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Abstract Objectives The role of adjuvant radiotherapy for lymph node-negative stage IB patients with tumor-related negative prognostic factors is not uniformly accepted. It is advocated based on the GOG 92 trial, which was initiated in 1989. The aim of the current study is to report the oncological outcome of "intermediate risk" patients treated by tailored surgery without adjuvant radiotherapy. Data from two institutions that refer these patients for adjuvant radiotherapy served as a control group. Methods Included were patients with stage IB cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy, who had negative pelvic lymph nodes but a combination of negative prognostic factors adopted from the GOG 92 trial. Data were obtained from prospectively collected databases of three institutions. Radical surgery was a single-treatment modality in one of them and in the remaining two institutes it was followed by adjuvant chemoradiation. Results In 127 patients who received only radical surgery, with a median follow-up of 6.1 years, the local recurrence rate was 1.6% (2 cases), and total recurrence was 6.3% (8 cases). Disease-specific survival at 5 years was 95.7% (91.9%; 99.4%) and 91% (83.7%; 98.3%) at 10 years. The only significant factor for disease-specific survival was tumor size ≥4 cm (P = 0.032). The recurrence rate, local control or overall survival did not differ from the control group. Adjuvant radiotherapy was not a significant prognostic factor within the whole cohort. Conclusions An excellent oncological outcome, especially local control, can be achieved by both radical surgery or combined treatment in stage IB lymph node-negative cervical cancer patients with negative prognostic factors. The substantially better outcome than in the GOG 92 trial can be attributed to more accurate pre-operative and pathological staging and an improvement in surgical techniques. Highlights • Intermediate risk patients with IB N0 cervical cancer have excellent oncological outcome after radical surgery only. • Recurrence rate in this group was 6% and local recurrence rate 2%, without adjuvant treatment. • No significant differences in oncological outcome were found between the groups with or without adjuvant radiotherapy. • Substantially better outcome was reported in our groups in comparison to the original GOG 92 trial. [ABSTRACT FROM AUTHOR]

To compare long-term oncologic outcomes in patients with clinically uterine-confined endometrioid endometrial cancer who underwent surgical staging with robot-assisted (RA) versus conventional laparoscopy. We performed a retrospective chart review of patients with newly diagnosed, uterine-confined endometrioid endometrial cancer who were treated and had primary surgery at our institution between 1/1/2009–1/1/2018. Clinicopathologic, surgical, and survival data were collected. Appropriate statistical methods were applied. Of 1728 patients identified, 1389 (80.4%) underwent RA and 339 (19.6%) conventional laparoscopy. At diagnosis, median age was 60 years (range, 24–92) and median BMI was 30.2 kg/m2 (range, 15.1–71.5). In the RA group, patients had longer operative time (170 vs 152 min, P <.001), lower conversion rate to laparotomy (0.6% vs 4.7%, P <.001), and a higher proportion had a BMI > 40 kg/m2 (17.2% vs 11.5%, P =.01) and same-day discharge (19.2% vs 5.3%, P <.001). Overall, 93% (RA) and 90% (conventional) of patients underwent lymph node assessment (P =.1). Comparing the RA versus conventional groups, final surgical stage on pathology (P =.6), median follow-up (55.7 vs 52.9 months, P =.4), and rates of perioperative complications (9.9% vs 7.7%, P =.6), recurrence (9.5% vs 7.4%, P =.3), 5-year PFS (88.5% vs 91.0%, P =.3), and 5-year OS (92.5% vs 92.4%, P =.7) were not significantly different. No significant increase in risk of recurrence (HR = 1.2, 95% CI: 0.8–1.9, P =.3) or poorer OS outcomes (HR = 0.9, 95% CI: 0.6–1.4, P =.7) were observed in the RA group. In uterine-confined endometrioid endometrial cancers, surgical staging using RA laparoscopy was not associated with adverse survival outcomes compared to conventional laparoscopy. • Robot-assisted laparoscopy was not associated with adverse survival outcomes compared to conventional laparoscopy. • Complication rates were similar between robot-assisted and conventional laparoscopy in early-stage endometrial cancer. • Lower rate of conversion to laparotomy and higher rate of same-day discharge were observed with robot-assisted laparoscopy. [ABSTRACT FROM AUTHOR]

Objectives: To compare the clinical-pathologic features and survival outcomes for patients with FIGO Stage IIIA endometrial cancer with uterine serosa or adnexal involvement. Methods: This was an international, multi-institutional, IRB- approved retrospective research collaboration spanning 2000 to 2019. Patients (pts) with surgically staged (FIGO 2009) IIIA endometrial cancer were included for analysis (tumor involving the uterine serosa or adnexa). Patients with sarcoma or concurrent endometrial/ ovarian malignancy, neoadjuvant treatment, positive lymph nodes, or peritoneal disease were excluded. Appropriate statistical tests were performed. Results: A total of 184 pts met inclusion criteria: 138 adnexa only (AO), 40 serosa only (SO), and six with combined adnexal and serosal involvement (AS). Median age at diagnosis for the cohort was 60 years (range: 23-89 years). Compared with AO, 50% SO had endometrioid FIGO Grade 3 (vs 19%, p<0.01), and 58% had lymphovascular invasion (vs 33%, p<0.01). Five pts with AS had non-endometrioid histology (83%). The distribution of surgical approach, cervical stromal involvement, pelvic cytology, or receipt of adjuvant treatment (chemotherapy +/- radiation, radiation, or none) were independent of each other within the three groups. Median follow-up was 77 months (0.6-254 months). Five-year progression-free survival (PFS) for pts with AO was 79% (SE 3.8), SO 61% (SE 8.3), and AS 33% (SE 19.2) (p<0.01). Five- year overall survival for pts with AO was 85% (SE 3.7), SO 70% (SE 7.8), and AS 60% (SE 21.9) (p=0.09). Unadjusted hazard ratios for all FIGO stage IIIA groupings (AO, SO and AS), histology, and lymphovascular invasion (LVSI) were significantly associated with PFS. Stage IIIA tumors with serosal involvement had a negative impact on PFS when adjusted for histologic subtype, receipt of adjuvant treatment, and LVSI (for SO: HR: 2.2, 95% CI 1.1-4.5; for AS: HR: 2.4, 95% CI 0.7-8.4; p=0.04). Conclusions: FIGO Stage IIIA endometrial cancers have distinct survival outcomes depending upon serosa only, adnexa only, or combined involvement. Progression-free survival was poorest for serosa-involved pts (SO and AS) when adjusting for histology, adjuvant treatment, and LVSI. These data suggest that endometrial cancers with serosa involvement should be considered a higher risk group within the Stage IIIA diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: To describe endometrial carcinoma (EC) molecular classification utilizing clinical next-generation sequencing (NGS) and immunohistochemistry (IHC) and to assess the clinical, pathologic, and survival outcomes based on molecular data. Methods: We identified all primary and recurrent EC samples of 341-505 cancer-related genes undergoing NGS (MSK-Integrated Mutation Profiling of Actionable Cancer Targets; MSK-IMPACT) from test inception in 2014 through 2020. Samples were classified into the Cancer Genome Atlas (TCGA) molecular subtypes utilizing MSK-IMPACT results for POLE hotspot mutations, TP53 mutations, and MSIsensor score; and mismatch repair (MMR) and p53 IHC results collected from pathology reports. Tumors not classified per TCGA based on available NGS and IHC data were excluded from the analysis. Clinical, pathologic, and survival data were obtained for primary ECs undergoing initial staging surgery or treatment at our institution after staging surgery. Only NGS performed prior to documented recurrence was used for survival analysis, to avoid ascertainment bias. Appropriate statistical tests were applied. Results: Clinical MSK-IMPACT sequencing was performed on 2174 ECs. Except for 40 unclassifiable cases, 2134 tumors corresponded to 2066 unique patients, including 1712 (80%) primary and 409 (19%) recurrent tumors. Molecular classification was distributed as 5% POLE (n =113), 22% microsatellite instability-high (MSI-H; n =479), 38% copy-number high (CN-H) (n =818), and 34% CN-low (n =724). MMR-deficiency by IHC was found in 16% of POLE , and IHC-based aberrant p53 expression in 12% of POLE and 2% of MSI-H ECs. Due to the hierarchy of our hybrid classification algorithm, this did not affect molecular designation. Otherwise, all available MMR and p53 IHC results were concordant with NGS results to determine classification. CN-H was 91% non-endometrioid with 67% FIGO G3 within the endometrioid type, while POLE , MSI, and CN-L were 10-32% and 17-21%, respectively (p<0.05). Criteria for survival analysis using primary tumor NGS results were met by 1118 patients. The median follow-up was 22.5 months (0.5-214 months). Three-year progression-free survival was 97% for POLE (SE 2.0), 90% CN-L (SE 2.1), 80% MSI-H (SE 3.1), and 46% CN-H (SE 3.5), (p<0.01). Three-year overall survival was 100% for POLE , 94% MSI-H (SE 2.1), 93% CN-L (SE 2.2), and 71% CN-H (SE 3.6), (p<0.01). CN-H classification remained prognostic for recurrence outcomes when adjusting for age, stage, and histology (HR: 6.2, 95% CI: 1.5-26.6; p=0.04). Conclusions: Our approach to molecular classification involves a hybrid strategy utilizing combined NGS and IHC analysis as a surrogate for whole-exome sequencing employed by TCGA. Our current database is mostly CN-H, which may reflect the referral-based nature of our institution. When applying appropriate criteria for survival analysis, CN-H portends the worst outcomes. Future studies should consider the histological heterogeneity of CN-H when considering treatment options. [Display omitted] [ABSTRACT FROM AUTHOR]

