Extrauterine inflammatory myofibroblastic tumor: A case report.

•This is the first case report of inflammatory myofibroblastic tumor in the literature to present with extrauterine disease.•A prompt work-up of symptoms may have precluded a tumor debulking procedure.

Comparison of current staging systems and a novel staging system for uterine leiomyosarcoma.

OBJECTIVES: Uterine leiomyosarcoma (LMS) was traditionally staged by modified 1988 International Federation of Gynecology and Obstetrics (FIGO) staging criteria for endometrial adenocarcinoma. Contemporary methods of staging include the 2009 FIGO system for uterine LMS and the 2010 American Joint Committee on Cancer (AJCC) soft tissue sarcoma system. The aim of this study was to compare the accuracy of these 3 staging systems and a novel system in predicting disease-specific survival for patients with uterine LMS. METHODS: Patients, evaluated at our institution with uterine LMS from 1976 to 2009, were identified. Stage was assigned retrospectively based on operative and pathology reports. Staging systems performance was compared using confidence indices. RESULTS: We identified 244 patients with uterine LMS with sufficient information to be staged by all 3 systems. For each staging method, lower stage was associated with significantly improved disease-specific survival, P < 0.001. Patients with 2010 AJCC stage IA disease (low-grade, ≤5 cm) experienced no disease-specific deaths. We created a novel staging system, which used size and grade to stratify patients with disease confined to the uterus and/or cervix and combined the remaining patients with extrauterine disease as stage IV. Based on confidence index, the 2010 AJCC system and our novel system provided more accurate prognostic information than either of the 2 FIGO systems. CONCLUSIONS: Uterine LMS remains a clinically aggressive malignancy. Size and grade provided accurate prognostic information for patients with disease confined to the uterus and/or cervix. Patients with small, low-grade uterine LMS do not benefit from adjuvant therapy.

Introduction of checklists at daily progress notes improves patient care among the gynecological oncology service.

OBJECTIVES: To evaluate the impact of the introduction of checklists at the daily progress note to improve patient care among gynecologic oncology patients. METHODS: A progress note incorporating checklists that were pertinent for our patient population was developed with input obtained from all staff involved on patients care. The form was approved by the hospital. The average length of stay, compliance with prophylactic guidelines (anticoagulation, peptic ulcer disease), reason for admission, and readmission rate were compared among the preimplementation and postimplementation periods. RESULTS: A total of 492 discharge summaries were evaluated through the study period (267 for the preimplementation period and 225 for the postimplementation period). The mean length of stay was of 4.46 days for the preimplementation and 3.46 days for the postimplementation period (P = 0.007). TEDs/SCDs were not used in 9.3% of the patients in the pre group versus 0.6% in the post group (P < 0.001). DVT prophylaxis was given to 30.1% of the pre group versus 34.8% of the post group (P = 0.0013). The administration of PUD prophylaxis also increased from 28.3% in the pre group to 40.2% of the post group (P < 0.001). There was a decrease in the nonsurgical admissions from 22.2% in the pre group versus 14.6% in the post group (P = 0.049). CONCLUSIONS: The use of checklists in daily progress notes enhances patient care by improving the delivery of routine care that is often overlooked in the light of major medical issues.

Rectosigmoid resection at the time of primary cytoreduction for advanced ovarian cancer. A multi-center analysis of surgical and oncological outcomes.

OBJECTIVE: The aim of the study was to determine the impact of rectosigmoid resection, at the time of primary cytoreductive surgery, on morbidity and survival of patients with advanced ovarian cancer. METHODS: We performed a retrospective medical chart review of patients who underwent rectosigmoid resection for ovarian, tubal and peritoneal cancers between 1998 and 2008 at the IEO in Milan and JHMI in Baltimore. Perioperative and follow-up data were collected. RESULTS: A total of 238 patients were identified; 180 (75%) had stages IIC-IIIC and 58 (25%) had stage IV. Complete cytoreduction was achieved in 41% of the cases. Stapled coloproctostomy was performed in 98% while hand sewn in only 2%; a protective ileostomy and colostomy were necessary (constructed) in 2 (0.8%) and 5 (2%) cases respectively. The complications associated to rectosigmoid resection were anastomotic leakage in 7 (3%) patients and pelvic abscess in 9 (3.7%). Fifty percent of patients recurred during the study period, but only 5% of them showed a relapse at the level of the pelvis whereas 8% presented with abdominal recurrence associated with pelvic disease as well. The median overall survival time among patients with complete cytoreduction was 72 months compared with 42 months among the rest of patients (p=0.002). CONCLUSIONS: Rectosigmoid colectomy may significantly contribute to achieve a complete primary cytoreduction for advanced stage ovarian, tubal and peritoneal cancers. Pelvic complete debulking accomplished by rectosigmoid resection could be associated with a lower rate of pelvic recurrence as well.

