Spotlight On: Oncology

This month, we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Oncology (SIG) led by Chair Masoud Azodi, MD.

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video and JMIG article recommendations by our SIGs are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today!

SIG Recommended SurgeryU Video #1: 
2024 AAGL Global Congress Panel: AAGL/SGO: Updates in Fertility Sparing Treatment of Endometrial Cancer – Womb for Improvement
By Amanda Nickles Fader, Ursula Catena, Mindy Christianson, Jennifer Mueller, Shannon Westin

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The landscape of endometrial cancer is evolving, with new advances and molecular targets now available for therapy. This joint discussion between AAGL and SGO shares the multi-faceted approach to fertility-sparing approaches in endometrial cancer.

• Talk 1: Candidates and Clinical Trials: Who Benefits from Fertility-Sparing Medical Treatment for Endometrial Cancer?
  Shannon Westin
• Talk 2: When Can Ovarian Conservation at Hysterectomy for Endometrial Cancer be Considered?
  Jennifer Mueller
• Talk 3: What are the Molecular, Genomic, Generational, and Racial/Ethnic Consideration in Fertility-Sparing Endometrial Cancer Treatment?
  Ursula Catena
• Talk 4: Disease Surveillance and Reproductive Outcomes: How Do You Optimize Conditions for Patients?
  Mindy Christianson

SIG Recommended SurgeryU Video #2:
Performing Oncologically Safe Minimally Invasive Surgery
By Yukio Sonoda, Dario Roque, Michael Shu, M. Yvette Williams-Brown

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• Talk 1: Management of Adnexal Masses with Minimally Invasive Surgery
  Dario Roque
• Talk 2: Management of Uterine Masses and Endometrial Hyperplasia with Minimally Invasive Surgery
  Michael Shu
• Talk 3: Management of Cervical Cancer with Minimally Invasive Surgery
  Yvette Williams-Brown

JMIG Article Recommendation #1:

Predictors of Bilateral Sentinel Lymph Node Mapping Failure in Endometrial Cancer: A Systematic Review and Meta-Analysis
Zhaojuan Qin, MM, Yi Du, MD, Qi Wan, MD, Ai Zheng, MD

Prior studies including FIRES and SENTOR report on the reliability of sentinel lymph node biopsy in both the low and high-risk group, respectively. This systematic review and meta-analysis attempts to uncover the various factors that may contribute to failed sentinel mapping.

JMIG Article Recommendation #2:

Risk, Prevalence and Survival Outcomes of Ovarian Cancer in Women With Endometriosis: The Endocancer Systematic Review and Meta-Analysis
KIlaria Piacenti, MD, Veronica Tius, MD, Benedetta Gomba, MD, Stefano Restaino, MD, Martina Arcieri, MD, Silvia Zermano, MD, Anna Biasioli, MD, Federica Perelli, MD, Diego Raimondo, MD, Lucia Lazzeri, MD, Alberto Mattei, MD, Errico Zupi, MD, Renato Seracchioli, MD, Giuseppe Vizzielli, PhD

Endometriosis has been linked with an increased risk of epithelial ovarian cancer, especially the histologic clear cell and endometrioid subtypes. This systematic review and meta-analysis reports on the characteristics of those who go on to develop ovarian cancer, their survival comparison, recurrence risk, and platinum sensitivity.

JMIG Article Recommendations By:
Michael Shu, MD

Dr. Shu is a Gynecologic Oncology Fellow at the Rutgers Cancer Institute of New Jersey.

Recurrent Oligometastatic Cervical Carcinoma

A 50-year-old with history of stage IB1 moderately differentiated adenosquamous carcinoma of the endocervix presented with progressive right lower extremity symptoms, including thigh discomfort, groin fullness, and asymmetric swelling of the right thigh. She was diagnosed with cervical cancer in 2013 and underwent a robotic-assisted radical hysterectomy with pelvic lymphadenectomy. Final pathology demonstrated low-risk features, and adjuvant chemotherapy or radiation therapy was not indicated.

More than a decade later, evaluation of her persistent right lower extremity symptoms revealed a 3.9 cm retroperitoneal mass adjacent to the right common iliac vessels on abdominal ultrasound. Laparoscopic biopsy confirmed HPV-associated carcinoma consistent with recurrent cervical cancer. PET/CT demonstrated a solitary 4.5 cm FDG-avid right common iliac lymph node (SUVmax 13.4), abutting the right common iliac artery and vein as well as the iliopsoas muscle, with no other metastatic disease (Figure 1).

