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Because there is no screening test for ovarian cancer, effective prevention strategies may be the best way to reduce the mortality of this most lethal gynecologic malignancy. Increasing evidence supports the hypothesis that the fallopian tube is the site of origin for the vast majority of high-grade serous carcinomas. Our growing understanding of the pathogenesis of this disease offers a rare opportunity to explore new preventive measures, such as bilateral salpingectomy, which may provide great benefit without compromising ovarian function. If the tubal paradigm is accurate, then the impact of bilateral salpingectomy could extend to BRCA1 and BRCA2 mutation carriers, high-risk noncarriers, and average-risk women. The authors present a review of the literature on the role of risk-reducing salpingectomy in all women and in high-risk groups, with a focus on morbidity, ovarian function, potential clinical applicability, and epidemiological considerations. Cancer 2017;123:1714-1720. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

To compare oncologic outcomes of secondary cytoreductive surgery (SCS) before and after FDA approval of Poly(ADP-ribose) polymerase inhibitor (PARPi) and bevacizumab maintenance therapies for platinum-sensitive recurrent ovarian cancer (PS-ROC). Patients who underwent SCS for first recurrence of PS-ROC from 1/1/2013–1/1/2020 were identified. Exclusion criteria included prior chemotherapy for recurrence, bowel obstruction procedures, and palliative surgery. Data were dichotomized pre/post 1/2017, relative to FDA approval of PARPi and bevacizumab maintenance for ROC. Second progression-free survival (PFS2), the primary endpoint, was estimated using Kaplan-Meier method. Overall, 245 patients underwent SCS—131 (53%) pre- and 114 (47%) post-approval. Most patients had high-grade serous tumors (83% and 90%, respectively; p = 0.13). Deleterious BRCA1/2 alterations were identified in 27% (32/120) and 28% (32/113) of tested patients, respectively (p = 0.88). Disease-free intervals pre- and post-approval were: 6–12 months, 16% and 18%; 12–30 months, 56% and 59%; and >30 months, 28% and 24%, respectively (p = 0.73). Overall, 85% and 86% of patients, respectively, achieved complete gross resection (CGR; p > 0.99). PARPi maintenance use increased from 3.8% to 27% (p < 0.001) following approval, and bevacizumab from 1.5% to 12% (p < 0.001). Median PFS2 was 19 and 20.1 months, respectively. In the post group, 1-year PFS2 rate was 84.5% (95% CI, 75.7–90.4%) for patients with CGR vs 56.2% (95% CI, 29.5–76.2%) for those with residual disease; 3-year PFS2 rates were 31.3% (95% CI, 21.6–41.4%) and 12.5% (95% CI, 2.1–32.8%), respectively (p = 0.001). CGR during SCS is associated with improved PFS2 compared to suboptimal resection. Prospective randomized trials are warranted to elucidate the role of SCS as more therapeutics become available. • Since 2017, the use of targeted maintenance therapies in recurrent platinum-sensitive ovarian cancer has increased. • Patients who achieved complete gross resection at secondary cytoreductive surgery had longer PFS. • In this targeted therapy era, surgical resection retains value in treatment of platinum-sensitive recurrent ovarian cancer. [ABSTRACT FROM AUTHOR]

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

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

We sought to describe clinicopathologic and surgical factors associated with oncologic outcomes in patients undergoing tertiary cytoreduction and to present a clinical model to identify patients with high-grade serous ovarian cancer (HGSOC) who may benefit most from tertiary cytoreduction. We retrospectively identified patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who underwent tertiary cytoreduction at our institution from 1/1/1990–1/1/2019. Kaplan-Meier curves were used to estimate survival and compared using the log-rank test. Cox-proportional hazards regression was used to detect variables associated with survival. Of 114 patients who met inclusion criteria, 79 (69.2%) had high-grade serous tumors. Of patients with available genetic testing (n = 66), 22 (33%) harbored germline or somatic BRCA mutations. Fifty-eight women (50.9%) died of disease. Complete gross resection (CGR) at tertiary cytoreduction, treatment-free interval (TFI), and platinum sensitivity were all significantly associated with disease-specific survival (DSS) and maintained significance on multivariate analysis (HR 3.71, 95% CI: 1.59–8.70; HR 0.49, 95% CI: 0.28–0.85; and HR 2.94, 95% CI: 1.22–7.07, respectively). Postoperative treatment was not associated with a survival difference. Patients with HGSOC and a single site of recurrence who were ≥2 years from secondary cytoreduction had the longest survival after tertiary cytoreduction (median DSS, 79.5 months). Proper patient selection for tertiary cytoreduction is essential. Those who achieve CGR likely derive the greatest benefit from tertiary surgery. Platinum sensitivity and prolonged TFI are also associated with improved DSS. Patients with HGSOC and single-site recurrence who were ≥2 years out from secondary cytoreduction had the longest DSS. • Patients who undergo complete gross resection derive the greatest survival benefit from tertiary surgery. • Platinum sensitivity and prolonged treatment-free interval are associated with improved survival after tertiary surgery. • HGSOC patients with single-site recurrence who are ≥2 years from secondary surgery may benefit most from tertiary surgery. [ABSTRACT FROM AUTHOR]

To assess the impact of short-term postoperative complications on oncologic outcomes for patients with epithelial ovarian cancer undergoing primary cytoreductive surgery (PCS) or interval cytoreductive surgery (ICS) with intestinal resection. A retrospective chart review was performed for patients with ovarian cancer who underwent PCS or ICS with at least one intestinal resection at our institution from 1/1/2015 to 12/31/2020. Progression-free survival (PFS) and overall survival (OS) were analyzed for the PCS and ICS cohorts separately. Short-term complications within 30 days of surgery (surgical secondary events [SSEs]) were graded by a validated institutional SSE system. Among 437 patients who underwent intestinal resections during PCS (n = 289) or ICS (n = 148), 183 (42%) had one, 180 (41%) had two, and 74 (17%) had three intestinal resections. Six (1.4%) of 437 patients experienced an anastomotic leak postoperatively. There were no perioperative deaths. There was no difference in PFS and OS for patients who underwent PCS with any SSE vs. no SSE within 30 days of surgery (HR, 1.05; 95% CI: 0.76–1.47; p = 0.75 and HR, 0.79; 95% CI: 0.49–1.26; p = 0.32, respectively). There was no difference in PFS and OS for patients who underwent ICS with any SSE vs. no SSE within 30 days of surgery (HR, 1.43; 95% CI: 0.99–2.07; p = 0.055 and HR. 1.18; 95% CI: 0.72–1.93; p = 0.52, respectively. Short-term postoperative morbidity for patients who underwent intestinal surgery during primary surgical management for advanced ovarian cancer did not impact oncologic outcomes. • Grade ≥3 adverse events occurred in 12% of patients within 30 days of primary (PCS) or interval cytoreductive surgery (ICS). • In the entire cohort, 6 patients (1.4%) experienced an anastomotic leak postoperatively. • Postoperative morbidity after PCS and ICS led to a 3- and 5-day delay to chemotherapy initiation, respectively. • Patients initiating postoperative chemotherapy < or > 42 days after PCS and ICS had no difference in PFS and OS. • Postoperative morbidity after PCS or ICS with intestinal surgery did not impact oncologic outcomes. [ABSTRACT FROM AUTHOR]

This Viewpoint explains the use of opportunistic salpingectomy, removal of the fallopian tubes for the primary prevention of ovarian cancer in a woman already undergoing pelvic surgery for another indication. [ABSTRACT FROM AUTHOR]

