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

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

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

Ovarian cancer associated ascites contains soluble inhibitory factors. The ascites was cleared of cellular debris by centrifugation as previously described (18). (A, B) The ascites was filtered 0.2 micron filter and fractionated- f1: 50. (C) The ascites was treated with 50 μg/ml proteinase K at 37{degree sign}C for 1 hour and then incubated at 95{degree sign}C for 10min to heat inactivate the enzyme. The antigen presenting cells were treated with the clarified supernantants for 4 h at 37{degree sign}C, then washed extensively with PBS, and cocultured with NKT hybridomas for 20-24 h at 37{degree sign}C. Cytokine released (IL-2) was measured as an indication of NKT cell activation and was measured by standard sandwich ELISA.

The source of GD3 impacts CD1d-mediated antigen presentation.(A) LCD1d cells were treated with GD3 from different sources for 4 hours, then washed extensively and cocultured with NKT cell hybridomas. IL-2 was measured, as an indication of NKT cell activation, by standard cytokine ELISA. (B) Pretreatment of a-GalCer loaded aAPC with GD3. a-GalCer loaded aAPC were incubated for 4hr with either medium, GD3, GD2, or ovarian cancer-associated ascites. The aAPC were washed extensively and then cocultured with a Va14+ NKT cell hybridoma, N38-3C3. NKT cell recognition of CD1d was assessed by measuring IL-2 production in the supernatants by ELISA.

PDF file - 225K, Schematic of Ganglioside GD3 and other glycolipids used or referred to in this paper

ObjectivesTo investigate the impact of malignant ascites volume on the outcomes of patients with advanced epithelial ovarian carcinoma who undergo primary debulking surgery.MethodsPatients diagnosed with stage III–IV epithelial ovarian carcinoma and bulky intra-abdominal (TIIIC) disease between 2010 and 2015, who underwent primary debulking surgery followed by multi-agent chemotherapy and known status of residual disease, were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was categorized as absent, low (>980 mL) volume. Median overall survival was determined from Kaplan–Meier curves and compared with the log rank test. A multivariate Cox model was constructed to control for confounders.Results2493 patients were identified; 31.9% (n=795) had no ascites, 40.2% (n=1001) had low, and 28% (n=697) had high volume malignant ascites. Rate of complete gross resection was higher for patients with no ascites (65.9%) compared with those with low (35.6%) and high (23%) volume ascites (pConclusionsThe presence and volume of malignant ascites at the time of primary debulking surgery was associated with the likelihood of achieving a complete gross resection and worse overall survival.

The NCCN Guidelines for Uterine Neoplasms provide recommendations for diagnostic workup, clinical staging, and treatment options for patients with endometrial cancer or uterine sarcoma. These NCCN Guidelines Insights focus on the recent addition of molecular profiling information to aid in accurate diagnosis, classification, and treatment of uterine sarcomas.

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

ObjectiveTo investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size <2 cm who underwent open or minimally invasive radical hysterectomy.MethodsThe Pubmed/Medline, Embase, and Web-of-Science databases were queried from inception to January 2021 (PROSPERO CRD 42020207971). Observational studies reporting progression-free survival and/or overall survival for patients who had open or minimally invasive radical hysterectomy for early-stage cervical carcinoma and tumor size <2 cm were selected. Level of statistical heterogeneity was evaluated with the I2 statistic. A random-effects model was used to compare progression and overall survival between the two groups and HR with 95% confidence intervals were calculated with the Der Simonian and Laird approach. Risk of bias and quality of included studies was assessed with the Newcastle-Ottawa scale.ResultsA total of 10 studies that met the inclusion criteria were included encompassing 4935 patients. Of these, 2394 (48.5%) patients had minimally invasive and 2541 (51.5%) patients had open radical hysterectomy; respectively. Patients who underwent minimally invasive hysterectomy had worse progression-free survival than those who had open surgery (HR 1.68, 95% CI 1.20, 2.36, I2 26%). Based on five studies, patients who had minimally invasive (n=1808) hysterectomy had a trend towards worse overall survival than those who had open surgery (n=1853) (HR 1.64, 95% CI 1.00 to 2.68, I2 15%).ConclusionBased on a systematic review of the literature and meta-analysis of studies that control for confounders, for patients with cervical cancer and tumor size <2 cm, minimally invasive radical hysterectomy was associated with worse progression-free survival than laparotomy.

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

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

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.

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

The NCCN Guidelines for Cervical Cancer provide recommendations for diagnostic workup, staging, and treatment of patients with the disease. These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to first- and second-line systemic therapy recommendations for patients with recurrent or metastatic disease, and emerging evidence on a new histopathologic classification system for HPV-related endocervical adenocarcinoma.

