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The standard of care for treatment of advanced-stage epithelial ovarian cancer is primarily surgery followed by platinum-based chemotherapy, with the operative goal to achieve complete gross resection. Cytoreductive surgeries for epithelial ovarian cancer historically were performed via open laparotomy; however, as minimally invasive techniques became more widely accepted within gynecologic oncology, interest in employing this approach in the setting of cytoreductive surgery for epithelial ovarian cancer has grown. The purpose of this review was to examine the current debate between the use of minimally invasive surgery versus laparotomy as an approach to interval cytoreductive surgery in advanced epithelial ovarian cancer. While numerous retrospective and feasibility studies have found comparable outcomes with respect to complete gross residual disease, progression-free survival, and overall survival between minimally invasive and laparotomy approaches to interval cytoreductive surgery for epithelial ovarian cancer, methodological challenges limit the utility of these data. Given potential risks of underestimating disease burden and failing to achieve complete resection using a minimally invasive approach, further rigorous studies are needed to evaluate the safety and efficacy of minimally invasive surgery in this setting and to better define the subset of patients who would receive the greatest benefit from a minimally invasive approach. [ABSTRACT FROM AUTHOR]

We sought to describe clinicopathologic and surgical factors associated with oncologic outcomes in patients undergoing tertiary cytoreduction and to present a clinical model to identify patients with high-grade serous ovarian cancer (HGSOC) who may benefit most from tertiary cytoreduction. We retrospectively identified patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who underwent tertiary cytoreduction at our institution from 1/1/1990–1/1/2019. Kaplan-Meier curves were used to estimate survival and compared using the log-rank test. Cox-proportional hazards regression was used to detect variables associated with survival. Of 114 patients who met inclusion criteria, 79 (69.2%) had high-grade serous tumors. Of patients with available genetic testing (n = 66), 22 (33%) harbored germline or somatic BRCA mutations. Fifty-eight women (50.9%) died of disease. Complete gross resection (CGR) at tertiary cytoreduction, treatment-free interval (TFI), and platinum sensitivity were all significantly associated with disease-specific survival (DSS) and maintained significance on multivariate analysis (HR 3.71, 95% CI: 1.59–8.70; HR 0.49, 95% CI: 0.28–0.85; and HR 2.94, 95% CI: 1.22–7.07, respectively). Postoperative treatment was not associated with a survival difference. Patients with HGSOC and a single site of recurrence who were ≥2 years from secondary cytoreduction had the longest survival after tertiary cytoreduction (median DSS, 79.5 months). Proper patient selection for tertiary cytoreduction is essential. Those who achieve CGR likely derive the greatest benefit from tertiary surgery. Platinum sensitivity and prolonged TFI are also associated with improved DSS. Patients with HGSOC and single-site recurrence who were ≥2 years out from secondary cytoreduction had the longest DSS. • Patients who undergo complete gross resection derive the greatest survival benefit from tertiary surgery. • Platinum sensitivity and prolonged treatment-free interval are associated with improved survival after tertiary surgery. • HGSOC patients with single-site recurrence who are ≥2 years from secondary surgery may benefit most from tertiary surgery. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice. • Since the inception of gynecologic oncology major changes have occurred, many related to surgical training and practice. • Gynecologic oncology has evolved to a versatile group of oncologists, but with an identity crisis as surgeons. • It is time for our subspecialty to reevaluate its scope of surgical training and practice. [ABSTRACT FROM AUTHOR]

• Mentorship is critical in a successful academic career. • Trust, respect, and mutual agreement on expectations are vital. • Mentorship provides the framework for upholding the standards of the field. This commentary is presenting opinions and advice on mentorship in the field of gynecologic oncology. Eleven academic gynecologic oncologists from across the country were interviewed and their thoughts about mentorship were recorded with recurring themes and ideas described in this commentary. Trust, respect, and mutual agreement on expectations were all described as vital to a functioning mentor/mentee relationship. Mentorship is critical for fellows and junior faculty to expand and uphold the standards of the field. [ABSTRACT FROM AUTHOR]

The article presents a study that describe the results of a prospective quality improvement program that screened all patients presenting to the institution with suspected advanced-stage epithelial ovarian cancer. It mentions that the program aims to standardize the selection of candidates for primary debulking surgery based on intra-abdominal tumor burden. The study illustrates that personalized surgical care for patients with advanced-stage ovarian cancer should be conducted.

The article presents the results of the lymphadenectomy in ovarian neoplasms (LION) trial. The topics discussed include the effectiveness of LION in the systematic eradication of lymph nodes after its maximal cytoreduction, the survival of patiens who underwent lymphadenectomy, and the possible complications that should be prevented.

Abstract: Objective: The recent EORTC-NCIC randomized trial comparing primary debulking surgery (PDS) to neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian carcinoma (EOC) reported a median progression-free survival (PFS) of 12months and overall survival (OS) of 30months for both arms. Due to the equivalent survival and decreased morbidity with NACT, many now consider it the preferred approach. We analyzed the outcomes of patients treated with PDS at our institution during the same time period in which the EORTC-NCIC trial was conducted, using identical inclusion criteria. Methods: We identified all patients undergoing primary treatment for advanced EOC at our institution from 9/98-12/06. Study inclusion and exclusion criteria were identical to those of the EORTC-NCIC trial. Standard statistical tests were used. Results: Of 316 eligible patients, 285 (90%) underwent PDS and 31 (10%) received NACT due to extra-abdominal disease, medical comorbidities, and/or advanced age (>85years). Of the 285 patients who underwent PDS, most had carcinoma of ovarian origin (248, 87%); stage IIIC disease (249, 87%); grade 3 tumors (237, 83%); and serous histology (249, 87%). Optimal cytoreduction (≤1cm residual) was achieved in 203 patients (71%). Postoperative platinum-based chemotherapy was given to 281 of 285 patients (99%). The median PFS and OS were 17 and 50months, respectively. Conclusion: PDS should continue to be the preferred initial management for patients with bulky stages IIIC–IV ovarian carcinoma. NACT should be reserved for those who cannot tolerate PDS and/or for whom optimal cytoreduction is not feasible. [Copyright &y& Elsevier]

Ovarian cancer is the second most common gynecological malignancy in the USA, and the majority of patients with newly diagnosed ovarian cancer present with advanced-stage disease. The standard treatment of these patients involves primary cytoreduction followed by combination chemotherapy. As the evidence has accumulated regarding the benefit of surgical cytoreduction, and as the definition of optimal cytoreduction has evolved, the surgical techniques have expanded in order to achieve this goal. This article discusses the different facets of the surgical management of ovarian cancer, with a special emphasis on the most recent additions to our current knowledge. [ABSTRACT FROM AUTHOR]

Abstract: Objective . : To assess the morbidity and mortality associated with extensive upper abdominal surgery (EUAS) performed during primary cytoreduction for advanced ovarian carcinoma. Methods . : We identified all patients who underwent EUAS during primary cytoreduction for advanced ovarian, tubal, or peritoneal cancer at our institution from 1/01 to 12/06. Major grade 3–5 complications were those that led to invasive radiologic intervention, re-operation, unplanned ICU admission, chronic disability, or death within 30days of surgery. Results . : There were 141 eligible patients, with a median age of 60years (range, 38–82). The majority of patients had stage IIIC disease, 103 (73%); serous histology, 131 (93%); and ascites, 118 (84%). There were 229 EUAS procedures performed—diaphragm peritonectomy, 101 (72%); splenectomy, 45 (32%); full-thickness diaphragm resection, 19 (14%); partial hepatectomy, 18 (13%); distal pancreatectomy, 17 (12%); cholecystectomy, 15 (11%); and resection of porta hepatis tumor, 14 (10%). Cytoreductive outcomes were: no gross residual, 42 (30%); residual≤1cm, 85 (60%); and residual >1cm, 14 (10%). Grade 3–5 complications occurred in 31 (22%) patients, including 2 mortalities (1.4%). In 21/31 (68%), the complication was successfully managed with percutaneous drainage of infected or non-infected collections. Overall median survival for all patients was 57months. Conclusions . : Rates of major morbidity and mortality following EUAS for primary cytoreduction were 22% and 1.4%, respectively. Approximately two-thirds of complications were readily managed by percutaneous drainage of collections. With an overall median survival of 57months in a cohort of patients with a large tumor burden, this rate of morbidity and mortality appears acceptable. [Copyright &y& Elsevier]

