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Uterine serous carcinoma is a rare but aggressive subtype of endometrial adenocarcinoma. Our objective was to compare adjuvant treatment strategies for patients with early stage uterine serous carcinoma.This multi-institutional, retrospective cohort study evaluated patients with early stage uterine serous carcinoma. Patients with FIGO Stage IA-II disease after surgery, whose tumors had serous or any mixed serous/non-serous histology were included. Patients with carcinosarcoma were excluded. Clinical data were abstracted from local medical records. Summary statistics, Fisher's exact, and Kruskal-Wallis tests were used to analyze demographic and clinical characteristics. Univariable and multivariable analyses were performed for recurrence-free and overall survival.There were 737 patients included. Most patients had Stage IA disease (75%), 49% of which had no myometrial invasion. Only 164 (24%) tumors had lymphatic/vascular space invasion. Adjuvant treatment varied: 22% received no adjuvant therapy, 17% had chemotherapy alone, 19% had cuff brachytherapy, 35% had cuff brachytherapy with chemotherapy, and 6% underwent pelvic radiation. Adjuvant treatment was significantly associated with a decreased risk of recurrence (p = 0.04). Compared with no adjuvant therapy, patients who received brachytherapy or brachytherapy/chemotherapy had improved recurrence-free survival (HR 0.59, 95% CI 0.40-0.86; HR 0.65, 95% CI 0.49-0.88, respectively) and overall survival (HR 0.53, 95% CI 0.35-0.79; HR 0.49, 95% CI 0.35-0.69, respectively). Improved survival with brachytherapy and brachytherapy/chemotherapy persisted on multivariable analyses. Chemotherapy alone was also associated with improved overall survival compared with no adjuvant treatment (HR 0.55, 95% CI 0.37-0.81).Adjuvant therapy was associated with a decreased risk of recurrence relative to observation alone. Adjuvant cuff brachytherapy with and without chemotherapy was associated with improved survival outcomes in patients with early stage uterine serous carcinoma.

To assess the impact of frailty in patients with ovarian cancer on surgical procedures and outcomes.A retrospective review of patients with stage II-IV ovarian cancer from April 2013 to September 2017 was performed. Patients were triaged by laparoscopy to determine primary resectability. The adjusted modified frailty index score (amFI) was calculated and amFI ≥2 classified as high frailty. Clinical outcomes, progression free survival (PFS) and overall survival (OS) were estimated.592 patients met inclusion criteria; amFI of 0, 1 and ≥ 2 was noted in 57%, 29%, and 14%, respectively. Patients with high frailty were less likely to be offered laparoscopic assessment for primary surgery (49% v. 43% v. 28% for amFI = 0, 1, and ≥ 2, p = 0.004), and more likely to have a Fagotti score ≥ 8 (58%, 48%, and 34%, p = 0.04). Only 17% of the high frailty cohort had primary tumor reductive surgery compared to 26% and 34% in patients with amFI = 1 and amFI = 0 (p = 0.02). Furthermore, patients with higher amFI were less likely to undergo any tumor reductive surgery (85% v. 74% v. 59%, p0.001). Postoperative complications were more frequent in patients with higher amFI (44% v. 56% v. 64%, p = 0.01). Death within thirty days of treatment initiation was significantly higher in patients with high frailty (0.4% v. 2% v. 9%, p = 0.005). In multivariate analysis, high frailty was associated with worse PFS (p = 0.02) and OS (p0.05).Postoperative morbidity, PFS, and OS were worse in patients with high frailty scores. Quantification of frailty may be useful for clinical decision making in patients with newly diagnosed advanced ovarian cancer.

OBJECTIVES: To evaluate the factors associated with response to neoadjuvant chemotherapy (NACT) and the ability to undergo interval tumor reductive surgery (iTRS) in patients with advanced ovarian cancer. METHODS: We performed a retrospective review from April 2013 to March 2019 of patients with advanced stage ovarian cancer triaged to NACT based on our standard triage algorithm. Clinicopathologic and treatment data were analyzed for factors associated with response to NACT, outcomes at iTRS, and their impact on progression-free survival (PFS). RESULTS: 562 patients met inclusion criteria and triaged to NACT following laparoscopy (n=132) or without laparoscopy (n=430). 413 patients underwent iTRS (74%). Factors that correlated with a patient reaching iTRS included increasing age (p1cm, p

In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. Despite these advances, the incidence of endometrial cancer as well as the deaths attributable to the disease have continued to rise; from 1987 to 2014 there has been a 75% increase in cases and almost 300% increase in endometrial cancer deaths. Fortunately, since then, there has been progress in the treatment of patients with endometrial cancer with increased utilization of molecular pathology, greater understanding of genetic predisposition, enhanced methods for lymph node assessment, a broader understanding of the efficacy of radiation and chemotherapy, and a more efficient approach to survivorship and surveillance. The purpose of this document is to present a comprehensive review of this progress.The authors reviewed the available evidence, contributed to the development of this manuscript, provided critical review of the guidelines, and finalized the manuscript recommendations. The review was also presented to and approved by the Society of Gynecologic Oncology (SGO) Clinical Practice Committee, SGO Publications Committee, and the SGO board members prior to submission for publication. The recommendations for this manuscript were developed by a panel of gynecologic oncologists who were members of the SGO Clinical Practice and Education Committees. Panelists reviewed and considered evidence from current uterine cancer literature. The terminology used in these guidelines was adopted from the ASCCP management guidelines [1] using a two-part rating system to grade the strength of recommendation and quality of evidence (Table 1). The rating for each recommendation is given in parentheses.

In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. This manuscript, Part II in a two-part series, includes specific recommendations on treatment of recurrent disease, post treatment surveillance and survivorship, considerations for younger women, and special situations. Part I covered histopathology and molecular pathology, risk factors, presentation and diagnostic approach, surgical approach and adjuvant therapy.

OBJECTIVE: To identify the optimal adjuvant treatment regimen for patients with endometrioid and non-endometrioid node-positive endometrial cancer. METHODS: We retrospectively identified 249 women with FIGO 2009 stage IIIC endometrial cancer at our institution who underwent surgical staging from 1985 to 2015 followed by external beam radiotherapy (RT), chemotherapy (CT), or a combination of CT+RT. Survival rates were calculated using the Kaplan-Meier method. RESULTS: The 5-year disease-specific survival (DSS) rate for all patients was 65%. Adjuvant CT+RT conferred higher rates of 5-year DSS as compared to CT alone in patients with grade 3 endometrioid and non-endometrioid tumors (61% vs. 27%, P = 0.04 and 67% vs. 38%, P = 0.02, respectively). Among patients with non-endometrioid tumors, treatment with concurrent chemoradiotherapy followed by additional sequential chemotherapy had higher 5-year DSS rates than with concurrent chemoradiotherapy alone (74% vs. 50%, P = 0.02). The 3-year pelvic recurrence rate was 5% with RT±CT and 35% with CT alone (P < 0.001) for all patients. No paraaortic nodal failures were observed following extended-field RT, but 14% of patients who received pelvic-only RT or CT alone developed recurrences in the paraaortic nodes (P < 0.001). CONCLUSIONS: Combined-modality therapy including adjuvant external beam pelvic radiotherapy yields excellent outcomes for patients with all subtypes of node-positive endometrial cancer. The most pronounced DSS advantage from adjuvant chemoradiotherapy was evident in women with non-endometrioid endometrial cancer.