To investigate the safety of uterine preservation in patients with high-grade epithelial ovarian carcinoma (EOC).The Surveillance, Epidemiology, and End Results database was accessed (1988-2014) and patients aged = 45 years, diagnosed with an unilateral high-grade non-clear cell EOC confined to the ovary were selected. Based on surgery codes we determined whether hysterectomy was performed. Overall (OS) and cancer-specific survival (CSS) was estimated calculated following generation of Kaplan-Meier curves and compared using the log-rank test. Cox hazard model was constructed to control for possible confounders.A total of 1039 patients with a median follow-up of 119 months were identified. Rate of uterine preservation was 31.8 %. Patients who had hysterectomy were older (median 41 vs 32 yrs, p 0.001). Patients with mucinous tumors were less likely to undergo hysterectomy (58.9 %) compared to those with endometrioid (73.9 %) and serous (75.9 %) carcinoma, p 0.001. There was no difference in CSS between patients who did and did not have hysterectomy, p = 0.70 (5-yr rates were 93.9 % vs 92.2 %, respectively). After controlling for year of diagnosis, tumor histology (serous vs non-serous), disease stage, performance of lymph node dissection (LND) and tumor grade, uterine preservation was not associated with a worse cancer-specific (HR: 1.08, 95 % CI:0.69,1.71) and overall (HR:0.88, 95 % CI: 0.59, 1.32) mortality.In this retrospective cohort of patients with unilateral high-grade non-clear cell EOC confined to the ovary, uterine preservation was not associated with a worse prognosis.

To evaluate factors associated with survival of patients with advanced stage mucinous ovarian carcinoma (MOC) using a large multi-institutional database. Patients diagnosed between 2004 and 2014 with advanced stage (III–IV) MOC were identified within the National Cancer Database. Those without a personal history of another primary tumor who received cancer-directed surgery with a curative intent were selected for further analysis. Overall survival (OS) was evaluated with Kaplan–Meier curves, and compared with the log-rank test. Multivariate Cox analysis was performed to identify independent predictors of survival. A total of 1509 patients with a median age of 59 years (IQR 20) met the inclusion criteria: stage III (n = 1045, 69.3%) and stage IV disease (n = 464, 30.7%). Patients who received chemotherapy (n = 1065, 70.6%) had better OS compared to those who did not (n = 385, 25.5%), (median OS 15.44 vs 5.06 months, p

ObjectiveInvestigate the overall survival of patients with stage IC2/IC3 epithelial ovarian carcinoma undergoing fertility-sparing surgery.MethodsPatients aged <45 years diagnosed between January 2004 and December 2015 with epithelial ovarian carcinoma, who underwent surgical staging and had tumor involving the ovarian surface (IC2), malignant ascites or positive cytology (IC3), were identified in the National Cancer Database. The fertility-sparing surgery group included patients who had preservation of the uterus and the contralateral ovary while the radical surgery group included patients who had hysterectomy with bilateral salpingo-oophorectomy. Overall survival was evaluated following generation of Kaplan–Meier curves while a Cox model was constructed to control for tumor grade and performance of lymphadenectomy. A systematic review of the literature was performed and cumulative relapse rate among patients with IC2/IC3 disease who underwent fertility-sparing surgery was calculated.ResultsA total of 235 cases were identified; 105 (44.7%) patients underwent fertility-sparing surgery. There was no difference in overall survival between the fertility-sparing and radical surgery groups (p=0.37; 5- year overall survival rates 90.2% and 85%, respectively). After controlling for tumor grade and performance of lymphadenectomy, fertility-sparing surgery was not associated with worse overall survival (HR 1.22, 95% CI 0.56, 2.62). A systematic review identified 151 patients with stage IC2/IC3 disease who underwent fertility-sparing surgery. Cumulative relapse rate was 19.3% (n=29) while 12 (6.7%) deaths were reported. Median time to recurrence was 19 (range 1–128.5) months. Tumor recurrence involved the ovary exclusively in 42% (11/26) of patients, while 15% (4/26) had a lymph node, 35% (9/26) a pelvic/abdominal, and 8% (2/26) a distant tumor relapse.ConclusionsIn a large cohort of patients with stage IC2/IC3 epithelial ovarian carcinoma, fertility-sparing surgery was not associated with worse overall survival. However, based on a literature review, relapse rate is approximately 20%.

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

IntroductionThe National Comprehensive Cancer Network (NCCN) guidelines recommend intraperitoneal chemotherapy in optimally debulked stage III ovarian cancer patients. The objective of this investigation was to determine the rate of intraperitoneal port placement in patients undergoing surgery for ovarian cancer in a national database maintained by the American College of Surgeons.MethodWe identified ovarian cancer patients in the National Surgical Quality Improvement Program database from 2006 to 2012. Demographics, comorbidities, operative outcomes, and postoperative complications were abstracted. Descriptive analyses were conducted using Wilcoxon rank-sum and Chi square tests, and multivariate regression models were used to analyze pre-operative and post-operative variables associated with intraperitoneal port placement.ResultsWe identified 2659 ovarian cancer patients who underwent primary surgical management. Of these patients, only 128 (4.8%) had an intraperitoneal port placed at the time of surgery. In multivariable analyses, intraperitoneal ports were associated with body mass index ≤25, disseminated cancer, later portion of the study period (2009–2012), and operative time >200 min. Intraperitoneal port placement was not associated with any difference in surgical site infection, wound disruption, major postoperative complication, readmission within 30 days, or death within 30 days.DiscussionRecent investigation of practice at NCCN institutions between 2003 and 2012 found only 35% of eligible ovarian cancer patients received intraperitoneal chemotherapy. Using intraperitoneal port placement as a surrogate for intraperitoneal chemotherapy administration, our investigation suggests an even lower rate (4.8%) nationally.