Figure 1. PET/CT demonstrating a 4.5 cm FDG-avid right common iliac lymph node metastasis (SUVmax 13.4) abutting the right common iliac artery, right common iliac vein, and iliopsoas muscle

Given the isolated nodal recurrence, our tumor board recommended a multimodality treatment approach with neoadjuvant radiation therapy, surgical resection, and adjuvant systemic chemotherapy. The patient received 45 Gy of IMRT delivered in 25 fractions. Preoperative MRI of the abdomen and pelvis demonstrated interval enlargement of the right common iliac nodal metastasis to 6.2 cm despite radiation treatment (Figure 2).

Figure 2. Preoperative MRI of the abdomen and pelvis demonstrating 6.2 cm right common iliac nodal metastasis.

Approximately 4 weeks after completing radiation therapy, the patient underwent a robotic-assisted resection of this right common iliac node (Figure 3). A right ureteral catheter was placed intraoperatively with indocyanine green (ICG) instillation to facilitate ureteral identification during the dissection. The procedure was performed using the da Vinci 5 Surgical System. The patient was positioned in dorsal lithotomy with 39 degrees of Trendelenburg. Abdominal entry was obtained via Hasson technique at the umbilicus, which served as an assistant port. An 8-mm robotic trocar was placed in the suprapubic position for the camera. One 8-mm robotic trocar was placed in the right lower quadrant, caudal to the anterior superior iliac spine, and two additional 8-mm robotic trocars were positioned in the left lower quadrant as caudally as possible (Figure 4). A 5 to 12-mm assistant port can be placed lateral to the camera port to facilitate retraction and specimen handling.

Figure 3. Robotic-assisted resection of the right common iliac nodal metastasis. (A) Right common iliac nodal metastasis; (B) ureter; (C) right common iliac artery; and (D) right external iliac artery.

Figure 4. Robotic trocar configuration. 11-mm Hasson trocar was placed at the umbilicus. 8-mm robotic trocar was positioned in the suprapubic location and utilized as the camera port. One 8-mm robotic trocar was placed in the right lower quadrant caudal to the anterior superior iliac spine, and two 8-mm robotic trocars were placed in the left lower quadrant. 5-12 mm assistant port was placed lateral to the suprapubic port.

The dissection began with mobilization of the cecum, followed by incision of the peritoneum overlying the right common iliac artery and extending the incision cephalad toward the aortic bifurcation. The inferior vena cava was exposed early in the procedure to optimize visualization and facilitate prompt vascular control in the event of inadvertent venous injury. The right ureter, enhanced by ICG fluorescence, was dissected free from the nodal mass (Figure 5).

Figure 5. Intraoperative Firefly fluorescence imaging demonstrating the right ureter (B), enhanced with ICG, dissected free from the right common iliac nodal metastasis (A).

The operative time was 3 hours and 16 minutes, with an estimated blood loss of 100 mL. No intraoperative complications occurred. Given the proximity of the dissection to the right ureter, an indwelling 6 Fr × 24 cm double-pigtail ureteral stent was placed. Fibrin sealant was applied to the surgical bed at procedure completion. Final pathology revealed a 5.2 cm metastatic adenosquamous carcinoma. Her postoperative course was complicated by cystitis, which was successfully treated with oral antibiotics. She is scheduled to initiate systemic therapy consisting of carboplatin, paclitaxel, pembrolizumab, and bevacizumab approximately 4 to 6 weeks postoperatively.

About the Author: 
Ritchie Delara, MD, FACOG, FACS

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Gynecologic Oncology: From Theory to Real-World Application

The first clinical applications of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for use in gynecology were performed in 2011, with documented use in the medical literature appearing in 2012 [1-2]. At the time, vNOTES was performed solely for benign disease [2-3]. In the following years, reports of vNOTES performed for gynecologic malignancy were published as early as 2014 [4-5]. Over the past decade, vNOTES has developed into another minimally invasive approach in the armamentarium of the gynecologic oncologist.