Abstract: Objective: To determine the impact on progression-free survival (PFS) and overall survival (OS) of a programmatic change in surgical approach to advanced epithelial ovarian cancer. Methods: Two groups of patients with stage IIIC and IV ovarian, tubal, and peritoneal carcinoma were compared. Group 1, the control group, consisted of all 168 patients who underwent primary cytoreduction from 1/96 to 12/99. Group 2, the study group, consisted of all 210 patients who underwent primary surgery from 1/01 to 12/04, during which time a more comprehensive debulking of upper abdominal disease was utilized. Results: There were no differences between the groups in age, primary site of disease, surgical stage, tumor grade, American Society of Anesthesiologists class, preoperative serum CA-125 and platelet levels, percentage with or amount of ascites, size or location of largest tumor mass, or type of postoperative chemotherapy. Patients in Group 2 vs Group 1 more frequently had extensive upper abdominal procedure(s) (38% vs 0%, respectively; P <0.001) and cytoreduction to residual disease <1 cm (80% vs 46%, respectively; P <0.01). Five-year PFS and OS rates were significantly improved in Group 2. For Group 2 vs Group 1 patients, 5-year PFS rates were 31% vs 14%, respectively (hazard ratio, 0.757; 95% CI, 0.601–0.953;P =0.01]; and 5-year OS rates were 47% vs 35%, respectively (HR, 0.764; 95% CI, 0.592–0.987;P =0.03]. Conclusion: The incorporation of extensive upper abdominal procedures resulted in increased optimal cytoreduction rates and significantly improved PFS and OS. A paradigm shift toward more complete primary cytoreduction can improve survival for patients with advanced ovarian, tubal, and peritoneal carcinomas. [Copyright &y& Elsevier]

Abstract: Objective: We previously reported that preoperative CA-125 may predict primary cytoreductive outcome in patients with stage III ovarian carcinoma (OC). The objective of this study was to perform a contemporary analysis of the ability of CA-125 to predict cytoreductive outcome in advanced OC since our programmatic change in surgical approach that currently incorporates the utilization of extensive upper abdominal procedures, as needed, to achieve maximal cytoreduction. Methods: We reviewed the records of all patients with advanced ovarian, tubal or peritoneal carcinoma who underwent primary cytoreduction at our institution between 1/01 and 4/05. Results: The study cohort included 277 patients. Primary disease sites were: ovary, 232 (84%); tubal, 9 (3%); and peritoneum, 36 (13%). Stages were: IIIA, 6 (2%); IIIB, 12 (4%); IIIC, 215 (78%); and IV, 44 (16%). Tumor grades were: grade 1, 6 (2%); grade 2, 30 (11%); grade 3, 233 (84%), and undifferentiated, 8 (3%). Cytoreductive outcomes were: no gross residual disease (RD), 68 (25%); ≤1 cm RD, 153 (55%); and >cm RD, 56 (20%). There was no threshold CA-125 level that accurately predicted cytoreductive outcome. However, with CA-125 values >500 U/mL, 50% (57/113) of patients required extensive upper abdominal surgery to achieve RD ≤1 cm, compared to 27% (25/93) for those with CA-125 <500 U/mL (P =0.001). Conclusion: Following our change in surgical paradigm that the incorporated extensive upper abdominal procedures to attain optimal debulking, preoperative CA-125 did not predict the primary cytoreductive outcome of patients with advanced ovarian, tubal, or peritoneal carcinoma. However, with a preoperative CA-125 >500 U/mL, extensive upper abdominal procedures were necessary in 50% of cases to achieve residual disease ≤1 cm. These data may be useful as part of preoperative surgical counseling and planning. [Copyright &y& Elsevier]

Abstract: Objective. : Nomograms have been developed for numerous malignancies to predict a specific individual''s probability of long-term survival based on known prognostic factors. To date, only one prediction model has been reported for patients with epithelial ovarian carcinoma (EOC). The objective of this study was to develop a more accurate survival nomogram for patients with bulky stage IIIC EOC. Patients and methods. : Nomogram predictor variables included age, tumor grade, histologic type, preoperative platelet count, ascites, and residual disease after primary cytoreduction. Disease-specific survival was estimated by the Kaplan–Meier method. Cox proportional hazards regression was used for multivariate analysis, which was the basis for the nomogram. The concordance index was used as an accuracy measure with bootstrapping to correct for optimistic bias. Results. : A total of 424 evaluable patients with bulky stage IIIC EOC underwent primary surgery at our institution during the study period of 1/89 to 12/03. All patients received postoperative platinum-based systemic chemotherapy. EOC-specific survival at 5 years was 51%. Using the six predictor variables, a nomogram was constructed and internally validated using bootstrapping. It was shown to have excellent calibration with a bootstrap corrected concordance index of 0.67, which was more accurate in predicting survival at this stage than the previously published model (concordance index=0.53). Conclusion. : Utilizing six readily accessible predictor variables, our nomogram more accurately predicted 5-year disease-specific survival for bulky stage IIIC EOC than the previously published model. This tool may be useful for patient counseling, determination of clinical trial eligibility, and postoperative management. [Copyright &y& Elsevier]

Abstract: Introduction. : Due to the rarity of ovarian carcinosarcomas, the optimal chemotherapeutic regimen to treat this aggressive disease is yet to be determined. The purpose of this study was to determine the response rate, recurrence-free survival, and overall survival of patients with ovarian carcinosarcoma who were treated with the combination of platinum and a taxane as first-line chemotherapy. Methods. : We identified all patients with ovarian carcinosarcoma who received a combination of platinum and taxane either after initial tumor resection or as neoadjuvant therapy. Data extracted from the medical records included residual tumor after surgery, number, type and dose of chemotherapy cycles, tumor response, and survival outcome. Results. : Between 1991 and 2005, 30 patients were identified for analysis. Twenty-four patients had stage III disease, 5 had stage IV disease, and 1 had stage II disease. All patients underwent surgical resection and 17 (57%) were cytoreduced to less than 1 cm. Twenty-eight patients received chemotherapy after surgery, and 2 patients received chemotherapy before surgery. Twenty-four patients (80%) received carboplatin and paclitaxel, 3 (10%) received carboplatin and docetaxel, and 3 (10%) received cisplatin and paclitaxel. Twelve (40%) had a complete response, 7 (23%) a partial response, 2 (7%) stable disease, and 9 (30%) progression of disease. The median time to progression for responders was 12 months. With a median follow-up of 23 months, the median overall survival was 43 months for survivors. The 3- and 5-year survival rates were 53% and 30%, respectively. Conclusion. : The combination of platinum and a taxane is a viable first-line treatment option for patients with ovarian carcinosarcoma. [Copyright &y& Elsevier]

Abstract: Objective : To determine the overall survival and relative effect of multiple prognostic variables in cohorts of patients with advanced-stage ovarian cancer treated with platinum-based neoadjuvant chemotherapy in lieu of primary cytoreductive surgery. Methods : Twenty-two cohorts of patients with Stage III and IV ovarian cancer (835 patients) were identified from articles in MEDLINE (1989–2005). Linear regression models, with weighted correlation calculations, were used to assess the effect on median survival time of the proportion of each cohort undergoing maximum interval cytoreduction, proportion of patients with Stage IV disease, median number of pre-operative chemotherapy cycles, median age, and year of publication. Results : The mean weighted median overall survival time for all cohorts was 24.5 months. The weighted mean proportion of patients in each cohort undergoing maximal interval cytoreduction was 65.0%. Each 10% increase in maximal cytoreduction was associated with a 1.9 month increase in median survival time (p =0.027). Median overall survival was positively correlated with platinum–taxane chemotherapy (p <0.001) and increasing year of publication (p =0.004) and negatively correlated with the proportion of Stage IV disease (p =0.002). Each incremental increase in pre-operative chemotherapy cycles was associated with a decrease in median survival time of 4.1 months (p =0.046). Conclusions : Neoadjuvant chemotherapy in lieu of primary cytoreduction is associated with inferior overall survival compared to initial surgery. Increasing percent maximal cytoreduction is positively associated with median cohort survival; however, the negative survival effect of increasing number of chemotherapy cycles prior to interval surgery suggests that definitive operative intervention should be undertaken as early in the treatment program as possible. [Copyright &y& Elsevier]