Stage I noninvasive and minimally invasive uterine serous carcinoma: comprehensive staging associated with improved survival.

OBJECTIVE: The aim of this study was to determine if comprehensive surgical staging is a better predictor of outcome than incomplete staging for women with stage I noninvasive or minimally invasive (≤3 mm) uterine serous carcinoma (USC). METHODS: Retrospective chart review was used to identify patients undergoing hysterectomy at the Johns Hopkins Hospital from 1989 to 2010. Relevant clinical and pathologic data were extracted. Patients with noninvasive and minimally invasive (≤3-mm myometrial invasion) USC were identified. Stage was assigned based on the 2009 International Federation of Gynecology and Obstetrics endometrial cancer criteria. Survival curves were generated using the Kaplan-Meier method. RESULTS: We identified 63 patients with noninvasive or minimally invasive (≤3 mm) USC. Stages I, II, III, and IV disease were noted in 65% (41/63), 6% (4/63), 14% (9/63), and 14% (9/63) of the patients, respectively. Lower stage was associated with a significantly improved disease-specific survival (P = 0.001). Comprehensive staging, including total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal biopsies, was completed in 29% (12/41) of the patients with stage I disease. There were no disease-specific deaths in the comprehensive staging group. Compared with incomplete staging, comprehensive staging was associated with a significantly improved disease-specific survival (P = 0.039). CONCLUSIONS: Patients with stage I noninvasive and minimally invasive USC on comprehensive staging have an excellent prognosis. Adjuvant therapy may not benefit this patient population.

Analysis of racial disparities in stage IIIC epithelial ovarian cancer care and outcomes in a tertiary gynecologic oncology referral center.

OBJECTIVE: To examine disparities in delivery of care and survival according to racial classification among White and African-American women with Stage IIIC epithelial ovarian cancer undergoing initial treatment in a tertiary referral center setting. METHODS: All consecutive patients diagnosed with Stage IIIC epithelial ovarian cancer between 1/1/95 and 12/31/08 were identified and clinic-pathologic variables retrospectively collected. Differences in initial treatment paradigm, surgical and adjuvant therapy, and overall survival according to racial classification were assessed by univariate and multivariate analyses. RESULTS: A total of 405 patients (White, n=366; African-American, n=39) were identified. There were no significant differences according to racial classification in age, CA125, ASA class, histology, tumor grade, the frequency of initial surgery (90.4% vs 82.1%, p=0.06), optimal residual disease (73.0% vs 69.2%, p=0.28), no gross residual disease (51.4% vs 53.8%, p=0.49), and platinum-taxane chemotherapy (88.3% vs 87.2%, p=0.55). The median overall survival for White patients was 50.5 months (95%CI=43.2-57.9 months), compared to 47.0 (95%CI=36.2-57.8) months for African-Americans (p=0.57). On multivariate analysis, age, tumor grade 3, serum albumin <3.0 g/dl, platinum-based chemotherapy, and no gross residual disease were independently associated with overall survival, while African-American race was not (HR=1.06, 95%CI=0.61-1.79). CONCLUSIONS: Among women undergoing initial treatment for ovarian cancer at a tertiary referral center, African-American patients were as likely as White patients to undergo cytoreductive surgery, be left with minimal post-surgical residual disease, and receive appropriate chemotherapy. With equal access to gynecologic oncology care and multidisciplinary cancer resources, the survival disparities according to race observed in population-based studies are largely mitigated.

Late onset hemorrhage caused by ruptured uterine artery pseudoaneurysm after robotic-assisted total hysterectomy.

Robotic surgery has been used increasingly for the management of benign or malignant gynecologic conditions. Vaginal hemorrhage after hysterectomy is fairly uncommon. Uterine artery pseudoaneurysm is a rare phenomenon causing late onset hemorrhage that could be potentially life-threatening. This case describes the management of vaginal bleeding due to ruptured uterine artery pseudoaneurysm after robotic-assisted total hysterectomy. This is the first known reported case of a ruptured uterine artery pseudoaneurysm after a robotic-assisted hysterectomy.

Analysis of postoperative complications associated with the use of anti-adhesion sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier after cytoreductive surgery for ovarian, fallopian tube and peritoneal cancers.