To compare outcomes of patients with high-grade epithelial ovarian cancer (EOC) who underwent secondary cytoreduction surgery (SCS) after up-front treatment with neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) versus primary debulking surgery (PDS). Patients with high-grade EOC who underwent SCS from 2/1/2004–10/31/2021 were classified by up-front treatment. Clinical and treatment characteristics were compared between cohorts. Progression-free survival (PFS2) and overall survival (OS2) following SCS were compared using a Cox model adjusted for stage, age at SCS, and number of years between end of chemotherapy and SCS. Of 374 patients, 62 (17%) underwent NACT-IDS and 312 (83%) PDS. Justification for NACT was disease extent (n = 57, 92%), comorbidities (n = 3, 5%), and thromboembolism (n = 2, 3%). The NACT-IDS cohort had a higher median age at SCS (64 years [IQR: 56–70] vs 59 years [IQR: 53–66]; P =.03), higher proportion of stage III/IV disease (100% vs 81%; P <.001), and shorter median interval between end of chemotherapy and SCS (1.5 years [IQR: 1.1–2.3] vs 1.9 years [IQR: 1.3–3.1]; P =.01). Achievement of complete gross resection at SCS did not differ between NACT-IDS and PDS (84% vs 88%; P =.18). PFS2 (HR: 1.19, 95% CI: 0.83–1.71) and OS2 (HR: 0.96, 95% CI: 0.57–1.63) did not vary by primary treatment modality after adjusting for clinically relevant covariates. Despite more extensive disease at presentation, patients with high-grade EOC who recur after NACT-IDS seem to have similar surgical and survival outcomes after SCS compared to patients who recur after PDS, suggesting that prior NACT-IDS should not preclude SCS. • Patients with SCS after NACT-IDS were older, had higher stage at diagnosis, and less time from end of chemotherapy to SCS. • Recurrence and overall survival after SCS did not differ by primary treatment modality (NACT-IDS vs PDS). • Prior treatment modality should not preclude consideration for SCS at time of recurrence. [ABSTRACT FROM AUTHOR]

Background: Data on platinum sensitivity of low‐grade serous ovarian carcinoma (LGSOC) in the upfront setting is lacking, and there is limited and contradictory information on chemotherapy responses in recurrent disease. Methods: Patients with LGSOC seen at a comprehensive cancer center from January 1, 1998 to September 30, 2021 were identified from institutional databases. Response to neoadjuvant chemotherapy (NACT) or adjuvant platinum‐based chemotherapy and to second‐ to fifth‐line regimens was retrospectively characterized by Response Evaluation Criteria in Solid Tumors (RECIST) v1.1. Wilcoxon rank‐sum and two‐tailed Fisher exact tests were employed. Results: Of 50 patients, 12 received platinum doublets for suboptimal residual disease and 11 as NACT. Of 12 patients with suboptimal residual disease, seven (58%) achieved objective responses (five partial responses [PRs] and two complete responses); of the 11 patients who underwent NACT, one (9%) achieved a PR (p =.027). The 15 remaining patients had stable disease on first‐line platinum chemotherapy. Of 44 patients who recurred, 20 had RECIST‐evaluable responses to second‐line and 27 to third‐line chemotherapy. Objective response rates to platinum‐based chemotherapy were 22% (two of nine) in the second line and 10% (one of 10) in the third. In second and third lines, highest response rates were observed with nonplatinum chemotherapy with bevacizumab, at 100% (two of two) and 30% (three of 10), respectively. Conclusions: Primary platinum‐based chemotherapy has moderate activity in LGSOC and minimal activity in the recurrent setting, suggesting standard definitions of platinum sensitivity may not apply in LGSOC. In the second and third lines, nonplatinum chemotherapy/bevacizumab elicited the highest response rates. Front‐line platinum‐based chemotherapy has moderate activity in low‐grade serous ovarian carcinoma (LGSOC) and minimal activity in the recurrent setting, suggesting standard definitions of platinum sensitivity may not apply in LGSOC. In the second and third lines, nonplatinum chemotherapy/bevacizumab elicited the highest response rates. [ABSTRACT FROM AUTHOR]

We investigated the feasibility, safety, and survival outcomes of intrathoracic cytoreduction during primary debulking surgery (PDS) for advanced ovarian cancer. We conducted a database review of patients with stage IIIB-IV ovarian (including fallopian tube and primary peritoneal) carcinoma who underwent PDS at our institution from 01/01/2006–9/30/2021. Patients who underwent intrathoracic cytoreduction as part of primary treatment were included. Patients who received neoadjuvant chemotherapy or surgery for reasons other than cytoreduction were excluded. Among 178 patients identified for inclusion, complete gross resection (CGR) in the abdomen and thorax was achieved in 131 (74%); 45 (25%) had optimal cytoreduction, and 2 (1%) had suboptimal cytoreduction. Thirty-one patients (17%) had at least one grade ≥ 3 complication; 8 were possibly related to intrathoracic cytoreduction. There were no deaths within 30 days following surgery. Median length of follow-up among survivors was 53.4 months. Among all patients, the median PFS was 33.6 months (95% CI: 24.7–61.9) and the 3-year PFS rate was 48.9% (95% CI: 41.2%–56.2%). Median OS was 81.3 months (95% CI: 68.9–103). When stratified by residual disease status, median PFS was 51.8 months when CGR was achieved versus 16.7 months with residual disease (HR: 2.17; P <.001) and median OS was 97.6 months when CGR was achieved versus 65.9 months with residual disease (HR: 2.05; P =.003). Intrathoracic cytoreduction during PDS for advanced ovarian cancer is both safe and feasible. CGR can be achieved in patients with intrathoracic disease if properly selected, and could significantly improve both PFS and OS. • Intrathoracic surgery for advanced ovarian cancer is both safe and feasible. • Complete gross resection of ovarian cancer can be obtained in patients with intrathoracic disease. • Primary cytoreductive surgery with intrathoracic procedures can offer excellent survival outcomes in select patients. [ABSTRACT FROM AUTHOR]

To assess long-term outcomes of patients with advanced-stage ovarian cancer by treatment type. Patients with newly diagnosed stage III-IV ovarian cancer who underwent primary treatment at our tertiary cancer center from 01/01/2015–12/31/2015 were included. We reviewed electronic medical records for clinicopathological, treatment, and survival characteristics. Of 153 patients, 88 (58%) had stage III and 65 (42%) stage IV disease. Median follow-up was 65.8 months (range, 3.6–75.3). Eighty-nine patients (58%) underwent primary debulking surgery (PDS), 50 (33%) received neoadjuvant chemotherapy followed by interval debulking surgery (IDS), and 14 (9%) received chemotherapy alone, without surgery (NSx). Median PFS to first recurrence was 26.2 months (range, 20.1–36.2), 13.5 months (range, 12–15.1), and 4.2 months (range, 1.1–5.8) in the PDS, IDS, and NSx groups, respectively (P <.001). At first recurrence/progression, 80 patients (72.7%) were treated with chemotherapy, 28 (25.5%) underwent secondary cytoreductive surgery (CRS) followed by chemotherapy, and 2 (1.8%) received no treatment. Seven patients (4.6%) underwent palliative surgery for malignant bowel obstruction. Overall, 62.7% received 1–3 lines of chemotherapy. The 5-year OS rates were 53.2% (95% CI: 44.7%–61%) for the entire cohort, 71.5% (95% CI: 60.2%–80%) for the PDS group, 35.2% (95% CI: 22.2–48.5%) for the IDS group, and 7.9% (95% CI: 0.5%–29.9%) for the NSx group. The longitudinal treatment modalities and outcomes of patients with advanced ovarian cancer described here can be useful for patient counseling, long-term planning, and future comparison studies. • The 5-year OS rate in our cohort was favorably longer compared to what is described in the literature. • The majority of patients (62.7%) received 1–3 lines of chemotherapy. • Nearly 5% of patients underwent palliative surgery for malignant bowel obstruction. • Longitudinal data on treatment modalities and outcomes are useful for patient counseling, planning, and comparison studies. [ABSTRACT FROM AUTHOR]

