Search

We report the case of a woman in her 60s with intravascular leiomyomatosis. She suffered from numerous non-specific symptoms including weight loss, anaemia and sudden swelling of the left lower extremity. CT imaging showed the presence of an enlarged left ovary and a thrombus extending from the left ovarian venous plexus intruding into the right atrium of the heart. Cancer antigen 125 was 20 U/mL. Pelvic transvaginal ultrasound examination identified two normal ovaries and a mass adjacent to the left ovary. A second opinion on the CT scan was requested at a oncogynaecological multidisciplinary team meeting, where the radiologist of the team identified an intervascular leiomyomatosis. After further investigation, surgical treatment was planned and completed in collaboration with the departments of cardiothoracic and vascular surgery. The patient recovered fully.

Background: Nonepithelial ovarian cancer (NEOC) represents a wide variety of rare tumors. They are often diagnosed at an early stage and have a good prognosis compared to epithelial ovarian cancer. In the Nordic countries, the total annual number of patients diagnosed with ovarian cancer, Fallopian tube cancer or primary peritoneal carcinoma (hereafter ovarian cancer) was 2281 in 2014–2018, of which 3–10% were NEOC. International guidelines for diagnosis, treatment and follow-up have been developed. We present the results of a survey, aiming at clarifying current clinical practice in the Nordic countries. Material and Methods: Between 09.2020 and 02.2021 a 33-question electronic survey was distributed to 22 hospitals in Finland, Sweden, Norway, Iceland and Denmark via the Nordic Society of Gynecological Oncology (NSGO) National Representatives. Data were collected in a secure web-based software platform. The questionnaire focused on demographics, diagnosis, treatment and follow-up programs. Results: Twenty-one (95,4%) centers completed the survey. A total of 155 annual new NEOC cases treated in the Nordic countries were reported, corresponding to approximately 7% of all ovarian cancer cases. Most centers measured some or all of the recommended biomarkers routinely. Vaginal ultrasound and computed tomography (CT) were the preferred imaging modalities. The majority of centers conducted multidisciplinary team (MDT) meetings. The primary reported treatment was surgery. In 65% of centers, lymph node dissection was only performed in cases with suspicious lymph nodes. Surveillance was usually offered > four years. Discussion: Despite, the presence of clinical European guidelines, variation in the current clinical practice amongst participating centers adhering to national guidelines was observed. Prospective clinical national research programs are sparse, and an enhanced cooperation in the Nordic countries toward development of a Nordic guideline and database is highly warranted and a prerequisite for future research, preferably in cooperation with the larger international groups.

OBJECTIVE: Lymph node metastases (pN+) in presumed early-stage cervical cancer negatively impact prognosis. Using federated learning, we aimed to develop a tool to identify a group of women at low risk of pN+, to guide the shared decision-making process concerning the extent of lymph node dissection.METHODS: Women with cervical cancer between 2005 and 2020 were identified retrospectively from population-based registries: the Danish Gynaecological Cancer Database, Swedish Quality Registry for Gynaecologic Cancer and Netherlands Cancer Registry. Inclusion criteria were: squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma; The International Federation of Gynecology and Obstetrics 2009 IA2, IB1 and IIA1; treatment with radical hysterectomy and pelvic lymph node assessment. We applied privacy-preserving federated logistic regression to identify risk factors of pN+. Significant factors were used to stratify the risk of pN+.RESULTS: We included 3606 women (pN+ 11%). The most important risk factors of pN+ were lymphovascular space invasion (LVSI) (odds ratio [OR] 5.16, 95% confidence interval [CI], 4.59-5.79), tumour size 21-40 mm (OR 2.14, 95% CI, 1.89-2.43) and depth of invasion>10 mm (OR 1.81, 95% CI, 1.59-2.08). A group of 1469 women (41%)-with tumours without LVSI, tumour size ≤20 mm, and depth of invasion ≤10 mm-had a very low risk of pN+ (2.4%, 95% CI, 1.7-3.3%).CONCLUSION: Early-stage cervical cancer without LVSI, a tumour size ≤20 mm and depth of invasion ≤10 mm, confers a low risk of pN+. Based on an international privacy-preserving analysis, we developed a useful tool to guide the shared decision-making process regarding lymph node dissection.

Objective: To evaluate patient-reported incidence and severity of early lymphedema and its impact on quality of life (QoL) after sentinel lymph node (SLN) mapping only and after SLN and pelvic lymphadenectomy (PL) in women undergoing surgery for early-stage cervical cancer.Methods: In a national prospective multicenter study, we included women with early-stage cervical cancer from March 2017-January 2021 to undergo radical surgery including SLN mapping. Women with tumors >20 mm underwent completion PL. The incidence and severity of early lymphedema and its influence on QoL were evaluated using validated patient-reported outcome measures before surgery and three months postoperative. We investigated changes over time using linear regression.Results: Two hundred of 245 (81.6%) included women completed questionnaires at baseline and three months postoperatively. The incidence of early lymphedema was 5.6% (95% CI 2.1-11.8%) and 32.3% (95% CI 22.9-42.7%) in women who underwent SLN mapping only and SLN + PL, respectively. Lymphedema symptoms in the legs, genitals, and groins increased in both groups postoperatively but three times more in women who underwent PL. Lymphedema symptoms after SLN + PL significantly impaired physical performance (p = 0.001) and appearance (p = 0.007). Reporting lymphedema was significantly associated with impaired body image, physical-, role-, and social functioning, and a high level of fatigue.Conclusions: SLN mapping alone carries a low risk of lymphedema in women undergoing surgery for early-stage cervical cancer. In contrast, completion PL is associated with a high incidence of early lymphedema. Reporting lymphedema is associated with significant impairment of several physical, psychological, and social aspects of QoL.