The success of targeted and immune therapies in other malignancies has led to an exponential increase in the number of active and pending clinical trials using these therapeutic approaches in patients with gynecologic cancers. These novel investigational agents are associated with unique and potentially life-threatening toxicities and many require special multidisciplinary logistical considerations. The objective of this review is to describe a practical approach for the safe implementation of targeted and immune therapies in academic gynecologic oncology practices based on our experience at M.D. Anderson Cancer Center.

Objectives: Surgeons have significant choices when selecting specific disposable operating room (OR) equipment and supplies, while most are unaware of the costs associated with these choices. We used a cost transparency tool to demonstrate an impact on discretionary OR spending for disposable supplies. Methods: Patients undergoing laparoscopic hysterectomy or debulking within a gynecologic oncology department were included in this prospective, single-institution study. The operating room staff as well as the surgeons were informed of the cost of disposable equipment including the lowest-cost alternatives for commonly used supplies. Intraoperative supply cost feedback for all included procedures were provided to all surgeons in the department via a custom dashboard and monthly email reports with itemized costs. The results for all surgeons were transparent to all other surgeons in the department and the lowest cost surgeons were highlighted monthly. The primary outcome was percentage change in the cost of disposable supplies in the intervention year (11/1/2018-10/31/2019) as compared to baseline (11/1/2017-10/31/2018). Major postoperative complications including return to OR, wound dehiscence and wound infection were also collected. Results: A total of 21 surgeons performed 539 laparoscopic hysterectomies and a total of 18 surgeons performed 119 debulkings between 11/1/2017-10/31/2019. For laparoscopic hysterectomy, there was an overall average cost increase of 4.6% between the baseline year and the intervention year. Five (28%) of 18 surgeons with surgeries in both years demonstrated average decreases in costs by more than 5%. For debulking, there was an overall average cost decrease of 12.9% from baseline to the intervention year. Eight (53%) of the 15 surgeons with surgeries in both years demonstrated decreased costs by more than 5%. Complication rates did not change significantly over the study period (p=0.83). Conclusions: Transparency in the cost of disposable OR equipment and supplies may result in significant decrease in OR spending without affecting major postoperative complications.

Objectives: The androgen receptor (AR) is more widely expressed than the estrogen or progesterone receptor in endometrial cancer (EC), including up to 90% of endometrioid type. Enzalutamide binds to the AR thereby nuclear translocation of receptors and blocking the association of the AR with DNA. We sought to evaluate the efficacy of paclitaxel, carboplatin and enzalutamide in a phase II study of advanced or recurrent endometrioid EC. Methods: Women with chemo-naive, advanced-stage or recurrent endometrioid EC with measurable disease and adequate end organ function were eligible. Documented AR expression was not required. A safety lead in of the triplet was performed to confirm dose. In phase II, patients received 28 days of enzalutamide (160mg daily) as a single agent before starting triplet therapy. Pre- and post-treatment biopsies were obtained during the single agent lead in for evaluation of molecular markers including AR receptor expression and activation, expression of AR-related genes/proteins, and DNA copy number alterations and mutations. Patients then received carboplatin (AUC 6 IV Q3wk), paclitaxel (175 mg/m2), and enzalutamide (160mg daily). Response per RECIST 1.1 was assessed every 3 cycles for a maximum of 9 cycles. Evaluable patients received at least 6 cycles of triplet therapy. Progression free survival (PFS) was calculated from date of treatment initiation to earliest date of progression, death, or last contact. This study was approved and funded in part by the National Comprehensive Cancer Network (NCCN) Oncology Research Program from general research support provided by Astellas Pharma Global Development, Inc. Results: A total 81 patients were screened with 49 patients treated to date (safety lead in n=7; phase II n=42). Median age was 64 years (range 41-81) and the majority of patients had grade 2 histology (53.1%) and recurrent disease (81.6%). There were no dose-limiting toxicities observed during the safety lead in. Patients received a median of 9 cycles of triplet therapy (range 0-9). 8 patients (16.3%) did not receive chemotherapy due to rapid progression during single agent enzalutamide (n=3), unrelated death (n=2), withdrawal (n=2), and unrelated stroke (n=1). PFS for the entire cohort was 11.47 months (95% CI 9.86 - 17.94; Figure 1a) and 6-month PFS probability was 0.77 (95% CI 0.61-0.87). Among 35 evaluable patients, confirmed objective response rate was 71% (95% CI 54–85%), 6 months PFS probability was 0.83 (95% CI 0.66-0.92) and median PFS was 14.42 months (95% CI 11.2-25.5; Figure 1B). The most common adverse events were as expected for chemotherapy alone, including neutropenia (20%), anemia (18%), fatigue (18%), neuropathy (10%), hyperglycemia (14%), nausea (8%), and thrombocytopenia (8%). Download : Download high-res image (41KB) Download : Download full-size image Conclusions: The combination of enzalutamide, carboplatin, and paclitaxel was tolerable and had promising clinical outcomes in chemo-naive advanced or recurrent endometrioid EC. Further analyses are ongoing regarding predictors of response and resistance to androgen-inhibitor therapy. Clinical Trials Registration: NCT02684227.

Objectives: We aimed to assess the impact of frailty in ovarian cancer patients on surgical procedures and outcomes. Methods: A retrospective review of a prospectively collected database from April 2013 to September 2017 was performed. Patients with advanced disease were triaged by laparoscopy to determine primary resectability. The modified frailty index score (mFI) was calculated based on the sum of 10 items: chronic obstructive pulmonary disease or recent pneumonia, congestive heart failure, myocardial infarction, coronary artery disease, diabetes, hypertension, peripheral vascular disease, cerebrovascular disease (CVA), CVA with neurologic deficit, and Eastern Cooperative Oncology Group (ECOG) status 3 or 4, with each item receiving a score of 1 if present. Patients with an mFI ≥2 were classified as high frailty. Clinical outcomes were assessed and compared by mFI using t-test or Fisher's exact test. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Results: A total of 591 patients met inclusion criteria. A total of 57% of patients had an mFI of 0, 29% mFI of 1, and 14% mFI ≥2. There was no difference in stage by mFI (p=0.984). Patients with high frailty were less likely to be offered a laparoscopic surgery to determine primary resectability than those with an mFI of 1 or 0 (27.63% vs 42.77% vs 48.58%, respectively, p=0.004). If laparoscopy was performed, the modified Fagotti score was more likely to be ≥8 in patients with a higher frailty score (58%, 48%, and 34% for a score of ≥2, 1, and 0, respectively, p=0.038), leading to only 17% of the high frailty cohort proceeding with primary debulking surgery, compared to 26% and 34% in patients with mFI = 1 and mFI = 0 (p=0.015). Furthermore, patients with a higher frailty score were less likely to undergo any tumor reductive surgery (TRS), whether primary or interval (59% vs 74% vs 85% for a score of ≥2, 1, and 0, respectively, p Conclusions: Frailty is associated with bulkier disease, decreased surgical intervention, and worse clinical outcomes.

