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Investigate outcomes for advanced stage epithelial ovarian cancer (EOC) patients based on facility-level utilization of neoadjuvant chemotherapy (NACT).Stage III-IV EOC patients diagnosed between 2010 and 2016 were identified in the National Cancer Database. Percentage of patients managed with NACT was calculated for facilities, reporting ≥120 patients. Facilities with lowest and highest quartile of NACT rate comprised the low and high-utilizing groups. Clinico-pathological characteristics were collected, and appropriate statistical analysis performed.High- and low-utilizing facilities managed on average 54.1% and 25.4% of patients with NACT respectively. Patients managed at high-utilizing facilities were significantly more likely to be65 (p = 0.029), have stage IV disease (p0.001) and comorbidities (p0.001). Patients managed with primary debulking surgery (PDS) at low-utilizing facilities were significantly more likely to be65, have stage IV disease, and have comorbidities (all, p0.001). Patients undergoing PDS at low-utilizing facilities were significantly less likely to achieve complete gross resection (p0.001), and were significantly more likely to experience 90-day mortality (p0.001), and unplanned 30-day readmission (p0.001). After controlling for age, comorbidities, race, insurance status, stage, grade and histology, high-utilizing facilities trended towards better overall survival (OS) (HR: 0.92, 95% CI: 0.85-0.99). Overall, patients undergoing PDS had better OS compared to those who had NACT (median 42 vs 27 months, p0.001).Despite treating an EOC population with more advanced disease and comorbidities, high-utilizing facilities have lower surgical morbidity and mortality with no detrimental impact on long-term survival. Careful patient selection to minimize the morbidity and mortality associated with PDS is pivotal.

Evaluate whether the addition of external beam radiation (EBRT) to adjuvant chemotherapy with or without vaginal brachytherapy is associated with better survival for patients with stage IIIC endometrioid endometrial carcinoma.Patients diagnosed between 2010 and 2015 with apparent early-stage endometrioid adenocarcinoma, without a history of another tumor, who underwent hysterectomy with lymphadenectomy and had positive lymph nodes were identified in the National Cancer Database. Those who received adjuvant chemotherapy (defined as receipt of treatment within 6 mo from surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared between patients who did and did not receive EBRT within 6 months from surgery with the log-rank test. A Cox model was also constructed to control for confounders.A total of 3116 patients were identified; 1458 (46.8%) received chemotherapy without and 1658 (53.2%) with EBRT. Pathologic characteristics (tumor grade, size, endocervical, and lymph-vascular invasion) were comparable between the two groups. Patients who received external beam radiation had better survival compared with those who did not, P =0.001; 5-year overall survival rates were 83.1% and 77.9%, respectively. After controlling for patient age, race, presence of comorbidities, insurance status, tumor size, grade and endocervical invasion, and the presence of lymph-vascular invasion, the addition of EBRT was associated with a survival benefit (HR: 0.75, 95% CI: 0.62, 0.91).For patients with endometrioid adenocarcinoma metastatic to the lymph nodes, addition of external beam radiation to adjuvant chemotherapy may be associated with a survival benefit.

ObjectiveTo investigate the utilization and outcomes of ovarian preservation for premenopausal patients with International Federation of Gynecology and Obstetrics (FIGO) stage I grade 2 and 3 endometrioid endometrial carcinoma undergoing hysterectomy.MethodsThe National Cancer Database was accessed; patients aged ≤45 years diagnosed between January 2004 and December 2015 with FIGO stage I grade 2 or 3 endometrioid endometrial carcinoma, who underwent hysterectomy with or without bilateral salpingo-oophorectomy and had at least 1 month of follow-up, were identified. Overall survival was assessed following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected variables.ResultsA total of 2941 patients who met the inclusion criteria were identified; 200 (6.8%) patients did not undergo bilateral salpingo-oophorectomy. Rate of ovarian preservation was comparable between patients with grade 2 (n=163, 6.6%) and grade 3 (n=37, 7.7%) tumors (p=0.38). Patients who did not undergo bilateral salpingo-oophorectomy were younger (median 39 vs 41 years, pConclusionsFor patients with grade 2 and 3 FIGO stage I endometrioid carcinoma undergoing hysterectomy, ovarian preservation is rarely performed while no clear detrimental effect on overall survival was found.