Abstract: Objective. : Prolonged survival in patients with recurrent ovarian cancer isolated to the spleen has been demonstrated after successful splenectomy. The purpose of this study was to report the outcomes of a series of patients who underwent splenectomy for persistent or recurrent ovarian cancer via laparoscopy or hand-assisted laparoscopy. Methods. : We reviewed the charts of all patients who underwent laparoscopic or hand-assisted laparoscopic splenectomy for presumed persistent or recurrent ovarian cancer. Demographic, clinical, pathologic, and follow-up information was abstracted. Results. : Six patients underwent laparoscopy or hand-assisted laparoscopy for presumed ovarian cancer involving the spleen. In 5 of the 6 cases, laparoscopic or hand-assisted laparoscopic splenectomy was successfully performed. For the 5 laparoscopic cases, operative times varied from 155 to 315 min, and estimated blood loss ranged from 50 to 300 ml. There were no perioperative mortalities or significant complications. Hospitalization lasted from 3 to 5 days. Four patients are alive with no evidence of disease at 2–84 months from the splenectomy, while 1 patient died of disease 20 months after the procedure. The sixth patient underwent initial hand-assisted laparoscopy, and the case was immediately converted to laparotomy for resection of peritoneal carcinomatosis. Conclusion. : Laparoscopic and hand-assisted laparoscopic splenectomies are safe and feasible in the management of patients with presumed persistent or recurrent ovarian cancer. Larger studies are necessary and eagerly awaited to help determine the long-term risks and benefits as well as the most appropriate candidates and selection criteria. [Copyright &y& Elsevier]

Abstract: Objectives.: To determine the incidence and prognostic implications of positive mesorectal lymph nodes in patients undergoing total pelvic exenteration for recurrent gynecologic malignancies. Methods.: We performed a retrospective chart review of all patients who had undergone total pelvic exenteration for a gynecologic malignancy between July 1992 and December 2003. Patient charts were reviewed for information regarding demographics, site of cancer, histology, pathology report, and time to recurrence. Results.: Fifty-eight women had undergone total pelvic exenteration for recurrent gynecologic malignancies during the study period and 57 were available for analysis. Primary cancer site was as follows: cervix, 37 (65%); vagina, 8 (14%); vulva, 5 (9%); and uterine corpus, 7 (12%). In 30 patients (53%), the mesorectal lymph node status was pathologically evaluated. Of these 30 patients, 3 (10%) had positive mesorectal lymph nodes at the time of total pelvic exenteration. All 3 patients had rectal wall involvement (rectal submucosa, 2; rectal mucosa, 1), and all 3 patients recurred within 4 months of pelvic exenteration. The median time to recurrence after surgery was 2.4 months in those patients with positive mesorectal lymph nodes compared with 7.3 months in those with negative mesorectal lymph nodes (P = 0.005). When individually adjusted for other prognostic variables, such as margin status, tumor grade, lymphovascular space involvement, primary cancer site, and histologic type, a finding of positive mesorectal lymph nodes was associated with a shorter time to recurrence of disease (all P < 0.05). Conclusions.: Mesorectal lymph node involvement is a common finding at total pelvic exenteration, particularly in patients with rectal wall involvement. Patients with positive mesorectal lymph nodes appear to have a worse outcome with a shorter time to recurrence of disease. [Copyright &y& Elsevier]

Objective. To determine the impact of the incorporation of extensive upper abdominal debulking procedures on the rates of optimal primary cytoreduction and complications in stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal carcinomas.Methods. Two groups of patients were identified for comparison. Group 1, the control group, consisted of 70 consecutive patients who underwent “standard” primary cytoreductive surgery before May 2000. Group 2, the study group, was composed of 70 consecutive patients who underwent surgery after January 2001, during which time, a more comprehensive debulking of upper abdominal disease was used, including diaphragm stripping/resection, splenectomy, distal pancreatectomy, liver resection, resection of porta hepatis tumor, and cholecystectomy.Results. The median age of the entire cohort was 60 years (range, 36–88 years). The majority had stage IIIC disease (86%) and serous histology (76%). Optimal cytoreduction (residual disease ≤1 cm) rates were 50% for group 1 and 76% for group 2 (P < 0.01). Patients in group 2 were more likely to have undergone extensive procedure(s) (27% versus 3%; P < 0.001). Operative time and estimated blood loss were greater in group 2 than group 1 (264 versus 174 min, 880 versus 460 cc, respectively; P < 0.001 for both). Complication rates and length of hospitalization were not significantly different between the two groups.Conclusion. The use of extensive upper abdominal surgical procedures significantly increased the rate of optimal primary cytoreduction. Although operative time and estimated blood loss were increased, the rate of major complications and length of hospitalization remained the same. [Copyright &y& Elsevier]

Objective. To analyze the findings and impact on the management of video-assisted thoracoscopic surgery (VATS) before planned abdominal exploration in patients with suspected advanced ovarian cancer and moderate to large pleural effusions.Methods. We reviewed the charts of all patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent VATS from 10/01 to 7/03. VATS was performed under double lumen endotracheal anesthesia. A 2-cm chest wall incision was made in the fifth intercostal space on the side of the effusion. The thoracoscope was introduced and biopsies of suspicious lesions were performed through the single incision. After VATS, all patients had a chest tube placed through the incision, and those with malignant effusions underwent talc pleurodesis either intraoperatively or postoperatively.Results. Twelve patients underwent VATS during the study period. Median operative time for VATS was 31 min (range: 20–49 min) with no complications attributable to the procedure. The median amount of pleural fluid drained was 1000 ml (range: 500–2000 ml). Solid, pleural-based tumor was found in six cases (50%), with nodules >1 cm noted in four patients (33%) and nodules <1 cm noted in two patients (17%). Of the six cases with no grossly visible pleural tumor, the pleural fluid was positive for malignant cells in two patients (17%) and negative in four patients (33%). Further initial patient management included the following: laparotomy with optimal cytoreduction, 6 (50%); diagnostic laparoscopy, 3 (25%); and no abdominal exploration, 3 (25%). Final diagnosis of primary disease site was as follows: ovary, 9 (75%); fallopian tube, 1 (8%); endometrium, 1 (8%); and lymphoma, 1 (8%). Based on the findings during VATS, laparotomy and attempted cytoreduction were avoided in four patients (33%), and the cytoreductive procedure was modified in one patient (8%).Conclusion. Fifty percent of patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent VATS had solid pleural-based tumor identified, and in 33% of cases the tumor nodules were >1 cm in diameter. VATS should be considered in these cases to delineate the extent of disease, treat the effusion, and to potentially select patients for either intrathoracic cytoreduction or a neoadjuvant chemotherapy approach. [Copyright &y& Elsevier]

This clinical needs assessment retrospectively identified 11 women with a history of gynecologic cancer who had undergone pelvic exenteration within the last 4 years, of whom six were available for interview. All patients agreed to telephone interviews, which lasted approximately 45–60 min and addressed their surgical experience. Seven themes emerged from the interviews: concerns about recovery, complications, ostomies, social support, sexuality, disclosure, and fear. The findings of our needs assessment concur with the existing literature noting decreased sexual interest/activity and difficulties with body image. An improvement in mood and an increase in activities over time postoperatively were noted. We also found reluctance by participants to disclose information about their exenterative procedure. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