Objectives: To compare clinical and pathologic characteristics of women with surgical stage I endometrial cancer by location of first recurrence; to describe characteristics of isolated vaginal recurrence. Methods: All women with surgical stage I endometrial carcinoma treated at two major cancer centers from 2009-2017 were identified. Surveillance was done at standard intervals and consisted of symptom assessment and pelvic exam. Imaging was ordered as clinically indicated. Appropriate statistical analyses were used to compare isolated with extra-vaginal recurrences. Vaginal recurrence in the presence of other sites of disease were included in the extra-vaginal recurrence group. Results: 2817 women were analyzed. Median age at diagnosis was 61 years (range 26-92 yrs). At a median follow-up of 36 months (range, 0-139 mos). 280 (10%) recurred: 61 (2%) isolated vaginal, 219 (8%) extra-vaginal (which included 18 cases with a vaginal component). Of the 61 isolated vaginal recurrences, 42 (69%) were located at the cuff, 19 (31%) along the vaginal canal (Figure 1). All isolated recurrences were clinically detected on exam, except for 1 (2%) detected by imaging; endometrioid histology and Grade II were the most common findings (85% and 44%, respectively).Median time to recurrence after initial diagnosis for isolated vaginal recurrence was 11 months (range, 1-68 mos); for extra-vaginal recurrence, 20 months (range, 1-98 mos) (p Download : Download high-res image (134KB) Download : Download full-size image Conclusions: Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences, likely due to frequency of clinical exams after initial staging surgery. Surgical approach does not seem to impact overall or isolated recurrence. Adjuvant IVRT alone after primary surgery carries a 2% risk of isolated cuff recurrence.

Objectives: Pembrolizumab/lenvatinib demonstrated impressive response rates in advanced/recurrent endometrial cancer (EC) in a recent phase II clinical trial, leading to its accelerated FDA approval. However, tolerability of the recommended 20 mg starting dose of lenvatinib may pose clinical challenges. To comprehend how this regimen translates into daily clinical practice, we evaluated our preliminary data regarding toxicity and efficacy of pembrolizumab/lenvatinib in the treatment of advanced/recurrent EC at the University of Texas MD Anderson Cancer Center. Methods: In this single-institution, retrospective cohort study, we evaluated recurrent/advanced EC patients who received ≥1 cycle of pembrolizumab/lenvatinib treatment. Toxicity was evaluated through rates of hospitalization and treatment interruptions or discontinuations, as well as number of dose reductions. Clinical efficacy was evaluated by best radiologic response to treatment. Clinical benefit was defined as having stable disease or partial/complete response. Results: From October 2019 to July 2020, 83 EC patients were identified but 16 were excluded for unconfirmed administration of pembrolizumab/lenvatinib or lack of toxicity or response data. Thus, 67 EC patients were included in the analysis with a median follow-up of 5 months (range 1 - 11). The median age and number of prior lines of therapy were 67 (range 31–77) and 2 (range 1–9), respectively. The majority had an ECOG performance status of 0 to 1 (91%). The predominant histologic subtype was endometrioid and serous (n=19 each) followed by carcinosarcoma (n=13), mixed (n=8), clear cell (n=4), and other (n=4). The most common starting dose of lenvatinib was 14 mg (n=43; 64.2%), followed by 20 mg (n=15; 22.4%). Treatment-related hospitalizations occurred in 26.9% of patients but did not differ between lenvatinib dosage groups (p=0.37). Compared to those with a lower starting dosage level, patients started on 20 mg doses had significantly higher treatment discontinuations (100% vs 69.2%, p=0.01) and numbers of lenvatinib dose reductions (1.0 vs 0.38, p=0.004), with a trend of higher treatment interruptions (93.3% vs 73.1%, p=0.09). Among the 56 patients with evaluable radiologic response, there were 21 (37.5%) patients with either a partial (n=18) or complete response (n=3), while 18 patients (32.1%) had stable disease. Of the patients with complete response, all patients had a starting lenvatinib dose of 14 mg. Based on a starting lenvatinib dose of 20 mg vs Conclusions: In treatment of recurrent/advanced EC, lower starting dosage of lenvatinib was associated with fewer treatment interruptions/discontinuations and dose de-escalations compared to the FDA recommended 20 mg dosage level while maintaining equivalent response and clinical benefit rates. Furthermore, patients with carcinosarcoma histology also appeared to benefit from pembrolizumab/lenvatinib. While larger studies are needed to validate these safety and efficacy findings, our preliminary data supports starting a lower dosage of lenvatinib in clinical practice.

The COVID-19 pandemic has challenged our abilities to provide timely surgical care for patients, including women with gynecologic cancer In March 2020, the American College of Surgeons, The US Surgeon General, and many medical and surgical academic societies recommended postponing elective surgical interventions Recognizing that the pandemic may occur in waves, special considerations should be made for appropriate indications for surgical intervention in the setting of strained resources and personnel to meet surgical demand and prioritize excellent patient care The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to hesitate, and reintegrate surgery Regarding prioritization, patients should be counseled on risks of surgical delay versus in-hospital or community-acquired COVID-19 exposure in the perioperative setting Patients should be informed that surgical prioritization is based on (1) local projected resources, (2) disease prevalence, (3) patient and tumor characteristics, and (4) expected outcomes from delays Several prioritization algorithms have been developed that take into account disease characteristics, patient comorbidities, available personal protective equipment, length of hospital stay, local COVID-10 prevalence, and more Most oncological procedures have been classified as semiurgent, with a high priority tier 3 designation (second to emergent cases and trauma) Published literature demonstrates that most women with newly diagnosed gynecologic cancer are unlikely to be impacted by a few weeks surgical delay Those with malignancies with a propensity for metastasis or advanced stage ovarian and uterine malignancies that require interval cytoreduction should be prioritized when possible For mitigation of complications before, during, and after surgery, patients should be educated on recommendations for social distancing, hand hygiene, and personal protective equipment such as face masks Providers should abide by similar recommendations and use eye protection in the ambulatory and inpatient settings N95 respirators or powered air-purifying respirators are recommended in the care of suspected or known COVID-19 patients Clinical screening should be done at multiple points, COVID-19 testing should be done preoperatively, and a positive test result should delay surgery until asymptomatic formore than 14 days Safety protocols are critical during procedural intubation and extubation, as this is themost hazardous aspect of surgery in a COVID-19-positive/unknown patient Open surgery should not be considered safer than minimally invasive surgery Practitioners for whom the risk of severe disease and death is highest should avoid participating in the surgical care of known COVID-19-positive patients, if possible Telemedicine should be incorporated to limit provider and patient exposure in the postoperative setting Virtual platforms have also demonstrated efficacy in virtual rounding as well as patient care settings to involve family members in treatment planning and discussions around diagnosis Platforms emphasizing enhanced recovery time and same-day discharge should be prioritized, and measures should be taken to reduce delirium risk given lack of patient visitors Reintegration efforts should focus on systematically prioritizing the nonurgent cases that were initially delayed Surgical restrictions are likely to continue for some time, and institutional and departmental leadership will be paramount to optimize surgical manpower, support operative personnel, and use hospital resources equitably and responsibly