Objective The aim of the present study was to investigate the patterns of use and prognostic significance of adjuvant chemotherapy (CT) for patients with stage IC ovarian granulosa cell tumors (GCTs). Methods We identified patients with stage IC GCTs diagnosed between 2004 and 2015 in the National Cancer Data Base (NCDB). Logistic regression was performed to identify variables independently associated with chemotherapy administration. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for known confounders. Results A total of 492 patients with stage IC GCTs were identified, of which 166 (33.7%) received CT. Tumor size > = 10 cm (OR: 1.85, 95% CI: 1.21, 2.82) was independently associated with the administration of CT. There was no difference in OS between patients who did (n = 145) and did not (n = 282) receive CT, p = 0.52; 5-yr OS rates were 93.7% and 91.6% respectively. After controlling for patient age (, Highlights • In a cohort of patients with stage IC GCTs rate of adjuvant chemotherapy use was 33.7%. • Tumor size > = 10 cm was associated with the administration of chemotherapy. • Adjuvant chemotherapy was not associated with a survival benefit.

PURPOSE: Seventeen percent of patients with cancer visit the emergency department (ED) annually, often with nonemergent complaints. We sought to describe the burden of treat-and-release ED utilization by patients with gynecologic cancers and to identify opportunities for improved triage. MATERIALS AND METHODS: Patients with gynecologic cancer diagnoses who were treated and released were identified within the Nationwide Emergency Department Sample, a stratified sample of US hospital-based ED visits, from 2009 to 2013. Sample weights were applied to generate national estimates. Associations with visit charges were assessed with weighted multivariable linear regression. RESULTS: Between 2009 and 2013, there were an estimated 174,092 annual treat-and-release ED visits by patients with gynecologic cancer (95% CI, 163,480 to 184,703 visits), which corresponded to $736 million in annual charges with an average visit charge of $4,232 (95% CI, $4,099 to $4,366). Annual visits and total charges increased significantly over the 5 years under study. Visits were more frequent for patients with cervical cancer (44.1%) versus ovarian (27.8%) and uterine (24.6%) cancer. These patients were younger and more likely to be from low socioeconomic status areas. The most common primary diagnoses were similar across cancers, including abdominal pain (10.5%), chest pain (6.1%), and urinary tract infection (5.2%). The most frequent diagnostics were culture/smear, computed tomography scan, and x-ray, and the most frequent therapeutic procedures included wound care, transfusion, and paracentesis. CONCLUSION: Patients with gynecologic cancers, and cervical cancer in particular, are frequently seen in the ED with issues that could be less expensively managed in an outpatient clinic or urgent care setting. Visit frequency, but not per-visit cost, is increasing over time.

OBJECTIVE: Platinum-resistant, high-grade serous ovarian cancer (HGSOC) has limited treatment options. Preclinical data suggest that poly(ADP-ribose) polymerase inhibitors (PARPi) and ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) are synergistic. CAPRI (NCT03462342) is an investigator-initiated study of olaparib plus ceralasertib in recurrent HGSOC. Herein, we present results from the platinum-resistant cohort. METHODS: A Simon 2-stage design was utilized. Platinum-resistant HGSOC patients received ceralasertib 160mg orally daily, days 1–7 and olaparib 300mg orally twice daily, days 1–28 of a 28-day cycle until toxicity or progression. Primary endpoints were toxicity and efficacy including objective response rate (ORR) by RECIST. Secondary endpoint was progression-free survival (PFS). The null hypothesis (≤5% ORR) would be rejected if there were ≥1 responses in 12 patients. RESULTS: Fourteen PARPi-naïve patients were evaluable for toxicity; 12 were evaluable for response. Three had BRCA1 mutations (1 germline, 2 somatic). Adverse events possibly related to treatment were primarily grade (G) ½. G3 toxicities included nausea (14.3%), fatigue (7.1%), anorexia (7.1%), and anemia (7.1%). No objective responses occurred. Best response was stable disease in 9 patients and progressive disease in three. Five patients had a ≥20% to 50% CA-125 decline, including 2 with CA-125 normalization. Median PFS was 4.2 months overall (90% CI:3.5–8.2) and 8.2 months (3.6 months–not determined) for patients with BRCA1 mutations. CONCLUSIONS: Olaparib plus ceralasertib is well-tolerated. No objective responses occurred, though a signal of activity was seen particularly in disease associated with BRCA1. Further evaluation of this combination should include alternate dosing strategies in genomically-selected populations.

