J.K. Chan

Racial disparities in presentation and survival of ovarian yolk sac cancer patients: a study of 423 women

Chan. Racial disparities in presentation and survival of ovarian yolk sac cancer patients: a study of 423 women. Am J Obstet Gynecol 2016. TO THE EDITORS: Ovarian germ cell cancers comprise 3-5% of all ovarian malignancies. Patients with yolk sac tumors have a worse prognosis compared to those with dysgerminomas or immature teratomas. Due to the rarity of yolk sac tumors, few studies have evaluated their distinct demographic and clinicopathologic features. Previous studies have demonstrated that Asians and blacks have an increased incidence of germ cell cancers. We propose to determine the factors associated with the presentation and survival rates of ovarian yolk sac cancer patients. Data were obtained from the Surveillance, Epidemiology, and End Results database From 1973 through 2012. The c tests, Kaplan-Meier methods, and multivariate Cox regression models were used for statistical analyses (SAS, Version 9.3; SAS Institute Inc, Cary, NC). Of 423 patients, the median age was 22 (range 1-91) years. In all, 51.3% were white, 16.5% black, 15.6% Hispanic, 15.6% Asian, and 1% other. Although Asians comprise only 5% of the US population, they constitute >15% of yolk sac cancer patients in this study (Figure). Of 193 patients with detailed primary surgery information, 149 (77.2%) had fertility-sparing surgeries. Of those with pathology data, 54% had stage I, 6% stage II, 28% stage III, and 12% stage IV disease. Grade 1, 2, and 3 disease was found in 8%, 13%, and 79% of patients, respectively. The overall 5-year diseasespecific survival (DSS) was 86.9%. The DSS of younger women (age <22 years, median) was 91.4% compared to 82.4% of older patients (P < .01). The DSS improved over 3 time periods from the years 1973 through 1986, 1987 through 1999, and 2000 through 2012 with corresponding survival rates of 74%, 85.1%, and 92.1% (P < .01). The DSS of Asians was 95.1% compared to 85.7% for whites, 85.6% for Hispanics, and 82.9% for blacks (P 1⁄4 .2). Stage I, II, III, and IV disease patients had associated DSS of 91.9%, 100%, 93%, and 76.7%, respectively (P 1⁄4 .03). Those who had fertility-sparing surgeries had DSS of 95.7% compared to 80.7% for those after nonfertility-sparing surgery (P < .01). In multivariate analysis, younger age (<22 years) and lower stage of disease (I and II) were independent predictors associated with improved DSS (age: hazard ratio, 0.53; 95% confidence interval, 0.29e0.99; P 1⁄4 .05; and stage: hazard ratio, 0.18; 95% confidence interval, 0.07e0.44; P < .001). The overall survival of ovarian yolk sac cancer patients was high at >85% and has improved over time. Asians have a disproportionately higher rate of yolk sac cancers compared to other races. Although this is one of the larger studies on yolk sac cancer, our data was limited by the lack of information regarding surgeon specialty, extent of residual disease, central pathology review, and chemotherapy and biomarker data. Nevertheless, this study provides an updated analysis on the clinical factors and racial disparities in the clinicopathologic parameters and outcomes of this uncommon cancer. -

A Comparative Study of Minimally Invasive Versus Open Hysterectomy for Women With Fibroid Uterus - A Nationwide Study of 65,216 Patients.

Study Objective: Conversion to laparotomy can be considered as quality indicator for laparoscopic surgery. Data on conversion rates for laparoscopic myomectomy (LM) are limited, with a reported incidence between 0% and 41%. The aim of this study is to evaluate patient characteristics associated with LM in comparison with abdominal myomectomy (AM), and, secondly to calculate the rate of conversion during LM and the risk factors associated with it. Design: Retrospective cohort study. Setting: Tertiary academic center. Patients: All patients who underwent LM and AM from 2009 2012. Measurements and Main Results: The cohort included 966 patients; 731 laparoscopic cases (75.7% including 343 robotic cases) and 235 abdominal cases (24.3%). Patients undergoing AM had a larger number of fibroids removed with greater specimen weight compared to the laparoscopic approach (12.6 vs. 3.54 fibroids, p=\0.001; 592.75 vs. 263.4 grams, p=\0.001). In eight LM cases a conversion was necessary (1.09%). All conversions were reactive ones and were associated with high blood loss (1381.25 vs 167.95 mL, p=\0.001) and a longer hospital stay (3.13 vs. 0.55 days, p=\0.001). Furthermore, both the number and the weight of removed fibroids were associated with a higher conversion rate (667.9 vs. 259.25 grams, p=0.003; 9.75 vs 3.48 fibroids, p=0.015), especially with fibroids weighing more than 500 grams (p=0.005). Conclusion: Conversion rate for LM was low (1.09%) in our center. Number of removed fibroids and their weight were found to be a risk factor for conversion. LM should be the standard approach for surgical management of fibroids. However, when fibroids are expected to weigh > 500 grams we suggest that only highly experienced surgeons in specialized centers should perform those cases.