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Pneumatosis cystoides-like pattern is a group of histopathological features occasionally found in ovarian teratomas. This is a case of laparoscopic ovarian cystectomy performed for incomplete adnexal torsion where histology reported mature ovarian teratoma with “pneumatosis cystoides-like appearance”. This term is used to describe the presence of multiple cystic spaces within the tumor wall. It has been reported also in other organs, such as gastrointestinal tract, urinary bladder and the vagina. It may be secondary to mechanical, bacterial or ischemic causes, with the pathogenesis remaining unclear. It is benign and may exist more often than reported.

Aim of the study Our aim was to analyse the feasibility of white blood cell and platelet counts along with their ratios as a prognostic factor in patients who underwent surgery for ovarian mass. Material and methods We retrospectively studied the patients admitted in the Department of Gynaecology due to adnexal mass. The potential association of the neutrophil-to-lymphocyte-ratio (NLR), neutrophil-to-monocyte (NMR), platelet-to-lymphocyte (PLR), lymphocyte-to-monocyte (LMR), monocyte-to-platelet, and malignancy was evaluated. Results Patients with malignant tumours were found with significantly higher ratios of NLR (p < 0.001) and PLR (p < 0.001) and lower LMR ratio (p < 0.001) compared to those with benign tumours. Furthermore, higher lymphocyte count (p = 0.04) and platelet count (p = 0.004) were found in cancer patients when compared with borderline tumours. No significant variations were detected regarding white blood cell count (p = 0.238), NMR ratio (p = 0.28), platelet-to-neutrophil ratio (p = 0.12), and platelet-to-monocyte ratio (p = 0.34). Conclusions Inflammation biomarker ratios can easily and inexpensive assist in distinguishing malignant ovarian tumours from benign ones.

As the prevalence of obesity has been rising during the past decades worldwide and especially in Greece, surgeons have faced significant challenges concerning the treatment of morbidly obese women with gynecologic cancer. Panniculectomy is a safe procedure that offers better visualization of pelvic anatomy and prevention of major complications in these women. Aim of this study is to describe a single-center experience of surgical treatment of morbidly obese women with gynecologic cancer and concurrent panniculectomy. We, also, review the literature for articles that report concurrent gynecologic surgery and panniculectomy, to summarize the complications that were encountered. From 2015 to 2018, 38 obese women were treated with concurrent panniculectomy at the time of gynecologic surgery for cancer in a single institution. Median age was 55.62 years old, median BMI 43.79 kg/m2, median blood loss 243.75 ml and median operative time approximately 200 min. Twenty-nine patients had endometrial cancer, one patient had concurrent endometrial cancer and fallopian tube cancer, six patients had borderline ovarian cancer, and two had adult granulosa ovarian tumour. Intraoperative and postoperative complications were documented. Five patients suffered from wound infection and were treated with antibiotics and one patient died after wound infection, wound dehiscence, and renal failure. For selected obese patients, concurrent panniculectomy with surgical treatment of gynecological cancer is a safe and efficient procedure.

Panniculectomy combined with gynaecological surgery constitutes an alternative approach for endometrial cancer (EC) in obese patients. The present study aimed to assess the current knowledge concerning the safety and efficacy of combining panniculectomy in surgical management of EC. Four electronic databases were systematically searched for articles published up to May 2019. A total of five studies, of which two were non-comparative and three comparative, were included. Meta-analysis of complications among panniculectomy and conventional laparotomy group revealed no difference in either intra- or post-operative complication rates. Moreover, no difference was reported in surgical site complications (p=0.59), while wound breakdown rates were significantly elevated in the laparotomy group (p=0.02). Panniculectomy combined surgery for the management of EC appears to be a safe procedure and results in comparable outcomes compared with conventional laparotomy with regard to complications and improved wound breakdown rates.

