Stamatios Petousis

Background: Obstetric hysterectomy remains a life-saving intervention for placenta accreta spectrum and uncontrolled obstetric hemorrhage. Evidence regarding the outcomes of planned versus urgent obstetric hysterectomy in contemporary tertiary practice in Greece remains limited. We compared maternal and neonatal outcomes between elective and urgent procedures at a tertiary referral center in Thessaloniki. Methods: We retrospectively reviewed 30 women who underwent obstetric hysterectomy between January 2020 and June 2025. The elective group included women with prenatal PAS diagnosis and planned delivery at ≥34 weeks (n = 17), whereas the urgent group included women requiring unplanned delivery for hemorrhage or active labor without prior surgical preparation (n = 13). Maternal characteristics, intraoperative findings, transfusion requirements, complications, hospital stay, and neonatal outcomes were compared using bivariate statistical tests. Results: Maternal age was similar between groups (36.1 ± 6.1 vs. 37.9 ± 6.8 years; p = 0.44). Elective cases had higher parity (median 3 vs. 1; p = 0.002), had more previous cesarean deliveries (median 2 vs. 0; p = 0.002), and were more frequently diagnosed with placenta previa (p = 0.027). Uterine atony occurred more often in urgent cases (p < 0.001). Bakri balloon tamponade was used only in urgent cases and failed to control hemorrhage (p < 0.001). Operative time, transfusion requirement, hospital stay, and urinary tract injury rates were comparable. No maternal deaths occurred. Birth weight, Apgar scores, and NICU admission rates were also similar. Conclusions: Planned obstetric hysterectomy within a multidisciplinary setting was associated with fewer emergency hemorrhage-control interventions, while major perioperative and neonatal outcomes were comparable between groups.

Mismatch repair deficiency (MMRd) is a critical biomarker in endometrial cancer (EC) for prognostication, Lynch syndrome screening, and immunotherapy eligibility. This study aimed to determine the prevalence of MMRd and its correlation with clinicopathological characteristics in EC. This prospective observational cohort included 93 patients with EC undergoing primary surgical treatment, managed as per the European Society of Gynaecological Oncology (ESGO) guidelines. MLH1, PMS2, MSH2, and MSH6 expression was assessed through immunohistochemistry (IHC) on formalin-fixed, paraffin-embedded hysterectomy specimens. Associations between mismatch repair (MMR) status and histology, grade, lymphovascular space invasion (LVSI), myometrial invasion, FIGO 2023 stage, nodal status, recurrence, and survival were analyzed. The median age was 66 years. Most tumors were endometrioid (86%), 29% were grade 3, 45.2% showed deep myometrial invasion, and 23.7% had substantial LVSI. MMRd was identified in 41.9% of cases, with MLH1 and PMS2 loss being most frequent, and was significantly associated with endometrioid histology (p = 0.027) and deep myometrial invasion (p = 0.011). No significant correlations were found with grade, LVSI, FIGO stage, nodal involvement, recurrence, or overall survival. Routine MMR assessment may refine risk stratification and guide individualized treatment decisions.

Objective: To characterize the structural organization of Enhanced Recovery After Surgery (ERAS) component implementation in gynecologic oncology and determine whether ERAS elements operate as an interconnected perioperative system during early pathway integration. Methods: This study represents a secondary analysis of the prospective multicenter Enhanced Recovery in Gynecologic Oncology (ERGO) cohort, including the first 300 consecutive patients undergoing surgery for gynecologic malignancy across five tertiary institutions. Components with prevalence between 5% and 95% were included in a regularized Ising network model to estimate conditional dependencies between pathway elements. Node-level centrality metrics and global network characteristics were calculated to identify structurally influential ERAS components and to describe the overall implementation architecture. Results: Thirteen central ERAS components met the predefined prevalence criterion (5–95%) and were included in the conditional dependency network. The estimated network demonstrated substantial inter-component connectivity, indicating that ERAS practices were frequently implemented in coordinated patterns rather than as isolated interventions. Centrality analysis identified postoperative laxatives or chewing gum, tranexamic acid administration, perioperative intravenous fluid management, and avoidance of drain placement as highly connected elements within the network. Early nutritional advancement and postoperative bowel stimulation measures also demonstrated relatively central positions within the recovery-related component cluster. Community detection analysis revealed distinct modules of co-adopted ERAS practices spanning multiple perioperative phases. Conclusions: ERAS implementation in gynecologic oncology appears to follow a structured architecture characterized by interconnected perioperative practices rather than independent protocol elements. Understanding these implementation structures may help guide targeted quality-improvement strategies aimed at optimizing ERAS integration in routine clinical practice.

