Predictive model of venous thromboembolism in endometrial cancer.

OBJECTIVE: To profile characteristics and survival of endometrial cancer patients who develop venous thromboembolism (VTE) and to establish a predictive model of VTE in endometrial cancer. METHODS: Cases were identified using an institutional database between 2000 and 2011. VTE was correlated to clinico-pathological information and survival outcomes. Frequency and odds ratio (OR) of VTE were examined in a predictive model based on combination patterns of independent risk factors for VTE. RESULTS: VTE was seen in 42 (8.1%, 95% CI 5.8-10.5) out of 516 cases subsequent to the diagnosis of endometrial cancer. Multivariate analysis identified 4 independent risk factors for VTE: elevated CA-125 (hazard ratio [HR] 5.38, p<0.001), extrauterine disease (HR 2.87, p=0.019), thrombocytosis (HR 2.11, p=0.04), and high risk histology (serous and clear cell, HR 2.09, p=0.049). VTE was the strongest variable for decreased progression-free survival (HR 4.28) and the second strongest variable for decreased overall survival (HR 5.65) in multivariate analysis. In a predictive model of VTE, the presence of multiple risk factors was associated with significantly increased risk of VTE: frequency of VTE, 1.4% if no risk factors, 0-9.3% (OR 1.0-4.2) if a single risk factor, 11.1-25.0% (OR 9.0-24.0) if two risk factors, and 42.9-46.2% (OR 54.0-61.7) if ≥3 risk factors. CONCLUSION: VTE represents a surrogate for aggressive disease in endometrial cancer. Multiple risk factors of VTE in our predictive model demonstrated exceedingly high risk of VTE, suggesting that there may be a certain population of endometrial cancer patients who would benefit from long-term anti-coagulant prophylaxis to improve survival outcome.

Successful extraction of cardiac-extending intravenous leiomyomatosis through gonadal vein.

OBJECTIVE: To report a conservative surgical management of cardiac-extending intravenous (IV) leiomyomatosis. DESIGN: Case report. SETTING: Tertiary care center. PATIENT(S): A 40-year-old nulligravid with incidentally identified IV leiomyomatosis arising from the right gonadal vein and extending into the right atrium. INTERVENTION(S): First, intraoperative transesophageal echocardiogram was performed that demonstrated the IV leiomyomatosis stalk to be 1.1 cm in diameter without an enlarged tip or adherence to the vessel lumen. Next, the 20-week-size uterus was gently pulled caudally under live visualization of the IV leiomyomatosis tip with transesophageal echocardiogram. As the uterus was pulled caudally, the IV leiomyomatosis tip obviously protruded from the right atrium and down into inferior vena cava. Lastly, the gonadal vein was incised longitudinally and the stalk of the tumor was grasped and extracted through the incision. MAIN OUTCOME MEASURE(S): One-step abdominal surgery for complete tumor resection without sternotomy or cardiac bypass surgery. RESULT(S): To our knowledge, this is the first reported case of a cardiac-extending IV leiomyomatosis successfully extracted through the gonadal vein. CONCLUSION(S): In a selected case with logistic step-by-step approach, conservative surgical treatment via gonadal vein extraction could be a feasible option in the management of cardiac-extending IV leiomyomatosis. Systematic literature review highlights important clinical characteristics and management options for IV leiomyomatosis.

Pelvic exenteration: ten-year experience at the European Institute of Oncology in Milan.

OBJECTIVES: Analyze morbidity and survival after pelvic exenteration (PE) of gynecological malignancies. METHODS: We reviewed 106 consecutive patients with gynecologic malignancies who underwent PE from June 1996 to April 2007 at the Division of Gynecology, European Institute of Oncology (IEO), Milan. RESULTS: PE was performed for cancer of the cervix (62 patients), vagina (21 patients), vulva (9 patients), endometrium (9 patients), ovary (4 patients) and 1 uterine sarcoma. Mean age was 53.6 (30-78) years. 97% of the patients received radiotherapy before PE and 3 patients had PE as primary treatment. We performed 53 anterior, 48 total and 5 posterior PE. Median operation time, estimated blood loss and hospital stay were respectively 490 (200-780) minutes, 1240 (300-6500) ml and 21.6 (11-55) days. No residual tumor was left in 93% of the patients. Median follow-up was 22.3 (1.6-117) months. There were no post-operative deaths (<30 days from surgery) nor intra-operative mortality. Total morbidity rate was 66%; 48% of patients had early complications (<30 days after PE) whereas 52 patients (48.5%) had late complications; 70% of these occurred to the urinary tract and 25% were due to bowel occlusions or fistulas. Overall survival was 52%, 35%, 19% and 16% respectively for cervical, endometrial, vaginal and vulvar cancer. CONCLUSIONS: PE is a feasible technique with no post-operative mortality and high percentage of long-survivors, although the morbidity rate still remains significantly high. Careful patient selection, pre- and post-operative care and optimal surgical skills in a Gynecologic Oncologic Center are the cornerstones to further improve quality of life and survival for these patients.

Classification of radical hysterectomy.

