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Purpose: To identify novel endometrial cancer-specific methylation markers and to determine their association with clinicopathologic variables and survival outcomes.Experimental Design: Differential methylation hybridization analysis (DMH) was done for 20 endometrioid endometrial cancers using normal endometrial DNA as a reference control. Combined bisulfite restriction analysis (COBRA) was used to verify methylation of sequences identified by DMH. Bisulfite sequencing was undertaken to further define CpG island methylation and to confirm the reliability of the COBRA. The methylation status of newly identified markers and the MLH1 promoter was evaluated by COBRA in a large series of endometrioid (n = 361) and non-endometrioid uterine cancers (n = 23).Results: DMH and COBRA identified two CpG islands methylated in tumors but not in normal DNAs: SESN3 (PY2B4) and TITF1 (SC77F6/154). Bisulfite sequencing showed dense methylation of the CpG islands and confirmed the COBRA assays. SESN3 and TITF1 were methylated in 20% and 70% of endometrioid tumors, respectively. MLH1 methylation was seen in 28% of the tumors. TITF1 and SESN3 methylation was highly associated with MLH1 methylation (P < 0.0001). SESN3 and TITF1 were methylated in endometrioid and non-endometrioid tumors, whereas MLH1 methylation was restricted to endometrioid tumors. Methylation at these markers was not associated with survival outcomes.Conclusions: The 5′ CpG islands for SESN3 and TITF1 are novel cancer-specific methylation markers. Methylation at these loci is strongly associated with aberrant MLH1 methylation in endometrial cancers. SESN3, TITF1 and MLH1 methylation did not predict overall survival or disease-free survival in this large cohort of patients with endometrioid endometrial cancer.

Objective We aimed to evaluate the efficacy and safety of combination bevacizumab/pemetrexed for the treatment of recurrent epithelial ovarian cancer (EOC). Methods Platinum-sensitive or -resistant patients with recurrent or persistent EOC were eligible if they had received up to 2 prior chemotherapy regimens, including a platinum/taxane regimen without prior bevacizumab. Pemetrexed 500mg/m 2 IV and bevacizumab 15mg/kg IV were administered every 3weeks. The primary endpoint was 6-month progression-free survival (PFS); other endpoints included toxicities, PFS and overall survival (OS). Results Thirty-four patients received a median of 7 treatment cycles (range, 2–26). Median follow-up was 25.7months (range, 3.0–47.2). Six month progression-free survival (PFS) was 56% (95% CI: 38–71). The following response rates were documented (%; 95% CI): 0 complete response, 14 partial responses (41%; 25–59), 18 stable disease (53%; 35–70) and 2 progressive disease (6%; 1–20). Median PFS was 7.9months (95% CI, 4.6–10.9), with a median OS of 25.7months (95% CI, 15.4–29.8). Twenty-two patients (64.7%) had a platinum-free interval (PFI) of >6months prior to enrollment. Grade 3–4 hematologic toxicities included neutropenia (50%), leukopenia (26%), thrombocytopenia (12%) and anemia (9%). Non-hematologic grade 3–4 toxicities included metabolic (29%), constitutional (18%), pain (18%) and gastrointestinal (15%). Two patients developed hematologic malignancies within one year of treatment. Conclusions Combination bevacizumab/pemetrexed is an active option for both platinum-sensitive and -resistant recurrent EOC. Further investigation of cost and novel toxicities associated with this regimen may be warranted.

OBJECTIVE To characterize gynecologic oncology patients' perceptions of the process of disclosure of a cancer diagnosis. METHODS We surveyed 100 gynecologic oncology patients between December 2011 and September 2012. An 83-item tool based on three validated assessment tools evaluated patient-centered factors, physician behavior and communication skills, and environmental factors. Associations between patients' satisfaction and these variables were analyzed using Wilcoxon rank-sum, Kruskal-Wallis, and Spearman's rho tests. Poisson regression was used to assess factors associated with patient's satisfaction. RESULTS Twenty-four percent of patients were notified of their diagnosis by phone, 60% in the physician's office, and 16% in the hospital. Disclosure was performed by an obstetrician-gynecologist (58%), gynecologic oncologist (26%), primary care physician (8%), or other (8%). Fifty-two percent of all patients were accompanied by a support person. Higher patient satisfaction scores were associated with face-to-face disclosure (mean score 91% compared with over the phone 72%, P=.02), a private setting (mean score 92% compared with impersonal setting 72%, P=.004), and duration of the encounter of greater than 10 minutes (mean score 94% compared with less than 10 minutes 79%, P

Objective The aim of this study was to report clinical outcomes of cervical cancer patients treated with weekly cisplatin chemo-radiation therapy (chemoRT) stratified by pre-treatment cisplatin in vitro chemosensitivity. Methods This was a retrospective analysis of patients with cervical cancer seen at our institution between May 2009 and August 2011. Patients underwent pre-treatment in vitro chemoresponse testing (Precision Therapeutics, Inc.) and were treated with concurrent weekly cisplatin chemoRT. The study consisted of 33 patients with FIGO tumor stages Ib2 to IIIb. Pre-treatment cisplatin chemoresponse of individual patient tumors was determined from chemoresponse dose response curves and scored as responsive (R), intermediate response (IR), or nonresponsive (NR). Results There were 28 patients with squamous cell carcinoma and 5 with adenocarcinoma. Cisplatin chemosensitivity was R and IR in 18 patient specimens and NR in 15. The 2-year recurrence-free survivals (RFS) were 87% for patients whose specimens tested R+IR to cisplatin compared to 58% for those whose specimens were NR (p=0.036). The 2-year RFS were 86% for the R+IR group compared to 46% for the NR group for patients with tumors of squamous cell histology (p=0.009). Stepwise proportional hazards modeling for RFS demonstrated that chemoresponsiveness to cisplatin (p=0.029) and FDG-PET lymph node status (p=0.011) were the only independent predictors of RFS for patients with tumors of squamous cell histology. Conclusion Pre-treatment in vitro cisplatin chemoresponse testing of cervix cancer biopsies was technically feasible and prognostic of RFS in patients treated with weekly cisplatin chemoRT.

MicroRNAs (miRNAs) are endogenous, non-coding RNA transcripts that regulate gene expression. Here, we report 175 putative novel miRNAs identified in uterine cancers profiled by Next Generation Sequencing. Our data indicate that one of these putative miRNAs (BCM-173) is conserved across multiple species and is expressed at levels similar to known human miRNAs. Functionally, this miRNA promotes the growth and migration of uterine cancer cell lines by targeting vinculin and altering the distribution of focal adhesions. These results expand our insight into the repertoire of human miRNAs and identify novel pathways by which dysregulated miRNA expression promotes uterine cancer growth.