We evaluated the effectiveness, safety and efficacy of robotic interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) treated with neoadjuvant chemotherapy (NACT). We conducted a systematic review of the published relevant studies. Α total of 102 patients were evaluated. Mean operative time ranged from 164 to 312 min (mean ± SD: 246 ± 61 min) while mean estimated blood loss ranged from 106.9 to 262.5 ml (mean ± SD: 168 ± 68 ml) and postoperative blood transfusion rate was 19% (n = 19/98). Complete cytoreduction rate (R0 resection) was achieved in 75 patients (76.5%), whereas residual disease ≤ 1 cm in 21 women (21.5%). Mean hospital stay was 2.4 days. No intraoperative and six postoperative (14.6%) complications were reported. Laparotomy conversion rate was 9.2% (9/98) mostly in the terms of achieving complete cytoreduction and 30-day mortality rate was 9.2% (n = 9/98). The median overall survival varied from 39.7 to 47.2 months, while the progression-free survival ranged from 20.6 to 21.2 months during a median follow-up period from 2 to 86 months (median 25.3 months). A total of 60 women (61%) developed disease recurrence. One of the studies reported significantly improved OS and PFS in patients who underwent robotic IDS when compared to those who had laparotomy either during or before the addition of robotic surgery in the management of advanced ovarian cancer disease (47.2 vs 37.8 vs 37.9, p = 0.004 for OS and 20.6 vs 13.9 vs 11.9, p = 0.005 for PFS, respectively). The same was also observed when controlling the parameters of age and stage for patients in the robotic arm (p = 0.02). Robotic interval debulking surgery can be considered in the management of advanced ovarian cancer patients after receiving neoadjuvant chemotherapy. Larger meta-analyses including multicenter randomized control trials are necessary to specify the exact profile of the patients that could benefit from this treatment strategy.

The change in life expectancy affects the clinical presentation and the prognosis of elderly patients with gynecological cancer. The in-crease of life expectancy and increased numbers of elderly patients, the healthcare systems have to deal more frequently with patients who are not simply older adults but have also severe comorbidities and physiological, psychological, functional, and social needs that require individualised management. Discussing every individual after detailed assessment in a multidisciplinary meeting is extremely important. Several studies have shown that elderly patients with gynecological malignancies are not treated to the same extent as young-er patients and have lower odds of receiving standard care according to the oncological protocols. Individualization of management in these patients could be identified in several studies in the literature showing that increasing age at diagnosis predicts deviation from guidelines for surgical therapy, adjuvant radiotherapy or chemotherapy. The authors performed a literature review to clarify whether there are any changes in the treatment of such patients, and whether their management should be considered to be individualized, depending on their age and comorbidities.

Fibroids are the most common benign tumors affecting fertility and quality of life. Different methods either definitive or fertility sparing are used for their management by using open, laparoscopic and robotic techniques. This is a narrative review presenting the role and the advantages of robotic surgery in fibroids (myomectomies or hysterectomies). Such a management is effective, safe and feasible in hands of well-trained teams even for multiple, large or deep located fibroids.

Dermatomyositis (DM) is defined as an autoimmune inflammatory disease that affects the skin, the blood vessels and the muscles. It typically presents with erythema affecting mostly the eyes and the hands as well as proximal muscle weakness. It has been also correlated with various types of cancer, including ovarian cancer. A systematic PubMed and Scopus search was conducted. A total of 110 women were included in our review. The median age of the patients was 52.5 years (8-85). The most frequent histological type of malignancy was epithelial (87 cases, 79.1%) and in only one patient (0.9%) DM was co-existing with a cancer recurrence. A clinical diagnosis of DM or PM preceded the diagnosis of ovarian cancer in 69.1% (76/110), while paraneoplastic DM after the diagnosis of ovarian cancer was reported in 31% (34/110). Serum antibodies were present in 22.5% (25/110) and the median creatine kinase during first evaluation was 886 (56.6-16,596). Postoperative improvement of the symptoms was observed in 24.6% (27/110) while also 24.6% (27/110) needed post-treatment rheumatological management. Neoadjuvant chemotherapy or radiotherapy was necessary in 58.2% (64/110) and a cancer recurrence was identified in 28.2% (31/110), with a median follow up of 24.5 months (5-210). Finally, 52 (47.3%) deaths were reported in a median follow-up period of 16 months (0-210). It is crucial that DM patients should receive a thorough evaluation for ovarian cancer, among other malignancies, encompassing an abdominal CT or MRI scan and serum Ca-125 marker measurements. Treatment of ovarian cancer is usually accompanied by remission of DM symptoms in most of the cases.

