ABSTRACT
BACKGROUND: Our study aimed to establish 'real-world' performance and cost-effectiveness of ovarian cancer (OC) surveillance in women with pathogenic germline BRCA1/2 variants who defer risk-reducing bilateral salpingo-oophorectomy (RRSO). METHODS: Our study recruited 875 female BRCA1/2-heterozygotes at 13 UK centres and via an online media campaign, with 767 undergoing at least one 4-monthly surveillance test with the Risk of Ovarian Cancer Algorithm (ROCA) test. Surveillance performance was calculated with modelling of occult cancers detected at RRSO. The incremental cost-effectiveness ratio (ICER) was calculated using Markov population cohort simulation. RESULTS: Our study identified 8 OCs during 1277 women screen years: 2 occult OCs at RRSO (both stage 1a), and 6 screen-detected; 3 of 6 (50%) were ≤stage 3a and 5 of 6 (83%) were completely surgically cytoreduced. Modelled sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for OC were 87.5% (95% CI, 47.3 to 99.7), 99.9% (99.9-100), 75% (34.9-96.8) and 99.9% (99.9-100), respectively. The predicted number of quality-adjusted life years (QALY) gained by surveillance was 0.179 with an ICER cost-saving of -£102,496/QALY. CONCLUSION: OC surveillance for women deferring RRSO in a 'real-world' setting is feasible and demonstrates similar performance to research trials; it down-stages OC, leading to a high complete cytoreduction rate and is cost-saving in the UK National Health Service (NHS) setting. While RRSO remains recommended management, ROCA-based surveillance may be considered for female BRCA-heterozygotes who are deferring such surgery.
ABSTRACT
IntroductionRemoval of large ovarian cysts has a high risk of spillage. Various techniques have been described for benign cysts, using plastic self-retractors or a laparoscopic bag. This video highlights a technique for safely draining and removing a large ovarian mass.Description86 years old woman presented with abdominal distension and intraabdominal pressure symptoms for 6 months in Covid19 pandemic. She was anorexic, severely anaemic requiring blood transfusions, with severe bilateral pedal oedema. The eGFR=38. CT demonstrated a large abdominopelvic mass, with intraabdominal compression effect. A 10 cm midline laparotomy was performed. The suction tube was connected to the gas inflow valve of the 5 mm laparoscopic port. DERMABOND ADVANCED® skin adhesive was applied over the external area of the bowel bag. The cyst surface was dried. Further adhesive was applied over the cyst wall, followed by the bag, and a gentle pressure for 2 minutes for a good seal. Once complete coverage was secured, the port with the suction attached was inserted. Ten litres of fluid were aspirated, an 40x20 cm cyst removed, containing 4L of bloodstained fluid.Conclusion/ImplicationsWe recommend this technique because it is easy to perform, straightforward, and very simple in case of fluid filled enlarged ovarian cysts. The incision is small and there is a safe aspiration of the cyst contents. Patient’s recovery is fast. It can be used for benign cysts, known malignant cysts, where the dissemination is not of a concern, and in palliative cases where the performance status does not allow a more complex operation.
ABSTRACT
BACKGROUND: Surgery is the cornerstone of gynecological cancer management, but inpatient treatment may expose both patients and healthcare staff to COVID-19 infections. Plans to mitigate the impact of the COVID-19 pandemic have been implemented widely, but few studies have evaluated the effectiveness of these plans in maintaining safe surgical care delivery. AIM: To evaluate the effects of mitigating plans implemented on the delivery of gynecological cancer surgery during the COVID-19 pandemic. METHODS: A comparative cohort study of patients treated in a high-volume tertiary gyneoncological centre in the United Kingdom. Prospectively-recorded consecutive operations performed and early peri-operative outcomes during the same calendar periods (January-August) in 2019 and 2020 were compared. RESULTS: In total, 585 operations were performed (296 in 2019; 289 in 2020). There was no significant difference in patient demographics. Types of surgery performed were different (p = 0.034), with fewer cytoreductive surgeries for ovarian cancer and laparoscopic procedures (p = 0.002) in 2020. There was no difference in intra-operative complication rates, critical care admission rates or length of stay. One patient had confirmed COVID-19 infection (0.4%). The 30-day post-operative complication rates were significantly higher in 2020 than in 2019 (58 [20.1%] versus 32 [10.8%]; p = 0.002) for both minor and major complications. This increase, primarily from March 2020 onwards, coincided with the first peak of the COVID-19 pandemic in the UK. CONCLUSIONS: Maintaining surgical throughput with meticulous and timely planning is feasible during the COVID-19 pandemic but this was associated with an increase in post-operative complications due to a multitude of reasons.