Fluorodeoxyglucose positron-emission tomography-magnetic resonance hybrid imaging: An emerging tool for staging of cancer of the uterine cervix.

Positron-emission tomography-magnetic resonance imaging (PET-MRI) is an emerging hybrid imaging modality that utilizes the superior soft tissue resolution of MR with the metabolic data from PET. In this study, we sought to assess the clinical value of fluorodeoxyglucose (FDG) PET-MRI with dedicated pelvic PET-MR in the initial staging of cervical cancer. In this institutional-approved study, we identified 23 adult females who underwent FDG PET-MRI on hybrid camera for staging of primary uterine cervical cancer that included a dedicated PET-MR of the pelvis. A nuclear medicine physician and a radiologist reviewed the PET, MRI, and fusion-body and pelvis images alone and then with consensus read characterizing PET and MR abnormal findings. There were 23 patients who underwent FDG PET-MRI for initial staging of cervical cancer with an average age of 52.2 ± 14.0 years. A total of 23 suspected lymph nodes in eight different patients were detected within the pelvis with increased metabolic activity on PET. Both the dedicated pelvis and whole-body PET imaging detected the same corresponding pelvic lymph nodes, although the pelvic PET imaging had better lymph node uptake delineation due to longer acquisition time. Using a 10-mm short-axis criterion, MRI identified only 43.5% of the FDG avid lymph nodes. The average SUVmax on the pelvis PET sequences was higher with SUV 8.9 ± 5.2 compared to the whole-body PET with SUV 7.8 ± 5.4 but was not statistically significant (P > 0.05). Primary cervical cancer was identified in 18 patients on both PET imaging and MRI with dedicated MR pelvis providing better characterization. Based on our results of the patients with cervical cancer evaluated for initial staging, combining dedicated pelvic PET-MRI with whole-body PET/MR provides the most complete status of malignant disease in reference to delineation of primary tumor, involvement of surrounding tissues, and regional lymph nodes.

Inguinal pain and fullness due to an intravascular leiomyoma in the external iliac vein.

Intravascular leiomyomatosis (IVL) is a benign smooth muscle tumor that evolves from the pelvic veins and can spread to the central veins and heart. Cardiac involvement is the most commonly reported presentation. Initial diagnosis is difficult, and IVL is commonly misdiagnosed as thrombus or atrial myxoma. Appropriate imaging and a high clinical suspicion are required for accurate diagnosis. We report a rare case of IVL in the external iliac vein that recurred 4 years after hysterectomy. Only four cases have been reported in the literature to involve the external iliac vein as it has no direct connection to pelvic venous drainage.

Perceptions of obesity and cancer risk in female bariatric surgery candidates: highlighting the need for physician action for unsuspectingly obese and high risk patients.

OBJECTIVES: To determine: 1) whether obese women perceive themselves to be obese or at risk for malignancy, 2) perceived impact of obesity on cancer risks, 3) compliance with cancer screening, and 4) rates of menstrual dysfunction. METHODS: Surveys were administered to female patients presenting for bariatric weight loss surgery. Demographics, gynecologic history, perception of cancer risk, and screening history were collected/analyzed. Women were categorized as obese (BMI: 30-39kg/m(2)), morbidly obese (40-49kg/m(2)), super obese (≥50kg/m(2)) and compared. RESULTS: Ninety-three women (mean age: 44.9 years, mean BMI: 48.7kg/m(2)) participated and 45.7% felt they were in 'good', 'very good', or 'excellent' health despite frequent medical comorbidities. As BMI increased, women were more likely to correctly identify themselves as obese (23% of obese vs. 77% of morbidly obese vs. 85% of super obese; p<0.001) but there were no significant differences in comorbidities. Two-thirds of women correctly identified obesity as a risk factor for uterine cancer, yet 48% of those retaining a uterus perceived that it was "not likely/not possible" to develop uterine cancer. Menstrual irregularities were common as was evaluation and interventions for the same; 32% had prior hysterectomy. Participation in cancer screening was robust. CONCLUSIONS: Women presenting for bariatric surgery have high rates of menstrual dysfunction. While they perceive that obesity increases uterine cancer risk, they often do not perceive themselves to be at risk. This disconnect may stem from the fact that many failed to identify themselves as obese perhaps because overweight/obesity has become the norm in U.S. society.

Vulvar necrotizing soft tissue infection: A review of a multi-disciplinary surgical emergency and management in the modern era.

► Mortality from necrotizing soft tissue infections of the vulva is 14% in this study. ► Multi-disciplinary care may contribute to the lower mortality in this case series.

It's not just for laparoscopy anymore: use of insufflation under ultrasound and fluoroscopic guidance by Interventional Radiologists for percutaneous placement of intraperitoneal chemotherapy catheters.