The emphasis in contemporary medical oncology has been “precision” or “personalized” medicine, terms that imply a strategy to improve efficacy through targeted therapies. Similar attempts at precision are occurring in surgical oncology. Sentinel lymph node (SLN) mapping has recently been introduced into the surgical staging of endometrial cancer with the goal to reduce morbidity associated with comprehensive lymphadenectomy, yet obtain prognostic information from lymph node status. The Society of Gynecologic Oncology's (SGO) Clinical Practice Committee and SLN Working Group reviewed the current literature for preparation of this document. Literature-based recommendations for the inclusion of SLN assessment in the treatment of patients with endometrial cancer are presented. This article examines: • History and various techniques of SLN mapping in endometrial cancer • Pathology and clinical outcomes from SLN assessment • Controversies and future directions for research in SLN assessment in endometrial cancer. [ABSTRACT FROM AUTHOR]

With rapidly rising health care costs, affordability is a major concern of cancer treatment and survivorship. We sought to determine the role oncologists believe they should play in decreasing costs and improving cancer care affordability. A survey was developed to assess oncologists' attitudes toward affordability and assess whether a range of provider-based solutions to reduce financial toxicity for patients would be practical or acceptable to practicing clinicians. Attending physicians practicing clinical cancer care at an urban, academic, tertiary referral center, were emailed a voluntarily, anonymous survey. Surveys were administered via REDCap between February and March 2020. Four reminder emails were sent to encourage participation. Of 851 eligible physicians, 346 completed the survey (41% response rate); 342 answered all questions (99% completion rate). A total of 118 (34%) were medical oncologists, 52 (15%) were surgical oncologists, 46 (13%) were radiation oncologists, 7 (2%) were neuro-oncologists, and 123 (36%) were other specialty oncologists. One hundred twelve (32%) were within 5 years of their terminal year of training, 165 (48%) were 6-25 years out, and 69 (20%) were more than 25 years out. One hundred eighty-eight (54%) were male. Of all participants, 308 (89%) indicated they believed that at least 20% of patients on active treatment have significant financial issues related to paying for their cancer treatment; 57 participants (16%) indicated they thought that at least 60% of patients may have this concern; 286 (83%) felt there was at least some way of either preventing or mitigating patient financial toxicity; 285 (82%) indicated they thought they should play an active role in minimizing financial toxicity; and 270 (78%) indicated they thought they should be aware of a patient's risk for financial toxicity prior to making treatment recommendations. Two hundred thirty-nine participants (70%) believed they could modify test or treatment plans to reduce costs for patients at high risk for financial burden if they knew, and 232 (67%) said they would modify their plans; this included 55 (24%) who would modify treatment dosing/frequency, 152 (66%) would change testing/imaging frequency, and 154 (67%) who would change follow-up interval. A total of 223 (65%) felt that national guidelines should incorporate patient affordability concerns when being developed. Only 76 (22%) had received any training on costs, affordability, or value-based care, and only 18 (5%) had received any training on cost conversations. Academic oncologists overwhelmingly believe they should play an active role in addressing affordability issues for patients, and the majority believe it is possible to reduce financial toxicity through various means. Provider-facing interventions to improve patient affordability may include proactively identifying patients at high risk for financial burden in order to create tailored plans to reduce their risk of high costs and resultant financial toxicity. [ABSTRACT FROM AUTHOR]

Objectives: To assess the prognosis of isolated tumor cells (ITCs) within sentinel lymph nodes (SLN) compared with node-negative (NN) disease in early-stage endometrioid endometrial cancer and to perform additional evaluation by molecular classification. Methods: Patients (pts) who underwent primary surgical management of uterine cancer from 2007-2019 with a final diagnosis of Stage IA, IB, and II endometrioid endometrial cancer were identified. All SLN underwent ultrastaging per institutional protocol. Cytokeratin-positive cells, ITCs with micrometastasis, and ITCs with macrometastasis were excluded. Clinical-pathologic variables were reviewed. Tumors were classified as POLE, MSI-H, CN-high, or CN-low, based on the TCGA, by utilizing MSK-IMPACT next-generation sequencing (NGS) results and tumor IHC staining. Appropriate statistical analyses were performed. Results: We identified 1381 pts who met the inclusion criteria: 1256 NN (91%) and 125 ITCs (9%). Adjuvant treatment was given to 85% of pts with ITCs compared to 40% of NN pts (p<0.01). Compared to NN patients, the presence of ITCs had a greater association with myoinvasion ≥50% (41% vs 13%, p<0.01), lymphovascular space invasion (77% vs 23%, p<0.01), and chemotherapy +/- radiation (62% vs 7%, p<0.01). The Median follow-up time was 36.5 months (0.4-167 months). There was no significant difference in survival when comparing node status (3-yr PFS: 94% ITC vs 90% NN, p=0.09; 3-yr OS: 98% ITC vs 96% NN, p=0.6). Progression-free survival of ITC-positive pts was not significantly different among those receiving no treatment, chemotherapy +/- radiation, or radiation (p=0.3; Figure 1). TCGA classification was available for 34 ITC and 300 NN pts. Distribution by molecular classification for ITC pts was 3% POLE, 35% MSI-H, 9% CN-high and 53% CN-low; for NN pts, 16% POLE, 36% MSI-H, 4% CN-high, and 43% CN-low (p=0.2). Molecular-based survival outcomes were performed for pts who underwent MSK-IMPACT prior to documented recurrence. There was a significant difference in survival when stratifying the entire cohort by molecular classification, with CN-high having worse outcomes (3-yr PFS: 73% vs 90-95%, p=0.046; 3-yr OS: 78% vs 94-100%, p=0.02). Nine NN patients and two ITC patients were classified as CN-high. Statistics were not applied due to limited numbers. Conclusions: ITCs are associated with less favorable pathologic features than NN disease but are not statistically significantly associated with survival outcomes. Molecular classification type does not have a significant association with the presence of ITCs, but CN-high remains a poor prognostic indicator that may be of clinical value. The role of postoperative therapy in the presence of ITCs or CN-high requires further investigation. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the sensitivity of sentinel node (SN) ultrastaging and to define parameters that may reduce the overall false-negative rate in women with early-stage cervical cancer. Methods: We analyzed data from a large retrospective multicenter cohort group with FIGO stages IA–IIB cervical cancer in whom at least one SN was identified and systematic pelvic lymphadenectomy was uniformly performed. All who were SN negative by initial evaluation were subjected to ultrastaging. Results: In all, 645 patients were evaluable. SN were detected bilaterally in 72% of cases and unilaterally in 28%. Patients with optimal bilateral SN detection were significantly more likely to have any metastasis detected (33.3% vs. 19.2%; P <0.001) as well as micrometastasis detected in their SN (39.6% vs. 11.4%). SN ultrastaging resulted in a low overall false-negative rate of 2.8% (whole group) and an even lower false-negative rate of 1.3% for patients with optimal bilateral mapping. Patients with false-negative SN after ultrastaging had a higher prevalence of LVSI and more frequent unilateral SN detection. Sensitivity of SN ultrastaging was 91% (95% CI: 86%–95%) for the whole group and 97% (95% CI: 91%–99%) in the subgroup with bilateral SN detection. Conclusion: These data confirm previous observations that optimal bilateral SN detection substantially decreases the false negative rate of SN ultrastaging and increases detection of micrometastasis. In patients with bilateral SN detection, the sensitivity of SN ultrastaging is not reduced in more advanced stages of the disease. SN mapping and ultrastaging should become standard practice in the surgical management of early-stage cervical cancer. [Copyright &y& Elsevier]