Objective To analyze the kind of ovarian cancer relapse by separating residual from recurrent disease and correlating them with patient survival. Material and methods This was a retrospective study of 200 women with ovarian carcinoma relapse between 2005 and 2017. Results The main sites of residual disease included the great omentum, epiploic appendices, liver round ligament, gallbladder, and cervical/vaginal stump. The median survival for women with residual disease treated with cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC) + systemic chemotherapy was 38 months compared with the control group, which reached 23.8 months. The morbidity rates were 18% vs 7%, respectively, and the mortality rates were 2.5% vs 1.3%. The main sites of recurrent disease included the mesenterium, pelvic floor, diaphragm, and Glisson’s capsule. Women with recurrent disease treated with CRS + HIPEC + systemic chemotherapy had median survival rates of 26 months vs 16 months in the control group. The morbidity rates were 22% vs 15%, respectively, and the mortality rates were 3.3% vs 0%. Conclusion Patients undergoing secondary debulking plus HIPEC for ovarian carcinoma relapse have a different prognosis when compared with patients with residual and recurrent disease. A different prognosis is presented in women undergoing secondary debulking plus HIPEC for ovarian carcinoma relapse when comparing patients with residual and recurrent disease.

With great deal of interest we read the published article entitled “Intraoperative complications and conversion to laparotomy in gynecologic robotic surgery” [1]. The authors analyzed their single ...

Altered fetal growth, either reduced or exacerbated, is associated with adverse perinatal outcomes. The underlying pathogenetic mechanisms of altered growth remain unclear. Fibroblast growth factor 21 (FGF21) and insulin are both considered to be major regulators of tissue growth and metabolism. The aim of our study was to investigate the association of second trimester amniotic fluid FGF21 and insulin concentrations with fetal growth. The amniotic fluid concentrations of FGF21 and insulin were determined in 80 cases of different fetal growth patterns (SGA—small for gestational age, LGA—large for gestational age, and AGA—appropriate for gestational age fetuses). Both peptides were found to be increased in cases of abnormal fetal growth, reduced growth velocity (SGA), or macrosomia (LGA). Specifically, FGF21 was significantly increased, as higher FGF21 levels were observed in the amniotic fluid of SGA and LGA fetuses compared with AGA fetuses (p &lt, 0.05). Furthermore, the more severe the fetal smallness, the higher the FGF21 levels (p &lt, 0.05). Similarly, higher insulin levels were noted in the amniotic fluid of SGA and LGA fetuses compared with those in AGA fetuses, though this was not statistically significant (p &gt, 0.05). Again, the more severe the reduced fetal growth, the higher the insulin levels.

Human papillomavirus (HPV) has been directly related to acuminate warts and cervical cancer, the second most common neoplasia among women. Given the lack of treatment against the virus itself, many medications have been utilised, mainly aiming in modifying the host’s immunological response. We present the case of a 54 years old postmenopausal patient with a history of vaginal cuff wart and HPV persistence that we managed in our clinic for 6 months with a mix of curcumin, aloe vera, amla and other natural ingredients. As the patient was found to be intolerant to imiquimod (one of the most common conservative methods of treatment) we attempted the use of curcumin, which was applied to the area of the wart three times per week for 6 months. Both clinical and colposcopical improvement was noted in regular clinic visits with regression of the lesion. The outcome of this case encourages our view that curcumin should be considered as a significant treatment modality against HPV infection and acuminate warts.

Primary fallopian tube carcinoma (PFTC) is extremely uncommon, accounting for between 0.1 and 1.8% of all gynaecological cancers diagnosed (Ayumu et al. 2018). Hence, in the past decade, arising da...

To present the clinical and laboratory characteristics, as well as the management, of patients with primary peritoneal serous papillary carcinoma (PPSPC). This is a retrospective study of 19 patients with PPSPC who underwent debulking surgery followed by first line chemotherapy and were managed in Metaxa Memorial Cancer Hospital between January 2002 and December 2017. The median age of the patients was found to be 66 years (range 44–76 years). Clinical presentation of PPSPC included abdominal distention and pain, constipation, as well as loss of appetite and weight gain. Two of the patients did not mention any symptomatology and the disease was suspected by an abnormal cervical smear and elevated CA125 levels respectively. Biomarkers measurement during the initial management of the patients revealed abnormal values of CA125 for all the participants (median value 565 U/ml). Human epididymis secretory protein 4 (HE4) and ratios of blood count were also measured. Perioperative Peritoneal Cancer Index ranged from 6 to 20. Optimal debulking was achieved in 5 cases. All patients were staged as IIIC and IVA PPSPC and received standard chemotherapy with paclitaxel and carboplatin, whereas bevacizumab was added in the 5 most recent cases. Median overall survival was 29 months. PPSPC is a rare malignancy, the management of which should take place in tertiary oncology centers.

