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Objectives. Planar lymphoscintigraphy (LSG) is frequently performed for the assessment of the sentinel lymph nodes (SLN) in gynecologic malignancies. Planar imaging helps to localize hot nodes but lacks accuracy of the anatomic location of those nodes. In this study, we compared SPECT-CT to planar LSG in endometrial and cervical cancer to assess its ability to localize SLN. Methods. We conducted a prospective nonrandomized study of SLN mapping in women with endometrial and cervical cancer. Forty patients with endometrial cancer and 10 with cervical cancer underwent pre-operative LSG with 1 or 4 mCi of 99m Tc sulfur colloid administered as injections into the cervix. All patients were scanned immediately with planar LSG obtained in the anterior and lateral views. SPECT-CT imaging was obtained following the planar imaging. Results. Planar LSG alone localized SLN in 30/40 (75%) endometrial cancer patients while SPECT-CT localized SLN in all 40 patients (100%). In the 10 cases where SLN was not identified with planar imaging, SPECT-CT localized nodes in the external iliac, internal iliac, common iliac and obturator groups. In cervical cancer, planar LSG alone localized sentinel lymph nodes in 8/10 patients (80%) as compared to SPECT-CT, which localized nodes in all 10 patients (100%). SPECT-CT imaging was especially useful in delineating external iliac versus internal iliac or obturator nodes, and the parametrial nodal uptake. Conclusions. SPECT-CT appears to improve sentinel lymph node detection and anatomic localization as compared to planar imaging in cervical and uterine cancer.

Objective Patients with advanced or recurrent endometrial cancer often have distant metastases found within the lymph nodes, liver, and/or lung. However, there have been reported cases of primary endometrial cancer with metastasis to the bone. The objective of this study was to describe the clinical and pathologic features of endometrial cancer metastatic to bone. Methods A retrospective chart review of our clinical and pathology database was performed to identify women diagnosed with endometrial cancer metastatic to the bone between 1990 and 2007. Clinical data and outcomes were obtained from medical records. Slides were re-reviewed to confirm the diagnosis. Results Twenty-one patients with endometrial cancer metastatic to the bone were identified; in 12 patients (57%), the diagnosis was confirmed by a bone biopsy. The median age of diagnosis of primary endometrial cancer was 60years (range, 32–84). Fourteen patients (67%) had FIGO stage III/IV disease. Six patients (29%) had a bone metastasis at the time of diagnosis while 15 patients (71%) had a bone lesion as a recurrence. The median time to a diagnosis of bone metastasis recurrence was 10months (range, 3–148). The overall survival of those patients with bone metastases at primary diagnosis was 17months (95% CI: 2–32) compared to 32months (95% CI: 14–49) for those with a recurrent bone metastasis. Conclusion Although a rare event, endometrial cancer can metastasize to the bone. If a bone lesion is identified, treatment using a multimodality approach is reasonable, especially if found as an isolated recurrence.

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.

Objective The purpose of this study was to determine posthysterectomy pathologic findings in patients with a preoperative endometrial sampling diagnosis of International Federation of Gynecology and Obstetrics (FIGO) grade 1 endometrial adenocarcinoma with a background of complex atypical hyperplasia (CAH). Study Design We reviewed 1423 consecutive cases of endometrial cancer to identify cases with a preoperative endometrial biopsy that demonstrated FIGO grade 1 endometrial adenocarcinoma. Final uterine pathologic findings were grouped into low- and high-risk based on FIGO and Gynecologic Oncology Group criteria. Results We identified 123 cases with a background of CAH and 367 cases without a background of CAH. FIGO grade in the hysterectomy specimen was more than FIGO grade 1 in 11 of 123 cases (8.9%) with a background of CAH, compared with 60 of 359 cases (16.7%) without a background of CAH ( P = .04). Conclusion An endometrial sampling diagnosis of FIGO grade 1 endometrial adenocarcinoma with a background of CAH is more likely to correlate with final posthysterectomy grade than a diagnosis not arising with a background of CAH.

Objectives To determine whether HA-CMC was associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for ovarian, fallopian tube, or primary peritoneal malignancies. Methods We retrospectively identified all laparotomies performed for these malignancies from March 1, 2005 to December 31, 2007. The use of HA-CMC was identified. Laparotomies for malignant bowel obstruction or repair of fistulae were excluded. Intra-abdominal collections, non-infected and infected, were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. All other complications were also captured. Appropriate statistical tests were applied using SPSS 15.0. Results We identified 219 laparotomies with HA-CMC and 204 without HA-CMC. Upper abdominal resections were performed in 65/219 (30%) HA-CMC cases compared to 39/204 (19%) cases without HA-CMC ( P =0.01). The rates of large bowel and/or rectal resections were similar in both cohorts. Intra-abdominal collections were seen in 18/219 (8.2%) HA-CMC cases compared to 5/204 (2.5%) cases without HA-CMC ( P =0.009). HA-CMC was independently associated with the diagnosis of a postoperative intra-abdominal collection ( P =0.01). All but 2 collections developed in patients undergoing debulking procedures. Conclusions HA-CMC appears to be associated with a higher rate of postoperative intra-abdominal collections. This seems to be greatest in patients who are undergoing a debulking procedure.

The treatment of ovarian cancer truly involves a multimodal approach with surgery as the cornerstone. Surgery serves many roles in addition to providing a definitive diagnosis. In disease grossly confined to the ovary and/or pelvis, surgery can provide accurate and comprehensive staging based on the known patterns of spread. Many patients with clinically apparent early-stage ovarian cancer will be upstaged after comprehensive surgical staging. Accurate staging is crucial for a credible prognosis and as a guide for additional therapeutic approaches. The role of surgery for grossly advanced ovarian cancer is cytoreduction (debulking) of large tumor volume, which results in improved outcomes. Surgical cytoreduction also may improve the survival in select patients with recurrent disease. Surgery is considered in the palliation of many symptoms of advanced ovarian cancer. Patients with ovarian cancer will benefit from being treated by physicians with special expertise in the surgical management of this disease. Invasive epithelial ovarian cancers account for the vast majority of ovarian cancers. This chapter primarily refers to this type of ovarian cancer unless otherwise specified.

