Hiroyuki Kanao

Yoshihara K, et al. J Gynecol Oncol. 2027 ;38:e5. https://doi.org/10.3802/jgo.2027.38.e5

Oligometastases of uterine cervical cancer, particularly in the lungs, present a challenging clinical scenario, as clear guidelines for adjuvant therapy following metastasectomy are lacking. This study investigated whether postoperative chemotherapy is necessary for patients with completely resected pulmonary oligometastases. This multicenter retrospective study included 40 patients with recurrent cervical cancer and pulmonary oligometastasis who underwent complete metastasectomy between April 2005 and December 2018. Patients were divided into a chemotherapy group (n = 14) and a chemotherapy-free group (n = 26). We compared the 5-year overall survival and progression-free survival from metastasectomy and evaluated the prognostic factors using univariate and multivariate analyses. The 5-year progression-free survival rates were 64.3% (95% CI, 34.3–83.3%) and 53.0% (95% CI, 32.2–70.1%) in the chemotherapy and chemotherapy-free groups, while the 5-year overall survival rates were 77.9% (95% CI, 45.9–92.3%) and 84.9% (95% CI, 64.0–93.9%), respectively. A total of eight deaths occurred during follow-up, including three in the chemotherapy group and five in the chemotherapy-free group. No statistically significant differences in progression-free or overall survival were observed between the two groups. However, the small sample size, limited number of survival events, and potential selection bias preclude definitive conclusions regarding the benefit of postoperative chemotherapy. Further large-scale, multicenter studies are warranted to clarify its role following complete resection of pulmonary oligometastases from cervical cancer.

The surgical management of early-stage cervical cancer is undergoing a paradigm shift from a uniform radical approach to a risk-adapted de-escalation strategy. Improved oncologic outcomes have increased long-term survival, bringing attention to the importance of addressing treatment-related morbidity and quality of life. Emerging clinical evidence has challenged the necessity of extensive surgery in selected patients. This narrative review summarizes recent evidence supporting surgical de-escalation across three domains: uterine surgery, nodal management, and surgical approach. Studies were identified through a targeted narrative literature search and selected based on study design, oncologic outcomes, and methodological considerations. For uterine surgery, randomized trials demonstrate that omitting or reducing parametrial resection is oncologically safe for rigorously defined low-risk patients, yielding consistent improvements in postoperative functional outcomes. In nodal management, sentinel lymph node-based strategies allow the omission of systematic pelvic lymphadenectomy without compromising oncologic safety, when strict mapping algorithms and high-quality pathological assessment are applied. For surgical approach, however, de-escalation remains more controversial. Current evidence suggests that oncologic safety in minimally invasive surgery may depend on protocol-driven prevention of intraoperative tumor spillage and appropriate patient selection, but this approach remains investigational. Surgical de-escalation should not be viewed as merely reducing procedures. Rather, it represents a structured, evidence-based strategy incorporating risk stratification, standardized surgical techniques, and rigorous quality assurance. When these prerequisites are met, de-escalation optimally balances oncologic safety with quality-of-life preservation, potentially guiding future tailored surgical strategies for early-stage cervical cancer.

Universal tumor testing is increasingly recommended for Lynch syndrome (LS). However, data involving younger Japanese patients are still limited. This study aimed to prospectively evaluate the prevalence and clinicopathologic profile of DNA mismatch repair (MMR)-deficient (dMMR) endometrial cancers (EC) in patients aged under 50 years, and characterize immunohistochemical (IHC) loss patterns and genetic testing results. Patients with EC aged under 50 years who consented to study participation were prospectively enrolled at a single Japanese institution. Diagnostic specimens underwent MMR IHC (MLH1, MSH2, MSH6, and PMS2). Clinicopathologic variables were compared between proficient MMR (pMMR) and dMMR. Among 111 patients, 26 (23.4%) had dMMR. Grades differed when dichotomized as G1 versus G2-G3 (p < 0.01). FIGO stage distribution also varied between groups (p = 0.035). Among dMMR tumors, IHC patterns were loss of MLH1/PMS2 (n = 12), loss of MSH2/MSH6 (n = 8), and isolated loss of MSH6 (n = 6). Of the 12 (46.2%) patients with dMMR who underwent germline testing, 9 had LS (MLH1/PMS2 loss: 3/5; MSH2/MSH6 loss: 4/4; MSH6 isolated loss: 2/3). The overall dMMR prevalence in this young cohort was comparable to that in all-age series from multiple regions. This represents a minimum prevalence of LS in the overall study cohort, as germline testing was performed only in a subset of patients with dMMR tumors. In this prospective Japanese cohort, approximately one in four patients with EC had dMMR, with clinicopathologic features skewing toward a higher grade. Notably, many dMMR tumors were grade 2-3, suggesting that a substantial proportion of patients may fall outside the conventional criteria for fertility-sparing treatment.