Objective The objective of this study was to assess patients’ preferences of the timing of referral for genetic counseling and testing in relation to the diagnosis, treatment, and recurrence of ovarian, tubal, or primary peritoneal cancers. Methods Ninety-two patients who underwent counseling and testing by 1 certified genetic counselor were identified. An introductory letter, consent form, and questionnaire were mailed to gather information regarding factors influencing the decision to undergo genetic counseling and testing and opinions regarding optimal timing. Medical records were reviewed for demographic and clinical data. Results Of 47 consenting women, 45 underwent testing. Eight (18%) were found to have a genetic mutation. Women lacked consensus about the optimal time for referral for and to undergo genetic testing, although women with stage I disease preferred testing after completion of chemotherapy. Most women were comfortable receiving the results by phone, but one third preferred an office visit. Conclusions Patients’ views regarding the best time to be referred for and undergo counseling and testing varied greatly. Because of the high mortality of this disease, clinicians should discuss referral early and personalize the timing to each patient. The subset of patients who prefer results disclosure during an office visit should be identified at the time of their initial counseling.

Objective To determine the frequency and spectrum of mutations in RPL22 a gene identified by The Cancer Genome Atlas (TCGA) as mutated in endometrioid endometrial cancer, and determine the relationship between RPL22 defects and clinicopathologic features. Methods Direct sequencing of the entire coding region of the RPL22 cDNA and exons 2/4 was performed in tumors with/without microsatellite instability (MSI). RPL22 expression was assessed by immunofluorescence microscopy in the KLE, RL952 and AN3CA cell lines, wildtype, heterozygous and homozygous mutants, respectively. Relationships between RPL22 mutation and clinicopathological features were assessed using Chi-squared analysis and Student's t test. Progression-free survival (PFS) was calculated from the date of diagnosis to the date of recurrence. Results A single nucleotide deletion in an A8 coding repeat was identified in exon 2 of the RPL22 gene in 116/226 (52%) of MSI-high tumors. No mutations were identified in MSI-stable tumors. Only 2% of the tumors expressed a homozygous A deletion. RPL22 mutation was not associated with stage, grade, race and lymphovascular space invasion. Women whose tumors harbored RPL22 mutations were significantly older (67 vs. 63years, p =0.005). There was no difference in PFS between patients with the wildtype and mutant genotypes. Conclusions RPL22 is frequently mutated in MSI-high endometrioid endometrial cancers. The A8 mutation identified was not reported in the whole exome sequences analyzed by the TCGA. The demonstration of frequent mutation in RPL22 may point to a limitation of the exome capture and next generation sequencing analysis methods for some mononucleotide string mutations. Functional assessment of the RPL22 knockdown may be warranted.

Objective Lithium chloride (LiCl) has been shown to demonstrate anticancer properties at supratherapeutic doses. This study was designed to determine whether LiCl, as a single agent or in combination with cytotoxic agents, reduces ovarian cancer cell growth and metabolic activity at clinically achievable levels. Methods We studied the effects of LiCl on 2 high-grade serous ovarian cancer cell lines, SKOV3 and OVCA 433, and primary cultures developed from ascitic fluid collected from patients with metastatic high-grade serous ovarian cancer. We assessed proliferation and metabolism using cell cycle analysis, MTT assays, and cellular proliferation and clonogenic potential assays. Results Treatment with 1 mM LiCl had no effect on the cell cycle distribution or metabolic activity of the SKOV3 and OVCA 433 cell lines. Combination treatment with cisplatin or paclitaxel led to statistically significant decreases in metabolic activity in the OVCA 433 cell line and 50% of cultures investigated. The decreased metabolic activity was not, however, associated with decreased cell growth or clonogenic potential. Conclusions Combination treatment with LiCl and cytotoxic agents at physiologically achievable drug concentrations reduces ovarian cancer cell metabolism but does not appear to affect cellular proliferation. The potential for combined lithium/cytoxic therapies appears to be limited based on our analysis of both established cell lines and short-term ovarian cancer cultures.

Squamous cell carcinoma antigen (SCC Ag) is a serum biomarker for squamous cell carcinoma (SCC) of the cervix. We investigated the prognostic significance of SCC Ag levels before and at the completion of chemoradiotherapy and compared these levels with the results of pre- and posttreatment positron emission tomography/computed tomography (PET/CT) using [(18)F]fluorodeoxyglucose (FDG).The records of 63 women who underwent definitive chemoradiotherapy for SCC of the cervix were reviewed. SCC Ag levels were obtained before and at the completion of radiotherapy. Patients were divided into two groups on the basis of their pretreatment SCC Ag level (30 ng/mL vs. ≤30 ng/mL). Pre- and posttreatment FDG-PET/CT characteristics and progression-free survival (PFS) were analyzed according to SCC Ag groups.Median follow-up was 12 months. Women with SCC Ag30 ng/mL at diagnosis had more advanced lymph node disease on pretreatment FDG-PET/CT than those with SCC Ag ≤30 ng/mL (p = .002). Women whose SCC Ag normalized at the completion of chemoradiotherapy were more likely to have a complete metabolic response on their 3-month posttreatment FDG-PET/CT than those whose SCC Ag did not normalize (p = .006). The 2-year PFS was 73% for patients with a SCC Ag level ≤30 ng/mL at diagnosis compared with 0% for those with a SCC Ag level30 ng/mL at diagnosis (p.0001). The 2-year PFS was 62% for patients whose SCC Ag normalized at the completion of chemoradiotherapy compared with 0% for those whose SCC Ag did not normalize (p = .0004).Elevated SCC Ag at diagnosis and failure of the SCC Ag to normalize at the completion of treatment are associated with incomplete metabolic response and decreased PFS.

A subgroup of endometrial cancer patients with early-stage disease will progress or eventually present with recurrent disease. Multiple risk stratification strategies have been attempted to direct adjuvant therapeutic interventions. Radiation has been the most common form of adjuvant therapy offered to these patients. Unfortunately, its use has not translated into survival improvements. There is growing evidence supporting the use of adjuvant chemotherapy and multimodal interventions for patients with endometrial cancer. This review focuses on the role of adjuvant therapies for patients with early-stage disease with emphasis on future directions for risk stratification and personalized treatment.