Objective To report a single institution experience in surgical stage I–II serous endometrial cancer using combined carboplatin/paclitaxel and intravaginal radiation (IVRT). Methods Between 10/00 and 12/06, 25 stage I–II patients with serous endometrial cancer were treated at our institution with surgery, postoperative IVRT, and concurrent chemotherapy (CT). Results The mean age was 67 years old (range, 53–80 years). Surgery consisted of hysterectomy (TAH/BSO, 64%, LAVH/BSO, 36%), peritoneal washing, omental biopsy, and pelvic lymph-node dissection (median 14 nodes). Para-aortic node sampling was done in 88% (median, 6). IVRT median dose was 21 Gy (range, 18–21 Gy, in 3 fractions) and concurrent CT consisted of carboplatin to AUC=5 and taxol to 175 mg/m 2 given every 3 weeks for 6 cycles. CT was well tolerated with 22/25 (88%) receiving 6 cycles. Three patients received ≤5 cycles; 2 owing to physician preference (3 and 4 cycles) and 1 owing to toxicity (5 cycles). Only 1 patient (4%) had grade 3 toxicity (abscess). Grade 2 neurotoxicity was seen in 5 patients (20%). All patients finished their IVRT as scheduled, and there was no grade 3 toxicity. With a median follow-up of 30 months, the 5-year progression-free and overall survival rate was 88%. None of the patients developed vaginal recurrence. Conclusions Based on this study, surgical staging followed by IVRT and carboplatin/paclitaxel is well tolerated and effective in stage I–II serous endometrial cancer. Confirmation of these results on a larger number of patients with longer follow-up is still needed.

To compare the accuracy of DC vs office endometrial biopsy in predicting final post-hysterectomy FIGO grade in patients diagnosed with a preoperative FIGO grade 1 endometrial adenocarcinoma.We reviewed 1423 consecutive cases of endometrial cancer treated at our institution between 1/1/93 and 5/31/06 and identified cases with an unequivocal preoperative endometrial biopsy demonstrating FIGO grade 1 endometrial adenocarcinoma. All cases were pathologically confirmed and underwent surgical therapy at our institution. FIGO grade and histology diagnosed in the hysterectomy specimen were noted. The findings in the hysterectomy specimen were then compared between those patients who had a preoperative DC vs an office endometrial sampling. Chi-square and Fisher-exact test were used as appropriate.We identified 490 cases with a preoperative FIGO grade 1 endometrial adenocarcinoma. In 482 cases, FIGO grade was determined to be greater in 71 (14.7%) cases; in the final hysterectomy specimen, 66 (13.7%) were found to be grade 2 and 5 (1%) were found to be grades 2-3/3. Serous or clear cell histology was diagnosed in 6 (1.2%) additional cases. DC was performed in 187 (38.6%) cases and office endometrial sampling in 298 (61.4%); in 5 cases the method used was not discernible. The final post-hysterectomy FIGO grade was higher in 16/187 (8.7%) cases diagnosed by DC compared to 52/298 (17.4%) diagnosed by office endometrial sampling (P=0.007).Preoperative FIGO grade 1 diagnosis correlates with final grade diagnosis in 85% of cases. While DC more accurately reflects final FIGO grade, a higher grade will be found in 8.7% of the cases at the time of hysterectomy.

A breast and/or axillary mass in a patient with epithelial ovarian cancer (EOC) may be due to an EOC breast metastasis or a second primary breast cancer. We sought to review our experience with patients with a history of EOC presenting with a breast and/or axillary mass to determine if clinical features differed between these entities.Between 1/90 and 10/07, 29 women with epithelial EOC presented with a breast or axillary mass, including 10 patients with EOC metastatic to the breast and/or axilla and 19 patients with a second primary breast cancer following their original EOC diagnosis. Clinicopathologic factors/survival were retrospectively abstracted from medical records.The mean EOC disease-free survival (DFS) was 14.9 mo versus 77.4 mo (P0.001) for patients with recurrent epithelial ovarian cancer metastatic to the breast and/or axilla and patients with a second primary breast cancer, respectively. Similarly, the mean interval between diagnosis of EOC and the breast and/or axillary event was 31.2 mo versus 70.7 mo for those patients who had metastatic recurrent EOC and those patients with breast cancer (P=0.02). Patients with a second primary breast cancer were more likely to be diagnosed on mammogram and have a family history of breast and ovarian carcinoma than patients with metastatic EOC to the breast and/or axilla (14/19 [73.7%] versus 2/9 [22.8%], P=0.02; and 12/18 [66.7%] versus 2/10 [20%], P=0.05, respectively). Median overall survival for patients with EOC metastasis was 26 mo but was not yet reached for those patients with a second primary breast cancer. On univariate analysis, an ovarian cancer DFS of 12 mo or more and the performance of breast/axillary surgery were associated with a significantly longer overall survival (P=0.01 and 0.02, respectively), whereas an elevated CA125 level at the time of the breast/axilla event and the presence of EOC metastases to the breast and axilla were significant negative predictors of survival (P=0.01 and 0.05, respectively).The interval between EOC diagnosis and the breast and/or axilla event, an elevated CA125 level, and a family history of breast and/or ovarian cancer may help differentiate patients with metastatic EOC to the breast and/or axilla from those patients with a second primary breast cancer. The presence of a metastatic EOC portends a poor prognosis.

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.

Objective To determine the incidence, management, and outcome of patients diagnosed with a pancreatic leak after a distal pancreatectomy during primary surgical cytoreduction for ovarian, peritoneal, or tubal cancer. Methods We performed a retrospective chart review of all patients who had a distal pancreatectomy at the time of primary surgery. Charts were reviewed to identify those patients who developed a persistent left upper quadrant abdominal fluid collection with elevated amylase levels. Results A total of 17 patients had a distal pancreatectomy; of these, 4 patients (24%) developed a postoperative pancreatic leak. In these patients, persistent leukocytosis prompted evaluation with a computed tomography scan, which subsequently revealed a fluid collection. The median time from surgery to drainage of this collection was 9 days (range, 8–66). The drain remained in situ for a median of 29 days (range, 22–82). The median amylase level of the fluid was 22,945 U/L (range, 763–47,250). The median length of hospital stay for those patients with a leak was 33 days (range, 25–44), which was longer than those without a leak. However, the median time from surgery to treatment with systemic chemotherapy was 31 days (range, 16–43), which was equivalent to those without a pancreatic leak. Conclusion Twenty-four percent of patients who had undergone a distal pancreatectomy developed a pancreatic leak. This complication, which usually presents early in the postoperative period, can be managed conservatively with percutaneous drainage. Oral intake may be resumed, and total parenteral nutrition is not needed in the majority of cases. Systemic chemotherapy can be administered without significant delay.