Investigate the overall survival of patients with FIGO stage I endometrioid endometrial carcinoma who underwent sentinel lymph node biopsy (SLNBx).Patients diagnosed between 2012 and 2015 with pathological stage I endometrioid endometrial carcinoma who underwent minimally invasive hysterectomy and had at least one month of follow-up were identified in the National Cancer Database (NCDB). Patients who underwent SLNBx or systematic lymphadenectomy (LND) (defined as at least 20 lymph nodes removed) were selected. Overall survival (OS) was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders.A total of 13,010 patients with endometrioid endometrial carcinoma who met the inclusion criteria were identified; 9861 (75.8%) and 3149 (24.2%) patients had systematic LND and SLNBx, respectively. Patients who had LND were more likely to receive radiation therapy (27.4% vs 19.3%, p 0.001) and chemotherapy (13% vs 8.7%, p 0.001) compared to those who had SLNBx. After controlling for patient age, race, insurance status, depth of myometrial invasion, tumor grade, tumor size, presence of lymph-vascular invasion and receipt of radiation therapy, the performance of SLNBx was not associated with worse survival (HR: 0.99, 95% CI: 0.80, 1.21). For high-intermediate risk patients (based on GOG-99 criteria) after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.07, 95% CI: 0.80, 1.44). For intermediate risk patients who did not receive external beam radiation therapy or chemotherapy after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.58, 95% CI: 0.94, 2.65).SLNBx had no negative impact on the survival of patients with FIGO stage I endometrioid endometrial carcinoma who undergo hysterectomy.

ObjectiveTo investigate the survival of patients with lymph node positive endometrial carcinoma by type of surgical lymph node assessment.MethodsPatients diagnosed between January 2012 and December 2015 with endometrial carcinoma and uterine confined disease and nodal metastases on final pathology who underwent minimally invasive hysterectomy were identified in the National Cancer Database. Patients who had sentinel lymph node biopsy alone or underwent systematic lymphadenectomy were selected. Overall survival was evaluated following generation of Kaplan–Meier curves and compared with the log rank test. A Cox model was constructed to evaluate survival after controlling for confounders.ResultsA total of 1432 patients were identified: 1323 (92.4%) and 109 (7.6%) underwent systematic lymphadenectomy and sentinel lymph node biopsy only, respectively. The rate of adjuvant treatment was comparable between patients who had sentinel lymph node biopsy alone and systematic lymphadenectomy (83.5% vs 86.6%, p=0.39). However, patients who had sentinel lymph node biopsy were less likely to receive chemotherapy alone (13.6% vs 36.6%, p0.05). After controlling for confounders, there was no difference in survival between the systematic lymphadenectomy and sentinel lymph node biopsy alone groups (hazard ratio 0.82, 95% confidence interval 0.46 to 1.45).ConclusionsPerformance of sentinel lymph node biopsy alone was not associated with an adverse impact on survival in patients with lymph node positive endometrial cancer.

ObjectivesWe aimed to evaluate the utilization and impact of surgical para-aortic lymph node staging on the survival of patients with locally advanced stage cervical carcinoma receiving definitive chemoradiation.MethodsWe identified patients in the National Cancer Database diagnosed between January 2010 and December 2015 with locally advanced (FIGO 2009 stage IB2-IVA) cervical carcinoma who did not undergo hysterectomy, received primary chemoradiation and had at least 1 month of follow-up. Two groups of patients were formed based on the assessment method of para-aortic lymph node status – radiologic assessment only versus surgical lymphadenectomy. Overall survival was compared with the log-rank test after Kaplan-Meier curves were generated. A Cox model was constructed to control for a priori selected confounders.ResultsWe identified a total of 3540 patients who met the inclusion criteria. Para-aortic staging was performed in 333 (9.4%) patients. These patients were younger (median age 46 vs 52 years, pConclusionsIn a large cohort of patients with locally advanced stage cervical carcinoma, para-aortic lymphadenectomy was rarely performed and not associated with a survival benefit.