OBJECTIVES: Sentinel lymph node (SLN) mapping may replace staging radical pelvic lymphadenectomy in women with early-stage cervical cancer. In a national multicenter setting, we evaluated SLN mapping in women with early-stage cervical cancer and investigated the accuracy of SLN mapping and FDG-PET/CT in tumors >20 mm.METHODS: We prospectively included women with early-stage cervical cancer from March 2017-January 2021 to undergo SLN mapping. Women with tumors >20 mm underwent completion pelvic lymphadenectomy and removal of FDG-PET/CT positive nodes. We determined SLN detection rates, incidence of nodal disease, sensitivity and negative predictive value (NPV) of SLN mapping, and the sensitivity, specificity, NPV, and positive predictive value (PPV) of FDG-PET/CT.RESULTS: We included 245 women, and 38 (15.5%) had nodal metastasis. The SLN detection rate was 96.3% (236/245), with 82.0% (201/245) bilateral detection. In a stratified analysis of 103 women with tumors >20 mm, 27 (26.2%) had nodal metastases. The sensitivity of SLN mapping adhering to the algorithm was 96.3% (95% CI 81.0-99.9%) and the NPV 98.7% (95% CI 93.0-100%). For FDG-PET/CT imaging the sensitivity was 14.8% (95% CI 4.2-33.7%), the specificity 85.5% (95% CI 75.6-92.5%), the NPV 73.9% (95% CI 63.4-82.7%), and the PPV 26.7% (95% CI 7.8-55.1%).CONCLUSIONS: SLN mapping seems to be an adequate staging procedure in early-stage cervical cancer tumors ≤20 mm. In tumors >20 mm, SLN mapping is highly sensitive but demands full adherence to the SLN algorithm. We recommend completion pelvic lymphadenectomy in tumors >20 mm until the oncological safety is established. FDG-PET/CT for nodal staging of women with early-stage cervical cancer seems limited.

Cervical cancer is one of the most common cancers in pregnancy. Early diagnosis is of utmost importance for the outcome of the woman and her child. Vaginal bleeding in pregnancy should prompt gynaecological examination, and further diagnostic is needed in women with persistent symptoms. A decision on preservation of the pregnancy in women who are diagnosed with early-stage cervical cancer depends on stage and gestational age, as argued in this review.

Cervical cancer is one of the most common cancers in pregnancy. Early diagnosis is of utmost importance for the outcome of the woman and her child. Vaginal bleeding in pregnancy should prompt gynaecological examination, and further diagnostic is needed in women with persistent symptoms. A decision on preservation of the pregnancy in women who are diagnosed with early-stage cervical cancer depends on stage and gestational age, as argued in this review.

Introduction: Understanding whether human papillomavirus (HPV) may establish latency in the uterine cervix is important. A better understanding of HPV natural history is useful for clinical counseling of women attending screening and to accurately inform health prevention strategies such as screening and HPV vaccination. We evaluated the extent of latent HPV infections in older women with a history of abnormal cytology. Material and Methods: We conducted a cross-sectional study in Aarhus, Denmark, from March 2013 through April 2015. Women were enrolled if they underwent cervical amputation or total hysterectomy because of benign disease. Prior to surgery, women completed a questionnaire and a cervical smear was collected for HPV testing and morphological assessment. For evaluation of latency (i.e., no evidence of active HPV infection, but HPV detected in the tissue), we selected women with a history of abnormal cervical cytology or histology, as these women were considered at increased risk of harboring a latent infection. Cervical tissue underwent extensive HPV testing using the SPF10-DEIA-LipA25 assay. Results: Of 103 women enrolled, 26 were included in this analysis. Median age was 55 years (interquartile range [IQR] 52–65), and most women were postmenopausal and parous. The median number of sexual partners over the lifetime was six (IQR 3–10), and 85% reported no recent new sexual partner. Five women (19.2%) had evidence of active infection at the time of surgery, and 19 underwent latency evaluation. Of these, a latent infection was detected in 11 (57.9%), with HPV16 being the most prevalent type (50%). Nearly 80% (n = 14) of the 18 women with a history of previous low-grade or high-grade cytology with no treatment had an active or latent HPV infection, with latent infections predominating. HPV was detected in two of the six women with a history of high-grade cytology and subsequent excisional treatment, both as latent infections. Conclusions: HPV can be detected in cervical tissue specimens without any evidence of an active HPV infection, indicative of a latent, immunologically controlled infection. Modeling studies should consider including a latent state in their model when estimating the appropriate age to stop screening and when evaluating the impact of HPV vaccination.