To compare the surgical and pathologic outcomes utilizing two surgical approaches for fertility-sparing radical trachelectomy in patients with stage IB1 cervical cancer.A prospectively maintained database of vaginal radical trachelectomy (VRT) and abdominal radical trachelectomy (ART) procedures was analyzed. All procedures were performed in a standardized manner by the same surgical group. Parametrial measurements were recorded from the final pathology report. Standard statistical tests were used.Between 12/2001 and 7/2007, 43 adult patients with FIGO stage IB1 cervical cancer underwent surgery with the intent to perform a fertility-sparing radical trachelectomy. VRT was attempted in 28 patients (65%) and ART in 15 patients (35%). The median measured parametrial length in the VRT group was 1.45 cm compared to 3.97 cm in the ART group, P0.0001. None of the parametrial specimens in the VRT group contained parametrial nodes. Parametrial nodes were detected in 8 (57.3%) of the ART specimens (P=0.0002). There was no difference in histologic subtypes, lymph vascular space invasion, or median total regional lymph nodes removed in the two groups. Median blood loss was greater but not clinically significant in the ART group, and median operating time was less in the ART group. The overall complication rate was not significantly different in the two groups.Using standardized techniques, radical abdominal trachelectomy provides similar surgical and pathologic outcomes with possibly a wider parametrial resection, including contiguous parametrial nodes, as compared to the radical vaginal approach.

To compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma.We performed a case-control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan-Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method.Forty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P=NS). On multivariate analysis in this group of stage IB1 lesions, tumor size2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P=0.033 and 0.005, respectively).For selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.

BACKGROUND. The aim was to determine the long-term outcome for patients with FIGO stage IV epithelial ovarian carcinoma (EOC) treated with intraperitoneal (IP) chemotherapy after second-look assessment. METHODS. By using data from a retrospective cohort of 433 patients who received IP therapy after second-look assessment after primary surgery and initial systemic therapy for EOC between 1984 and 1998 at our institution, all FIGO stage IIIC and IV patients were identified. Standard statistical methods were used. RESULTS. Overall, 297 patients met study criteria (246 stage IIIC; 51 stage IV). The median survival for patients with stage IV disease was 34 months compared with 42 months for patients with stage IIIC disease (P = .02). The only significant predictor of overall survival in patients with stage IV disease was the presence of gross residual disease at initiation of IP therapy (P = .027). When comparing stage IV patients with and without pleural effusions to all stage IIIC patients, there was a significant trend toward improved survival in the patients with pleural effusions only compared with other stage IV patients (P = .01). CONCLUSIONS. Prolonged overall survival was observed in patients with no gross residual disease at the time of IP chemotherapy initiation. When compared with similarly treated stage IIIC patients, stage IV patients with malignant pleural effusions appear to have a better outcome than those with other sites of metastasis. Future prospective trials should evaluate the use of IP therapy for patients with stage IV EOC by virtue of malignant pleural effusions only who responded to initial systemic therapy. Cancer 2008. ©2008 American Cancer Society.

Uterine carcinosarcomas (CSs) are aggressive neoplasms, with 5-year overall survival (OS) rates of less than 35%. They are customarily separated into types harboring either heterologous or homologous mesenchymal elements, but the prognostic significance of this finding is controversial. Our goal was to study clinicopathologic features of possible prognostic relevance in surgical stage I uterine CS. A retrospective clinical and histopathologic review was performed for all women diagnosed with surgical stage I uterine CS. These tumors were compared with stage I high-grade endometrial (HGEm) carcinomas for clinical outcomes. There were 42 cases of surgical stage I uterine CS identified between January 1990 and January 2004. The disease-free survival and OS rates for patients with stage I CS were significantly worse compared with stage I HGEm (P=0.001; P=0.01). The median disease-free survival for patients with heterologous CS was 15 months and had not been reached for women with homologous CS (P=0.001). The 3-year OS rates were 45% versus 93% in women with heterologous compared with homologous stage I CS (P0.001). The 3-year OS rates for homologous CS and HGEm were both90%. Homologous stage I CSs have survival outcomes that are similar to HGEm. This further supports the concept that homologous stage I CSs are carcinomas with sarcomatoid features, not sarcomas. More importantly, the presence of heterologous sarcomatous elements is a powerful negative prognostic factor in surgical stage I uterine CS.

Purpose To compare surgeons' operative assessments of residual disease (RD) to those identified on postoperative computed tomography (CT) scans in patients with advanced ovarian carcinoma reported to have undergone optimal primary cytoreduction. Patients and Methods All patients at one of two institutions, who were scheduled to have primary surgery for presumed advanced ovarian cancer, were asked to consent to a postoperative CT scan if cytoreduction to ≤ 1 cm RD was reported. CT scan findings were graded using a qualitative analysis scale from 1 (normal) to 5 (definitely malignant). Results From January 2001 to September 2006, 285 patients were enrolled. A total of 78 patients met eligibility criteria and had postoperative CT scans. In 41 cases (52%), postoperative scan findings correlated with the surgical report of no RD more than 1 cm, and in seven cases (9%), the CT findings were indeterminate. In 10 cases (13%), more than 1 cm RD was noted by the radiologist as probably malignant, and in 20 cases (26%), definitely malignant. In these 30 cases, the radiologically reported median largest residual mass was 1.9 cm (range, 1.1 to 5.1), with RD more than 1 cm reported most commonly in the right upper quadrant (15 patients [50%]) and central abdomen (nine patients [30%]). Conclusion There was only a 52% correlation between surgeons' assessments and postoperative CT scan evaluations of RD in patients reported to have undergone optimal cytoreduction. Further study is required to determine whether this lack of correlation is due to rapid interval tumor regrowth, RD underestimated by the surgeons, and/or overestimated by the radiologists; and to determine the clinical implications of these discrepancies.