Imiquimod has been demonstrated to be rather effective in patients with anal as well as perianal high-grade squamous intraepithelial lesions (HSILs). Nevertheless, until now the intra-anal use of imiquimod has been considered off-label. The aim of this study is to review the clinical evidence related to the intra-anal use of imiquimod in the treatment of human papillomavirus-related anal lesions. A systematic search in PubMed and Scopus was performed. In total, 422 patients were included. The most common referred comorbidity was HIV infection (281 patients, 66.6%). The principal clinical entities, which were treated with intra-anal imiquimod, were HSILs. The most frequent formulation was self-applied imiquimod cream. In the HSIL group, there was complete healing in 74 patients (35%) and partial in 44 patients (20.9%), while in the wart group, there was complete healing in 128 patients (67%). Recurrence of HSIL was present in 19 patients (15%), while in cases with warts recurrence was present in 38 patients (19.8%). The most common adverse events were pain, itching, and burning sensation. In conclusion, the adverse effects associated with the intra-anal use of imiquimod seem to be minor. The present clinical evidence suggests that imiquimod may be proposed as effective, safe, and relatively well tolerated treatment.

The development of leiomyomas on the grounds of an aplastic/hypoplastic uterus in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS) has been rarely described. We report the first case of development of multiple leiomyomas in a patient with MRKHS complicated with pulmonary valve stenosis, and we present a narrative review of the existing literature. A 44-year-old patient with MRKHS attended our clinic because of pelvic pain, which was attributed to a pelvic mass found on ultrasound. Magnetic resonance imaging revealed a multinodular mass, indicating either ovarian pathology or the presence of leiomyomas. Exploratory laparotomy was performed, and multiple solid masses on the grounds of two rudimentary uterine buds were observed. Histological analysis revealed multiple leiomyomas arising from parametrial or paratubal tissue. We searched medical databases for articles relevant to leiomyomas and MRKHS. We present a review of the current literature and summarize the clinical manifestation, diagnosis, management, and histopathological findings of all the cases described. We underline that it is important for gynecologists to be aware of this rare clinical entity, and symptomatic leiomyomas cannot be excluded in patients with MRKHS.

Bisphenol A (BPA), a ubiquitous endocrine-disrupting chemical (EDC), is increasingly hypothesized to be a factor contributing to changes in fetal growth velocity. BPA exposure may be environmental, occupational, and/or dietary, with canned foods and plastic bottles contributing significantly. Our systematic review aims to evaluate the current literature and to investigate the role of BPA in abnormal fetal growth patterns. A search was conducted in the PubMed and Cochrane databases. A total of 25 articles met the eligibility criteria and were included in this systematic review. Eleven of them failed to show a clear relationship between BPA and abnormal fetal growth. The majority of the remaining studies (9/14) found an inverse association of BPA with indicators of fetal growth, whereas three studies suggested increased fetal growth, and two studies produced contradictory findings. Of note, both of the studies that collected a sample (amniotic fluid) directly reflecting BPA concentration in the fetus during the first half of pregnancy revealed an inverse association with birth weight. In conclusion, there is mounting evidence that combined exposure to BPA from dietary and non-dietary sources during pregnancy may contribute to abnormal fetal growth; a tendency towards fetal growth restriction was shown, especially when exposure occurs during the first half.

Objective. To review the existing studies on single-site robotic myomectomy and test the safety and feasibility of this innovative minimally invasive technique. Data Sources. PubMed, Scopus, Google Scholar (from their inception to October 2019), as well as Clinicaltrials.gov databases up to April 2020. Methods of Study Selection. Clinical trials (prospective or retrospective) that reported the outcomes of single-site robotic myomectomy, with a sample of at least 20 patients were considered eligible for the review. Results. The present review was performed in accordance with the guidelines for Systematic Reviews and Meta-Analyses (PRISMA). Four (4) studies met the inclusion criteria, and a total of 267 patients were included with a mean age from 37.1 to 39.1 years and BMI from 21.6 to 29.4 kg/m2. The mean operative time ranged from 131.4 to 154.2 min, the mean docking time from 5.1 to 5.45 min, and the mean blood loss from 57.9 to 182.62 ml. No intraoperative complications were observed, and a conversion rate of 3.8% was reported by a sole study. The overall postoperative complication rate was estimated at 2.2%, and the mean hospital stay ranged from 0.57 to 4.7 days. No significant differences were detected when single-site robotic myomectomy was compared to the multiport technique concerning operative time, blood loss, and total complication rate. Conclusion. Our findings support the safety of single-site robotic myomectomy and its equivalency with the multiport technique on the most studied outcomes. Further studies are needed to conclude on the optimal minimally invasive technique for myomectomy.