OBJECTIVES: While intraperitoneal (IP) chemotherapy has shown significant survival benefits, the ability to successfully deliver IP chemotherapy has been limited. In GOG 172, surgically-placed IP catheters had a reported complication rate of 34%. In addition, IP catheters have to be placed surgically. We have developed a novel percutaneous placement technique for IP catheters in patients without ascites. METHODS: This study was a retrospective analysis of all patients receiving percutaneously-placed IP catheters from 12/2008 to present. Catheters were placed using a two-step technique under conscious sedation. IP access was gained using ultrasound-guided peritoneal puncture over the right lobe of the liver. A 5 Fr catheter was placed into the peritoneal cavity and the abdomen insufflated with carbon dioxide (CO(2)). Access was gained in the RLQ once distention separated the bowel from the abdominal wall. A 14.5 Fr multi-side hole catheter was coiled in the pelvis, and a reservoir tunneled onto the lower anterior chest wall. For this analysis, abstracted data included patient demographics, indication for catheter placement, complications (procedural and with chemotherapy delivery), fluoroscopy time, and timing/indication of catheter removal. RESULTS: Eleven patients received IP catheters. The mean age was 58 years, mean body mass index was 27.1, and mean number of days from surgical debulking was 38. There were two stage 2, and eight stage 3 patients. Two patients had fallopian tube, and nine patients had ovarian cancer. All patients had an optimal debulking procedure. Seven of 11 patients also obtained central intravenous access when the IP port was placed. Follow-up data were as follows: Average fluoroscopy time was 9 min. One patient (9%) had an intra-procedural complication but the catheter was successfully placed. Zero patients had catheter-related complications in the course of receiving chemotherapy. Five of the 11 patients (45%) completed the planned IP chemotherapy treatments, with three additional patients (27%) currently receiving therapy. The remaining three patients (27%) discontinued chemotherapy for reasons unrelated to IP catheter function: two due to chemotherapy side effects, and one with sepsis from a perforated diverticulum. CONCLUSIONS: Thus far, our experience with percutaneous placement of IP catheters is associated with a low risk of catheter-related complications and high technical success rates. CO(2) insufflation may make peritoneal puncture easier and potentially safer. This procedure offers an alternative to surgical placement, even in patients without clinically significant ascites.

The revolving door: hospital readmissions of gynecologic oncology patients.

OBJECTIVE: Rehospitalization within 30 days of discharge was identified by the Obama Administration as a target for reducing health care spending. We examined readmissions to our gynecologic oncology service to determine: 1) rates of readmission, 2) indication for readmissions, 3) whether the admission was planned, and 4) costs. METHODS: IRB approval was obtained for this 5-year retrospective review (2004-2008). Gynecologic oncology patients were included if they were readmitted within 30 days of discharge at a single academic hospital. Abstracted data included: demographics, dates of hospitalizations, cancer history, indication for admission, and cost. A series of admissions was any number of admissions that occurred within 30 days of discharge. An index admission was the first admission in a series. RESULTS: In the study period, 2455 unique patients were admitted to Gynecologic Oncology. 324 unique patients (13.2%) were readmitted within 30 days, with 37 experiencing >1 series of admission. 87.3% were readmitted to Gynecologic Oncology. Within a series of admissions, patients were admitted on average 1.5 times following the index admission, up to 9 admissions. The median cost of index admission was $9820; for readmissions, $8059. The total cost of readmissions over 5 years was $6,421,733. Unplanned readmissions accounted for the majority of this cost. CONCLUSIONS: Hospital readmissions affect the cost of care, but also the quality of care delivered to our patients. When extrapolated across institutions and across the country, unplanned readmissions are a costly expenditure to patients and the health system, deserving of attention.

Pre-operative gynecologic evaluation of bariatric surgery patients: improving cancer detection in a high-risk population.

BACKGROUND: Obesity is strongly associated with endometrial and breast cancers; further, obese women are less likely to undergo recommended cancer screening. The objective was to determine the preoperative practices of bariatric surgeons with regard to gynecologic assessment and cancer screening. STUDY DESIGN: A 28-question survey was mailed to 1,503 US bariatric surgeons to assess self-reported perceptions of gynecologic cancer screening, preoperative evaluation of female patients, and gynecologic oncology awareness and knowledge. RESULTS: Of 1,503 surgeons, 274 responded (18%) and 11 incomplete surveys were excluded, leaving 263 (17%) for analysis. Mean surgeon age was 46.8 years. Surgeons averaged 13.9 years postresidency and were predominantly male (89%). Eighty percent obtained gynecologic histories, but 56% and 49%, respectively, did not require Pap tests or mammograms before bariatric surgery. Only 21% had ever referred a patient for endometrial evaluation. Female surgeons were more likely to obtain menstrual and cancer-related family histories (p < 0.05). Surgeons who graduated from residency 10 or more years ago were more likely to obtain a pregnancy history (p = 0.006). One-fifth of surgeons reported that they do not consistently counsel their patients about increased cancer risks due to obesity. Last, surgeons correctly identified the following signs and risk factors of endometrial cancer at variable rates: postmenopausal bleeding (99%), obesity (97%), irregular or heavy periods (69%), hereditary nonpolyposis colorectal cancer (21%), infertility (20.2%), diabetes (14.1%), and hypertension (4.9%). CONCLUSIONS: Given the massive increases in morbid obesity and bariatric surgery in women, surgeons could serve a vital role in educating patients about both gynecologic and nongynecologic malignancy risks. With appropriate referral for cancer screening, patient outcomes could improve.

