Sabina Ioana Nistor

Background and Objective: The field of Gynaecological Oncology (GO) has undergone a paradigm shift over recent decades, shaped by advancements in prevention, molecular therapeutics, and surgical innovation. We explore how the management of gynaecological malignancies has transformed in the past 25 years. Methods: A structured narrative review of landmark publications and guideline updates published between 2000 and 2025 was undertaken. Key developments in the management of cervical, ovarian, endometrial, vulvar, and vaginal cancers were critically analysed, with particular focus on prevention strategies, surgical evolution, and integration of targeted and immune therapies. Key Content and Findings: In cervical cancer, population-level human papillomavirus (HPV) vaccination has dramatically reduced incidence, while the LACC and SHAPE trials prompted a return to open and less radical surgery, respectively. Sentinel node biopsy is supplanting systematic lymphadenectomy, and combined chemoradiotherapy (CRT) with immunotherapy is improving survival in locally advanced disease. For ovarian cancer, optimal cytoreduction remains key, with TRUST highlighting surgical quality, while heated intraperitoneal chemotherapy (HIPEC) and poly-ADP ribose polymerase (PARP) inhibitors—alone or combined with immunotherapy—extend progression-free survival (PFS). Endometrial cancer management is now driven by molecular classification [The Cancer Genome Atlas (TCGA)/Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE)], with immunotherapy and targeted therapy transforming outcomes. In vulvar and vaginal cancers, GROINSS-V (Groin Sentinel Node Trial in Vulvar Cancer) and related studies underpin de-escalated and minimally invasive nodal surgery, while immunotherapy emerges for advanced disease. Conclusions: Modern GO is defined by prevention, precision, and personalisation. The contemporary Gynaecological Oncologist now integrates molecular insight, function-preserving surgery, and multidisciplinary collaboration to deliver optimised, patient-centred care.

Background/Objectives: Although the binarism between type I and II endometrial cancer was dismissed and substituted with molecular classification, histopathological features remain of paramount importance. Hence, analysing survival outcomes according to histological type, our aim is to clarify whether the morphological features of the tumour retain prognostic relevance in the context of advanced disease. Methods: This is a retrospective analysis led within the Thames Valley Cancer Alliance Network. Results: We include 148 FIGO 2009 stage III–IV patients affected by endometrioid endometrial cancer (EEC) G1, G2, and G3, carcinosarcoma (CS), serous carcinoma (SC), and clear cell carcinoma (CCC) of the uterus. Five year overall survival (OS) is distinct among the histological groups (p-value < 0.001), being 73.3% for G2 endometrioid, 49.2% for G3 endometrioid, 8.3% for CS, and 28.4% for SC. The divergence was marked also for 5 year progression-free survival (PFS) (p-value < 0.001) as follows: for G2 endometrioid, was 76.4%; for G3 endometrioid, 52.7%; and for carcinosarcoma, 5.9%. PFS after 18 months for serous carcinoma was 5.7%. The multivariate analysis found G3 endometrioid (HR 2.91, 95% CI 1.20–7.11, p-value 0.018), carcinosarcoma (HR 12.15, 95% CI 5.07–29.11, p-value < 0.001), and serous carcinoma (HR 4.84, 95% CI 2.16–10.83, p-value < 0.001) as independent predictors of poor survival, as well as cervical invasion (HR 1.83, 95% CI 1.10–3.05, p-value 0.020) as the only histopathological feature confirmed. Regarding progression-free only carcinosarcoma (HR 14.91, 95% CI 5.28–41.11) and serous carcinoma (HR 17.68, 95% CI 6.41–48.75) were associated with an increased risk of recurrence. Conclusions: Our findings testify that, beyond the disease stage, histological subtype remains a major determinant of survival outcome. Cervical involvement is associated with a more aggressive disease, possibly correlated to death beyond relapse. Prospective trials involving advanced stage endometrial cancer, stratified by histological subtype and integrated with the molecular classification, are required.