To analyze the impact of bulky upper abdominal disease (UAD) cephalad to the greater omentum on surgical outcomes for patients with stage IIIC epithelial ovarian, fallopian tube, and primary peritoneal carcinoma.All patients with stage IIIC epithelial ovarian, fallopian tube, and primary peritoneal carcinoma who underwent primary cytoreductive surgery at our institution from 1989 to 2005 were eligible for the study. UAD cephalad to the greater omentum was defined as cancerous lesions involving the diaphragm, liver, porta hepatis, spleen, pancreas, stomach, and lesser sac. The study group was divided into three groups based on the presence and size of UAD cephalad to the greater omentum at the beginning of surgery-group 1, no disease; group 2,or = 1 cm disease; and group 3, bulky disease1 cm. These three groups were further divided into two subsets based on the routine use of extensive upper abdominal surgery after January 1, 2001. Standard statistical analyses were utilized.We identified 490 patients who met study inclusion criteria. Their median age was 61 years (range, 25-88). UAD status was recorded in 474 patients as follows: group 1 (no UAD), 116 (24%); group 2 (or = 1 cm UAD), 161 (34%); and group 3 (bulky UAD1 cm), 197 (42%). Bulky UAD was associated with ascites volume (P0.001). Among the patients with ascites volumes500 ml, 54% had bulky UAD cephalad to the greater omentum, 37% had minimal UAD, and 9% had no evidence of UAD. Optimal surgical outcome (or = 1 cm residual disease) was achieved in 81%, 63%, and 39% of patients in groups 1, 2, and 3, respectively (P0.001). A significant increase in optimal cytoreduction was observed after 2001 (40% before 2001 vs. 78% after 2001; P0.001). This effect was more pronounced in patients with bulky UAD (11%, before 2001 vs. 70% after 2001) than in patients with no or minimal UAD (P0.001).The upper abdomen cephalad to the greater omentum is frequently involved in patients with stage IIIC ovarian, tubal, and peritoneal carcinoma. This disease site is significantly associated with large-volume ascites and suboptimal cytoreduction. Over the course of 17 years, however, the significant improvement in optimal cytoreduction rates has been most apparent in patients with bulky UAD. These findings emphasize the importance of comprehensive training, preparation, and referral when appropriate to centers that specialize in the surgical management of patients with advanced ovarian, tubal, and peritoneal carcinoma.

Women with mutations in BRCA1 or BRCA2 are at tremendously increased lifetime risk of both breast and BRCA-associated gynecologic (ovarian, fallopian tube, and primary peritoneal) cancer. Because of limitations in the efficacy of available screening and chemopreventive approaches for women with a mutation in one of these genes, surgical risk reduction, particularly risk-reducing salpingo-oophorectomy (RRSO), has become an important component of the management options in hereditary breast-ovarian cancer syndrome. This article will review the rationale and efficacy of RRSO for prevention of breast and BRCA-associated gynecologic cancer. Surgical technique and methods of pathologic evaluation will be presented. Controversies regarding uterine preservation and post-RRSO hormone replacement therapy will be addressed. Considerations that may impact the appropriate timing of the procedure will be reviewed, and the potential role of RRSO in BRCA-negative hereditary breast cancer families will also be discussed.

Objective Platinum/Paclitaxel-based chemotherapy is a current treatment for advanced epithelial ovarian cancer. We sought to explore the association between weight change during treatment and survival, as well as the association between pre-chemotherapy body mass index (BMI) and survival. Methods A retrospective data review was conducted of 792 advanced ovarian cancer patients who participated in a phase III randomized trial of cisplatin/paclitaxel versus carboplatin/paclitaxel. Pre-chemotherapy BMI was calculated following surgery. Weight change was defined as the ratio of body weight at completion of protocol therapy to pre-chemotherapy body weight. Progression-free survival (PFS) and overall survival (OS), classified by BMI or relative weight change, were estimated by Kaplan–Meier, and associations were assessed using a Cox model controlled for known prognostic variables (age, race, performance status, histology, tumor grade, tumor residual and treatment group). Results There was no association between pre-chemotherapy BMI and survival. There was a significant relationship between median OS and weight change as follows: >5% decrease=48.0 months; 0–5% decrease=49.3 months; 0–5% increase=61.1 months; and >5% increase=68.2 months. Adjusted for covariates, the relative risk of death increased by 7% for each 5% decrease in body weight (HR=0.93, 95% CI=0.88–0.99; p =0.013). Conclusions Change of body weight during primary chemotherapy was a strong prognostic factor for overall survival. Loss of body weight during primary therapy is an indicator for poor OS; weight gain is an indicator for improved survival. This study supports the development of strategies to minimize weight loss that can be assessed in a prospective, randomized study to improve patient outcomes.

The objective of this study was to describe the management of patients with recurrent cervical cancer after total pelvic exenteration (TPE). We reviewed the records of patients who underwent TPE for recurrent cervical cancer between June 1992 and December 2003 and subsequently developed recurrent disease. Thirty-seven patients underwent TPE during the study period, and 25 (68%) subsequently developed recurrence proven by radiographic and/or biopsy studies. Recurrence sites included pelvic (12), inguinal (5), retroperitoneal (5), hepatic (4), vulva (2), perineum (1), transposed ovary (1), and lung (1). The median time to recurrence was 7 months (range 2–73 months), with 92% (23/25) occurring within 2 years of TPE. Management of recurrence was known in 21 of 25 patients, which included chemotherapy (10), surgical resection (7), and no further treatment (4). Surgically resected recurrences were isolated to the groin (2), vulva (2), perineum (1), transposed ovary (1), and psoas muscle (1). The four patients who underwent ovarian, perineal, and vulvar resections succumbed to their disease in a median time of 13 months (range 2–21 months). Of the two patients with surgically resected groin recurrences, one is alive with disease 21 months after initial recurrence and the other is alive without evidence of disease 85 months later. One patient had an isolated 4-cm recurrence involving the psoas muscle and the femoral nerve and is without the evidence of disease 9 months later. Resection of isolated recurrences after TPE is a reasonable option in selected patients, particularly in those with solitary inguinal metastases

