Gautam G. Rao

Surgical staging of ovarian low malignant potential tumors

OBJECTIVE: Women diagnosed with ovarian tumors of low malignant potential have an excellent prognosis. Because few will receive adjuvant therapy, the benefit of surgical staging has recently been challenged. The purpose of this study was to compare the outcome of surgically staged patients with low malignant potential tumors with those who were not staged. METHODS: Between 1984 and 2003, all women with ovarian low malignant potential tumors were identified at 3 institutions. Data were extracted from clinical records. RESULTS: One hundred eighty-three (74%) of 248 women were surgically staged. Forty of 183 staged patients had clinically obvious extraovarian disease. Forty (28%) of the remaining 143 women with disease apparently confined to the ovary were upstaged. Cytologic washings were positive in 28 cases, 10 had microscopic implants detected by peritoneal or omental biopsy, and 2 were upstaged to stage IIIC solely on the basis of nodal metastases. One hundred eighteen women underwent pelvic node dissection (median: 5 nodes), and 86 underwent para-aortic node dissection (median: 2 nodes). Overall, 9 (1%) metastases were detected in 832 submitted pelvic nodes. All 314 para-aortic nodes were negative. Intraoperative blood loss (P < .001) and length of hospital stay (P < .001) were increased in women without gross disease who were surgically staged. Eight (3%) of 248 patients received adjuvant platinum-based chemotherapy, but neither of the women upstaged to IIIC based on the results of their nodal dissection were treated. Fifteen (6%) recurrences developed and 1 (0.4%) death occurred after a median follow-up of 28 (range, 1–208) months. CONCLUSION: Routine pelvic and para-aortic lymph node dissection is not necessary in the majority of women with ovarian low malignant potential tumors. LEVEL OF EVIDENCE: III

ACR Appropriateness Criteria® Pretreatment Planning of Invasive Cancer of the Cervix

The prognosis of cervical cancer is linked to lymph node involvement, and this is predicted clinically and pathologically by the stage of the disease, as well as the volume and grade of the tumor. Staging of cervical cancer based on International Federation of Gynecology and Obstetrics (FIGO) staging uses physical examination, cystoscopy, proctoscopy, intravenous urography, and barium enema. It does not include CT or MRI. Evaluation of the parametrium is limited in FIGO staging, and lymph node metastasis, an important prognostic factor, is not included in FIGO staging. The most important role for imaging is to distinguish stages Ia, Ib, and IIa disease treated with surgery from advanced disease treated with radiation therapy with or without chemotherapy. This article reviews the current role of imaging in pretreatment planning of invasive cervical cancer. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® on Advanced Cervical Cancer Expert Panel on Radiation Oncology—Gynecology

*University of Utah Medical Center, Salt Lake City, UT; yMedical College of Wisconsin, Milwaukee, WI; zUniversity of Texas, M.D. Anderson Cancer Center, Houston, TX; xOhio State Comprehensive Cancer Center-James Cancer Hospital, Columbus, OH; {Long Beach Memorial Medical Center, Long Beach, CA; kIndiana University School of Medicine, Indianapolis, IN; American College of Obstetricians and Gynecologists, Washington, DC; **Tennessee Oncology, Nashville, TN; yyAmerican Society of Clinical Oncology, Alexandria, VA; zzRobert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL; xxUniversity of North Carolina Hospital, Chapel Hill, NC; {{University of Miami, Miami, FL; kkUniversity of California San Diego, San Diego, CA; Ohio State University, Columbus, OH; ***Indiana University Medical Center, Indianapolis, IN

ACR appropriateness criteria® management of locoregionally advanced squamous cell carcinoma of the vulva

Objectives: Locoregionally advanced vulvar cancer (LRAVC) is a rare disease that presents many challenging medical decisions. An expert panel was convened to reach consensus on the most appropriate pretreatment assessment and therapeutic interventions in LRAVC patients. Methods: The American College of Radiology Appropriateness Criteria are evidenced-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journal and the application of a well-established consensus methodology (modified Delphi) to rate appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to formulate recommendations. Results: Three clinical variants were developed to address common scenarios in the management of LRAVC. Group members reached consensus on the appropriateness of specific evaluation and treatment approaches, with numerical ratings and descriptive commentary. Conclusions: In combining available medical literature and expert opinion, this manuscript may serve as an aid for other practitioners in the appropriate management of patients with LRAVC.

ACR Appropriateness Criteria® role of adjuvant therapy in the management of early stage cervical cancer

OBJECTIVE The use of adjuvant treatment(s) following initial hysterectomy and retroperitoneal nodal harvesting of patients with clinical stage I and II cervical carcinoma is (are) presently based on the pathological assessment of surgical specimens. This report sought to delineate further the clinical application of potential therapeutic interventions and associated follow-up investigations of this patient cohort. METHODS The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journal and the application of a well-established consensus methodology (modified Delphi) to rate appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS From this process, 5 unique clinical variants were developed. These scenarios pertained to options of adjuvant radiation therapy and chemotherapy, methods of delivery of radiotherapy to optimize target volume coverage while simultaneously minimizing radiation exposure of adjacent healthy organs, and recommendations for patient follow-up care. Group members reached consensus of topic ratings in descending order of importance. A risk assessment breakdown was established to highlight the most likely indications for adjuvant treatment(s). CONCLUSION This assembly by the ACR of physicians involved in the management of patients with early stage cervical cancer was able to describe appropriateness criteria to aid other practitioners in selecting reasonable implementation of postoperative therapies and subsequent surveillance studies. These guidelines await further validation and refinement by both current and future prospectively randomized clinical studies regarding this patient population.