OBJECTIVE: To investigate the clinical, pathological, and genetic characteristics of patients with vaginal melanoma in a nationwide setting.MATERIALS/METHODS: All patients diagnosed with vaginal melanoma from 1980 to 2018 were collected by searching the digital archives of the Danish Registry of Pathology (Patobank). Patient specimens were examined, the histological diagnoses were validated, and targeted next-generation sequencing (NGS) of known frequent hot spots in 163 genes was performed.RESULTS: Fifty-two patients were included. The incidence for primary melanoma of the vagina in the Danish population (5.5 million people) was calculated to be 0.24 cases/million/year from 1980 to 2018. For all patients, the median OS was 17.5 months (95% CI: 13.0-24.0), and the 5-year OS was 19.4% (95% CI: 10.9-34.3). We identified frequent mutations in ATRX (7/25 cases) and TP53 (7/25 cases). Mutations found in TP53 were associated with a significant decrease in OS (p = 0.043), whereas mutations in the ATRX gene alone did not show a significant impact on OS (p = 0.3649). Patients who harbored co-mutations in both ATRX and TP53 showed a significant reduction in OS (p = 0.0081), with a median OS of 9.5 months compared to 20 months in those without the co-mutation.CONCLUSIONS: Vaginal melanoma is a rare disease with a poor prognosis presumably due to vague symptoms and the anatomical location of the disease. Co-mutations in ATRX and TP53 and mutations in TP53 alone were associated with a poor prognosis, and these genes are potentially interesting targets for future therapy.

INTRODUCTION: It is debated whether women with FIGO (International Federation of Gynecology and Obstetrics) Stage IV epithelial ovarian cancer should be offered primary debulking surgery (PDS) or interval debulking surgery (IDS). Furthermore, the impact of complete resection of intra-abdominal disease (R0) despite their extra-abdominal metastases is questioned. The objective of this study was to investigate the impact of intra-abdominal residual tumor, Stage IVA vs IVB, the localization and number of metastases defining Stage IV disease on overall survival (OS) comparing PDS and IDS in FIGO Stage IV epithelial ovarian cancer.MATERIAL AND METHODS: We included 2091 women registered with Stage IIIC-IV ovarian cancer in the Danish Gynecological Cancer Database during 2009-2016. The impact of residual tumor was evaluated using univariate and multivariate analyses.RESULTS: In total, 681 patients had stage IV disease, of whom 26% underwent PDS, 38% IDS, and 36% chemotherapy only. Overall survival for PDS and IDS were similar. Patients achieving R0 at PDS showed a tendency towards a higher OS than patients achieving R0 at IDS, though the difference was non-significant. In women with Stage IVA and IVB disease there was a survival benefit in achieving R0 both when treated with PDS and IDS. Women with Stage IVB disease treated with chemotherapy only had a significantly lower OS than patients achieving R0 at both PDS and IDS. Malignant pleural effusion and having five metastatic sites compared with having one was associated with a poorer OS.CONCLUSIONS: Our study shows similar OS in patients with Stage IV disease treated with IDS compared with PDS. Complete intra-abdominal tumor resection improves the prognosis in both PDS and IDS in Stage IV ovarian cancer. Malignant pleural effusion seems to be a negative prognostic factor and should have more focus in future studies.

AIM: Lately, the safety of minimally invasive surgery (MIS) in the treatment of cervical cancer (CC) has been questioned. This study aimed to evaluate the risk of recurrence and survival after a nationwide adoption of robotic MIS for the treatment of early-stage CC in Denmark.METHODS: Population-based data on all Danish women with early-stage CC, who underwent radical hysterectomy January 1st 2005-June 30th 2017 were retrieved from the Danish Gynecologic Cancer Database and enriched with follow-up data on recurrence, death and cause of death. The cohort was divided into two groups according to the year of robotic MIS introduction at each cancer centre. Chi-squared or Fischer test, the Kaplan Meier method and multivariate Cox regression were used for comparison between groups.RESULTS: One thousand one hundred twenty-five patients with CC were included; 530 underwent surgery before (group 1) and 595 underwent surgery after (group 2) the introduction of robotic MIS. The 5-year rate of recurrence was low: 8.2% and 6.3% (p = 0.55) in group 1 and 2, respectively. In adjusted analyses, this corresponded to a five-year disease-free survival, hazard ratio (HR) 1.23 [95% confidence interval (CI) 0.79-1.93]. No difference in site of recurrence (P = 0.19) was observed. The cumulative cancer-specific survival was 94.1% and 95.9% (P = 0.10) in group 1 and 2, respectively, corresponding to a HR 0.60 [95% CI 0.32-1.11] in adjusted analyses.CONCLUSION: In this population-based cohort study, the Danish nationwide adoption of robotic MIS for early-stage CC was not associated with increased risk of recurrence or reduction in survival outcomes.