The aim of this study was to assess the efficacy and tolerability of paclitaxel and carboplatin (TC) in the treatment of patients with advanced or recurrent endometrial cancer. Patients eligible for this retrospective analysis had endometrial cancer with either advanced or recurrent measurable disease (untreated primary stage III/IV or stage III/IV patients with persistent, measurable disease [≥2 cm] after surgery), Eastern Cooperative Oncology Group (ECOG) performance status ≥3, and received at least one cycle of TC. Response rates were determined using Response Evaluation Criteria in Solid Tumors criteria. Institutional Review Board approval was obtained prior to the initiation of this study. Eighty-five eligible patients, with a median age of 62 years (range 36–80) were identified. Fifty-seven (67%) of patients were treated at the time of recurrence. Prior radiation therapy had been used in the treatment of 36 (42%) patients, while 13 (15%) patients had received prior chemotherapy. Median follow-up time was 11.7 months (range 1.1–96.7 months), and the median number of cycles of therapy received was six (range 1–18). The overall response rate (ORR) was 43%, with a complete response rate of 5% and a partial response rate of 38%. Chemotherapy-naive patients had an ORR of 47%. Only seven (8%) patients had to discontinue therapy due to toxicity. Median progression-free survival was 5.3 months (95% CI, 4.6–7.4), with a median overall survival of 13.2 months (95% CI, 11.7–18.2). We conclude that TC is an active and tolerable regimen in the treatment of patients with advanced or recurrent endometrial cancer

Recent reports have suggested that only half of women ageor =65 with advanced ovarian cancer are treated with platinum-based chemotherapy. The objective of this study was to compare the response to platinum-taxane chemotherapy and subsequent outcomes between patients older and younger than 65 years of age with stages IIIC-IV epithelial ovarian cancer (EOC).A cohort study was performed of all patients with stages IIIC-IV EOC who had their primary surgery at our institution from 1998 to 2004 and subsequently began platinum-taxane chemotherapy. Main outcomes were response to primary chemotherapy, platinum resistance and progression-free (PFS) and overall survival (OS).A total of 292 patients began primary platinum-taxane therapy after surgery and comprised our study group. Of these, 108 (37%) wereor =65 years old and 184 (63%) were65. Stage of disease, optimal cytoreduction rate, number of chemotherapy cycles and chemotherapy regimen alterations were similar between groups. Patientsor =65 achieved a clinical complete response with a similar frequency to those65 (70% vs. 79%) and had similar rates of platinum sensitivity at 6 months (61% vs. 65%). Patientsor =65 had equivalent PFS (P=0.99) and OS (P=0.36) to those65. Ageor =65 years was not independently associated with impaired survival.Patientsor =65 years of age demonstrated similar rates of initial response, platinum resistance, PFS and OS to younger patients. Elderly women who can tolerate primary cytoreductive surgery should receive combination platinum-taxane chemotherapy.

I nternational evidence-based consensus statements are important for defining standards of care and developing guidelines for communities worldwide. For ovarian cancer, successful international consensus meetings have been organized, and the most important was the meeting in Baden-Baden, Germany, in September 2004, which was organized by the Gynecological Cancer Intergroup. Its statements still are valid and are applied in daily routine. See related article on pages 692–702, this issue.

Purpose To determine the accuracy of 18 FDG PET in identifying sites of metastatic disease prior to pelvic exenteration or radical resection in patients (pts) with recurrent cervical or vaginal cancers. Methods Pts with recurrent cervical or vaginal cancer being evaluated for surgical resection were enrolled in a prospective study approved by the institutional human subjects review board. All patients underwent 18 FDG PET scans as well as CT and/or MRI scans and were required to have pathologic confirmation of any sites suggestive of tumor recurrence. Results Between 1998 and 2002 a total of 27 pts were enrolled on the study. Seven patients did not complete all study requirements and are excluded from further analysis. All pts had undergone prior pelvic radiation therapy and five patients had also received chemotherapy. CT/MRI scans identified three patients with possible metastatic disease in the following sites: (1) iliac nodes (2 pts) and (2) lungs (1 pt). After surgical and pathological evaluation, only one of these sites, the lungs, was confirmed to have metastatic disease. PET scans identified possible metastatic disease in nine patients and included the following sites: (1) pelvic nodes (4 pts), (2) para-aortic nodes (2 pts), (3) axillary node (1 pt), (4) bowel wall (1 pt) and (5) lungs (1 pt). After surgical and pathologic evaluation metastatic disease was identified in five of these pts at the following sites: iliac nodes, 2; para-aortic nodes, 1; bowel wall, 1; and lungs, 1. Of the sites identified by PET scan as areas of metastasis CT scan only identified the pulmonary metastasis. Conclusion 18 FDG PET was found to have a sensitivity of 100% and a specificity of 73% in detecting sites of extra-pelvic metastasis and may be the most accurate test to determine eligibility for pelvic exenteration.

Objectives. Malignant transformation of mature cystic teratomas is rare, with squamous cell carcinoma being the most common type. The prognosis is generally poor when disease has spread beyond the ovary. We conducted this study to review our experience with this disease and describe our current treatment modality. Methods. During a 22-year period (1983–2005), we identified 17 women treated for squamous cell carcinoma arising in a mature cystic teratoma of the ovary. All pathologic diagnoses were confirmed at our institution. A retrospective chart review and comprehensive review of the literature were conducted. Results. The median age was 55 (mean, 54.8; range, 37–75). Eight cases were stage I, 5 were stage II, and 4 were stage III. Mean tumor size was 14.2 cm. All patients underwent surgery, with positive lymph nodes noted in 0 of 10 cases that included lymph node dissection. Ten patients received adjuvant treatment—6 with chemotherapy and 4 with chemoradiation. Six patients had recurrent disease in the pelvis after adjuvant treatment. Four patients died of disease. The overall 1-year survival rate was 60%. The 4 patients with stages IA–IIB disease treated with adjuvant platinum-based chemotherapy and radiation survived at 12–56 months' follow-up. Conclusions. Squamous carcinomas arising in mature cystic teratomas are commonly large ovarian tumors that occur in perimenopausal women and often present as an incidental pathologic finding. While the prognosis seems highly dependent on surgical stage, there is a lack of consensus in the literature regarding adjuvant treatment. Platinum-based chemotherapy with pelvic radiation may be a reasonable adjuvant therapy for early-stage disease.