: BackgroundIn the treatment of gynecologic cancer, surgical planning depends on the site and extent of disease. The evaluation of the origin of a large pelvic mass with combined pelvic examination and ultrasound is often adequate. However, the following case report illustrates the utility of magnetic resonance imaging (MRI) when sonographic findings are indeterminate and the origin of a pelvic mass is unclear.: CaseA 73-year-old woman presented for her first gynecologic exam in over 40 years. On speculum examination the cervix was not visible. A large, mobile pelvic mass was palpated during physical examination. Pelvic ultrasound revealed a large, cystic pelvic mass thought to be ovarian in origin. Surgery for presumed ovarian carcinoma was planned. Because a vaginal Pap smear revealed squamous-cell carcinoma, MRI was performed for further evaluation. MRI demonstrated a blood distended uterus with a large cervical tumor obstructing the endocervical os. After cervical dilatation under sonographic guidance, evacuation of the hematometrium was performed. Multiple biopsies of the cervix confirmed the diagnosis of a bulky Stage IIA squamous-cell carcinoma of the cervix. The patient was subsequently treated with concomitant chemotherapy and radiation therapy. Follow-up MRI demonstrated an excellent treatment response. Modified radical hysterectomy was performed demonstrating very small residual tumor.: ConclusionsMagnetic resonance imaging, through multiplanar capabilities and high-contrast resolution, is a valuable tool that can assist the clinician in the evaluation, diagnosis, and management of challenging gynecologic malignancies. [Copyright &y& Elsevier]

: ObjectiveThe objective was to describe the results, technique, and complications of transperitoneal laparoscopic (LSC) pelvic and aortic lymph node dissection (LND) using the argon-beam coagulator (ABC) and monopolar electrosurgical instruments in women with gynecologic malignancies.: MethodsA retrospective chart review of 114 patients who underwent LSC pelvic and/or aortic LND in addition to other LSC procedures between 1/1994 and 12/2001 was conducted. All intraoperative complications and complications that occurred within the first 30 postoperative days were included. Complications were graded according to an institutional surgical secondary events reference. During the same time period, 89 patients underwent LSC followed immediately by laparotomy that included LND, resulting in a total of 203 cases. These 203 total cases are used as a denominator to determine the etiology of cases converted from LSC to laparotomy. Monopolar electrosurgical instruments or the 10-mm ABC (Conmed) set at 70 W with argon flow of 3–4 L/m min were used for laparoscopic nodal dissection.: ResultsSixty-one of 114 (53%) patients underwent pelvic LND, 35 (31%) underwent both pelvic and aortic LND, and 18 (16%) underwent aortic LND only. Mean patient age and body mass index were 53.3 years (range, 16 to 87 years) and 25 (range, 16 to 40), respectively. In addition, the mean number of pelvic and aortic lymph nodes removed was 10.7 (range, 1 to 39) and 5.7 (range, 0 to 21), respectively. The mean estimated blood loss was 151 mL (range, 25 to 600 ml) and the mean hospital stay was 2.8 days (range, 0 to 35 days). Overall, complications occurred in eight (7%) cases. There were no fatal complications, and no patient required conversion to laparotomy due to uncontrollable bleeding from the laparoscopic nodal dissection. Only 17 of 203 (8%) patients required conversion to laparotomy secondary to adhesions and unsatisfactory exposure.: ConclusionsLaparoscopic pelvic and aortic LND for gynecologic malignancies can be satisfactorily performed in the majority of patients, with only 8% of patients requiring conversion to laparotomy due to adhesions or unsatisfactory exposure. The overall complication rate was 7% and was limited to grade 3 or less. [Copyright &y& Elsevier]

Background. Previous studies have reported the results of hepatic resection for metastatic ovarian cancer at the time of primary cytoreductive surgery and at the time of recurrence.Case. We present the first case of major hepatic resection performed at the time of interval cytoreduction for metastatic ovarian carcinoma.Conclusion. Interval debulking with hepatic resection may be a promising approach for patients left with bulky parenchymal liver metastasis after primary cytoreductive surgery. [Copyright &y& Elsevier]

Background. Although central nervous system (CNS) metastases from epithelial ovarian carcinoma are rare, recent studies indicate that the incidence may be increasing. Numerous series have reported various modalities for treatment with median survivals of 3 to 5 months, but the role of craniotomy has not been specifically addressed.Methods. We conducted a retrospective review of all patients who underwent craniotomy between 1989 and 2001 for pathologically confirmed recurrent epithelial ovarian cancer metastatic to the CNS.Results. We identified 14 patients who had a mean age at diagnosis of 59.3 years (range, 45 to 70). Distribution by stage and grade was as follows: Stage I, 0; II, 1; III, 12; and IV, 1; and grade 1,0; 2,4; and 3,10. Histologic distribution was as follows: papillary serous, 9; endometrioid, 2; mixed papillary serous and endometrioid, 1; carcinosarcoma, 1; and poorly differentiated adenocarcinoma, 1. Six patients had optimal primary cytoreduction, while 7 had suboptimal primary cytoreduction. All patients received initial platinum-based chemotherapy. Ten of 14 patients underwent second-look evaluation, and in 8 patients the findings were negative. The median time from initial diagnosis of ovarian carcinoma to CNS relapse was 3.5 years (range, 1.3 to 8.2). In 7 patients (50%), the CNS recurrence was the first site of relapse. Eight patients (57%) had extracranial disease at the time of craniotomy. Distribution of CNS lesions were as follows: supratentorial, 12; and cerebellar, 2. The mean operative time for craniotomy was 178 min (range, 70 to 305). The average blood loss was 125 mL (range, 20 to 250). The only major operative complications were deep vein thromboses that developed in two patients. No patient developed a neurologic deficit as a result of craniotomy. One patient died of progressive disease 37 days after surgery. Postoperative treatment included whole-brain radiation in 11 patients, chemotherapy in 4, and hormonal therapy in 4. Four patients (29%) had a CNS relapse after craniotomy. The median survival of patients after craniotomy was 18 months, and the 1- and 2-year survival rates were 66% (95% confidence interval (CI): 43–100) and 39% (95% CI: 17–90), respectively.Conclusions. Despite optimal cytoreduction, platinum-based chemotherapy, and negative second-look surgical assessment, patients with ovarian cancer can fail distantly with CNS metastases. Craniotomy with adjuvant radiation therapy can provide control of brain metastases in the majority of these patients and may result in improved survival over radiation therapy alone in selected patients. [Copyright &y& Elsevier]

We evaluated the performance of a chatbot compared to the National Comprehensive Cancer Network (NCCN) Guidelines for the management of ovarian cancer. Using NCCN Guidelines, we generated 10 questions and answers regarding management of ovarian cancer at a single point in time. Questions were thematically divided into risk factors, surgical management, medical management, and surveillance. We asked ChatGPT (GPT-4) to provide responses without prompting (unprompted GPT) and with prompt engineering (prompted GPT). Responses were blinded and evaluated for accuracy and completeness by 5 gynecologic oncologists. A score of 0 was defined as inaccurate, 1 as accurate and incomplete, and 2 as accurate and complete. Evaluations were compared among NCCN, unprompted GPT, and prompted GPT answers. Overall, 48% of responses from NCCN, 64% from unprompted GPT, and 66% from prompted GPT were accurate and complete. The percentage of accurate but incomplete responses was higher for NCCN vs GPT-4. The percentage of accurate and complete scores for questions regarding risk factors, surgical management, and surveillance was higher for GPT-4 vs NCCN; however, for questions regarding medical management, the percentage was lower for GPT-4 vs NCCN. Overall, 14% of responses from unprompted GPT, 12% from prompted GPT, and 10% from NCCN were inaccurate. GPT-4 provided accurate and complete responses at a single point in time to a limited set of questions regarding ovarian cancer, with best performance in areas of risk factors, surgical management, and surveillance. Occasional inaccuracies, however, should limit unsupervised use of chatbots at this time. • There is interest in expanding the use of chatbot technology in medicine. • A high percentage of responses from ChatGPT to questions about ovarian cancer were graded as accurate and complete. • ChatGPT had a higher percentage of inaccurate responses compared to the National Comprehensive Cancer Network Guidelines. • ChatGPT received the highest scores in response to questions regarding risk factors, surgical management, and surveillance. [ABSTRACT FROM AUTHOR]