Substantial changes in the composition of the vaginal microbiome occur following the end of pregnancy. To identify potential drivers of microbiome changes in individual women during the pregnancy to postpartum transition, we evaluated vaginal samples from 48 pregnant women during their first and third trimesters and postpartum. We determined the species composition of vaginal communities and the vaginal fluid levels of compounds involved in mediating changes in host physiology and the immune system at each time point. We used linear mixed-effects models to characterize associations. Consistent with previous reports, but with a larger sample size, a US population, and variations in the dominant bacteria, the vaginal microbiome was found to be more diverse during the postpartum period. There was a lower abundance of Lactobacillus and significantly higher proportions of Streptococcus anginosus and Prevotella bivia. Moreover, we uniquely demonstrated that postpartum vaginal secretions were also altered postpartum. There were elevated levels of hyaluronan and Hsp70 and decreased levels of the D- and L-lactic acid isomers. We posit that these variations are consequences of alterations in the vagina after delivery that profoundly alter the host environment and, thus, lead to changes in the capability of different bacterial species to survive and proliferate.

Objective To assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes. Methods Retrospective cohort study of the National Cancer Database, selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression. Results Among 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; ORITT = 0.53; 95%CI 0.39–0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; ORPP = 0.49; 95%CI 0.32–0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; ORITT = 0.51; 95%CI 0.40–0.64; ORPP = 0.39; 95%CI 0.28–0.55), and unplanned readmission (overall rate 2.3%; ORPP = 0.52; 95%CI 0.33–0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND. Conclusion We identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes.

ObjectiveFertility sparing surgery for patients with early stage ovarian clear cell carcinoma is controversial. We aimed to investigate the impact of fertility sparing surgery on the oncologic outcomes of young patients with stage I ovarian clear cell carcinoma.MethodsThe National Cancer Database was accessed and patients with pathological stage IA or IC ovarian clear cell carcinoma, aged <45 years, were selected. Based on site specific surgery codes, patients who underwent fertility sparing or radical surgery were identified. Overall survival was evaluated following generation of Kaplan–Meier curves, and compared with the log rank test. Multivariate Cox analysis was performed to control for possible confounders. A systematic review of literature of the Pubmed, EMBASE and Web of Science databases was also performed to summarize all reported cases.ResultsA total of 57 (35.8%) and 102 (64.2%) patients underwent fertility sparing and radical surgery. There was no difference in overall survival between patients who had fertility sparing and radical surgery (p=0.92); 5 year overall survival rates were 89% and 87.9%, respectively. After controlling for the performance of lymphadenectomy and disease substage, fertility sparing surgery was not associated with worse survival (hazard ratio 0.83, 95% confidence interval 0.30 to 2.32). A systematic review of the literature identified 132 patients with stage I disease who underwent fertility sparing surgery; a total of 20 patients (15.2%) experienced a relapse at a median of 18 months from surgery.ConclusionsIn a large cohort of young patients with stage I ovarian clear cell carcinoma, fertility sparing surgery was not associated with worse survival.

Objective Investigate the reproductive outcomes of patients diagnosed with malignant ovarian germ cell tumors (MOGCTs) following fertility-sparing surgery (FSS). Methods A systematic review of the Pubmed/Medline, EMBASE and Web-of-Science databases between January 1st 1990 and February 28th 2020 was performed. Full articles reporting on at least 10 patients with MOGCT who underwent FSS and provided data on fertility or pregnancy outcomes were included. Results A total of 47 studies that included 2189 patients with MOGCT who underwent FSS were included. Rate of chemotherapy use was 79.9% while cumulative relapse rate was 8.7%. Based on 1110 patient from 27 studies rate of premature ovarian failure was 3.7%. Fecundity rate was 24.6% (n = 1980, from 42 studies), while 80.6% of patients attempting pregnancy had at least one pregnancy (n = 474, from 27 studies). Based on 294 live births, the rate of preterm delivery was 3% while among 261 live infants, only 3 (1.2%) malformations were reported. Conclusions The majority of patients with MOGCTs have normal menstrual and reproductive function following FSS. Fecundity and pregnancy outcomes are comparable to the general population.

