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Single-site laparoscopy has proven to be a desirable option for patients undergoing gynecologic surgery, with some studies indicating improved cosmesis and less perioperative pain compared with standard approaches. This study describes the safety and feasibility of a novel robotic laparoendoscopic single-site surgery (R-LESS) platform as it is incorporated into a surgeon's practice with extensive multiport robotic surgical experience but limited LESS experience. We reviewed 83 women undergoing R-LESS by a single surgeon from September 2013 through August 2015. Operative times (total operative time, console time, docking time) were collected prospectively for the first 53 cases, and total operative time was collected retrospectively for the next 30 cases. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, conversion to laparotomy, procedure type, uterine weight, length of hospital stay, and complications, were retrospectively collected from medical charts. Eighty-two of 83 surgeries were completed successfully with a single incision. One surgery was converted to multiport robotics for para-aortic lymph node dissection. Twelve surgeries were performed for cancer (ovary 1, uterus 8, and cervix 3). Eight patients underwent pelvic lymph node biopsy. The median total operative time for hysterectomies was 128 minutes (range, 60–275). After the first 13 hysterectomies the total operative time and the console time decreased significantly from 165.3 to 131.1 minutes (p = .032) and from 84.9 to 57.1 minutes (p = .028), respectively. Mean docking time halved from 7.8 minutes to 3.4 minutes comparing the first 10 cases to the last 10 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. The mean uterine weight was 164 g (range, 30–460). Complications included 2 umbilical hernias (2.4%) and 1 conversion to multiport. In conclusion, R-LESS is a feasible and safe surgical platform for gynecologic procedures. A small number of cases are needed to significantly improve operative times when it is introduced on a surgeon's practice with limited experience in LESS but familiar with robotic surgery. Further study is needed to investigate the cost, benefits, and long-term outcomes of R-LESS.

Ovarian cancers diagnosed between 2000 and 2013 were examined and cases with and without endometriosis compared. Among 139 epithelial ovarian, there were 49 (35%) with endometriosis and 90 (65%) without endometriosis. Endometriosis associated ovarian cancers were more likely to be confined to the pelvis (54% vs. 9%, p < 0.0001) and lower grade (51% vs. 29%, p = 0.014). Younger age and earlier stage independently predicted the presence of endometriosis (p = 0.0011 and p < 0.0001, respectively). Ovarian cancer patients with endometriosis had improved PFS and OS [(HR = 0.20; 95% CI, 0.09-0.43), (HR = 0.18; 95% CI, 0.04-0.81)], compared to patients without endometriosis; however, endometriosis had no independent prognostic significance.

Patients with solid tumors are at greatest risk for dying from their cancers in the five years following diagnosis. For most malignancies, deaths from other chronic diseases begin to exceed those from cancer at some point. As little is known about the causes of death among long-term survivors of ovarian cancer, we examined causes of death by years from diagnosis.The Surveillance, Epidemiology, and End Results (SEER) database was used to identify women diagnosed with ovarian cancer between 1988 and 2012. We compared causes of death by stage, age, and interval time after diagnosis.A total of 67,385 women were identified. For stage I neoplasms, 13.6% (CI, 13.0-14.2%) died from ovarian cancer, 4.2% (CI, 3.8-4.5%) from cardiovascular disease, 3.6% (CI, 3.3-3.9%) from other causes and 2.6% (CI, 2.4-2.9%) from other tumors; ovarian cancer was the leading cause of death until 7 years after diagnosis after which time deaths are more frequently due to other causes. For those with stage III-IV tumors, 67.8% (CI, 67.3-68.2%) died from ovarian cancer, 2.8% (CI, 2.6-2.9%) from other causes, 2.3% (CI, 2.2-2.4%) from cardiovascular disease and 1.9% (CI, 1.7-2.0%) from other cancers; ovarian cancer was the most frequent cause of death in years 1-15 after which time deaths were more commonly due to other causes.The probability of dying from ovarian cancer decreases with time. Ovarian cancer remains the most common cause of death for 15 years after diagnosis in women with stage III-IV tumors.