Dear Editor, With a great deal of interest we read the article entitled ‘Does sites of recurrence impact survival in secondary cytoreduction surgery for recurrent epithelial ovarian cancer?’ by Kum...

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Introduction/Background Cervical cancer is oftentimes plagued by several urological complications during or post treatment. Early disease is mainly managed with radical hysterectomy, while more advanced disease is usually treated by chemoradiation. Although urological complications of cervical cancer treatment have declined during the past decades, owing to improvements in various therapeutic modalities, the incidence of those complications has not yet precisely defined. Methodology Cervical cancer patients between 2009 and 2020 were retrospectively reviewed from the cancer database of our tertiary institution. Results 420 women were diagnosed with cervical cancer of any stage in our cancer hospital. 122 (29%) of those women had early stage disease and thus were managed with radical hysterectomy (RH); the remaining 294 (71%) underwent chemoradiation, chemotherapy, or palliative therapy. 5 out of 122 RH patients (4%) experienced urological adverse events, and namely intraoperative ureteric injury, intraoperative and urinary bladder injury and postoperative ureteral necrosis. One patient (0.8%) was managed with primary end to end ureteral anastomosis, another (0.8%) with intraoperative bladder repair, one patient (0.8%) had Boari flap formation, and two (1.6%) underwent ureteral reimplantation (reoperation on the 10th and 14th postoperative day respectively). In 24 RH patients (19.6%% ) prophylactic cystoscopic ureteral stenting had taken place before the operation. As for the non RH group (294 patients) 10 (3.4%) had prophylactic cystoscopic stenting, while 3 patients (1%) underwent nephrostomy placement. Conclusion Cervical cancer management –either surgical or conservative -is often accompanied by various urological complications. Prophylactic ureteral stenting, meticulous surgical technique, prompt diagnosis and management of urological adverse events are of paramount importance when dealing with cervical cancer. Disclosures The authors declare no conflicts of interest.

Introduction/Background Endometrial cancer (EC) is the most commonly diagnosed gynecological malignancy in the developed countries. Obesity, diabetes mellitus and infertility are some of the contributory factors. Some patients with EC wish to preserve their fertility or others have several comorbidities that contraindicate surgery. These groups of patients could benefit from a conservative treatment strategy such as the use of metformin. This agent is an option in women with increased EC risk as well as in those with atypical endometrial hyperplasia. Methodology We evaluated the protective effects of metformin in EC patients, its preventive role in breast cancer and obese patients and its effectiveness, safety and efficacy in addition to progesterone monotherapy in treatment of fertility sparing candidates. We reviewed the literature and then conducted a meta-analysis of the relevant parameters. A total of 6 studies was included in the meta-analysis. Results Comparing the pre-surgical treatment with metformin versus placebo, meta-analysis of mean difference in Ki-67 after treatment among two groups, revealed no difference (MD -7.10, 95% CI -23.31 to 9.11, p=0.39). Meta-analysis of fertility sparing EC management with a combination of megestrol acetate (MA) and metformin (500 mg three times a day) in comparison with monotherapy with 160 mg daily MA revealed no difference in either complete response or partial response rates (166 patients OR 2.94, 95% CI 0.85 to 10.15, p=0.09 and 166 patients OR 0.76, 95% CI 0.34 to 1.66, p=0.49, respectively). Regarding breast cancer survivors under tamoxifen, metformin was related with significantly reduced median endometrial thickness after 52 weeks of evaluation when compared to women in placebo group (2.3 mm vs 3.0 mm, p=0.05). Conclusion Metformin neither was found to have a preventative role against the development of endometrial cancer nor a beneficial one in addition to the progesterone monotherapy for EC fertility sparing candidates. However, metformin was found to be protective in breast cancer survivors under tamoxifen. Disclosures Nothing to disclose.