OBJECTIVES: We aimed to evaluate if the revised staging according to FIGO-2018 in early-stage cervical cancer correctly predicts the risk for nodal metastases.METHODS: We reallocated 245 women with early-stage cervical cancer from FIGO-2009 to FIGO-2018 stages using data from a national, prospective cohort study on sentinel lymph node (SLN) mapping. We used univariate and multivariate binary regression models to investigate the association between FIGO-2018 stages, tumor characteristics, and nodal metastases.RESULTS: Stage migration occurred in 54.7% (134/245) (95% CI 48.2-61.0), due to tumor size or depth of invasion (71.6%, 96/134) and nodal metastases (28.4%, 38/134). Imaging preoperatively upstaged 7.3% (18/245); seven had nodal metastatic disease on final pathology. Upstaging occurred in 49.8% (122/245) (95% CI 43.4-56.2%) and downstaging to FIGO-2018 IA stages in 4.9% (12/245) (95% CI 2.6-8.4). The tumor size ranged from 3.0-19.0 mm in women with FIGO-2018 IA tumor characteristics, and none of the 14 women had nodal metastases. In multivariate analysis, risk factors significantly associated with nodal metastases were FIGO-2018 ≥ IB2 (RR 5.01, 95% CI 2.30-10.93, p < 0.001), proportionate depth of invasion >2/3 (RR 1.88, 95% CI 1.05-3.35, p = 0.033), and lymphovascular space invasion (RR 5.56, 95% CI 2.92-10.62, p < 0.001).CONCLUSIONS: The FIGO-2018 revised staging system causes stage migration for a large proportion of women with early-stage cervical cancer. Women who were downstaged to FIGO-2018 IA stages did not have nodal metastatic disease. The attention on depth of invasion rather than horizontal dimension seems to correctly reflect the risk of nodal metastases.

Introduction/Background* Sentinel lymph node (SLN) mapping represents a less invasive and more accurate staging technique in women with early-stage cervical cancer, which may reduce or prevent late effects as lymphedema. Despite the increased implementation of SLN mapping, evidence on the potential reduction of lymphedema and its effects on quality of life (QoL) in these women remains scarce. We prospectively evaluated patient-reported lower limb lymphedema and QoL in women with early-stage cervical cancer undergoing radical surgery with SLN mapping. Methodology In a national multi-institutional study, we included women with early-stage cervical cancer from March 2017-January 2021 to undergo radical surgery including SLN mapping. Women with tumours >20 mm underwent completion pelvic lymphadenectomy (PL). The incidence and severity of lymphedema and QoL were evaluated using validated patient-reported outcome measures before surgery and three months postoperative. Changes over time were investigated using linear regression. Result(s)* Two hundred of 245 (81.6%) included women completed the baseline and three-month questionnaires. The incidence of lymphedema was 7.2% versus 31.5% in women who underwent SLN mapping alone and completion PL, respectively (p Conclusion* SLN mapping combined with PL is associated with a significantly higher incidence and more severe lymphedema three months postoperatively than SLN mapping alone. Lymphedema was associated with lower QoL in several domains.

Introduction/Background* The International Federation of Gynaecology and Obstetrics (FIGO) revised cervical cancer staging in 2018. We aimed to evaluate risk factors associated with lymph node macro- and micrometastases in women with early-stage cervical cancer, focusing on the revised FIGO-2018 staging system. The overall purpose was to evaluate if the stage migration related to the implementation of FIGO-2018 correctly reflects risk groups as indicated by the presence of lymph node metastases. Methodology Using data from a national prospective cohort study on sentinel lymph node (SLN) mapping in 245 women with early-stage cervical cancer, we reallocated women from FIGO-2009 to FIGO-2018 stages. We used binary and multiple regression models to investigate the risk ratio of FIGO-2018 stages and tumour characteristics associated with nodal metastases. Result(s)* Stage migration occurred in 80.4% (197/245), due to tumour size or depth of invasion in 75.1% (148/197), nodal metastases in 19.3% (38/197), and imaging in 4.5% (11/245). Downstaging to FIGO-2018 IA stages occurred in 36,7% (90/245). Six (5.7%) women with stage IA tumour characteristics were upstaged to IIIC1 due to the findings of nodal metastases. The depth of invasion ranged from 4-5 mm and the tumour size from 9-22 mm; all six metastases were SLNs. For the whole population, risk factors significantly associated with nodal metastases were FIGO-2018 ≥ IB2 (p Conclusion* The FIGO-2018 revised staging system causes stage migration for a large proportion of women with early-stage cervical cancer. The attention on depth of invasion rather than horizontal dimension seems to reflect the risk of nodal metastases correctly. The use of sentinel node mapping in stage IA FIGO-2018 appears to be justified.