Background Malignant peritoneal mesothelioma (MPM) can masquerade as an ovarian epithelial neoplasm, with very similar presenting clinical symptoms and imaging findings. The gold standard in differentiating between these two diagnoses lies in tissue pathology. Case report This is a case of MPM that was initially misdiagnosed as ovarian cancer based on family history, imaging, and surgical findings. Tissue diagnosis preoperatively would have changed the planned procedure. Retrospectively, after the diagnosis of MPM, the patient was found to have had an indirect exposure to asbestos through her father. Conclusions This case highlights the importance of keeping a broad differential when diagnosing ovarian malignancies, collecting both family and social histories (including screening for exposure to asbestos), and the benefit of obtaining tissue diagnosis when MPM is suspected., Highlights • Malignant peritoneal mesothelioma can masquerade as ovarian epithelial neoplasm. • Due to similar presenting clinical symptoms, differential diagnosis can be difficult. • The key to differentiating between these two diagnoses lies in tissue pathology. • Family, social, and occupational exposure histories are crucial if suspected ovarian malignancy • Importance of considering broad differential when ovarian malignancy is suspected.

OBJECTIVE Kaiser Permanente Northern California (KPNC) introduced 3-year Pap and human papillomavirus DNA cotesting for cervical cancer screening in women 30 years or older in 2003 to 2004. Patient and provider willingness to extend screening intervals and the impact on annual cervical cancer incidence after interval extension are evaluated. MATERIALS AND METHODS Age-adjusted cervical cancer rates and screening intervals were calculated from KPNC Regional Laboratory databases and Northern California Cancer Registry from 2000 to 2009. RESULTS The median screening interval between negative cotests was 36 months compared to the 16 months after a negative Pap test alone before the implementation of cotesting. The age-adjusted invasive cancer rate was 6.5 per 100,000 women in 2000 and 6.3 in 2009; there was no difference in the rates of cervical cancer in women 30 years or older from 2000 to 2009 (p(trend) = .7). CONCLUSIONS Patients and providers were compliant with the extension of screening intervals with cotesting. Cervical cancer rates remained constant during the 10-year study period despite extending screening intervals after a negative cotest.

Laparoscopic approaches are routinely used for a variety of procedures in general surgery and various surgical specialties including surgical oncology. Since publication of the first series of laparoscopic cholecystectomy in the late 1980s, the field of minimally invasive surgery (MIS) has expanded dramatically and is now regarded as an established specialty. Many oncologic procedures have proved not only feasible and safe, but oncologically equivalent to traditional open procedures regarding both immediate operative variables of interest (margins, lymph node retrieval, and morbidity) and long-term outcomes. Pancreaticoduodenectomy (PD) poses a particular challenge. During this procedure, there is extensive retroperitoneal dissection around anatomically complex and hazardous structures, and a prolonged reconstruction that includes 3 technically demanding anastomoses. Given this complex gastrointestinal reconstruction, it has been generally thought that the minimally invasive approach would not significantly decrease recovery time (hospital stay), yet it would significantly increase operative time. Even though minimally invasive PD was reported as early as 1994, laparoscopic surgeons have been reluctant to routinely perform it. Since this first description now almost 20 years ago, a large number of single-institution series of minimally invasive (including laparoscopic-assisted, totally laparoscopic, and more