Objectives: Uterine leiomyosarcoma (ULMS) is a rare tumor with limited therapeutic options and no clearly established best treatment sequence strategy. The objective of this study was to evaluate treatment sequencing for ULMS following primary surgical management and determine predictors of survival. Methods: Women with a diagnosis of ULMS between 1/2013 and 1/2018 were identified. Clinical data was collected; for this analysis, only women treated with primary surgical management were included. Descriptive statistics were performed and predictors of overall survival (OS) and progression free survival (PFS) were analyzed using Cox regression and Kaplan-Meier methodology. Results: 179 patients were included. Median age was 52 years (20-78), 94% had grade 3 tumors, and over half the total population were treated with adjuvant chemotherapy (n=100, 56%). In the subset of patients with early stage disease (126), 49% were treated with surgery only while 51% received adjuvant chemotherapy. There was no difference in PFS between early stage patients who did or did not receive adjuvant chemotherapy (p=0.60). For the overall cohort, the most common adjuvant therapy regimens were gemcitabine/docetaxel (gem/doce, 40.9%) or ifosphamide/doxorubicin (ifos/doxo, 11.4%).137 patients (76.5%) experienced recurrence, progression or death during their follow up. The median PFS was 1.76 years (95% CI: 1.27- 2.08). The median survival for those treated with surgery alone was 1.79 years, for those treated with gem/doce was 1.27 years, and other chemotherapy regimen was 0.43 years. Median survival was not estimated for the ifos/doxo regimen due to small patient number. Upfront therapy regimen significantly impacted PFS (Figure 1, p=0.003), but was not significantly associated with OS (p=0.069). The one-year PFS probability was 0.58 for gem/doce (95% CI 0.45-0.68) compared with 0.80 for ifos/doxo (95% CI 0.54-0.91). Download : Download high-res image (94KB) Download : Download full-size image Conclusions: Median PFS was 1.76 years, despite many women undergoing adjuvant therapy after surgery, most commonly with either gem/doce or ifos/doxo regimens. Primary treatment with ifos/doxo was associated with higher one-year PFS. This finding warrants additional evaluation to determine the optimal adjuvant therapy for these women.

Objectives: Sentinel lymph node (SLN) biopsy is widely accepted as the standard of care for surgical staging in low grade endometrial cancer, but its value in high grade endometrial cancer remains unclear. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of SLN biopsy compared with pelvic lymphadenectomy in endometrial cancer patients with high-grade histology (PROSPERO ID: CRD42020160280). Methods: We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Ovid MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (January 1, 2000 to February 4, 2020) for prospective observational studies evaluating SLN biopsy in clinical stage I high grade endometrial cancer patients (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated/dedifferentiated, high grade not otherwise specified). Studies in which patients underwent cervical injection of indocyanine green for SLN detection, and at least a bilateral pelvic lymphadenectomy as a reference standard, were eligible for inclusion. If data was not reported specifically for patients with high grade histology, authors were contacted for aggregate data. We pooled detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit link, and assessed risk of bias using the QUADAS-II tool. Results: We identified 20 eligible studies, of which the authors for 8 provided data on 427 high grade patients specifically. The study-level median age was 66.9 years (range 44-82.8) and the study-level median BMI was 28.8 kg/m2 (range 18.9-45.2). The pooled detection rates were 91% per patient (95% CI 85-95; I2=62%) and 64% bilaterally (95% CI 53-73, I 2=72%). The overall node-positivity rate was 26% (95% CI 20-34; I 2=47%). Of 87 node positive patients, SLN biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% CI 84-96; I2=0%) (Figure 1), false negative rate of 8% (95% CI 4-16; I2=0%), and negative predictive value of 97% (95% CI 95-99; I 2=0%). Download : Download high-res image (94KB) Download : Download full-size image Conclusions: SLN biopsy accurately detects lymph node metastases in high grade endometrial cancer, with a false negative rate comparable to that observed in melanoma and breast cancer. Diagnostic accuracy would be even higher if a strict SLN algorithm was followed in all included studies. SLN biopsy can replace complete lymphadenectomy in patients with high grade endometrial cancer.

Sentinel lymph node (SLN) mapping continues to evolve in the surgical staging of endometrial cancer (EC). The purpose of this trial was to identify the sensitivity, false negative rate (FNR) and FN predictive value (FNPV) of SLN compared to complete pelvic and para-aortic lymphadenectomy (LAD) in women with high-risk EC.Women with high-risk EC (grade 3, serous, clear cell, carcinosarcoma) were enrolled in this prospective surgical trial. All patients underwent preoperative PET/CT and intraoperative SLN biopsy followed by LAD. Patients with peritoneal disease on imaging or at the time of surgery were excluded. Patients were evaluable if SLN was attempted and complete LAD was performed.123 patients were enrolled between 4/13 and 5/16; 101 were evaluable. At least 1 SLN was identified in 89% (90); bilateral detection 58%, unilateral pelvic 40%, para-aortic only 2%. Indocyanine green was used in 61%, blue dye in 28%, and blue dye and technetium in 11%. Twenty-three pts. (23%) had ≥1 positive node. In 20/23, ≥1 SLN was identified and in 19/20 the SLN was positive. Only 1 patient had bilateral negative SLN and positive non-SLNs on final pathology. Overall, sensitivity of SLN was 95% (19/20), FNR was 5% (1/20) and FNPV was 1.4% (1/71). If side-specific LAD was performed when a SLN was not detected, the FNR decreased to 4.3% (1/23).This prospective trial demonstrated that SLN biopsy plus side-specific LAD, when SLN is not detected, is a reasonable alternative to a complete LAD in high-risk endometrial cancer.

To assess the impact of body mass index (BMI) and operative approach on surgical morbidity and costs in patients with endometrial carcinoma (EC) and hyperplasia (EH).All women with BMI data who underwent surgery for EC or EH from 2008 to 2014 were identified from MarketScan, a healthcare claims database. Differences in 30-day complications and costs were compared between BMI groups and stratified by surgical modality.Of 1112 patients, 35%, 36%, and 29% had a BMI of ≤29, 30-39, and ≥40kg/mMIS may increase the value of care by minimizing complications and decreasing costs. This may be most pronounced in morbidly obese women.

To longitudinally assess quality of life (QOL) in women undergoing radical trachelectomy for early-stage cervical cancer.We prospectively enrolled patients with stage IA1-IB1 cervical cancer prior to undergoing radical trachelectomy to complete validated QOL instruments. These instruments included the General Health-Related QOL (SF-12), Functional Assessment of Cancer Therapy-Cervix (FACT-Cx), MD Anderson Symptom Inventory (MDASI), Female Sexual Functioning Index (FSFI), and Satisfaction with Decision scale (SWD). Instruments were filled out at baseline, postoperatively at 6weeks, 6months, 1year, and annually thereafter for 4years.Thirty-nine patients enrolled in the study, and 32 patients were evaluable. The scores for FSFI-arousal (p=0.0002), lubrication (p0.0001), orgasm (p=0.006), pain (p=0.01), satisfaction (p=0.03) and total score (p=0.004) showed a significant decline at 6weeks then returned to baseline levels by 6 months. The scores for FACT-Cx functional well-being (p=0.02) and physical well-being (p0.0001), SF-12 bodily pain (p0.0001), physical functioning (p0.0001), role physical (p0.0001), role emotional (p=0.03), social functioning (p=0.002), and MDASI total (p=0.04) showed significantly worsened symptoms at 6weeks then returned to baseline by 6months. The scores for FACT-Cx emotional well-being showed significant worsening of symptoms that persisted at 6-weeks (p=0.004), 6months (p=0.007), 1year (p=0.001), 2years (p=0.002), and 4 years (p=0.03). There was no difference in SWD.Several quality of life assessments decline immediately postoperatively after radical trachelectomy, however, return to baseline thereafter. The long-term emotional impact of this surgery highlights a need for perioperative counseling in these patients.