Introduction/Background Safety and efficacy of robotic interval debulking surgery (IDS) after treatment with neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian cancer (EOC) was evaluated. Methodology A systematic review of the literature was conducted. Results We evaluated 102 patients in total. Perioperative outcomes were estimated as following: mean estimated blood loss ranged from 106.9 to 262.5 ml (mean± SD: 168±68 ml), mean operative time ranged from 164 to 312 min (mean± SD: 246±61 min), mean hospital stay was 2.4 days and postoperative blood transfusion rate was 19% (n=19/98). Regarding the oncological outcomes, 75patients received a R0 resection (complete cytoreduction), while by 21 women there was a residual disease ≤1 cm. Regarding complications, no intraoperative and 6 postoperative (14,6%) complications were recorded, with a 30-d mortality rate of 9.2% (n=9/98), whereas the laparotomy conversion rate was 9.2% (9/98) as well, mostly in the terms of achieving complete cytoreduction. During a median follow up period of 2 to 86 months (median 25.3 months), the median overall survival from 39.7 to 47.2 months and the progression free survival varied from 20.6 to 21.2 months. Recurrent disease was reported in 60 women (61%). Our results are in harmony (p=0.02) with those of the one study that presented significantly improved OS and PFS in the robotic arm compared to laparotomy (47.2 vs 37.8 vs 37.9, p=0.004 for OS and 20.6 vs 13.9 vs 11.9, p=0.005 for PFS, respectively). Conclusion Robotic interval debulking surgery is a safe and efficient regarding the management of advanced ovarian cancer patients who receive neoadjuvant chemotherapy. The patients that are more eligible and could benefit from this treatment strategy should be specified through larger, double-blind randomized control trials. Disclosures All authors declare no conflict of interest.

Ovarian cancer is the leading cause of death among gynecologic malignancies. Combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) can benefit patients with advanced ovarian cancer. We evaluate the role of small bowel peritoneal cancer index (sb-PCI) score as a prognostic factor. We retrospectively analyzed characteristics and clinical outcomes of patients that underwent intermediate cytoreductive surgery combined with HIPEC after neoadjuvant chemotherapy and patient’s characteristics underwent debulking surgery plus HIPEC for recurrence disease. One hundred thirty patients were included. Eighty-five of them (65.4%) were treated for recurrent ovarian cancer, while 45 (34.6%) underwent intermediate cytoreductive surgery after neoadjuvant chemotherapy with a mean age of 52 years. Mean intraoperative peritoneal cancer index (PCI) was 11.84 with a mean sb-PCI score of 5.57. Univariate analysis revealed that PCI, sb-PCI, and completeness of cytoreduction (CC) were parameters that correlated significantly with overall survival, while after multivariate analysis sb-PCI and CC were identified as independent prognostic factors of survival. A statistically significant correlation between sb-PCI score and overall survival of patients with advanced ovarian cancer was revealed. Further larger future studies are required to confirm our conclusion in order to change the treatment of advanced ovarian cancer patients.

Objective. To evaluate the contribution of PlasmaJet application in achieving optimal cytoreduction in advanced ovarian cancer. Methods. We systematically searched for articles published up to June 2019 using MEDLINE, Scopus, Google Scholar databases and clinicaltrials.gov along with the references of the articles retrieved in full text. Observational studies and case reports addressing cases of women with peritoneal spread due to advanced stage ovarian cancer who were treated with application of PlasmaJet device were considered eligible for inclusion. Results. Three studies were excluded from further analysis when they were retrieved in full text. Five studies (2 retrospective, 1 prospective, and 2 case reports) that comprised 77 patients with age range from 38 to 85 years were included. Forty-three women underwent interval debulking surgery, 24 patients primary debulking surgery, and 6 had optimal debulking surgery, while in the remaining 4, a secondary debulking surgery was performed. Incidence of intraoperative complications was 32% (8/25), but none of them was due to the application of PlasmaJet. Complete macroscopic resection was achieved in 59 out of 70 (84.3%) women. Postoperatively, 17 out of 72 patients (23.6%) developed complications such as pneumothorax due to diaphragmatic resection, systemic infections, or wound-related complications. No postoperative mortality was recorded. Conclusions. Preliminary data on the use of PlasmaJet for ablation of ovarian cancer implants in the peritoneal cavity showed its safety and presented with promising outcomes in achieving complete cytoreduction.