To determine the safety and efficacy of the oral progesterone antagonist onapristone extended release (onapristone-XR) in patients with recurrent progesterone receptor (PR)-positive adult-type granulosa cell tumor (aGCT), low-grade serous ovarian cancer (LGSOC), or endometrioid endometrial cancer (EEC). This single-institution phase II study included patients with PR-positive aGCT, LGSOC, or EEC who received ≥1 prior line of chemotherapy. Patients were enrolled from 5/2019–5/2020. PR status was evaluated via immunohistochemistry. Eligible patients had PR expression ≥1% on tissue collected within 3 years of enrollment. Patients received 50 mg of onapristone-XR twice daily until disease progression or treatment discontinuation. Adverse events were graded by Common Terminology Criteria for Adverse Events version 5.0. The primary endpoint was overall response rate (ORR) by Response Evaluation Criteria in Solid Tumors 1.1. Secondary endpoints were response duration, clinical benefit rate (CBR), and safety. Five patients with LGSOC and 1 with EEC enrolled, but both cohorts closed early due to slow accrual. Fourteen patients with aGCT enrolled and completed stage 1 accrual. No responses were observed. Four patients with LGSOC were evaluable, with median PFS of 4.4 months (range, 1.8-NE) and CBR of 50% (range, 6.8%–93.2%). All 14 patients with aGCT were evaluable, with median PFS of 2.8 months (range, 1.6–4.9), 6-month PFS rate of 21.4% (range, 5.2%–44.8%), 12-month PFS rate of 14.3% (range, 2.3%–36.6%), and a CBR of 35.7% (range, 12.8%–64.9%). The study did not meet its primary endpoint. While onapristone-XR was well tolerated in all 3 arms, no objective responses were observed. • Onapristone extended release (ONA-XR) was well tolerated in all 3 arms; however, no objective responses were observed. • Two patients with adult-type granulosa-cell tumor (aGCT) had durable treatment response and continued treatment for >30 mos. • ONA-XR administration resulted in a 12-month progression-free survival rate of 14.3% in patients with aGCT. • ONA-XR administration resulted in a 12-month clinical benefit rate of 35.7% in patients with aGCT. • ONA-XR may have a therapeutic role in heavily pretreated patients with recurrent progesterone receptor-positive aGCT. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions Homologous recombination deficiency (HRD) testing is used to determine the appropriateness of poly ADP‐ribose polymerase inhibitors for patients with epithelial ovarian cancer and no germline/somatic BRCA1/2 alterations. Myriad MyChoice CDx reports a genomic instability score (GIS) to quantify the level of HRD, with a positive score defined as ≥42. The authors sought to define factors associated with obtaining an inconclusive HRD test result.GIS was retrieved for patients at their institution with epithelial ovarian cancer without germline/somatic BRCA1/2 deleterious alterations who underwent HRD testing from April 2020–August 2023. Clinical data were abstracted from the medical record.Of 477 HRD test results identified, 57 (12%) were inconclusive. High‐grade serous ovarian cancers had higher GIS than other histologic types (median 29 vs. 21, p < .001). Most HRD cases were of high‐grade serous histology; no cases with clear cell or endometrioid histology were HRD‐positive. On univariate analysis, interval versus primary cytoreductive surgery, other specimen sources versus surgical specimens, and chemotherapy exposure were risk factors for inconclusive HRD testing. On multivariable analysis, chemotherapy exposure, and tissue source were associated with an inconclusive test result, with surgical specimens more likely to yield a conclusive result than other sources (biopsy, cytology, other). Age, stage, self‐reported race, and histology were not associated with an inconclusive result.Surgical tissue was more likely to yield a conclusive HRD test result versus other sources of epithelial ovarian cancer tissue acquisition. When feasible, laparoscopic biopsy before initiation of neoadjuvant chemotherapy may increase the likelihood of obtaining interpretable HRD test results. [ABSTRACT FROM AUTHOR]

To evaluate procedures performed during primary debulking surgery (PDS) and interval debulking surgery (IDS) for ovarian cancer. Patients surgically treated at our institution for newly diagnosed stage IIIC/IV epithelial ovarian cancer between 6/1/2015–12/31/2021 were identified using a prospectively collected database. Patients were triaged to PDS or neoadjuvant chemotherapy (NACT) followed by IDS using an institutional algorithm. Data on specific procedures performed, including consultants called, were collected from operative and pathology reports. Appropriate statistical analyses were applied. Overall, 467 patients underwent PDS and 434 underwent IDS; 76% (PDS) and 71% (IDS) of cases achieved complete gross resection. Comparing PDS vs IDS cohorts, median age was 63 years (range, 23–86) vs 67 years (range, 35–95), 79% vs 86% of patients had high-grade serous histology, and 38% vs 70% had stage IV disease. Most procedures (except ostomy, distal pancreatectomy) were more common during PDS (P <.05). Bowel surgery was performed during 65% of PDS and 33% of IDS, and upper abdominal surgery during 72% of PDS and 52% of IDS; both were more common during PDS (P <.001). Estimated blood loss (median, 500 mL [PDS] vs 300 mL [IDS]) and operative time (median, 362 min [PDS] vs 267 min [IDS]) were higher for PDS (P <.001). A consulting surgeon was utilized during 31% of PDS and 18% of IDS, with hepatopancreaticobiliary as the most commonly called service (61% and 65%, respectively). In our study of patients with advanced-stage ovarian cancer, while most procedures were more often performed during PDS, NACT did not obviate the need for radical surgical resection. Thus, advanced surgical skills remain essential. • Complete gross resection was achieved at the time of primary or interval debulking surgery in >70% of patients • Most advanced surgical procedures were more common during primary than interval debulking surgery • Bowel and upper abdominal surgery were performed often during both primary and interval debulking surgery • Neoadjuvant chemotherapy did not obviate need for radical surgical resection; advanced surgical skills remain essential [ABSTRACT FROM AUTHOR]

To compare oncologic outcomes of secondary cytoreductive surgery (SCS) before and after FDA approval of Poly(ADP-ribose) polymerase inhibitor (PARPi) and bevacizumab maintenance therapies for platinum-sensitive recurrent ovarian cancer (PS-ROC). Patients who underwent SCS for first recurrence of PS-ROC from 1/1/2013–1/1/2020 were identified. Exclusion criteria included prior chemotherapy for recurrence, bowel obstruction procedures, and palliative surgery. Data were dichotomized pre/post 1/2017, relative to FDA approval of PARPi and bevacizumab maintenance for ROC. Second progression-free survival (PFS2), the primary endpoint, was estimated using Kaplan-Meier method. Overall, 245 patients underwent SCS—131 (53%) pre- and 114 (47%) post-approval. Most patients had high-grade serous tumors (83% and 90%, respectively; p = 0.13). Deleterious BRCA1/2 alterations were identified in 27% (32/120) and 28% (32/113) of tested patients, respectively (p = 0.88). Disease-free intervals pre- and post-approval were: 6–12 months, 16% and 18%; 12–30 months, 56% and 59%; and >30 months, 28% and 24%, respectively (p = 0.73). Overall, 85% and 86% of patients, respectively, achieved complete gross resection (CGR; p > 0.99). PARPi maintenance use increased from 3.8% to 27% (p < 0.001) following approval, and bevacizumab from 1.5% to 12% (p < 0.001). Median PFS2 was 19 and 20.1 months, respectively. In the post group, 1-year PFS2 rate was 84.5% (95% CI, 75.7–90.4%) for patients with CGR vs 56.2% (95% CI, 29.5–76.2%) for those with residual disease; 3-year PFS2 rates were 31.3% (95% CI, 21.6–41.4%) and 12.5% (95% CI, 2.1–32.8%), respectively (p = 0.001). CGR during SCS is associated with improved PFS2 compared to suboptimal resection. Prospective randomized trials are warranted to elucidate the role of SCS as more therapeutics become available. • Since 2017, the use of targeted maintenance therapies in recurrent platinum-sensitive ovarian cancer has increased. • Patients who achieved complete gross resection at secondary cytoreductive surgery had longer PFS. • In this targeted therapy era, surgical resection retains value in treatment of platinum-sensitive recurrent ovarian cancer. [ABSTRACT FROM AUTHOR]