Objective Metformin reduces cancer incidence and improves overall survival in diabetic patients. In preclinical studies, metformin decreases endometrial cancer (EC) cell growth by activation of AMPK/mTOR inhibition. We sought to determine the effects of metformin on serum/tumor biomarkers in women with EC. Methods In this prospective trial, newly diagnosed EC patients underwent pre-treatment blood draw/endometrial biopsy, were administered oral metformin 850mg daily for ≥7days, and underwent post-treatment blood draw/definitive surgery. Pre- and post- serum analyses were performed. Tumor samples were evaluated for changes in AMPK, PI3K/AKT pathway, proliferation, and apoptosis by immunohistochemistry. Results Twenty patients completed the trial. Median age and BMI were 57years (range: 27–67) and 34.5kg/m 2 (range: 21.9–50.0). Median duration of metformin was 9.5days (range: 7–24). A majority of women had endometrioid adenocarcinomas (90%) and were early stage (85%). After metformin, there were significant decreases in serum IGF-1 ( p =0.046), omentin ( p =0.007), insulin ( p =0.012), C-peptide ( p =0.018), and leptin ( p =0.0035). Compared to baseline, post-treatment tissue showed decreased phospho-AKT in 18/20 patients (90%, p =0.0002), decreased phospho-S6rp in 14/20 patients (70%, p =0.057), and decreased phospho-p44/42MAPK in 15/18 patients (83.3%, p =0.0038). There was no difference in Ki67, phospho-ACC, or caspase 3. Changes did not correlate with BMI, grade, or KRAS mutation. Conclusion In this prospective window of opportunity study, we demonstrated that relevant serum and molecular changes occur in patients with newly diagnosed EC after a short course of metformin. Ongoing clinical trials will help determine the appropriate role for metformin in the treatment of women with EC.

Objective To evaluate clinicopathologic factors and adjuvant treatment effects on recurrence free (RFS) and overall survival (OS) in early stage uterine clear cell carcinoma (UCCC). Methods Our retrospective review included central pathology confirmed stage I or II UCCC treated and/or followed between 2000 and 2016. Cases with pure or mixed histology with >50% UCCC were included. Data were analyzed using Kaplan-Meier method and Cox proportional hazards regressions. Results 112 women were identified. Median age was 65.5 years (range 34–94). Most patients had mixed UCCC (61%), while 39% had pure UCCC. The majority of patients had stage IA UCCC (66%) versus stage IB (15%) or stage II (18%) disease. Adjuvant treatment included chemotherapy + radiation (26%), brachytherapy (27%), whole pelvic radiation (15%), chemotherapy alone (8%), and observation (24%). Thirty-eight (34%) women had recurrent disease. Median RFS was 4.32 years (95% CI 2.77–5.78). On multivariate analysis, age ≥70 (HR 2.48, 95% 1.28–4.81) and positive LVSI (HR 2.19, 95% CI 1.15–4.18) were associated with shorter RFS. Median OS was 9.8 years (95% CI 7.46–15.93). On multivariate analyses, age ≥70 (HR 3.57, 95% CI 1.64–7.74) and positive LVSI (HR 2.46, 95% CI 1.12–5.37) were associated with shorter OS. In this retrospective descriptive uncontrolled patient series, adjuvant treatment type did not impact RFS or OS. Conclusions OS approaches 10 years for early stage UCCC patients. Women ≥70 years have worse PFS and OS regardless of treatment modality, encouraging consideration of quality of life implications when electing for adjuvant therapy.

Objective Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. Methods We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. Results From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. Conclusions This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.

There are well-described benefits to minimally invasive surgery including decreased blood loss, shorter hospital-stay, and faster recovery. The role of robotic surgery in gynecologic oncology has become increasingly prominent; however limited data are available on quality of life (QOL) after robotic surgery.In this prospective, IRB-approved study, women scheduled for robotic surgery for a gynecologic indication between May 2008 and February 2012 completed validated QOL measures at baseline, 6 weeks (6wk), and 4 months postoperative (4mo). Functional status (SF-12), symptom severity and interference (MDASI), sexual function (FSFI), and satisfaction with decision (SWD) were assessed at relevant time points. Differences between groups were evaluated using the Mann-Whitney test.Among 408 women who underwent robotic surgery 278 (68%) completed the QOL measures. Median age was 55.6 years (range 25.7-85.1). Median BMI was 31.3kg/m(2). The majority of patients were white (75%). The most common indication for surgery was endometrial cancer/hyperplasia (59.7%). While physical functioning declined from baseline to 6wk (51.4 to 41.6, p0.001), it improved by 4mo (53.5). Mental functioning improved over time (baseline 48.6, 6wk 52.8, and 4mo 55.6, p0.001). Symptom severity decreased over time (p0.001) as did symptom interference (p0.001). Sexual function improved significantly from baseline (8.6) to 4mo (20.2, p0.001). Patients were satisfied with their decision making (SWD=30).In this prospective study, general health, symptom burden and sexual function returned to or improved beyond baseline levels within 6 weeks of surgery. Overall, women were satisfied with their decision to undergo robotic surgery.

The ratio of positive to negative lymph nodes, or lymph node ratio (LNR), is an important prognostic factor in several solid tumors. The objective of this study was to determine if LNR can be used to define a high-risk category of patients with node-positive early stage cervical cancer.We performed a retrospective review of patients diagnosed with node-positive stage I or II cervical cancer who underwent radical hysterectomy and pelvic +/- para-aortic lymphadenectomy at MD Anderson from January 1990 to December 2011. Univariate and multivariate analyses were used to identify prognostic factors for progression-free (PFS) and overall survival (OS).Ninety-five patients met the inclusion criteria and were included in the analysis. Median total nodes removed were 19 (range 1-58), and median number of positive nodes was 1 (range 1-12). Fifty-eight patients (61%) received radiation with concurrent cisplatin and 27 patients (28%) received radiotherapy alone. Twenty-one (22%) patients recurred. On multivariate analysis, a LNR6.6% was associated with a worse PFS (HR = 2.97, 95% CI 1.26-7.02, p = 0.01), and a LNR7.6% with a worse OS (HR = 3.96, 95% CI 1.31-11.98, p = 0.01). On multivariate analysis, positive margins were associated with worse PFS (p = 0.001) and OS (p = 0.002), and adjuvant radiotherapy (p = 0.01) with improved OS.LNR appears to be a useful tool to identify patients with worse prognosis in node-positive early stage cervical cancer. LNR may be used in addition to pathologic risk factors to tailor adjuvant treatment in this population.

Objective To assess the rate and risk factors for position-related injury in robotic gynecologic surgery. Methods A prospective database from 12/2006 to 1/2014 of all planned robotic gynecologic procedures was retrospectively reviewed for patients who experienced neurologic injury, musculoskeletal injury, or vascular compromise related to patient positioning in the operating room. Analysis was performed to determine risk-factors and incidence for position-related injury. Results Of the 831 patients who underwent robotic surgery during the study time period, only 7 (0.8%) experienced positioning-related injury. The injuries included minor head contusions ( n =3), two lower extremity neuropathies ( n =2), brachial plexus injury ( n =1) and one large subcutaneous ecchymosis on the left flank and thigh ( n =1). There were no long term sequelae from the positioning-related injuries. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery ( P =0.05). There were no significant associations between position-related injuries and operative time ( P =0.232), body mass index ( P =0.847), age ( P =0.152), smoking history ( P =0.161), or medical comorbidities ( P =0.229–0.999). Conclusions The incidence of position-related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify modifiable risk factors for position-related injury following robotic surgery. A standardized, team-oriented approach may significantly decrease position-related injuries following robotic gynecologic surgery.

