Recommendations for the surgical management of gynecological cancers during the COVID-19 pandemic - FRANCOGYN group for the CNGOF



## All multidisciplinary meetings
All multidisciplinary meetings should be organized following the recommendations of the ONCORIF group (https://www. oncorif.fr/2020/03/coronavirus-recommandations-et-contenusfiables/). As far as possible, multidisciplinary meetings should be held with a triple objective: not to delay the care of patients who need it; not to unnecessarily mobilize doctors who are not absolutely necessary for the discussion; not to promote the transmission of the virus between cardiopulmonary resuscitation (CPR) doctors. It is strongly advised to hold dematerialized meetings when possible based on video or teleconferencing even if the doctors practice in the same establishment.
2. We propose the following adaptations for the management of patients with gynecologic pelvic cancer during the COVID-19 pandemic period

## For cervical cancer
Radiotherapy and concomitant radiochemotherapy should replace surgery as first-line treatment whenever possible. In particular, the value of lymph node staging surgeries must be reviewed on a case-by-case basis depending on the site, the results of imaging tests and the disease stage. Hysterectomy after concomitant radiochmotherapy is only indicated if a posttherapeutic tumor residue is identified.

## For ovarian cancer
For advanced cancers which may require the use of postoperative resuscitation for cytoreduction surgery, neoadjuvant chemotherapy should be the preferred option even if primary cytoreduction surgery could be envisaged. It is legitimate not to offer hyperthermic intraperitoneal chemotherapy (HIPEC) to patients during the COVID-19 pandemic period when resuscitation resources are saturated. If access to the operating theater is restricted due to the crisis, patients scheduled to undergo interval surgery after 3 or 4 cycles of chemotherapy could continue their chemotherapy and surgery be performed after 6 cycles of chemotherapy. The patient should then undergo at least two new cycles of chemotherapy after their closing surgery (in agreement with INCa recommendations https://www.e-cancer. fr/Expertises-et-publications/Catalogue-des-publications/Summary-Initial-management-of-epithelial-ovarian-cancer-cases).
For presumed early stage ovarian cancers according to adnexectomy, restaging surgery can be deferred from 1-2 months if access to anesthesia-resuscitation is saturated.
Furthermore, in case of saturation of access to anesthesiaresuscitation, a 2-step strategy is recommended for images suggestive of ovarian cancer on an isolated ovarian mass: adnexectomy of the suspect mass, and decision to perform complete staging surgery on final histologic analysis and decision of a CPR doctor.

## For endometrial cancer
Early stage cancers Surgical treatment remains the gold standard for early stage endometrial cancer. The minimally invasive laparoscopic robotassisted or non-assisted route is the preferred option. Total hysterectomy with bilateral adnexectomy associated with a sentinel node procedure should be performed in patients of low and intermediate preoperative ESMO risk. Surgery can be postponed for 1-2 months for low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy) if there is no element of discrepancy on the initial assessment, especially if the patient is elderly and / or with comorbidities, without loss of oncological chance for the patient.
For patients at high ESMO risk according to pelvic and lumbaraortic lymphadenectomy staging, comorbidities and the terrain (obesity, anticoagulant treatment, diabetes, age) should be taken into account. In this context, it would be legitimate to apply the MSKCC algorithm (associating PET CT and GS procedure) to avoid lymphadenectomy which increases the risk of per-and postoperative complications and the subsequent risk of requiring postoperative resuscitation.
For advanced endometrial cancers (stages III and IV), first-line medical treatment should be administered.
For suspected endometrial cancer For a patient who presents postmenopausal metrorrhagia and endometrial thickening on ultrasound, endometrial pipelle sampling should be performed in consultation. Diagnostic hysteroscopy in consultation should be avoided unless performed at the same time (to limit the number of patient trips). In the event of a non-contributory diagnostic assessment, the date of the diagnostic hysteroscopy and biopsy curettage should be adjusted according to the degree of suspicion of endometrial cancer and the constraints of access to the operating room. If the risk of cancer appears low and the patient is elderly, the procedure under general anesthesia can be postponed until after the confinement period for COVID-19.

## For vulvar cancers
The management of vulvar cancers, for which surgery remains the standard and often the only treatment option, should not change. However, this cancer often affects the elderly and if a tumor has not progressed much in an elderly patient, treatment may be postponed for a few weeks. The patient should be discharged as early as possible and cared for at home to reduce the duration of hospitalization.
When surgical management involves heavy surgery (amputation), the use of concomitant radiochemotherapy should be discussed in CPR.

## For vaginal cancer
Most patients presenting with vaginal cancer are at an advanced stage and will require exclusive radio-/ chemo-/ brachytherapy treatment. The value of lymph node staging surgery must be reviewed on a case-by-case basis depending on the location, the results of imaging tests, and the disease stage.

## For trophoblastic tumors
Trophoblastic tumors are considered curable but have a high metastatic potential. This justifies maintaining the care of these young patients without delay.
Patients with low risk trophoblastic tumors (FIGO score 6) should be administered methotrexate at home to avoid the four injections of each cure in an outpatient setting. Patients with high-risk tumors should be administered multidrug regimens without delay given the generally multimetastatic nature from the outset.
Finally, hydatidiform moles should be managed by the standard treatment of curettage suction under ultrasound control and not by medicinal evacuation which carries a high risk of retention.
The French Reference Center for Trophoblastic Diseases is available for case-by-case discussion and can provide the treatment protocol with methotrexate at home if necessary (touria.hajri@chu-lyon.fr).

## Post-therapeutic follow-up
Post-therapeutic oncological follow-up consultations should be postponed for 2 months (i.e., after the COVID-19 confinement period), because there is no obvious loss of chance. Follow-up can be performed by teleconsultation when the technical tools are available. However, follow-up of endometrial and / or cervical cancer is based on clinical examination, which cannot be replaced by teleconsultation, and avoid a follow-up consultation 2 months later.
[fig] $: Groupe FRANCOGYN (Groupe de Recherche en chirurgie Oncologique et Gynecologique), Groupe D'interet du CNGOF (College National des Gynecologues Obstetriciens Francais). 91, boulevard de Sebastopol. 75002 P. http://dx.doi.org/10.1016/j.jogoh.2020.101729 2468-7847/ 2020 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ [/fig]