BackgroundThe aim of this survey was to acquire an overview of the current management of ovarian cancer with an emphasis on the utility of hyperthermic intraperitoneal chemotherapy (HIPEC).Methods: An email was sent to Oncologists prior to PSOGI International Symposium on Advanced Ovarian Cancer, Athens 11–13 April 2019. Doctors submitted responses on the relevant website. The self-report survey contained 17 questions.ResultsIn total, 467 Medical Oncologists, Surgical Oncologists or Gynaecologic Oncologists were participated and answered to this survey. The resectability of disease was evaluated by laparoscopy from 48.5% of the participants, while 51.5% answered that they stage their patients pre-surgically with the use of CT or MRI. The preferred first intervention in advanced ovarian cancer patients is the neoadjuvant chemotherapy followed by interval cytoreductive surgery (72%). Regarding the use of HIPEC, almost half of the participants answered that there is role of HIPEC use in ovarian cancer patients undergoing interval debulking surgery, while almost 70% answered positively about the utility of HIPEC use in ovarian cancer recurrence. As for the role of lymphadenectomy in advanced ovarian cancer patients, half of the responders answered negatively. Finally, only 25% of the participants responded that they always check the BRCA status of their ovarian cancer patients, despite the possible differentiation of treatment based on the molecular profiling (80%).ConclusionsThe results of this survey indicate the utility of HIPEC in treatment of ovarian cancer patients and the differences in the overall management of ovarian cancer patients in the current clinical practice.

Microcystic, elongated, fragmented (MELF) pattern of myometrial invasion has been proposed as a prognostic marker in patients with endometrial carcinoma (EC). Its prognostic and predictive effect still remains elusive. The aim of the present study is to accumulate the current knowledge on the role of MELF pattern in the prognosis and survival of patients with EC. Medline, Scopus, Google Scholar, and Clinicaltrials.gov databases were searched for articles published up to May 2018, along with the references of all articles. Prospective and retrospective trials reporting outcomes of cases with EC who were examined for MELF pattern were considered eligible for inclusion in the present systematic review. Of the 196 records screened, 14 were considered eligible. A total of 14 studies which comprised 588 women were finally included in the present systematic review. All the included patients were evaluated for presence of MELF pattern of myometrial invasion. MELF positive (+) patients were more likely to present with larger and higher grade tumors, lymph node metastasis, lymphovascular invasion and >50% myometrial invasion. No difference was reported in disease free survival (DFS) and disease specific survival (DSS) as well as in vaginal recurrence rates. MELF (+) was reported as a significant indicator of survival. In conclusion, MELF pattern of myometrial invasion plays a critical role in lymphovascular space invasion and lymph node metastasis in patients with EC. Regardless, its implication in survival and recurrences is ill determined.

Background/aim Para-aortic lymphadenectomy is established as a standard procedure for disease staging and management of patients with advanced cervical, ovarian and high-risk endometrial cancer. Our meta-analysis accumulated the current evidence on the impact of transperitoneal (TLL) and extraperitoneal (ELL) laparoscopic lymphadenectomy for the management of patients with gynecological malignancies. Materials and methods A systematic search of the literature was undertaken for articles published up to April 2018. Statistical meta-analysis was performed using the RevMan 5.3 software. Results Seven studies were eligible for meta-analysis and comprised a total of 608 women. ELL was associated with significantly shorter operative times for lymphadenectomy, whereas total operative times were not different between the two groups. Significantly increased intraoperative complications were found in the TLL group. Conclusion ELL is safe and efficient with outcomes comparable to TLL in terms of lymph node yield and improved operative outcomes with regard to lymphadenectomy times and intraoperative complications.

Cancer during pregnancy is a particularly challenging complication. The incidence has increased in recent years due to childbearing at advanced maternal ages due to career choices and/or the development of reproductive technology. Approximately two thirds of cancer cases during pregnancy comprise invasive cervical cancers and breast cancer. Cancer during gestation is characterized by a need for specialized treatment due to major changes in the hormonal profile (estrogen-progesterone), metabolism (enhancement of anabolism), hemodynamic changes (hyperdynamic circulation), immunologic changes (cell-mediated and humoral immunity), and increased angiogenesis (increased blood flow towards the uterus). Moreover, the management of such patients is based on the trimester of pregnancy, type and stage of cancer, and informed consent of the mother based on her wishes. The optimal treatment of cancer during pregnancy remains elusive because there are limited data from retrospective studies with small samples. As a result, it is crucial that data regarding survival of the women and long-term follow-up of the children from different cancer centers and registries are shared. This need is dictated by the fact that the incidence of cancer during pregnancy will continue to rise as child-bearing age continues to increase.