There are currently no standard guidelines on the use of Papanicolaou (Pap) tests for surveillance after radical trachelectomy for cervical cancer. The goal of this study was to determine the usefulness of Pap tests in routine surveillance after radical trachelectomy for cervical cancer.Cervical cancer patients who underwent radical trachelectomy from January 2004 through October 2015 and subsequently had at least one Pap test were retrospectively identified. Demographic and clinical characteristics were described and compared between patients with and without at least one abnormal Pap test. The Kaplan-Meier method was used to estimate time to first abnormal Pap test.Forty-one patients met inclusion criteria. Of these, 30 (73%) had at least one year in which more than one Pap test per year was obtained. Twenty-four (59%) had at least one abnormal Pap test. Of 238 total Pap tests collected, 44 (18%) were abnormal. The most common abnormality was ASCUS (52%, n=23). Other findings included LSIL (20%, n=9), HSIL (2%, n=1), and AGUS (25%, n=11). Median time from radical trachelectomy to first abnormal Pap test was 17.2months (range, 11.8-86.3). No patient had disease recurrence. Surgery type (laparoscopic, open, or robotic), trachelectomy specimen size, histology, device for stenosis prevention (pediatric Foley catheter or Smit Sleeve), and cerclage placement were not significant predictors of an abnormal Pap test.The rate of abnormal Pap tests after radical trachelectomy is high; however, the clinical significance of such abnormalities appears limited. The routine use of cervical cytology as surveillance after radical trachelectomy does not appear to substantially impact management decisions.

Objectives The study objective was to analyze the impact of prognostic factors, including treatment modality, on outcome in patients with advanced-stage uterine serous carcinoma (USC). Methods A retrospective review of patients diagnosed with stage III or IV USC between 1993 and 2012 was performed. Summary statistics were used to describe demographic and clinical characteristics. Overall survival (OS) and recurrence free survival (RFS) were estimated by Kaplan-Meier analysis. Cox proportional hazards regression was used to model the association of potential prognostic factors with OS and RFS. Results The study included 260 patients with median follow-up of 26.6months (range 1–172.8). Median age was 63years (range 30–88) and 52.3% had stage III disease. In all, 60% were treated with surgery followed by chemotherapy, 18.1% received surgery, chemotherapy, and radiotherapy, 11.5% had surgery and radiotherapy, and 10.4% had neoadjuvant chemotherapy. The overall complete response rate was 68.9%, and the cumulative incidence of recurrence was 82.7%. Treatment that included surgery, chemotherapy, and radiation and stage III disease were associated with improved RFS on multivariate analysis. For OS, therapy with surgery, chemotherapy, and radiation, mixed histology, and stage III disease were associated with better OS on multivariate analysis. Conclusions Patients with advanced-stage USC have a poor prognosis, regardless of clinical factors or treatment received. However, combination therapy that includes chemotherapy and radiation appears to be associated with improved survival in these women.

To determine risk factors associated with conversion to laparotomy for women undergoing robotic gynecologic surgery.The medical records of 459 consecutive robotic surgery cases performed between December 2006 and October 2011 by 8 different surgeons at a single institution were retrospectively reviewed. Cases converted to laparotomy were compared to those completed robotically. Descriptive statistics were used to summarize the demographic and clinical characteristics.Forty of 459 (8.7%, 95% CI 6.3%-11.7%) patients had conversion to open surgery. Reason for conversion included poor visualization due to adhesions (13), inability to tolerate Trendelenburg (7), enlarged uterus (7), extensive peritoneal disease (5), bowel injury (2), ureteral injury (1), vascular injury (1), bladder injury (1), technical difficulty with the robot (2), and inability to access abdominal cavity (1). 5% of cases were converted prior to docking the robot. On univariate analysis, preoperative diagnosis (p=0.012), non-White race (p=0.004), history of asthma (p=0.027), ASA score (p=0.032), bowel injury (p=0.012), greater BMI (p0.001), need for blood transfusion (p0.001), and expected blood loss (p0.001) were associated with conversion. On multivariate analysis, non-White race (OR 2.88, 95% CI 1.39-5.96, p=0.004), bowel injury (OR 35.40, 95% CI 3.00-417.28, p=0.005), and increasing BMI (OR 1.06, 95% CI 1.03-1.09, p0.001) were significantly associated with increased risk for conversion. Prior surgery was not associated with conversion to open surgery (p=0.347).Conversion to laparotomy was required for 8.7% of patients undergoing robotic surgery for a gynecologic indication. Increasing BMI and non-white race were identified as the two preoperative risk factors associated with conversion.

Our objective was to characterize the intra and peritumoral immune profile in recurrent cervical cancers to identify rational immunotherapy targets.Archival pelvic exenteration specimens were examined using a validated multiplex immuno-fluorescent panel of antibodies against cluster of differentiation 8 (CD8), cluster of differentiation 68 (CD68), forkhead box P3 (FoxP3), programmed cell death protein 1 (PD1), and programmed death-ligand 1 (PD-L1, N=28). Clinical data were abstracted from the electronic medical record.Cytotoxic T cells, macrophages, and regulatory T cells were found in higher densities in peritumoral stroma (CD8+ density 497.7 vs 83.5, p0.0001, CD68+ density 345.0 vs 196.7, p=0.04, FoxP3+ density 214.5 vs 35.6, p0.0001). Antigen experienced T cells (PD1+) were higher in peritumoral compared to tumor tissue (median normalized fluorescence intensity 0.05 vs 0.0085, p0.001). Although there was a higher median density of intratumoral cytotoxic T cells and macrophages compared to regulatory T cells (median density CD8+ 83.5 vs 35.6, p0.05, median density 196.7 vs 35.6, p0.05), the presence of macrophages correlated with the presence of regulatory T cells in tumors (r=0.58, p=0.001).While cytotoxic T cells are present in tumor tissue to varying degrees, their density is lower than in peritumoral stroma, suggesting intratumoral exclusion or destruction of T cells. Higher densities of intratumoral macrophages compared to regulatory T cells suggest macrophages may be important contributors to the immunosuppressive tumor environment. Future directions for combination therapy include altering T cell trafficking and targeting tumor associated macrophages (TAMs) to enhance intratumoral activated T cell density and effect a more robust immune response.

The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons.A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared.Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p0.001), BSO 7% to 75% (p=0.005), right PLND 4% to 44% (p0.001), left PLND 0% to 56% (p0.001), and VCC 59% to 82% (p=0.024). Console times (min) were similar for SH (60 vs. 63, p=0.73), BSO (48 vs. 43, p=0.55), and VCC (20 vs. 22, p=0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p=0.04, left 23 vs. 27, p=0.02). Nodal counts were not significantly different (right 7 vs. 8, p=0.17 or left 7 vs. 7, p=0.87).Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.

To compare outcomes of patients undergoing continent or incontinent urinary diversion after pelvic exenteration for gynecologic malignancies.Data on patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 were collected. A multivariate logistic regression model was used and statistical significance was P0.05.A total of 133 patients were included in this study. The mean age at exenteration was 47.6 (range, 30-73) years in the continent urinary diversion group and 57.2 (range, 27-86) years in the incontinent urinary diversion group (P0.0001). Forty-six patients (34.6%) had continent urinary diversion, and 87 patients (65.4%) had incontinent urinary diversion. The rates of postoperative complications in patients with continent and incontinent urinary diversion, respectively, were as follows: pyelonephritis, 32.6% versus 37.9% (P=0.58); urinary stone formation, 34.8% versus 2.3% (P0.001); renal insufficiency, 4.4% versus 14.9% (P=0.09); urostomy stricture, 13.0% versus 1.2% (P=0.007); ureteral (anastomotic) leak, 4.4% versus 6.9% (P=0.71); ureteral (anastomotic) stricture, 13.0% versus 23% (P=0.25); fistula formation, 21.7% versus 19.5% (P=0.82); and reoperation because of complications of urinary diversion, 6.5% versus 2.3% (P=0.34). Among patients with continent urinary diversion, the incidence of incontinence was 28.3%, and 15.2% had difficulty with self-catheterization.There were no differences in postoperative complications between patients with continent and incontinent conduits except that stone formation was more common in patients with continent conduits.

