Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis.

OBJECTIVE: Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism. METHODS: A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies. RESULTS: A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population. TRIAL REGISTRATION: PROSPERO CRD42022339602.

Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Advanced Ovarian Cancer and Impact on Survival.

OBJECTIVE: To determine the incidence of venous thromboembolism (VTE) in patients with ovarian cancer receiving neoadjuvant chemotherapy (NACT), identify risk factors for VTE, and assess the effect of VTE on treatment trajectory and overall survival. METHODS: This is a retrospective cohort study of patients diagnosed with ovarian, fallopian tube, or primary peritoneal cancer treated with NACT between 2013 to 2016 in Alberta, Canada. The primary outcome was incidence of VTE during NACT. Secondary outcomes were risk factors for VTE and overall survival. Data related to patient demographics, cancer treatment, and incidence of VTE were collected. Statistical analyses included Kaplan-Meier estimates and univariate and multivariate Cox regression analysis. RESULTS: A total of 284 patients were included in this study. Average age at diagnosis was 63.8 years. The incidence of VTE during NACT was 13.3%. Patients with VTE were less likely to undergo interval debulking surgery (58.3%) than patients without VTE (78.6%). Kaplan-Meier estimates demonstrated a decrease in overall survival in patients who had VTE during NACT (15.0 mo; 95% CI 14.5-16.5) compared with patients who did not (26.8 mo; 95% CI 22.8-30.9) (P < 0.0001). Multivariate analysis identified albumin <35 g/L, BMI >30 kg/m2, and non-serous histology as risk factors for VTE. CONCLUSION: The risk of VTE in this cohort was 13.3%, which was associated with decreased overall survival. These findings suggest that thromboprophylaxis may have a role in this patient population.

Cytology positive pericardial effusion causing tamponade in patients with high grade serous carcinoma of the ovary.

•Three patients with cytology positive pericardial effusions from high grade serous carcinoma.•Patients' conditions amenable to treatment with chemotherapy after effusion symptom improvement.•Patient with pericardial effusion from high grade serous ovarian cancer post a poly ADP ribose polymerase inhibitor.

Universal Testing to Identify Lynch Syndrome Among Women With Newly Diagnosed Endometrial Carcinoma.

BACKGROUND: Lynch syndrome (LS) is an autosomal dominant cancer syndrome caused by a germline mutation in the mismatch repair (MMR) genes. Protocols based on immunohistochemical expression of MMR proteins in cancer are used to identify patients with LS. METHODS: The universal LS screening protocol of the Tom Baker Cancer Centre (Calgary, AB) of all patients diagnosed between April 1, 2013 and April 1, 2015 with endometrioid carcinoma of the endometrium was audited through a retrospective chart review. LS status and frequency of protocol compliance at each of the key steps were calculated (Canadian Task Force Classification II-2). RESULTS: The cohort consisted of 375 patients. MMR immunohistochemical testing was requested for 321 (85.6%). Expression of at least one protein was lost in 86 (26.8%). Twenty-one (6.5%) patients were eligible for genetic counselling because PMS2, MSH2, or MSH6 protein expression was lost in 19, and two patients had a family history of LS. Eleven (91.7%) of 12 (57.1%) who attended had germline testing, and six (54.5%) showed a mutation diagnostic of LS. LS status among the cohort of 375 patients was positive in six (1.6%), negative in 294 (78.4%), and unknown in 75 (20%) because of protocol non-compliance. LS was confirmed in six (2%) of the 321 women who completed the protocol. CONCLUSION: This is the first audit of a Canadian-based universal LS screening protocol of patients with endometrial cancer. The success of the protocol is endorsed by the 80% compliance and by the 2% prevalence of LS, which is within the published range.

Impact of transversus abdominis plane blocks versus non-steroidal anti-inflammatory on post-operative opioid use in ERAS ovarian cancer surgery.