Lymphadenectomy represents the standard treatment for various types of cancer. The introduction of robotics in lymph node dissection may have an important impact on post-lymphadenectomy complications. A systematic literature review was performed. In our review, robotic inguinal lymphadenectomy was performed on 51 patients. Penile squamous cell carcinoma was the most common histological type of the primary neoplasia. No intra-operative complications were reported. One case of conversion to open was reported. The mean duration of hospitalization was 2 days. The duration of drainage ranged from 7 to 72 days. The most common postoperative complications were lymphocele (13.7%), lymphedema (7.8%), cellulitis (7.8%), seroma (3.9%), abscess (3.9%), wound breakdown/wound infection (3.9%), sepsis (1.9%), prolonged lymphorrhea (1 out of 51 patients, 1.9%) and skin necrosis (1 out of 51 patients, 1.9%). Until now there has not been sufficient evidence regarding the role of robotics in groin lymph node dissection, though this approach appears to be safe and oncologically effective, with morbidity rates relatively lower compared to open surgery.

Single-incision approach in robotic gynecology is a relatively new concept. The role of single-port systems in robotic hysterectomy, their advantages and disadvantages, as well as the technical challenges, are still under investigation. A systematic review was performed by searching in PubMed and Scopus databases. In 810 out of 1225 patients, hysterectomy was performed for non-neoplastic disease. Single-Site® was the most common port system. Duration of the procedure and relative blood loss ranged from 60 to 311 min and 7 to 750 ml, respectively. The weight of the removed uteri ranged from 39 to 520 g. 4.9% of the included patients presented complications, among which bleeding, vaginal haematoma, laceration and dehiscence, umbilical hernia, and visceral injuries. Conversion rate to laparotomy reached 2.8%. Although some technical difficulties are still described in the literature, the single-port approach is becoming more standardized nowadays and performed by more surgeons. The initial phase of the learning curve can be achieved after five cases, while a proficiency in intracorporeal cuff suturing after 14 cases. Uterus weight and previous abdominal surgical history can still be limitations of the technique. Compared to our previous study, we can see that the technique has been used in more elderly or obese patients. The complication rate can reach 4.9% while the conversion rate can reach 2.8%. However, we consider that complication and conversion rates as well as surgical time could be improved with experience. Regarding post-operative pain and cosmetic outcomes, the lack of information do not allow us to draw any safe conclusions.

Aim The aim of the present study was to evaluate the role of metformin in endometrial cancer (EC), focusing on its potential preventive effect in breast cancer and obese patients and its safety and efficacy when added to progesterone monotherapy in EC patients who wish to preserve their fertility. Methods We reviewed the literature and then conducted a meta-analysis of the relevant parameters. Results A total of 6 studies was included in the meta-analysis. Regarding the pre-surgical treatment with metformin versus placebo, meta-analysis of mean difference in Ki-67 after treatment among two groups, revealed no difference (MD -7.10, 95% CI -23.31 to 9.11, p = 0.39). Meta-analysis of fertility sparing EC management with a combination of megestrol acetate (MA) and metformin (500 mg three times a day) in comparison with monotherapy with 160 mg daily MA revealed no difference in either complete response or partial response rates (166 patients OR 2.94, 95% CI 0.85 to 10.15, p = 0.09 and 166 patients OR 0.76, 95% CI 0.34 to 1.66, p = 0.49, respectively). As far as breast cancer survivors under tamoxifen are concerned, metformin was associated with significantly reduced median endometrial thickness after 52 weeks of evaluation compared to women in placebo group (2.3 mm vs 3.0 mm, p = 0.05). Conclusions Metformin neither was found to be an anti-proliferative agent against the development of endometrial cancer nor beneficial in addition to the progesterone monotherapy for EC fertility sparing candidates. However, a protective effect of metformin was demonstrated in breast cancer survivors under tamoxifen. Clinical outcomes of the ongoing trials are warranted to evaluate the therapeutic use of metformin in EC.