To investigate the epidemiology, clinico-pathological characteristics and outcomes of patients diagnosed with malignant ovarian Sertoli-Leydig cell tumors (SLCTs) in comparison to granulosa cell tumors (GCTs). The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database were accessed and patients diagnosed with a malignant SLCT and GCT between 1988 and 2013 were selected. Demographic and clinico-pathological characteristics were compared using the Mann–Whitney and chi-square tests. Overall (OS) and cancer-specific survival (CSS) rates were estimated with the Kaplan–Meier method and compared with the log-rank test. Cox hazard models were constructed to control for confounders. A total of 175 and 1361 patients diagnosed with SLCT and GCT, respectively, were identified. Compared to patients with GCT, those with SLCT were younger (median age 32 vs. 51 years, p 10 cm), SCLTs were associated with a worse cancer-specific mortality compared to GCTs. SLCTs are extremely rare, commonly arise in premenopausal patients. They are associated with a poorer prognosis compared to GCT.

Investigate the prevalence of bilateral salpingo-oophorectomy (BSO) for women ≤50 years with early stage low-grade endometrial stromal sarcoma (LGESS) and its impact on overall survival (OS).Women ≤50 years, diagnosed with stage I LGESS and managed with hysterectomy between 2004 and 2015 were identified from the National Cancer Database. Patient demographics were recorded and compared with the chi-square test. OS for patients diagnosed between 2004 and 2014 with at least one month of follow-up was assessed using Kaplan-Meier curves, and compared with the log-rank test.A total 743 patients with a median age of 44 years met the inclusion criteria. Use of radiatiotherapy (9%), chemotherapy (0.8%) and hormonal therapy (11%) was infrequent. BSO was performed in 541 (72.8%) patients. Patients who had ovarian preservation (OP) were younger (median age 43 vs 45 years, p 0.001), less likely to have comorbidities (6.9% vs 12.4%, p = 0.034), or undergo LND (30.7% vs 44.4%, p = 0.001). There were no differences between the two groups in terms of substage or patient race. Five year OS rates for patients who did (n = 490) and did not (n = 191) undergo BSO were 96.2% and 97.1% and there was no difference in OS, p = 0.50. Even after controlling for presence of comorbidities performance of BSO was not associated with better survival (HR: 1.28, 95% CI: 0.51, 3.19).Ovarian function was preserved in approximately one third of women ≤50 years with stage I LGESS with no clear detriment to overall survival. As BSO is associated with long term health effects in this patient population OP could be considered in selected women with stage I LGESS.

ObjectiveMost studies evaluating the oncologic safety of minimally invasive surgery for endometrial cancer focus on patients with stage I disease. The aim of this study was to investigate the outcomes of minimally invasive surgery for patients with endometrial carcinoma involving the cervix.MethodsPatients diagnosed between January 2010 and December 2015, with clinical stage II endometrial carcinoma, who underwent hysterectomy with lymphadenectomy, were drawn from the National Cancer Database. Inclusion criteria were clinical International Federation of Gynecology and Obstetrics (FIGO 2009) stage II, patients who underwent hysterectomy with lymphadenectomy, and known route of surgery (open or minimally invasive). Patients who received radiation therapy prior to surgery, those who had subtotal/supracervical hysterectomy, or unknown type of hysterectomy were excluded. The exposure of interest was performance of minimally invasive surgery either laparoscopic or robotic-assisted. Overall survival (primary endpoint) was assessed for patients diagnosed between January 2010 and December 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.ResultsA total of 2175 patients were identified and 1282 (58.9%) had minimally invasive surgery. Of these, 339 and 943 patients had laparoscopic or robotic-assisted laparoscopic hysterectomy, respectively. Minimally invasive surgery was converted to open surgery in 74 (5.8%) patients. Those undergoing minimally invasive surgery had shorter hospital stay (median 1 vs 3 days, pConclusionsIn this retrospective analysis, minimally invasive surgery in patients with stage II endometrial carcinoma was associated with superior short-term peri-operative outcomes and improved 3-year overall survival.