BACKGROUND: Treatment of ovarian cancer often requires extensive surgical resection. The transversus abdominis plane (TAP) block has been utilized in benign gynecologic surgery to decrease post-operative pain and opioid use. We hypothesized that TAP blocks would decrease total opioid use in the first 24 hours and decrease length of stay following staging and cytoreductive surgery for ovarian cancer compared with either no local anesthetic or local wound infiltration alone. METHODS: All patients undergoing surgery for ovarian cancer from November 2016 to June 2017 were included in this retrospective cohort study. Median opioid use at 24, 48, and 72 hours post-operatively, as well as length of stay, were assessed. Multivariate median regression analysis was performed to adjust for potential confounders: post-operative non-steroidal anti-inflammatory drug (NSAID) usage, pre-operative opioid consumption, and extent of cytoreductive surgery. Length of stay was compared using Cox regression analysis. RESULTS: One-hundred-and-twenty patients were included in the analysis. Eighty-two patients had a TAP block, while 38 did not. After adjusting for potential confounders there was no difference in median 24 hours opioid consumption (p=0.29) or length of stay (HR 0.95, p=0.78) between patients receiving TAP block compared with those without. After adjusting for potential confounders, patients receiving scheduled NSAIDs had a 2.6-fold greater likelihood of being discharged (p<0.0005) and a significant reduction in median opioid use at 24 hours (23.5 vs 14.5 mg) (p=0.017) compared with those patients without NSAIDs. DISCUSSION: Post-operative administration of NSAIDs, but not TAP block, was associated with a decrease in post-operative opioid use and length of stay following surgery for ovarian cancer. Further investigation into alternative regional anesthetics for Enhanced Recovery after Surgery (ERAS) protocols is warranted.

The Impact of Gynaecological Tumour Board Rounds on Patient Care.

OBJECTIVE: The goal of this study was to determine the impact of tumour board rounds (TBRs) on the additional management of patients with gynaecologic malignancy. METHODS: A retrospective chart review of 1604 patients discussed between January 2011 and December 2013 at gynaecologic TBRs was conducted to determine the frequency and type of diagnostic discrepancies found post-TBRs and their potential impact on additional patient management. A discrepancy was defined as major if it affected patient management by cancelling, initiating, or modifying treatment; otherwise, the discrepancy was minor. Data collected included patients' demographics, pre- and post-TBR diagnoses, and management. RESULTS: The patients' mean age was 57.6 ± 14.1. Endometrial disease accounted for (43%) of the TBRs. The remaining sites were ovarian (25%), cervical (23%), and others (9%). Overall, 13.2% (n = 212) had a discrepancy; 3.4% (n = 54) of these discrepancies were major, and 9.9% (n = 158) were minor. Most major discrepancies related to changes in the tumours' primary site or stage, and most minor discrepancies were related to changes in tumour histotype. Among the 54 (25.5%) major discrepancies, 18 (33.3%) occurred in patients who had their additional management cancelled, 17 (31.5%) required chemotherapy, 4 (7.4%) required a change in the chemotherapy regimen, 10 (18.5%) required additional surgery, and 5 (9.3%) required chemoradiation. CONCLUSION: The 13% frequency of discrepancies, approximately 26% of which were major and resulted in changes in patient management, highlights the importance of TBRs as a quality tool.

Unsupervised classification of petroleum Certified Reference Materials and other fuels by chemometric analysis of gas chromatography-mass spectrometry data.

As feedstocks transition from conventional oil to unconventional petroleum sources and biomass, it will be necessary to determine whether a particular fuel or fuel blend is suitable for use in engines. Certifying a fuel as safe for use is time-consuming and expensive and must be performed for each new fuel. In principle, suitability of a fuel should be completely determined by its chemical composition. This composition can be probed through use of detailed analytical techniques such as gas chromatography-mass spectroscopy (GC-MS). In traditional analysis, chromatograms would be used to determine the details of the composition. In the approach taken in this paper, the chromatogram is assumed to be entirely representative of the composition of a fuel, and is used directly as the input to an algorithm in order to develop a model that is predictive of a fuel's suitability. When a new fuel is proposed for service, its suitability for any application could then be ascertained by using this model to compare its chromatogram with those of the fuels already known to be suitable for that application. In this paper, we lay the mathematical and informatics groundwork for a predictive model of hydrocarbon properties. The objective of this work was to develop a reliable model for unsupervised classification of the hydrocarbons as a prelude to developing a predictive model of their engine-relevant physical and chemical properties. A set of hydrocarbons including biodiesel fuels, gasoline, highway and marine diesel fuels, and crude oils was collected and GC-MS profiles obtained. These profiles were then analyzed using multi-way principal components analysis (MPCA), principal factors analysis (PARAFAC), and a self-organizing map (SOM), which is a kind of artificial neural network. It was found that, while MPCA and PARAFAC were able to recover descriptive models of the fuels, their linear nature obscured some of the finer physical details due to the widely varying composition of the fuels. The SOM was able to find a descriptive classification model which has the potential for practical recognition and perhaps prediction of fuel properties.