Introduction: The best tissue sample is still very important for the diagnosis of mesothorax lymphadenopathy. In the past 20 years endobronchial ultrasound (EBUS) has been used efficiently in most cases of primary lung cancer disease or metastatic disease. Several new type of needles have been created such 19G, 18G and hybrid biopsies with cryoprobes. Rapid on-site evaluation (ROSE) is used as an additional initial diagnostic tool. Confocal microscopy is a method of rapid on-site evaluation.

Viral carcinogenesis as a causative mechanism of breast cancer has been intensively researched during the last decades. The role of Epstein–Barr virus (EBV) and Bovine Leukemia virus (BLV) in breast oncogenesis has been investigated in a plethora of studies, but with conflicting results. The aim of this systematic review and meta-analysis was to compare the frequency of molecular detection of the EBV genome and BLV genome between women with breast cancer and women without malignant breast tumors. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, SCOPUS, Cochrane CENTRAL and ClinicalTrials.gov were searched up to 20 May 2024. Included studies were those comparing the frequency of molecular detection of the EBV and/or BLV genome in breast tissue specimens with polymerase chain reaction (PCR) methods between patients with breast cancer and women without breast malignancies. The primary outcomes of the study were the frequency of molecular detection of the EBV genome and BLV genome. Methodological quality of included studies was assessed using the Newcastle–Ottawa Scale. A total of 29 studies met the selection criteria and were included in this meta-analysis; 19 studies reported results for molecular detection of the EBV genome, 9 studies for detection of the BLV genome and 1 study for detection of genomic material of both viruses. The frequency of molecular detection of viral genomes was significantly higher in patients with breast cancer, compared to women with healthy breasts or benign breast diseases, regarding both EBV (OR: 3.041, 95% CI: 1.791 to 5.164, p < 0.0001) and BLV (OR: 3.459, 95% CI: 2.118 to 5.650, p < 0.0001). The frequency of molecular detection of EBV and BLV genomes is higher, in a statistically significant manner, in patients with breast cancer compared to women without breast malignancies. The presence of these viral factors in breast tissue could imply their potential contribution in breast carcinogenesis, but is not sufficient to establish it, and the molecular detection of their genomes could be potentially exploited in the future for preventive, diagnostic and therapeutic purposes. Further studies are required to thoroughly investigate and establish a causal relationship between EBV and BLV infection and breast carcinogenesis, as well as to support the use of viral genome molecular detection in clinical settings for the management of breast cancer patients.

Background/Objectives: Molecular classification has become integral to endometrial cancer (EC) management, with mismatch repair deficiency (dMMR) representing a key biomarker for prognostication, Lynch syndrome screening, and immunotherapy eligibility. However, reported dMMR rates and their associations with histopathological features remain variable. This study aimed to determine the prevalence of dMMR and its correlation with clinicopathological characteristics in early-stage EC. Methods: In this prospective observational cohort study, 93 patients with early-stage EC undergoing primary surgical treatment between September 2022 and December 2025 were included. All patients were managed according to European Society of Gynaecological Oncology (ESGO) guidelines. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded hysterectomy specimens to assess MLH1, PMS2, MSH2, and MSH6 expression. dMMR was defined as complete or subclonal loss of nuclear staining in ≥1 protein, while proficient MMR (pMMR) required preserved (> 90%) expression of all four proteins. Associations between MMR status and histology, grade, lymphovascular space invasion (LVSI), depth of myometrial invasion, FIGO 2023 stage, nodal status, recurrence, and survival were analyzed. Results: Median age was 66 years (range 35–86). Most tumors were endometrioid (86%), 27.9% were grade 3, 44% demonstrated deep myometrial invasion, and 23.6% showed substantial LVSI. dMMR was identified in 41.9% (39/93) of cases. MLH1 (38.0%) and PMS2 (39.8%) loss were most frequent, whereas MSH2 (3.2%) and MSH6 (4.3%) loss was uncommon. dMMR was significantly associated with endometrioid histology (p = 0.03) and deep myometrial invasion (p = 0.011). No significant correlations were observed with tumor grade, LVSI, FIGO stage, nodal involvement, recurrence, or overall survival during follow-up. Conclusions: dMMR was detected in approximately 40% of early-stage ECs and was significantly associated with endometrioid histology and deep myometrial invasion. Routine assessment of MMR status may refine risk stratification and support individualized therapeutic decision-making. Further studies with longer follow-up are warranted to clarify its prognostic impact.