The clinicopathologic significance of lower uterine segment involvement (LUSI) in endometrial cancer patients remains unclear. Although LUSI has been reported to be a prognostic indicator, literature is limited. We studied 481 surgically staged endometrioid endometrial cancers with disease confined to the uterus (FIGO 1988 stage I or II). Primary outcomes were overall survival (OS) and disease-free survival (DFS). The relationships between LUSI and OS and DFS were assessed using the Kaplan–Meier method and Cox proportional hazard models. The t test or Fisher exact test was used for evaluating relationships between variables of interest. LUSI was present in 223 cases (46.4%), and was associated with both decreased disease free survival (P = 0.02) and overall survival (P = 0.01) in univariate analysis. Multivariate analysis confirmed the association between LUSI and increased risk for recurrence [hazard ratio (HR) 2.27; 95% confidence interval (95% CI) 1.09–4.7; P = 0.03] and increased mortality (HR 1.76; 95% CI 1.12–2.78; P = 0.01). LUSI in patients with early-stage endometrioid endometrial cancer is associated with decreased survival.

Recent randomized controlled data suggest that neoadjuvant chemotherapy (NACT) with interval debulking (ID) may produce similar overall survival and progression free survival compared to standard primary cytoreduction followed by chemotherapy. The object of our study was to assess current patterns of care among members of the Society of Gynecologic Oncologists (SGO), specifically collating their opinions on and use of NACT for advanced stage ovarian cancer.A 20-item questionnaire was sent to all working e-mail addresses of SGO members (n=1137). The data was collected and analyzed using descriptive statistics with commercially available online survey software. The Chi-square test for independence was used to determine differences in responses between groups.Of 339 (30%) responding members, most rarely employ NACT, with 60% of respondents using NACT in less than 10% of advanced stage ovarian cancer cases. Respondents did not consider available evidence sufficient to justify NACT followed by ID (82%), nor did most think it should be preferred (74%). Sixty-two percent of respondents thought it was impossible to accurately predict preoperatively whether an optimal cytoreduction is possible. Thirty-nine percent believed that women with bulky upper abdominal disease on preoperative imaging would benefit from NACT versus primary debulking. If gross disease were found at ID, 43% would continue to treat with IV chemotherapy, and 42% would place an IP port if optimally cytoreduced. When ID reveals microscopic disease, 51% would continue IV treatment and the remaining IP therapy. Eighty-six percent of the respondents believed that both biological and surgical factors determine patient outcomes.The majority of responding SGO members do not treat patients with NACT followed by ID. Currently available studies of NACT/ID have been insufficient to convince most gynecologic oncologists to incorporate it into practice. Our results provide a benchmark against which further research can assess the penetration of NACT/ID into clinical practice.

INTRODUCTION:Despite equal access to family history and screening guidelines, we hypothesize that there is a failure to identify “automatic referral” patients (i.e. < 50 years old, histology, and family history) for genetic counseling services among oncologic practices.METHODS:A retrospective chart

The aim of this study was to evaluate the effect of number of chemotherapy cycles and other clinical and pathologic factors on progression-free (PFS) and overall survival (OS) in patients with newly diagnosed cervical cancer.We identified 118 patients with locally advanced cervical cancer (stages IB2-IVA) treated with combination weekly cisplatin (40 mg/m(2)) and radiation therapy (RT) between 2003 and 2007. Kaplan-Meier and Cox proportional hazard models were utilized to evaluate PFS and OS for associations with number of chemotherapy cycles and other factors.The majority of patients had stage IB2 or II disease (70%), squamous histology (91%), and size6 cm (65%). Median RT duration was 50 days and 95% received brachytherapy. Thirty percent of patients completed6 cycles of chemotherapy, and estimated PFS and OS were 63% and 75%, respectively. In multivariate analyses, the number of chemotherapy cycles was independently predictive of PFS and OS. Patients who received6 cycles of cisplatin had a worse PFS (HR 2.65; 95% CI 1.35-5.17; p=0.0045) and OS (HR 4.47; 95% CI 1.83-10.9; p=0.001). Advanced stage, longer time to RT completion, and absence of brachytherapy were also associated with decreased OS and PFS (p0.05). Similar results were found when analysis was conducted using a breakpoint of at least five but not less than five chemotherapy cycles. Higher grade was associated with decreased PFS (p=0.03) but not OS. Age, race, BMI, tumor size, smoking, histology, and IMRT were not statistically significant for OS or PFS.Aggressive supportive care to minimize missed chemotherapy treatments may improve survival after chemoradiation.

To explore the yield and impact of perioperative imaging on management among patients undergoing surgical resection and treatment of uterine sarcomas.A retrospective chart review was done for women with histologically confirmed uterine sarcomas treated at Barnes Jewish Hospital/Washington University from 2001 to 2007. Descriptive statistics, Cox multivariate models, and Kaplan-Meier plots were used to evaluate associations and survival.A total of 92 patients were identified and 55 (60%) were diagnosed with stage III-IV disease. Perioperative imaging was obtained in 84 (91%) cases, including chest X-ray in 66 (72%), computerized tomography (CT) of the abdomen and pelvis in 59 (64%), chest CT in 33 (36%), positron emission tomography (PET) in 8 (9%), and CT of the head, pelvic magnetic resonance imaging (MRI), or bone scan in a total of 2 (2.2%). Imaging identified abnormalities concerning for metastases in 30 (32%) studies. Thirty-four recurrences have been documented, and 21 (62%) of these treatment failures were extrapelvic. Multivariate analysis of this series noted that tomographic evidence of extrauterine disease predicted recurrence (p=0.028) and incomplete surgical resection (p=0.003, HR 6.0 95% CI 1.9-19.9) predicted disease-free survival. Imaging contributed to change in surgical and post-surgical treatment decisions in 8 (9%) patients.Pretreatment imaging studies change management in a minority of patients with newly diagnosed uterine sarcomas.