The importance of surgical staging in women with uterine serous carcinoma: experience in a single institution reveals a survival benefit.

OBJECTIVE: To assess the appropriate extent of surgical staging in women with clinically early stage uterine serous carcinoma (USC). METHODS: We conducted a single-institution retrospective cohort study of all women with USC between 2007 and 2012. Treatment practices, outcomes, and factors affecting survival were analyzed using univariate and multivariate analysis. RESULTS: Eighty-four patients were identified, 76 of whom were included in the analysis. Preoperative pathology correctly identified USC in 73.3% of cases. Surgical stage distribution was 44.7% stage I, 7.9% stage II, 31.6% stage III, and 15.8% stage IV. Women thought to have early stage disease preoperatively encompassed 84.2% (64) of the cohort. Fifty-two (81.3%) of these women with clinically early stage disease had complete surgical staging. Thirty-four (53.1%) were determined to have surgical stage I, and the remaining 30 (46.9%) had occult advanced stage disease. Median follow-up was 43.2 months. Univariate analysis found a significant increase in progression-free survival and overall survival for women with clinically early stage disease with positive lymphovascular space invasion (P < 0.001 and P = 0.002, respectively), positive peritoneal cytology (P = 0.022 and P = 0.04, respectively), early stage (P < 0.001 and P = 0.004, respectively), and elevated serum CA125 at diagnosis (P = 0.003 and P = 0.001, respectively). On multivariate analysis, early stage (hazard ratio [HR] 9.87; 95% CI 2.79 to 34.92, P < 0.001) and complete surgical staging (HR 2.96; 95% CI 1.05 to 8.37, P = 0.040) were associated with prolonged progression-free survival, while overall survival was not affected by complete surgical staging (HR 1.92; 95% CI 0.64 to 5.76, P = 0.79). CONCLUSION: Complete surgical staging prolongs the progression-free survival of women with clinical early-stage uterine serous cancer. Although this does not extend to overall survival, this enables patients to have an improved quality of life with a longer interval without the burden of disease.

Objectif : Déterminer l'ampleur adéquate de la stadification chirurgicale chez les femmes qui présentent un carcinome séreux de l'utérus (CSU) de stade clinique précoce. Méthodes : Nous avons mené une étude de cohorte rétrospective portant sur toutes les femmes qui ont présenté un CSU entre 2007 et 2012 au sein d'un seul établissement. Les pratiques de traitement, les issues et les facteurs affectant la survie ont été étudiés au moyen d'analyses univariées et multivariées. Résultats : Quatre-vingt-quatre patientes ont été identifiées, 76 desquelles ont été admises à l'analyse. L'analyse pathologique préopératoire a correctement identifié le CSU dans 73,3 % des cas. La distribution des stades chirurgicaux était la suivante : stade I, 44,7 %; stade II, 7,9 %; stade III, 31,6 %; et stade IV, 15,8 %. Les femmes qui, avant l'opération, semblaient présenter une maladie de stade précoce représentaient 84,2 % (64) de la cohorte. Cinquante-deux (81,3 %) de ces femmes présentant une maladie de stade clinique précoce ont subi une stadification chirurgicale complète. Il a été déterminé que 34 (53,1 %) de ces 64 femmes présentaient un stade chirurgical I, tandis que les 30 autres (46,9 %) présentaient une maladie occulte de stade avancé. Le suivi médian a été de 43,2 mois. L'analyse univariée a constaté une hausse significative des taux de survie sans progression et de survie globale chez les femmes connaissant une maladie de stade clinique précoce qui avaient obtenu des résultats positifs en ce qui concerne l'invasion de l'espace lymphovasculaire (P < 0,001 et P = 0,002, respectivement), qui avaient obtenu des résultats positifs dans le cadre de la cytologie péritonéale (P = 0,022 et P = 0,04, respectivement), qui présentaient un stade précoce (P < 0,001 et P = 0,004, respectivement) et chez lesquelles un taux sérique élevé de CA125 avait été constaté au moment du diagnostic (P = 0,003 et P = 0,001, respectivement). Dans le cadre de l'analyse multivariée, la présence d'un stade précoce (rapport des risques instantanés [RRI], 9,87; IC à 95 %, 2,79 - 34,92, P < 0,001) et la tenue d'une stadification chirurgicale complète (RRI, 2,96; IC à 95 %, 1,05 - 8,37, P = 0,040) ont été associées à une prolongation de la survie sans progression, tandis que la survie globale n'a pas été affectée par la tenue d'une stadification chirurgicale complète (RRI, 1,92; IC à 95 %, 0,64 - 5,76, P = 0,79). Conclusion : La tenue d'une stadification chirurgicale complète prolonge la survie sans progression des femmes qui présentent un carcinome séreux de l'utérus de stade clinique précoce. Bien que cette intervention n'exerce pas d'effets sur la survie globale, elle permet aux patientes de connaître une amélioration de leur qualité de vie (prolongation de l'intervalle dans le cadre duquel les patientes n'ont pas à vivre avec le fardeau de la maladie).