Abstract: Objectives: To assess the utility of thoracoscopy in defining the extent of intrathoracic disease and survival outcomes in patients with moderate to large pleural effusions at the time of diagnosis of advanced ovarian carcinoma. Methods: We reviewed the records of all patients with untreated advanced ovarian carcinoma and moderate to large pleural effusions who underwent video-assisted thoracoscopic surgery (VATS) our institution between 6/01 and 10/08. Demographic, clinicopathologic and outcome data were collected for all patients with a final diagnosis of ovarian carcinoma. Results: Forty-two patients met eligibility criteria, with a median age of 58 years; median CA-125 level of 1747 U/mL; and medium serum albumin of 3.9 g/dl. VATS was performed for right-sided effusions in 30 patients (71%). Macroscopic pleural disease was found in 29 patients (69%). Of the 11 patients with negative cytology, macroscopic pleural disease was found in 4 (36%). Intrathoracic cytoreductive surgery was performed in 6 (33%) of the 18 patients with intrathoracic disease >1 cm. After VATS, 29/42 (69%) patients underwent attempted primary abdominal surgical debulking. Thirteen patients (31%) received neoadjuvant chemotherapy. Twelve (92%) of these patients underwent interval cytoreductive surgery. Patients who were directed after VATS to neoadjuvant chemotherapy instead of primary surgical cytoreduction had a 2-year PFS rate of 22% compared to 42% for the primary cytoreductive group (P =0.36). Conclusions: Overall, management was altered based on VATS findings in 43% of cases. Further investigation is needed to define the prognostic significance of VATS evaluation of the burden of pleural disease. [Copyright &y& Elsevier]

Abstract: Objective: To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer. Methods: A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm3 of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis. Results: Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1–14) and 14.5 non-SLNs (range, 4–55) were examined. In all, 4/36 (11%) had positive SLNs—3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%. Conclusion: Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping. [Copyright &y& Elsevier]

Abstract: Purpose: To determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone. Methods: Memorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT). Results: Forty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I=15 (31%); II=5 (10%); III=21 (43%); IV=8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR=1.98 [0.9–4.33]); P =0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR=1.26 [0.47–3.41]); P =0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR=1.74 [0.79–3.85]); P =0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR=2.02 [0.77–5.33]); P =0.146. Conclusions: Our study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation. [Copyright &y& Elsevier]

Abstract: Objectives: To describe the surgical and pathologic findings of fertility-sparing radical abdominal trachelectomy using a standardized surgical technique, and report the rate of post-trachelectomy adjuvant therapy that results in permanent sterility. Methods: A prospectively maintained database of all patients with FIGO stage IB1 cervical cancer admitted to the operating room for planned fertility-sparing radical abdominal trachelectomy was analyzed. Sentinel node mapping was performed via cervical injection of Technetium and blue dye. Results: Between 6/2005 and 5/2008, 22 consecutive patients with FIGO stage IB1 cervical cancer underwent laparotomy for planned fertility-sparing radical abdominal trachelectomy. Median age was 33 years (range, 23–43). Histology included 13 (59%) with adenocarcinoma and 9 (41%) with squamous carcinoma. Lymph-vascular invasion was seen in 9 (41%) cases. Only 3 (14%) needed immediate completion radical hysterectomy due to intraoperative findings (2 for positive nodes, 1 for positive endocervical margin). Median number of nodes evaluated was 23 (range, 11–44); and 6 (27%) patients had positive pelvic nodes on final pathology — all received postoperative chemoradiation. Sixteen (73%) patients agreed to participate in sentinel node mapping which yielded a detection rate of 100%, sensitivity of 83%, specificity of 100% and false-negative rate of 17%. Eighteen of 19 (95%) patients who completed trachelectomy had a cerclage placed, and 9/22 (41%) patients had no residual cervical carcinoma on final pathology. Median time in the operating room was 298 min (range, 180–425). Median estimated blood loss was 250 ml (range, 50–700), and median hospital stay was 4 days (range, 3–6). No recurrences were noted at the time of this report. Conclusions: Cervical adenocarcinoma and lymph-vascular invasion are common features of patients selected for radical abdominal trachelectomy. The majority of patients can undergo the operation successfully; however, nearly 32% of all selected cases will require hysterectomy or postoperative chemoradiation for oncologic reasons. Sentinel node mapping is useful but until lower false-negative rates are achieved total lymphadenectomy remains the gold standard. Investigating alternative fertility-sparing adjuvant therapy in node positive patients is needed. [Copyright &y& Elsevier]

Abstract: Objective: To determine the impact of the decrease in use of postoperative pelvic external beam radiation (EBRT) in favor of intravaginal RT (IVRT) alone in patients with early stage endometrial cancer who had lymphovascular invasion (LVI). Methods: Between 11/1988 and 5/2005, 126 patients treated with simple hysterectomy and postoperative RT had a final pathologic diagnosis of stage IB–IIB adenocarcinoma of endometrioid histology with documented LVI. The patients were divided into two groups based on the era of treatment, (early era: 1988–1996, vs. late era: 1997–2005), in order to best capture the shift away from the routine use of EBRT in favor of surgical staging and IVRT. Results: Of the 126 patients, 35% (n =44) were treated in the early era and 65% (n =82) in the late era. The two groups were balanced in regards to age, race, depth of myometrial invasion, histologic grade, and cervical involvement. Significantly more patients had surgical staging and received IVRT alone in the late than early era (p =0.0001, 0.004, respectively). The rate of pelvic control was 93% for the early era compared to 97% for latter era (p =0.3). There was no significant impact of the treatment era on vaginal control, disease-free survival, or overall survival. Conclusions: These data suggest that the mere presence of LVI need not trigger the use of pelvic EBRT. Instead, the decision on whether to omit EBRT in patients with LVI should be made in the context of a patient''s competing risk factors and comorbid conditions. [Copyright &y& Elsevier]

