19 pandemic for 39 patients, representing 22% of gynecological cancers. Conclusion This study provided observational data of the impact of the COVID-19 health crisis on the surgical management of gynecological cancers.

Endocervical microglandular hyperplasia (MGH) is a reactive type of glandular lesion that may be confused with endocervical adenocarcinoma from the macroscopic and the colposcopic findings, as well as from a histological. Differential diagnosis is very important. Here, we report a case of a 21 years-old women with a challenging differential diagnosis in the colposcopy and a MGH as histological finding.

High peritoneal recurrence rate in advanced epithelial ovarian cancer after complete macroscopic cytoreductive surgery and platinum-based chemotherapy, raises the issue of peritoneal microscopic disease management and requires the development of additional locoregional treatment strategies. Photodynamic therapy is an effective treatment already applied in other medical and surgical indications. After administration of a photosensitizer which accumulates in cancer cells, illumination with a light of adequate wavelength may induce photochemical reaction between photosensitizer and tissue oxygen which lead to reactive oxygen species production and cytotoxic phenomenon. Photodynamic therapy's ability to treat superficial lesions disseminated on large area makes it an excellent candidate to insure destruction of microscopic peritoneal metastases in addition to macroscopic cytoreductive surgery in order to decrease peritoneal recurrence rate. Development of intraperitoneal photodynamic therapy has been limited by its poor tolerance related to the lack of specificity of photosensitizers and the location of the metastases in proximity to adjacent intraperitoneal organs. Our aim is to review clinical data concerning intraperitoneal photodynamic therapy and epithelial ovarian cancer to identify the limits of this strategy and to provide solutions which may be applied to solve these barriers and enable safe and effective treatment. Targeted photosensitizers and innovative illumination solutions are mandatory to continue research in this field and to consider the feasibility of clinical trials.

Resume Objectif Le pronostic des cancers epitheliaux de l’ovaire reste conditionne par la qualite de l’exerese chirurgicale. Un des principaux facteurs de reduction des recidives peritoneales est l’absence de residu macroscopique en fin d’intervention. L’association chirurgie–chimiotherapie ne previent pas toujours la survenue de ces recidives qui concernent 60 % des femmes en remission a l’issue de ce traitement. Parmi les hypotheses expliquant ce taux eleve de recidive, l’existence d’une maladie microscopique residuelle en fin chirurgie est evoquee. Notre objectif est de traiter par therapie photodynamique (PDT) les metastases peritoneales ignorees lors de la chirurgie. Le ciblage therapeutique est indispensable. Nous presentons ici les proprietes d’un photosensibilisateur couple a l’acide folique et ainsi dirige vers le recepteur au folate, surexprime par la majorite des CEO. Methode Le photosensibilisateur a ete teste in vitro sur lignees cellulaires et in vivo sur un modele animal de carcinose peritoneale pour l’evaluation de ses capacites a atteindre la cible tumorale, a emettre une fluorescence detectable, a induire la destruction du tissu cible. Resultats Nous avons montre la bonne specificite de la molecule pour sa cible. Les lignees cellulaires emettent une fluorescence detectable apres mise en culture dans un milieu enrichi en photosensibilisateur ce qui indique leur capacite a incorporer la molecule d’interet. Cette fluorescence a ete detectee in vivo au niveau des metastases peritoneales. La PDT permet d’obtenir la mort cellulaire des cellules humaines in vitro avec une bonne efficacite. Conclusion Un photosensibilisateur specifique pourrait autoriser le developpement d’une technique de PDT sure et efficace.

Understanding biology and progression mechanisms of peritoneal metastases of epithelial ovarian cancer (EOC) is a cornerstone in the knowledge and the comprehensive management of the disease. Despite clinical remission after the association of complete cytoreductive surgery and platinum-based chemotherapy, peritoneal recurrence still occurs in 60% of patients. Eligible studies, published from 1980 to June 2016, were retrieved through ClinicalTrials.gov, MEDLINE, Cochrane databases and bibliography searches. We reviewed all publications that deals with microscopic peritoneal metastases of EOC in French and English. To discuss expected benefits of intraperitoneal (IP) chemotherapy, fluorescence-guided surgery or IP photodynamic therapy, we reviewed most recent and relevant studies. The final reference list was generated on the basis of originality and relevance to the broad scope of this review. Published data concerning early-stage ovarian cancer suggest that occult peritoneal or epiploic metastases are present in 1.2%-15.1% of cases. In the frequent case of advanced-stage disease, residual microscopic lesions are ignored by conventional surgery. We are convinced that microscopic peritoneal metastases are a relevant surgical therapeutic target. This article discusses existing data on microscopic peritoneal metastases, the treatment indications, the diagnostic and therapeutic surgical approaches to be developed and their expected benefits. A local therapeutic strategy to target microscopic lesions is needed in addition to complete macroscopic cytoreductive surgery to decrease the rate of peritoneal recurrence. Intraperitoneal chemotherapy, and targeted photodynamic therapy could play a role in this new paradigm. The roles of these different options must be defined by future researches.