The effects of anemia and blood transfusion on patients with stage III-IV ovarian cancer.

OBJECTIVES: The objective of this study was to examine the overall and recurrence-free survival in patients with advanced ovarian cancer based on hemoglobin and blood transfusions. METHODS: A retrospective chart review was performed between 2003 and 2007 on patients with pathologically confirmed stage 3-4 ovarian, fallopian, or peritoneal cancers. Data were collected on date of diagnosis, recurrence and death, stage, grade, age, surgery, estimated blood loss, hemoglobin (nadir and average levels), and number of blood transfusions. RESULTS: Two hundred sixteen patients were included in the final analysis. In the perichemotherapy, perioperative, and total time frames, 88%, 81%, and 95% of patients were anemic, and 9%, 22%, and 26% of the patients had severe anemia. After adjusting for age, stage, and optimal debulking status, the perichemotherapy hemoglobin level as a continuous variable was weakly associated with recurrence-free survival (adjusted hazard ratio [AHR], 0.98; P = 0.03), and as a categorical variable with both recurrence-free survival (AHR, 2.49; P = 0.003) and overall survival (AHR, 1.91; P = 0.02). The total number of transfusions was also weakly associated with poor recurrence-free survival (AHR, 1.06; P = 0.03). CONCLUSIONS: Our study is a retrospective analysis of the effects of anemia and transfusion on ovarian cancer. The rates of anemia in chemotherapy patients are higher than previously reported. Although maintaining average hemoglobin greater than 80 g/L during chemotherapy portends an improved overall survival, blood transfusion does not have any effect. The role of transfusion should therefore be limited to symptomatic patients while giving 1 unit at a time. Further prospective studies will be needed to confirm these results.

The diagnostic utility of TP53 and CDKN2A to distinguish ovarian high-grade serous carcinoma from low-grade serous ovarian tumors.

Low-grade serous carcinomas and serous borderline tumors, combined herein and referred to as low-grade serous tumors, show distinct molecular alterations and clinical behaviors compared with high-grade serous carcinomas. The discrimination between low-grade serous tumors and high-grade serous carcinomas can be challenging on small tissue samples, such as cell blocks of paracentesis fluid or biopsies from omental disease. The purpose of this study was to test the ability of TP53 and CDKN2A immunohistochemistry to distinguish between high-grade serous carcinomas and low-grade serous tumors on small tissue samples. Tissue microarrays containing 582 high-grade serous carcinomas, 45 low-grade serous carcinomas, and 49 serous borderline tumors, confirmed by contemporary histopathological review, were stained for TP53 and CDKN2A (DO7 and E6H4 antibody clones, respectively). TP53 was scored as completely absent, wild-type pattern or overexpressed (>60%), and CDKN2A was scored as either negative/patchy (<90%) or block expression (>90%). The combination of the two markers, ie, the TP53 wild-type pattern and CDKN2A patchy expression, had sensitivity for low-grade serous tumors of 89%, a specificity of 93%, a positive predictive value of 68%, and a negative predictive value of 98%. These markers can, therefore, be used on small biopsies/cell blocks to refute a diagnosis of low-grade serous tumors. These findings may inform emerging neoadjuvant therapeutic strategies in advanced ovarian cancers and may be crucial for future clinical trials on molecular-based therapies.