OBJECTIVE: To evaluate the risk of postoperative complications related to HA-CMC use in patients undergoing optimal cytoreductive surgery for primary and recurrent ovarian, fallopian tube, and peritoneal cancers. METHODS: A single institution retrospective review identified all patients undergoing optimal (≤1 cm) cytoreductive surgery for primary or recurrent ovarian, fallopian tube, and peritoneal cancers between 1/95 and 12/08. Operative details and post-operative complications (<30 days) were extracted from the medical record. Fisher's exact test, Mann-Whitney-U, and multiple regression analyses were performed to identify factors, including HA-CMC use, associated with post-operative complications. RESULTS: Three hundred seventy-five cases were analyzed: HA-CMC was utilized in 168 debulking procedures. There was no difference in the incidence of overall morbidity for patients with HA-CMC compared to those without HA-CMC (OR 1.07; 95% CI: 0.68-1.67). On univariate analysis, application of HA-CMC increased the risk of pelvic abscess (OR 2.66; 95% CI: 1.21-5.86), particularly in the primary surgery setting (OR 4.65; 95% CI: 1.67-12.98) and in patients undergoing hysterectomy (OR 3.36; 95% CI: 1.18-9.53). After controlling for confounding factors using multiple linear regression, HA-CMC use approached statistical significance in predicting an increased risk of pelvic abscess but not major postoperative morbidity. CONCLUSIONS: HA-CMC adhesion barrier placement at the time of optimal cytoreductive surgery for ovarian, fallopian tube, and peritoneal cancer is not associated with major postoperative complications but may be associated with increased risk of pelvic abscess.

Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer.

OBJECTIVE: To describe the technique and short-term post-operative outcomes associated with diaphragm full-thickness resection (FTR) and intraoperative trans-diaphragmatic decompression of the resultant pneumothorax (TDDP). METHODS: All patients undergoing cytoreductive surgery for primary or recurrent ovarian cancer between 8/1/98 and 7/30/09 were retrospectively identified from the tumor registry database. Patients undergoing diaphragm FTR were selected for detailed review of the operative technique and post-operative outcomes. The operative technique of TDDP using a fenestrated Robinson catheter is described. RESULTS: A total of 45 patients met study inclusion criteria. Diaphragm FTR surgery was performed exclusively by gynecologic oncologists in 73.3% of cases. The median patient age was 60 years, and the majority (75.6%) of cases were performed for primary cytoreduction of Stage IIIC (n=27) or Stage IV (n=18) disease. The two-dimensional surface area of tumor involvement ranged from 9 cm(2) to 192 cm(2). The right hemi-diaphragm alone was involved in 71.1% of cases, while both the right and left hemi-diaphragms were involved in 24.4%. TDDP was performed in 41 of the 45 patients undergoing diaphragm FTR, while 4 patients had intraoperative thoracostomy tubes placed. Among the 41 TDDP patients, post-operative days 3-4 radiographic imaging revealed that 56% had a small residual pleural effusion and 9.8% had a residual pneumothorax; however, only 2 patients (4.9%) required post-operative thoracostomy tube placement or thoracentesis. CONCLUSION: The technique of TDDP eliminates the need of intraoperative and post-operative thoracostomy tube/thoracentesis in 95.1% of patients undergoing diaphragm FTR as a component of ovarian cancer cytoreductive surgery.

Secondary cytoreductive surgery including rectosigmoid colectomy for recurrent ovarian cancer: operative technique and clinical outcome.

OBJECTIVE: To describe the operative technique and associated clinical outcomes of patients undergoing rectosigmoid colectomy as a component of secondary cytoreductive surgery for recurrent ovarian cancer. METHODS: Consecutive patients undergoing rectosigmoid colectomy for recurrent epithelial ovarian cancer between 1/01 and 12/07 were retrospectively identified and clinical data abstracted from the medical record. The surgical technique, associated morbidity, and clinical outcomes are described. RESULTS: Fifty-six patients were identified. The median age at secondary surgery was 56 years; 78.6% had advanced-stage disease at initial diagnosis; 69.6% had grade 3 tumors; 73.2% had serous histology. Complete cytoreduction to no gross residual disease was achieved in 85.7% of cases. Concurrent distal ureterectomy/partial cystectomy was required in 8 cases (14.3%). The median number of regional cytoreductive procedures outside the pelvis was 1 (range=0-4). A stapled coloproctostomy was performed in 98.2% of patients; a protective colostomy/ileostomy was constructed in 7 cases (12.5%), and one patient (1.8%) underwent end colostomy. The median EBL was 500 cm(3) and the median operative time was 225 min. Blood transfusion was administered to 48.2% of patients. Post-operative morbidity occurred in 23.2% of patients, with a bowel fistula rate of 5.4% and a mortality rate of 1.8%. The median LOS was 9 days. Post-operative platinum-based chemotherapy was administered in 73.2% of patients. The median overall survival time from secondary surgery was 38.4 months. CONCLUSIONS: Rectosigmoid colectomy can contribute significantly to a maximal cytoreductive surgical effort for recurrent ovarian cancer. Despite technical differences, including a frequent requirement for resection of the distal urinary tract, morbidity is comparable to rectosigmoid colectomy performed for primary cytoreduction and the associated survival outcome appears favorable.