Objectives Recent data has highlighted the role of PET/CT in the pretreatment evaluation and follow-up of patients with cervical cancer. The objective of our study was to assess the acceptance of PET/CT into the management of patients with cervical cancer. We also explored potential barriers to the use of these imaging modalities in patients with cervical cancer. Methods A 14-item electronic questionnaire was initially sent to all working addresses of members of the SGO ( n =1048). An opt-out option was offered. For members who did not respond within 3 weeks, a second electronic invitation was sent. A third request was finally sent to further improve response rates. Data were collected and analyzed using a commercially available on-line survey database. Results A total of 305 responses were collected for an overall 30% response rate. PET/CT appears to be widely available (99%) and accessible (75%) in most practices. Although 83% of members order routine CT imaging for all newly diagnosed cervical cancer cases, only 28% routinely order a PET/CT. Conversely, 64% would order a PET/CT for newly diagnosed patients with advanced disease or those at high risk for distant metastatic disease. Most members (82%) do not routinely use PET/CT to assess response to treatment. Twenty percent of members believe that no useful prognostic information can be obtained from routine use of molecular imaging in patients with cervical cancer. The most common barriers for use of PET/CT cited by members were perceived lack of third-party payer coverage and lack of scientific evidence. Conclusions Despite clear scientific data supporting the use of PET/CT in patients with cervical cancer and apparent widespread availability, this imaging modality remains highly underutilized in clinical practice. Clarifying insurance coverage early in the evaluation process and replicating studies that have shown effectiveness of PET/CT in multiple roles may improve adoption of this potentially useful imaging modality.

Purpose Mutations in the DNA damage response gene ATR (exon 10 A10 mononucleotide repeat) have been previously described in endometrial and other cancers with defective DNA mismatch repair. In vitro studies showed that endometrial cancer cell lines with A10 repeat tract truncating mutations have a failure in the ATR-dependent DNA damage response. Cell lines carrying A10 mutations fail to trigger Chk1 activation in response to ionizing radiation and topoisomerase inhibitors. We sought to determine the frequency and clinicopathologic significance of ATR mutations in patients with endometrioid endometrial cancer. Patients and Methods The ATR exon 10 A10 repeat was analyzed by direct sequencing in 141 tumors with microsatellite instability (MSI-positive) and 107 microsatellite stable (MSI-negative) tumors. The relationships between mutations and clinicopathologic variables, including overall and disease-free survival, were assessed using contingency table tests and Cox proportional hazard models. Results ATR mutations were identified in 12 cases (4.8%; three cases with insertions and nine cases with deletions). Mutations occurred exclusively in MSI-positive tumors (P = .02), with an overall mutation rate of 8.5%. Mutation was not associated with age, race, surgical stage, International Federation of Gynecology and Obstetrics grade, or adjuvant treatment. Multivariate analyses revealed a significant association with reduced overall survival (hazard ratio [HR] = 3.88; 95% CI, 1.64 to 9.18; P = .002) and disease-free survival (HR = 4.29; 95% CI, 1.48 to 12.45; P = .007). Conclusion Truncating ATR mutations in endometrial cancers are associated with biologic aggressiveness as evidenced by reduced disease-free and overall survival. Knowledge of ATR mutation status may hold promise for individualized treatment and targeted therapies in patients with endometrial cancer.

We ascertained a large kindred with an excess of Lynch syndrome-associated cancers. Our objective was to determine if a defect in one of the DNA mismatch repair (DMMR) genes was the probable cause of cancer susceptibility as microsatellite instability (MSI) and immunohistochemical (IHC) analysis of the probands' tumors did not provide a clear indication.A detailed history and review of medical records was undertaken to construct a four-generation pedigree. Blood samples were obtained for analysis of germline DNA. Polymorphic repeats from the MLH1, MSH2, MSH6, and PMS2 loci were genotyped and the co-segregation of markers and disease was assessed. DMMR gene expression for all available tumors was evaluated by IHC. Combined bisulfite restriction analysis (COBRA) of MLH1 was utilized to test for germline epimutation.Four gynecologic carcinomas, 3 colon carcinomas, and 13 cases of adenomatous polyps were identified. The family met Amsterdam II criteria. The mean age of cancer diagnosis in the kindred was 63 years (range 44-82 years). DNA marker analyses excluded linkage to MLH1, MSH2, MSH6, and PMS2. Furthermore, MSI and IHC analysis of tumors did not suggest a role for DMMR. Methylation of the MLH1 promoter was identified in the peripheral blood leukocytes (PBLs) of a family member with an early onset colon cancer.We identified a large family with multiple Lynch malignancies and no evidence for an inherited defect in DMMR. This family represents an important but poorly understood form of autosomal dominant inherited cancer susceptibility. Aberrant MLH1 promoter methylation in normal tissues may be a marker for cancer susceptibility in families such as this.

Purpose Most studies of microsatellite instability (MSI) and outcomes in endometrial cancer patients have included varied histologic subtypes. Nonetheless, MSI occurs almost exclusively in endometrioid tumors. The impact of MSI on outcomes in patients with endometrial cancer is controversial. We sought to determine whether MSI and MLH1 methylation are associated with clinicopathologic variables and survival outcomes in a large series of patients with endometrial carcinomas of the endometrioid type. Patients and Methods Tumor samples, blood, and clinicopathologic data were prospectively collected and analyzed for 446 patients with endometrioid carcinomas. MSI was determined using five National Cancer Institute (NCI) consensus panel markers, and the methylation status of the MLH1 promoter was determined by combined bisulfite restriction analysis (COBRA). Associations with clinicopathologic variables and survival outcomes were evaluated. Results MSI was identified in 147 cases (33%). MSI was associated with higher International Federation of Gynecology and Obstetrics (FIGO) grade (P < .0001). MSI+ tumors without MLH1 methylation were associated with younger age (P < .001). MSI was not associated with overall survival (OS; hazard ratio [HR], 1.011; 95% CI, 0.688 to 1.484; P = .96) or disease-free survival (DFS; HR 0.951; 95% CI, 0.554 to 1.635; P = .86). The combined MSI/MLH1 methylation status (treating MSI− as the reference) did not predict OS (MSI+/MLH1-U: HR, 0.62; 95% CI, 0.27 to 1.44; P = .26; MSI+/MLH1-M: HR, 0.95; 95% CI, 0.62 to 1.46; P = .82) or DFS (MSI+/MLH1-U: HR, 0.51; 95% CI, 0.22 to 1.19; P = .12; MSI+/MLH1-M: HR, 0.93; 95% CI, 0.62 to 1.40; P = .72). Conclusion MSI is not associated with survival in patients with endometrioid endometrial cancer.

