Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

AIM: Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. PATIENTS AND METHODS: We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. RESULTS: A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. CONCLUSION: Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Oncologic outcomes in older women with endometrial carcinoma (≥70 years).

Data are limited in the management of elderly women with endometrial cancer as they are under-represented in clinical trials. The aim of this study was to evaluate the outcomes of women ≥70 years who underwent hysterectomy. One hundred and twenty-one patients met the inclusion criteria. The median age among the cohort was 75 years (range: 70-91), and 52% underwent robotic surgery. The five-year overall survival (OS) rate was 67%. The five-year cumulative incidence of recurrence was 19%. Based on univariate analysis, white race, lower ASA score, higher pre-operative and post-operative haematocrit, lower estimated blood loss, stage I and robotic surgery were associated with improved OS. On multivariable analysis, ASA score, preoperative haematocrit, estimated blood loss and stage were associated with survival.Survival rates among older women were low and disease recurrence was high. Robotic surgery was safe and appeared to improve perioperative outcomes in older women with endometrial cancer.Impact StatementWhat is already known on this subject? Endometrial cancer is the most common gynaecologic cancer with an overall survival above 90%. Surgery is the cornerstone of treatment. With an ageing population, an increased incidence of endometrial cancer is also expected. Increased frailty and comorbid conditions may prevent this population from undergoing surgery; consequently, these patients are often undertreated for a potentially curable disease.What do the results of this study add? Older women with endometrial cancer have low survival rates and high disease recurrence rates. Elderly women can tolerate robotic surgery to reduce the risk of adverse events.What are the implications of these findings for clinical practice and/or further research? It is important to develop best practices to optimise patients for minimally invasive surgery. The benefits of robotic surgery may encourage patients and surgeons to partake in this approach. A multidisciplinary approach with geriatric evaluation may improve post-operative care and survival. Future clinical trials should include elderly women.

Survival After Minimally Invasive Surgery in Older Women With Endometrial Carcinoma.

BACKGROUND/AIM: To analyze the impact of minimally invasive surgery for endometrial cancer on overall survival among age >65. PATIENTS AND METHODS: We examined women who underwent hysterectomy from 2010 to 2015 from the U.S. National Cancer Data Base (NCDB). We evaluated the impact of surgical approach on survival. RESULTS: Of 243,601 endometrial cancer cases, 42,458 met the inclusion criteria. Laparoscopic approach was associated with improved survival by 14% (HR=0.86; 95%CI=0.80-0.92; p<0.001) and robotic approach was associated with improved survival by 12% (HR=0.88; 95%CI=0.83-0.93; p<0.0001), compared to the open approach. Similarly, the weighted adjusted 5-year overall survival was 73.1% (95%CI=72%-74.2%), 76.4% (95%CI=75.1-77.7%), and 75.5% (95%CI=74.7-76.4%) for open, laparoscopic, and robotic approaches, respectively (p<0.001). CONCLUSION: Minimally invasive surgery improved overall survival in women over 65 years with endometrial cancer.

Robotic assisted cytoreductive surgery, removal of a recurrent disease in the right pericaval lymph node in a patient with ovarian cancer with the robotic Xi platform.

OBJECTIVE: The standard approach for recurrent ovarian cancer is laparotomy. In this video, we present a cytoreductive surgery using the robotic Xi platform to remove a 2.7 cm pericaval tumor. METHODS: A narrative video demonstration of robotic-assisted surgery to remove recurrent ovarian cancer in a pericaval lymph node. A 62-year-old female presented with recurrent carcinoma of the pericaval lymph node. After 40 months of surveillance, the patient was asymptomatic, but a computed tomography (CT) scan showed an isolated mass (2.7×2.3 cm) in the right pericaval lymph node. Her cancer antigen (CA)-125 level increased from 26 to 46 U/mL. The robotic Xi platform was used to remove the metastatic lymph nodes. The first step was diagnostic laparoscopy. The second step was robotic port placement below the umbilicus. The third step was dissection and identification of landmarks, and the last step was removal of the tumor and closure. RESULTS: The metastatic lymph nodes were removed. The patient was discharged on postoperative day 1 and had no postoperative complications. Her CA-125 level dropped to 17 U/mL two weeks after surgery. Pathology showed metastatic high-grade serous carcinoma in one lymph node, consistent with the patient's known primary. Two additional lymph nodes were removed and negative for carcinoma. Pelvic washings were negative for malignancy. CONCLUSION: Robotic-assisted surgery is safe and feasible in selected patients with isolated recurrent disease.