Background: The optimal approach for early-stage ovarian cancer detection remains unclear, particularly in patients with hereditary breast and ovarian cancer (HBOC). As ovarian cancer in HBOC is often thought to originate from the fallopian tube fimbriae, endometrial cytology may play a role in detecting early-stage disease. This retrospective study aimed to assess the positive rate of endometrial cytology and compare to cervical cytology in ovarian cancer patients with patients with BRCA1/2 germline pathogenic variants (gPV). Methods: Patients with genetically confirmed BRCA1/2 gPV diagnosed with ovarian, fallopian tube, or primary peritoneal cancer from May 1998 to April 2024 at our institution were included. Those who underwent endometrial and cervical cytology prior to initial treatment were eligible for this analysis. The positive rates for each cytology type were evaluated. Results: A total of 154 patients with BRCA1/2 gPV were enrolled, 118 underwent both endometrial and cervical cytology. The positive rate for endometrial cytology was significantly higher than that for cervical cytology (36.4% vs. 15.3%; p < 0.001). Additionally, a correlation was observed between the positive rate of endometrial cytology and cancer stage (Stage I 16.6%, Stage II 25%, Stage III 41.5%, Stage IV 58.6%; r = 0.9895). Conclusion: In this retrospective study, the positive rate of endometrial cytology surpassed that of cervical cytology. Endometrial cytology may play a role as a potential surveillance tool for women with BRCA1/2 gPV, even at early stages of ovarian cancer.

Background: The optimal timing of cytoreductive surgery for advanced high-grade serous carcinoma (HGSC) remains a critical unmet question in the modern era of platinum-based chemotherapy and PARP inhibitor (PARPi) maintenance. To address this gap, we compared outcomes following primary debulking surgery (PDS) versus interval debulking surgery (IDS) in a uniformly treated, contemporary cohort. Methods: Patients with FIGO stage IIIB–IVB HGSC treated between 2019 and 2023 were retrospectively analyzed. Baseline tumor burden was assessed using detailed radiologic and laparoscopic evaluations, including both presurgical and intraoperative assessments. Progression-free survival (PFS) and overall survival (OS) were examined using multivariable Cox proportional hazards models and reported as adjusted hazard ratios (aHRs). Subgroup analyses were rigorously conducted according to residual disease status and BRCA mutation status. Results: Among 221 patients (PDS, n = 60; IDS, n = 151), the median follow-up was 40 months. In the overall cohort, adjusted PFS and OS did not differ significantly between the PDS and IDS groups (PFS: aHR, 1.15; 95%CI, 0.67–1.98; OS: aHR, 1.24; 95%CI, 0.54–2.83). Outcomes were comparable among patients achieving R0 resection. Notably, BRCA-mutated patients demonstrated a substantial survival advantage with PDS (BRCA-mutated PFS: aHR, 3.34; 95%CI, 1.06–16.67; OS: aHR, 6.07; 95%CI, 2.13–∞), whereas BRCA wild-type patients showed no significant difference between surgical strategies. Conclusions: The findings suggest that BRCA-mutated patients may derive a survival benefit from PDS, whereas surgical timing had a limited impact on BRCA wild-type disease. This result underscores the importance of integrating molecular profiling, particularly BRCA mutation status, with surgical assessment to guide optimal and personalized treatment strategies in the PARPi era.

Toyohara Y, et al. J Gynecol Oncol. 2026 ;37:e82. https://doi.org/10.3802/jgo.2026.37.e82

Kanao H, et al. J Gynecol Oncol. 2025 Sep;37:e21. https://doi.org/10.3802/jgo.2026.37.e21