When 'never-events' occur despite adherence to clinical guidelines: the case of venous thromboembolism in clear cell cancer of the ovary compared with other epithelial histologic subtypes.

OBJECTIVE: To determine the incidence of clinically significant venous thromboembolism (VTE) in women diagnosed with clear cell carcinoma of the ovary (CCC-O) interpreted in the context of Centers for Medicare and Medicaid Services (CMS) 'never-events.' METHODS: Using the institutional pathology Tumor Registry at the Massachusetts General Hospital (MGH), all women diagnosed with a CCC-O from 1994 to 2004 were identified. Controls with epithelial ovarian cancer of other histologies were matched for stage, age and year of diagnosis. Medical records were abstracted and pathology reviewed. All patients had surgical staging and/or cytoreductive surgery by a Gynecologic Oncologist at the MGH. All patients received appropriate peri- and post-operative prophylaxis with subcutaneous heparin and/or sequential compression devices. VTE was diagnosed with standard imaging techniques when clinical suspicion arose. RESULTS: Fifty-eight (58) women were diagnosed with CCC-O during the study period, 43 of whom had complete data available for analysis. Patients with Stage I or II disease comprised 70% of the patients. The mean age of the cohort was 55 and the mean weight 71 kg. Eighty-six (86) age, stage, and year of diagnosis matched controls were selected. The majority of controls had serous tumors (47%) with the remainder being endometrioid (33%), mucinous (14%), transitional cell (2%), sarcoma (2%) and mixed (2%). CCC-O was often seen in association with endometriosis 70% compared with 22% of controls (p<0.0001). Overall, 18 of 43 CCC-O patients (42%) had VTE while only 19 of 86 control patients (22%) had VTE (p=0.024, OR=2.5 CI 1.1504-5.60). The rate of VTE was not influenced by weight or smoking. In the CCC-O patients, seventeen percent (17%) of VTE was diagnosed at presentation while 50% was diagnosed postoperatively and 33% at the time of disease recurrence or progression. Overall, including cases and controls, late stage disease was more likely associated with VTE (18 of 39, 46%) vs. early stage disease (19 of 90, 21%), p=0.004. CONCLUSIONS: Women with CCC-O have a 2.5-times greater risk of disease related VTE than women with other histologies of epithelial ovarian cancer despite adherence to prophylactic guidelines. Given the high rate of VTE postoperatively as well as with disease recurrence, one should consider indefinite therapeutic anticoagulation in women with CCC-O. The case of CCC-O is one example of the impracticality of payment denial for 'never-events,' as VTE arises despite best efforts at prevention.

Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy?

OBJECTIVE: To compare outcomes between robotic versus laparoscopic hysterectomy and lymphadenectomy in patients with endometrial cancer. METHODS: A cohort study was performed by prospectively identifying all patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy and lymphadenectomy from 2006-2008 and retrospectively comparing data using the same surgeons' laparoscopic hysterectomy and lymphadenectomy cases from 1998-2005, prior to our robotic experience. Patient demographics, operative times, complications, conversion rates, pathologic results, and length of stay were analyzed. RESULTS: 181 patients (105 robotic and 76 laparoscopic) met inclusion criteria. There was no significant difference between the two groups in median age, uterine weight, bilateral pelvic or aortic lymph node counts, or complication rates in patients whose surgeries were completed minimally invasively. Despite a higher BMI (34 vs. 29, P<0.001), the estimated blood loss (100 vs. 250 mL, P<0.001), transfusion rate (3% vs. 18%, RR 0.18, 95%CI 0.05-0.64, P=0.002), laparotomy conversion rate (12% vs. 26%, RR 0.47, 95%CI 0.25-0.89, P=0.017), and length of stay (median: 1 vs. 2 nights, P<0.001) were lower in the robotic patients compared to the laparoscopic cohort. The odds ratio of conversion to laparotomy based on BMI for robotics compared to laparoscopy is 0.20 (95% CI 0.08-0.56, P=0.002). The mean skin to skin time (242 vs. 287 min, P<0.001) and total room time (305 vs. 336 min, P<0.001) was shorter for the robotic cohort. CONCLUSION: Robotic hysterectomy and lymphadenectomy for endometrial carcinoma can be accomplished in heavier patients and results in shorter operating times and hospital length of stay, a lower transfusion rate, and less frequent conversion to laparotomy when compared to laparoscopic hysterectomy and lymphadenectomy.