Sclerosing mesenteritis, inflammatory pseudotumor, retroperitoneal fibrosis and IgG-4 related disease are rare inflammatory conditions that may present as a pelvic mass and mimic malignancy or infection. There is considerable overlap between these inflammatory conditions often leading to diagnostic and therapeutic confusion. Sclerosing mesenteritis is characterized by chronic inflammation, fibrosis and fat necrosis, and is thought to originate from the small bowel mesentery (Akram et al., 2007 May;5). Inflammatory pseudotumors are characterized histologically by myofibroblast-derived spindle cells and lymphoplasmacytic infiltrates. They may affect numerous organs of the body, most notably the orbit and lung, and they are often mistaken for malignancy (Yagmur et al., 2014). Retroperitoneal fibrosis is characterized by fibrosis and inflammation of the retroperitoneum, often causing encasement of retroperitoneal organs including the ureters and aorta (Liu et al., 2014 Nov). IgG 4-related disease is characterized by dense lymphoplasmacytic infiltrate, storiform (irregularly whorled) fibrosis, and obliterative phlebitis (Stone et al., 2012 Feb 9) (Carruthers et al., 2012 Jan). Inflammatory diseases of the retroperitoneum typically occur in men in the sixth to seventh decade of life, occurring twice as often in men than woman. Some hypothesize that risk factors for sclerosing mesenteritis may include autoimmunity, trauma, previous surgery, infectious, and ischemic injury (Akram et al., 2007 May;5). Patients typically present with progressive abdominal and flank pain, abdominal distension, and at times diarrhea, malaise, weight loss, fevers and lower extremity edema. Some patients present acutely with renal failure and hydronephrosis secondary to mass effect and ureteral obstruction (Akram et al., 2007 May;5, Liu et al., 2014 Nov 8). Inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate are often elevated in these patients. An elevated serum IgG-4 level may be helpful in the diagnosis of IgG-4 related disease, although up to 30% of these patients have normal serum levels. Computed tomography scans are the most common imaging study used to aid in diagnosis. Scans may reveal connective tissue around the abdominal ureters, aorta, or show a large mass that broadly occupies the retroperitoneum (Stone et al., 2012 Feb 9). These masses may also show calcifications, retroperitoneal and mesenteric lymphadenopathy, and increased collateral circulation (Liu et al., 2014 Nov). While clinical suspicion and serologic studies may help in diagnosis, histopathological features from a tissue sample remain key to proving a diagnosis. While these conditions can affect almost every organ system, gynecologists will encounter them when a patient presents with a retroperitoneal pelvic mass. These masses are often unresectable, but as their etiology is thought to be immune-mediated, they tend to respond well to immunosuppressive therapy.

Although the contemporary management of endometrial cancer is straightforward in many ways, novel data has emerged over the past decade that has altered the clinical standards of care while generating new controversies that will require further investigation. Fortunately most cases are diagnosed at early stages, but high-risk histologies and poorly differentiated tumors have high metastatic potential with a significantly worse prognosis. Initial management typically requires surgery, but the role and extent of lymphadenectomy are debated especially with well-differentiated tumors. With the changes in surgical staging, prognosis correlates more closely with stage, and the importance of cytology has been questioned and is under evaluation. The roles of radiation in intermediate-risk patients and chemotherapy in high-risk patients are emerging. The therapeutic index of brachytherapy needs to be considered, and the best sequencing of combined modalities needs to balance efficacy and toxicities. Additionally novel targeted therapies show promise, and further studies are needed to determine the appropriate use of these new agents. Management of endometrial cancer will continue to evolve as clinical trials continue to answer unsolved clinical questions.

Objective To characterize the antecedent screening of women 65years of age and older diagnosed with cervical cancer. Methods Screening histories of women 65years of age and older who were diagnosed with cervical cancer between 2003 and 2008 were examined utilizing the organization's databases and the regional Cancer Registry. Stopping screening was recommended at age 65 for members who had either 3 consecutive negative Paps or a single negative Pap plus HPV test ("cotest"). Results From 2003 through 2008 there were 56 Kaiser Permanente Northern California members 65years of age and older diagnosed with cervical cancer. During the same time period there were 1,323,100 woman-years of membership in women age 65 and older. The risk of invasive cancer among women age 65 and older was 4.2/100,000/year in 2003–2008. 33 of 56 (59%) had one or more Pap smears prior to diagnosis. Of the 33, 14 women (25%) had 3 consecutive negative Pap smears prior to diagnosis. Three of 46,401 women with 1 or more negative cotests at age 65 and older were subsequently diagnosed with invasive cancer during 132,639 women-years of follow-up (2.3/100,000/year). Conclusions Most cervical cancers diagnosed at age 65 and older occur in women who have not met our criteria for stopping screening. A few cancers will continue to occur at age 65 and older despite multiple negative tests, as is true in other age groups. We currently have no evidence that these cancers would be prevented with continued screening at ages 65 and older.