Dose-dense paclitaxel with carboplatin for advanced ovarian cancer: a feasible treatment alternative.

OBJECTIVE: Epithelial ovarian cancer is the leading cause of death from gynaecologic cancers in the Western world. If possible, initial cytoreductive surgery is the treatment of choice, followed by adjuvant chemotherapy, usually with a platinum/taxane combination. Increased survival has been recently reported in women who were given adjuvant chemotherapy weekly rather than at three-week intervals, which has been the standard. At our centre, we have been treating patients with advanced ovarian cancer with a dose-dense protocol since March 2010. Treatment is given in an outpatient setting on days 1, 8, and 15 of a 21-day cycle for six cycles. Carboplatin for an AUC of 5 mg/mL/min and paclitaxel 80mg/m² are given on day 1, followed by paclitaxel 80mg/m² on days 8 and 15. Our objective was to determine whether this protocol is a feasible alternative treatment in our population and whether or not the toxicity profile is acceptable. METHODS: We performed a chart review of 46 patients undergoing treatment with dose-dense chemotherapy for advanced ovarian cancer. Demographic information, patient characteristics, adverse events, and treatment endpoints were recorded. RESULTS: Sixty-one percent of women completed the six-cycle protocol as planned with minimal interruption, which is comparable to the only previously reported trial using this regimen. The most common side effects of treatment were fatigue, neuropathy, and neutropenia. Supplementation with regular magnesium and granulocyte colony-stimulating factor reduced delays. CONCLUSION: Dose-dense paclitaxel with carboplatin chemotherapy for the treatment of advanced ovarian cancer shows promise in terms of progression-free and overall survival. We have shown this protocol to be practical and feasible in our population.

Quantification of ER/PR expression in ovarian low-grade serous carcinoma.

OBJECTIVE: Case reports suggest that hormonal therapy may be a useful treatment option for low-grade serous carcinomas (LGSC) but the clinical value remains uncertain. We hypothesized that LGSCs show a constitutive high hormone receptor expression and that type diagnosis may be sufficient to initiate hormonal therapy. METHODS: We assessed ER and PR expression on 27 LGSC, 69 high-grade serous carcinomas (HGSC), 36 serous borderline tumors (SBOT), and five normal fallopian tubes using three different platforms/antibodies on tissue microarrays. Staining from the Leica Bond Max and DAKO PharmDx platforms was evaluated using the Allred score. Quantitative fluorescence immunohistochemistry was performed using the HistoRx AQUAnalysis platform. A second cohort of 12 LGSC and 183 HGSC was assessed using the HistoRx AQUAnalysis platform. Welch ANOVA or Fisher's Exact Test was used to compare differences in the histological types for each platform. Nonparametric bivariate density plots were used to graphically demonstrate the relationship between ER and PR for the various histological types. RESULTS: LGSC have higher ER and PR expression compared to HGSC but significantly less than FT and SBOT. Nonparametric bivariate density revealed two populations of LGSC: one fifth of LGSC are ER high/PR high expressers similar to SBOT but the majority show low ER/PR expression more like HGSC. CONCLUSIONS: Quantitative assessment of ER/PR expression using the HistoRx AQUAnalysis platform may be useful as a predictive diagnostic for hormonal therapy in LGSC, assuming that only the fraction of double high expressers benefit from hormonal treatment.

Architectural patterns of ovarian/pelvic high-grade serous carcinoma.

We describe the architectural patterns of advanced ovarian/pelvic high-grade serous carcinomas that have been treated with upfront surgery, followed by adjuvant chemotherapy or neoadjuvant chemotherapy, followed by interval debulking to explore the association with the chemotherapeutic response. For 70 cases of advanced (i.e. stage III/IV) high-grade serous carcinomas (33 platinum resistant/intermediate, 37 platinum sensitive; 24 neoadjuvantly treated, 44 primary surgery), all tumor-containing histologic slides were reviewed by 1 of 3 pathologists. Histologic type was confirmed and the following features were assessed: major architectural pattern and the presence of any of 8 predefined minor architectural patterns (papillary, transitional cell carcinoma-like, micropapillary, microcystic, nested papillary, slit-like, glandular, solid). A semiquantitative assessment of psammoma bodies, histiocytic response, necrosis, nuclear atypia, and single-cell invasion was performed. Mitotic count was performed in 10 HPF and 1 HPF was counted for intraepithelial lymphocytes. The morphologic features were tested for an association with previous neoadjuvant chemotherapy and response to chemotherapy (resistant/intermediate versus chemotherapy-sensitive cases stratified by neoadjuvant chemotherapy), which was carried out using χ tests for categorical variables and analysis of variance for continuous data. Combinations of features were analyzed using unsupervised clustering (Wald). Although 8 of 18 features were significantly different when samples from neoadjuvantly treated patients were compared with those not previously treated, no individual histomorphologic feature or a combination of features was associated with response to chemotherapy. Further subtyping of high-grade serous carcinomas will likely need ancillary molecular markers that may have a greater potential to identify cases that will not respond to platinum-based chemotherapy.