We assessed a conditional probability of survival (CPS) model to determine the probability of living 10 years after ovarian cancer diagnosis after having already survived 5 years. We identified patients newly diagnosed with high-grade epithelial ovarian cancer from 1/1/2001–12/31/2009 and treated at our institution. Patients with <3 years follow-up were excluded. CPS was defined as the probability of surviving additional years (y) based on the condition a patient had already survived a given time (x): S (x + y)/ S (x). Confidence intervals were estimated using a variation of Greenwood's formula. Of 916 patients meeting inclusion criteria, 473 (52%) were diagnosed from 2001 to 2005 and 443 (48%) from 2006 to 2009. Median age at diagnosis was 60 years (range, 25–95). The conventional 10-year OS rate for all patients was 29% (95% CI: 26%–32%)—75% (95% CI: 68%–82%) for stage I/II disease, 22% (95% CI: 19%–26%) for stage III, and 6.9% (95% CI: 3.9%–12%) for stage IV. For patients <65 years, the 10-year CPS for 5-year survivors was 65% (95% CI: 59%–70%); for those ≥65 years, it was 48% (95% CI: 38%–57%). For patients <65 years, the 10-year CPS for 5-year survivors by stage was: stage I/II, 89% (95% CI: 81%–94%); stage III, 58% (95% CI: 50%–66%); and stage IV, 26% (95% CI: 12%–42%). For patients ≥65 years, rates by stage were 78% (95% CI: 53%–91%), 42% (95% CI: 30%–53%), and 29% (95% CI: 7%–56%), respectively. For long-term survivors with high-grade epithelial ovarian cancer, CPS provides better prediction of survival than conventional methods. • Traditional 5-year overall survival rates do not account for changes in survival probability over time. • For survivors with ovarian cancer, survival probability strongly depends upon the amount of time elapsed since diagnosis. • Ten-year conditional probability of survival (CPS) gives a more accurate prediction of survival than conventional methods. • CPS can be utilized to benefit patient counseling and prospective trial planning. [ABSTRACT FROM AUTHOR]

To determine the relationship between bowel preparation and surgical-site infection (SSI) incidence following colorectal resection during gynecologic oncology surgery. This post-hoc analysis used data from a randomized controlled trial of patients enrolled from 03/01/2016–08/20/2019 with presumed gynecologic malignancy investigating negative-pressure wound therapy among those requiring laparotomy. Patients were treated preoperatively without bowel preparation, oral antibiotic bowel preparation (OABP), or OABP plus mechanical bowel preparation (MBP) per surgeon preference. Univariate and multivariable analyses with stepwise model selection for SSI were performed for confirmed gynecologic malignancies requiring colorectal resection. Of 161 cases, 15 (9%) had no preparation, 39 (24%) OABP only, and 107 (66%) OABP+MBP. The overall SSI rate was 19% (n = 31)—53% (n = 8/15) in the no preparation, 21% (n = 8/39) in the OABP alone, and 14% (n = 15/107) in the OABP+MBP groups (P = 0.003). The difference between OABP and OABP+MBP was non-significant (P = 0.44). The median length of stay was 9 (range, 6–12), 6 (range, 5–8), and 7 days (range, 6–10), respectively (P = 0.045). The overall complication rate (34%; n = 54) did not significantly vary by preparation type (P = 0.23). On univariate logistic regression analysis, OABP (OR, 0.23; 95% CI: 0.06–0.80) and OABP+MBP (OR, 0.14; 95% CI: 0.04–0.45) were associated with decreased SSI risk compared to no preparation (P = 0.004). On multivariate analysis, both methods of preparation retained a significant impact on SSI rates (P = 0.004). Bowel preparation is associated with reduced SSI incidence and is beneficial for patients undergoing gynecologic oncology surgery with anticipated colorectal resection. Further investigation is needed to determine whether OABP alone is sufficient. • An antibiotic-based bowel preparation is associated with a decreased risk of surgical-site infection. • Surgeon assessment of the risk for colorectal resection can aid in tailoring the need for bowel preparation. • Oral bowel preparation alone may be sufficient to reduce risk of surgical-site infection , but further research is required. [ABSTRACT FROM AUTHOR]

To evaluate postoperative and oncologic outcomes associated with pelvic exenteration for non-ovarian gynecologic malignancies. This was a retrospective review of patients who underwent pelvic exenteration for non-ovarian gynecologic malignancies at our institution from 1/1/2010–12/31/2019. Palliative exenteration cases were excluded from survival analysis. Postoperative complications were early (≤30 days) or late (31–180 days). Complications were graded using a validated institutional scale. Major complications were considered grade ≥ 3. Categorical variables were compared using the chi-square test, and the Kaplan-Meier method was used for survival analysis. Of 100 patients identified, 89 underwent pelvic exenteration for recurrent disease, 5 for palliation, 5 for primary disease, and 1 for persistent disease. Thirty percent had cervical, 27% vulvar, 24% uterine, and 19% vaginal cancer. Sixty-two percent underwent total, 30% anterior, and 8% posterior exenteration. No deaths occurred intraoperatively or within 30 days of surgery. Six patients died after 30 days. Ninety-seven experienced a perioperative complication—49 early, 1 late, and 47 both. Fifty experienced a major complication—22 (44%) early, 19 (38%) late, and 9 (18%) both. No variables were statistically associated with complication development. The 3-year progression-free survival rate was 61.0%; the 3-year overall survival rate was 61.6%. Of 58 surviving patients, 16 (28%) and 4 (7%) were alive after 5 and 10 years, respectively. The overall complication rate for pelvic exenteration remains high. No variables demonstrated association with complication development as the rate was nearly 100%. The low rate of perioperative mortality is likely due to improved perioperative care. [ABSTRACT FROM AUTHOR]

To determine the effect of hyperthermic intraperitoneal chemotherapy (HIPEC) with carboplatin on the transcriptomic profiles of normal and ovarian cancer (OC) tissues. Normal and tumor samples from four OCs were prospectively collected pre- and immediately post-HIPEC treatment and subjected to RNA-sequencing. Differential gene expression, gene ontology enrichment and pathway analyses were performed. Heat shock protein and immune-response protein expression was assessed using protein arrays and western blotting. RNA-sequencing revealed 4231 and 322 genes significantly differentially expressed between pre- and post-treatment normal and OC tissues, respectively (both adjusted p -value <0.05). Gene enrichment analyses demonstrated that the most significantly upregulated genes in normal tissues played a role in immune as well as heat shock response (both adjusted p < 0.001). In contrast, HIPEC induced an increased expression of primarily heat shock response and protein folding-related genes in tumor tissues (both adjusted p < 0.001). HIPEC-induced heat shock protein (HSP) expression changes, including in HSP90, HSP40, HSP60, and HSP70, were also observed at the protein level in both normal and tumor tissues. HIPEC with carboplatin resulted in an upregulation of heat shock-related genes in both normal and tumor tissue, with an additional immune response gene induction in normal and protein folding in tumor tissue. The findings of our exploratory study provide evidence to suggest that HIPEC administration may suffice to induce gene expression changes in residual tumor cells and raises a biological basis for the consideration of combinatorial treatments with HSP inhibitors. • HIPEC causes transcriptomic changes in normal and tumor tissues. • HIPEC induces upregulation of heat shock-related genes in normal and OC tissues. • Genes implicated in protein folding are induced in OC tissues post HIPEC. • Genes playing a role in immune response are induced in normal tissues post HIPEC. • The production of heat shock response proteins changes after HIPEC administration. [ABSTRACT FROM AUTHOR]

