Dan S. Veljovich

Robotic surgery in gynecologic oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging

OBJECTIVE The objective of the study was to evaluate outcomes during the first year of a robotic surgery program in gynecologic oncology. STUDY DESIGN We studied the initiation of a robotic surgery program with prospective data collection, including intraoperative times, estimated blood loss (EBL), length of stay (LOS), lymph node yields, and complications. Patients were compared with historical and contemporary open staging surgery for endometrial cancer. RESULTS One hundred eighteen patients underwent robotic surgery (mean age 52.5 years, body mass index of 26.3 kg/m(2), hospital stay of 32.4 hours), with 8 major and 13 minor complications. Compared with open endometrial staging (n = 131), the robotic procedure (n = 25) was longer (283 vs 139 minutes, P < .0001), had less blood loss (66.6 vs 197.6 mL, P < .0001), and had shorter length of stay (40.3 vs 127 hours, P < .0001) with comparable node yields (17.5 vs 13.1, P = .1109). CONCLUSION Robotic surgery is feasible in gynecologic oncology and facilitated a dramatic expansion in our minimally invasive surgical practice. Despite longer operative times, EBL and LOS are reduced and lymph node yields are comparable.

Surgical outcomes in gynecologic oncology in the era of robotics: analysis of first 1000 cases.

OBJECTIVE We sought to examine outcomes in an expanding robotic surgery (RS) program. STUDY DESIGN In all, 1000 women underwent RS from May 2006 through December 2009. We analyzed patient characteristics and outcomes. A total of 377 women undergoing RS for endometrial cancer staging (ECS) were compared with the historical data of 131 undergoing open ECS. RESULTS For the entire RS cohort of 1000, the conversion rate was 2.9%. Body mass index increased over 3 time intervals: T1 = 26.2, T2 = 29.5, T3 = 30.1 (T1:T2, P = .01; T1:T3, P = .0001; T2:T3, P = .037). Increasing body mass index was not associated with increased major complications: T1 = 8.7%, T2 = 4.3%, T3 = 5.7%. In the ECS cohort, as compared with open ECS, women undergoing RS had lower blood loss (46.9 vs 197.6 mL, P < .0001), shorter hospitalization (1.4 vs 5.3 days, P < .0001), fewer major complications (6.4% vs 20.6%, P < .0001), with higher lymph node counts (15.5 vs 13.1, P = .007). CONCLUSION RS is associated with favorable morbidity and conversion rates in an unselected cohort. Compared to laparotomy, robotic ECS results in improved outcomes.

Atypical glandular cells of undetermined significance: A five-year retrospective histopathologic study

OBJECTIVE Our purpose was to ascertain the types and frequency of pathologic conditions associated with atypical glandular cells of undetermined significance on Papanicolaou smears. STUDY DESIGN A 5-year retrospective review of screening cervical cytologic examinations diagnosed as atypical glandular cells of undetermined significance was performed at the University of Virginia to determine pathologic findings associated with atypical glandular cells of undetermined significance on Papanicolaou smears stratified by subtype and overall. RESULTS Pathologic findings for the respective Papanicolaou smears with the diagnosis of atypical glandular cells of undetermined significance not otherwise specified, favor benign, squamous intraepithelial lesions, and favor neoplasia through the follow-up interval were as follows: squamous intraepithelial lesions in 11%, 8%, 38%, and 20%; adenocarcinoma in situ in 3%, 0%, 0%, and 10%; endometrial hyperplasia in 3%, 5%, 1%, and 2%; and cancer in 8%, 3%, 1%, and 7%. Overall, 63 patients (32%) had preinvasive or invasive lesions. CONCLUSIONS Atypical glandular cells of undetermined significance on Papanicolaou smears were correlated with significant findings in 45% of patients (32% with preinvasive or invasive lesions and 13% with benign lesions). A prompt and aggressive workup is recommended.

Combined Weekly Topotecan and Biweekly Bevacizumab in Women With Platinum- Resistant Ovarian, Peritoneal, or Fallopian Tube Cancer

A phase 2 trial was conducted to determine the toxicity and efficacy of combined weekly topotecan and biweekly bevacizumab in patients with primary or secondary platinum‐resistant ovarian, peritoneal, or fallopian tube cancer (OC).