Background/Objectives: Pelvic exenteration is a complex surgery considered for locally advanced or recurrent pelvic malignancies, entailing a radical en-block resection of multiple adjacent pelvic organs, followed by reconstructive surgery. Achieving R0 resection (complete removal of macroscopic and microscopic disease) is critical for improving survival outcomes. This study aimed to define patient, tumour, and surgical predictors of R0 resection in an irradiated field, thereby optimising patient selection and establishing a surgical roadmap for pelvic exenterations. Methods: Our retrospective observational cohort study includes consecutive patients undergoing exenteration post-radiotherapy for non-ovarian gynaecological malignancies at Oxford University Hospitals between 1 January 2011 and 31 December 2024. The primary outcome was margin status. Secondary outcomes were intraoperative and postoperative complications. Results: Twenty-seven patients were identified, with a median age of 63 years (range 41–81) and median BMI of 27 (range 17–45). Primary tumour sites included the vulva (11.1%), vagina (14.8%), cervix (40.7%), and uterus (33.3%). R0 was achieved in 77.8% (n = 21) of cases. Intraoperative complications occurred in 29.6%, and significant postoperative complications (Clavien-Dindo IIIA/IIIB) in 22.2% of patients. R0 resection was significantly associated with younger age (median 61 vs. 70 years, p = 0.035) and primary cervical tumours (p = 0.036). On univariable logistic regression, tumour size on imaging (p = 0.038, OR 2.9) and on histology (p = 0.020, OR 2.01), and estimated blood loss (p = 0.048, OR 1.002) were significant predictors of R0 resection. None of these variables retained significance in multivariable logistic regression. Conclusions: Tumour size, primary tumour site, and patient age should be considered when selecting patients for pelvic exenteration following radiotherapy, and blood loss should be kept minimal in order to maximise the chances of achieving R0 resection.

Ovarian Low Grade Serous Carcinoma (LGSC) is a rare gynecological cancer with limited representation in literature. Achieving R0 through maximal cytoreductive effort is indicated to provide the best outcome. Gynecological cancer surgery increases risk of pulmonary embolism—balancing this with bleeding risk complicates the post‐operative landscape.

Background/Objectives: To evaluate the clinicopathological features, treatment, and survival outcomes and to identify independent prognosticators for recurrence and mortality in patients with endometrioid ovarian cancer. Methods: The medical records of patients diagnosed with endometrioid ovarian carcinoma between January 2010 and December 2022 were reviewed retrospectively. Demographic and disease-related data were evaluated. Kaplan–Meier survival analysis using log rank test and Cox regression was performed. Results: Seventy-six patients were included in the study. The median age at diagnosis was 54 years (range 31–86). A total of 85.5% of the patients were diagnosed with early-stage disease and 88.1% of the tumours represented low-grade carcinomas. Synchronous endometrioid endometrial cancer was confirmed in 19.7% of the cases. All patients underwent surgical management and 65.8% received adjuvant chemotherapy. Median follow-up time was 67.5 months. The 5-year disease-free survival and overall survival were 92.1% and 93.4%, respectively. The risk of cancer-related death was higher in advanced stages (HR = 13.86; 95% CI 2.16–57.17; p < 0.001) and in the presence of residual disease (HR = 15.18; 95% CI 2.36–87.17; p < 0.002). Residual disease and advanced stages were also identified as independent risk factors for disease relapse with HR = 16.04 (95% CI 2.61–93.7; p < 0.002) and HR = 11.73 (95% CI 1.92–41.6; p < 0.001), respectively. Conclusions: Endometrioid ovarian carcinoma usually affects younger patients with the majority of the cases representing low-grade carcinomas diagnosed at early stages. Residual disease and advanced stages are independently associated with inferior survival outcomes. There was no significance of lymph node dissection and adjuvant chemotherapy in the overall and recurrence-free survival rates. Further research focusing on molecular profiling should aim to define the prevalence and the prognostic value of major molecular alterations and develop precise stratification models to plan personalised treatment for optimal care.

Retroperitoneal lipomas are exceptionally rare tumors that mimic liposarcomas. We present a case of a woman in her 30s undergoing fertility investigations, with an incidental finding of a retroperitoneal tumor on MRI. PET and MRI scans suggested this may be a liposarcoma, with widespread effects on the surrounding iliac vessels. Collaboration between the orthopedic sarcoma service, gynecological oncology, and vascular surgery was required to excise the tumor without damaging the surrounding vessels. The patient underwent an exploratory midline laparotomy, with mobilization of the ascending colon along the Toldt line to gain access to the tumor. The morbid adherence of the tumor to neurovascular structures added significant complexity to this procedure; however, complete tumor resection was achieved with mobilization and excision of the obturator nerve only. The initial histological diagnosis was well‐differentiated liposarcoma; however, subsequent molecular analysis showed no evidence of MDM2 amplification, suggesting a final diagnosis of benign lipoma. This case exemplifies diagnostic challenges in lipomatous retroperitoneal tumors, as well as the importance of inter‐disciplinary collaboration in surgery to achieve the best surgical and oncological outcomes.