Background: Rectovaginal fistula in long-standing Crohn’s disease is possibly associated with malignant transformation to mucinous adenocarcinoma of the vagina. However, there have been no previously reported cases documenting vulvar cancer in association with rectovaginal fistula in Crohn’s disease. We report 2 cases of vulvar mucinous adenocarcinoma associated with Crohn’s disease. Both showed vulvar symptoms after the development of rectovaginal fistula. Case 1: A 48-year-old woman, with a 30-year history of Crohn’s disease including a rectovaginal fistula, developed persistent pyoderma gangrenosum. Further workup revealed metastatic vulvar mucinous adenocarcinoma. Case 2: A 37-year-old woman with long-standing Crohn’s disease including numerous episodes of perianal or rectovaginal fistulas complained of a vulvar mass suspicious for an abscess. Biopsy showed mucinous adenocarcinoma. Conclusion: Vulvar lesions or symptoms in the setting of rectovaginal fistula in Crohn’s disease are an important clinical feature and the possible development of vulvar cancer should be considered. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: To determine the safety and efficacy of ultrasonic surgical aspiration (USA) in the treatment of vaginal intraepithelial neoplasia (VAIN). Methods: Using the ICD code for VAIN, all patients who underwent USA were evaluated. Patient demographics, clinicopathologic data, and follow-up outcomes were abstracted from the medical records. Results: Ninety-two patients underwent USA for VAIN. No surgical complications or postoperative scarring were recorded, and all patients were followed without further therapy after the procedure. Pathologic evaluation of the degree of VAIN in the aspirate obtained at the time of USA correlated with the preoperative biopsy results in all cases. With a median follow-up period of 4.5 years, the overall recurrence rate was 19.6%. The recurrence rate for high grade VAIN was significantly greater than that for low grade VAIN (32.3% vs 13.1%, P=0.044). Conclusion: Ultrasonic surgical aspiration is a safe and effective surgical option for VAIN, providing a histologic sample with minimal invasiveness. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To describe the incidence of isolated paraaortic nodal recurrences in patients with a final diagnosis of grade 1 endometrial carcinoma initially treated with surgery. Methods: Records from a prospectively maintained endometrial carcinoma database were reviewed to identify sites of recurrence. Patients with any papillary serous or clear cell carcinoma, leiomyosarcoma, endometrial stromal sarcoma, squamous carcinoma, or adenosarcoma were excluded. Recurrence sites were classified into 4 main categories: 1) pelvic (including vaginal and other soft tissue pelvic sites); 2) abdominal (including peritoneum, omentum and liver); 3) distant (including lung, brain, supraclavicular, and groins); and 4) isolated paraaortic nodal recurrence (including any nodal recurrence between the midcommon iliac to renal vessels). Results: Between 1/93 and 5/06, 1453 patients with endometrial carcinoma met the study inclusion criteria. Final grade distribution included: grade 1 endometrial adenocarcinoma, 310 (21%); grade 2, 578 (40%); grade 3, 481 (33%); and incomplete, 84 (5.8%). In all, 154 patients (11%) had documented recurrences. Recurrence sites for all patients/all grades included: pelvis, 52 (34%); abdomen, 51 (33%); distant, 41 (27%), and isolated paraaortic, 10 (6%). None of the isolated paraaortic recurrences occurred in patients with a final diagnosis of grade 1 carcinoma. Furthermore, 9/10 (90%) isolated paraaortic nodal recurrences were in grade 3 tumors. Only 8 (2.6%) of 310 patients with grade 1 tumors recurred. Sites of recurrence for grade 1 tumors included: abdomen, 3; pelvis, 3; and distant, 2. Conclusions: This large series of endometrial carcinoma patients initially treated with surgery confirms that isolated paraaortic nodal recurrence in women with a final diagnosis of grade 1 endometrial carcinoma is extremely rare. These rare isolated paraaortic nodal recurrences appear to be limited to high-grade endometrial carcinomas. [Copyright &y& Elsevier]

Although genetic testing (GT) is universally recommended for patients with epithelial ovarian cancer (EOC), rates are low (34%). In 1/2019, we implemented mainstreaming—GT in parallel with tumor testing via MSK-IMPACT within oncology clinics. We sought to determine GT rates pre/post-mainstreaming and patient characteristics associated with GT. Patients with newly diagnosed EOC seen at our institution from 7/1/2015–3/31/2022 were included. Clinical data were abstracted including social determinants of health (SDOH) variables, race/ethnicity, marital status, insurance, language, comorbidities, employment, and Yost index, a measure of socioeconomic status. GT rates were calculated overall and pre−/post-mainstreaming (1/2019). Logistic regression models were fit to identify variables associated with GT. Of 1742 patients with EOC, 1591 (91%) underwent GT. Rates of GT increased from 87% to 95% after mainstreaming (p < 0.001). Among 151 patients not undergoing GT, major reasons were lack of provider recommendation (n = 76, 50%) and logistical issues (n = 38, 25%) with few declining (n = 14, 9%) or having medical complications preventing GT (n = 7, 4.6%). High-grade serous histology, advanced stage (III/IV), and having a spouse/partner were associated with increased GT uptake (p < 0.01). Among SDOH variables, there were no differences by insurance, Yost score, language, comorbidities, employment, or race/ethnicity. In multivariable models, likelihood of GT increased with mainstreaming, even after adjustment for histology, stage, and marital status (OR 3.77; 95% CI: 2.56–5.66). Mainstreaming increased the likelihood of GT in patients with EOC. We found lower testing rates in patients without partners/spouses, non–high-grade serous histology, and early-stage disease, representing potential areas for future interventions. • Mainstreaming with tumor testing via MSK-IMPACT increased genetic testing (GT) in patients with ovarian cancer. • Those without spouses/partners and with non–high-grade serous histology and early-stage disease were less likely to get GT. • No differences in GT uptake were observed by race/ethnicity or other social determinants of health variables. • Our results will inform future interventions built into mainstreaming strategies to address missed opportunities for GT. [ABSTRACT FROM AUTHOR]

Mesonephric (MA) and mesonephric-like (MLA) adenocarcinomas are rare cancers, and data on clinical behavior and response to therapy are limited. We sought to report molecular features, treatment, and outcomes of MA/MLA from a single institution. Patients with MA (cervix) or MLA (uterus, ovary, other) treated at Memorial Sloan Kettering Cancer Center (MSK) from 1/2008–12/2021 underwent pathologic re-review. For patients with initial treatment at MSK, progression-free survival (PFS1) was calculated as time from initial surgery to progression or death; second PFS (PFS2) was calculated as time from start of treatment for recurrence to subsequent progression or death. Overall survival (OS) was calculated for all patients. Images were retrospectively reviewed to determine treatment response. Somatic genetic alterations were assessed by clinical tumor-normal sequencing (MSK-Integrated Mutation Profiling of Actionable Cancer Targets [MSK-IMPACT]). Of 81 patients with confirmed gynecologic MA/MLA, 36 received initial treatment at MSK. Sites of origin included cervix (n = 9, 11%), uterus (n = 42, 52%), ovary (n = 28, 35%), and other (n = 2, 2%). Of the 36 patients who received initial treatment at MSK, 20 (56%) recurred; median PFS1 was 33 months (95% CI: 17-not evaluable), median PFS2 was 8.3 months (95% CI: 6.9–14), and median OS was 87 months (95% CI: 58.2-not evaluable). Twenty-six of the 36 patients underwent MSK-IMPACT testing, and 25 (96%) harbored MAPK pathway alterations. Most patients diagnosed with early-stage disease ultimately recurred. Somatic MAPK signaling pathway mutations appear to be highly prevalent in MA/MLA, and therapeutics that target this pathway are worthy of further study. • Mesonephric adenocarcinoma (MA) and mesonephric-like adenocarcinoma (MLA) of gynecologic origin are rare cancers. • The majority of patients who presented with early-stage disease ultimately recurred, typically in the lung. • Somatic MAPK signaling pathway mutations are highly prevalent in MA and MLA. • Therapeutics that target the MAPK signaling pathway are worthy of further study in MA and MLA of gynecologic origin. [ABSTRACT FROM AUTHOR]