Abstract: Objective. In advanced ovarian cancer, patients cytoreduced to no visible disease appear to have improved survival compared to patients with visible residual tumor ≤10 mm. It remains unresolved whether this is due to better chemotherapy response and/or simply “re-setting the clock,” such that patients with less residual disease take longer to recur and succumb to their disease. Methods. We reviewed the records of all patients who had primary surgery for stage IIIC–IV ovarian cancer at our institution from 1998–2004, followed by intravenous platinum-taxane chemotherapy. Primary outcome measures were complete response (CR) to initial chemotherapy, platinum resistance at 6 months, progression-free (PFS), and overall survival (OS). Results. A total of 296 patients met study criteria, of whom 64 (22%) had cytoreduction to no visible disease, 145 (49%) had 1–10 mm residual disease, and 87 (29%) had >10 mm residual disease. After multivariate analyses, patients cytoreduced to no visible disease demonstrated significant improvements in rates of initial complete response and incidence of platinum resistance, as well as subsequent improvement in PFS and OS, compared to the other two groups. Similarly, patients with 1–10 mm residual disease had improved outcomes compared to patients with >10 mm residual disease for each endpoint. Conclusions. In ovarian cancer patients with <10 mm residual disease who began platinum-taxane therapy, maximal cytoreduction to no visible residual disease was associated with improved initial chemotherapy response, less platinum resistance, and improved survival. Maximal cytoreduction may improve survival through increased sensitivity to initial chemotherapy and should be the goal of initial surgery in these patients. [Copyright &y& Elsevier]

Abstract: Objectives. : We previously reported our initial experience of patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent video-assessed thoracic surgery (VATS) before planned abdominal exploration. The objective of this study was to report the surgical findings and management of patients who underwent VATS in an update of our experience. Methods. : We performed a retrospective review of all patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent VATS for assessment of extent of intrathoracic disease at our institution between 6/01 and 8/05. Results. : Twenty-three patients with a median age of 61 years (range, 36–79) were identified. VATS was performed for right-sided effusions in 17 patients (74%), and a median of 1350 ml (400–3700 ml) of pleural fluid was drained. VATS demonstrated macroscopic disease in 15 (65%) patients, with nodules >1 cm in 11/15 (73%), and nodules <1 cm in 4/15 (27%). Macroscopic intrathoracic disease was found in 4/10 (40%) patients with negative cytology. Intrathoracic cytoreduction was performed in 3/11 patients (27%) with intrathoracic disease >1 cm. After VATS, 12/23 patients (52%) underwent primary surgical management, with cytoreduction to ≤1 cm achieved in 11/12 patients (92%). The other eleven patients received primary chemotherapy after undergoing diagnostic laparoscopy alone (4/11) or no further abdominal exploration (7/11). Nine of these patients proceeded to interval cytoreduction, while 2 had pathology demonstrating upper gastrointestinal and lymphoma primaries at the time of VATS. Final diagnosis of primary site of disease included: ovary, 14 (61%); endometrial, 2 (9%); dual ovarian/endometrial primaries, 1 (4%); fallopian tube, 1 (4%); primary peritoneal, 1 (4%); other, 4 (17%). Overall, findings at VATS altered primary surgical management in 11/23 (48%) patients. Conclusions. : Sixty-five percent of patients with suspected advanced ovarian cancer and moderate to large pleural effusions had gross intrathoracic disease identified at VATS, with the majority (11/15, 73%) having disease >1 cm in diameter. Use of VATS allows for assessment of intrathoracic disease and may help identify candidates for primary cytoreductive surgery and possible intrathoracic cytoreduction versus neoadjuvant chemotherapy. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the survival impact of adding extensive upper abdominal surgical cytoreduction to standard surgical techniques for advanced ovarian cancer. Methods: The records of all patients with stages IIIC–IV epithelial ovarian cancer who underwent primary surgery at our institution from 1998 to 2003 were reviewed. The cohort was divided into 3 groups. Group 1 patients required extensive upper abdominal surgery, such as diaphragm peritonectomy/resection, resection of parenchymal liver or porta hepatis disease and/or splenectomy with or without distal pancreatectomy, to achieve optimal cytoreduction (residual disease ≤1 cm). Group 2 patients were optimally cytoreduced by standard surgical techniques, including hysterectomy, oophorectomy, omentectomy, and bowel resection. Group 3 patients were suboptimally cytoreduced. Primary outcome measures were response to primary chemotherapy, progression-free survival, and overall survival. Results: The cohort of 262 patients was divided as follows: Group 1, 57 patients; Group 2, 122 patients; and Group 3, 83 patients. The median follow-up was 36 months (range, 1–94 months). Frequency of clinical complete response in Groups 1, 2, and 3 was 82%, 78%, and 57%, respectively. The median progression-free survival for Groups 1, 2, and 3 was 24, 23, and 11 months, respectively. Progression-free survival for Groups 1 and 2 were equivalent (P =0.53) and were significantly longer than for Group 3 (P <0.001). The median overall survival was 84 and 38 months for Groups 2 and 3, respectively, and had not been reached for Group 1 by 68 months. Patients in Group 1 had equivalent overall survival to patients in Group 2 (P =0.74) and improved survival over patients in Group 3 (P <0.001). Prognostic factors significant on multivariate analysis included stage, optimal status, and ascites. Conclusions: Patients requiring extensive upper abdominal procedures to achieve optimal cytoreduction demonstrated a similar initial response, progression-free survival, and overall survival to patients optimally cytoreduced by standard surgical techniques. The presence of bulky upper abdominal disease alone did not appear to indicate poor tumor biology. This initial maximal surgical effort was associated with improved survival in patients who would have otherwise been suboptimally cytoreduced. [Copyright &y& Elsevier]

Abstract: Objectives. : Radical trachelectomy has emerged as a reasonable fertility-sparing operation for selected patients with stage I cervical cancer. The purpose of this report is to describe our technique of radical abdominal trachelectomy, a fertility-sparing operation in women with cervical cancer, and review the current literature on this procedure. Methods. : A review of a prospectively maintained database of all fertility-sparing radical trachelectomy procedures performed at our institution. Results. : Between 11/01 and 3/06, we performed a total of 42 fertility-preserving radical trachelectomies with pelvic lymphadenectomy for women with invasive cervical cancer. We had previously reported on 2 pediatric abdominal trachelectomies, which are excluded from this report. Five of the remaining 40 cases had undergone a radical abdominal trachelectomy, and 35 cases were performed laparoscopically with a radical vaginal approach. The characteristics of the 5 adult patients who underwent abdominal radical trachelectomy included stage IB1 disease in all cases, a mean age of 36 years (range, 33–39), and a mean estimated blood loss of 280 ml (range, 50–400); 1 patient with squamous cell carcinoma needed completion radical hysterectomy at the time of trachelectomy due to disease extending into the endometrium, and 1 patient needed postoperative chemoradiation due to a positive parametrial lymph node. The remaining 3 patients resumed normal menstruation postoperatively. All patients remain disease-free at the time of this report. The only remaining uterine blood supply in these patients are the utero-ovarian vessels. There were no postoperative complications, and transurethral Foley catheters were removed in all cases within 2 weeks. Conclusions. : Radical abdominal trachelectomy with pelvic lymphadenectomy is a feasible operation for selected women with stage I cervical cancer who desire to preserve reproductive function. Menstruation and reproductive function may be preserved after bilateral uterine vessel ligation. The procedure expands the inclusion criteria of radical vaginal trachelectomy to patients with distorted cervicovaginal anatomy in which the vaginal approach may not be feasible. [Copyright &y& Elsevier]