Since the first publications about surgery for cervical cancer, many radical procedures that accord with different degrees of radicality have been described and done. Here, we propose a basis for a new and simple classification for cervical-cancer surgery, taking into account the curative effect of surgery and adverse effects, such as bladder dysfunction. The international anatomical nomenclature is used where it applies. For simplification, the classification is based only on lateral extent of resection. We describe four types of radical hysterectomy (A-D), adding when necessary a few subtypes that consider nerve preservation and paracervical lymphadenectomy. Lymph-node dissection is considered separately: four levels (1-4) are defined according to corresponding arterial anatomy and radicality of the procedure. The classification applies to fertility-sparing surgery, and can be adapted to open, vaginal, laparoscopic, or robotic surgery. In the future, internationally standardised description of techniques for communication, comparison, clinical research, and quality control will be a basic part of every surgical procedure.

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program.

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.

Influence of quantity of lymph vascular space invasion on time to recurrence in women with early-stage squamous cancer of the cervix.

OBJECTIVE: To determine if the quantity of lymph vascular space invasion (LVSI) correlates with time to recurrence in women with early-stage squamous carcinoma of the cervix. METHODS: 101 consecutive women with Stages IA2, IB, and IIA squamous carcinoma of the cervix who had undergone radical hysterectomy between 1991 and 1997, with previously reported histopathologic quantification of LVSI by four methods, were prospectively followed. The outcome measure was time to recurrence. Univariate and stratified log-rank test analysis was performed to test the association of time to recurrence with prognostic factors. Further analysis was focused on recurrence in those patients who had negative surgical margins and whose tumors contained LVSI, incorporating the four quantification measures. RESULTS: Nineteen (19%) women had cancer recurrence. The presence of LVSI (P = 0.05), cervical stromal invasion (P = 0.01), parametrial involvement (P < 0.001), and positive margins (P < 0.0001) were significantly related to time to recurrence on univariate analysis. In patients whose tumors had negative surgical margins and contained LVSI (65%), percentage of all sections with LVSI >29% and total number of foci with LVSI >5 were significantly related to time to recurrence (P = 0.006). When stratifying for cervical stromal invasion, lymph node status, and parametrial involvement in this group, percentage of all sections with LVSI >29% and total number of foci with LVSI >5 were significantly related to time to recurrence (P = 0.05). CONCLUSION: The quantity of LVSI, as defined by the percentage of all sections with LVSI and total number of foci with LVSI, is an independent prognostic factor for time to recurrence in women with early-stage squamous carcinoma of the cervix.

Extraperitoneal laparoscopic lymph node staging: the University of Southern California experience.

OBJECTIVES: To describe our experience with extraperitoneal lymph node staging in gynecologic oncology. MATERIALS AND METHODS: The extraperitoneal approach was performed to assess the lymph node histology in patients with gynecologic malignancies. The nodes are approached from a lateral approach after dissecting open the extraperitoneal space bluntly and with insufflation. Bilateral aortic nodes are taken from a left-sided or right-sided approach depending on the patient's characteristics. RESULTS: Forty-six patients underwent this procedure over a 2.5-year period. Thirty-seven patients had cervical cancer. The median BMI was 27.1 (17.7-38.1). The median lymph node yield was 14 (0-60). Two patients had disruption of the peritoneum such that the aortic lymphadenectomy had to be completed transperitoneally. No patients required laparotomy. No patients required transfusion. DISCUSSION: This technique permits histologic evaluation of the retroperitoneal nodes with minimal risk of intraabdominal adhesions. Recovery is rapid and further therapy can be prescribed shortly. The data on the nodes can assist in treatment planning.

Radical vaginal trachelectomy and pelvic lymphadenectomy for preservation of fertility in early cervical carcinoma.

OBJECTIVE: The aim of this study was to examine our experience with radical vaginal trachelectomy in women with early cervical cancers who desire to maintain fertility. METHODS: Women who underwent radical vaginal trachelectomy with pelvic lymphadenectomy over a 6-year period are the basis of this report. Subjects were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. All subjects were informed that this therapy did not represent standard treatment for early stage cervical cancer. Obstetrical and oncologic outcomes were evaluated. RESULTS: Twenty-one women underwent this procedure. The median age was 30 years (range 23-41); 14 were nulligravid and 16 were nulliparous. Mean tumor diameter was 1.1 cm (range 0.3-3.0). Mean operative time was 318 min, with a mean blood loss of 293 cc, and average hospital stay was 3 days. Three patients had transient neuropathy postoperatively. No patient required laparotomy. Two patients had completion of radical vaginal hysterectomy for an inability to clear the cancer with trachelectomy and 1 had postoperative radiation for high-risk features on final pathology. With an average follow-up of 31.5 months, there have been no recurrences. Three women have become pregnant: 1 woman delivered twins at 24 weeks, 1 woman delivered a singleton at term, and 1 patient had rupture of membranes and chorioamnionitis at 20 weeks gestation. CONCLUSIONS: Radical vaginal trachelectomy with pelvic lymphadenectomy permits preservation of fertility in selected patients. To date, with more than 150 cases reported in the literature, recurrence rates are comparable to those seen with radical hysterectomy.