To evaluate the theoretical impact of regionalizing cytoreductive surgery for ovarian cancer (OC) to high-volume facilities on patient travel. We retrospectively identified patients with OC who underwent cytoreduction between 1/1/2004–12/31/2018 from the New York State Cancer Registry and Statewide Planning and Research Cooperative System. Hospitals were stratified by low-volume (<21 cytoreductive surgical procedures for OC annually) and high-volume centers (≥21 procedures annually). A simulation was performed; outcomes of interest were driving distance and time between the centroid of the patient's residence zip code and the treating facility zip code. Overall, 60,493 patients met inclusion criteria. Between 2004 and 2018, 210 facilities were performing cytoreductive surgery for OC in New York; 159 facilities (75.7%) met low-volume and 51 (24.3%) met high-volume criteria. Overall, 10,514 patients (17.4%) were treated at low-volume and 49,979 (82.6%) at high-volume facilities. In 2004, 78.2% of patients were treated at high-volume facilities, which increased to 84.6% in 2018 (P <.0001). Median travel distance and time for patients treated at high-volume centers was 12.2 miles (IQR, 5.6–25.5) and 23.0 min (IQR, 15.2–37.0), and 8.2 miles (IQR, 3.7–15.9) and 16.8 min (IQR, 12.4–26.0) for patients treated at low-volume centers. If cytoreductive surgery was centralized to high-volume centers, median distance and time traveled for patients originally treated at low-volume centers would be 11.2 miles (IQR, 3.8–32.3; P <.001) and 20.2 min (IQR, 13.6–43.0; P <.001). Centralizing cytoreductive surgery for OC to high-volume centers in New York would increase patient travel burden by negligible amounts of distance and time for most patients. • The impact on patient travel from ovarian cancer surgery regionalization to high-volume centers has not been studied. • Centralizing ovarian cancer surgery in New York State would increase patient travel by negligible distance and time. • These findings could have future implications for patient education and health policy on the regionalization of care. [ABSTRACT FROM AUTHOR]

To define molecular features of ovarian cancer (OC) with germline pathogenic variants (PVs) in non-BRCA homologous recombination (HR) genes and analyze survival compared to BRCA1/2 and wildtype (WT) OC. We included patients with OC undergoing tumor-normal sequencing (MSK-IMPACT) from 07/01/2015–12/31/2020, including germline assessment of BRCA1/2 and other HR genes ATM, BARD1, BRIP1, FANCA, FANCC, NBN, PALB2, RAD50, RAD51B, RAD51C, and RAD51D. Biallelic inactivation was assessed within tumors. Progression-free (PFS) and overall survival (OS) were calculated from pathologic diagnosis using the Kaplan-Meier method with left truncation. Whole-exome sequencing (WES) was performed in a subset. Of 882 patients with OC, 56 (6.3%) had germline PVs in non-BRCA HR genes; 95 (11%) had BRCA1 -associated OC (58 germline, 37 somatic); and 59 (6.7%) had BRCA2 -associated OC (40 germline, 19 somatic). High rates of biallelic alterations were observed among germline PVs in BRIP1 (11/13), PALB2 (3/4), RAD51B (3/4), RAD51C (3/4), and RAD51D (8/10). In cases with WES (27/35), there was higher tumor mutational burden (TMB; median 2.5 [1.1–6.0] vs. 1.2 mut/Mb [0.6–2.6]) and enrichment of HR-deficient (HRD) mutational signatures in tumors associated with germline PALB2 and RAD51B/C/D compared with BRIP1 PVs (p < 0.01). Other features of HRD, including telomeric-allelic imbalance (TAI) and large-scale state transitions (LSTs), were similar. Although there was heterogeneity in PFS/OS by gene group, only BRCA1/2 -associated OC had improved survival compared to WT OC (p < 0.01). OCs associated with germline PVs in non-BRCA HR genes represent a heterogenous group, with PALB2 and RAD51B/C/D associated with an HRD phenotype. • Those with germline pathogenic variants (PV) in non- BRCA1/2 homologous recombination (HR) genes were a heterogeneous group. • There was enrichment of HR-deficient (HRD) phenotype in those with germline PVs in PALB2 and RAD51B/C/D compared to BRIP1. • Patients with BRCA1/2- associated ovarian cancer (OC) had improved survival compared to those with wildtype OC. • Survival was variable among those with germline PVs in other HR genes. • OC associated with germline PVs in PALB2 and RAD51B/C/D may have similar features to BRCA1/2 -associated OC. [ABSTRACT FROM AUTHOR]

To assess the impact of short-term postoperative complications on oncologic outcomes for patients with epithelial ovarian cancer undergoing primary cytoreductive surgery (PCS) or interval cytoreductive surgery (ICS) with intestinal resection. A retrospective chart review was performed for patients with ovarian cancer who underwent PCS or ICS with at least one intestinal resection at our institution from 1/1/2015 to 12/31/2020. Progression-free survival (PFS) and overall survival (OS) were analyzed for the PCS and ICS cohorts separately. Short-term complications within 30 days of surgery (surgical secondary events [SSEs]) were graded by a validated institutional SSE system. Among 437 patients who underwent intestinal resections during PCS (n = 289) or ICS (n = 148), 183 (42%) had one, 180 (41%) had two, and 74 (17%) had three intestinal resections. Six (1.4%) of 437 patients experienced an anastomotic leak postoperatively. There were no perioperative deaths. There was no difference in PFS and OS for patients who underwent PCS with any SSE vs. no SSE within 30 days of surgery (HR, 1.05; 95% CI: 0.76–1.47; p = 0.75 and HR, 0.79; 95% CI: 0.49–1.26; p = 0.32, respectively). There was no difference in PFS and OS for patients who underwent ICS with any SSE vs. no SSE within 30 days of surgery (HR, 1.43; 95% CI: 0.99–2.07; p = 0.055 and HR. 1.18; 95% CI: 0.72–1.93; p = 0.52, respectively. Short-term postoperative morbidity for patients who underwent intestinal surgery during primary surgical management for advanced ovarian cancer did not impact oncologic outcomes. • Grade ≥3 adverse events occurred in 12% of patients within 30 days of primary (PCS) or interval cytoreductive surgery (ICS). • In the entire cohort, 6 patients (1.4%) experienced an anastomotic leak postoperatively. • Postoperative morbidity after PCS and ICS led to a 3- and 5-day delay to chemotherapy initiation, respectively. • Patients initiating postoperative chemotherapy < or > 42 days after PCS and ICS had no difference in PFS and OS. • Postoperative morbidity after PCS or ICS with intestinal surgery did not impact oncologic outcomes. [ABSTRACT FROM AUTHOR]

The treatment of recurrent ovarian cancer has been based on systemic therapy. The role of secondary cytoreductive surgery has been addressed recently in several trials. Imaging plays a key role in helping the surgical team to decide which patients will have resectable disease and benefit from surgery. The role of staging laparoscopy and several imaging and clinical scores has been extensively debated in the field. In other surgical fields there have been reports of using 3D imaging software and 3D printed models to help surgeons better plan the surgical approach. To the best of our knowledge, we report the first case of a patient with recurrent ovarian cancer undergoing 3D modeling before secondary cytoreductive surgery. The 3D modeling was of most value to evaluate the extension of the disease in our patient who underwent a successful secondary cytoreductive surgery and is currently free of the disease. [ABSTRACT FROM AUTHOR]