To assess oncologic outcomes in endometrial cancer patients with low-volume metastasis (LVM) in the sentinel lymph nodes (SLNs).Patients with endometrial cancer and SLN-LVM (≤2 mm) from December 3, 2009, to December 31, 2018, were retrospectively identified from 22 centers worldwide. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV, adnexal involvement, or unknown adjuvant therapy (ATx) were excluded.Of 247 patients included, 132 had isolated tumor cell (ITC) and 115 had micrometastasis (MM). Overall 4-year recurrence-free survival (RFS) was 77.6% (95% CI, 70.2%-85.9%); median follow-up for patients without recurrence was 29.6 (interquartile range, 19.2-41.5) months. At multivariate analysis, Non-endometrioid (NE) (HR, 5.00; 95% CI, 2.50-9.99; P .001), lymphovascular space invasion (LVSI) (HR, 3.26; 95% CI, 1.45-7.31; P = .004), and uterine serosal invasion (USI) (HR, 3.70; 95% CI, 1.44-9.54; P = .007) were independent predictors of recurrence. Among 47 endometrioid ITC patients without ATx, 4-year RFS was 82.6% (95% CI, 70.1%-97.2). Considering 18 ITC patients with endometrioid grade 1 disease, without LVSI, USI, or ATx, only 1 had recurrence (median follow-up, 24.8 months).In patients with SLN-LVM, NE, LVSI, and USI were independent risk factors for recurrence. Patients with any risk factor had poor prognosis, even when receiving ATx. Patients with ITC and grade 1 endometrioid disease (no LVSI/USI) had favorable prognosis, even without ATx. Further analysis (with more patients and longer follow-up) is needed to assess whether ATx can be withheld in this low-risk subgroup.

ObjectiveTo investigate the prognostic significance of comprehensive lymphadenectomy at the time of primary debulking surgery for patients with rare histologic sub-types of epithelial ovarian carcinoma and clinically advanced stage disease who underwent complete gross resection.MethodsThe National Cancer Database was accessed and patients diagnosed between January 2010 and December 2015 with stage III–IV clear cell, endometrioid, mucinous, and low-grade serous carcinoma who underwent primary debulking surgery and achieved complete gross resection were identified. Patients who did not undergo lymphadenectomy and those who underwent comprehensive lymphadenectomy (defined as at least 20 lymph nodes removed) were selected for further analysis. Overall survival was compared with the log-rank test and a Cox model was constructed to control for confounders.ResultsA total of 381 patients were identified; 133 (34.9%) patients underwent comprehensive lymphadenectomy while 248 (65.1%) patients did not. There were no differences between the two groups in terms of patient race, age, presence of co-morbidities, type of treatment facility, disease stage, histology, and extent of intra-abdominal disease (p>0.05). There was no difference in overall survival between patients who did and did not undergo comprehensive lymphadenectomy (p=0.42); median overall survival was 51.48 and 47.38 months, respectively. After controlling for patient age, race, insurance status, presence of co-morbidities, intra-abdominal tumor spread, stage and histology, performance of systematic lymphadenectomy was not associated with better survival (HR 0.96, 95% CI 0.69 to 1.35).ConclusionComprehensive lymphadenectomy is not associated with a survival benefit for patients with rare histologic sub-types of epithelial ovarian carcinoma and advanced stage disease who underwent primary debulking surgery and complete gross resection.

ObjectiveTo evaluate the outcomes of minimally invasive surgery for patients with stage IA cervical carcinoma undergoing hysterectomy.MethodsPatients with pathological stage IA (IA1, IA2, IA not otherwise specified) squamous, adenocarcinoma, adenosquamous carcinoma of the cervix, no history of another tumor, who underwent radical or simple hysterectomy with known mode of surgery, diagnosed between 2010 and 2015 with at least 1 month of follow-up, were drawn from the National Cancer Database. Comparisons of demographic and clinicopathologic characteristics were made with the χ2 test. The impact of minimally invasive surgery (robotic-assisted or traditional laparoscopic) on overall survival was assessed with the log-rank test following generation of Kaplan–Meier curves. A Cox model was constructed to control for confounders.ResultsA total of 1930 patients were identified; the majority (73.3%, 1414 patients) had stage IA1 disease, while 458 (23.7%) patients had stage IA2, and 58 (3%) patients had stage IA not otherwise specified. In the present cohort, 685 patients (35.5%) had open, 438 patients (22.7%) had laparoscopic, and 807 patients (41.8%) had robotic-assisted laparoscopic hysterectomy. Patients who had an open approach were more likely to undergo lymphadenectomy (58.1% vs 52.7%, p=0.021) and have radical hysterectomy (42% vs 32.4%, pConclusionsIn a large cohort of patients with stage IA cervical carcinoma, performance of minimally invasive hysterectomy was not associated with a detrimental effect on overall survival.

