Aimee C. Fleury

Stage I noninvasive and minimally invasive uterine serous carcinoma: Comprehensive staging associated with improved survival

Objective The aim of this study was to determine if comprehensive surgical staging is a better predictor of outcome than incomplete staging for women with stage I noninvasive or minimally invasive (⩽3 mm) uterine serous carcinoma (USC). Methods Retrospective chart review was used to identify patients undergoing hysterectomy at the Johns Hopkins Hospital from 1989 to 2010. Relevant clinical and pathologic data were extracted. Patients with noninvasive and minimally invasive (⩽3-mm myometrial invasion) USC were identified. Stage was assigned based on the 2009 International Federation of Gynecology and Obstetrics endometrial cancer criteria. Survival curves were generated using the Kaplan-Meier method. Results We identified 63 patients with noninvasive or minimally invasive (⩽3 mm) USC. Stages I, II, III, and IV disease were noted in 65% (41/63), 6% (4/63), 14% (9/63), and 14% (9/63) of the patients, respectively. Lower stage was associated with a significantly improved disease-specific survival (P = 0.001). Comprehensive staging, including total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal biopsies, was completed in 29% (12/41) of the patients with stage I disease. There were no disease-specific deaths in the comprehensive staging group. Compared with incomplete staging, comprehensive staging was associated with a significantly improved disease-specific survival (P = 0.039). Conclusions Patients with stage I noninvasive and minimally invasive USC on comprehensive staging have an excellent prognosis. Adjuvant therapy may not benefit this patient population.

Primary uterine cancer in maryland impact of distance on access to surgical care at high-volume hospitals

Objective To evaluate the influence of distance on access to high-volume surgical treatment for patients with uterine cancer in Maryland. Methods The Maryland Health Services Cost Review Commission database was retrospectively searched to identify primary uterine cancer surgical cases from 1994 to 2010. Race, type of insurance, year of surgery, community setting, and both surgeon and hospital volume were collected. Geographical coordinates of hospital and patient’s zip code were used to calculate primary independent outcomes of distance traveled and distance from nearest high-volume hospital (HVH). Logistic regression was used to calculate odds ratios and confidence intervals. Results From 1994 to 2010, 8529 women underwent primary surgical management of uterine cancer in Maryland. Multivariable analysis demonstrated white race, rural residence, surgery by a high-volume surgeon and surgery from 2003 to 2010 to be associated with both travel 50 miles or more to the treating hospital and residence 50 miles or more from the nearest HVH (all P < 0.05). Patients who travel 50 miles or more to the treating hospital are more likely to have surgery at a HVH (odds ratio, 6.03; 95% confidence interval, 4.67–7.79) In contrast, patients, who reside ≥50 miles from a HVH, are less likely to have their surgery at an HVH. (odds ratio, 0.37; 95% confidence interval, 0.32–0.42). Conclusion In Maryland, 50 miles or more from residence to the nearest HVH is a barrier to high-volume care. However, patients who travel 50 miles or more seem to do so to receive care by a high-volume surgeon at an HVH. In Maryland, Nonwhites are more likely to live closer to an HVH and more likely to use these services.