Background and Objective: Krukenberg tumours (KTs) are metastatic signet ring cell (SRC) adenocarcinomas of the ovary, arising from the stomach in most cases (70%). Other common primary sites are the colon, appendix and breast. The use of the term “Krukenberg tumour” is inconsistent in the literature which makes data interpretation difficult. Prognosis of KTs is dismal and, in the absence of randomised controlled trials, the best treatment strategies remain controversial. Evidence from retrospective studies suggests that metastectomy is associated with improved survival. Our narrative literature review set out to determine which patients gain maximal survival benefit from surgical management. Methods: A comprehensive literature search was performed using PubMed and Google Scholar databases, from 1 January 2000 to 15 July 2024, with the terms ‘Krukenberg’, ‘metastatic mucinous adenocarcinoma of ovary’. This search identified 20 full-text manuscripts, including data on 1,815 patients. Key Content and Findings: We found that the overall prognosis of these patients remains poor, with a median overall survival (mOS) ranging between 9 and 50 months. Metastectomy is associated with survival benefit only when all visible disease is removed (R0): mOS in patients with microscopic residual disease (R1) or gross residual disease (R2) is similar to mOS in unresected patients (11 vs. 10 months). The following other factors have been identified as independent prognostic factors for survival in multivariate analyses: heated intraperitoneal chemotherapy (HIPEC), adjuvant chemotherapy, curative surgery for the primary tumour, i.e., gastrectomy, no ascites, non-gastric origin, a good performance status, less extensive metastatic disease, i.e., no extra-ovarian disease or no extra-pelvic disease, no peritoneal carcinomatosis or a low Peritoneal Cancer Index (PCI), smaller size of lesion, no SRC features, expression of oestrogen receptor-β (ER-β) and progesterone receptors (PR), metachronous tumours, linitis plastica, tumour grade. Conclusions: Multiple retrospective analyses have demonstrated that metastectomy is associated with a survival benefit in patients with metastatic mucinous ovarian adenocarcinomas. However, patients with poor prognostic factors are less likely to benefit from surgery and should be counselled accordingly. Diagnostic laparoscopy could be considered before debulking surgery, to assess resectability of disease and to avoid a futile exploratory laparotomy. HIPEC after cytoreductive surgery (CRS) remains controversial, with possible survival benefit for KTs of gastric origin, particularly when peritoneal dissemination is present but the PCI is low.

Key Clinical Message: A surgical MDT approach to high‐complexity surgeries can allow maximal resection in order to achieve disease control and excellent functional outcomes, as demonstrated here for a case of hidradenitis suppurativa in a patient with Crohn's disease. Hidradenitis suppurativa is an autoimmune disease characterized by abscess and fistula formation with purulent discharge in intertriginous zones, and is associated with inflammatory bowel disease. We present the case of a patient with severe ongoing hidradenitis suppurativa causing osteomyelitis and affecting the perineum, on a background of Crohn's disease previously treated with panprotocolectomy and permanent ileostomy. The hidradenitis suppurativa was having a severe impact on the patient's quality of life, and she had failed to respond to conservative management. The patient opted for a radical two‐step procedure: first her coccyx and sacrum were removed. The second step was a radical bilateral anterior vulvectomy and posterior vaginectomy, with preservation of the uterine body and cervix. An anterolateral thigh flap was used to reconstruct the perineum. This complex procedure required the expertise of multiple surgical specialties, including plastic, general, spinal, and gynecological oncology surgeons to achieve maximal disease resection, minimizing the risk of recurrence.

A retrospective study including 49 women with ovarian clear cell carcinoma between January 2009 and December 2021 at Oxford cancer centre was done. The mean age was 63 years, with 78% post-menopausal. All women underwent cytoreductive surgery with no residual disease (R0) in 39 women. The follow-up time ranged between 12-144 months, with mean of 105.5 months. The 3-year OS was 73.4%, and 3-year PFS was 81.3%, with a mean of 101.7months (95%CI, 84.63-118.93). As expected, women with stage 1 disease had the best outcome. In comparing OS in respect to absence or presence of residual disease, the 3-year OS was 88.6% (95% CI 108.6-141.8), compared to 12.5% (95% CI 4.48-32.11) respectively (P200 IU/ml), Hb (< or >115 g/L), albumin (< or >40 g/L), associated endometriosis, ascites, residual disease, and FIGO staging. FIGO stage was the only independent prognostic indicator of OS with (p<0.05). Surgery to achieve no residual tumour is necessary to improve the prognosis in advanced OCCC. At present, the true challenge is to predict which patients with early-stage disease are at higher risk of recurrence and would most benefit from adjuvant treatments.