PURPOSE: To describe the development and implementation of a new digital health clinical tool (Gynecologic Survivorship Tool [GST]) for symptom management of women surgically treated for gynecologic cancer; to assess its feasibility; and to conduct a retrospective review of the data. MATERIALS AND METHODS: The GST was developed on the basis of a comprehensive review of the literature, multidisciplinary expert opinion, and feedback from women with a history of gynecologic cancer. It is composed of 17 questions addressing six main categories—gynecologic health (abnormal bleeding/pain), lymphedema, vaginal/vulvar dryness, sexual health, menopause (hot flushes/sleep difficulties), and bowel/urinary issues. An electronic version using the Memorial Sloan Kettering Cancer Center Engage platform was piloted in two clinics for patients with endometrial or cervical cancer. Health information was generated into clinical summaries and identified concerns for actionable response. Associations of symptom and survey time point were assessed by longitudinal models using generalized estimating equations. RESULTS: From January 1, 2019, to February 29, 2020, 3,357 GST assessments were assigned to 1,405 patients, with a 71% completion rate (90% within 5 minutes). Sixty-eight percent were performed at home via a patient portal, 32% at follow-ups using a clinic iPad. The most common symptoms were bowel problems, swelling/fluid, pain during examination, vaginal or vulvar dryness, and vaginal bleeding. Implementation challenges included improving patient compliance and ensuring that reports were reviewed by all clinical teams. We developed screening e-mails detailing patients whose assessments were due, planned training sessions for multidisciplinary teams, and incorporated feedback on methods for reviewing symptoms reports. CONCLUSION: The GST demonstrated feasibility, a high completion rate, and minimal time commitment. It was an effective electronic reporting mechanism for patients, enabling the medical team to develop specific strategies for alleviating bothersome symptoms during follow-up. [ABSTRACT FROM AUTHOR]

To determine the incidence of venous thromboembolism (VTE) and define clinical risk factors associated with the development of new-onset VTE in patients receiving neoadjuvant chemotherapy (NACT) for ovarian cancer (OC). An institutional ovarian cancer database was used to identify all OC patients receiving NACT from 04/2015–09/2018. VTE events were recorded and included clinically diagnosed deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The incidence of VTE events was categorized according to treatment phases (P): P0) First visit/prior to induction of NACT; P1) during NACT before interval debulking surgery (IDS); P2) intraoperative through day 28 post-IDS; P3) during adjuvant chemotherapy. A total of 290 patients were identified during the study period. Seventy-five (25.9%) developed a VTE at some point from time of presentation through the peri-operative period. Forty (13.8%) presented with VTE prior to initiation of NACT. An additional 27 (11.6%) developed a VTE during NACT (P1); 6 (3.9%) during the intraoperative and 28-day post-operative period (P2); and 2 (1.3%) during the adjuvant period (P3). The overall VTE rate was 25.9% (n = 75). FIGO stage IV disease was the only factor associated with increased risk for a new-onset VTE [Odds Ratio (OR): 3.9 (95% Confidence Interval [CI] = 1.2–13.6; p = 0.03]. Patients receiving NACT for advanced OC are at extremely high risk for developing thromboembolic events, either at initial presentation or during induction of NACT, a treatment phase that is traditionally without use of prophylactic anticoagulation. Since Khorana scoring is not predictive in this population, clinicians might need to consider increased screening or use of prophylactic anticoagulation in patients receiving NACT for OC, particularly in advanced metastatic disease. • The overall risk of venous thromboembolism (VTE) in ovarian cancer (OC) patients receiving NACT was >25%. • The highest rate was observed at initial presentation and during the induction of NACT. • FIGO stage IV disease was the only risk factor associated with an increased risk for VTE. • Prophylactic anticoagulation should be considered in OC patients receiving NACT, especially those with metastatic disease. [ABSTRACT FROM AUTHOR]

To determine if the mutational landscapes and genomic features of homologous recombination DNA repair defects (HRD) vary between younger and older patients with high-grade serous ovarian cancer (HGSOC). Younger and older women were defined as bottom and top age quartiles, respectively. HGSOCs from 15 younger (median 49 years, range 35–53) and 15 older women (median 72 years, range 70–87) were subjected to whole-exome sequencing (WES). For validation, HGSOC WES data were obtained from The Cancer Genome Atlas (TCGA), including 38 younger (median 45 years, range 34–50) and 30 older women (median 74 years, range 68–84). Mutational profiles, BRCA1/2 status, genomic HRD features, and for TCGA cases RNA-sequencing-based HRD transcriptomic signatures were assessed. In the institutional cohort, pathogenic germline BRCA1/2 mutations were more frequent in younger (5/15) than older women (0/15, p = 0.042). No somatic BRCA1/2 mutations were identified. HGSOCs from older patients preferentially displayed aging-related mutational signatures and, in contrast to younger patients, harbored CCNE1 amplifications (3/15, 20%). In the TCGA cohort, pathogenic germline BRCA1 (younger 8/38, older 0/30, p = 0.007) but not BRCA2 mutations (young 3/38, older 4/30, p = 0.691) were more frequent in younger patients. Again, no somatic BRCA1/2 mutations were identified. HGSOCs from younger women more frequently displayed genomic features of HRD (all, p < 0.05), a significant HRD gene-signature enrichment, but less frequently CCNE1 amplification (p = 0.05). Immunoreactive CLOVAR subtypes were more common in HGSOCs from younger women, and proliferative subtypes in HGSOCs from older women (p = 0.041). HGSOC patients diagnosed at an older age less frequently harbor pathogenic BRCA1 germline mutations and genomic features of HRD than younger women. Individualized treatment options, particularly pertaining to use of PARP inhibitors, in older women may be warranted. • Germline BRCA1/2 mutations are less common in older women with HGSOC. • Genomic HRD features are more frequent in HGSOCs in younger women. • HGSOCs in older women more frequently harbor CCNE1 amplification. • HGSOCs have a dominant HRD signature in younger and aging signature in older women. [ABSTRACT FROM AUTHOR]

To evaluate the clinical significance and genomic associations of concurrent serous tubal intraepithelial carcinoma (STIC) with high-grade serous carcinoma (HGSC) of the ovary in women undergoing primary debulking surgery (PDS). All patients who underwent PDS for HGSC between 01/2015 and 12/2018 were captured in a prospectively maintained institutional database. Patients were categorized based on the presence or absence of concurrent STIC noted on final pathology. Demographic, perioperative, and outcomes data were collected, and groups were compared using standard statistical tests. Progression-free survival (PFS) and overall survival (OS) were evaluated using the Kaplan-Meier method. For comparison of differences in somatic alterations between the two cohorts, specimens were sequenced using MSK-IMPACT. Of 306 eligible patients, 87 (28%) had a concurrent STIC lesion (+STIC) and 219 (72%) did not (no-STIC). Demographics and clinicopathological factors were similar between the two cohorts, except for a significantly higher median preoperative CA-125 level in the no-STIC group (423 U/mL vs. 321 U/mL; p=0.029). There were no significant differences in median PFS (22.7 months [95%CI: 18.9-28.4] vs. 27.7 months [95%CI: 25.5-30.5]; p=0.126) and 3- year OS rate (81% [95%CI: 70-88%] vs. 85% [95%CI: 78-90%]; p=0.392) between +STIC and no-STIC patients, respectively. Targeted DNA-sequencing via MSK-IMPACT showed a similar distribution of driver mutations or structural genetic alterations, and affected genetic signaling pathways were similar between the cohorts. There were no identifiable clinical and genetic differences in patients with HGSC and concurrent STIC. These data suggest a comparable, if not identical, disease process. • Concurrent STIC lesion is common in patients with advanced HGSC of the ovary • There was no difference in germline genetics between patients with advanced ovarian HGCS with or without concurrent STIC • There was no difference in clinical outcomes between patients with advanced ovarian HGCS with or without concurrent STIC [ABSTRACT FROM AUTHOR]