Limited utility of conventional criteria for predicting unresectable disease in patients with advanced stage epithelial ovarian cancer.

OBJECTIVE: To evaluate the predictive value of conventional criteria for identifying surgically unresectable disease among patients with ovarian cancer undergoing initial operative intervention at tertiary referral centers employing a so-called aggressive approach to surgical cytoreduction. METHODS: All patients with advanced epithelial ovarian cancer undergoing primary surgery between August 1997 and August 2006 were identified. Surgical/pathological documentation of disease extent pre/post-cytoreduction was extracted from the medical record retrospectively. All patients meeting conventional criteria for unresectable disease criteria (ascites >1000 mL, omental extension to spleen >1 cm, parenchymal liver disease >1 cm, porta hepatis involvement >1 cm, diaphragmatic disease >1 cm, carcinomatosis >1 cm, and suprarenal adenopathy >1 cm) were selected for further study. RESULTS: A total of 180 consecutive patients had disease meeting conventional criteria for unresectability at =1 site(s). Optimal cytoreduction (residual disease=1 cm) was achieved in 166 patients (92.2%). Optimal resection rates according to the most common individual unresectable disease criteria were as follows: ascites >1000 mL=91.3% (116/127), carcinomatosis >1 cm=91.0% (81/89), and splenic involvement >1 cm=84.9% (45/53). For patients with ascites >1000 mL alone, optimal cytoreduction was achieved in 95.8% (46/48) of cases. Optimal resection rates according to the total number of unresectable disease sites were as follows: 1 site=95.0% (19/20), 2 sites=93.8% (61/65), 3 sites=81.5% (22/27), 4 sites=93.3% (14/15), and 5 sites=80.0% (4/5). CONCLUSIONS: These data suggest that commonly accepted criteria of surgically unresectable disease for women with advanced ovarian cancer lack the necessary precision to guide clinical management. Pre-operative assessment of resectability should be made by an experienced surgical team prior to deferring the initial attempt at surgical cytoreduction.

A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers.

OBJECTIVES: To evaluate the safety, feasibility, and economic impact of a clinical pathway, including rapid diet advancement, for patients undergoing rectosigmoid colectomy as part of cytoreductive surgery for advanced ovarian and primary peritoneal cancers. METHODS: Between 8/1/98 and 6/30/06, 64 consecutive patients met study inclusion criteria. Using case-control methodology, post-operative management was dictated by a prescribed clinical pathway in 19 patients (Group A) and directed by individual surgeon preference in 45 patients (Group B). Critical elements of the clinical pathway included: rapid diet advancement, early discontinuance of nasogastric suction, criteria-based utilization of parenteral nutrition, selective laboratory testing, and deferring initiation of chemotherapy until after discharge. RESULTS: Stage IIIC/IV disease was present in 94% of all patients. The median time to flatus was 6 days for both groups (p=0.95); however, the median time to tolerance of diet was 3 days for Group A and 6 days for Group B (p=0.013). Compared to Group B, patients in Group A had a significantly shorter median length of hospital stay (7 days vs 10 days, p=0.014) and lower median 30-day post-operative hospital cost ($19,700 vs $25,110, p=0.028), with no significant difference in 30-day readmission rate (21% vs 33%, p=0.379). Clinical pathway-directed management was associated with a median reduction in hospital cost of $5410 per patient. CONCLUSIONS: A critical pathway incorporating rapid diet advancement for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for ovarian and primary peritoneal cancers is feasible, safe, and associated with a significant reduction in length of hospital stay and hospital-related costs.

Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma.