Introduction/Background* Sentinel lymph node (SLN) mapping is routinely used in many centres to evaluate the lymph node status of women with cervical cancer and small volume disease. However, there is limited evidence regarding the accuracy of SLN mapping for larger cervical tumours. In a national multicentre setting, we evaluated the SLN detection rate and incidence of nodal disease in women with early-stage cervical cancer and investigated the accuracy of SLN mapping and FDG-PET/CT in tumours >20 mm. Methodology We prospectively included women with early-stage cervical cancer from March 2017-January 2021 to undergo SLN mapping. Women with tumours >20 mm underwent completion pelvic lymphadenectomy and removal of FDG-PET/CT positive nodes. We followed an SLN algorithm with ultrastaging of all SLNs, removal of clinically suspicious lymph nodes and hemi- or full pelvic lymphadenectomy in cases of failed SLN mapping. We determined SLN detection rates, incidence of nodal disease, sensitivity and negative predictive value (NPV) of SLN mapping, and the sensitivity, specificity, NPV, and positive predictive value (PPV) of FDG-PET/CT. Result(s)* We included 245 women, and 38 (15.5%) had nodal metastasis. The SLN detection rate was 96.3% (236/245), with 82.0% (201/245) bilateral detection. In a stratified analysis of 103 women with tumours >20 mm, 27 (26.2%) had nodal metastases. The sensitivity of SLN mapping adhering to the algorithm was 96.3% (95% CI 81.0-99.9%) and the NPV 98.7% (95% CI 93.0-100%). For FDG-PET/CT imaging the sensitivity was 14.8% (95% CI 4.2-33.7%), the specificity 85.5% (95% CI 75.6-92.5%), the NPV 73.9% (95% CI 63.4-82.7%), and the PPV 26.7% (95% CI 7.8-55.1%). Conclusion* Our results suggest that SLN mapping is a reliable method in women with early-stage cervical cancer when adhering to an SLN algorithm. However, until the oncological safety is established, we recommend completion pelvic lymphadenectomy in women with tumours >20 mm. The use of FDG-PET/CT for nodal staging in women with early-stage cervical cancer should be re-evaluated.

This was a surgical pilot study to systematically introduce the technique of sentinel lymph node (SLN) mapping in women with early-stage stage cervical cancer (CC) and endometrial cancer (EC) in Denmark. The study aimed to facilitate structured surgical training to ensure surgeon proficiency in SLN mapping. The study precedes two national prospective studies on the oncological safety and correct patient selection for SLN mapping in CC and EC.The study was conducted at four gynaecological cancer centres at Odense and Aarhus University Hospital, Rigshospitalet and Herlev Hospital, between September 2016 and August 2019. All centres went through a protocolled introduction to the surgical technique, pelvic lymphatic drainage, pathological ultra-staging and data entry. A criterion of a total (uni- and bilateral) SLN detection of80%, based on 30 SLN mappings was set.The four centres performed 140 (range: 30-46) procedures. The total SLN detection rate was 91.3% with bilateral SLN detection in 68.8% and unilateral SLN detection in 22.5% of cases. The cumulated total SLN detection rate at three centres was above the pre-set 80% criterion from the beginning of inclusion, whereas one centre reached the criterion after 20 procedures.In this study, all centres demonstrated international-level SLN detection rates within 30 procedures. Hence, all centres met the study criterion regarding surgeon proficiency and were eligible for the national studies.Eva and Henry Frænkels Fond, Frimodt-Heineke Fonden, Kong Christian X Fond.The study was approved by the Danish Data Protection Agency (R. no.15/52037). The SENTIREC studies including this pilot study are registered with clinicaltrials.gov (NCT02825355 and NCT02820506).

Background In developed countries, women attend follow-up after treatment for cervical cancer to detect recurrence. The aim of this study was to describe the Danish population of women with early-stage cervical cancer at risk for recurrence and death due to recurrence. Methods Data were extracted from 3 nationwide databases to find women diagnosed with stage 1A1 to 1B1 cervical cancer in 2005-2013. Recurrences were determined from data on oncological or surgical treatment more than 3 months after the initial diagnosis and were cross-checked with patient journals. Results In all, 1523 patients were diagnosed with stage 1A1 to 1B1 cervical cancer. Eighty women experienced recurrences: 8 at International Federation of Gynecology and Obstetrics (FIGO) stage 1A1, 0 at FIGO stage 1A2, and 72 at FIGO stage 1B1. The 5-year recurrence rate was 6.4%; 67.5% of the women had symptomatic recurrences, and 28.8% had asymptomatic recurrences. At significantly greater risk for recurrence were women at stage 1B1, regardless of their lymph node (LN) status at diagnosis (hazard ratio with a positive LN, 5.10; 95% confidence interval [CI], 1.65-15.76; P = .0047; hazard ratio with a negative LN, 3.14; 95% CI, 1.25-7.93; P = .0153; hazard ratio with LN data missing, 6.33; 95% CI, 1.80-22.26; P = .004), women older than 50 years (hazard ratio, 1.81; 95% CI, 1.12-2.94; P = .0158), and women with lymphatic and lymphovascular space invasion (LVSI; hazard ratio, 1.92; 95% CI, 1.11-3.30; P = .0188). In a multivariate analysis, significantly inferior survival was found after recurrence for patients with lymphatic LVSI (hazard ratio, 2.23; 95% CI, 1.04-4.80; P = .0401), a symptomatic diagnosis of recurrence (hazard ratio, 2.52; 95% CI, 1.08-5.90; P = .0332), and multiple sites of recurrence (hazard ratio, 2.72; 95% CI, 1.32-5.61; P = .0066). Conclusions This study has identified a group of women at FIGO stage 1A1 in no need of specialized, hospital-based follow-up. Many of the recurrences at FIGO stage 1B1 are asymptomatic, and this may show a need for follow-up in this group. Further prospective investigation is needed. Cancer 2018;124:943-51. © 2017 American Cancer Society.