To independently validate a published risk-calculator for adverse perioperative outcomes in patients with epithelial ovarian cancer undergoing debulking surgery at a high-volume surgical center. Using our institution's curated prospective ovarian cancer database, we identified patients with epithelial ovarian cancer who underwent a debulking procedure from 7/2015 to 5/2019, to be used as the validation cohort. Variables used in the published nomogram were collected. These included American Society of Anesthesiology classification, preoperative albumin, history of bleeding disorder, presence of ascites on preoperative imaging, designation of elective or emergent surgery, age of the patient, and a procedure score. Patients were included if they had information available for all the variables used in the nomogram, and 30-day follow-up within our institution. The primary outcome was Clavien-Dindo Class IV with specific conditions (postoperative sepsis, septic shock, cardiac arrest, myocardial infarction, pulmonary embolism, ventilation >48 h, or unplanned intubation) and 30-day mortality. The combination of these endpoints is called the combined complication rate. A total of 700 patients who underwent debulking surgery for epithelial ovarian cancer during the timeframe met inclusion criteria. The combined complication rate was 11.7%; 9.9% of patients were readmitted; 2.7% required reoperation. Sepsis was the most common primary endpoint complication (4.4%), followed by septic shock (1.4%). There was no 30-day mortality in our cohort. The nomogram performed well, with a c index of 0.715 (95% CI 0.66–0.768), which was comparable to the published nomogram. We independently validated a complication nomogram at a high-volume surgical center. This nomogram performs well at predicting a lower likelihood of serious postoperative complications. An enhanced nomogram would help identify patients at higher risk for serious complications. • This study describes independent validation of a complication nomogram at a high-volume center. • Preoperative characteristics can be used to predict postoperative complications. • Postoperative risk calculators can aid in patient-centric care. [ABSTRACT FROM AUTHOR]

To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012–04/2017). Standard statistical tests were used. There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618–1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317–1.092); p = 0.093]. ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits. • In PDS with high intraoperative blood loss, use of ANH prevents the need for allogenic blood transfusions • The application of ANH does not preclude maximal surgical efforts, with achievement of high complete gross resection rates • ANH is not associated with any detrimental impact on long-term oncologic outcomes [ABSTRACT FROM AUTHOR]

We assessed the utility of video-assisted thoracic surgery (VATS) in defining extent of intrathoracic disease in advanced ovarian carcinoma with moderate-to-large pleural effusions. Beginning in 2001, VATS was performed on all patients with suspected advanced ovarian carcinoma and moderate-to-large pleural effusions, evaluating for macroscopic intrathoracic disease. The algorithm recommended primary debulking surgery (PDS) for ≤1 cm, neoadjuvant chemotherapy (NACT)/interval debulking surgery (IDS) for >1 cm intrathoracic disease. We reviewed records of patients undergoing VATS from 10/01–01/19. Differences between treatment groups were tested using standard statistical techniques. One-hundred patients met eligibility criteria (median age, 60; median CA-125 level, 1158 U/mL; medium serum albumin, 3.8 g/dL). Macroscopic pleural disease was found in 70 (70%). After VATS, 50 (50%) underwent attempted PDS (PDS group), 50 (50%) received NACT (NACT/IDS group). Forty-seven (94%) underwent IDS. Median overall survival (OS) for the entire cohort (n = 100) was 44.5 months (95% CI: 37.8–51.7). The PDS group had significantly longer survival than the NACT/IDS group [45.8 (95% CI: 40.5–87.8) vs. 37.4 months (95% CI: 33.3–45.2); p =.016]. On multivariable analysis, macroscopic intrathoracic disease (HR 2.18, 95% CI: 1.14–4.18; p =.019) and age ≥ 65 (HR 1.98, 95% CI: 1.16–3.40; p =.013) were independently associated with elevated death risk. Patients with the best outcome had no macroscopic disease at VATS and underwent PDS (median OS, 87.8 months). VATS is useful in therapeutic decision-making for PDS vs. NACT/IDS in advanced ovarian cancer with moderate-to-large pleural effusions. • Macroscopic intrathoracic disease with moderate-to-large pleural effusions predicts poor survival in advanced ovarian cancer. • Analysis of pleural cytology alone is insufficient to assess macroscopic pleural disease. • Nearly 30% of patients with negative cytology had gross disease at VATS. • In patients with confirmed intrathoracic disease that cannot be debulked, PDS does not improve survival. • Patients with confirmed intrathoracic disease that cannot be completely debulked should be treated with NACT and IDS. [ABSTRACT FROM AUTHOR]

To describe outcomes using a multimodal algorithm to triage patients with advanced epithelial ovarian cancer (EOC) to primary debulking surgery (PDS) versus neoadjuvant chemotherapy (NACT). All patients with EOC treated at our institution from 04/2015–08/2018 were identified. We included patients without contraindication to PDS who underwent prospective calculation of a Resectability (R)-score. A low risk score for suboptimal cytoreduction was defined as ≤6, and a high risk score ≥7. Patients were triaged to laparotomy/PDS, laparoscopic evaluation of resectability (LSC), or NACT depending on R-score. Among 299 participants, 226 (76%) had a low risk score and 73 (24%) a high risk score. For patients with a low risk score, management included laparotomy/PDS, 181 (80%); LSC, 43 (19%) (with subsequent triage: PDS, 31; NACT, 12); and NACT, 2 (1%). For patients with a high risk score, management included laparotomy/PDS, 9 (12%); LSC, 51 (70%) (with subsequent triage: PDS, 28; NACT, 23); and NACT, 13 (18%). Overall, 83% underwent PDS, with a 75% CGR rate and 94% optimal cytoreduction rate. Use of the algorithm resulted in a 31% LSC rate and a 6% rate of suboptimal PDS. The multimodal algorithm led to excellent surgical results; 94% of patients achieved an optimal resection, with a very low rate of suboptimal cytoreduction. • A multimodal algorithm combining clinical and radiologic data with diagnostic laparoscopy for advanced ovarian cancer • A multimodal preoperative algorithm leads to precise resource utilization without compromising outcomes. • Excellent surgical outcomes with a modest utilization of diagnostic laparoscopy and a very low rate of futile laparotomy [ABSTRACT FROM AUTHOR]

Reducing anastomotic leak rates after rectosigmoid resection and anastomosis is a priority in patients undergoing gynecologic oncology surgery. Therefore, we investigated the implications of performing near-infrared angiography (NIR) via proctoscopy to assess anastomotic perfusion at the time of rectosigmoid resection and anastomosis. We identified all patients who underwent rectosigmoid resection and anastomosis for a gynecologic malignancy between January 1, 2013 and December 31, 2018. NIR proctoscopy was assessed via the PINPOINT Endoscopic Imaging System (Stryker). A total of 410 patients were identified, among whom NIR was utilized in 133 (32.4%). There were no statistically significant differences in age, race, BMI, type of malignancy, surgery, histology, FIGO stage, hypertension, diabetes, or preoperative chemotherapy between NIR and non-NIR groups. All cases of rectosigmoid resection underwent stapled anastomosis. The anastomotic leak rate was 2/133 (1.5%) in the NIR cohort compared with 13/277 (4.7%) in the non-NIR cohort (p = 0.16). Diverting ostomy was performed in 9/133 (6.8%) NIR and 53/277 (19.9%) non-NIR patients (p < 0.001). Postoperative abscesses occurred in 8/133 (6.0%) NIR and 44/277 (15.9%) non-NIR patients (p = 0.004). The NIR cohort had significantly fewer post-operative interventional procedures (12/133, 9.0% NIR vs. 55/277, 19.9% non-NIR, p = 0.006) and significantly fewer 30-day readmissions (14/133, 10.5% NIR vs. 61/277, 22% non-NIR, p = 0.004). NIR proctoscopy is a safe tool for assessing anastomotic rectal perfusion after rectosigmoid resection and anastomosis, with a low anastomotic leak rate of 1.5%. Its potential usefulness should be evaluated in randomized trials in patients undergoing gynecologic cancer surgery. • There is a 1.5% leak rate when NIR technology is used to evaluate anastomotic perfusion after a rectosigmoid resection. • Use of NIR proctoscopy to assess anastomotic perfusion is associated with improved postoperative outcomes. • NIR proctoscopy offers an intraoperative tool to aid in surgical decision-making regarding the integrity of an anastomosis. [ABSTRACT FROM AUTHOR]