To investigate the clinicopathological characteristics and survival of patients with malignant ovarian carcinoid tumor (OC).The National Cancer Database was accessed and patients diagnosed between 2004 and 2015 with a OC who did not have a personal history of a tumor at another site were selected. Overall survival (OS) was assessed for patients who had ≥1 month of follow-up. OS rates were estimated following generation of Kaplan-Meier curves and compared with the log-rank test.A total of 588 patients with a median age of 51.5 years were identified. The majority were White (71.6%), had unilateral tumors (94.2%) with a median size of 3.8 cm that were confined to the ovary (88%). Patients with early stage disease (n = 431) had excellent OS compared to those with advanced stage (II-IV) disease (n = 51), p 0.001; 5-yr OS rates were 95.4% and 53.1% respectively. For patients with stage I disease, there was no difference in OS between those who did (n = 211) and did not (n = 175) have hysterectomy, p = 0.92. For patients with advanced stage disease, administration of adjuvant chemotherapy was not associated with better survival, p = 0.093.OCs are typically small, unilateral tumors confined to the ovary arising in perimenopausal patients. Survival outcomes are excellent for patients with early stage disease and unilateral salpingo-oophorectomy appears to be curative.

To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes.Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests.A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p 0.001), hysterectomy (3.5% vs 22%, p 0.001) and LND (45.6% vs 54.7%, p 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p 0.05).Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.

Introduction The benefit of adjuvant chemotherapy for Stage IC grade 1 and stage IA/IB grade 2 endometrioid ovarian adenocarcinoma (EOOC) remains unclear as the NCCN guidelines recommend either observation only or adjuvant chemotherapy. Therefore, we sought to determine whether patients with stage I EOOC had improved overall survival (OS) following receipt of adjuvant chemotherapy. Methods Patients with pathological stage I ovarian endometrioid adenocarcinoma diagnosed between 2004 and 2014 were identified from the National Cancer Database. Demographics, pathologic factors including tumor grade, and treatment information including receipt of adjuvant chemotherapy were collected. The impact of chemotherapy on OS was evaluated with Kaplan-Meier curves, and compared with log-rank tests. Multivariate Cox analysis was performed to control for confounders. Results A total of 4538 patients were identified and the median age was 55 years The rate of adjuvant chemotherapy use was 50.9%. Higher rates were noted among patients with stage IC and grade 3 tumors. Following stratification by tumor grade, substage and extent of lymphadenectomy, adjuvant chemotherapy was associated with a survival benefit for patients with grade 2 tumors who did not undergo (stage IA/IB: 95.7% vs 83%, p = 0.038; stage IC: 84.5% vs 84.8%, p = 0.39) or had limited lymphadenectomy (stage IA/IB: 96% vs 89.5%, p = 0.03; stage IC: 97.2% vs 83.9%, p = 0.001). A survival difference was also seen for patients with grade 3 tumors who did not undergo lymphadenectomy but did not reach statistical significance. Conclusion Adjuvant chemotherapy was associated with an overall survival benefit for patients with inadequately-staged, grade 2 stage I ovarian endometrioid adenocarcinoma. A possible benefit for inadequately-staged patients with grade 3 tumors cannot be excluded.

PURPOSE: To identify biomarkers that prospectively predict IVF cycle cancellation. METHODS: In this prospective study, sera were obtained prior to any intervention, from women about to undergo an IVF cycle. The sera were assayed by ELISA for levels of insulin-like growth factor (IGF)-1, IGF-2, IGF binding protein (BP)-1, and soluble fms-like tyrosine kinase (sFLT-1). The cancellation or progression of the IVF cycle was subsequently obtained by chart review. Associations between serum components and outcome were analyzed by the Mann-Whitney test. Receiver operator curves were constructed to evaluate the strength of the correlations between biomarkers and cycle cancellation, as assessed from the area under the curve (AUC). RESULTS: A total of 205 women were included. Twenty-seven (13.2%) cycle cancellations due to poor response were recorded. Women with a cancelled cycle had reduced anti-Mullerian hormone (AMH) values (p < 0.001) and antral follicle count (p = 0.003). There were no significant differences between the two groups with regard to age and BMI. Median concentrations of IGF-1 and sFLT-1 were elevated in sera from women whose IVF cycles were cancelled as compared to those with ongoing cycles (p = 0.015 and p < 0.001, respectively); AUC for IGF-1 and sFLT-1 were 0.67 and 0.75, respectively. Concentrations of sFLT-1 remained significantly higher in patients with cancelled cycles even after controlling for AMH levels. There were no differences in IGF-2 and IGFBP-1 levels between the two groups. CONCLUSIONS: Measurement of circulating IGF-1 and sFLT-1 levels prior to initiation of an IVF cycle has the potential to identify women whose cycles have an increased likelihood to be subsequently cancelled.