Lymphatic mapping studies in women with cervical cancer typically identify sentinel nodes (SLNs) in the pelvis and not the parametrium. We added India ink as a mapping agent to determine whether this would allow us to pathologically identify sentinel parametrial nodes and to test our hypothesis that the parametrial nodes are the true SLNs in women with cervical cancer.We performed lymphatic mapping and SLN biopsy in 20 women with early-stage cervical cancer undergoing radical hysterectomy or trachelectomy using a "triple injection" technique with blue dye, radiocolloid, and India ink. Pathologic processing of parametrium and nodal tissue was then performed to identify India ink in specimens.On pathology review, 15 (75%) patients had a parametrial node identified, and 9 patients (45%) had bilateral parametrial nodes identified; the median number of parametrial nodes identified was 2 (range, 0-7). India ink was seen in at least 1 parametrial node in 13 (87%) of the 15 patients with a parametrial node identified pathologically. Of the 9 patients with bilateral parametrial nodes identified pathologically, only 5 (54%) had bilateral parametrial nodes containing India ink. India ink was found in 26 (44%) of 59 SLNs and only 1 (0.3%) of 289 non-SLNs. In 5 patients, India ink was seen in a SLN on the same side of the pelvis where a parametrial node was identified but not microscopically black.There appears to be direct drainage of cervical lesions to pelvic nodal basins bypassing small parametrial nodes. Parametrial nodes, therefore, may not always be the SLNs in women with cervical cancer.

Objective To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery. Methods We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30days after surgery Results Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p=0.015) and had younger median age 49years, 51years, and 46years, respectively; p=0.035. Nineteen (2.3%) patients experienced pulmonary complications — symptomatic atelectasis (n=9), pneumonia (n=5), acute respiratory failure (n=2), hypoxemia (n=1), pneumomediastinum (n=1), and pneumothorax (n=2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers. Conclusion In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.

To help determine whether global collaborations for prospective gynecologic surgery trials should include hospitals in developing countries, we compared surgical and oncologic outcomes of patients undergoing laparoscopic radical hysterectomy at a large comprehensive cancer center in the United States and a cancer center in Colombia.Records of the first 50 consecutive patients who underwent laparoscopic radical hysterectomy at The University of Texas MD Anderson Cancer Center in Houston (between April 2004 and July 2007) and the first 50 consecutive patients who underwent the same procedure at the Instituto de Cancerología-Clínica las Américas in Medellín (between December 2008 and October 2010) were retrospectively reviewed. Surgical and oncologic outcomes were compared between the 2 groups.There was no significant difference in median patient age (US 41.9 years [range 23-73] vs. Colombia 44.5 years [range 24-75], P=0.09). Patients in Colombia had a lower median body mass index than patients in the US (24.4 kg/m(2) vs. 28.7 kg/m(2), P=0.002). Compared to patients treated in Colombia, patients who underwent surgery in the US had a greater median estimated blood loss (200 mL vs. 79 mL, P0.001), longer median operative time (328.5 min vs. 235 min, P0.001), and longer postoperative hospital stay (2 days vs. 1 day, P0.001).Surgical and oncologic outcomes of laparoscopic radical hysterectomy were not worse at a cancer center in a developing country than at a large comprehensive cancer center in the United States. These results support consideration of developing countries for inclusion in collaborations for prospective surgical studies.

To compare intra-operative, postoperative and pathologic outcomes of three surgical approaches to radical hysterectomy and bilateral pelvic lymph node dissection over a three year time period during which all three approaches were used.We reviewed all patients who underwent radical hysterectomy with pelvic lymph node dissection between 1/2007 and 11/2010. Comparison was made between robotic, laparoscopic and open procedures in regard to surgical times, complication rates, and pathologic findings.A total of 95 radical hysterectomy procedures were performed during the study period: 30 open (RAH), 31 laparoscopic (LRH) and 34 robotic (RRH). There were no differences in age, body mass index or other demographic factors between the groups. Operative time was significantly shorter in the RAH compared to LRH and RRH (265 vs 338 vs 328min, p=0.002). Estimated blood loss was significantly lower in LRH and RRH compared with RAH (100 vs 100 vs 350mL, p0.001). Thirteen (24%) of RAH required blood transfusion. Conversion rates were higher in the LRH (16%) compared to RRH (3%) although not significant (p=0.10). Median length of stay was significantly shorter in RRH (1day) vs LRH or RAH (2 vs 4days, p0.01). Pathologic findings were similar among all groups.Minimally invasive surgery has made a significant impact on patients undergoing radical hysterectomy including decrease in blood loss and transfusion rates however; operative times were significantly longer compared to open radical hysterectomy. Our findings suggest that the robotic approach may have the added benefit of even shorter length of stay compared to traditional laparoscopy.

Several controversies surround lymphadenectomy for endometrial cancer; surgical approach, who to stage, and the anatomic borders of the lymphadenectomy. The purpose of this study was to identify practice patterns among gynecologic oncologists when performing a lymph node evaluation during staging for endometrial cancer.A self-administered survey was sent via email to all SGO members on 3 occasions between 2/09 and 4/09. The survey addressed surgical approach, algorithms used to determine staging, and anatomic landmarks defining lymphadenectomy.Four hundred and six members (40%) responded. Eighty-two percent completed fellowship and 14% were fellows. Thirty-four percent finished fellowship in 2000 or later. Eighty-five percent educate fellows/residents in either academic (65%) or private practice settings (20%). For a majority of cases 40% prefer laparotomy, 31% perform robotic surgery, and 29% use laparoscopy. Minimally invasive surgery was associated with university-based practice (p=0.048). Most (53%) never/rarely use frozen section to determine whether or not to perform lymphadenectomy. A majority perform staging on all grade 2 and grade 3 cancers (66% and 90%, respectively). When performing paraaortic lymphadenectomy, 50% of respondents use the IMA as the upper border and 11% take the dissection to the renal vessels. Participants who completed fellowship in 2000 or later were less likely to go to the renal vessels (p=0.002).Current controversies in surgical staging for endometrial cancer are reflected in the practice patterns among gynecologic oncologists. At this point it is unclear if standardizing surgical practice patterns will improve outcomes for patients with endometrial cancer.