To compare oncologic and perioperative outcomes in patients who underwent minimally invasive surgery (MIS) compared to laparotomy for newly diagnosed early-stage cervical carcinoma. We retrospectively identified patients who underwent radical hysterectomy for stage IA1 with lymphovascular invasion (LVI), IA2, or IB1 cervical carcinoma at our institution from 1/2007–12/2017. Clinicopathologic characteristics and surgical and oncologic survival outcomes were compared using appropriate statistical testing. Multivariable Cox regression analysis was used to control for potential confounders. We identified 196 evaluable cases—117 MIS (106 robotic [90.6%]) and 79 laparotomy cases. Cohorts had similar age, BMI, substage, histologic subtype, clinical and pathologic tumor size, positive margins, and presence of LVI. The MIS group had more cases with no residual tumor in the hysterectomy (24.8% vs. 10.1%, P = 0.01). The laparotomy group had more cases with positive nodes (29.1% vs. 17.1%, P = 0.046) and more patients who received adjuvant therapy (53.2% vs. 33.3%, P = 0.006). Median follow-up was ~4 years. Five-year disease-free survival (DFS) rates were 87.0% in the MIS group and 86.6% in the laparotomy group (P = 0.92); 5-year disease-specific survival (DSS) rates were 96.5% and 93.9%, respectively (P = 0.93); and 5-year overall survival (OS) rates were 96.5% and 87.4%, respectively (P = 0.15). MIS was not associated with DFS, DSS, or OS on multivariable regression analysis. The rate of postoperative complications was significantly lower in the MIS cohort (11.1% vs. 20.3%; P = 0.04). MIS radical hysterectomy for cervical carcinoma did not confer worse oncologic outcomes in our single-center and concurrent series of patients with early-stage cervical carcinoma. • Minimally invasive surgery (MIS) is an appropriate option in early-stage cervical carcinoma. • MIS confers similar survival outcomes compared with laparotomy for the management of early-stage cervical carcinoma. • MIS is associated with fewer postoperative complications compared with laparotomy in the management of these patients. [ABSTRACT FROM AUTHOR]

To compare the prevalence of patient-reported lower-extremity lymphedema (LEL) with sentinel lymph node (SLN) mapping versus comprehensive lymph node dissection (LND) for the surgical management of newly diagnosed endometrial carcinoma. Patients who underwent primary surgery for endometrial cancer from 01/2006-12/2012 were mailed a survey that included a validated 13-item LEL screening questionnaire in 08/2016. Patients diagnosed with LEL prior to surgery and those who answered ≤6 survey items were excluded. Of 1275 potential participants, 623 (49%) responded to the survey and 599 were evaluable (180 SLN, 352 LND, 67 hysterectomy alone). Median BMI was similar among cohorts (P = 0.99). External-beam radiation therapy (EBRT) was used in 10/180 (5.5%) SLN and 35/352 (10%) LND patients (P = 0.1). Self-reported LEL prevalence was 27% (49/180) and 41% (144/352), respectively (OR, 1.85; 95% CI, 1.25–2.74; P = 0.002). LEL prevalence was 51% (23/45) in patients who received EBRT and 35% (170/487) in those who did not (OR, 1.95; 95% CI, 1.06–3.6; P = 0.03). High BMI was associated with increased prevalence of LEL (OR, 1.04; 95% CI, 1.02–1.06; P = 0.001). After controlling for EBRT and BMI, LND retained independent association with an increased prevalence of LEL over SLN (OR, 1.8; 95% CI, 1.22–2.69; P = 0.003). Patients with self-reported LEL had significantly worse QOL compared to those without self-reported LEL. This is the first study to assess patient-reported LEL after SLN mapping for endometrial cancer. SLN mapping was independently associated with a significantly lower prevalence of patient-reported LEL. High BMI and adjuvant EBRT were associated with an increased prevalence of patient-reported LEL. • SLN mapping was independently associated with significantly lower rate of patient-reported lower extremity lymphedema (LEL). • Increasing BMI and use of adjuvant EBRT were associated with an increased prevalence of patient-reported LEL. • SLN mapping in the surgical management of newly diagnosed endometrial cancer may spare these patients from LEL. • Survival outcomes were similar between SLN mapping and comprehensive lymphadenectomy after endometrial cancer surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Disparities exist between population subgroups in the use of gynecologic oncologists and high-volume hospitals. The objectives of this study were to explore the experiences of black women obtaining ovarian cancer (OC) care at a high-volume center (HVC) and to identify patient-, provider-, and systems-related factors affecting their access to and use of this level of care. MATERIALS AND METHODS: Twenty-one semistructured interviews were conducted as part of an institutional review board–approved protocol with women who self-identified as black or African American, treated for OC at a single HVC from January 2013 to May 2017. Recurring themes were identified in transcribed interviews through the process of independent and collaborative thematic content analysis. RESULTS: Five themes were identified: (1) internal attributes contributing to black women's ability/desire to be treated at an HVC, (2) pathways to high- and low-volume centers, (3) obstacles to obtaining care, (4) potential barriers for black women interested in treatment at an HVC, and (5) suggestions for improving HVC use by black women. Study participants who successfully accessed care were comfortable navigating the health care system, understood the importance of self-advocacy, and valued the expertise of an HVC. Barriers to obtaining care at an HVC included lack of knowledge about the HVC, lack of referral, transportation difficulties, and lack of insurance coverage. CONCLUSION: In this qualitative study, black women treated at an HVC shared attributes and experiences that helped them access care. There is a need to collaborate with black communities and establish interventions to reduce barriers, facilitate access, and disseminate information about the value of receiving care for OC at an HVC. [ABSTRACT FROM AUTHOR]

PURPOSE: Mutations in DNA mismatch repair genes and PTEN, diagnostic of Lynch and Cowden syndromes, respectively, represent the only established inherited predisposition genes in endometrial cancer to date. The prevalence of other cancer predisposition genes remains unclear. We determined the prevalence of pathogenic germline variants in unselected patients with endometrial cancer scheduled for surgical consultation. PATIENTS AND METHODS: Patients prospectively consented (April 2016 to May 2017) to an institutional review board–approved protocol of tumor-normal sequencing via a custom next-generation sequencing panel—the Memorial Sloan Kettering–Integrated Mutation Profiling of Actionable Cancer Targets—that yielded germline results for more than 75 cancer predisposition genes. Tumors were assessed for microsatellite instability. Per institutional standards, all tumors underwent Lynch syndrome screening via immunohistochemistry (IHC) for mismatch repair proteins. RESULTS: Of 156 patients who consented to germline genetic testing, 118 (76%) had stage I disease. In 104 patients (67%), tumors were endometrioid, and 60 (58%) of those tumors were grade 1. Twenty-four pathogenic germline variants were identified in 22 patients (14%): seven (4.5%) had highly penetrant cancer syndromes and 15 (9.6%) had variants in low-penetrance, moderate-penetrance, or recessive genes. Of these, five (21%) were in Lynch syndrome genes (two MSH6 , two PMS2 , and one MLH1). All five tumors had concordant IHC staining; two (40%) were definitively microsatellite instability–high by next-generation sequencing. One patient had a known BRCA1 mutation, and one had an SMARCA4 deletion. The remaining 17 variants (71%) were incremental findings in low- and moderate-penetrance variants or genes associated with recessive disease. CONCLUSION: In unselected patients with predominantly low-risk, early-stage endometrial cancer, germline multigene panel testing identified cancer predisposition gene variants in 14%. This finding may have implications for future cancer screening and risk-reduction recommendations. Universal IHC screening for Lynch syndrome successfully identifies the majority (71%) of high-penetrance germline mutations. [ABSTRACT FROM AUTHOR]