ACR appropriateness criteria® definitive therapy for early-stage cervical cancer

Objectives:The definitive treatment of early-stage cervical cancer involves multidisciplinary decision making. This expert panel was convened to reach consensus on the selection of appropriate therapies based on patient and disease characteristics at presentation. Methods:The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or the treatment. Results:Three clinical variants were developed to represent common scenarios in the treatment of early-stage cervical cancer. Group members reached consensus on the appropriateness of therapeutic options. This process yielded numerical ratings and descriptive commentary. Conclusions:This manuscript represents the consensus opinion of an expert panel based on a survey of all available medical literature. This manuscript may be used to inform the clinical decision making of physicians involved in the treatment of early-stage cervical cancer.

ACR appropriateness criteria® advanced stage endometrial cancer

Objectives:Patients with advanced stage endometrial carcinoma constitute a heterogeneous group of patients with different stages, tumor histologic types, and involved sites. Hysterectomy, bilateral salpingo-ophorectomy, and surgical staging are the cornerstone of surgical management in these patients. The optimal adjuvant therapy is yet to be established. An expert panel was convened to reach consensus on the most appropriate management options in this group of patients. Methods:The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Results:Four clinical variants were developed to address common scenarios in the management of women with advanced-stage endometrial carcinoma. Group members reached consensus on the appropriateness of specific evaluation and treatment approaches with numerical ratings. Conclusions:In combining available medical literature and expert opinions, this manuscript may serve as an aid for other practitioners in the appropriate management of women with advanced-stage endometrial carcinoma.

Transitional cell ovarian carcinoma in a BRCA1 mutation carrier.

BACKGROUND BRCA1 mutation carriers are at high risk of developing epithelial ovarian cancer, but the transitional cell variant has not been previously reported in these patients. CASE A nulligravid, perimenopausal woman underwent exploratory laparotomy for a pelvic mass, ascites, and omental caking. Intraoperatively, frozen section of a tumor implant revealed high-grade epithelial ovarian carcinoma. Optimal surgical cytoreduction was performed. The final surgical pathology confirmed International Federation of Gynecology and Obstetrics stage IIIC transitional cell ovarian carcinoma. Her family history was significant for a sister with premenopausal breast cancer and a paternal aunt with ovarian cancer. The patient was counseled and elected to undergo genetic testing. Comprehensive gene sequence analysis detected the germline BRCA1 5382insC mutation. CONCLUSION Transitional cell ovarian carcinoma is a rare histologic variant of epithelial ovarian cancer that may occur in BRCA1 mutation carriers.

Pelvic floor disorders in women with gynecologic malignancies: a systematic review

Introduction and hypothesisPelvic floor disorders (PFDs) negatively affect quality of life in the general population, and their prevalence in gynecologic cancer survivors has not been systematically described. This study aimed to determine the prevalence of PFDs in cancer survivors. We hypothesized that the prevalence of PFDs in the gynecologic cancer population would be higher than in the general female population.MethodsWe searched PubMed (1809 to present), EMBASE (1974 to present), and the Cochrane Central Register of Controlled Trials (CENTRAL) through May 2017. The search combined subject headings, title, and abstract words for gynecologic cancer, PFDs, and prevalence. Any studies evaluating the prevalence of PFDs in gynecologic malignancies were included.ResultsA total of 550 articles met the designated search criteria and 31 articles were included in this review. In cervical cancer survivors, before treatment the prevalences of stress urinary incontinence (SUI), urgency urinary incontinence (UUI) and fecal incontinence (FI) were 24–29%, 8–18% and 6%, respectively, and after treatment the prevalences of SUI, UUI, urinary retention, FI, fecal urge, dyspareunia and vaginal dryness were 4–76%, 4–59%, 0.4–39%, 2–34%, 3–49%, 12–58% and 15–47%, respectively. In uterine cancer survivors, before treatment the prevalences of SUI, UUI and FI were 29–36%, 15–25% and 3%, respectively, and after treatment the prevalences of urinary incontinence (UI) and dyspareunia were 2–44% and 7–39%, respectively. In vulvar cancer survivors, after treatment the prevalences of UI, SUI and FI were 4–32%, 6–20% and 1–20%, respectively. In ovarian cancer survivors, the prevalences of SUI, UUI, prolapse and sexual dysfunction were 32–42%, 15–39%, 17% and 62–75%, respectively.ConclusionsPFDs are prevalent in gynecologic cancer survivors and this is an important area of clinical concern and future research.

Risk, risk reduction and management of occult malignancy diagnosed after uterine morcellation: a commentary

Minimally invasive surgical techniques compared with laparotomy offer the advantages of less intraoperative blood loss, shorter hospitalization, fewer wound complications and faster return to baseline activity for both hysterectomy and myomectomy. While morcellation allows for the laparoscopic removal of large specimens, it may result in intraperitoneal dissemination of benign disease or upstaging of occult malignancy leading to compromised survival. There has been heightened scrutiny over appropriate patient selection and preoperative assessment in light of recent warnings against power morcellation issued by the US FDA. This commentary therefore summarizes the magnitude of such risks associated with uterine morcellation, current national regulatory statements and potential merits of risk-reducing approaches such as contained morcellation. The importance of patient counseling is underscored.