The preponderance of experience with vNOTES and gynecologic malignancy has been for endometrial cancer [6]. It has proven to be a safe route for surgery in early uterine-confined pathology and for staging procedures. In a recent systematic review, overall bilateral sentinel lymph node detection rates were 89.2%, with a higher detection rate when performed retroperitoneally compared to transperitoneally (94.3% vs 81.1%) and a failure rate of 3.9% [7]. Endometrial staging procedures may also be performed in high-risk histologies without limitation when the upper abdomen requires evaluation [8]. In various countries where morbid obesity have increasingly contributed as risk factors, vNOTES presents itself as a tenable solution to accomplish adequate staging in this population of women [9].

A new frontier exists in the setting of cervical cancer, as vNOTES provides potential modern solutions for management. Controversial debate exists on the approach for surgical management of women with cervical cancer, especially following the Laparoscopic Approach to Cervical Cancer (LACC) trial and competing ongoing clinical trials [10-11]. However, surgical development processes are underway to revisit the concept of a minimally invasive approach. In patients who do not fulfill Simple Hysterectomy And Pelvic node assessment in Early-stage cervical cancer (SHAPE) criteria, a radical hysterectomy may be performed via vNOTES and has been published [12]. Time will tell as to vNOTES’ safety profile for cervical cancer and should be viewed currently as investigational and as part of clinical trials in the appropriately counseled patient.

While vaginal surgery is not typically indicated or utilized for the evaluation and management of gynecologic oncology patients, vNOTES may see a unique adoption under the appropriate environment and surgical ecosystem. Recent randomized control trials have endorsed shorter operative time, even among patients with larger uteri or higher BMI, as well as improved postoperative pain scores as compared to traditional laparoscopic surgery [13-15]. Importantly, a recent meta-analysis confirms fewer postoperative complications even when using data accrued from surgeons during the learning phase of vNOTES adoption [16].

Several platforms now offer communities for surgeons interested in gaining familiarity and expertise in vNOTES. These resources describe the technical aspects of the vNOTES approach (Image A), including the lateral fornix approach for entry into the retroperitoneal space in contrast to anterior or posterior fornix entry (Image B), as well as the caudal-to-cranial visualization of the retroperitoneal anatomy rather than the cranial-to-caudal orientation typically encountered during transabdominal laparoscopy (Image C) [5]. Photographed is a radical hysterectomy specimen performed at the time of this article, which was excised using vNOTES (Image D).

Image A. Operative approach via VNOTES. 3 Instrument access from a vaginal access gelport.

Image B. Right paracervical incision/entry – a 3 cm vertical incision made 1 cm lateral to the cervicovaginal junction. Clamps at 12:00 and 8:00 are holding the anterior and posterior edges of the incision. Tenaculum at 5:00 is holding the cervix.

Image C. Right external iliac sentinel lymph nodes viewed from caudal-to-cranial via vNOTES

Image D. Radical hysterectomy specimen performed by vNOTES (by HR)

References:

[1] Yang, Y.S., Hur, M.H., Oh, K.Y. and Kim, S.Y. (2013), NOTES for adnexal masses. J Obstet Gynaecol Res, 39: 1604-1609. https://doi.org/10.1111/jog.12108

[2] Ahn KH, Song JY, Kim SH, Lee KW, Kim T. Transvaginal single-port natural orifice transluminal endoscopic surgery for benign uterine adnexal pathologies. J Minim Invasive Gynecol. 2012 Sep-Oct;19(5):631-5. doi: 10.1016/j.jmig.2012.04.001. Epub 2012 Jul 3. PMID: 22763314.

[3] Su H, Yen CF, Wu KY, Han CM, Lee CL. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): feasibility of an innovative approach. Taiwan J Obstet Gynecol. 2012 Jun;51(2):217-21. doi: 10.1016/j.tjog.2012.04.009. PMID: 22795097.

[4] Lee CL, Wu KY, Tsao FY, et al. Natural orifice transvaginal endoscopic surgery for endometrial cancer. Gynecol Minim Invasive Ther. 2014;3:89–92. doi:10.1016/j.gmit.2014.08.004.

[5] Baekelandt JF. New Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery Approach to Sentinel Node for Endometrial Cancer: A Demonstration Video. J Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1231-1232. doi: 10.1016/j.jmig.2019.05.002. Epub 2019 May 11. PMID: 31082514.