ObjectiveTo investigate the prognostic significance of complete gross resection following cytoreductive surgery for patients with advanced stage malignant ovarian germ cell tumors.MethodsThe National Cancer Data Base was accessed and patients diagnosed with an advanced stage (II-IV) malignant ovarian germ cell tumor who underwent primary cytoreductive surgery between 2011 and 2014 were selected for further analysis. For analysis purposes two groups were formed: patients with complete gross resection and those with macroscopic residual disease. Demographic and clinico-pathological characteristics were compared with the chi-square and Mann–Whitney U test. Univariate survival analysis was performed with the log-rank test after generation of Kaplan–Meier curves, while a Cox proportional hazard model was constructed to evaluate mortality after controlling for confounders.ResultsA total of 343 patients who met the inclusion criteria were identified. Residual disease status was available for 276 patients: the rate of complete gross resection was 69.2 %. By univariate analysis there was no difference in overall survival between patients in the complete gross resection and macroscopic residual disease groups, P= 0.26; 3-year overall survival rates: 86.4 % and 82.8 %, respectively. No difference in overall survival was noted following stratification by histology; P = 0.64 and P = 0.24 for dysgerminoma and non-dysgerminoma tumor groups. After controlling for stage IV disease, histology and the administration of chemotherapy, macroscopic residual disease was not associated with a worse mortality (HR: 1.22, 95% CI: 0.61 to 2.46).ConclusionsMacroscopic residual disease following primary cancer-directed surgery was not associated with a worse prognosis in a cohort of patients with advanced stage malignant ovarian germ cell tumors.

An elevated level of insulin growth factor (IGF-1) in rat uterine fluid has been shown to exert detrimental effects of embryo development possibly leading to an increase in pregnancy loss. Interestingly, the administration of somatostatin to rats undergoing superovulation reduced IGF-1 levels in uterine luminal fluid and thus reversed its deleterious effects on embryo development and increased the number of normal embryos. Therefore, we investigated whether serum levels of IGF-1 correlate with the incidence of pregnancy loss following IVF. To account for aneuploidy and the effect of hormonal supplementation on serum IGF levels, we only included natural frozen-thawed euploid embryo transfer (N-FET) cycles. Sera collected in the follicular phase (cycle day 10) were tested for levels of IGF-1, IGF-2, and IGF-binding protein 1 (IGFBP-1) using quantitative ELISA. A total of 156 N-FET cycles were included: 120 resulted in a live birth whereas 36 led to a first trimester pregnancy loss. Women with a pregnancy loss had significantly higher serum IGF-1 levels compared to those who achieved a live birth (18.0 ± 1.1 vs. 14.6 ± 0.7 ng/mL, respectively). The two groups had comparable serum IGF-2 and IGFBP-1 levels. There was no significant difference in maternal age, body mass index, gravidity, parity, number of prior miscarriages, peak endometrial thickness, or infertility diagnosis between the two groups. In conclusion, women undergoing euploid blastocyst transfer with elevated serum IGF-1 concentrations may be at increased risk of pregnancy loss. This may constitute a novel molecular explanation of pregnancy loss of euploid conceptus.

Objectives: Investigate the impact of trachelectomy facility-volume on the outcomes of patients with early-stage cervical carcinoma. Methods: Patients aged Results: A total of 774 trachelectomies were performed for patients with cervical cancer at 269 institutions. Ten (3.3%) institutions reported at least 10 cases between 2004 and 2016, while most institutions (190, 70.6%) reported one or two cases. Outcomes were evaluated for 514 patients with known histology, stage I disease who underwent lymphadenectomy; 29.4% were managed at a high-volume facility. Patients who underwent trachelectomy at a high-volume center were more likely to have private insurance (88.1% vs 77.7%, p=0.023) while there were no differences in terms of race, presence of comorbidities and tumor histology (p>0.05) between high and low volume facilities. Patients who underwent surgery at a high-volume center had lower 30-day re-admission rate (1.3% vs 6.4%, p=0.013) but comparable rate of prolonged (>5 days) hospitalization (8.2% vs 6.5%, p=0.48). There was no difference in OS between high and low-volume centers, p=0.47; 5-year OS rates were 93.8% and 95.4% respectively. After controlling for the presence of comorbidities and tumor histology, performance of trachelectomy at a high-volume facility was not associated with better survival (HR: 1.21, 95% CI: 0.48, 3.05). Conclusions: Given the low incidence of cervical cancer in this age group, and possible de-centralization, facility-volume for trachelectomy is very low with no clear detrimental effect on survival or perioperative outcomes. Further research is needed to determine if centralization to high volume centers is associated with superior reproductive and survival outcomes.