Purpose: To identify novel endometrial cancer-specific methylation markers and to determine their association with clinicopathologic variables and survival outcomes.Experimental Design: Differential methylation hybridization analysis (DMH) was done for 20 endometrioid endometrial cancers using normal endometrial DNA as a reference control. Combined bisulfite restriction analysis (COBRA) was used to verify methylation of sequences identified by DMH. Bisulfite sequencing was undertaken to further define CpG island methylation and to confirm the reliability of the COBRA. The methylation status of newly identified markers and the MLH1 promoter was evaluated by COBRA in a large series of endometrioid (n = 361) and non-endometrioid uterine cancers (n = 23).Results: DMH and COBRA identified two CpG islands methylated in tumors but not in normal DNAs: SESN3 (PY2B4) and TITF1 (SC77F6/154). Bisulfite sequencing showed dense methylation of the CpG islands and confirmed the COBRA assays. SESN3 and TITF1 were methylated in 20% and 70% of endometrioid tumors, respectively. MLH1 methylation was seen in 28% of the tumors. TITF1 and SESN3 methylation was highly associated with MLH1 methylation (P < 0.0001). SESN3 and TITF1 were methylated in endometrioid and non-endometrioid tumors, whereas MLH1 methylation was restricted to endometrioid tumors. Methylation at these markers was not associated with survival outcomes.Conclusions: The 5′ CpG islands for SESN3 and TITF1 are novel cancer-specific methylation markers. Methylation at these loci is strongly associated with aberrant MLH1 methylation in endometrial cancers. SESN3, TITF1 and MLH1 methylation did not predict overall survival or disease-free survival in this large cohort of patients with endometrioid endometrial cancer.

Objective To examine maternal temperature changes after epidural analgesia. Methods A prospective cohort of nulliparas at term was monitored with hourly maternal tympanic temperatures after epidural analgesia (n=99). Temperature response after epidural analgesia was examined in the group as a whole. Subsequently, mean maternal temperature curves were compared between women who remained afebrile throughout labor (n=77) and women who developed intrapartum fever with body temperature greater than 100.4 degrees F (n=22). Baseline maternal characteristics were assessed. Results Women who later developed intrapartum fever had a higher mean temperature within 1 hour after epidural analgesia. In contrast, women who remained afebrile had no increase in core temperature. During the first 4 hours after epidural analgesia initiation, women who later develop intrapartum fever have an increase in mean tympanic temperature of 0.33 degrees F per hour. Conclusion Epidural analgesia is not associated with increased temperature in the majority of women. Hyperthermia is an abnormal response confined to a minority subset, which occurs immediately after exposure. Our findings do not support a universal perturbation of maternal thermoregulation after epidural analgesia. Level of evidence II.

Objective We sought to validate the clinicopathologic implications and prognostic significance of ATR (ataxia telangiectasia mutated and Rad3-related) mutation in patients with endometrioid endometrial cancer and defective DNA mismatch repair enrolled in a cooperative group molecular staging study of endometrial cancer. Methods After pathology review, only endometrioid tumors with high neoplastic cellularity (≥70%) and high quality DNA for molecular analyses were included. MSI (microsatellite instability) typing was performed and the target sequence in exon 10 of ATR was evaluated by direct sequencing in all MSI-high tumors. Associations between ATR mutations and clinicopathologic variables were assessed using contingency table tests. Differences in overall survival (OS) and disease-free survival (DFS) were evaluated by univariate analyses and multivariable Cox proportional hazard models. Results A total of 475 eligible cases were identified. Of 368 MSI+ cases, the sequence of interest could be successfully genotyped in 357 cases. ATR mutations were exclusively identified in 46 tumors with high level microsatellite instability (MSI+) (12.9%, p ATR mutations were not associated with OS (HR 1.16; 95% CI, 0.58–2.32; p=0.68) or DFS (HR 0.61; 95% CI, 0.25–1.50; p=0.28). Conclusion Truncating mutations in exon 10 of ATR occur exclusively in tumors with evidence of defective DNA mismatch repair. We were not able to confirm the prognostic value of these mutations in patients with endometrioid endometrial cancer.

We sought to review outcomes in patients with stage IVB carcinoma of the cervix treated with irradiation in combination with chemotherapy. We report outcomes of 24 consecutive patients with good performance status treated from 1998 to 2005. Most of these patients underwent concurrent irradiation with platinum-based chemotherapy. Some patients received subsequent systemic chemotherapy. All patients underwent external beam radiotherapy; 7 patients (29%) had additional high-dose-rate and 12 (50%) low-dose-rate brachytherapy. Two patients (8%) received an IMRT boost instead of brachytherapy. The mean dose to point A was variable (73.9 ± 19.2 Gy). Twenty patients (83%) received radio-sensitizing platinum-based chemotherapy, and the remaining had radiotherapy alone. Seven patients (29%) had further combination chemotherapy. Therapy was well tolerated. The overall survival was 44% at 36 months and 22% at 5 years. Patients with stage IVB cervical cancer have mostly been treated with palliative intent. With the advent of concurrent chemoradiation, we have treated many of these cases with aggressive combination therapy. In this series, the use of radiotherapy and multiagent chemotherapy in patients with stage IVB cervical carcinoma and good performance status was well tolerated and resulted in higher survival rates than previously reported.

Cystoscopy can be performed during hysterectomy for many reasons, especially for suspicion of urologic injury (Ribeiro et al., 1999). Though it is debated whether routine cystoscopy should be performed at every hysterectomy, especially with regard to cost-effectiveness, routine cystoscopy is still commonly performed. Although not cost-effective in the general population, another potential use of routine cystoscopy is to evaluate for non-iatrogenic ureteral abnormalities. Additionally, some surgeons at large academic institutions take advantage of universal or selective post-operative cystoscopy as an opportunity to teach trainees this important surgical skill. At the time of hysterectomy, most urologic findings (e.g. hematuria or lack of ureteral efflux) are due to bladder and/or ureteral injuries. Many of these findings are due to idiopathic and self-resolving causes (Wilson and Merkur, 2008). However, urologic findings in certain gynecologic oncology patients should raise concern about the possibility of synchronous malignancies. For instance, Lynch syndrome (hereditary non-polyposis colorectal cancer, HNPCC) is a rare but significant risk factor for ureteral transitional cell carcinoma (TCC). Whereas there have been reports of intraoperatively-found incidental lymphoepithelial ureteral carcinomas (Ma et al., 2008), a Pubmed search using the terms “transitional cell carcinoma” (or ureteral tumor), “incidental” and “hysterectomy” revealed no prior reports of incidentally-found ureteral TCCs associated with and leading to the diagnosis of Lynch syndrome.