Knuckle cracking at night associated with sodium oxybate treatment.

NONE: During upward titration of a dose of sodium oxybate therapy for narcolepsy with cataplexy, a 25-year-old woman was observed by her husband to have new onset of knuckle-cracking and moaning behaviors during sleep ≥1 nights each week. The patient did previously occasionally crack her knuckles during the day (but never at night). These behaviors had not been evaluated by polysomnography. After transition of care, polysomnography with video monitoring was ordered and revealed 2 knuckle-cracking episodes that developed out of stage N2 sleep and were likely a non-rapid eye movement sleep parasomnia associated with sodium oxybate treatment.

Incidence of venous thromboembolism after robotic-assisted hysterectomy in obese patients with endometrial cancer: do we need extended prophylaxis?

Robotic surgery for gynecologic malignancy is associated with a lower rate of venous thromboembolism (VTE) than laparotomy. Obese patients represent a particularly high-risk group for VTE, but prior studies tend to focus on patients with a much lower BMI and without extended VTE prophylaxis. Our objective was to examine the role of extended thromboprophylaxis in obese patients who underwent robotic-assisted surgery for endometrial cancer. We conducted a retrospective cohort study of obese patients (BMI ≥ 35 kg/m2) who underwent robotic surgery for newly diagnosed endometrial cancer. The primary outcome measured was the occurrence of a VTE event within the 30-day postoperative period. The Farrington-Manning score test was used for equivalence analysis with a 5% margin. Secondary outcomes were perioperative complications. One hundred thirty-two robotic cases for endometrial cancer met our criteria. One hundred twenty-one (92%) received preoperative pharmacologic thromboprophylaxis, and 100% used pneumatic compression devices. Ninety-three percent and 90% received preoperative pharmacologic prophylaxis in the extended and no extended group, respectively (p-value = 0.7). Seventy patients (54%) received 4-week extended prophylaxis. Estimated blood loss was similar in both groups (75 mL vs 60 mL, p-value = 0.6). Perioperative complications and readmissions were similar between the two groups. There were no VTE events during hospital stay. One patient in the group that did not receive extended prophylaxis developed a VTE in the 30-day postoperative period (1.6%), versus 0% in the group that did receive extended prophylaxis (p-value = 0.1). The risk of VTE was low. The absence of extended VTE prophylaxis did not significantly increase the risk for VTE in obese patients with newly diagnosed endometrial cancer who underwent robotic-assisted surgery.

Human papilloma virus-associated metachronous squamous cell carcinoma of the larynx and uterine cervix: Case report and review of the literature.

60 year old woman with a history of laryngeal carcinoma-HPV 16 positive, presents seven years later with an abnormal Pap smear. Cervical biopsy showed squamous cell carcinoma. Clinical stage was IB1. Patient underwent open radical hysterectomy and lymphadenectomy. Based on pathologic findings no adjuvant therapy was recommended. Uterine cervix carcinoma was also positive for HPV-16. There are no guidelines for cervical cancer screening in patients with laryngeal cancer and vice versa. Our recommendation is that patient with HPV-positive laryngeal cancer should be encouraged HPV vaccine as current guidelines, but more frequent screening, as recommended for women with specific co-morbid conditions, needs to be investigated. Research is needed to assess the role of screening for laryngeal cancer in women with cervical cancer and the effect of HPV vaccine on laryngeal cancer prevention.

Langerhans cell sarcoma of the vulva: Case report and review of the literature.

Langerhans cell sarcoma (LCS) is a rare, malignant neoplastic disorder of Langerhans cells thought to arise from antecedent Langerhans cell histiocytosis (LCH) or de novo. There are less than 70 cases of LCS reported in the medical literature, with this case being the first report of primary vulvar LCS. We present the case of a 73-year-old female with a painful 2 cm ulcerated lesion of the right labia majora. The patient was treated with oral antibiotics without resolution. On referral to gynecologic oncology an office biopsy showed LCS. Surgical excision was performed with clear margins and diagnostic confirmation of LCS by histopathological features and immunohistochemical evaluation. The patient received adjuvant radiation therapy (45.6 Gy). After 33 months of surveillance, the patient remains with no evidence of disease. Due to the rarity of this disease, there is a lack of standardized recommendations for adjuvant therapy, including radiotherapy and chemotherapy regimens for both localized and systemic LCS. This case report supports the management of localized disease by surgical excision followed by radiotherapy as effective for preventing recurrence and metastatic progression. Early recognition and treatment are critical for cure, and can be accomplished by prompt referral to a specialist as well as low threshold for biopsy. Further investigation is needed for establishing a standardized management guideline for LCS.