Abstract: Objectives. : To describe the incidence of symptomatic postoperative lower-extremity lymphedema in women treated for uterine corpus cancer, and to evaluate its relationship to regional lymph node removal and postoperative therapy. Methods. : A retrospective chart review of all patients with uterine corpus cancer managed over a 12-year period (1/93–12/04). All patients had a hysterectomy as part of their therapy. We identified patients with leg lymphedema – as described by the physician or reported by the patient – through medical records. We excluded cases of leg edema that developed secondary to medical conditions such as cardiovascular and renal disease, venous thrombosis, and end-stage recurrent malignancy. Lymphedema dermal changes and related fibrosis were graded using the common terminology criteria for adverse events. Results. : In all, 1289 patients with uterine corpus malignancy were evaluated. We excluded other chronic lower-extremity edema that was related to a variety of medical conditions in 74 patients (5.7%). With a median follow-up of 3 years (interquartile range, 1.1–5.4 years), new symptomatic post-treatment lower-extremity lymphedema was noted in 16 patients. Patients who had lymph nodes removed at initial surgery had a higher rate of developing lymphedema (16/670, 2.4%) than those who did not (0/619, 0%) (P = 0.0001). Furthermore, symptomatic lymphedema was limited to patients who had 10 or more regional lymph nodes removed 16/469 (3.4%). Lymphedema was noted at a median of 5.3 months after surgery (range, 1–32 months). Lymphedema was unilateral in 11 patients (69%) and bilateral in 5 (31%); moreover, it was considered grade 1 in 12 patients (75%) and grade 2 in 4 (25%). Age, weight, stage, type of hysterectomy, and type of postoperative adjuvant therapy were not associated with lymphedema. Conclusions. : To date, this is the largest series evaluating symptomatic lower-extremity lymphedema in women with uterine corpus cancer. Patients who had 10 or more regional lymph nodes removed at initial surgery appeared to be at higher risk for developing new symptomatic leg lymphedema. Patients undergoing surgery with lymphadenectomy for uterine corpus malignancy should be informed about the possibility of postoperative new symptomatic leg lymphedema. A prospective evaluation of leg lymphedema is needed to accurately determine the incidence, severity, and risk factors of this complication. [Copyright &y& Elsevier]

Abstract: Objective. : To describe the incidence of retroperitoneal pelvic or paraaortic lymph node metastasis in patients with primary and recurrent ovarian granulosa cell tumors. Methods. : At Memorial Sloan-Kettering Cancer Center, we conducted a retrospective chart review of all patients with ovarian granulosa cell tumors managed as inpatients from January 1991 to July 2005. The initial date of diagnosis ranged from 1971 to 2005. Results. : We identified 68 patients with a median age of 49 years (mean, 47.5 years; range, 19–78 years). Sixty-four (94%) patients had adult type and 4 (6%) had juvenile granulosa cell tumors. Fifty-three (78%) patients had their initial surgery at another institution and 55 (81%) were incompletely surgically staged at diagnosis due to the absence of pelvic and/or aortic lymph node dissection. Patients were assigned an International Federation of Gynecology and Obstetrics (FIGO) stage that included IA, 39; IC, 15; IIB, 3; IIC, 3; IIIC, 1. In 7 patients, the original stage was not assigned. Only 16 (24%) patients had a pelvic lymph node sampling and 13 (19%) also had a paraaortic lymph node sampling at primary surgery or at restaging surgery performed shortly following initial diagnosis; however, in these cases, lymph nodes were negative for metastasis. The median number of pelvic lymph nodes removed was 10 (mean, 11.6 nodes; range, 0–36 nodes). The median number of paraaortic lymph nodes removed was 4 (mean, 6 nodes; range, 0–19 nodes). Nine of 15 (60%) of patients managed initially at our institution were surgically staged compared to 4 of 53 (7.5%) who were managed initially elsewhere (P < 0.001). Thirty-four patients with recurrent granulosa cell tumors were managed during the study, 31 (91%) had adult type granulosa cell tumor, and 3 had juvenile histology. Thirty-three of 34 patients who recurred were incompletely surgically staged at the initial operation. Original “clinical” FIGO stage for patients who recurred included IA, 15; IC, 8; IIB, 1; IIC, 3; IIIC, 1; and in 6 patients, the original stage was not available. The median disease-free interval to first recurrence was 63 months (mean,69.4 months; range, 4–170 months). First recurrence sites included pelvis, 24/34 (70%); pelvis and abdomen, 3 (9%); retroperitoneum only, 2 (6%); pelvis and retroperitoneum, 2 (6%); pelvis/abdomen/retroperitoneum, 1(3%); abdomen only, 1 (3%); and bone, 1 (3%). Conclusions. : Complete surgical staging was performed in approximately 1/5 women with ovarian granulosa cell tumors; however, in those initially surgically staged, no nodal metastasis was identified. Clinical stage IA disease was the most common original diagnosis in women who recurred, and approximately 15% of first recurrences appear to involve the retroperitoneum. [Copyright &y& Elsevier]

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

Abstract: Objective: : The aim of this study was to describe the feasibility and outcome of laparoscopic risk-reducing salpingo-oophorectomy (RRSO) in patients with a history of breast cancer who previously had undergone a transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. Methods: : We performed a retrospective review of patients with a history of breast cancer who had undergone laparoscopic RRSO between February 1995 and April 2002. Patients who had undergone TRAM flap reconstructive surgery were compared with patients who had undergone laparoscopic RRSO without prior reconstructive surgery. Results: : We identified 102 patients with a history of breast cancer who were candidates for a laparoscopic RRSO during the study period. One hundred one of these patients underwent the procedure, including 10 patients with a history of TRAM flap breast reconstructive surgery. One patient did not undergo the procedure because she was noted to be hypotensive prior to the procedure from her bowel preparation. There were no differences between the groups with or without prior history of TRAM flap reconstruction with respect to body mass index, prior abdominal surgery, menopausal status, or preoperative ultrasound characteristics. Operatively, there was no difference between the groups with respect to estimated blood loss, hospital stay, and intraoperative and postoperative complication rates. The only noted difference between the two groups was the estimated operating time (TRAM group, 91 min; non-TRAM group, 70 min [P < 0.01]). Conclusions: : Laparoscopic RRSO is safe and feasible in patients who have undergone a prior TRAM flap reconstruction. [Copyright &y& Elsevier]

Abstract: Objective.: To determine whether perioperative packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions during ovarian, tubal, or peritoneal cancer surgery increase the risk of symptomatic postoperative venous thromboembolism (VTE) and adversely affect overall survival. Methods.: We conducted a retrospective review of all cases of surgical exploration for resection of stage IIIC-IV adnexal/peritoneal cancer between November 1998 and May 2002 at Memorial Sloan-Kettering Cancer Center. Patients with a history of prior or active preoperative VTE were excluded. Routine intraoperative and postoperative VTE prophylaxis including lower extremity external pneumatic compression with or without postoperative subcutaneous heparin was utilized in all cases. Symptomatic postoperative VTE was diagnosed by lower extremity Doppler or computerized tomography (excluding cases with only ovarian vein thrombosis). Clinical parameters were examined by a logistic regression analysis to identify independent prognostic predictors of postoperative symptomatic VTE, which occurred within 30 days of surgery. Survival was calculated using the Kaplan–Meier method. Results.: In all, 174 patients underwent exploratory surgery, and 6 (3.4%) were excluded due to active or prior history of VTE. Of the remaining 168 patients, 71 (42%) received at least one perioperative transfusion of PRBC or FFP. Postoperative VTE was documented in 5 of 46 (11%) patients who received a postoperative transfusion compared to 3 of 122 (2.5%) patients who did not (P = 0.04; odds ratio, 4.8); moreover, VTE was noted in 3:16 (19%) patients who received postoperative FFP compared to 5:152 (3.3%) patients who did not (P = 0.01, odds ratio of 6.78). Age, stage, body mass index, length of the operation, blood loss, presence of ascites, volume of ascites, residual disease status, preoperative hemoglobin level and coagulation profile were not associated with increased risk for VTE. When survival results were stratified by transfusion utilization and controlling for optimal debulking status, perioperative transfusions had no apparent effect on overall survival. Conclusion.: In women with stage IIIC-V disease, postoperative blood product transfusions particularly FFP were associated with increased risk of DVT and PE, but transfusions had no impact on overall survival. [Copyright &y& Elsevier]