Introduction/Background Since the introduction of robotic assisted laparoscopy it has been the preferred surgical approach for early stage cervical cancer (ECC) in the Nordic countries. Lately, a randomized trial comparing open access vs. minimal invasive surgery has questioned the oncological safety of robotic surgery in ECC. The aim of the present study was to evaluate the safety of robotic surgery in the treatment of ECC in Denmark.Methodology Clinical and follow-up data on all consecutive patients with ECC stage IA2-IB1 who underwent radical hysterectomy in the period January 1st 2005 - June 30th 2017 were derived from the Danish Gynecologic Cancer Database (DGCD). Data was validated with other registers and patient files. Descriptive statistics with univariate and multivariate analyses were used.Results 1125 ECC patients were included; 530 who underwent a radical hysterectomy before the introduction of robotic-assisted laparoscopy (period 1) and 595 who underwent surgery after the introduction of robotic-assisted laparoscopy (period 2). No significant differences in the rate of recurrence, recurrence location, or use of chemo-radiation between the two cohorts was observed. Furthermore, no significant differences in the five-year cancer specific survival between cases diagnosed before and after the introduction of robotic-assisted laparoscopy was found - five year cancer specific survivals of 94.15.9p-value=0.10) in period 1 and period 2, respectively.Conclusion Based on national and prospectively collected data our cohort study found no indication that the oncologic safety such as risk of recurrence and survival has been compromised by the introduction of the robotic platform. However, use of robotic surgery for early cervical cancer will be followed closely throug our national cancer database (DGCD) in the future.Disclosure Nothing to disclose. Introduction/Background Since the introduction of robotic assisted laparoscopy it has been the preferred surgical approach for early stage cervical cancer (ECC) in the Nordic countries. Lately, a randomized trial comparing open access vs. minimal invasive surgery has questioned the oncological safety of robotic surgery in ECC. The aim of the present study was to evaluate the safety of robotic surgery in the treatment of ECC in Denmark.Methodology Clinical and follow-up data on all consecutive patients with ECC stage IA2-IB1 who underwent radical hysterectomy in the period January 1st 2005 - June 30th 2017 were derived from the Danish Gynecologic Cancer Database (DGCD). Data was validated with other registers and patient files. Descriptive statistics with univariate and multivariate analyses were used.Results 1125 ECC patients were included; 530 who underwent a radical hysterectomy before the introduction of robotic-assisted laparoscopy (period 1) and 595 who underwent surgery after the introduction of robotic-assisted laparoscopy (period 2). No significant differences in the rate of recurrence, recurrence location, or use of chemo-radiation between the two cohorts was observed. Furthermore, no significant differences in the five-year cancer specific survival between cases diagnosed before and after the introduction of robotic-assisted laparoscopy was found - five year cancer specific survivals of 94.1% and 95.9% (p-value=0.10) in period 1 and period 2, respectively.Conclusion Based on national and prospectively collected data our cohort study found no indication that the oncologic safety such as risk of recurrence and survival has been compromised by the introduction of the robotic platform. However, use of robotic surgery for early cervical cancer will be followed closely throug our national cancer database (DGCD) in the future.

IntroductionWomen with cervical cancer in the Nordic countries are increasingly undergoing pretreatment imaging by ultrasound, magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT) or computed tomography, or sentinel lymph node procedure. The present survey reports the influence of pretreatment imaging findings on the recorded clinical International Federation of Gynecology and Obstetrics (FIGO) stage in Nordic countries and its impact on treatment planning and preferred surgical approach in cervical cancer.Material and methodsThe Nordic Society of Gynecological Oncology Surgical Subcommittee developed a questionnaire-based survey that was conducted from 1 January to 31 March 2017. All the 22 Nordic Gynecological Oncology Centers (Denmark 5, Finland 5, Iceland 1, Norway 4, and Sweden 7) were invited to participate.ResultsThe questionnaires were returned by 19 of 22 (86.3%) centers. The median number (range) of women with cervical cancer treated at each center annually was 32 (15-120). In 58% (11/19) of the centers, imaging findings were reported to influence the clinical staging. MRI in combination with PET-CT was the preferred imaging method and the results influenced treatment planning. Robotic-assisted radical hysterectomy was the preferred surgical method in 72% (13/18) of the centers. Sentinel lymph node procedure was not routinely implemented in the majority of the Nordic centers.ConclusionMore than half of the Nordic Gynecological Oncology Centers already report a clinical FIGO stage influenced by pretreatment imaging findings. The trend in preferred treatment is robotic-assisted radical hysterectomy and the sentinel lymph node procedure is gradually being introduced.