BACKGROUND Lysophosphatidic acid acyltransferase-β (LPAAT-β) tumor expression is an emerging prognostic, diagnostic, and therapeutic target in early epithelial ovarian cancer (EOC). The significance of tumor overexpression of LPAAT-β was investigated in a large number of advanced- and early-stage EOC patients. METHODS LPAAT-β expression was analyzed by immunohistochemistry (IHC) in 158 ovarian tumors, including 68 advanced and 90 low-stage tumors, representing all grades and histologies (including 33 borderline tumors). In advanced-stage patients, tissue from multiple sites was evaluated to assess differential expression of LPAAT-β in local tumor and distant metastases. RESULTS LPAAT-β was overexpressed in 90 (57%) of all 158 ovarian tumors. Forty-nine (72%) of 68 advanced tumors overexpressed LPAAT-β. LPAAT-β was associated with the presence of carcinoma versus borderline histology (67% vs. 18%, P < .0001), high histologic grade [according to the Silverberg Grading Scheme] (Grade 1, 25%; Grade 2, 21%; and Grade 3, 54%; P < .0001), and with papillary-serous histology. In an analysis of the 125 carcinoma patients, LPAAT-β increased with but was not significantly associated with advanced clinical stage (P = .1431). LPAAT-β expression was associated with shortened progression-free survival (PFS) (5-year PFS, 32% for LPAAT-β-positive vs. 60% for LPAAT-β-negative; P = .0318) and decreased overall survival (OS) (5-year OS, 54% for LPAAT-β-positive vs. 74% for LPAAT-β-negative; P = .0173). CONCLUSIONS LPAAT-β is highly expressed in advanced ovarian tumors and is associated with aggressive histology and decreased PFS and OS. LPAAT-β is an intriguing prognostic tool for the identification of high-risk EOC and a potential target for directed therapy that warrants further study. Cancer 2006. © 2006 American Cancer Society.

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.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.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 nodules1 cm in 11/15 (73%), and nodules1 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 disease1 cm. After VATS, 12/23 patients (52%) underwent primary surgical management, with cytoreduction toor =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.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 disease1 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.

YKL-40 is a secreted glycoprotein of the chitinase family that has been previously described as a diagnostic and prognostic marker for a number of cancers, including epithelial ovarian cancer. In this study, we examined the frequency of serum elevation as well as the diagnostic and prognostic significance of this serum marker in endometrial cancer.Preoperative serum levels of YKL-40 and CA125 were evaluated by enzyme-linked immunosorbent assay (ELISA) for all endometrial cancer patient samples (34) available in the Memorial Sloan-Kettering Cancer Center Gynecology Service Tissue Bank between the years 1987 and 2002, and compared to a cohort of normal individuals. A YKL-40 value of 61 ng/mL has previously been determined to represent the upper limit of normal. YKL-40 values were correlated with clinical characteristics, including patient age, tumor grade, histology, clinical stage, and clinical outcome (progression-free survival [PFS] and overall survival [OS]).YKL-40 was elevated (61 ng/mL) in 26 (76%) of 34 endometrial cancer patients compared with elevations of CA125 in 21 (62%) of 34 patients (P=0.09). Twenty-eight (82%) of all 34 patients had elevations of either CA125 or YKL-40 or both; 16 (89%) of 18 advanced-stage endometrial cancer patients had elevation of at least one of these two markers. Median preoperative YKL-40 value was 137 ng/mL (range, 22-1738 ng/mL) for endometrial cancer patients compared with 28 ng/mL (range, 15-72 ng/mL) for normal healthy subjects (P0.0001). There was no statistically significant association of YKL-40 with patient age, tumor grade, histology, or stage. Elevation of YKL-40 (80 ng/mL) was correlated with poor clinical outcome in univariate analysis, but was not demonstrated in multivariate analysis. At 5 years' follow-up, the PFS rate was 80% for patients with YKL-4080 ng/mL compared with 43% for patients with YKL-4080 ng/mL (P=0.004). The 5-year OS rate for patients with YKL-4080 ng/mL was 79% compared with 48% for patients with YKL-4080 ng/mL (P=0.047).Preoperative serum YKL-40 is frequently elevated and may represent a novel marker for the detection of endometrial cancer and the identification of high-risk subsets of patients with worse clinical outcome. Further investigation of this promising endometrial cancer marker in larger studies is warranted.

Objectives. Diaphragm peritonectomy or resection is an effective way to cytoreduce diaphragm disease but frequently results in sympathetic pleural effusions. Our objective was to determine the incidence and management of effusions that developed after diaphragm surgery in patients with advanced mullerian cancer. Methods. We reviewed the records of all patients with stage IIIC–IV epithelial ovarian, fallopian tube, or peritoneal cancer who had diaphragm peritonectomy or resection as part of optimal primary cytoreduction at our institution from 2000–2003. All patients had preoperative and serial postoperative chest X-rays to detect and follow pleural effusions. Factors evaluated included the presence and size of preoperative and postoperative effusions, their laterality, and subsequent need for thoracentesis and/or chest tube placement for symptomatic effusions. Results. Of the 215 patients who had primary cytoreduction during the study period, 59 (27%) underwent diaphragm peritonectomy or resection. In addition to standard cytoreduction, 31 (53%) of these 59 patients had diaphragm surgery alone, while 28 (47%) had diaphragm surgery in combination with other upper abdominal resections. Laterality of diaphragm surgery was as follows: right only, 43 (73%); left only, 2 (3%); and bilateral, 14 (24%). Intraoperative chest tubes were placed in 7 (12%) patients. In the remaining 12 patients with preoperative effusions, postoperative effusions on the same side as the diaphragm surgery increased in 6 patients (50%), and 3 patients (25%) required postoperative thoracentesis or chest tube. In the remaining 40 patients without preoperative effusions, ipsilateral effusions developed in 24 patients (60%), and 5 patients (13%) required postoperative chest tubes. The overall rate of new or increased ipsilateral effusions was 58%; the overall rate of postoperative thoracentesis or chest tube placement was 15%. In 75% of the patients, thoracentesis or chest tubes were placed within 5 days of surgery (median, 3 days; range, 2–24). Conclusions. More than half of patients developed ipsilateral pleural effusions after diaphragm peritonectomy for cytoreduction. Most were managed conservatively without requiring a chest tube or thoracentesis. The incidence of symptomatic effusions was not high enough to recommend routine chest tube placement at the time of diaphragm peritonectomy or resection.

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.

