Christina L. Kushnir

Virtual reality robotic surgical simulation: an analysis of gynecology trainees.

STUDY OBJECTIVE To analyze the learning curves of gynecology trainees on several virtual reality da Vinci Skills Simulator exercises. DESIGN Prospective cohort pilot study. SETTING Academic hospital-based gynecology training program. PARTICIPANTS Novice robotic surgeons from a gynecology training program. METHODS Novice robotic surgeons from an academic gynecology training program completed 10 repetitions of 4 exercises on the da Vinci Skills Simulator: matchboard, ring and rail, suture sponge, and energy switching. Performance metrics measured included time to completion, economy of instrument movement, excessive force, collisions, master workspace range, missed targets, misapplied energy, critical errors, and overall score. Statistical analyses were conducted to define the learning curve for trainees and the optimal number of repetitions for each exercise. RESULTS A total of 34 participants were enrolled, of which 9 were medical students, 22 were residents, and 3 were fellows. There was a significant improvement in performance between the 1st and 10th repetitions across multiple metrics for all exercises. Senior trainees performed the suture exercise significantly faster than the junior trainees during the first and last repetitions (p = 0.004 and p = 0.003, respectively). However, the performance gap between seniors and juniors narrowed significantly by the 10th repetition. The mean number of repetitions required to achieve performance plateau ranged from 6.4 to 9.3. CONCLUSION Virtual reality robotic simulation improves ability through repetition at all levels of training. Further, a performance plateau may exist during a single training session. Larger studies are needed to further define the most high-yield simulator exercises, the ideal number of repetitions, and recommended intervals between training sessions to improve operative performance.

Extrauterine inflammatory myofibroblastic tumor: A case report.

Highlights • This is the first case report of inflammatory myofibroblastic tumor in the literature to present with extrauterine disease.• A prompt work-up of symptoms may have precluded a tumor debulking procedure.

Impact of histology and surgical approach on survival among women with early-stage, high-grade uterine cancer: An NRG Oncology/Gynecologic Oncology Group ancillary analysis

OBJECTIVES We sought to analyze the clinicopathologic features, recurrence patterns and survival outcomes of women with high-grade uterine cancer (UC) enrolled on The Gynecologic Oncology Group (GOG) LAP2 trial. METHODS This is a post-hoc analysis of LAP-2 patients with grade 3 endometrioid adenocarcinoma (ENDO), uterine serous (USC), clear cell (CC) and carcinosarcoma (CS). Demographics, clinicopathologic features, and recurrence patterns, were compared by histology and surgical approach. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS Of the 2600 patients enrolled in LAP-2, 753 patients had high-grade UC: 350 had ENDO, 289 had USC, 42 had CC and 72 had CS. Compared with the ENDO cohort, those with other high-grade subtypes were older (p<0.001) and were more likely to have positive peritoneal cytology (p<0.001), positive lymph nodes (p=0.05) and higher disease stage on final pathology (p<0.001). With a median follow-up time of 60months, compared to patients with ENDO, those with USC, CCC and CS subtypes had higher recurrence rates (p<0.001), extra-pelvic recurrences (p<0.001) and poorer PFS (p<0.001) and OS (p<0.001). Those diagnosed with USC and CS experienced the worst survival outcomes (p=0.003). Patterns of recurrence and survival were not different in those staged with LSC vs LAP. On multivariable analysis, age, stage, pelvic washings and Type II histology were independently and adversely associated with survival. CONCLUSIONS Women with apparent early-stage, USC and CS histologies have poorer outcomes than women with grade 3 endometrioid adenocarcinoma. Patterns of recurrence and survival were not impacted by surgical approach.

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.

