Factors associated with successful bilateral sentinel lymph node mapping in endometrial cancer.

OBJECTIVE: As our understanding of sentinel lymph node (SLN) mapping for endometrial cancer (EC) evolves, tailoring the technique to individual patients at high risk for failed mapping may result in a higher rate of successful bilateral mapping (SBM). The study objective is to identify patient, tumor, and surgeon factors associated with successful SBM in patients with EC and complex atypical hyperplasia (CAH). METHODS: From September 2012 to November 2014, women with EC or CAH underwent SLN mapping via cervical injection followed by robot-assisted total laparoscopic hysterectomy (RA-TLH) at a tertiary care academic center. Completion lymphadenectomy and ultrastaging were performed according to an institutional protocol. Patient demographics, tumor and surgeon/intraoperative variables were prospectively collected and analyzed. Univariate and multivariate analyses were performed evaluating factors known or hypothesized to impact the rate of successful lymphatic mapping. RESULTS: RA-TLH and SLN mapping was performed in 111 women; 93 had EC and 18 had CAH. Eighty women had low grade and 31 had high grade disease. Overall, at least one SLN was identified in 85.6% of patients with SBM in 62.2% of patients. Dye choice (indocyanine green versus isosulfan blue), odds ratio (OR: 4.5), body mass index (OR: 0.95), and clinically enlarged lymph nodes (OR: 0.24) were associated with SBM rate on multivariate analyses. The use of indocyanine green dye was particularly beneficial in patients with a body mass index greater than 30. CONCLUSION: Injection dye, BMI, and clinically enlarged lymph nodes are important considerations when performing sentinel lymph node mapping for EC.

Intraoperative hypothermia during primary surgical cytoreduction for advanced ovarian cancer: risk factors and associations with postoperative morbidity.

OBJECTIVE: The objective of this study was to evaluate the risk factors and potential morbidity associated with intraoperative hypothermia (IH) during cytoreductive surgery (CRS) for advanced ovarian cancer. METHODS: Demographic and perioperative data were collected for all patients with stage IIIC-IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent primary CRS at our institution from 2001 to 2010. Only patients with carcinomatosis and/or bulky upper abdominal disease and residual disease of <1cm were included. Intraoperative hypothermia was defined as temperature of <36.0 degrees Celsius (°C). Associations with 21 perioperative factors, 12 systems-based complications, and specific complications including but not limited to venous thromboembolism and surgical site infection were evaluated. RESULTS: Two hundred ninety-seven patients met the inclusion criteria. An intraoperative temperature <36°C was noted in 72.1% of patients, and a temperature <36°C at the time of abdominal closure was noted in 45.5%. Intraoperative vasopressors (P=0.02), epidural anesthesia (P=0.01), transfusion of fresh frozen plasma (P<0.05), and blood loss (P=0.01) were associated with IH. There was no association between IH and postoperative complications in general (P=0.48) or specifically grade 3-5 complications (P=0.34). Univariate analysis did show an association between hematologic complications and IH; however, this did not persist on multivariate analysis (P=0.14). CONCLUSIONS: In patients who underwent optimal primary CRS for advanced ovarian cancer, IH alone was not associated with the development of postoperative complications. Postoperative morbidity in these patients is multifactorial and further investigation into modifiable risk factors is warranted.

Parenchymal splenic metastasis is an independent negative predictor of overall survival in advanced ovarian, fallopian tube, and primary peritoneal cancer.

OBJECTIVE: The purpose of this study was to evaluate the significance of parenchymal splenic metastasis (PSM) in ovarian (OC), fallopian tube (FTC), and primary peritoneal cancer (PPC). METHODS: All patients with stage IIIB-IV OC, FTC, and PPC undergoing primary cytoreduction from 2001 to 2010 at our institution were identified. In patients undergoing splenectomy, pathology was reviewed for the presence of PSM. Multivariate Cox regression and Kaplan-Meier survival analysis were used to evaluate factors associated with overall survival (OS). RESULTS: Of 576 patients identified, stage was: IIIB - 23 (4%), IIIC - 468 (81.2%), and IV - 85 (14.8%). Optimal cytoreduction was achieved in 430 patients (74.7%), including 85 of 97 patients (87.6%) undergoing splenectomy. PSM was identified in 20 patients (20.6%) undergoing splenectomy, including 3 of 5 patients (60%) with radiographically identified parenchymal liver metastases and 17 of 92 patients (18.5%) without such radiographic findings (P=0.059). Age, preoperative albumin, residual disease, stage, bulky upper abdominal disease, IP chemotherapy, and PSM were associated with OS on univariate analysis. Splenectomy was not associated with survival. Age, preoperative albumin, residual disease, stage, and PSM (HR=0.46; 95% CI, 0.27-0.77) were associated with OS on multivariate analysis. In the subset of patients undergoing splenectomy, OS was lower for patients with PSM versus those without PSM (28.5 v 51.2months, P=0.004). CONCLUSIONS: PSM is independently associated with decreased OS in patients with advanced OC, FTC, and PPC. PSM occurs in the setting of other evidence of hematogenously disseminated disease, but also occurs outside this setting. PSM should be considered a criterion for stage IV disease.