[6] Koulakmanidis AM, Kontogeorgi E, Zacharakis D, Prodromidou A, Sapantzoglou I, Mascellino G, Kypriotis K, Kathopoulis N, Sioutis D, Voros C, Vrysis C, Athanasiou S, Grigoriadis T. Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Patients with Gynecological Malignancies: A Systematic Review. J Clin Med. 2026 May 25;15(11):4089. doi: 10.3390/jcm15114089. PMID: 42278953; PMCID: PMC13258491.

[7] Wernly D, Nef J, Huber D. Sentinel lymph node biopsy by transvaginal natural orifice transluminal endoscopic surgery for early-stage endometrial cancer: a systematic literature review. Front Surg. 2025 Oct 23;12:1663469. doi: 10.3389/fsurg.2025.1663469. PMID: 41209068; PMCID: PMC12589802.

[8] Hurni Y, Huber D. Omentectomy for oncological surgical staging by transvaginal natural orifice transluminal endoscopic surgery (vNOTES): a preliminary study. Front Surg. 2023 Jul 27;10:1224770. doi: 10.3389/fsurg.2023.1224770. PMID: 37576921; PMCID: PMC10413260.

[9] Burnett AF, Pitman TC, Baekelandt JF. vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience. Arch Gynecol Obstet. 2024 Feb;309(2):565-570. doi: 10.1007/s00404-023-07250-y. Epub 2023 Oct 25. PMID: 37880384.

[10] Ramirez PT, Robledo KP, Frumovitz M, Pareja R, Ribeiro R, Lopez A, Yan X, Isla D, Moretti R, Bernardini MQ, Gebski V, Asher R, Behan V, Coleman RL, Obermair A. LACC Trial: Final Analysis on Overall Survival Comparing Open Versus Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer. J Clin Oncol. 2024 Aug 10;42(23):2741-2746. doi: 10.1200/JCO.23.02335. Epub 2024 May 29. PMID: 38810208.

[11] Leitao MM Jr, Bixel KL, Chase DM, Quick A, McCormick C, Black D, Lim PC, Eskander RN, Gotlieb WH, LoCoco S, Martino MA, Walker JL, Copeland LJ, Monk BJ, Randall LM. ROCC/GOG-3043: a randomized controlled trial of robotic versus open surgery for early-stage cervical cancer. Int J Gynecol Cancer. 2025 Jul;35(7):101760. doi: 10.1016/j.ijgc.2025.101760. Epub 2025 Feb 28. PMID: 40188007; PMCID: PMC13254790.

[12] Baekelandt J, Chuang L, Zepeda Ortega JH, Burnett A. A new approach to radical hysterectomy: First report of treatment via vNOTES for cervical cancer. Asian J Surg. 2023 Apr;46(4):1852-1853. doi: 10.1016/j.asjsur.2022.10.067. Epub 2022 Oct 29. PMID: 36319544.

[13] Baekelandt JF, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol B, Bosteels J. Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-care procedure: a randomised controlled trial. BJOG. 2019 Jan;126(1):105-113. doi: 10.1111/1471-0528.15504. PMID: 30325565.

[14] Baekelandt J, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Morlion B, Weyers S, Mol B, Bosteels J. Adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial). BJOG. 2021 Oct;128(11):1782-1791. doi: 10.1111/1471-0528.16838. Epub 2021 Jul 27. PMID: 34246198.

[15] Burnett AF, Pitman TC, Baekelandt JF. vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience. Arch Gynecol Obstet. 2024 Feb;309(2):565-570. doi: 10.1007/s00404-023-07250-y. Epub 2023 Oct 25. PMID: 37880384.

[16] Marchand GJ, Masoud AT, Ulibarri H, Arroyo A, Moir C, Blanco M, Herrera DG, Hamilton B, Ruffley K, Petersen M, Fernandez S, Azadi A. Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery vs laparoscopic hysterectomy. AJOG Glob Rep. 2024 Feb 8;4(1):100320. doi: 10.1016/j.xagr.2024.100320. PMID: 38440153; PMCID: PMC10910317.

About the Author: 
Radhika Kadakia, MD
Emily Brunette, MD
Henry Reyes, MD
Michael Shu, MD

Dr. Brunette is an Obstetrics and Gynecology Resident at the University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences in Buffalo, New York.