In developed countries, women attend follow-up after treatment for cervical cancer to detect recurrence. The aim of this study was to describe the Danish population of women with early-stage cervical cancer at risk for recurrence and death due to recurrence.Data were extracted from 3 nationwide databases to find women diagnosed with stage 1A1 to 1B1 cervical cancer in 2005-2013. Recurrences were determined from data on oncological or surgical treatment more than 3 months after the initial diagnosis and were cross-checked with patient journals.In all, 1523 patients were diagnosed with stage 1A1 to 1B1 cervical cancer. Eighty women experienced recurrences: 8 at International Federation of Gynecology and Obstetrics (FIGO) stage 1A1, 0 at FIGO stage 1A2, and 72 at FIGO stage 1B1. The 5-year recurrence rate was 6.4%; 67.5% of the women had symptomatic recurrences, and 28.8% had asymptomatic recurrences. At significantly greater risk for recurrence were women at stage 1B1, regardless of their lymph node (LN) status at diagnosis (hazard ratio with a positive LN, 5.10; 95% confidence interval [CI], 1.65-15.76; P = .0047; hazard ratio with a negative LN, 3.14; 95% CI, 1.25-7.93; P = .0153; hazard ratio with LN data missing, 6.33; 95% CI, 1.80-22.26; P = .004), women older than 50 years (hazard ratio, 1.81; 95% CI, 1.12-2.94; P = .0158), and women with lymphatic and lymphovascular space invasion (LVSI; hazard ratio, 1.92; 95% CI, 1.11-3.30; P = .0188). In a multivariate analysis, significantly inferior survival was found after recurrence for patients with lymphatic LVSI (hazard ratio, 2.23; 95% CI, 1.04-4.80; P = .0401), a symptomatic diagnosis of recurrence (hazard ratio, 2.52; 95% CI, 1.08-5.90; P = .0332), and multiple sites of recurrence (hazard ratio, 2.72; 95% CI, 1.32-5.61; P = .0066).This study has identified a group of women at FIGO stage 1A1 in no need of specialized, hospital-based follow-up. Many of the recurrences at FIGO stage 1B1 are asymptomatic, and this may show a need for follow-up in this group. Further prospective investigation is needed. Cancer 2018;124:943-51. © 2017 American Cancer Society.

We report a case where hemostatic fleece (TachoSil) was misinterpreted as residual disease on imaging after macro-radical surgery for ovarian cancer. Laparotomy was performed on a 51 year-old woman due to ovariancancer. At surgery, carcinomatosis was identified on the diaphragm with growth intothe diaphragmatic muscle. Total hysterectomy, bilateral salpingooophorectomy, omentectomy, pelvic and paraaortic lymphadenectomy, diaphragmatic peritonectomy, appendectomy and resection of sigmoid colon were performed. During surgery an incidental small liver lesion occurred and hemostatic fleece was applied for hemostasis. Total cytoreduction was achieved. The pathology report demonstrated stage IV serous ovarian cancer (grade III). The patient was therefore referred to the Department of oncology for six series of Paclitaxel/Carboplatin. A baseline CT scan revealed an area above the liver initially described as residual disease. At the multidisciplinary conference the CT scan was revised and compared with the surgical report and it was concluded that the suspected area concurred with the hemostatic fleece applied during surgery and not a sign of residual disease. After two months of adjuvant chemotherapy, a follow up CT scan revealed almost total regression and after six months, a MRI demonstrated almost no signs of the hemostatic fleece or recurrent disease. The patient is still disease free after18 months. Application of a hemostatic fleece may initiate inflammatory changes causing imaging artifacts. We, therefore, emphasize the importance of reporting in the operation note the specific location of hemostatic fleece applied during surgery to avoid hemostatic fleece being misinterpreted as residual disease on imaging.

Cesarean section in women with placenta previa is associated with the risk of heavy bleeding. We describe a new method where local hemostasis is obtained by applying a hemostatic fleece directly onto the lower uterine segment. During a 2-year period women undergoing cesarean section due to placenta previa were treated with this hemostatic fleece if they had ongoing bleeding during the surgical procedure despite routine treatment. Data were obtained retrospectively from the hospital records. Fifteen patients were treated by 15 different surgeons. No patients required reoperation. Three patients required blood transfusion due to anemia. No patients were readmitted to the hospital due to endometritis. We conclude that the application of a hemostatic fleece directly onto the bleeding surfaces in patients with post-cesarean bleeding due to placenta previa is technically unproblematic. The results suggest that this procedure should be considered in case of bleeding after delivery in women with placenta previa.

The age-specific cervical cancer incidence in Denmark is bimodal with peaks at ages 35-40 years and 75 years. Yet, Danish women ≥ 65 years are not offered screening for cervical cancer. Screening women beyond the age of 65 years may reduce cervical cancer incidence as well as mortality, and seems to be cost-effective. Older women may benefit more from human papillomavirus screening rather than by cytology. Thus, more research on cervical cancer screening in older women is warranted.

ObjectiveThis study examines surveillance after early-stage cervical cancer surgery. Since the 1980s, the value of surveillance has been discussed continuously. The main question explored is whether surveillance serves the purpose of ensuring early diagnosis of recurrence.Materials and MethodsA retrospective cohort study included 389 women with cervical cancer who underwent surgery as the primary treatment modality at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark, from 1996 to 2011. We used data from patient files and the Danish National Pathology Data Bank. The cumulative risk was estimated by the Kaplan-Meier method and tested by the log-rank test.ResultsForty-three women (11%) had recurrence. Only 27% of the recurrent cases were diagnosed at a scheduled surveillance appointment, but they were often asymptomatic and seemed to have a better outcome after treatment compared with the recurrent cases diagnosed at self-referral.The 5-year survival was overall 91.3%, recurrence-free survival was 96%, and cancer-specific survival was 54%. The median recurrence-free interval was 23 months (range, 4–144) for the symptomatic patients and 14 months (range, 4–48) for the asymptomatic patients. The median survival after recurrence was 12 months (range, 2–132) for the symptomatic patients and 156 months (range, 40–180) for the asymptomatic patients.ConclusionsAt the moment, neither the value of surveillance nor the significance of self-referral related to survival after recurrence is known. In this study, those who are diagnosed with recurrence before symptom onset seem to fare better in terms of 5-year survival than those who are diagnosed after self-referral because of symptoms.