Background: The importance of integrating enhanced recovery after surgery protocols in gynecologic oncology has been proven in numerous studies. However, the actual adherence to protocol among institutions remains inconsistent in clinical practice, particularly among those without prior structured implementation. This pragmatic multicenter study provides a preliminary report from the ongoing ERGO (Enhanced Recovery in Gynecologic Oncology) cohort study (ClinicalTrials.gov: NCT06655506) and aims to evaluate adherence to enhanced recovery protocols during the early phases of its adoption as well as identify factors that determine low uptake. Methods: Overall, 300 consecutive patients undergoing gynecologic oncology surgery across five institutions were included in the present study. Adherence to preoperative, intraoperative, and postoperative enhanced recovery elements was documented using standardized forms. Optimal adherence was predetermined as fulfillment of more than 70% of the enhanced recovery components included in the pathway. Multinomial analysis was used to identify predictors of adherence. Results: Overall, 70.3% of patients achieved optimal adherence; however, rates varied across centers (26.9–84.4%), reflecting the limited institutional familiarity with enhanced recovery pathways in most participating centers. The actual volume of cases handled was an important determinant of adherence, with high-volume units consistently demonstrating substantially higher compliance compared with lower-volume hospitals. Routine preoperative items demonstrated high uptake, whereas several intraoperative and early postoperative components showed low and heterogeneous implementation, which might be the result of anesthesiology-driven practices. Higher surgical complexity and poorer performance status independently predicted reduced adherence. Visual mapping confirmed that complex procedures resulted in lower adherence. Conclusions: The significant variability in enhanced recovery protocol adherence that was observed in our study indicates the need to institute structured workflows that help increase team familiarization, particularly in high-complexity cases and centers new to these elements.

Background: The importance of integrating enhanced recovery after surgery (ERAS) protocols in gynecologic oncology has been proven in numerous studies. However, the actual adherence to protocol among institutions remains inconsistent in clinical practice, particularly among those without prior structured implementation. This pragmatic multicenter study provides a preliminary report from the ongoing ERGO (Enhanced Recovery in Gynecologic Oncology) cohort study (ClinicalTrials.gov: NCT06655506) and aims to evaluate adherence to ERAS protocols during the early phases of its adoption as well as to determine factors determining low uptake. Methods: Overall, 300 consecutive patients undergoing gynecologic oncology surgery across five institutions were included in the present study. Adherence to preoperative, intraoperative, and postoperative ERAS elements was documented using standardized forms. Optimal adherence was predetermined as fulfillment of more than 70% of the ERAS components included in the pathway. Multinomial analysis was used to identify predictors of adherence. Results: Overall, 70.3% of patients achieved optimal adherence; however, rates varied across centers (26.9%–84.4%), reflecting the limited institutional familiarity with ERAS pathways in most participating centers. The actual volume of cases handled was as an important determinant of adherence, with high-volume units consistently demonstrating substantially higher compliance compared with lower-volume hospitals. Routine preoperative items demonstrated high uptake, whereas several intraoperative and early postoperative components showed low and heterogeneous implementation, that might be the result of anesthesiology-driven practices. Higher surgical complexity and poorer ECOG performance status independently predicted reduced adherence. Visual mapping confirmed that complex procedures resulted in lower adherence. Conclusion: The significant variability in ERAS adherence that was observed in our study indicates the need to institute structured workflows that help increase team familiarization, particularly in high-complexity cases and centers new to ERAS.