Outcomes of primary surgical cytoreduction in patients with BRCA-associated high-grade serous ovarian carcinoma.

OBJECTIVE: BRCA-associated and sporadic ovarian cancers have different pathologic and clinical features. Our goal was to determine if BRCA mutation status is an independent predictor of residual tumor volume following primary surgical cytoreduction. METHODS: We conducted a retrospective analysis of patients with FIGO stage IIIC-IV high-grade serous ovarian cancer classified for the presence or absence of germline BRCA mutations. The primary outcome was tumor-debulking status categorized as complete gross resection (0mm), optimal but visible disease (1-10 mm), or suboptimal debulking (>10 mm) following primary surgical cytoreduction. Overall survival by residual tumor size and BRCA status was also assessed as a secondary endpoint. RESULTS: Data from 367 patients (69 BRCA mutated, 298 BRCA wild-type) were analyzed. Rate of optimal tumor debulking (0-10 mm) in BRCA wild-type and BRCA-mutated patients were 70.1% and 84.1%, respectively (P=0.02). On univariate analysis, increasing age (10-year OR, 1.33; 95% CI, 1.07-1.65; P=0.01) and wild-type BRCA status (OR, 0.47; 95% CI, 0.23-0.94, P=0.03) were both significantly associated with suboptimal surgical outcome. On multivariate analysis, BRCA mutation status was no longer associated with residual tumor volume (OR, 0.63; 95% CI, 0.31-1.29; P=0.21) while age remained a borderline significant predictor (10-year OR, 1.25; 95% CI, 1.01-1.56; P=0.05). Both smaller residual tumor volume and mutant BRCA status were significantly associated with improved overall survival. CONCLUSION: BRCA mutation status is not associated with the rate of optimal tumor debulking at primary surgery after accounting for differences in patient age. Improved survival of BRCA carriers is unlikely the result of better surgical outcomes but instead intrinsic tumor biology.

Impact of operative start time on surgical outcomes in patients undergoing primary cytoreduction for advanced ovarian cancer.

OBJECTIVES: To evaluate the impact of operative start time (OST) on surgical outcomes in patients with advanced ovarian cancer. METHODS: All stage IIIB-IV serous ovarian cancer patients who underwent primary surgery at our institution from 1/01 to 1/10 were identified. Fourteen factors were evaluated for an association with surgical outcomes including OST and OR tumor index (1 point each for carcinomatosis and/or bulky [≥ 1 cm] upper abdominal disease). Univariate logistic regression considering within-surgeon clustering was performed for cytoreduction to ≤ 1 cm versus >1cm residual disease. In patients with ≤ 1 cm residual disease, univariate logistic regression considering within-surgeon clustering was performed for 1-10mm residual disease versus complete gross resection (CGR, 0mm residual). A multivariate logistic model was developed based on univariate analysis results in the ≤ 1 cm residual disease cohort. RESULTS: Of 422 patients, residual disease was: 0mm, 144 (34.1%); 1-10mm, 175 (41.5%); >10mm, 103 (23.3%). OST was not associated with cytoreduction to ≤ 1 cm residual disease on univariate analysis. In the ≤ 1 cm residual disease cohort, albumin, CA-125, ascites, ASA score, stage, OR tumor index, and OST were associated with CGR on univariate analysis. Earlier OSTs were associated with increased rates of CGR. On multivariate analysis, CA-125 was independently associated with CGR. OST was associated with CGR in patients with an OR tumor index of 2 but not an OR tumor index<2. CONCLUSIONS: OST was not associated with cytoreduction to ≤ 1 cm residual disease in patients with advanced serous ovarian cancer. In the cohort of patients with ≤ 1 cm residual disease, later OSTs were associated with reduced rates of CGR in patients with greater tumor burden.

Patterns of recurrence in 1988 FIGO stage IC endometrioid endometrial cancer.