Objective This clinical review aims to assess the efficacy of human papillomavirus 16/18 (HPV16/18) vaccination on the cell-mediated immune response in women with existing cervical intraepithelial neoplasia or cervical cancer induced by HPV16 or HPV18. Data sources and study selection A focused and thorough literature search conducted in five different databases found 996 publications. Six relevant articles were chosen for further review. In total, 154 patients (>18 years of age) were enrolled in prospective study trials with 3–15 months of follow up. The vaccine applications were administered two to four times. The vaccines contained different combinations of HPV16 and HPV18 and early proteins, E6 and E7. The primary outcome was the cell-mediated immune response. Correlation to clinical outcome (histopathology) and human leukocyte antigen genes were secondary endpoints. Results All vaccines triggered a detectable cell-mediated immune response, some of which were statistically significant. Correlations between immunological response and clinical outcome (histopathology) were not significant, so neoplasms may not be susceptible to vaccine-generated cytotoxic T cells (CD8+). Conclusions Prophylactic HPV vaccines have been introduced to reduce the incidence of cervical cancer in young women. Women already infected with HPV could benefit from a therapeutic HPV vaccination. Hence, it is important to continue the development of therapeutic HPV vaccines to lower the rate of HPV-associated malignancies and crucial to evaluate vaccine efficacy clinically. This clinical review represents an attempt to elucidate the theories supporting the development of an HPV vaccine with a therapeutic effect on human papillomavirus-induced malignancies of the cervix.

Background. Application of hemostatic fleece (TachoSil) directly onto the bleeding surfaces of the lower uterine segment has been used to obtain hemostasis during cesarean section caused by placenta previa.Methods. Eleven of 15 patients treated with TachoSil for excessive postpartum haemorrhage due to placenta previa were enrolled. An evaluation of the cesarean section scar by transvaginal ultrasound, the uterine cavity and endometrium by hysteroscopy, and the endometrium by biopsy were made. The main outcome measures were intrauterine adhesions, recovery of endometrium at the site of TachoSil application, visible remnants of TachoSil, and scar healing.Results. Eight patients had small remnants of TachoSil in the uterine cavity together with signs of resorption. All had a normal endometrial mucosa, and none had adhesions in the uterine cavity. All cesarean section scars were healed without defects.Conclusion. TachoSil did not seem to impair healing of the endometrium or scar formation in the uterus after intrauterine application. Resorption of TachoSil seems to progress individually. Intrauterine treatment with TachoSil is a valuable supplement to the traditional treatment of post partum haemorrhage and may help retain reproductive capability. This is a small study, and it will require more studies to confirm the reproducibility.

The case reported involves a 31-year-old gravida III para II at 20 + 2 weeks estimated gestational age. The patient presented with fever, malaise and a shortened cervix uteri. Cultures from blood and cervix uteri grew non-typeable Haemophilus influenzae and intravenous cefuroxim 1,5 g x 3 was initiated. Later the same day the patient spontaneously aborted a dead foetus. We discuss the case, the laboratory requirements for detection of H. influenzae and the importance of paying attention to febrilia in pregnancy.

ObjectiveAfter surgery due to cervical cancer women are offered to attend a follow-up program 10 times during five years with the purpose for early diagnosis of recurrence. The aim of this study is to evaluate the follow-up program, which has remained unchanged for 20 years even though reminding and concerning women, who we consider healthy after surgery.MethodsA retrospective longitudinal study of women attending follow-up program after surgery due to cervical cancer at the Department of Gynecology and Obstetrics, Aarhus University Hospital. 524 patients were identified from 1996 to 2011 with the diagnosis of cervical cancer combined with a surgical procedure. From the national pathological database and patient files information was extracted. Information was stored in Epidata. Associations were calculated using stratified analysis and logistic regression.Results133(25%) women of 524 needed further treatment. 45(12%) women of 391 treated by surgery had recurrence. Symptoms of recurrence and non-regional recurrence were negatively associated with survival. Diagnosis of recurrence at a scheduled control was positively associated with survival. Only 4(9.5%) cases of recurrence were diagnosed by PAP-smear.ConclusionsEvaluation on the follow-up program is valuable and might inspire to adjustments. By tradition a gynecological examination is processed along with a cytological test from the top of the vagina and a vaginal exploration. The results imply failing success in diagnosing recurrence by cytological test and a tendency for poorer outcome for patients debuting with symptoms in between scheduled follow-up visits.

The age-specific cervical cancer incidence in Denmark is bimodal, with peaks at ages 35-40 years and 75 years. Yet, Danish women ≥65 years are not offered screening for cervical cancer. Screening women beyond the age of 65 years may reduce cervical cancer incidence as well as mortality, and seems to be cost-effective. Older women may benefit more from HPV screening rather than by cytology. Thus, more research on cervical cancer screening in older women is warranted.