Use of aromatase inhibitors as first- and second-line medical therapy in patients with endometrial adenocarcinoma: a retrospective study.

OBJECTIVES: The primary objective of this study was to examine the role of aromatase inhibitors (AIs) as first- or second-line medical treatment in women with endometrial adenocarcinoma who were not candidates for surgical management. The secondary objective was to examine the role of AIs in adjuvant and palliative treatment. METHODS: Thirty women with endometrial adenocarcinoma who were treated with aromatase inhibitors between 2000 and 2010 at the Tom Baker Cancer Centre in Calgary, Alberta were assessed in a retrospective analysis. Disease response was based on response evaluation criteria in solid tumours. Kruskal-Wallis test was used to compare non-parametric variables and Fisher exact test was used to compare the health variables. RESULTS: Seventeen patients received AIs as first- or second-line medical treatment, five received adjuvant therapy, and eight received palliative treatment. The median age of patients in the first or second line medical treatment group was significantly greater than that of patients in the adjuvant or palliative group (P = 0.042). There was no significant difference in median weight or body mass index. The subjective clinical response rate with medical treatment was 70%. In the first- or second-line medical treatment group, only seven patients had available response data. Our study showed stable disease in 5/7 (71%), partial response in 1/7 (14%), and progression in 1/7 (14%) patients. CONCLUSION: This retrospective clinical series examining use of an aromatase inhibitor as first- or second-line medical therapy in women with endometrial carcinoma showed that AIs are a potential treatment for patients who have a contraindication to surgery and who either have failed or cannot use megestrol therapy.

Uterine sarcoma and aromatase inhibitors: Tom Baker Cancer Centre experience and review of the literature.

OBJECTIVES: Uterine sarcomas are a rare group of mesenchymal tumors with a poor prognosis and aggressive biology. Standard treatment involves surgical staging. The role of further adjuvant treatment is unclear. The goals of this study were to determine the response rates to treatment of patients with uterine sarcomas and to review the currently available literature on the use of aromatase inhibitors (AIs). MATERIALS AND METHODS: We performed a retrospective analysis on all patients with uterine sarcoma treated with an AI between 2000 and 2010 at the Tom Baker Cancer Centre in Calgary, Alberta. RESULTS: Four patients with endometrial stromal sarcoma and 3 patients with leiomyosarcoma received treatment with an AI. A literature search resulted in 10 case reports and 4 retrospective studies of patients with endometrial stromal sarcoma and 1 case report and 2 retrospective studies of patients with leiomyosarcoma. On the basis of the available literature, combined with the current findings, the overall response rate of endometrial stromal sarcoma to AIs is 67% (complete response of 7% and partial response of 60%), and the partial response rate of leiomyosarcoma to AIs is 11%, with no reported complete responses. CONCLUSIONS: Aromatase inhibitors are a well-tolerated class of medications that are effective in the treatment of endometrial stromal sarcomas. These medications may also have a role to help stabilize disease progression in the treatment of leiomyosarcoma. More large, prospective, multicentered trials will be needed to clarify this issue.

Optimal debulking targets in women with advanced stage ovarian cancer: a retrospective study of immediate versus interval debulking surgery.