OBJECTIVES: To analyze the feasibility of using percutaneous endoscopic gastrostomy (PEG) tube placement in ovarian cancer patients with malignant bowel obstruction and to analyze the outcome of these patients. METHODS: We performed a retrospective review of all patients with ovarian carcinoma who underwent PEG tube placement between 1995 and 2002 at our institution. Abstracted data included patient demographics, procedure information, symptom resolution, diet tolerated, complications, further treatment, and survival. RESULTS: Ninety-four patients with ovarian carcinoma requiring PEG tube placement for malignant bowel obstruction were identified. The mean age at the time of PEG tube placement was 56 years. The mean interval from the initial cancer diagnosis to the placement of the PEG tube was 3.1 years. Twenty-two of 77 patients who had a computed tomography (CT) scan prior to PEG tube placement had tumor encasing the stomach. Fifty-nine (63%) of 94 patients had ascites, 25 of whom underwent a pre-PEG paracentesis (mean, 2845 ml). Ninety-four patients had a successful PEG tube placement under conscious sedation by the gastroenterology service (92) and/or by interventional radiology (2). Symptomatic relief, defined as no nausea or vomiting within 7 days of PEG tube placement, was noted in 86 (91%) of 94 patients undergoing PEG tube placement. Diets tolerated with and without the PEG tube being clamped were as follows: none, 3; sips, 9; liquids, 40; soft/regular, 40; and unknown, 2. The mean hospital stay after the procedure was 6 days. Eighteen patients had one or more of the following complications: leakage, 8; peristomal infection, 3; obstruction, 3; PEG tube migration, 2; catheter malfunction, 2; hemorrhage, 2; and peritonitis, 1. Nine patients required PEG tube revision due to complications. Chemotherapy after PEG tube placement was administered in 29 (31%) of the 94 patients, with resolution of obstruction and removal of the PEG tube in 4. In addition, 14 (15%) received limited total parental nutrition (TPN) after PEG tube insertion. Seventy-five (85%) of 88 patients died at home or under hospice care. The median overall survival for the 94 patients undergoing PEG tube placement was 8 weeks (95% CI, 6-10). Multivariate survival analysis revealed the presence of liver metastases (P < 0.001) and older age (P = 0.01) to be statistically significant predictors of shorter survival. The use of TPN after PEG tube placement was not a statistically significant prognostic factor in this model (P = 0.09). CONCLUSIONS: PEG tube placement in ovarian carcinoma is technically feasible and safe in the palliative setting. In addition, PEG tube placement allowed the majority of patients to have end-of-life care either at home or in an inpatient hospice. For the total population, no benefit was seen regarding survival with the use of TPN in this setting. Selected patients (younger age and without liver metastasis) may benefit from chemotherapy after PEG tube placement.

Reoperation for palliation of recurrent malignant bowel obstruction in ovarian carcinoma.

OBJECTIVE: While initial surgical treatment for palliation of malignant bowel obstruction is well described, data on reoperation for palliation of recurrent obstruction in ovarian carcinoma are limited. The purpose of this study was to analyze the outcome of patients undergoing reoperation for repeat bowel obstruction. METHODS: We reviewed the records of all patients with ovarian cancer who underwent repeat surgery for recurrent, malignant bowel obstruction at our institution between 1994 and 2002. RESULTS: Ten patients were identified. All patients had bowel obstruction caused by recurrent ovarian carcinoma and had a previous corrective surgical procedure for malignant bowel obstruction. The mean age at diagnosis of repeat obstruction was 54.1 years (range, 34-74 years). All patients had initial stage III or IV disease with moderately to poorly differentiated cancers. No patient received prior radiation therapy. The sites of obstruction in patients were as follows: small bowel, 3; large bowel, 3; both small and large bowel, 4. The mean number of prior laparotomies was 2.7 (range, 2-5). The mean interval from previous surgery for bowel obstruction to recurrent bowel obstruction was 8.3 months (range, 1-22 months). Surgical correction was possible in 5 (50%) of 10 patients, with 3 (60%) of these 5 patients obtaining successful palliation. Successful palliation is defined as the ability to tolerate a regular or low-residue diet at least 60 days postoperatively. Complications included enterocutaneous fistulas in three patients (two had enterotomies at time of surgery) and wound infection in one patient. There were no postoperative mortalities. The mean postoperative stay was 15.8 days (range, 8-29 days). Two of the three patients successfully palliated presented with a subsequent obstruction at 3 and 5 months postoperatively and were treated with gastrostomy tubes. The median length of survival for the entire cohort from the date of surgery for repeat obstruction was 4.5 months (range, 3-17 months). CONCLUSIONS: Patients undergoing repeat surgery for recurrent bowel obstruction have a low likelihood of successful palliation (30%). The surgery is associated with significant complications after surgery, rapid development of subsequent bowel obstructions, and limited survival rates. Alternative management approaches such as percutaneous endoscopic gastrostomy (PEG) tube placement should be considered in this group of patients.