Faculty Bibliography

•Highly suspicious pelvic mass may require preoperative biopsy for diagnosis.•Neoadjuvant imatinib lowers EGIST tumor burden in extensive disease preoperatively.•EGIST resection aims at complete surgical resection and negative margins.•This case was managed with complete surgical resection and adjuvant imatinib.•Prognostic factors in EGIST are size, mitosis, location and genetic mutations.

This review sought to evaluate the current literature on reproductive and oncologic outcomes after fertility-sparing surgery for early stage cervical cancer (stage IA1-IB1) including cold-knife conization/simple trachelectomy, vaginal radical trachelectomy, abdominal radical trachelectomy, and laparoscopic radical trachelectomy with or without robotic assistance. A systematic review using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist to evaluate the current literature on fertility-sparing surgery for early stage cervical cancer and its subsequent clinical pregnancy rate, reproductive outcomes, and cancer recurrence was performed. Sixty-five studies were included encompassing 3,044 patients who underwent fertility-sparing surgery, including 1,047 pregnancies with reported reproductive outcomes. The mean clinical pregnancy rate of patients trying to conceive was 55.4%, with the highest clinical pregnancy rate after vaginal radical trachelectomy (67.5%). The mean live-birth rate was 67.9% in our study. Twenty percent of pregnancies after fertility-sparing surgery required assisted reproductive technology. The mean cancer recurrence rate was 3.2%, and the cancer death rate was 0.6% after a median follow-up period of 39.7 months with no statistically significant difference across surgical approaches. Fertility-sparing surgery is a reasonable alternative to traditional radical hysterectomy for early-stage cervical cancer in women desiring fertility preservation. Vaginal radical trachelectomy had the highest clinical pregnancy rate, and minimally invasive approaches to fertility-sparing surgery had equivalent oncologic outcomes compared with an abdominal approach. The results of our study allow for appropriate patient counseling preoperatively and highlight the importance of a multidisciplinary approach to achieve the best outcomes for each patient.

Endometriosis is a gynecologic disease that affects over 10% of women of reproductive age causing pelvic pain, dysmenorrhea, and infertility, resulting in significant disability and reduced quality of life. Very recent genetic studies have suggested that endometriosis is a clonal disease in the epithelium and its development is independent of stroma, providing new insight into the genesis of endometriosis. The endometrioid tissue lining may also react by epithelial atypical hyperplasia and even neoplasia, in a manner somehow similar to that in the uterine cavity and under the same hormonal influences.

This chapter focuses on premalignant and malignant diseases of the endometrium (lining of the uterus). Endometrial carcinoma is the most common gynecologic cancer in the United States. Women have a 1 in 40 lifetime risk of being diagnosed with endometrial cancer, the fourth most common malignancy among women. An estimated 61,880 new diagnoses of uterine cancer and 12,160 deaths from the disease occurred in 2019 in the United States (American Cancer Society, Facts & Figures, https://www.cdc.gov/cancer/uterine/statistics/index.htm , 2019).

Randomized controlled trials (RCT)s of surgery are fundamentally different from RCTs of medications because it is difficult to blind or mask a surgical procedure or perform "sham' operations. An additional challenge is the variation in skills and surgical proficiency of participating centers and surgeons. Addressing heterogeneity in surgical proficiency remains of paramount importance, especially when RCTs involve a new or complex procedure such as minimally invasive radical surgery. In the presence of such heterogeneity, it is very cumbersome to objectively evaluate and monitor surgical skills so that most trials simply report associations that are averaged across surgeons and hospitals/centers. Such reporting is non-transparent because the rates of complications and adverse outcomes are reported only as averages, and these averages may not apply to the individual participating surgeons or centers. These factors, coupled with the inherent non-generalizability of findings from such RCTs - due to the strict inclusion and exclusion criteria for enrollment - may lead to conclusions that no longer apply to real life for individual surgeons or centers. Case in point is a recently published non-inferiority RCT that reported that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival (86% versus 96.5% at 4.5 years) and overall survival (93.8% versus 99% at 3 years) than open abdominal radical hysterectomy in patients with cervical cancer. However, RCTs involving two competing complex or new procedures may be affected by tremendous confounding due to variations in surgical proficiency and also non-standardization for other confounding factors such as patient selection categories (i.e. stage of cancer) and adjuvant post-operative therapies that may affect long-term survival. The purpose of this Viewpoint is not to provide an exhaustive review of the trial but to use it as an illustration to focus on two challenging areas that most RCTs of a new complex surgical procedure suffer from: un-adjusting or not correcting for surgical skill variability and non-transparent reporting of averaged results. We provide suggestions to overcome these deficiencies through robust methodological and statistical approaches.