OBJECTIVES: To evaluate patterns of recurrence in 1988 FIGO stage IC endometrioid endometrial adenocarcinoma. METHODS: A prospectively maintained endometrial cancer database was utilized to identify all patients with stage IC endometrioid endometrial adenocarcinoma treated between 2/93 and 6/09. Patterns of recurrence and risk factors were analyzed. RESULTS: One hundred thirty-four patients with stage IC endometrial cancer were identified. Median age was 66 years (range, 31-91 years). All patients were initially treated surgically, and 79% underwent comprehensive surgical staging with lymphadenectomy. Median number of lymph nodes removed was 18 (range, 1-45). Fifty-one patients (38%) had FIGO grade 1 tumors, 55 (41%) had grade 2 tumors, and 28 (21%) had grade 3 tumors. The majority of patients (91%) received adjuvant radiation therapy. With a median follow-up of 36 months (range, 0.6-141.4 months), 10 patients recurred. Of these, 2 (20%) were grade 1, 2 (20%) were grade 2, and 6 (60%) were grade 3. Nine (90%) of these recurrences had a distant component and 7 (70%) were fatal. Overall, the 3 year cumulative incidence failure rate for grade 1/2 tumors was 5.4%; for grade 3 tumors it was 28.9% (P<0.001). Age, BMI, and lymphovascular invasion were not associated with an increased risk of recurrence. CONCLUSIONS: Patients with stage IC, grade 3 endometrial cancer had a significantly increased risk of recurrence (28.9%). All of these recurrences had a distant component and the majority were fatal. Further investigation into the addition of adjuvant systemic therapy in these high-risk patients is warranted.

Hereditary ovarian cancer: recent molecular insights and their impact on screening strategies.

PURPOSE OF REVIEW: This review will focus on the implications of BRCA status in the patient with high-grade serous ovarian cancer, the differences between BRCA1 and BRCA2 mutations, and the most effective risk-reducing strategies. RECENT FINDINGS: Women with BRCA-associated epithelial ovarian cancer represent a unique group who commonly are diagnosed at a younger age, have advanced high-grade serous disease, have improved sensitivity to platinum-based chemotherapy in both the upfront and recurrent setting, and have an overall improved prognosis. Promising novel therapeutic agents such as poly (ADP-ribose) polymerase inhibitors have increased activity in patients with inherited BRCA mutations and may also have a role in patients with noninherited tumors that have decreased BRCA activity. Risk-reducing salpingo-oophorectomy (RRSO) is effective in decreasing risks of both breast and gynecologic cancer in women with BRCA mutations. However, when counseling women at inherited risk, the inherent phenotypical differences between BRCA1 and BRCA2 mutations must be considered. SUMMARY: Patients with BRCA-associated epithelial ovarian cancer have improved response to platinum-based chemotherapy, improved survival, and may be appropriate candidates for treatment with novel targeted therapies. RRSO remains the most effective risk-reduction strategy in women with BRCA mutations.

Ventral hernia following primary laparotomy for ovarian, fallopian tube, and primary peritoneal cancers.

OBJECTIVES: To evaluate the incidence and risk factors for ventral hernia development following primary laparotomy for ovarian, fallopian tube, and peritoneal cancers. METHODS: All patients who underwent primary laparotomy for ovarian, tubal, or peritoneal cancer from 3/05 to 12/07 were identified. Hernias were identified radiographically or during physical exam. One-year and 2-year hernia rates were calculated. Clinicopathologic factors were evaluated for an association with the development of hernia using univariate and multivariate analysis. RESULTS: We identified 239 cases with 12 months of follow-up. Median age was 60 years (17-89 years), and median body mass index (BMI) was 25.0 kg/m(2) (16.9-58.5 kg/m(2)). Advanced stage disease (FIGO stage III/IV) was diagnosed in 182/239 (76%). The 1-year hernia rate was 8.8% (21/239): 13/21 (61.9%) were symptomatic, and 8/21 (38.1%) underwent hernia repair operations. On multivariate analysis, only BMI (p=0.004) and intraperitoneal (IP) chemotherapy (p=0.016) retained their independent association with hernia development by 12 months. Of the 239 patients, 167 had 24 months of follow-up. The 2-year hernia rate was 23.4% (39/167): 25/39 (64.1%) were symptomatic, and 17/39 (43.6%) underwent hernia repair operations. Multivariate analysis in this group demonstrated that advanced stage (p=0.033), wound complications (p=0.029), and BMI (p=0.012) were independently associated with hernia development by 24 months. CONCLUSIONS: The development of ventral hernia is a significant postoperative morbidity in patients undergoing primary surgery for ovarian, tubal, or peritoneal cancer. Independent associations with hernia development include: BMI and IP chemotherapy by Year 1, and BMI, wound complications and advanced stage by Year 2.

Clinical Approach to Diagnosis and Management of Cancer of the Cervix and Vulva.

This content presents pathology of the cervix and vulva - its diagnosis, staging, treatment, and prognosis. The authors distinguish between the clinical staging of cervical cancer and the surgical staging of vulvar cancer and note advances in surgical, medical, and radiation oncology in the treatment of both cervical and vulvar carcinoma that allow for individualization of patient treatment resulting in improved oncologic outcomes and improved quality of life. Treatment algorithms are presented based on the varying stages at which the cancer is diagnosed.