Abstract: Objective : This paper provides a summary of the presentations given at the Fifth International Conference on Ovarian Cancer in Houston, Texas on December 1–4, 2004. Methods and Results : The focus of this meeting was to discuss the most current information regarding development, progression, diagnosis, and therapy of ovarian cancer. The presentations at this conference were grouped into 7 sessions, and are summarized in this paper as follows: ovarian cancer biology, novel therapeutic approaches, surgical and pathological controversies, quality of life/biobehavioral aspects of ovarian cancer, screening/prevention approaches, management of uncommon ovarian cancers, and treatment controversies. Conclusion : While many challenges remain in the overall management of ovarian carcinoma, the speakers at this conference reviewed the opportunities available to scientists and clinicians to work collaboratively to make advances. [Copyright &y& Elsevier]

Abstract: Introduction: Clear cell carcinoma of the cervix and vagina is rare in the pediatric population. Many of these tumors are associated with prior intrauterine diethylstilbestrol (DES) exposure. All DES-associated tumors are believed to contain microsatellite instability (MI). Historically, the recommended treatment is radical hysterectomy and pelvic lymphadenectomy, which result in infertility in all cases. Radical abdominal or vaginal trachelectomy and pelvic lymph node dissection is a new technique utilized in adult women with early cervical cancer who wish to retain fertility. This novel approach is also pertinent to the pediatric patient and is described in this report. A molecular analysis is also performed to determine if these are DES-associated tumors. Methods: Due to the narrow vaginal anatomy in pediatric patients, a vaginal approach is not possible, and an abdominal approach is performed. The resection includes the cervix, upper vagina, parametrium, and paracolpos. Pelvic lymphadenectomy is performed in a similar manner to the adult patient. Matched pairs of normal and tumor DNA from both cases were examined for evidence of MI using a consensus panel of microsatellite markers. Results: Two girls aged 6 and 8 years and without history of DES exposure presented with vaginal bleeding. Vaginoscopy revealed cervical polyp in both cases. Biopsies demonstrated clear cell cancer stage IB1 in both patients. They underwent radical abdominal trachelectomy and bilateral pelvic lymph node dissection along with anastomosis of uterine isthmus to upper vagina. Intraoperative frozen-section analysis confirmed negative uterine and vaginal margins. No adjuvant treatment was given and both girls remain disease free. Neither tumor showed evidence for MI, confirming that these are not DES-associated tumors. Conclusion: To our knowledge, this is the first report of radical abdominal trachelectomy in the pediatric age group and it is likely to include the youngest patient with clear cell carcinoma of the uterine cervix not associated with DES exposure. This novel approach is feasible and appears safe in the pediatric age group. [Copyright &y& Elsevier]

Abstract: Objective.: To determine the percentage of patients with early-stage cervical cancer who may be eligible for fertility preservation with laparoscopic radical vaginal trachelectomy (LRVT). Methods.: We retrospectively reviewed the records of patients who underwent a radical hysterectomy for invasive cervical cancer at our institution from 12/85 to 8/01, before our use of LRVT at Memorial Sloan-Kettering Cancer Center. Institutional eligibility criteria for LRVT were applied. Patients ≥40 years of age were considered ineligible. Results.: We identified 435 patients who had undergone radical hysterectomy for cervical cancer; 186 were age <40 at surgery and constituted our study population. Eighty-nine (48%) patients may have been eligible by our pathologic criteria. In 12 patients, LRVT may have been aborted or altered because of unexpected disease spread. Conclusion.: A significant number of patients <40 with early-stage cervical cancer may be pathologically eligible for LRVT and should be counseled on this preoperatively. [Copyright &y& Elsevier]

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

: BackgroundMinimally invasive surgical techniques are becoming more sophisticated as complex procedures are being incorporated into gynecologic oncology in routine and investigative settings.: CaseWe present a case of an aberrant supernumerary right renal artery ligation during periaortic laparoscopic lymph node dissection for endometrial cancer. This injury resulted in infarction of the lower pole of the right kidney, with no late sequela.: ConclusionThe gynecologic oncologist should be aware of the possibility of aberrant renal vasculature, and special care should be taken to avoid accidental ligation of supernumerary renal arteries during dissection of the periaortic lymph nodes. [Copyright &y& Elsevier]

: ObjectivesThe aim of this study was to describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy for stage I cervical cancer using the argon-beam coagulator.: MethodsA retrospective review was performed of patients with FIGO stage IA1–IB1 cervical cancer who underwent a total laparoscopic approach for definitive surgical treatment. Comparison was made to a cohort of 195 patients who were treated with laparotomy.: ResultsBetween 12/2000 and 12/2002, 19 patients were offered the laparoscopic approach. The procedure was completed laparoscopically in 17 patients (89.5%). Two patients, in the beginning of the study, underwent conversion to laparotomy, 1 due to parametrial bleeding and 1 due to pelvic adhesions and cystotomy. Mean age was 42.6 years (range, 30–69 years); mean body mass index was 23.1 (range, 18–30); FIGO stage included IA1 with LVI (2), IA2 (6), IB1 (11). Mean pelvic lymph node count was 25.5 (range, 15–39), and 1 patient (5.3%) had positive nodes. Mean estimated blood loss was 301 cc (range, 75–1500 cc) compared to 693 cc in the laparotomy group (P < 0.01), mean operating time was 371 min (range, 230–600 min) compared to 295 min in the laparotomy group (P < 0.01), and mean hospital stay was 4.5 days (range, 3–11 days) compared to 9.7 days in the laparotomy group (P < 0.01). There were no ureteral injuries or fistula formation. All patients remain clinically disease free at the time of this report.: ConclusionsTotal laparoscopic radical hysterectomy with pelvic lymphadenectomy for selected patients with stage I cervical cancer is feasible, safe, and associated with a low morbidity in the pilot phase. Estimated blood loss and postoperative hospitalization appear shorter than historical controls, at the cost of longer operating time. Oncologic outcome requires longer follow-up. [Copyright &y& Elsevier]