To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor sizeThe Pubmed/Medline, Embase, and Web-of-Science databases were queried from inception to January 2021 (PROSPERO CRD 42020207971). Observational studies reporting progression-free survival and/or overall survival for patients who had open or minimally invasive radical hysterectomy for early-stage cervical carcinoma and tumor sizeA total of 10 studies that met the inclusion criteria were included encompassing 4935 patients. Of these, 2394 (48.5%) patients had minimally invasive and 2541 (51.5%) patients had open radical hysterectomy; respectively. Patients who underwent minimally invasive hysterectomy had worse progression-free survival than those who had open surgery (HR 1.68, 95% CI 1.20, 2.36, IBased on a systematic review of the literature and meta-analysis of studies that control for confounders, for patients with cervical cancer and tumor size

Introduction Evaluate outcomes of minimally invasive radical hysterectomy (MIRH) for patients with FIGO (2019) stage IB2 (tumor size ≥2 and Methods Patients with pathological stage IB2 squamous, adenocarcinoma, adenosquamous carcinoma of the cervix, no history of another tumor, who underwent primary radical hysterectomy and lymphadenectomy with known mode of surgery, diagnosed between 2010–2015 with at least one month of follow-up were drawn from the National Cancer Database. Impact of MIRH (robotic-assisted or traditional laparoscopic) on overall survival (OS) was assessed with the log-rank test. A Cox model was constructed to control for confounders. Results A total of 1304 patients were identified; 621(47.6%) had open, 134 (10.3%) laparoscopic and 549 (42.1%) robotic-assisted laparoscopic radical hysterectomy. Overall conversion rate was 3.5%. Open and MIRH groups were comparable in terms of age, presence of co-morbidities and histology. Patients in both groups had a median of 18 lymph nodes removed (p=0.83). Patients who had MIRH had shorter hospital stay (median 1 vs 3 days, p Conclusions MIRH is associated with worse overall survival for patients with pathological stage IB2 cervical carcinoma.

Introduction Aim of the present study was to evaluate the incidence of lymph node metastasis among patients with apparent early stage endometrioid ovarian carcinoma (EOOC). Methods Patients with apparent early stage EOOC, with known tumor grade and substage diagnosed between 2004–2015 were drawn from the National Cancer Database. Performance of lymph node sampling/dissection (LND) and incidence of LN metastases were evaluated from the pathology report. Results A total of 9725 patients with apparent early stage EOOC were identified; 44.4%, 40.5% and 15.1% had grade 1, 2 and 3 tumors respectively. 7480 (76.9%) underwent LND with a median of 12.5 LNs removed. The overall incidence of LN metastasis was 2.2%; specifically, 1.2% for grade 1, 2.2% for grade 2, and 5.1% for grade 3 tumors (p Conclusions The incidence of LN metastasis for patients with grade 1 and 2 EOOC is overall low. LND should be considered for patients with grade 3 tumors.

Introduction Aim of the present study was to investigate patterns of use and outcomes of adjuvant treatment for patients with stage I adenosarcoma. Methods Patients diagnosed between 2004–2015 with stage I adenosarcoma without a history of another tumor who underwent hysterectomy with lymphadenectomy and had at least one month of follow-up were drawn from the National Cancer Database. Patients who received adjuvant chemotherapy (CT) and/or radiotherapy (RT) defined as treatment within 6 months from surgery were identified. Overall survival (OS) was evaluated after generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders. Results Among 735 patients with stage I adenosarcoma, 186 (25.3%) received adjuvant treatment; 61.3% RT only, 26.9% CT only and 11.8% both RT and CT. Rate of adjuvant treatment was 14.1% for patients with stage IA compared to 35.8% and 53.3% for those with stage IB and IC, p 0.05. Five year OS rate for patients who did not receive adjuvant treatment was 79.9% compared to 63.4%, 68.8% and 74.1% for those who received RT only, CT only and both CT and RT, p=0.002. After controlling for substage, patient age, insurance status and co-morbidities, administration of adjuvant treatment was not associated with a survival benefit (HR: 1.29, 95% CI: 0.92, 1.58) Conclusions There is no clear benefit in the use of adjuvant treatment for patients with early stage adenosarcoma.