OBJECTIVE: The objective of this study was to examine both overall and disease-free survival of patients with advanced stage ovarian cancer after immediate or interval debulking surgery based on residual disease. METHODS: We performed a retrospective chart review at the Tom Baker Cancer Centre in Calgary, Alberta of patients with pathologically confirmed stage III or IV ovarian cancer, fallopian tube cancer, or primary peritoneal cancer between 2003 and 2007. We collected data on the dates of diagnosis, recurrence, and death; cancer stage and grade, patients' age, surgery performed, and residual disease. RESULTS: One hundred ninety-two patients were included in the final analysis. The optimal debulking rate with immediate surgery was 64.8%, and with interval surgery it was 85.9%. There were improved overall and disease-free survival rates for optimally debulked disease (< 1 cm) with both immediate and interval surgery (P < 0.001) compared to suboptimally debulked disease. Overall survival rates for optimally debulked disease were not significantly different in patients having immediate and interval surgery (P = 0.25). In the immediate surgery group, patients with microscopic residual disease had better disease-free survival (P = 0.015) and overall survival (P = 0.005) than patients with < 1 cm residual disease. In patients who had interval surgery, those who had microscopic residual disease had more improved disease-free survival than those with < 1 cm disease (P = 0.05), but they did not have more improved overall survival (P = 0.42). Patients with microscopic residual disease who had immediate surgery had a significantly better overall survival rate than those who had interval surgery (P = 0.034). CONCLUSION: In women with advanced stage ovarian cancer, the goal of surgery should be resection of disease to microscopic residual at the initial procedure. This results in improved overall survival than lesser degrees of resection. Further studies are required to determine optimal surgical management.

The risk of diagnostic hysteroscopy in women with endometrial cancer.

OBJECTIVE: We sought to evaluate whether hysteroscopy in patients with endometrial cancer had an effect on disease stage or mortality. STUDY DESIGN: This was a retrospective cohort analysis of data linked between a registry of women diagnosed with endometrial cancer and physician billing data on hysteroscopy. RESULTS: A 99.8% match rate was obtained. Eighty-five percent of cases had complete data on staging. Of these 1972 cases, 672 (34.1%) had undergone hysteroscopy. There was no difference in stage III disease between the hysteroscopy (7.1%) vs no hysteroscopy (6.5%) group (P = .38). There was also no difference in death rates, 13.2% vs 15.2% (P = .25), or in the proportion of women dying of female genital organ cancer, 46.1% vs 42.1% (P = .53), respectively. CONCLUSION: Hysteroscopy is not associated with a higher rate of stage III disease or mortality. It allows for accurate diagnosis with direct visualization and biopsy, and should be considered a safe diagnostic tool.

Vacuum assisted wound closures in gynaecologic surgery.

Vacuum assisted closure and negative pressure (NP) dressings are innovative forms of wound management used in multiple fields of medicine, including surgery. We review here the current literature in this area relevant for the gynaecologist. Negative pressure dressings increase blood flow to the wound, decrease bacterial counts, decrease tension on wound edges, and increase the formation of granulation tissue. Until recently, use of NP dressings has been contraindicated in wounds that have been previously radiated or that have necrotic tissue, an infection, an open fistula, an underlying malignancy, or an exposed blood vessel. In this review, we discuss the use of negative pressure for the treatment of abdominal wounds, including those associated with dehiscence, fistula, and prior radiation. We also discuss the use of NP dressings in gynaecologic oncology, including the vulvar and perineal areas. Finally, we outline the basics of applying NP dressings, and discuss pressure settings, "foam counts," debridement, and interface dressings to optimize the benefits of vacuum dressings. When used in the appropriate setting, NP dressing is a unique and important modality of treatment in gynaecology.

Cutaneous metastatic disease in cervical cancer: a case report.

BACKGROUND: Cervical cancer metastasizes to skin in < 2% of patients. Cutaneous metastases can be confused with dermatitis. Their presence signals a poor prognosis. CASE: A 66-year-old postmenopausal woman with a diagnosis of stage IVa cervical carcinoma was treated with radical concurrent chemotherapy and radiation. Two months after completing treatment, the patient noted maculopapular skin lesions in the lower abdomen. These were confirmed on biopsy as metastases from the cervical cancer. The cutaneous metastases progressed rapidly to involve the inguinal regions, vulva, and perineum. Further assessment ruled out metastases to other organs. Despite six courses of palliative combination chemotherapy, the patient's disease progressed, and she died six months after the appearance of the cutaneous metastases. CONCLUSION: We reviewed the details of 47 reported cases of cutaneous metastases of cervical carcinoma. In the majority of these cases, patients presented within 10 years of initial diagnosis and died within a mean of 8.5 months from cutaneous metastasis.