Objective. This study aimed to determine the safety and feasibility of robotic radical trachelectomy and bilateral pelvic lymphadenectomy. We also describe our surgical technique. Methods. This is a retrospective review of all patients who underwent robotic radical trachelectomy and bilateral pelvic lymphadenectomy from October 2008 to May 2009. We analyzed our data to evaluate the safety and feasibility of this surgery. Results. This analysis included 4 patients with early-stage squamous cell carcinoma of the cervix. The median body mass index was 27.1 kg/m 2 (range, 22.7 to 39.1). Three patients had stage IA2 adenocarcinoma; 1 patient had stage IA1 adenocarcinoma with lymph-vascular space invasion. The median operative time was 339.5 min (range, 245 to 416). The median console time was 282.5 min (range, 217 to 338). The median estimated blood loss was 62.5 ml (range, 50 to 75). There were no conversions to laparotomy. There were no intraoperative complications. No patient required blood transfusion. The median length of hospital stay was 1.5 days (range, 1 to 2). One patient experienced a postoperative complication, transient left lower extremity sensory neuropathy. No patient had residual tumor in the trachelectomy specimen, and no patient underwent adjuvant therapy. The median number of pelvic lymph nodes removed was 20 (range, 18 to 27). The median time to a successful voiding trial was 8 days (range, 7 to 9). The median follow-up was 105 days (range, 82 to 217). There were no recurrences. Conclusion. Robotic radical trachelectomy and bilateral pelvic lymphadenectomy is feasible and safe and should be considered for patients desiring fertility-sparing surgery.

Objectives. The goal of this review is to summarize the latest literature on the subject of laparoscopic and robotic approaches for radical hysterectomy in patients with early-stage cervical cancer. Methods. We analyzed the published literature in search of all articles addressing surgical techniques, intraoperative and perioperative outcomes in patient undergoing radical hysterectomy by the minimally invasive approach. Results. Recurrence and overall survival rates in patients with early-stage cervical cancer are equivalent in patients who undergo laparoscopic radical hysterectomy and those who undergo surgery performed by laparotomy. There is growing evidence highlighting the benefits of robotic surgery in management of gynecologic malignancies. The advantages of the robotic system include three-dimensional vision, tremor reduction, seven degrees of intra-abdominal articulation, and motion scaling. Recent studies comparing radical hysterectomy performed through the open, laparoscopic, or robotics approach showed that there were no significant differences in intra- or postoperative complications among the three groups and no conversion in the robotic or laparoscopic groups. Conclusions. Total laparoscopic radical hysterectomy is a feasible and safe procedure that is associated with fewer intraoperative and postoperative complications than abdominal radical hysterectomy. We await results from additional series of radical hysterectomy performed by robotic surgery.

Objective. To retrospectively evaluate the feasibility and morbidity of total laparoscopic radical hysterectomy and lymphadenectomy. Methods. We performed a retrospective review of all patients who underwent a total laparoscopic radical hysterectomy at our institution between May 2004 and August 2005. Data collected included age, body mass index, stage, histopathologic subtype, tumor grade, estimated blood loss, perioperative blood transfusions, number and status of lymph nodes obtained, status of surgical margins, length of hospital stay, time to resumption of normal bladder function, intraoperative and postoperative complications, and disease-free interval. Results. Twenty patients underwent total laparoscopic radical hysterectomy during the study period. None of the surgeries required conversion to laparotomy. The median patient age was 41.5 years (range, 25–76). Eighteen patients had cervix cancer (5 stage IA2 and 13 stage IB1), and 2 had endometrial cancer (1 stage IB and 1 stage IIIA). Among those with cervix cancer, 12 had adenocarcinoma, 4 squamous cell carcinoma, and 2 adenosquamous carcinoma. The median weight was 70 kg (range, 49–112). The median number of resected pelvic lymph nodes was 13 (range, 9–26). One patient had nodal disease. The surgical margins were free of disease in all cases. The median blood loss was 200 ml (range, 25–700 ml). Only 1 patient required an intraoperative blood transfusion (1 U packed red blood cells). The median length of hospital stay was 1 day (range, 1–5). There were 3 short-term complications—unintentional cystotomy, pulmonary embolus, and pneumomediastinum with subcutaneous emphysema. There were 2 long-term complications—vaginal eviscerations and a lymphocyst. The median time to resumption of normal bladder function was 16 days (range, 13–29). The median follow-up time was 8 months range (1–16). All patients remain free of disease at the time of this report. Conclusions. Total laparoscopic radical hysterectomy can be performed safely with minimal blood loss and postoperative morbidity, and patients undergoing this procedure may be discharged after an overnight stay in the hospital.

To determine if young, normal-weight women with endometrial cancer have unique risk factors and clinical characteristics when compared with young, overweight and obese women with endometrial cancer.Between 1989 and 2003, 1531 patients were treated for endometrial cancer. 188 (12%) of these women were premenopausal and under the age of 50 at time of diagnosis. The patients were divided into three groups based on body mass index (BMI): normal weight (BMI25 kg/m2), overweight (BMI 25-30 kg/m2) and obese (BMIor = 30 kg/m2). Clinical and pathologic characteristics were compared.Of the 188 young endometrial cancer patients, 47 (25%) were of normal weight, 31 (17%) overweight and 106 (56%) obese. 4% of normal-weight, 12% of overweight and 0% of obese patients met criteria for Lynch syndrome/hereditary non-polyposis colorectal cancer (HNPCC). Irregular menstrual cycles were reported by 30% normal-weight, 32% of overweight and 61% of obese women (P = 0.001). 17% of normal-weight, 7% of overweight and 14% of obese women had a history of infertility (P = 0.723). Nulliparity was noted in 57% of normal-weight, 47% of overweight and 57% of obese patients (P = 0.583). Diabetes was reported in 4% of normal-weight, 13% of overweight and 35% of obese patients (P0.001). 28% of normal-weight, 26% of overweight and 14% of obese patients had synchronous primary tumors of the endometrium and ovary.As expected, a significantly higher proportion of obese and overweight women had diabetes and irregular menstrual cycles. Among the normal-weight women, a high proportion were nulliparous, had a history of infertility, irregular menstrual cycles and synchronous tumors of the endometrium and ovary when compared with the general population. This suggests that hormonal factors, and possibly polycystic ovarian syndrome (PCOS), may contribute to the development of endometrial cancer in young normal-weight women.

Objectives . Synchronous primary cancers of the endometrium and ovary are found in 10% of women with ovarian cancer and 5% of women with endometrial cancer. The purpose of this study was to characterize patients diagnosed with synchronous primary cancers of the endometrium and ovary with an emphasis on risk factors. Methods . Between 1989 and 2002, 84 patients with synchronous primary cancers of the endometrium and ovary were identified. Patients with uterine papillary serous carcinoma were excluded. Clinical and pathologic information was obtained from medical records. Parametric methods were used to compare clinical and pathologic features. Kaplan–Meier survival analyses were performed and compared using the log rank test. Results . Median age at diagnosis was 50 years. Median body mass index (BMI) was 28 kg/m 2 . Fifty-one percent (43/84) of the women were premenopausal and 33% (28/84) were nulliparous. The most common presenting symptom was abnormal vaginal bleeding; in those women with abnormal vaginal bleeding, 69% had stage I ovarian cancer. Ovarian cancer was an incidental finding in 48% of these patients. Sixty-eight percent of patients (57/84) had endometrioid histology of both their endometrial and ovarian cancers. Patients with early stage ovarian cancer tended to have a more favorable prognosis than those with advanced stage disease (median survival not reached in stage I and II versus 66 months in stage III and IV, P = 0.06). Patients with concordant endometrioid histology had a favorable prognosis (median survival 119 versus 48 months in all other groups, P = 0.02). Conclusions . In this large series of patients, women with synchronous primary cancers of the endometrium and ovary were young, obese, nulliparous, and premenopausal. Patients with concordant endometrioid tumors of the endometrium and ovary had a favorable prognosis, with median survival approaching 10 years.