Objective. To evaluate the clinicopathologic features of microinvasive adenocarcinoma of the cervix in order to guide the management of patients with this disease. Materials and methods. A retrospective review was conducted of patients diagnosed with early invasive, ≤5 mm stromal invasion, adenocarcinoma of the cervix by a cervical conization between 1992 and 1999 at our institution. Information was abstracted on tumor histopathologic type, grade, and depth of invasion as well as presence or absence of disease at the margins of conization, lymphovascular spread, and the presence of disease in subsequent pathology specimens including the parametrium and pelvic lymph nodes (PLNs). Results. Thirty-three patients were identified. The mean age of the patients in the study population was 41.6 years (range, 29–53 years). Fifteen women were age 35 years or younger. Six patients had invasion ≤1 mm, 9 patients had invasion >1 mm and ≤2 mm, 6 patients had invasion >2 mm and ≤3 mm, 6 patients had invasion >3 mm and ≤4 mm, and 6 patients had invasion >4 mm and ≤5 mm. Three patients were treated with a conization only, 4 patients were treated with a simple hysterectomy, 25 patients were treated with a radical hysterectomy (RH) and PLN dissection (PLND), and 1 patient was treated with a radical trachelectomy and PLND. Ten patients had positive conization margins for invasive cancer, 3 patients had margins positive for adenocarcinoma in situ, 14 patients had negative margins, and in 6 patients the margin status could not be evaluated. Of the 10 patients with positive margins, 5 of 10 (50%) had residual disease in the subsequent surgical specimen. Three patients who underwent definitive management with conization alone originally had positive margins, underwent a second repeat conization, and are included in this group. Of the 16 patients with negative margins, no patient had residual disease in a subsequent surgical specimen. Of the 25 patients who underwent a RH and PLND, none had parametrial involvement and none had PLN involvement. All patients remained without evidence of disease at median follow-up of 30 months. Conclusions. Historically, the standard management of early invasive adenocarcinoma of the cervix has been controversial, and some clinicians continue to favor radical treatments. Based on the absence of parametrial spread and PLN involvement in early lesions, physicians and patients should consider treatment with conization with negative margins (when future fertility is desired) or simple hysterectomy. Prospective studies are required to document the safety of this approach.

Purpose To determine the effect of estrogen replacement therapy (ERT) on recurrence rate and survival in women who have undergone surgery for stage I or II endometrial cancer. Patients and Methods After surgery, eligible patients were allocated to therapy with ERT or placebo after undergoing hysterectomy with or without pelvic and aortic nodal sampling. Planned duration of hormonal versus placebo treatment was 3 years, with an additional 2 years of follow-up. Results The median follow-up time for all 1,236 eligible and assessable patients was 35.7 months. Stage, grade, histologic subtype, and percentage of patients receiving adjuvant therapy were similarly distributed between the groups. The median age at diagnosis for the 618 patients randomly assigned to ERT was 57 years (range, 26 to 91 years). Two hundred fifty-one patients (41.1%) were compliant with ERT for the entire treatment period. Disease recurrence was experienced in 14 patients (2.3%). Eight patients (1.3%) developed a new malignancy. There were 26 deaths (4.2%), and five deaths (0.8%) were a result of endometrial cancer. The median age at diagnosis for the 618 patients in the placebo group was 57 years (range, 30 to 88 years). Twelve patients (1.9%) experienced disease recurrence. Ten patients (1.6%) developed a new malignancy. There were 9 deaths (3.1%) in the placebo group, and four deaths (0.6%) were a result of endometrial cancer. Conclusion Although this incomplete study cannot conclusively refute or support the safety of exogenous estrogen with regard to risk of endometrial recurrence, it is noteworthy that the absolute recurrence rate (2.1%) and the incidence of new malignancy were low.

Previous reports have suggested that patients who have undergone pelvic radiation for cervical cancer are at risk for developing poorly differentiated endometrial cancers with poor prognoses.We conducted a retrospective chart and histologic review of patients from Memorial Sloan-Kettering Cancer Center and MD Anderson Cancer Center diagnosed with endometrial cancer after radiation therapy (RT) for cervical cancer from 1976 to 2000. The comparison group comprised MSKCC endometrial cancer patients whose tumors were not radiation associated ("sporadic cancers").We identified 23 patients who developed endometrial carcinoma or carcinomasarcoma after RT for cervical carcinoma and 527 sporadic endometrial cancer patients. When radiation-associated endometrial cancers (RAECs) were compared with sporadic cancers, significant differences were noted with regard to stage, grade and histologic subtype distribution. In the RAEC group, there were 16 (70%) stages III and IV cancers compared with 101 (19%) in the sporadic group (P0.001). There were 20 (87%) grade 3 cancers in the RAEC group versus 161 (31%) in the sporadic group (P0.001). There were 16 (70%) high-risk histologic subtypes (serous, clear cell, carcinosarcoma, undifferentiated) in the RAEC group versus 79 (15%) in the sporadic group (P0.001). Median survival in the RAEC group was 24 months versus not reached in the sporadic group (P0.001). Radiation remained a significant factor for poor prognosis in a stratified analysis, in which we compared sporadic and RAEC cancers controlled for age, histology, grade and stage. However, radiation lost significance in a multivariate analysis, in which stage- and grade-matched cancers from both groups were compared.The clinicopathologic characteristics of RAECs, which include a preponderance of high-stage, high-grade and high-risk histologic subtypes, indicate that these tumors differ from sporadic endometrial carcinomas. However, patients with RAECs do not appear to have a significantly worse prognosis when compared with patients with high-stage and high-grade sporadic cancers.

Over the years, endometrial cancer has remained the most common gynecologic malignancy in the United States. Two categories of endometrial cancer exist: type I and type II. Type I cancers constitute the majority of cases of endometrial cancer, and the risk factors for this type have been studied in greatest detail. These cancers are driven by estrogen, and many of the risk factors are directly or indirectly linked to a state of excessive estrogen. Protective factors seem to be related to conditions that may result in decreased estrogen exposure. Cure rates for endometrial cancer remain high, mainly because of the early stage at which the majority of cases present. Warning signs of abnormal vaginal bleeding or discharge allow detection of these cancers in their early stages. Screening for these cancers is not effective and often leads to additional unnecessary tests; thus, it is not currently recommended in the general population.

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 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.