Abstract Objectives Our objective was to determine the safety and efficacy of acute normovolemic hemodilution (ANH) to reduce the requirement for allogenic red blood cell (RBC) transfusions in patients undergoing primary cytoreduction for advanced ovarian cancer. Methods Patients undergoing primary cytoreduction for advanced ovarian cancer were enrolled in a prospective trial assessing ANH at time of surgery. Intraoperative blood withdrawal was performed to a target hemoglobin of 8.0 g/dL. A standardized transfusion protocol first using autologous then allogenic blood was applied intraoperatively and throughout hospitalization according to institutional guidelines. The primary endpoint was to determine the overall rate of allogenic RBC transfusions in the intra- and postoperative periods. A predetermined allogenic RBC transfusion rate <35% was deemed a meaningful reduction from a 50% transfusion rate in historical controls. Results Forty-one patients consented to participate. Median blood withdrawn during ANH was 1650 mL (range, 700–3000). Cytoreductive outcomes were as follows: 0 mm, 30 (73%); 1–10 mm, 8 (20%); and >10 mm, 3 (7%) residual disease. Estimated blood loss was 1000 mL (range, 150–2700). Fourteen patients (34%) received allogenic RBC transfusions intra- or postoperatively, meeting the primary endpoint. No patients were transfused outside protocol guidelines. The rate of ≥grade 3 complications (20%) and anastomotic leaks (7%) were similar to historical controls and met predefined safety thresholds. Conclusions For patients with advanced ovarian cancer undergoing primary cytoreductive surgery, ANH appears to reduce allogenic RBC transfusion rates versus historical controls without increasing perioperative complications. Further evaluation of the technique is warranted. Highlights • Acute normovolemic hemodilution (ANH) reduces RBC transfusion rates during ovarian cancer surgery vs. historical controls. • ANH can be performed safely for patients undergoing cytoreductive surgery for ovarian cancer. • ANH appears to be a promising strategy to reduce RBC transfusion rates during cytoreductive surgery for ovarian cancer. [ABSTRACT FROM AUTHOR]

Abstract Objective Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer. Methods In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005–12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed. Results Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P =.005), carcinomatosis (87% vs. 80%, respectively; P =.027), and bulky upper abdominal disease (66% vs. 58%, respectively; P =.046). Complete gross resection was achieved in 48% and 32%, respectively (P <.001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P =.021); median OS was 62.4 months and 41.9 months, respectively (P <.001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066–1.653) and death (HR = 1.588; 95% CI, 1.224–2.06). Conclusions Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this setting. Highlights • Epidural use significantly improved progression-free and overall survival in patients undergoing surgery for ovarian cancer. • Epidural use was also found to be independently associated with progression-free and overall survival. • Perioperative epidural use in patients undergoing primary debulking surgery for advanced ovarian cancer may be warranted. [ABSTRACT FROM AUTHOR]

Abstract Objectives To assess complete gross resection (CGR) rates and survival outcomes in patients with advanced ovarian cancer who underwent primary debulking surgery (PDS) during a 13-year period in which specific changes to surgical paradigm were implemented. Methods We identified all patients with stage IIIB-IV high-grade ovarian carcinoma who underwent PDS at our institution, with the intent of maximal cytoreduction, from 1/2001–12/2013. Patients were categorized by year of PDS based on the implementation of surgical changes to our approach to ovarian cancer debulking (Group 1, 2001–2005; Group 2, 2006–2009; Group 3, 2010–2013). Results Among 978 patients, 78% had stage IIIC disease and 89% had disease of serous histology. Carcinomatosis was found in 81%, and 60% had bulky upper abdominal disease (UAD). Compared to Group 1, those who underwent PDS during the latter 2 time periods had higher ASA scores (p < 0.001), higher-stage disease (p < 0.001), and more often had carcinomatosis (p = 0.015) and bulky UAD (p = 0.009). CGR rates for Groups 1–3 increased from 29% to 40% to 55%, respectively (p < 0.001). Five-year progression-free survival (PFS) rates increased over time (15%, 16%, and 20%, respectively; p = 0.199), as did 5-year overall survival (OS) rates (40%, 44%, and 56%, respectively; p < 0.001). On multivariable analysis, CGR was independently associated with PFS (p < 0.001) and OS (p < 0.001). Conclusions Despite higher-stage disease and greater tumor burden, CGR rates, PFS and OS for patients who underwent PDS increased over a 13-year period. Surgical paradigm shifts implemented specifically to achieve more complete surgical cytoreduction are likely the reason for these improvements. Highlights • From 2001 to 2013, specific changes to our primary debulking surgery paradigm were implemented. • Despite greater stage and tumor burden, complete gross resection (CGR) rates rose from 29% to 55%. • 5-year progression-free survival (PFS) rates increased from 15% to 20%. • Overall survival (OS) rates increased from 40% to 56%. • CGR was independently associated with PFS and OS on multivariable analysis. [ABSTRACT FROM AUTHOR]

Objectives Surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) in primary treatment of advanced ovarian cancer has not been widely studied. We report on a cohort of patients undergoing CPLN resection during primary cytoreductive surgery (CRS), examining its feasibility, safety, and potential impact on clinical outcomes. Methods We identified all patients undergoing primary CRS/CPLN resection for Stages IIIB-IV high-grade epithelial ovarian cancer at our institution from 1/2001–12/2013. Clinical and pathological data were collected. Statistical tests were performed. Results 54 patients underwent CPLN resection. All had enlarged CPLNs on preoperative imaging. Median diameter of an enlarged CPLN: 1.3 cm (range 0.6–2.9). Median patient age: 59y (range 41–74). 48 (88.9%) underwent transdiaphragmatic resection; 6 (11.1%) underwent video-assisted thoracic surgery. A median of 3 nodes (range 1–23) were resected. A median of 2 nodes (range 0–22) were positive for metastasis. 51/54 (94.4%) had positive nodes. 51 (94.4%) had chest tube placement; median time to removal: 4d (range 2–12). 44 (81.4%) had peritoneal carcinomatosis. 19 (35%) experienced major postoperative complications; 4 of these (7%) were surgery-related. Median time to adjuvant chemotherapy: 40d (range 19–205). All patients were optimally cytoreduced, 30 (55.6%) without visible residual disease. Median progression-free survival: 17.2mos (95% CI 12.6–21.8); median overall survival: 70.1mos (95% CI 51.2–89.0). Conclusions Enlarged CPLNs can be identified on preoperative imaging and may indicate metastases. Resection can identify extra-abdominal disease, confirm Stage IV disease, obtain optimal cytoreduction. In the proper setting it is feasible, safe, and does not delay chemotherapy. In select patients, it may improve survival. [ABSTRACT FROM AUTHOR]

Objective To assess the ability of preoperative computed tomography scan and CA-125 to predict gross residual disease (RD) at primary cytoreduction in advanced ovarian cancer. Methods A prospective, non-randomized, multicenter trial of patients who underwent primary debulking for stage III–IV epithelial ovarian cancer previously identified 9 criteria associated with suboptimal (> 1 cm residual) cytoreduction. This is a secondary post-hoc analysis looking at the ability to predict any RD. Four clinical and 18 radiologic criteria were assessed, and a multivariate model predictive of RD was developed. Results From 7/2001–12/2012, 350 patients met eligibility criteria. The complete gross resection rate was 33%. On multivariate analysis, 3 clinical and 8 radiologic criteria were significantly associated with the presence of any RD: age ≥ 60 years (OR = 1.5); CA-125 ≥ 600 U/mL (OR = 1.3); ASA 3–4 (OR = 1.6); lesions in the root of the superior mesenteric artery (OR = 4.1), splenic hilum/ligaments (OR = 1.4), lesser sac > 1 cm (OR = 2.2), gastrohepatic ligament/porta hepatis (OR = 1.4), gallbladder fossa/intersegmental fissure (OR = 2); suprarenal retroperitoneal lymph nodes (OR = 1.3); small bowel adhesions/thickening (OR = 1.1); and moderate-severe ascites (OR = 2.2). All ORs were significant with p < 0.01. A ‘predictive score’ was assigned to each criterion based on its multivariate OR, and the rate of having any RD for patients who had a total score of 0–2, 3–5, 6–8, and ≥ 9 was 45%, 68%, 87%, and 96%, respectively. Conclusions We identified 11 criteria associated with RD, and developed a predictive model in which the rate of having any RD was directly proportional to a predictive score. This model may be helpful in treatment planning. [ABSTRACT FROM AUTHOR]