Background . Intraperitoneal seeding is the most common form of dissemination of epithelial ovarian cancer. Metastasis to the bowel mucosa can occur by invasion from the serosal surface or infiltration of the submucosal capillary network. Hematogenous dissemination usually occurs in the presence of advanced peritoneal disease. Case . A 39-year-old gravida 3 para 2 woman was diagnosed in October 2000 with a large pelvic mass. She underwent an exploratory laparotomy and a left salpingo-oophorectomy with multiple abdominal and pelvic biopsies. She was diagnosed with an ovarian tumor of low malignant potential, and no further treatment was recommended. Six months later, she developed abdominal discomfort and constipation. A colonoscopy was performed, and a biopsy showed metastatic carcinoma of ovarian origin. The patient presented to The University of Texas M.D. Anderson Cancer Center in September 2001 for consultation. The surgical pathology evaluation from her previous surgery indicated high-grade ovarian carcinoma. The patient underwent a total abdominal hysterectomy, right salpingo-oophorectomy, infracolic omentectomy, right pelvic lymph node sampling, and segmental resection with primary end-to-end sigmoid colon anastomosis. The tumor within the colon was a polypoid mass arising from the mucosa with no involvement of the colonic wall. Microscopically, the tumor was a high-grade ovarian papillary serous carcinoma with areas of endometrioid adenocarcinoma. The colonic tumor was immunohistochemically positive for cytokeratin-7 and negative for cytokeratin-20. The patient was treated with six cycles of carboplatin and paclitaxel. The patient then incidentally developed disseminated sarcoidosis. At the time of this report, the patient had no evidence of recurrent or metastatic disease for 2 years. Conclusions. Epithelial ovarian carcinomas may recur as intraluminal bowel lesions with serosal sparing even in the absence of peritoneal disease. Immunohistochemical staining using cytokeratins-7 and -20 may prove useful in differentiating such lesions from primary colonic malignancies.

Background Gastrointestinal stromal tumors (GISTs) are c-kit-positive tumors that may arise anywhere in the tubular gastrointestinal tract. Around 5% of the cases arise elsewhere in the abdominal cavity. Tumors originating in the omentum and mesentery have been reported. Case A 31-year-old woman presented with pelvic pain, a palpable pelvic mass, and elevated CA-125. Imaging showed innumerable pelvic and abdominal masses. Histopathology showed a GIST that was positive for c-kit and vimentin and negative for desmin and smooth muscle actin. The patient was started on imatinib mesylate. Six months after diagnosis the tumor has remained stable. Conclusions GI stromal tumors (GIST) may initially present as pelvic mass with elevated CA-125. Imatinib mesylate is the current mainstay therapy for GISTs after surgery.

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research.

To estimate the accuracy of vaginal cytology in postoperative surveillance for detecting recurrent endometrial cancer and to estimate the optimal management of squamous abnormalities detected in this setting.This review included women who underwent hysterectomy for endometrial cancer between January 1, 2006, and December 31, 2010, and had at least one postoperative Pap test. Clinical and demographic data were collected and outcomes including abnormal vaginal cytology, results of colposcopic examination, and endometrial cancer recurrence were assessed. A Cox regression model to estimate the risk of abnormal cytology was created. Sensitivity, specificity, and negative and positive predictive values of detecting vaginal recurrences were calculated.Four hundred thirty-three women contributed 2,378 Pap tests. At least one abnormal cytology result was found during follow-up of 55 (13%) women, representing 3% of all Pap tests. No recurrent endometrial cancers were diagnosed on the basis of isolated abnormal cytology. No cases of recurrent cancer were diagnosed in women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion (LSIL) Pap test results. In multivariable analysis, abnormal cytology was highly associated with prior postoperative radiation therapy (P.001). The sensitivity, specificity, and positive and negative predictive values of an abnormal Pap test result in detecting a local recurrence are 40%, 87.9%, 7.3%, and 98.4%, respectively.Colposcopy is not needed after a Pap test result read as atypical squamous cells of undetermined significance or LSIL.III.

Adjuvant radiotherapy improves local control but not survival in women with endometrial cancer. This benefit was shown in staged patients with "high intermediate risk" (HIR) disease. Other studies have challenged the need for systematic staging including lymphadenectomy. We sought to determine whether LVSI alone or in combination with other histologic factors predicts lymph node (LN) metastasis in patients with endometrioid endometrial cancer.A retrospective review was conducted of patients with endometrioid endometrial carcinoma who had confirmed presence/absence of LVSI and clinicopathologic data necessary to identify HIR criteria. Kaplan-Meier curves were generated and univariate and multivariate analyses performed as appropriate.We identified 757 eligible patients and 628 underwent systematic lymphadenectomy for staging purposes. In the surgically staged group, 242 (38%) patients met uterine HIR criteria and 196 (31%) had LVSI. Both HIR and LVSI were significantly associated with LN metastasis. Among the HIR positive group, 59 had LN metastasis (OR 4.46, 95% CI 2.72-7.32, P0.0001). Sixty-six LVSI positive patients had nodal metastasis (OR 11.04, 95% CI 6.39-19.07, P0.0001). The NPV of LVSI and HIR negative specimens was 95.6% and 93.4% respectively. In multivariate analysis, PFS and OS were significantly reduced in both LVSI positive (P0.0001) and HIR patients (P0.0001) when compared to patients who were LVSI and HIR negative.HIR status and LVSI are highly associated with LN metastasis. These features are useful in assessing risk of metastatic disease and may serve as a surrogate for prediction of extrauterine disease.