Mutations in ovarian cancer risk genes are found in women of diverse ancestries, supporting genetic testing for ALL PURPOSE: To evaluate rates of germline pathogenic/likely pathogenic variants (PVs) and genetic counseling by ancestry in patients with epithelial ovarian cancer (EOC). METHODS: Patients with pathologically confirmed EOC who underwent clinical tumor-normal sequencing from January 1, 2015, to December 31, 2020, inclusive of germline analysis of ≥76 genes were included. Patients with newly identified PVs were referred for Clinical Genetics Service (CGS) counseling. Ancestry groups were defined using self-reported race/ethnicity and Ashkenazi Jewish (AJ) heritage. Genetic ancestry was inferred computationally using validated algorithms. Logistic regression models were built. RESULTS: Of 1,266 patients, self-reported ancestry (AJ, 17%; Asian, 10%; Black/African American, 5.4%; Hispanic, 6.2%; non-Hispanic White, 57%; other, 0.16%; unknown, 4.0%) correlated with genetic ancestry (AJ ancestry, 18%; admixed, 10%; African, 4%; East Asian [EAS], 6%; European, 56%; Native American, 0.2%; South Asian [SAS], 4%; unknown, 2%). Germline PVs were observed in 313 (25%) patients, including 195 (15%) with PVs in EOC-associated genes. Those with PVs were younger at diagnosis (59 v 62 years; P <.001) and more likely to have high-grade serous ovarian cancer (83% v 72%; P =.009). PV prevalence varied between ancestry groups (P <.001), with highest rates in the AJ (39.9%) and Asian (26.5%) groups and similar rates (>10%) across other ancestry groups. Use of genetic ancestry demonstrated similar findings and further characterized high rates of PV in EAS/SAS groups. Younger age, high-grade serous histology, and self-reported AJ or Asian ancestry were associated with PV in an EOC-associated gene. Rates of CGS counseling for newly identified PVs were high (80%) across ancestry groups. CONCLUSION: Rates of PV, particularly in EOC-associated genes, were high regardless of ancestry, with similar rates of counseling between groups, emphasizing the importance of universal genetic testing in all patients with EOC. [ABSTRACT FROM AUTHOR]

To compare outcomes of patients with high-grade epithelial ovarian cancer (EOC) who underwent secondary cytoreduction surgery (SCS) after up-front treatment with neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) versus primary debulking surgery (PDS). Patients with high-grade EOC who underwent SCS from 2/1/2004–10/31/2021 were classified by up-front treatment. Clinical and treatment characteristics were compared between cohorts. Progression-free survival (PFS2) and overall survival (OS2) following SCS were compared using a Cox model adjusted for stage, age at SCS, and number of years between end of chemotherapy and SCS. Of 374 patients, 62 (17%) underwent NACT-IDS and 312 (83%) PDS. Justification for NACT was disease extent (n = 57, 92%), comorbidities (n = 3, 5%), and thromboembolism (n = 2, 3%). The NACT-IDS cohort had a higher median age at SCS (64 years [IQR: 56–70] vs 59 years [IQR: 53–66]; P =.03), higher proportion of stage III/IV disease (100% vs 81%; P <.001), and shorter median interval between end of chemotherapy and SCS (1.5 years [IQR: 1.1–2.3] vs 1.9 years [IQR: 1.3–3.1]; P =.01). Achievement of complete gross resection at SCS did not differ between NACT-IDS and PDS (84% vs 88%; P =.18). PFS2 (HR: 1.19, 95% CI: 0.83–1.71) and OS2 (HR: 0.96, 95% CI: 0.57–1.63) did not vary by primary treatment modality after adjusting for clinically relevant covariates. Despite more extensive disease at presentation, patients with high-grade EOC who recur after NACT-IDS seem to have similar surgical and survival outcomes after SCS compared to patients who recur after PDS, suggesting that prior NACT-IDS should not preclude SCS. • Patients with SCS after NACT-IDS were older, had higher stage at diagnosis, and less time from end of chemotherapy to SCS. • Recurrence and overall survival after SCS did not differ by primary treatment modality (NACT-IDS vs PDS). • Prior treatment modality should not preclude consideration for SCS at time of recurrence. [ABSTRACT FROM AUTHOR]

To evaluate clinical, laboratory, and radiological variables from preoperative contrast-enhanced computed tomography (CECT) for their ability to distinguish ovarian clear cell carcinoma (OCCC) from non-OCCC and to develop a nomogram to preoperatively predict the probability of OCCC. This IRB-approved, retrospective study included consecutive patients who underwent surgery for an ovarian tumor from 1/1/2000 to 12/31/2016 and CECT of the abdomen and pelvis ≤90 days before primary debulking surgery. Using a standardized form, two experienced oncologic radiologists independently analyzed imaging features and provided a subjective 5-point impression of the probability of the histological diagnosis. Nomogram models incorporating clinical, laboratory, and radiological features were created to predict histological diagnosis of OCCC over non-OCCC. The final analysis included 533 patients with surgically confirmed OCCC (n = 61) and non-OCCC (n = 472); history of endometriosis was more often found in patients with OCCC (20% versus 3.6%; p < 0.001), while CA-125 was significantly higher in patients with non-OCCC (351 ng/mL versus 70 ng/mL; p < 0.001). A nomogram model incorporating clinical (age, history of endometriosis and adenomyosis), laboratory (CA-125) and imaging findings (peritoneal implant distribution, morphology, laterality, and diameter of ovarian lesion and of the largest solid component) had an AUC of 0.9 (95% CI: 0.847, 0.949), which was comparable to the AUCs of the experienced radiologists' subjective impressions [0.8 (95% CI: 0.822, 0.891) and 0.9 (95% CI: 0.865, 0.936)]. A presurgical nomogram model incorporating readily accessible clinical, laboratory, and CECT variables was a powerful predictor of OCCC, a subtype often requiring a distinctive treatment approach. • Ovarian clear cell carcinoma tended to be associated with endometriosis. • A nomogram model combining clinical, laboratory, and contrast-enhanced CT variables was a powerful predictor of OCCC. • If validated, the imaging-inclusive nomogram for preoperatively predicting OCCC could aid in treatment planning. [ABSTRACT FROM AUTHOR]

To describe patient-reported postoperative symptoms and to evaluate the use of digital symptom tracking and alerts to detect postoperative complications. We retrospectively reviewed patients who underwent a minimally invasive hysterectomy and enrolled in our Recovery Tracker program from 4/5/17–12/31/21. The Recovery Tracker is an at-home virtual tool used to track patient-reported postoperative symptoms for 10 days. Predefined thresholds for "red" and "yellow" alerts are based on symptom severity and timing. Data on patient demographics, surgery, and postoperative course were collected to evaluate the association of alerts with complications and compare outcomes of patients who did/did not enroll in the program. Of 2362 eligible patients, 1694 (71.7%) enrolled in the Recovery Tracker program. Pain was the most severe symptom, followed by fatigue. Eighty-seven patients experienced 102 complications (5.1% complication rate) and 32 experienced 39 grade ≥ 2 complications (1.9% severe complication rate). Excluding complications that occurred prior to Recovery Tracker use, 1673 patients experienced 28 grade ≥ 2 complications. Of 345 patients (20.6%) who triggered a red alert, 13 (3.8%) had a grade ≥ 2 complication. Of 1328 patients (79.4%) with no red alerts, 15 (1.13%) had a grade ≥ 2 complication. Relative risk of a grade ≥ 2 complication if a red alert was triggered was 3.25 (95% CI: 1.6–6.9, P =.002). Rate of severe complications was significantly higher among patients who did not use the tool (3.3% vs 1.9%; P =.04). The Recovery Tracker tool may assist in early identification of postoperative symptoms after minimally invasive hysterectomy. • We report patient-reported symptoms and association with complications in patients after minimally invasive hysterectomy. • The most common symptoms reported by patients following minimally invasive hysterectomy were pain and fatigue. • Use of the digital at-home Recovery Tracker tool was associated with a decrease in severe postoperative complications. • Red alerts triggered by patient-reported symptoms were associated with a significant increase in grade ≥ 2 complications. • The Recovery Tracker tool may aid in the early detection of complications following minimally invasive hysterectomy. [ABSTRACT FROM AUTHOR]