: ObjectivesThe effects of CO2 pneumoperitoneum on the survival of women with metastatic ovarian cancer have not been documented. We sought to describe the survival of women with persistent stage III–IV ovarian cancer as documented by positive second-look laparoscopy or laparotomy and to see whether the laparoscopic approach with CO2 pneumoperitoneum has a negative effect on overall survival.: MethodsWe conducted a retrospective review of all patients with FIGO stage III–IV invasive epithelial ovarian cancer who were found to have persistent disease at second-look surgery. All patients underwent primary surgery followed by intravenous chemotherapy and were clinically without evidence of disease prior to second-look surgery. Second-look laparoscopy began to be utilized regularly in 1994. The selection of the second-look surgical approach depended on the surgeon''s discretion. CO2 pneumoperitoneum was utilized for all laparoscopic cases with the maximum intra-abdominal pressure maintained at 15 mm Hg. Patients received a variety of additional intravenous, intraperitoneal, or oral chemotherapy following positive second-look surgery.: ResultsBetween 6/1/91 and 6/30/02, 289 patients were found to have persistent ovarian/peritoneal cancer at second look. Second-look operations included 131 (45%) transperitoneal laparoscopies and 139 (48%) laparotomies. Nineteen (7%) patients underwent laparoscopy followed immediately by laparotomy. The mean age, stage distribution, histology, grade, and size of residual disease at second look did not differ between the two groups. The median overall survival for patients who underwent laparoscopy, 41.1 months (95% CI, 33.2–58.1), did not significantly differ from that of the laparotomy group, 38.8 months (95% CI, 31.9–44.2) (P = 0.742).: ConclusionsTransperitoneal laparoscopy with CO2 pneumoperitoneum does not appear to reduce the overall survival of women with persistent metastatic intra-abdominal carcinoma of ovarian/peritoneal origin. The overall survival appears to be independent of the second-look surgical approach. [Copyright &y& Elsevier]

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

To determine the impact of adjuvant therapy on oncologic outcomes in patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage IA, IB, or II endometrial clear cell carcinoma (ECCC). We conducted a retrospective review at 4 international institutions. Patients with newly diagnosed clinical stage I or II disease of either clear cell or mixed histology with a clear cell component treated between 01/01/2000–12/31/2015 were included. Oncologic outcomes were assessed for patients based on adjuvant treatment received, including chemotherapy, radiation, or chemotherapy with radiation. Of 125 patients identified and analyzed, 77 (61.6%) had clear cell histology and 118 (94.4%) had stage I disease. Median age at diagnosis was 65 years (range, 33–91). All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment. Twenty-five patients (20.0%) underwent surgical management alone and 100 (80.0%) received adjuvant therapy: 20 (16.0%) received postoperative chemotherapy, 47 (37.6%) received postoperative radiation, and 33 (26.4%) received postoperative chemotherapy with radiation. Median follow-up was 88.4 months (range, <1–234). Progression-free survival (PFS) or overall survival (OS) did not significantly differ between surgery alone and type of adjuvant therapy (P = 0.18 and P = 0.56, respectively). Patients with mixed ECCC did not have a survival advantage over those with pure ECCC (5-year PFS rate, 85.0% vs 82.7%, P = 0.77; 5-year OS rate, 88.3% vs 91.2%, P = 0.94). Receipt of adjuvant therapy in surgically staged I/II ECCC did not appear to offer a survival advantage over observation alone. Adjuvant therapy in early-stage ECCC with consideration of molecular classification should be evaluated. • Radiation only was the most common (38%) adjuvant therapy in patients with stage I-II endometrial clear cell carcinoma (ECCC) • Positive cytology impacted risk of recurrence and age > 65 years impacted overall survival in this cohort of patients • Survival outcomes of surgically staged patients with stage I-II ECCC were not impacted by receipt of adjuvant treatment • Patients with tumors of "pure" clear cell vs "mixed" clear cell histology had no difference in survival [ABSTRACT FROM AUTHOR]

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

• Sentinel lymph node mapping for endometrial cancer is an important surgical innovation. • Current payment systems fail to recognize the complexity and benefits of SLN mapping. • Payment systems need to be reformed to recognize value-enhancing surgical innovations. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the incidence of isolated paraaortic nodal metastasis in surgically staged endometrial cancer patients with negative pelvic lymph nodes. Methods: Using a prospectively maintained database we identified all cases of endometrial cancer that had both pelvic and aortic nodal dissection and determined the rate of isolated paraaortic nodal metastasis in the setting of negative pelvic nodes. For this report a satisfactory pelvic node dissection meant the identification of 8 or more pelvic nodes on final pathology. Results: 1942 endometrial cancer patients were surgically treated at our institution from 1/93 to 1/08. 847 had both pelvic and paraaortic nodes removed during surgery and identified by pathology. 734 had negative pelvic nodes with at least one paraaortic node identified. Only 12 (1.6%) had positive paraaortic nodes with negative pelvic nodes. Seven (1%) of 640 cases with 8 or more negative pelvic nodes had positive paraaortic nodes. Final grade for these cases included: G1 (2), G2 (2), G3 (1), papillary serous (1), and undifferentiated (1). Of the 570 cases with a final diagnosis of grade 1 endometrial cancer, 187 had both pelvic and aortic node dissection during the same operation, and 2/187 (1%) had a positive paraaortic node with negative pelvic nodes. Conclusions: Isolated paraaortic nodal metastasis in the setting of negative pelvic nodes occurs in ∼1% of surgically staged endometrial cancer cases. This low rate seems consistent for low- and high-grade lesions. Future studies looking at the incidence of isolated paraaortic nodal metastasis in the setting of negative sentinel pelvic nodes are warranted. [Copyright &y& Elsevier]

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

Abstract: Objectives.: To describe the role of temporary retrograde ureteral catheterization at the time of fertility-sparing radical vaginal or abdominal trachelectomy in women with early-stage cervical cancer. Methods.: We analyzed a prospectively maintained database of all patients with cervical cancer who were explored for radical vaginal or abdominal trachelectomy at our institution. Cystourethroscopy and ureteral catheterization were performed prior to the vaginal or abdominal operation in all patients, except two pediatric ones. Temporary bilateral retrograde ureteral catheters were planned for all patients as part of our routine procedure to facilitate identification of the distal ureters. 5Fr whistle-tip or open-ended catheters were used and usually advanced to approximately 20 cm. Catheters were removed at the end of the operation in all cases. All catheters were inserted by a gynecologic oncology fellow or attending. Results.: Between 11/01 and 12/05, 40 patients were taken to the operating room for planned fertility-sparing radical vaginal or abdominal trachelectomy. We previously reported on two pediatric patients; they are excluded from this report. The median age for adult patients was 32 years (mean, 31.6; range, 23–40). International Federation of Gynecology and Obstetrics (FIGO) stage included IB1 (26), IA2 (6), and IA1 with lymphovascular invasion (6). Thirty-four patients underwent radical vaginal trachelectomy and four underwent a radical abdominal trachelectomy. Two (5%) of 38 patients required immediate completion radical hysterectomy due to extensive endocervical disease (one in the vaginal group and one in the abdominal group). Bilateral ureteral catheters were inserted successfully in 37 (97%) of 38 patients and facilitated identification of the distal ureter during the dissection. In one case, the right ureteral orifice could not be successfully catheterized, and the case was completed with unilateral catheterization. The estimated time to perform this part of the operation was approximately 15–20 min. Twenty-eight patients (74%) had 5Fr whistle-tip ureteral catheters inserted, and 10 had open-ended catheters inserted. There were no intraoperative complications. Median hospital stay was 3 days (range, 3–7). Hematuria, evident in the drainage bag attached to the Foley catheter, usually resolved in 24–48 h. Two (20%) of 10 patients who had open-ended catheters inserted developed a transient rise in postoperative creatinine (1.7 and 3.5 mg/dl, respectively) compared to 0/28 patients who had whistle-tip catheters placed (P <0.001). Both were attributed to postoperative distal ureteral edema, and only one patient required reinsertion of temporary ureteral stents. No patient developed long-term urinary complications or fistulae. Conclusions.: Cystourethroscopy and bilateral retrograde ureteral catheterization by gynecologic oncologists is a simple and quick procedure that may facilitate identifying the distal ureter during radical vaginal or abdominal trachelectomy. We favor using 5Fr whistle-tip catheters as they may be associated with less ureteral mucosal trauma and subsequent postoperative edema. The skills needed for this procedure should be available to fellows in gynecologic oncology training. [Copyright &y& Elsevier]

