Personalized solutions for gynecological cancers

Editorial

Professor Jacques Marescaux
President and Founder of IRCAD

Interview of the month

Minimally invasive surgery: diverse solutions for personalized treatment of gynecological cancers

Professor Chérif Akladios
Head of the gynecology-obstetrics division at Strasbourg University Hospitals and President of the French Society of Onco-Gynecology (SFOG).

Professor Akladios, the 32nd SFOG Congress (French Society of Onco-Gynecology) begins on December 11 at IRCAD. What are the key themes of this edition dedicated to personalized treatment of gynecological cancers?

Professor Chérif Akladios: The unique feature of SFOG is its multidisciplinary approach, bringing together various specialties—gynecologists, medical oncologists, radiotherapists, radiologists, pathologists, and geneticists—who share a common goal: managing pelvic cancers in women. This multidisciplinary approach reflects the diagnostic and therapeutic strategies that must be implemented for each case.

This year, we aim to emphasize the importance of personalizing patient care as much as possible and broadly disseminating information about validated approaches, those no longer recommended, and areas where questions remain. Knowledge is evolving rapidly, and current guidelines are no longer the same as they were 5 or 10 years ago. Survival rates are much better today because we have a better understanding of cancers and access to improved treatments, including chemotherapy, hormone therapy, radiotherapy, immunotherapy, and minimally invasive surgery. However, knowledge levels remain uneven across France, so we must continue our efforts to inform and educate.

For example, cancers were long classified based on staging. However, with advances in research, we can now molecularly characterize cancers, making staging less significant. Previously, an early-stage localized tumor was considered prognostically favorable. Today, aggressiveness and prognosis are determined not only by disease stage but also, more importantly, by the tumor’s molecular profile. For instance, an early-stage endometrial cancer with a P53 mutation is inherently more aggressive and has a poorer prognosis than one without this mutation. We must therefore shift our thinking: instead of focusing solely on how far the tumor has spread, we must identify its molecular identity to tailor treatment more effectively. This is the key message we want to convey to the medical community.

We also aim to better inform the public and have launched an awareness campaign during “Turquoise September.”

This year’s Congress is being held at IRCAD France, a pioneer in research and teaching of minimally invasive techniques. Can you tell us more about the collaboration between SFOG and IRCAD?

Pr. C. A.: Minimally invasive surgery is now the preferred approach for most gynecological cancers, with robotic surgery playing an increasingly prominent role.

Take endometrial cancer, the most common pelvic cancer (approximately 9,000 cases per year). Its management requires sentinel lymph node mapping, performed via traditional laparoscopy or robot-assisted surgery. Additionally, one of the main risk factors for this cancer is obesity, as it is predominantly hormone-sensitive, and obese patients have elevated estrogen levels generated by fat. However, operating on obese patients is complicated by the volume of fat, which makes accessing and visualizing organs difficult. One of the greatest advantages of robotic surgery is the ability to operate more easily on obese patients, offering greater precision and improved visualization.

Managing gynecological cancers therefore necessitates learning minimally invasive techniques, and IRCAD is nationally and internationally recognized as the go-to center for such training. It is the reference center for both laparoscopy and robotic surgery. Each year, IRCAD trains nearly 9,000 surgeons from around the world in cutting-edge techniques across 18 specialties in laparoscopic and robotic surgery. The robotic platform at IRCAD is unique globally, with over 30 robots making it the largest platform of its kind. It offers five different training programs, each conducted by around 20 international experts.

Gynecological oncology courses are naturally held at IRCAD, with participation from SFOG members. I regularly teach international courses there. Furthermore, IRCAD is also a leading cancer research center, conducting numerous projects in collaboration with SFOG members and SFOG Campus.

Interactions between SFOG and IRCAD are therefore close, advancing the management of gynecological pelvic cancers.

The vNOTES approach is on the Congress program. What is your perspective on this minimally invasive technique that uses a natural route (vaginal) to access the uterus and ovaries, leaving no external scars?

In gynecological surgery, the vaginal approach offers patients the advantage of avoiding abdominal scars, reducing post-operative pain, and shortening hospitalization. However, traditional vaginal access has limited visualization of pelvic structures and organs, which is a significant concern in onco-gynecological surgery. The use of vNOTES, which is essentially laparoscopy through the vaginal route, provides good visualization of the surgical field. That said, creating the pneumo-vagina by inflating the vaginal cavity involves manipulating the uterus, which could risk the escape and migration of cancer cells. This issue has been widely debated and remains under discussion. In my opinion, the benefits of vNOTES in onco-gynecology are not yet clearly established, as we lack a prospective phase 3 study demonstrating no loss of therapeutic outcomes.

It’s worth noting that vNOTES could be a valuable option for obese patients, especially when combined with robotic assistance. For instance, I have a patient with severe obesity (BMI=67), where accessing the uterus is extremely challenging, whether via a simple vaginal route or traditional laparoscopy. Hysterectomy is very complicated, even with robotic assistance. By using the vaginal route combined with laparoscopy, we avoid the compression caused by the abdominal wall, gain sufficient space, and achieve good visualization, enabling precise surgical work.

Augmented reality and artificial intelligence are also part of this 32nd edition’s program. What is your view on their contribution to onco-gynecology?

These are tremendous advancements that are already influencing our practice and improving patient care. Augmented reality allows us to overlay CT or MRI images on the robotic screen, ensuring highly precise and comprehensive surgical maneuvers. Artificial intelligence, on the other hand, enhances cancer diagnostics, and accurate diagnostics inevitably improve prognosis, especially when effective therapeutic tools are available, as they are today.

Research is ongoing, and two studies are currently being conducted in collaboration with IRCAD. One focuses on using augmented reality for sentinel lymph node detection in endometrial cancers, a project jointly led by IRCAD, the Strasbourg IHU, and the Gemelli University Hospital in Rome. The other study explores the use of artificial intelligence for preoperative diagnostics of endometrial cancer, conducted in partnership with the Gynecology-Obstetrics Division of the Strasbourg University Hospitals, IRCAD, and the Strasbourg IHU.

Could artificial intelligence, combined with surgical robotics, eventually enable autonomous surgeries without the need for a surgeon?

I don’t think so because every individual is unique, which brings us back to the theme of this 32nd edition: personalization.

While human anatomy is broadly consistent from one person to another, no two individuals are exactly the same, even just considering their medical history—for example, adhesions from prior surgeries.

You can feed AI software with all the available data, but it’s impossible to provide every detail required to fully grasp each specific case. The “machine” may possess extensive knowledge, but it is not autonomous; it needs guidance and direction. Human expertise remains indispensable.

About IRCAD :

Founded in 1994 by Professor Jacques Marescaux, IRCAD is dedicated to training and research in minimally invasive surgery. The Strasbourg-based institute is internationally renowned for its excellent training courses, both face-to-face (nearly 8,800 surgeons trained annually in Strasbourg) and virtual, through the Websurg online university, which has over 470,000 members worldwide.

For more information, please visit https://www.ircad.com

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