Objectives: Investigate the management and outcomes of patients diagnosed with squamous cell carcinoma of the ovary (SCC-O). Methods: Patients with no history of another tumor diagnosed between 2004-2015 with SCC-O, known tumor stage and at least one month of follow-up were drawn from the National Cancer Database. Clinico-pathological and demographic characteristics were analyzed and overall survival (OS) was evaluated following generation of Kaplan-Meier curves. A Cox model was constructed to evaluate for independent predictors of survival. Results: A total of 440 patients with a median age of 53 years (range 15-90) were identified; 34.3% had stage I disease, while 19.5%, 26.8% and 19.3% had stage II, III and IV disease respectively. Most patients were White (72%) without co-morbidities (82%). Median tumor size was 9.5 cm while tumor grade was available for 370 cases; 52.4% had grade 3 tumors while 39.2% and 8.4% had grade 2 and 1 tumors respectively. Based on 87 patients with apparent early stage disease who underwent lymphadenectomy, lymph node involvement was rare (2%). Five-year OS rate for patients with stage I disease was 75.8% compared to 28.5%, 29.3% and 11.6% for those with stage II, III, IV disease, p Conclusions: SCC-O is a rare tumor with a poor prognosis especially for patients with advanced stage disease. Novel treatment options are greatly warranted.

Objectives: Evaluate if the addition of adjuvant chemotherapy to radiation therapy improves survival of patients with high-intermediate stage I endometrioid endometrial carcinoma with lympho-vascular invasion (LVSI). Methods: Patients without a history of another tumor, diagnosed between 2010 and 2015 with pathological stage I endometrioid endometrial adenocarcinoma with LVSI who underwent hysterectomy with at least 10 lymph nodes removed, and met the GOG-99 criteria for high-intermediate risk were identified in the National Cancer Database. Those who received adjuvant radiation therapy with or without adjuvant chemotherapy (defined as treatment received within 6 months from surgery) and had at least one month of follow-up were selected for further analysis. Overall survival (OS) was compared with the log-rank test following generation of Kaplan-Meier curves. A Cox multivariate model was constructed to control for confounders. Results: A total of 2342 patients who met the inclusion criteria were identified; 1938 (82.7%) patients received radiation therapy only (RT) while 404 (17.3%) received chemoradiation (CRT). The majority (74.9%) of patients received brachytherapy (VBT) while 16.8% received external beam radiation therapy (EBRT), and 8.3% received combination of both VBT and EBRT. Rate of adjuvant chemotherapy administration did not differ based on the type of radiation therapy administered; 17.9%, 17% and 17.9% for patients who received EBRT, VBT or combination of both respectively, p=0.88. Patients who received CRT were younger (median age 62 vs 65 years, p 0.05. Median follow-up in the RT and CRT groups was 41.0 and 45.2 months respectively. There was no difference in OS between patients who received RT and CRT, p=0.53; 4-year OS rates were 85.8% and 82.6% respectively. CRT did not confer a survival benefit for grade 2 (p=0.98) or grade 3 (p=0.34) tumors. After controlling for patient age, race, insurance status, presence of comorbidities, tumor grade, size, and depth of myometrial invasion, CRT was not associated with better survival (HR: 0.95, 95% CI: 0.71, 1.28). Conclusions: In a large cohort of patients with high-intermediate risk FIGO stage I endometrioid endometrial adenocarcinoma with lymph-vascular invasion, the addition of chemotherapy to radiation therapy was not associated with a survival benefit.