Robotic-assisted interval cytoreductive surgery in ovarian cancer: a feasibility study.

OBJECTIVE: The primary objective was to assess the feasibility of robotic-assisted interval cytoreductive surgery for achieving complete cytoreduction for patients with advanced-stage ovarian cancer. The secondary objective was to examine the perioperative outcomes. METHODS: A retrospective study of 12 patients with stage IIIC or IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent interval cytoreductive surgery after neo-adjuvant chemotherapy. RESULTS: Optimal cytoreduction was achieved in 100% of selected patients. Complete cytoreductive surgery was achieved in 75% of patients. The estimated mean blood loss was 100 mL. The median length of hospital stay was 2 days. Perioperative complication and 30-day readmission rates were 8.3% (1 patient). The median follow-up time was 9.5 months. CONCLUSION: Robotic-assisted interval cytoreductive surgery in ovarian cancer is safe and feasible and may be an alternative to standard laparotomy in selected patients.

Germline PALB2, ATM variants in a patient with breast and ovarian cancer at risk for familial cancer syndrome: Is there a role for risk-reducing salpingo-oophorectomy?

A 50-year-old non-Hispanic white Caucasian female was diagnosed with breast cancer and was subsequently found to possess the tumorigenic ataxia telangiectasia mutated (ATM) and PALB2 variants but not the BRCA1 and BRCA2 variants. She visited the gynecologic oncology office for routine counseling about risk-reducing salpingo-oophorectomy (RRSO). Although the patient was asymptomatic, an adnexal mass was discovered in the physical examination performed by palpation. Upon using pre-operative imaging techniques, an 8 cm complex adnexal mass was identified. Her CA-125 level was elevated. She underwent complete cytoreductive surgery. Pathological analysis showed a stage IC clear cell carcinoma of the left ovary; subsequently, she received 6 cycles of adjuvant chemotherapy with a combination of carboplatin and paclitaxel. The patient exhibited no signs ovarian cancer in a follow-up appointment after 32 months of treatment. However, bilateral RRSO is not recommended for patients positive for ATM and PALB2. Breast cancer patients with PALB2 and ATM mutations should extensively discuss the risks and benefits of RRSO in light of current data.

Minimally invasive interval cytoreductive surgery in ovarian cancer: systematic review and meta-analysis.

The introduction of minimally invasive surgery in other gynecologic cancers has shown benefits with similar oncologic outcomes. However, the biology and complexity of surgery for ovarian cancer may preclude this approach for ovarian cancer patients. Our objective is to assess feasibility to achieve complete cytoreductive surgery after neoadjuvant chemotherapy for stage IIIC-IV ovarian cancer patients via minimally invasive surgery. Our data sources include PubMed, Embase, Scopus, Biosis, Clinicaltrials.gov, and the Cochrane Library. Meta-analysis was performed using the random-effects model with DerSimonian and Laird estimator for the amount of heterogeneity to estimate the pooled outcomes. A funnel plot and Egger's regression test were used to test publication bias. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the studies. There were 6 studies (3 prospective, 3 retrospective) that met the criteria for meta-analysis with a total of 3231 patients, 567 were in the minimally invasive group and 2664 in the laparotomy group. Both groups were similar in stage and serous histology. Complete cytoreductive surgery was achieved in 74.50% (95% CI 40.41-97.65%) and 53.10% (95% CI 4.88-97.75%) of patients in the minimally invasive and laparotomy groups, respectively. There was no statistical significant difference between these 2 pooled proportions (p = 0.52). Three studies compared minimally invasive surgery vs laparotomy. No significant difference was observed between the 2 groups in obtaining complete cytoreductive surgery [OR = 0.90 (95% CI 0.70-1.16; p = 0.43)]. A symmetrical funnel plot indicated no publication bias. The pooled proportion for grade > 2 postoperative complications was not significant among the laparoscopy group [3.11% (95% CI 0.00-10.24%; p = 0.15)]. Complete cytoreductive surgery appears feasible and safe with minimally invasive surgery in selected advanced ovarian cancer patients after neoadjuvant chemotherapy.