ObjectiveA retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomyMethodsPatients diagnosed between January 2012 and December 2015 with vulvar squamous cell carcinoma of less than 4 cm in size, with invasion of at least 1 mm, who underwent sentinel lymph node biopsy, lymphadenectomy, or both were identified from the National Cancer Database. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test for patients who had at least 1 month of follow-up. A Cox model was constructed to control for confounders.ResultsA total of 1583 patients were identified; 304 patients (19.2%) underwent sentinel lymph node biopsy alone. Sentinel lymph node biopsy utilization increased 13.9% between 2012 and 2015. Patients who underwent sentinel node biopsy alone were less likely to have comorbidities compared with those undergoing lymphadenectomy only or sentinel node biopsy with lymphadenectomy (25.3% vs 32.9% vs 31.9%, p=0.042), had smaller tumors (median 1.6 vs 2.0 vs 2.0 cm, pConclusionsThe utilization of sentinel lymph node biopsy is increasing in the management of vulvar cancer and is associated with superior perioperative outcomes without impacting overall survival.

To determine the impact on overall survival (OS) of different modalities of adjuvant therapy for the treatment of stage III endometrial cancer (EC), by histology.Stage 3 endometrioid (EAC), serous (SER), clear cell (CC), and carcinosarcoma (CS) patients who underwent primary surgical staging from 2000 to 2013 were identified in SEER-Medicare. Adjuvant therapy was defined by a 4-arm comparator grouping (none; RT only; CT only; combination RT), as well as by an 8-arm comparator grouping (none; RT only; CT only; concurrent CT-RT; concurrent CT-RT then CT; Serial CT-RT; serial RT-CT; sandwich). Modality of RT and CT were analyzed using Kaplan-Meier estimates, log rank tests, and multivariable cox modeling.Of 2870 cases identified (1798 EAC, 606 SER, 118 CC, 348 CS), 31.5% received no adjuvant therapy. The remainder received RT or CT alone, concurrent RT-CT, serial or sandwich modalities. OS differed by adjuvant therapy in adjusted and unadjusted models, when combining all histologies, and when stratifying by histology using both the 4-arm, and 8-arm comparator analyses (log rank p .05, all). By histology, in adjusted analyses, sandwich modality had the greatest improvement in OS for endometrioid, but pairwise comparisons did not identify a superior chemotherapy-based regimen. For serous and clear cell, the greatest improvement in OS was seen with concurrent RT-CT, and for carcinosarcoma, CT alone.OS for advanced EC significantly differs by histology and mode of adjuvant therapy. Future studies should evaluate the efficacy of combination-based adjuvant therapy versus chemotherapy alone, by histologic subtype and molecular signature.

IntroductionPayment reform will give oncologists increasing responsibility for how patients with cancer meet unexpected care needs.ObjectiveTo differentiate how patients with gynecologic cancers use emergency care, and to assess the characteristics associated with potentially avoidable treat-and-release visits.MethodsWe performed a retrospective cohort study using the Nationwide Emergency Department Sample, a stratified sample of visits in United States hospital-based emergency departments, from 2010 to 2014. Visits by patients with a diagnosis of gynecologic cancer were selected. Sample weights were applied to calculate national estimates of care patterns and trends. Associations with treat-and-release disposition were assessed with weighted logistic regression.ResultsIn the study period, patients with gynecologic cancer made an estimated 370 104 annual emergency department visits (95% CI 351 997 to 388 211). A total of 50.2% of patients were treated and released, 48% were admitted, 1.6% were transferred, and 0.1% died. These visits corresponded to over US$1.27 billion in annual charges, with an average charge of US$3428 per visit (95% CI 3348 to 3509). Driven by growing treat-and-release utilization, annual visits increased, while admission rates fell over time. Patients with cervical cancer represented the plurality (36%) of visits; they were relatively younger, of lower socioeconomic status, and had fewer co-morbidities. Models for treat-and-release disposition did not vary significantly across different cancer populations. In the all-cancer model, increased odds of treat-and-release disposition was associated with cervical cancer diagnosis, younger age, lesser Elixhauser co-morbidity, Medicare coverage (OR=1.19; pDiscussionPatients with gynecologic cancers have been using the emergency department at increasing rates, primarily driven by treat-and-release visits that did not result in admission or death. Patients with cervical cancer have higher rates of treat-and-release utilization and may over-use emergency department care.