Background. The incidence of isolated aortic nodal metastasis in clinical stages I and II endometrial cancer is generally low. Nevertheless, para-aortic nodes are still assessed during staging procedures, which include hysterectomy, bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node sampling up to the level of the inferior mesenteric artery (IMA). The procedure can be performed either abdominally or laparoscopically. It is unclear, however, as to whether infrarenal aortic nodal sampling above the IMA should be routinely performed.Case. We describe a case of endometrial cancer metastatic to the infrarenal para-aortic lymph nodes above the IMA, missed during laparoscopic inframesenteric lymph node dissection, and found on subsequent laparotomy performed to resect matted pelvic nodes.Conclusion. The infrarenal para-aortic region above the IMA may be at risk for nodal metastasis in women with endometrial cancer. Consideration should be given to evaluate this area during staging laparotomy or laparoscopy. The role of routine bilateral infrarenal aortic nodal dissection needs further evaluation. [Copyright &y& Elsevier]

Adenoid cystic carcinoma (AdCC) of the Bartholin's gland (AdCC-BG) is a very rare gynecologic vulvar malignancy. AdCC-BGs are slow-growing but locally aggressive and are associated with high recurrence rates. Here we sought to characterize the molecular underpinning of AdCC-BGs. AdCC-BGs (n = 6) were subjected to a combination of RNA-sequencing, targeted DNA-sequencing, reverse-transcription PCR, fluorescence in situ hybridization (FISH) and MYB immunohistochemistry (IHC). Clinicopathologic variables, somatic mutations, copy number alterations and chimeric transcripts were assessed. All six AdCC-BGs were biphasic, composed of ductal and myoepithelial cells. Akin to salivary gland and breast AdCCs, three AdCC-BGs had the MYB :: NFIB fusion gene with varying breakpoints, all of which were associated with MYB overexpression by IHC. Two AdCC-BGs were underpinned by MYBL1 fusion genes with different gene partners, including MYBL1 :: RAD51B and MYBL1 :: EWSR1 gene fusions, and showed MYB protein expression. Although the final AdCC-BG studied had MYB protein overexpression, no gene fusion was identified. AdCC-BGs harbored few additional somatic genetic alterations, and only few mutations in cancer-related genes were identified, including GNAQ , GNAS , KDM6A , AKT1 and BCL2 , none of which were recurrent. Two AdCC-BGs, both with a MYB :: NFIB fusion gene, developed metastatic disease. AdCC-BGs constitute a convergent phenotype, whereby activation of MYB or MYBL1 can be driven by the MYB :: NFIB fusion gene or MYBL1 rearrangements. Our observations further support the notion that AdCCs, irrespective of organ site, constitute a genotypic–phenotypic correlation. Assessment of MYB or MYBL1 rearrangements may be used as an ancillary marker for the diagnosis of AdCC-BGs. • Adenoid cystic carcinoma of the Bartholin's gland (AdCC-BG) is underpinned by MYB or MYBL1 fusion genes. • AdCC-BGs have few somatic genetic alterations in addition to the MYB/ MYBL1 fusion gene. • AdCC-BG constitutes a genotypic–phenotypic correlation. • MYB/ MYBL1 rearrangement assessment may be used as an ancillary marker for AdCC-BG diagnosis. [ABSTRACT FROM AUTHOR]

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

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

POLE mutated endometrial carcinomas may represent a subspecific type of tumors harboring a more favorable prognosis. Grade 3 (G3 or high-grade) endometrioid endometrial carcinomas remain a clinical dilemma, with some tumors behaving as the low-grade counterparts and others presenting a more aggressive behavior. To determine the association between POLE mutational status and the overall-survival (OS) and progression-free-survival (PFS) of patients with G3 endometrioid endometrial cancer (EC). We also aimed to determine the prevalence of POLE mutations in G3 endometrioid EC. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO No: CRD4202340008). We searched the following electronic databases: PubMed/Medline, EMBASE, Cochrane Library, Scopus, and Web of Science. For time-to-event data, the effect of POLE mutation in G3 EC was described using hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Individual patient data for each study was investigated if available from the study authors. If individual patient data were not available, information regarding time-to-event outcomes was extracted using an appropriate methodology. OS and PFS were analyzed using both one-stage and two-stage approaches, the Kaplan-Meier method, and Cox-proportional hazards models. This systematic review and meta-analysis included 19 studies with 3092 patients who had high-grade endometrioid EC. Patients with POLE mutation s had lower risks of death (HR = 0.36, 95% CI 0.26 to 0.50, I2 = 0%, 10 trials) and disease progression (HR = 0.31, 95% CI 0.17 to 0.57, I2 = 33%, 10 trials). The pooled prevalence of POLE mutation was 11% (95% CI 9 to 13, I2 = 68%, 18 studies). POLE mutations in high-grade endometrioid EC are associated with a more favorable prognosis with increased OS and PFS. • Systematic review and meta-analysis of 19 studies (total of 3092 patients) with high-grade endometrioid endometrial cancer. • We found a lower risk of disease progression and death in patients with POLE mutations. • We estimated a pooled prevalence of POLE mutation of 11% (95% CI 9% to 13%, I2 = 68%). [ABSTRACT FROM AUTHOR]

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

To compare clinical and pathologic characteristics of women with surgical stage I endometrial carcinoma by location of first recurrence and describe characteristics of isolated vaginal recurrence. Patients with 2009 International Federation of Obstetrics and Gynecology (FIGO) stage I endometrial carcinoma treated at two large cancer centers from 1/1/2009–12/31/2017 were identified. Sarcoma histology was excluded. Recurrences were grouped into isolated vaginal or extravaginal. Isolated vaginal recurrences were localized by anatomic location within the vaginal vault. Clinical and pathologic variables were compared with chi-square analysis, and Kaplan-Meier curves with log-rank tests. Of 2815 women identified, 278 (10%) experienced a recurrence. Sixty-one patients (2%) had an isolated vaginal recurrence, including 42 (69%) at the vaginal apex; 217 (8%) had an extravaginal recurrence, including 18 with a vaginal component. Median time to recurrence was 11 months (range, 1–68) for isolated vaginal recurrence and 20 months (range, 1–98) for extravaginal recurrence (P <.004). Of 960 patients (34%) treated with adjuvant vaginal brachytherapy (VBT), 156 (16%) recurred; 19 (2%) had an isolated vaginal recurrence, including 16 (84%) at the vaginal apex. Three-year PFS rates for isolated vaginal recurrence were 97.6% (SE ± 0.4%) with minimally invasive surgery (MIS) versus 96.9% (SE ± 1.1%) with open (P =.8), and for extravaginal recurrence were 91.8% (SE ± 0.7%) with MIS versus 90.8% (SE ± 1.8%) with open (P =.8). Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences. Surgical approach does not appear to impact recurrence. Adjuvant VBT after primary surgery carries a 1%–2% risk of isolated vaginal apex recurrence. • Isolated vaginal recurrences in stage I endometrial carcinoma were found in 2% of all patients with or without treatment. • One percent of patients with treatment plans involving vaginal brachytherapy had an isolated vaginal recurrence. • The most common location for isolated vaginal recurrences within the vagina was at the apex. • Isolated vaginal recurrences were clinically detected sooner than extravaginal recurrences. • Minimally invasive surgical approach did not affect recurrence rates. [ABSTRACT FROM AUTHOR]