Hypothesis The hypothesis of this study is that routine blind peritoneal biopsies performed during the surgical staging of apparent early ovarian cancers rarely influence final cancer stage and thus are of little benefit to staging. Few studies have been done examining this question of whether the biopsies of grossly normal-appearing peritoneal tissue are of benefit to the surgical staging procedure. Methods Operative and pathology reports from 122 patients with early-stage epithelial ovarian cancer staged by gynecologic oncologists at Barnes-Jewish Hospital from 1995 to 2009 were reviewed. All had full surgical staging resulting in a final stage of IA to IIIA. The operative findings were assessed to determine how frequently the peritoneal biopsies upstaged the cancer. Other findings including age, grade, histological type, and preoperative CA-125 were assessed. Results The median age of the patients was 53 years (range, 23-81 years). The distribution of cancer types was endometrioid (42), serous (23), clear cell (19), mucinous (16), and mixed or other (22). The most frequent stage was IC (n = 50; 41%), followed by IA (n = 40; 33%). A total of 19 patients had positive peritoneal biopsies (16%). Of these, only 6 (5%) were microscopically positive, or from normal-appearing tissue. Five (4%) of these 6 subjects were upstaged by the random peritoneal biopsies alone. Five (4%) of the patients had microscopic metastases to the omentum, 4 (3%) of whom were upstaged by this finding alone. One patient had both microscopic peritoneal and omental disease. Conclusions Although the rate of microscopic metastases to peritoneal tissue is low, random peritoneal biopsies are still indicated in early-stage disease owing to the low morbidity of the procedure and a small but present possibility of upstaging and altered management. Furthermore, systematic peritoneal biopsies ensure careful palpation and examination of all surfaces.

To explore clinical correlates of wound complications in high-risk women undergoing abdominal gynecologic surgery in a tertiary referral center.Retrospective analysis of patient demographics, pre-operative and intra-operative information, and outcomes was performed in a cohort of patients who underwent abdominal surgery for suspected gynecologic malignancy between 1/2005 and 6/2008. The primary outcome was wound complication within 6 weeks of surgery. Univariate and multivariate logistic regression analyses were employed. A nomogram predicting post-operative wound complications was created and validated by receiver operating characteristic (ROC) curve analysis and 10-fold cross-validation.Median age of 373 women analyzed was 57years (range 25-88), median body mass index (BMI) 32.3kg/m(2) (range 14.0-70.7). A total of 150 patients (40%) had prior abdominal surgery; 40 (11%) had a pre-operative serum albumin3.5g/dl; and 78 (21%) had pulmonary disease. Wound complications occurred in 125 patients (34%). In multivariate analysis wound complications were correlated with BMI of 30-39.9kg/m(2) (OR=5.62, 95% CI 2.08-15.19, p0.0001) and BMI≥40kg/m(2) (OR=10.27, 95% CI 3.66-28.88, p0.0001), prior abdominal surgery (OR 3.28, 95%CI1.89-5.70, p0.0001), serum albumin≤3.5g/dl (OR 4.24, 95%CI 1.87-9.61, p=0.0005), pulmonary disease (OR 2.22, 95%CI 1.09-4.51, p=0.03), lysis of adhesions (OR 3.57, 95%CI 1.04-12.26, p=0.04), and length of surgery (OR 2.42, 95%CI 1.35-4.35, p=0.003). Risk for wound complication was lower with pelvic drain placement (OR 0.26, 95%CI 0.11-0.64, p=0.003).Wound complications are common in gynecologic oncology. Further studies should explore whether risk factor modification decreases complications.

Objective Venous thrombosis is a frequent complication of gynecologic cancer. Data regarding the use of inferior vena cava (IVC) filters in this population is limited. The aim of this study was to review our experience with gynecologic oncology patients who received an IVC filter, specifically to evaluate indications for filter placement and survival outcomes. Methods This was a retrospective, single-institution study of patients who had an IVC filter placed after a histologically confirmed gynecologic malignancy. Patients were identified from a prospectively collected interventional radiology (IR) database. Clinicopathologic characteristics, procedure details, and outcome data were obtained from outpatient and inpatient medical records. Survival after IVC filter placement was analyzed using the Kaplan–Meier product limit method and compared by log-rank test. Results A total of 128 patients were identified and 103 were found to be eligible for analysis. Most patients had ovarian cancer (52%), followed by cervical cancer (25%) and endometrial cancer (21%). Two-thirds had advanced stage disease (III/IV). The procedure complication rate was 2%. Median survival after IVC filter placement was 7.8months (95% CI, 4.1–13.6). The most common indication for IVC filter placement was contraindication to anticoagulation secondary to hemorrhage (44%), followed by perioperative indications (30%) and failed anticoagulation (14%). There was no difference in survival by IVC filter placement indication ( p =0.18). The majority of the IVC filters placed were permanent (90.5%) and in an infrarenal position (95.8%). There was no difference in survival according to specific thromboembolic event (DVT vs. PE vs. both). Patients able to receive anticoagulation after IVC filter placement had improved survival (HR 0.45, 95%CI 0.45–0.27, p =0.003). Conclusions We present the largest series of gynecologic oncology patients treated with IVC filters. Long-term survival after IVC filter placement is uncommon. Patients who receive anticoagulation after IVC filter placement have an improved survival over those who do not receive anticoagulation; this difference in survival may be secondary to worsening disease causing contraindications to anticoagulation.

BACKGROUND: The objective of this study was to determine whether lower expression levels of DICER1 are associated with disease recurrence in patients with endometrioid endometrial cancer. The authors also explored DNA methylation and haploinsufficiency as potential mechanisms related to altered DICER1 expression in these tumors. METHODS: DICER1 expression was assessed by quantitative polymerase chain reaction in a selected cohort of endometrioid endometrial tumors (N = 169). Loss of heterozygosity analyses were conducted using 2 single nucleotide polymorphisms, and combined bisulfate restriction analysis was used to assess methylation in the 5′-untranslated region of DICER1 in representative tumors. The correlations between DICER1 expression and clinicopathologic variables, including overall survival (OS) and disease-free survival (DFS), were assessed using nonparametric rank-sum tests and Cox proportional hazard models as appropriate. Survival distributions were described using the Kaplan-Meier method. A nested case-control analysis was conducted to confirm the association between transcript levels and disease recurrence. RESULTS: Lower DICER1 expression (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.05-1.75; P = .02) and advanced disease stage (HR, 2.79; 95%CI, 1.59-4.90; P < .001) were associated with worse DFS. Three variables were associated significantly with reduced OS: age (HR, 1.04; 95%CI, 1.02-1.06; P < .0001), advanced disease stage (HR, 6.41; 95%CI, 3.57-11.52; P < .0001), and high tumor grade (HR, 2.96; 95%CI, 1.46-5.99; P = .003). Nested case-control analyses confirmed that there were lower DICER1 transcript levels in patients who had recurrent disease (P = .01). Deletion of DICER1 sequences was an infrequent event (5% of analyzed patients), and no methylation was observed in the 5′ DICER1 regulatory region. CONCLUSIONS: Lower DICER1 transcript levels were correlated with disease recurrence and worse DFS survival in patients with endometrioid endometrial cancer. The factors that influence DICER1 transcript levels in primary endometrial cancers remain unknown. Cancer 2011. © 2010 American Cancer Society.