The 2012 national recommendations for cervical cancer screening will produce a lower level of cervical cancer protection than previously afforded by annual cytology or 3-year cotesting. After a single negative cotest result, the risk of cervical cancer is twice as large at 5 years as it is at 3 years. Modeling published since the 2012 guidelines were drafted indicates that extending the cotesting screening interval from 3 to 5 years at ages 30-64 years will result in an additional 1 woman in 369 compliant with screening receiving a cervical cancer diagnosis during her lifetime, and an additional 1 in 1,639 dying of cervical cancer. The authors believe that a significant number of patients and providers would not choose to accept these additional risks if they understood them, despite the recognition of potential harms associated with more intensive screening.

Although 5-year survival for early-stage ovarian cancer is favorable, prognosis at recurrence is poor, necessitating appropriate initial management. We examined the patterns of care and the impact of the duration of chemotherapy on survival for women with early-stage ovarian cancer.We used the SEER-Medicare database to identify women ≥ 65 years of age with stage I ovarian cancer diagnosed from 1992 to 2009. Patients were categorized as low-risk (non-clear cell histology, stage IA or IB, grade 1 or 2) or high-risk (clear cell histology, grade 3, or stage IC). We used multivariable logistic regression models to determine predictors of chemotherapy use and duration and Cox proportional hazards models to evaluate the effect of chemotherapy use and duration on survival.We identified 1394 patients. Among low-risk patients, 32.9% received adjuvant chemotherapy and the use of chemotherapy increased with time. Among high-risk patients, 71.9% received adjuvant chemotherapy; 44.2% had ≤ 3 months of treatment, and 55.8% had3 months of treatment. Older patients were less likely to receive chemotherapy, while those with higher stage and grade were more likely to receive chemotherapy (P0.05 for all). Among high-risk patients, the duration of chemotherapy did not impact overall (HR=0.93, 95% CI, 0.67-1.27) or cancer specific (HR=0.93; 95% CI, 0.61-1.42) survival.Among early-stage ovarian cancer patients, practice patterns are widely divergent. Extended duration chemotherapy does not appear to impact survival for women with high-risk disease.

Ovarian cancer and associated fallopian tube and primary peritoneal cancers fall under a continuum of malignancies arising from the mullerian tract.[...]

Objective To characterize the antecedent screening of women 65years of age and older diagnosed with cervical cancer. Methods Screening histories of women 65years of age and older who were diagnosed with cervical cancer between 2003 and 2008 were examined utilizing the organization's databases and the regional Cancer Registry. Stopping screening was recommended at age 65 for members who had either 3 consecutive negative Paps or a single negative Pap plus HPV test ("cotest"). Results From 2003 through 2008 there were 56 Kaiser Permanente Northern California members 65years of age and older diagnosed with cervical cancer. During the same time period there were 1,323,100 woman-years of membership in women age 65 and older. The risk of invasive cancer among women age 65 and older was 4.2/100,000/year in 2003–2008. 33 of 56 (59%) had one or more Pap smears prior to diagnosis. Of the 33, 14 women (25%) had 3 consecutive negative Pap smears prior to diagnosis. Three of 46,401 women with 1 or more negative cotests at age 65 and older were subsequently diagnosed with invasive cancer during 132,639 women-years of follow-up (2.3/100,000/year). Conclusions Most cervical cancers diagnosed at age 65 and older occur in women who have not met our criteria for stopping screening. A few cancers will continue to occur at age 65 and older despite multiple negative tests, as is true in other age groups. We currently have no evidence that these cancers would be prevented with continued screening at ages 65 and older.