The incidence (rate per 100 000) of borderline ovarian tumors (BOTs) increases progressively with age, starting at 15-19 years and peaking at around 4.5 cases per 100 000 at an age of 55-59 years (LE3) with a median age of 46 years. The five year survival for FIGO stages I, II, III and IV is 99.7 % (95 % CI: 96.2-100 %), 99.6 % (95 % CI: 92.6-100 %), 95.3 % (95 % CI: 91.8-97.4 %) and 77.1 % (95 % CI: 58.0-88.3 %), respectively (LE3). An epidemiological association exists between the individual risk of BOT and family history of BOT and certain other cancers (pancreatic, lung, bone, leukemia) (LE3), a personal history of benign ovarian cyst (LE2), a personal history of tubo-ovarian infection (LE3), the use of a levonorgestrel intrauterine device (LE3), oral contraceptive use (LE3), multiparity (LE3), Hormonal replacement therapy (LE3), high consumption of Coumestrol (LE4), medical treatment for infertility with progesterone (LE3) and non-steroidal anti-inflammatory drug use (LE3). Screening for BOTs is not recommended for patients (Grade C). The overall risk of recurrence of BOTs varies between 2% and 24 %, with an overall survival greater than 94 % at 10 years, and the risk of an invasive recurrence of a BOT ranges from 0.5 % to 3.8 %. The use of scores and nomograms can be useful in assessing the risk of recurrence, and providing patients with information (Grade C). The WHO classification is recommended for classifying BOTs. It is recommended that the presence of a microinvasive focus (5 mm) and microinvasive carcinoma (5 mm with an atypical nuclei and a desmoplastic stroma reaction) within a BOT be reported. In cases of serous BOT, it is recommended to specify the classic histological subtype or micropapillary / cribriform type (Grade C). When confronted with a BOT, it is recommended that the invasive or non-invasive nature of peritoneal implants can be investigated based solely on the invasion and destruction of underlying adipose or peritoneal tissue which has a desmoplastic stromal reaction where in contact with the invasive clusters (Grade B). For bilateral mucinous BOTs and / or in cases with peritoneal implants or peritoneal pseudomyxoma, it is recommended to also look for a primitive digestive or pancreato-biliary cancer (Grade C). It is recommended to sample ovarian tumors suspected of being BOTs by focusing samples on vegetations and solid components, with at least 1 sample per cm in tumors with a size less than 10 cm and 2 samples per cm in tumors with a size greater than 10 cm (Grade C). In cases of BOTs and in the absence of macroscopic omental involvement after careful macroscopic examination, it is recommended to perform at least 4-6 systematic sampling blocks and to include all peritoneal implants (Grade C). It is recommended to consult an expert pathologist in gynecology when a BOT suspicion requires intraoperative extemporaneous histology (grade C). Endo-vaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended that a pelvic MRI be performed (Grade A). To analyze an adnexal mass with MRI, it is recommended to use an MRI protocol with T2, T1, T1 Fat Sat, dynamic and diffusion sequences as well as gadolinium injection (Grade B). To characterize an adnexal mass with MRI, it is recommended to include a score system for malignancy (ADNEX MR/O-RADS) (Grade C) in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being a BOT (Grade C). Macroscopic MRI features should be analyzed to differentiate BOT subtypes (Grade C). Pelvic ultrasound is the first-line examination for the detection and characterization of adnexal masses during pregnancy (Grade C). Pelvic MRI is recommended from 12 weeks of gestation in case of an indeterminate adnexal mass and should provide a diagnostic score (Grade C). Gadolinium injection must be minimized as fetal impairment has been proven (Grade C). It is recommended that serum levels of HE4 and CA125 be evaluated and that the ROMA score for the diagnosis of an indeterminate ovarian mass on imaging be used (grade A). In case of suspicion of a mucinous BOT on imaging, dosage of serum levels of CA 19-9 can be considered (Grade C). If the determination of tumor markers is normal preoperatively, routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of preoperative elevation in tumor markers, the determination of serum CA 125 levels is recommended in the follow-up of BOT (Grade B). When conservative treatment of a BOT has been adopted, the use of endovaginal and transabdominal ultrasonography is recommended during follow-up (Grade B).

In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C). In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C).

Modern surgery tends to the improvement of minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy in many directions. Regarding the extraction of large uterus, morcellation is currently the only way to externalize surgical specimens (myomas, uterine), without increasing the skin opening while allowing to reduce postoperative complications compared to laparotomy. However, in 2014, the Food and Drug Administration (FDA) discourages the use of uterine morcellation because of oncological risk. This recommendation has been challenged by a part of the profession. Our review has sought to identify the evidence for and against the use of morcellation. We also tried to quantify surgical risk and the current means of prevention. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available could not enable any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnosis modalities (imaging, preoperative biopsy) are to continue to minimize the oncological risk.

Introduction In the context of the COVID-19 pandemic, specific recommendations are required for the management of patients with gynecologic cancer. Materials and method The FRANCOGYN group of the National College of French Gynecologists and Obstetricians (CNGOF) convened to develop recommendations based on the consensus conference model. Results If a patient with a gynecologic cancer presents with COVID-19, surgical management should be postponed for at least 15 days. For cervical cancer, radiotherapy and concomitant radiochemotherapy could replace surgery as first-line treatment and the value of lymph node staging should be reviewed on a case-by-case basis. For advanced ovarian cancers, neoadjuvant chemotherapy should be preferred over primary cytoreduction surgery. It is legitimate not to perform hyperthermic intraperitoneal chemotherapy during the COVID-19 pandemic. For patients who are scheduled to undergo interval surgery, chemotherapy can be continued and surgery performed after 6 cycles. For patients with early stage endometrial cancer of low and intermediate preoperative ESMO risk, hysterectomy with bilateral adnexectomy combined with a sentinel lymph node procedure is recommended. Surgery can be postponed for 1–2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1–2 endometrioid cancer on endometrial biopsy). For patients of high ESMO risk, the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) should be applied to avoid pelvic and lumbar-aortic lymphadenectomy. Conclusion During the COVID-19 pandemic, management of a patient with cancer should be adapted to limit the risks associated with the virus without incurring loss of chance.