Objectives: Although adjuvant therapy with radiation (RT) or chemotherapy (CT) is recommended for advanced endometrial cancer, prior studies have not defined which modality of adjuvant therapy is most effective for advanced node-negative versus node-positive disease. This study investigates the impact of various adjuvant therapies on overall survival (OS) for patients with Stage IIIA/IIIB and IIIC endometrioid endometrial cancer (EC). Methods: The SEER-Medicare database was used to identify patients with stage III endometrioid EC who underwent primary hysterectomy from 2005-2015, with Medicare claims data through 2016. Cases of stage IIIA/B and IIIC disease were analyzed separately. Demographic data, adjuvant therapy modality and sequence, and pathologic findings were collected. ‘Simplified Treatment Classification’ was defined by collapsing all modalities of combined CT/RT. ‘Treatment Sequence Specified’ maintained separate groups of sequence specifications. Descriptive analyses followed by Kaplan-Meier curves, Cox multivariable modeling, and pairwise comparisons with Bonferonni corrections were used to assess 5-year OS by treatment modality. Results: 2,045 patients were identified (n=1046 IIIA/B; n=977 IIIC). RT alone (33%) followed by CT alone (18%) were most commonly used in stage IIIA/B (33%); whereas CT alone (29%) and combination CT-RT (26%) were most common for stage IIIC. Treatment with RT alone decreased significantly for both groups after 2008 (42.32% to 20.25% for IIIA/B, 34.31% to 10.56% for IIIC, p 0.05 all). However, both CT alone and concurrent CT/RT were associated with improved survival compared to use of RT alone for IIIA/IIIB (CT HR 0.60, 95% CI 0.45, 0.81, p 0.05). Download : Download high-res image (141KB) Download : Download full-size image Conclusions: In stage IIIA/B, both concurrent CT/RT and CT alone conferred improved survival compared to RT alone. In contrast for IIIC, concurrent CT/RT conferred improved survival over RT alone, whereas CT alone did not. For both IIIA/IIIB and IIIC, pairwise comparisons did not show improvement of using combination CT-RT over CT alone. There did not appear to be a clear difference in pattern of efficacy of various CT or RT regimens between node positive (IIIC) versus node negative (IIIA/B) advanced stage endometrioid adenocarcinomas.

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

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

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

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

Investigate the role of lymphadenectomy for patients with apparent stage I uterine sarcoma.The National Cancer Database was accessed and patients without a history of another tumor diagnosed between 2004 and 2015 with an apparent early stage leiomyosarcoma, adenosarcoma, low-grade endometrial stromal and high-grade endometrial stromal/undifferentiated sarcoma who underwent hysterectomy with or without lymphadenectomy were identified. Overall survival was assessed after stratification by histology with the log-rank test while Cox models were constructed to control for confounders.A total of 6412 patients with apparent early stage uterine sarcoma who underwent hysterectomy were identified; 2820 (44%) underwent lymphadenectomy. Rate of lymph node metastasis was 3.4% (42/1250) for patients with leiomyosarcoma, 2.3% (19/826) for those with adenosarcoma, 4.5% (21/463) for patients with low-grade endometrial stromal sarcoma and 7.9% (22/280) for those with high-grade endometrial stromal/undifferentiated sarcoma, p 0.001. After controlling for confounders lymphadenectomy was not associated with better survival for patients with adenosarcoma (HR: 0.92, 95% CI: 0.73, 1.17), or low-grade endometrial stromal sarcoma (HR: 1.17, 95% CI: 0.73, 1.87). Patients with leiomyosarcoma who underwent lymphadenectomy had worse survival (HR: 1.15, 95% CI: 1.03, 1.28). Patients with high-grade endometrial stromal/undifferentiated sarcoma who underwent lymphadenectomy had better survival (HR: 0.66, 95% CI: 0.48, 0.89).Incidence of lymph node metastasis in apparent early stage uterine sarcoma is rare while the performance of lymphadenectomy was not associated with a clear survival benefit for all histologic subtypes except high-grade endometrial stromal/undifferentiated sarcoma.

OBJECTIVE To compare 30-day postsurgical readmission rates and associated risk factors for readmission among women undergoing gynecologic surgery for benign and malignant conditions. METHODS In a retrospective cohort study, we identified patients after surgery for benign and malignant gynecologic conditions in the National Surgical Quality Improvement Program database between January 1, 2011, and December 31, 2012. Data collected included surgical factors, perioperative characteristics, surgical complications, and 30-day readmissions. The primary study outcome was readmission rates after gynecologic surgery for benign and oncologic conditions. Secondary study outcomes were risk factors associated with readmission among gynecologic surgeries performed for benign and oncologic conditions. RESULTS Approximately 3% (1,444/46,718) compared with 8.2% (623/7,641) of patients who underwent gynecologic surgery for benign and malignant indications, respectively, were readmitted (P

Objectives To investigate the patterns of use and impact of lymphadenectomy (LND) on overall survival (OS) of patients with apparent early stage malignant ovarian germ cell tumors (MOGCTs). Methods Patients with apparent stage I MOGCT diagnosed between 2004 and 2015 were drawn from the National Cancer Database. The performance of LND was assessed from the pathology report. OS was evaluated using Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for confounders. Results A total of 2774 patients were identified; 1426 (51.4%) underwent LND. The median number of lymph nodes (LN) removed was 9 (range 1–81); 48.3% of patients had at least 10 lymph nodes removed. The rate of regional lymph node metastasis was 10.3% (147 patients). There was no difference in OS, between patients who did (n = 1287) and did not (n = 1210) undergo LND, p = 0.81; 5-yr OS rates were 96.5% and 97.6% respectively. After controlling for patient age, insurance status, histology, presence of medical comorbidities, and receipt of chemotherapy, the performance of LND was not associated with better survival (HR: 1.33, 95% CI: 0.82, 2.14). Conclusions While LN metastasis is common in apparent early stage MOGCTs, the performance of LND was not associated with a survival benefit.