Racial disparities in surgical care for uterine cancer

OBJECTIVE To evaluate the association of race and surgical approach for women who underwent surgical treatment for uterine cancer. METHODS The design was a retrospective cohort study of discharge data from nonfederal acute care hospitals in Maryland from 2000 to 2009. Women aged 18 and older who underwent hysterectomy for uterine cancer were included in the study population. The main outcome measure was receipt of lymphadenectomy. Secondary outcomes included receipt of minimally-invasive surgical approach, in-hospital mortality and individual surgeon and individual hospital annual uterine cancer case volume. The independent variable was race. We used logistic regression to calculate odds ratios and confidence intervals for each outcome of interest. Caucasians were the reference group. RESULTS Among 5470 women who underwent hysterectomy, 2727 (49.9%) underwent lymphadenectomy and 512 (9.4%) underwent surgery through a minimally-invasive approach. After adjusting for age, payer status and APR-DRG mortality risk score, African-Americans were more likely to be operated on by high-volume surgeons (adjusted OR=1.27, 95% CI: 1.09-1.49) yet were less likely to undergo minimally-invasive surgery (adjusted OR=0.60, 95% CI: 0.45-0.80). For the outcome of lymphadenectomy, there was no significant difference between Caucasians and African-Americans (OR=1.13, 95% CI: 0.98-1.30). There was no association between race and in-hospital mortality or between race and the odds of undergoing surgery at a high-volume hospital. CONCLUSION In this retrospective analysis of uterine cancer patients, race is associated with likelihood of undergoing surgery through a minimally-invasive approach. Further analysis using prospectively collected data with more detail regarding peri-operative parameters is needed to further clarify possible reasons for this disparity.

Abnormal Cervical Cytology in the Diagnosis of Uterine Papillary Serous Carcinoma: Earlier Detection of a Poor Prognostic Cancer Subtype?

Objective: Early detection of uterine papillary serous (UPSC), clear cell (CCC), and grade 3 endometrioid carcinomas (G3EC) – all poor prognostic variants of endometrial carcinoma (EC) – is of particular clinical relevance. The study objective was to assess the utility of liquid-based cytology (Pap) in the detection of high-grade EC. Study Design: A retrospective, two-institution analysis of patients diagnosed with UPSC, CCC, or G3EC with a preoperative Pap from 1999 to 2010 was conducted. Results: One hundred and one patients were evaluated; 51.5% had UPSC, 27.7% had CCC, and 20.8% had G3EC. Stage I/II disease was found in 69.3% of patients, and 46/101 patients (45.5%) had abnormal Paps. Significantly more patients with UPSC had abnormal Paps (65.7%) than those with CCC (25%) or G3EC (23.8%; p < 0.001). An abnormal Pap was the only presenting clinical finding in a significant number of asymptomatic UPSC patients (26.9%) compared with 4% of patients with CCC and G3EC (p = 0.005). On multivariate analysis, UPSC histology was the only variable associated with an abnormal Pap. Conclusions: A high incidence of abnormal cervical cytology was observed in women with high-grade EC, particularly in UPSC patients. Although hypothesis generating, a proportion of asymptomatic UPSC patients had abnormal cytology, signifying that Pap smear screening may help detect the disease before the patient develops symptoms.

Upper abdominal cytoreduction and thoracoscopy for advanced epithelial ovarian cancer: unanswered questions and the impact on treatment

Please cite this paper as: Fleury A, Kushnir C, Giuntoli R, Spirtos N. Upper abdominal cytoreduction and thoracoscopy for advanced epithelial ovarian cancer: unanswered questions and the impact on treatment. BJOG 2012;119:202–206.

Evaluation of exposures to healthcare personnel from cisplatin during a mock demonstration of intra-operative intraperitoneal chemotherapy administration

UNLABELLED Ovarian cancer is the leading cause of death from gynecologic malignancies in the United States. In 2006, the National Cancer Institute released an announcement supporting the use of intraperitoneal (IP) chemotherapy in advanced ovarian cancer. It remains unanswered how many cycles of IP chemotherapy are required to maintain a survival advantage. There may be a benefit with as few as three IP cycles and possibly as few as one IP chemotherapy cycle. OBJECTIVE In preparation for a clinical trial in which chemotherapy would be administered intra-operatively, the question of exposure to healthcare personnel arose, therefore, the purpose of this study was to perform an evaluation of healthcare personnel exposure to cisplatin during a mock demonstration of intraperitoneal chemotherapy administration. MATERIALS AND METHODS The National Institute of Occupational Safety and Health (NIOSH), the Womens Cancer Center of Nevada, and the staff of the University Medical Center, Las Vegas, participated in this mock demonstration. Employees wore personal protective equipment recommended by NIOSH. Wipe, area, and breathing zone air samples were taken from the pharmacy and operating room, and during sterilization of equipment. RESULTS All samples were negative for cisplatin, except for one surface wipe from the floor of the operating room (OR) after the mock procedure. Upon sanitization of the OR, no cisplatin was detected on the floor. CONCLUSION This was the first study evaluating the exposure of healthcare personnel to the administration of cisplatin intra-operatively. NIOSH endorsed this practice so long as the employees adhere to using the recommended personal protective equipment.