Unexpected gastrointestinal toxicity from Docetaxel/Carboplatin/Erlotinib followed by maintenance Erlotinib treatment for newly diagnosed stage III/IV ovarian cancer, primary peritoneal, or fallopian tube cancer

The Puget Sound Oncology Consortium conducted a phase I/II clinical trial that treated newly diagnosed stage III/IV ovarian cancer, primary peritoneal, or fallopian tube cancer patients with 6 cycles of chemotherapy combined with Erlotinib followed by maintenance therapy with Erlotinib. All patients underwent cytoreductive surgery and started chemotherapy within six weeks of surgery. Docetaxel 75 mg/m IV (capped BSA at 2 m), Carboplatin AUC 6 IV (based on Calvert formula using Jellife criteria to determine creatinine clearance) and escalating doses of Erlotinib, starting dose 50 mg orally daily, were planned for six cycles followed by maintenance therapy with fixed dose of Erlotinib 150 mg orally daily for 12 months. Seven ovarian cancer patients were treated on the study before it closed for toxicity. The stimulation of epidermal growth factor receptor (EGFR) is implicated in mediating tumor growth, proliferation, and maturation, inhibiting apoptosis, stimulating angiogenesis, and promoting tissue invasion. Nagai, N., et al. [1] found that about 77% of all ovarian cancers had EGF receptor expression and dysregulation of EGF/Erb receptors contributes to the etiology and progression of ovarian cancer [2]. Currently, there are a number of different compounds that are being investigated that interfere with EGFRs. Some are antibodies, others are small molecules, like Erlotinib, that target the tyrosine Kinase that is a key enzyme for EGFR function and is responsible for phosphorylation of EGFR and downstream signaling. Erlotinib is a selective Erbl-tyrosine Kinase inhibitor. It, thus, blocks transduction of proliferative signals. It inhibits the phosphorylation of the EGFR and its downstream P13/Aht and MAPK signal transduction pathways, thus resulting in p27 mediated all-cycle arrest. Erlotinib combined with taxanes has been shown to have additive growth inhibitor effects. Vasey, PA et al. [3] had published data on a randomized study of front-line therapywith Docetaxel and Carboplatin versus Paclitaxel/Carboplatin that showed no difference in outcome and superior quality of life with less neurological complications with Docetaxel and Carboplatin. We were therefore interested in studying this combination of chemotherapy with Erlotinib. We are reporting here on unexpected gastrointestinal toxicity found in 2 out of 7 patients treated. There was nothing unusual in their history prior to starting study therapy. One patient died of clostridium septicum entercolitis after the second cycle of combination therapy. One patient, 4 days after the sixth cycle of combination therapy, had an anastromic leak and perforation of her colon. She underwent surgical stabilization and survived the initial event; however, the patient died of complications of relapsed ovarian cancer one year after initial diagnosis. Because of the significant incidence of unexpected gastrointestinal toxicity, we closed accrual on the study. With the unexpected gastrointestinal toxicity we saw in this small group of patients, we believe that caution should be used in treating ovarian cancer patients with Erlotinib, Docetaxel and Carboplatin simultaneously as the combination may interfere with the integrity of bowel wall especially in areas underlying healing and repair from initial surgery. Disclosure: Unrestricted funding for study from Genentech and Sanofi-Aventis. There is no conflict of interest.

Surgical and oncologic outcomes after robotic radical hysterectomy as compared to open radical hysterectomy in the treatment of early cervical cancer

Objective The use of robotic radical hysterectomy has greatly increased in the treatment of early stage cervical cancer. We sought to compare surgical and oncologic outcomes of women undergoing robotic radical hysterectomy compared to open radical hysterectomy. Methods The clinic-pathologic, treatment, and recurrence data were abstracted through an Institutional Review Board-approved protocol at 2 separate large tertiary care centers in Seattle, Swedish Medical Center and the University of Washington. Data were collected from 2001–2012. Comparisons between the robotic and open cohorts were made for complications, recurrence, progression-free survival (PFS), and overall survival (OS). Results In the study period, 109 robotic radical hysterectomies were performed. These were compared to 202 open radical hysterectomies. The groups were comparable in terms of age and body mass index (BMI). Length of stay (LOS) was considerably shorter in the robotic group (42.7 vs. 112.6 hours, p<0.001) as was estimated blood loss (EBL; 105.9 vs. 482.6 mL, p<0.001). There were more complications in the open radical hysterectomy group, 23.4% vs. 9.2% in the robotic group (p=0.002). The recurrence rate was comparable between the groups (10.1% vs. 10.4%, p=0.730). In multivariate adjusted analysis, robotic surgery was not a statistically significant predictor of PFS (p=0.230) or OS (0.85). Conclusion Our study, one of the largest multi-institution cohorts of patients undergoing robotic radical hysterectomy, suggest robotic radical hysterectomy leads to comparable oncologic outcomes in the treatment of early stage cervical cancer with improved short-term surgical outcomes such as decreased LOS and EBL.