Objective Chances of survival after the diagnosis of recurrent endometrial cancer are poor. Although total pelvic exenteration has been described as a treatment for a select subset of patients with recurrent endometrial cancer, the use of other surgical procedures in this setting has not been well described. The objective of this study was to review our experience with non-exenterative surgery for recurrent endometrial cancer. Methods We reviewed the medical records of all patients who underwent non-exenterative surgery for recurrent endometrial cancer between 1/91 and 1/03. Survival was determined from the time of surgery for recurrence to last follow-up. Survival was estimated using Kaplan–Meier methods. Differences in survival were analyzed using the log-rank test. The Fisher's exact test was used to compare optimal versus suboptimal cytoreduction against possible predictive factors. Results Twenty-seven patients were identified. Fifteen patients (56%) had disease limited to the retroperitoneum, 10 patients (37%) had intraperitoneal disease, and 2 patients (7%) had both intra- and retroperitoneal disease. Cytoreduction to ≤2 cm of residual disease was achieved in 18 patients (67%), while 9 patients (33%) had cytoreduction to residual disease >2 cm. There were no major perioperative complications or mortalities. The median hospital stay was 7 days (range, 1–18 days). Additional therapies included intraoperative radiation therapy in 9 patients (33%), radiation therapy in 12 patients (44%), and chemotherapy in 10 patients (37%). The median follow-up for the entire cohort was 24 months (range, 5–84 months). The median progression-free survival was 14 months (95% CI, 6–23), and the median disease-specific survival was 35 months (95% CI, 24–not reached). Size of residual disease was the only significant predictor for both progression-free and disease-specific survival. Patients with residual disease ≤2 cm had a median disease-specific survival of 43 months (95% CI, 35–not reached) compared with 10 months (95% CI, 7–29) for those with >2 cm residual ( P = 0.01). Conclusions Surgical resection for recurrent endometrial cancer may provide an opportunity for long-term survival in a select patient population. The only factor associated with improved long-term outcome was the size of residual disease remaining at the end of surgical resection.

Objectives. To describe the results of laparoscopic management of adnexal masses in women with a history of nongynecologic malignancy. Methods. We conducted a retrospective review of 262 patients with history of prior nongynecologic malignancy who underwent laparoscopy for management of an adnexal mass between 1/1992 and 6/2004. Results. Median patient age at laparoscopy was 55 years (range, 20–91 years), and median BMI was 25 kg/m 2 (range, 14–41 kg/m 2 ). Of the 262 patients, 145 (55.3%) had prior abdominal/pelvic surgery. Prior cancer history included breast (202, 77.1%), lymphoma/leukemia (16, 6.1%), colorectal (8, 3.0%), lung (7, 2.7%), multiple myeloma (5, 1.9%), head/neck (5, 1.9%), genitourinary (5, 1.9%), upper gastrointestinal (4, 1.5%), and other (10, 3.8%). Median ovarian mass diameter measured on radiologic imaging was 3.8 cm (range, 0.2–13.5 cm); median CA-125 was 17.0 U/mL (range, 1–7000 U/mL). In all, 49 (18.7%) patients had malignancy identified at laparoscopy, with 30/49 (61.2%) diagnosed with metastatic malignancy to the ovary and 19/49 (38.8%) having a new primary ovarian malignancy . Median tumor diameter and CA-125 were significantly higher in women found to have a malignancy (4.7 vs. 3.7 cm, and 35 vs. 14 U/mL, respectively). Overall, conversion to laparotomy occurred in 34 (12.9%) cases. Twenty-one of 49 (42.9%) patients with malignancy were converted to laparotomy compared with 13/213 (6.1%) when benign disease was noted ( P Conclusions. Approximately 1 in 5 patients with a history of nongynecologic malignancy who were selected for laparoscopic management of an adnexal mass was found to have malignancy, with 60% being metastatic from other primaries. The majority of cases were managed laparoscopically even if malignancy was identified.

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.

Objective To compare the safety and efficacy of laparoscopic staging of ovarian or fallopian tube cancers to staging via laparotomy for epithelial ovarian carcinoma. Study design We performed a case-control study of all patients with apparent stage I adnexal cancers who had laparoscopic staging from October 2000 to March 2003. The control group consisted of all patients with apparent stage I epithelial ovarian carcinoma who had staging via laparotomy during the same time period. Results Staging was laparoscopic in 20 patients and via laparotomy in 30. There were no differences in mean age and body mass index. There were also no differences in omental specimen size and number of lymph nodes removed. Estimated blood loss and hospital stay were lower for laparoscopy, but operating time was longer. There were no conversions to laparotomy or complications in the laparoscopic group, compared with 3 minor complications in the laparotomy group. Conclusion In this preliminary analysis, it appears that patients with apparent stage I ovarian or fallopian tube cancer can safely and adequately undergo laparoscopic surgical staging.

Objectives. Studies from the colorectal literature have shown that factors associated with anastomotic leak after colorectal resection include long surgical time (>2 h), multiple blood transfusions, and short distance to the anal verge. The aim of this study was to assess the morbidity associated with en bloc resection of ovarian carcinoma with low anterior resection and anastomosis in patients undergoing primary cytoreductive surgery for advanced disease. Methods. We performed a retrospective chart review of all patients who had undergone primary cytoreduction for advanced epithelial ovarian cancer with rectosigmoid resection followed by low rectal anastomosis between January 1994 and June 2004. Patient characteristics, operative details, and postoperative complications were extracted from patients' charts. Results. Seventy patients met the above criteria and form our study group. The median age was 59 years (range, 25–82). There were 52 stage IIIC (74%) and 18 stage IV (26%) cancers. The median operating time was 315 min (range, 120–750) and the median estimated blood loss was 1200 ml (range, 250–8000), with 53 (76%) patients requiring blood transfusion. Twenty-eight patients (40%) underwent major upper abdominal procedures other than omentectomy, and 14 patients (20%) underwent a second bowel resection. Twelve patients (17%) underwent a protective ileostomy while the remainder (83%) did not. Of the 58 patients with no ostomy, the only complications associated with the resection and anastomoses were a pelvic abscess in 3 patients (5%) and an anastomotic leak requiring diverting colostomy in 1 patient (1.7%). Of the 12 patients who had protective ileostomies, 3 (25%) had complications related to their ileostomy short-bowel syndrome requiring early reversal, incarceration of the prolapsed loop requiring surgical correction, and prolapse corrected electively at the time of second-look surgery. Conclusions. In women undergoing primary cytoreductive surgery, the morbidity associated with en bloc resection of ovarian carcinoma with low rectosigmoid resection and anastomosis without protective ileostomy was acceptably low, with an anastomotic leak rate of less than 2%. Protective ileostomy is not always necessary and should be used selectively.