Background/Objectives: Cervical cancer (CC) is the fourth most common gynecologic malignancy, disproportionately affecting women in low- and middle-income countries. Despite the effectiveness of HPV vaccination and screening strategies, CC poses a major global health issue, accounting for approximately 94% of annual deaths. Τhis review aims to summarize the current evidence regarding adjuvant treatment indications for surgically treated cervical cancer patients and identify areas where further research is required. Methods: After a literature search, a comprehensive review of the existing guidelines, clinical trials, and cohort studies related to cervical cancer treatment was conducted, focusing on the role of adjuvant therapy in patients classified as at low, intermediate, and high risk for recurrence, who may require no further treatment. Results: Adjuvant therapy is generally unnecessary for low-risk patients, while high-risk patients with lymph node invasion, parametrial involvement, or large tumor size require chemoradiation (CRT). Ιntermediate-risk patients fall into a grey zone, where the necessity of adjuvant therapy is still debatable. Guidelines emphasize the need for individualization in treatment strategies, since, based on the published studies, careful surgery alone and observation can provide similar outcomes to adjuvant therapy. Conclusions: This review emphasizes that achieving monotherapy remains pivotal to optimize outcomes and minimize overtreatment. Definitive adjuvant treatment is indicated for high-risk cases, and intermediate-risk patients may benefit from careful observation following adequate surgical intervention, pointing out the necessity of well-designed clinical trials.

Importance: First-line maintenance therapy with poly(adenosine diphosphate-ribose) polymerase inhibitors (PARP inhibitors) after platinum-based chemotherapy improves progression-free survival (PFS) in advanced epithelial ovarian cancer (EOC), particularly in patients with BRCA -variant or homologous recombination-deficient tumors. However, overall survival (OS) benefits remain uncertain, and toxic effect profiles emphasize the need for optimized patient and agent selection. Objective: To evaluate the efficacy and safety of first-line PARP inhibitor maintenance therapy compared with chemotherapy alone in advanced-stage EOC, with subgroup analyses by BRCA and HRD status, up-front or interval surgery, chemotherapy response, and residual disease. Data sources: Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from database inception to August 19, 2024. Study Selection: Randomized clinical trials and prospective 2-arm studies evaluating PARP inhibitor maintenance therapy in patients with advanced-stage EOC responding to first-line platinum-based chemotherapy were included. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed in reporting this study. Data were independently extracted by 2 reviewers. Random-effects models were used for meta-analysis. Risk of bias was assessed with Cochrane risk of bias and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Main Outcomes and Measures: Primary outcomes were PFS and OS; secondary outcomes included high-grade adverse events. Results: A total of 7 randomized clinical trials with 4013 patients with advanced-stage epithelial ovarian cancer responding to first-line platinum-based chemotherapy were included. PARP inhibitor maintenance was associated with improved PFS in the overall population (hazard ratio [HR], 0.57; 95% CI, 0.46-0.70; high certainty) and in all molecular subgroups except the homologous recombination proficient group ( BRCA variant: HR, 0.40; 95% CI, 0.35-0.45; BRCA wild type: HR, 0.62; 95% CI, 0.44-0.86; homologous recombination deficient: HR, 0.44; 95% CI, 0.39-0.50; all high certainty). PFS benefits were consistent across surgical timing, chemotherapy responses, and residual disease; for example, surgical timing had HRs of 0.51 (95% CI, 0.31-0.84) for neoadjuvant chemotherapy and 0.54 (95% CI, 0.36-0.81) for primary cytoreductive surgery (all high certainty). No molecular subgroup showed a statistically significant OS improvement (high to low certainty). High-grade adverse events were more common in the PARP inhibitor group (HR, 2.40; 95% CI, 1.16-4.93; high certainty). Observed treatment efficacy and toxic effects varied across PARP inhibitor regimens; for example, the risk ratio for any recurrence or death in the overall study group ranged from 0.53 (95% CI, 0.40-0.70) for senaparib to 0.83 (95% CI, 0.68-1.00) for olaparib, while the risk ratio for high-grade adverse events ranged from 1.15 (95% CI, 0.64-2.06) for veliparib to 4.73 (95% CI, 2.77-8.07) for niraparib. Conclusions and Relevance: In this study, no subgroup showed an association between first-line PARP inhibitor maintenance therapy in advanced-stage EOC and improved OS, and findings suggest that the consistency of associated PFS benefits may vary, particularly in homologous recombination proficient and BRCA wild type tumors. Variability in efficacy and toxic effects across subgroups and PARP inhibitor regimens underscores the importance of individualized treatment decisions.