To evaluate the role of radical hysterectomy in the management of patients with stage II endometrial carcinoma.Patients diagnosed between 2004 and 2015, with stage II (based on the revised FIGO staging) endometrial carcinoma who had hysterectomy and regional lymph node surgery were identified in the National Cancer Database. Those who had radical or modified radical (RH), or total hysterectomy (TH) were selected. Overall survival (OS) was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders.A total of 7552 patients who met the inclusion criteria were identified. Rate of RH was 10.5%. Those who underwent RH had longer hospital stay (median 3 vs 2 days, p 0.001) and a higher 90-day (1.6% vs 0.8%, p = 0.05) mortality. There was no difference in OS between patients who had RH (n = 712) and SH (n = 5955) (p = 0.62); 5-year survival rates were 77.4% and 76.9%, respectively. After controlling for patient age (65, ≥65 years), race (white, black, other/unknown), insurance status, presence of comorbidities, tumor size (5, ≥5 cm, unknown), histology (endometrioid, non-endometrioid), performance of adequate lymphadenectomy, and receipt of adjuvant chemotherapy and radiation therapy, performance of radical hysterectomy was not associated with better survival (HR: 1.01, 95% CI: 0.85, 1.21).Radical hysterectomy was not associated with a survival benefit in a cohort of patients with stage II endometrial carcinoma.

To evaluate the prevalence and outcomes of minimally invasive surgery for stage I high grade endometrial cancer. We hypothesized that route of surgery is not associated with survival.Patients diagnosed between 2010 and 2014, with stage I grade 3 endometrioid, serous, clear cell and carcinosarcoma endometrial carcinoma, who underwent hysterectomy with lymphadenectomy were drawn from the National Cancer Database. Patients converted to open surgery were excluded. Overall survival was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.A total of 12852 patients were identified. The rate of minimally invasive surgery was 62.2%. An increase in the use between 2010 and 2014 was noted (p 0.001). Open surgery was associated with longer hospital stay (median 3 vs 1 day, p 0.001), higher 30-day unplanned re-admission rate (4.5% vs 2.4%, p 0.001) and 30-day mortality (0.6% vs 0.3%, p = 0.008). There was no difference in overall survival between patients who had open or minimally invasive surgery, p = 0.22; 3-yr overall survival rates were 83.7% and 84.4% respectively. After controlling for patient age, tumor histology, substage, type of insurance, type of reporting facility, receipt of radiation therapy and chemotherapy, extent of lymphadenectomy, the presence of comorbidities and personal history of another tumor, minimally invasive surgery was not associated with a worse survival (hazard ratio: 1.06, 95% confidence interval: 0.97, 1.15).Minimally invasive surgery for patients with stage I high grade endometrial cancer, was associated with superior short-term outcomes with no difference in overall survival noted.

Objectives: To compare the overall survival (OS) and cancer specific survival (CSS) by race for women with stage I-III endometrial cancer (EC) by histologic subtype. Methods: This is a retrospective cohort study of women with stage I-III endometrioid, serous, clear cell, and carcinosarcoma who underwent hysterectomy as primary surgical staging as identified within the SEER-Medicare database. Endometrial cancer cases diagnosed between 2000 and 2015 with Medicare enrollment data from 1999-2016 were included. Demographics, cancer data, and survival outcomes were collected. Demographic and treatment factors by race were compared using descriptive analyses. OS and CSS outcomes were stratified by race, stage and histology, then analyzed using log rank tests and multivariate cox modeling (adjusting for age, geographic region, Charlson comorbidity index, post-operative treatment sequencing, FIGO stage, and grade). Results: 24,142 total patients were included in this dataset. 85.5% were White, and 8.5% were BlackBlack. 19,351 stage I, 1,484 stage II, and 3,307 stage III cases were identified. Black women were diagnosed at a younger age bracket (40-69yo) than White patients for endometrioid stage I (40% vs 35%), II (37% vs 31%), and III (31% vs 28%); serous stage I (45% vs 31%) and III (42% vs 28%), and carcinosarcoma stage I (39% vs 27%), p Download : Download high-res image (212KB) Download : Download full-size image Conclusions: Prior studies have reported that BlackBlack women with endometrial cancer have worse survival consistently across stage and histology. However, we did not find this effect when evaluating by CSS and OS. For stage I, BlackBlack women had consistently worse CSS likely related to the disease itself and worse OS in adjusted analyses likely related to poorer overall health outcomes across all histologic subtypes except for clear cell. For stage II and III, racial disparities were seen only for CSS in endometrioid patients in the adjusted analyses, but not OS; and this may have been related to BlackBlack women with stage III cancer receiving less adjuvant therapy. When stratified by stage and histology, BlackBlack women with EC were diagnosed at younger age and with more comorbidities. Overall these findings emphasize the need to intervene in the early stage population, where a disparity exists and the largest population of women is affected.