Comparison of current staging systems and a novel staging system for uterine leiomyosarcoma

Objectives Uterine leiomyosarcoma (LMS) was traditionally staged by modified 1988 International Federation of Gynecology and Obstetrics (FIGO) staging criteria for endometrial adenocarcinoma. Contemporary methods of staging include the 2009 FIGO system for uterine LMS and the 2010 American Joint Committee on Cancer (AJCC) soft tissue sarcoma system. The aim of this study was to compare the accuracy of these 3 staging systems and a novel system in predicting disease-specific survival for patients with uterine LMS. Methods Patients, evaluated at our institution with uterine LMS from 1976 to 2009, were identified. Stage was assigned retrospectively based on operative and pathology reports. Staging systems performance was compared using confidence indices. Results We identified 244 patients with uterine LMS with sufficient information to be staged by all 3 systems. For each staging method, lower stage was associated with significantly improved disease-specific survival, P < 0.001. Patients with 2010 AJCC stage IA disease (low-grade, ≤5 cm) experienced no disease-specific deaths. We created a novel staging system, which used size and grade to stratify patients with disease confined to the uterus and/or cervix and combined the remaining patients with extrauterine disease as stage IV. Based on confidence index, the 2010 AJCC system and our novel system provided more accurate prognostic information than either of the 2 FIGO systems. Conclusions Uterine LMS remains a clinically aggressive malignancy. Size and grade provided accurate prognostic information for patients with disease confined to the uterus and/or cervix. Patients with small, low-grade uterine LMS do not benefit from adjuvant therapy.

Selective cardiac surveillance in patients with gynecologic cancer undergoing treatment with pegylated liposomal doxorubicin (PLD)

OBJECTIVE The study objective was to examine the safety and cost savings of selective cardiac surveillance (CS) during treatment with pegylated liposomal doxorubicin (PLD). METHODS A retrospective, dual institution study of women receiving PLD for the treatment of a gynecologic malignancy was performed. The study period was 2002-2014. At both institutions, a selective strategy for CS was implemented in which only high-risk women with a cardiac history or with symptoms suggestive of cardiac toxicity during PLD treatment underwent a cardiac evaluation. Patient demographics, clinical and treatment history were evaluated. Cost analyses were performed utilizing professional/technical fee rates for echocardiogram and multi-gated acquisition scan for each state. RESULTS PLD was administered in 184 women. The mean patient age was 62.7years, and 79% were treated for recurrent ovarian or peritoneal carcinoma. The median cumulative administered dose of PLD was 300mg/m(2); 24 received >550mg/m(2). The median follow-up time was 20months. Of the 184 patients, the majority (n=157, 85.3%) did not undergo either an initial cardiac evaluation or surveillance during or post-PLD treatment. Fifty-three patients considered high risk for anthracycline-induced cardiotoxicity underwent CS. Only three patients (1.6%) in the entire cohort developed CHF that was possibly related to PLD treatment; all had significant pre-existing cardiac risk factors. Selective instead of routine use of CS in the study population resulted in a cost savings of

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

182,552.28. CONCLUSION Utilizing cardiac surveillance in select women undergoing PLD treatment for gynecologic malignancies resulted in significant health care cost savings without adversely impacting clinical outcomes.

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

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.

Perioperative care in gynecologic oncology.

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.

Laparoendoscopic Single-site Radical Hysterectomy With Pelvic Lymphadenectomy: Initial Multi-institutional Experience for Treatment of Invasive Cervical Cancer

Purpose of review To review perioperative care in gynecologic oncology with special emphasis on areas of controversy. Recent findings Major gynecologic surgery still represents the cornerstone of management among women diagnosed with gynecologic malignancies. The implementation of clinical guidelines can significantly impact perioperative morbidity and mortality. Preoperative evaluation and preparation allows the surgeon to identify patient risks and develop risk factor modification strategies decreasing delays in preparation and cost and improving patient safety. Preoperative areas of controversy include preoperative testing and evaluation, use of mechanical bowel preparation, prophylactic antibiotics, and use of anticoagulants, and the timing of postoperative feeding. Summary In healthy women undergoing gynecologic cancer surgery preoperative evaluation requirements will be minimal. For women with extensive comorbid conditions a more detailed evaluation will be required to decrease perioperative morbidity and mortality. Mechanical bowel preparations should not be required preoperatively. Preoperative administration of antibiotics and anticoagulants should be provided to all patients undergoing major gynecologic cancer surgery.