Objectives: Evaluate the outcomes of hysterectomy for apparent early stage endometrial carcinoma performed at low-income hospitals. Methods: Patients diagnosed between 2004 and 2016 with an uterine, cervical or ovarian tumor with known insurance status were drawn from the National Cancer Database. Low-income hospitals (LIH) were determined as those with the highest percentage (>75th percentile) of uninsured or Medicaid patients. Hospitals with lowest percentage ( Results: A total of 1237 facilities who reported patients with gynecologic malignancies were identified. The average percentage of uninsured or Medicaid patients at LIH was 25.3% compared to 4.54% for non-LIH. A total of 53500 patients with apparent early stage endometrial carcinoma who met the inclusion criteria were identified; 40.3% were managed at a LIH. Compared to patients having surgery at a non-LIH, those undergoing hysterectomy at a LIH were younger (median 61 vs 62 years, p Conclusions: Patients with apparent early stage endometrial cancer undergoing surgery at a LIH have lower access to MIS techniques and increased peri-operative morbidity compared to those managed at non-LIH. A small increase in overall mortality was also noted.

Objectives: Given its rarity, the optimal management of patients with endometrial cancer extending to the parametria, vagina or pelvic sidewall in the absence of lymph node metastasis is not well defined. We aimed to investigate the outcomes of patients with stage IIIB endometrioid cancer following hysterectomy based on different adjuvant treatment strategies. Methods: Patients with no history of another tumor diagnosed between 2004 and 2015 with stage IIIB endometrioid adenocarcinoma of the uterus who underwent primary hysterectomy, had negative lymph nodes and at least one month of follow-up were selected from the National Cancer Database. Overall survival between patients who were observed or received chemotherapy-only (CT), radiotherapy-only (RT) and chemoradiation (CRT) were compared with the log-rank test after generation of Kaplan-Meier curves. A Cox multivariate model was constructed to control for confounders. Results: A total of 717 patients with a median age of 64 years who met the inclusion criteria were identified. Radical hysterectomy was performed for 17% of cases. Data on margin status was available for 638 cases; 73.5% had negative margins. Tumor was extending to the parametria for 239 (33.3%) patients, to the vagina for 235 (32.8%) cases, to the pelvic sidewall for 102 (14.2%) cases, and was abutting bladder/colon (without invasion) for 55 cases (7.7%) while 86 patients (12%) had stage IIIB not otherwise specified. A total of 147 (20.5%) patients did not receive adjuvant treatment, while 118 (16.5%) received chemotherapy-alone, 206 (28.7%) received radiotherapy-alone and 246 (34.3%) received chemoradiation. Tumor grade and presence of comorbidities was comparable between the groups. Five-year OS rates for patients who did not receive adjuvant treatment was 49.8% compared to 56% for those who had chemotherapy-alone, 60% for those who had radiotherapy-alone and 76.2% for those who received chemoradiation, p Conclusions: Chemoradiation is associated with better survival outcomes for patients with stage IIIB endometrial cancer

To evaluate the clinico-pathological characteristics, management and prognosis of women diagnosed with ovarian yolk sac tumors (OYSTs).The U.S National Cancer Data Base was queried for women diagnosed with OYST between 2004 and 2014. Overall survival (OS) was calculated following generation of Kaplan-Meir curves. Univariate analysis was performed with the log-rank test. A Cox model was constructed to determine independent predictors of mortality.A total of 561 women were identified with a median age of 23years. The majority (58.5%) had early stage (I-II), while 29.6% and 11.9% had stage III and IV disease respectively. Five-year OS for women with stage I, II, III and IV disease were 94.8%, 97.1%, 70.9% and 51.6% respectively, p0.001. Better 5-yr OS was observed for adolescents (94.4%) and young adults (89.3%) compared to older premenopausal (67.6%) and postmenopausal women (30.6%), p0.001. Omentectomy, hysterectomy and lymph node sampling/dissection (LND) were not associated with better OS. Women who received adjuvant chemotherapy had superior OS compared to those who did not, p=0.016. Early disease stage, younger age and receipt of adjuvant chemotherapy, but not LND were independently associated with better mortality.Women with OYST commonly present with early stage disease. Administration of adjuvant chemotherapy, early stage and younger age are associated with superior outcomes.