The use of argon beam coagulation in treating vulvar intraepithelial neoplasia III: A retrospective review

UNLABELLED Argon beam coagulation (ABC) has unique properties which make it suitable for the local treatment of superficial epithelial disorders such as vulvar intraepithelial neoplasia (VIN III). OBJECTIVE To evaluate argon beam coagulation in treating multifocal VIN III. METHODS Argon beam coagulation was used in twenty-nine patients. ABC was set at 80 W, 7 L/min. All patients were given 1% silvadene cream to apply to vulva. Patients had follow-up appointments two weeks and six weeks postoperatively. Patients were followed every three to six months for the subsequent year. RESULTS 2 of 29 (6.8%) experienced moderate pain within the first two weeks postoperatively requiring prescriptions for perocet. 2 of 29 (6.8%) had yeast infection requiring diflucan. Mean follow-up time was 34.9 months (11.7-37.4). 15 of 29 (51.7%) had no recurrence within the follow-up period. 14 of 29 (48.3%) recurred within the follow-up period. The mean time to recurrence is 23.2 months. CONCLUSION This small retrospective review is the first to evaluate argon beam coagulation in treating multifocal VIN III. This review indicates that ABC is comparable to other vulva organ conserving therapies. ABC retains cosmesis, and form of the vulva. This is a major advantage over surgery. Repeat treatments are also possible, which is important in a condition such as VIN, which tends to be multifocal and recurrent.

Vulvar basal cell carcinoma in a 20-year-old: Case report and review of the literature.

► Vulvar basal cell carcinoma is a rare tumor. ► This report highlights the presentation of vulvar basal cell carcinoma in a very young, non-White patient. ► The importance of provider vigilance and timely biopsy of vulvar lesions is highlighted.

Pre-operative assessment and post-operative outcomes of elderly women with gynecologic cancers, primary analysis of NRG CC-002: An NRG oncology group/gynecologic oncology group study

INTRODUCTION CC-002 is a prospective cooperative group study conducted by NRG Oncology to evaluate whether a pre-operative GA-GYN score derived from a predictive model utilizing components of an abbreviated geriatric assessment (GA) is associated with major post-operative complications in elderly women with suspected ovarian, fallopian tube, primary peritoneal or advanced stage papillary serous uterine (GYN) carcinoma undergoing primary open cytoreductive surgery. METHODS Patients 70 years or older with suspected advanced gynecologic cancers undergoing evaluation for surgery were eligible. A GA-GYN score was derived from a model utilizing the GA as a pre-operative tool. Patients were followed for six weeks post-operatively or until start of chemotherapy. Post-operative events were recorded either directly as binary occurrence (yes or no) using CTCAE version 4.0. RESULTS There were 189 eligible patients, 117 patients with primary surgical intervention and 37 patients undergoing interval cytoreduction surgery. The association between higher GA-GYN score and major postoperative complications in patients undergoing primary surgery was not significant (p = 0.1341). In a subgroup analysis of patients with advanced staged malignant disease who underwent primary cytoreductive surgery, there was a trend towards an association with the GA-GYN score and post-operative complications. CONCLUSION The pre-operative GA-GYN score derived from a predictive model utilizing components of an abbreviated geriatric assessment was not predictive of major post-operative complications in elderly patients undergoing primary open cytoreductive surgery. However, there was an association between GA-GYN score and post-operative complications in a subgroup of patients with advanced staged malignant disease.