Objectives Intraperitoneal (IP)-based chemotherapy following primary debulking surgery (PDS), although associated with substantial toxicity, is supported by a strong evidence base. We sought to determine feasibility and outcomes of IP chemotherapy after interval debulking surgery (IDS) among patients deemed ineligible for PDS. Methods We identified all patients with high-grade, stage III/IV ovarian cancer treated at our institution with neoadjuvant chemotherapy (NACT) followed by IDS and postoperative chemotherapy from 1/2008–5/2013. IP and intravenous (IV) regimens were defined; demographic and clinical data were analyzed using appropriate statistics. Results Of 128 evaluable patients, 118 (92%) achieved ≤ 1 cm residual disease at IDS and 74 (58%) achieved a complete gross resection (CGR). An IP port was placed in 54/128 patients (42%), with 89% port utilization. Forty-eight (38%) of 128 patients received IP chemotherapy, 17 (13%) weekly IV paclitaxel/q3week carboplatin, and 63 (49%) q3week IV carboplatin/paclitaxel. Patients completed a median of 3 IP cycles (range, 2–6), with 3 (5.5%) of 54 ports removed due to complications. Overall survival (OS) for patients with a CGR treated with IP and weekly IV chemotherapy was 53.2 months (range, 24.7-NE), and 44.2 months (range, 30.2-NE) with any visible residual disease ( p < 0.001). Median OS was 53.2 months (range, 44.5-NE) for IP-, not reached for weekly IV-, and 34.2 months (range, 27.5–49.8) for q3week IV-treated patients ( p = 0.1). Conclusions Patients administered IP after IDS had a high rate of successful port utilization, with few regimen switches. Oncologic outcomes were optimal in patients with a CGR at IDS, regardless of chemotherapy used. [ABSTRACT FROM AUTHOR]

Objective To examine the use, as well as postoperative and long-term oncologic outcomes of diverting loop ileostomy (DI) during primary debulking surgery (PDS) for ovarian cancer. Methods Patients with stage II-IV ovarian, fallopian tube, or primary peritoneal carcinoma who underwent colon resection during PDS from 1/2005–1/2014 were identified. Demographic and clinical data were analyzed. Results Of 331 patients, 320 (97%) had stage III/IV disease and 278 (84%) had disease of high-grade serous histology. Forty-four (13%) underwent a DI. There were no significant differences in age, comorbidity index, smoking status, serum albumin, or attending surgeon between the DI and non-DI groups. Operative time (OR = 1.21; 95% CI, 1.03–1.42; p = 0.02) and length of rectosigmoid resection (OR = 1.04; 95% CI, 1.01–1.08; p = 0.02) were predictors of DI on multivariable analysis. The overall anastomotic leak rate was 6%. A comparison of groups (DI vs non-DI) showed no significant differences in major complications (30% vs 23%; p = 0.41), anastomotic leak rate (5% vs 7%; p = 0 .60 ), hospital length of stay (10 vs 9 days; p = 0.25), readmission rate (23% vs 17%; p = 0.33), or interval to postoperative chemotherapy (41 vs 40 days; p = 0.20), respectively. Ileostomy reversal was successful in 89% of patients. Median follow-up was 52.6 months. There were no differences in median progression-free (17.9 vs 18.6 months; p = 0.88) and overall survival (48.7 vs 63.8 months; p = 0.25) between the groups. Conclusions In patients undergoing PDS, those with longer operative time and greater length of rectosigmoid resection more commonly underwent DI. DI does not appear to compromise postoperative outcomes or long-term survival. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the association between lymphopenia and survival in women with cervical cancer treated with primary chemoradiation. Methods. A single institution, retrospective analysis of patients with stage IB2-IVA cervical cancer who received upfront chemoradiation from 1998 to 2013 was performed. Complete blood counts from pre-treatment to 36 months post-treatment were analyzed. Lymphopenia and known prognostic factors were evaluated for an association with progression-free (PFS) and overall survival (OS). Results. Seventy-one patients met study criteria for whom 47 (66%) had a documented total lymphocyte count (TLC) two months after initiating chemoradiation. FIGO stage distribution was 6% Stage I, 46% Stage II, 45% Stage III and 3% Stage IV. Pre-treatment TLC was abnormal (<1000 cells/mm³) in 15% of patients. The mean reduction in TLC was 70% two months after initiating chemoradiation. Severe post-treatment lymphopenia (TLC <500 cells/mm³) was observed in 53% of patients; they experienced inferior median OS (21.2 vs 45.0 months, P = 0.03) and similar 25th percentile PFS (6.3 vs 7.7 months, P = 0.06) compared to patients without severe lymphopenia. Multivariate analysis demonstrated pre-treatment TLC ≥ 1000 cells/mm³ and post-treatment TLC N500 cells/mm3 had a 77% (HR: 0.23; 95%CI 0.05-1.03; P = 0.053) and 58% decrease in hazards of death (HR: 0.42; 95% CI 0.12-1.46; P = 0.17) respectively. Conclusion. More than half of cervical cancer patients treated with chemoradiation experienced severe and prolonged lymphopenia. Although statistical significance was not reached, the findings suggest that pre- and post-treatment lymphopenia may be associated with decreased survival. Further research is warranted, given that lymphopenia could be a reversible prognostic factor. [ABSTRACT FROM AUTHOR]

Objective To assess the ability of the Age-Adjusted Charlson Comorbidity Index (ACCI) to predict perioperative complications and survival in patients undergoing primary debulking for advanced epithelial ovarian cancer (EOC). Methods Data were analyzed for all patients with stage IIIB–IV EOC who underwent primary cytoreduction from 1/2001–1/2010 at our institution. Patients were divided into 3 groups based on an ACCI of 0–1, 2–3, and ≥ 4. Clinical and survival outcomes were assessed and compared. Results We identified 567 patients; 199 (35%) had an ACCI of 0–1, 271 (48%) had an ACCI of 2–3, and 97 (17%) had an ACCI of ≥ 4. The ACCI was significantly associated with the rate of complete gross resection (0–1 = 44%, 2–3 = 32%, and ≥ 4 = 32%; p = 0.02), but was not associated with the rate of minor (47% vs 47% vs 43%, p = 0.84) or major (18% vs 19% vs 16%, p = 0.8) complications. The ACCI was also significantly associated with progression-free (PFS) and overall survival (OS). Median PFS for patients with an ACCI of 0–1, 2–3, and ≥ 4 was 20.3, 16, and 15.4 months, respectively (p = 0.02). Median OS for patients with an ACCI of 0–1, 2–3, and ≥ 4 was 65.3, 49.9, and 42.3 months, respectively (p < 0.001). On multivariate analysis, the ACCI remained a significant prognostic factor for both PFS (p = 0.02) and OS (p < 0.001). Conclusions The ACCI was not associated with perioperative complications in patients undergoing primary cytoreduction for advanced EOC, but was a significant predictor of PFS and OS. Prospective clinical trials in ovarian cancer should consider stratifying for an age–comorbidity covariate. [ABSTRACT FROM AUTHOR]