Objective A 10-point "Surgical Apgar Score" (SAS) for predicting postoperative complications after general and vascular operations has recently been developed and validated. We sought to estimate the ability of this metric to predict major postoperative complications in women undergoing ovarian cancer cytoreductive procedures. Methods All eligible patients with stage III and IV epithelial ovarian, fallopian tube and primary peritoneal cancer undergoing surgical cytoreduction at our institution between 1999 and 2005 were included. Medical records were reviewed and demographic data, clinicopathologic characteristics, comorbidities and intra and postoperative complications were analyzed. The surgical score was calculated from intraoperative blood loss, lowest mean arterial pressure and lowest heart rate as previously described. Descriptive statistics, univariable and multivariable analyses were used as appropriate. Occurrence of major postoperative complications represented the primary outcome. Results A total of 232 cases were analyzed. Mean age was 62 years. Most patients were Caucasian (92%) and diagnosed with stage III disease (83%). Mean duration of surgical procedure was 171 (70–350) minutes. Median SAS was 6 points (range 1–9). On multivariable analyses, occurrence of major postoperative complications was associated with multiple comorbidities (OR 2.2; 95% CI:1.5–3.1; p p =0.03), ASA class (OR 2.4; 95% CI:1.2–4.7; p =0.01) and SAS≤4 (OR 7.4; 95% CI:2.9–18.8; p Conclusions Lower SAS (≤4) is the most powerful predictor of postoperative complications in patients undergoing cytoreductive surgery for advanced epithelial ovarian cancer. This prognostic tool may prove helpful for triaging such patients to optimal postoperative levels of care and directing counseling, monitoring and management in the postoperative period.

We assessed mismatch repair by immunohistochemistry (IHC) and microsatellite instability (MSI) analysis in an early onset endometrial cancer and a sister’s colon cancer. We demonstrated high-level MSI and normal expression for MLH1, MSH2 and MSH6. PMS2 failed to stain in both tumors, strongly implicating a PMS2 defect. This family did not meet clinical criteria for Lynch syndrome. However, early onset endometrial cancers in the proband and her sister, a metachronous colorectal cancer in the sister as well as MSI in endometrial and colonic tumors suggested a heritable mismatch repair defect. PCR-based direct exonic sequencing and multiplex ligation-dependent probe amplification (MLPA) were undertaken to search for PMS2 mutations in the germline DNA from the proband and her sister. No mutation was identified in the PMS2 gene. However, PMS2 exons 3, 4, 13, 14, 15 were not evaluated by MLPA and as such, rearrangements involving those exons cannot be excluded. Clinical testing for MLH1 and MSH2 mutation revealed a germline deletion of MLH1 exons 14 and 15. This MLH1 germline deletion leads to an immunodetectable stable C-terminal truncated MLH1 protein which based on the IHC staining must abrogate PMS2 stabilization. To the best of our knowledge, loss of PMS2 in MLH1 truncating mutation carriers that express MLH1 in their tumors has not been previously reported. This family points to a potential limitation of IHC-directed gene testing for suspected Lynch syndrome and the need to consider comprehensive MLH1 testing for individuals whose tumors lack PMS2 but for whom PMS2 mutations are not identified.

Background:The argon beam coagulation (ABC) is a safe and effective tool for surgical cytoreduction of metastatic ovarian carcinomas.Case:A 66-year-old woman with newly diagnosed advanced stage epithelial ovarian cancer underwent primary cytoreductive surgery involving ABC of tumor implants. Intraoperatively, she experienced cardiac arrest during use of the ABC. She was successfully resuscitated. The etiology of the arrest was thought to be secondary to a venous gas embolism.Conclusions:The risk associated with venous gas embolism in a laparotomy case is exceedingly low. This is the first case report of venous gas embolism during ABC in a surgical procedure for gynecologic malignancy. Proper monitoring and support services should always be immediately available when using ABC.

Acute colonic pseudoobstruction, or Ogilvie's syndrome, is a rare but serious medical and obstetric complication. When diagnosed early, treatment with expectant management or more invasive decompression is often successful. However, if not recognized promptly or managed appropriately, this condition can be fatal.We present an unusual case of acute colonic pseudoobstruction occurring after management of preterm labor in a monochorionic-diamniotic twin pregnancy at 29 weeks' gestation complicated with twin-twin transfusion syndrome.Acute colonic pseudoobstruction should be considered in the differential diagnosis in pregnant women who present with abdominal distention and vomiting.

Cervical cancer screening is ideally suited for the development of biomarkers due to the ease of tissue acquisition and the well-established histological transitions. Furthermore, cell and biologic fluid obtained from cervix samples undergo specific molecular changes that can be profiled. However, the ideal manner and techniques for preparing cervical samples remains to be determined. To address this critical issue a patient screening protein and nucleic acid collection protocol was established. RNAlater was used to collect the samples followed by proteomic methods to identify proteins that were differentially expressed in normal cervical epithelial versus cervical cancer cells. Three hundred ninety spots were identified via two-dimensional difference gel electrophoresis (2-D DIGE) that were expressed at either higher or lower levels (>3-fold) in cervical cancer samples. These proteomic results were compared to genes in a cDNA microarray analysis of microdissected neoplastic cervical specimens to identify overlapping patterns of expression. The most frequent pathways represented by the combined dataset were: cell cycle: G2/M DNA damage checkpoint regulation; aryl hydrocarbon receptor signaling; p53 signaling; cell cycle: G1/S checkpoint regulation; and the endoplasmic reticulum stress pathway. HNRPA2B1 was identified as a biomarker candidate with increased expression in cancer compared to normal cervix and validated by Western blot.

Background. Polypropylene mesh for abdominal wall reconstruction increases the risk of postoperative complications in previously irradiated patients or patients with contaminated operative fields. A novel alternative, acellular dermal matrix, easily incorporates into native tissue when used for fascial reconstruction, forming a strong repair with minimal adhesions and lower infection rates. Case. We describe a patient previously treated with radiation for cervical cancer who presented with a contaminated operative field due to enteral spillage and pelvic infection. Acellular dermal matrix was used as part of a stepwise secondary closure of a large fascial defect in the anterior abdominal wall that was the result of repeated surgical procedures. Conclusion. Use of acellular dermal matrix rather than traditional polypropylene mesh should be considered for patients with contaminated or irradiated operative fields.