John K. Chan

Significance of comprehensive surgical staging in noninvasive papillary serous carcinoma of the endometrium.

OBJECTIVEnTo evaluate the biological behavior of noninvasive papillary serous carcinoma of the endometrium. METHODS; From 1990 to 2001, all women with noninvasive uterine papillary serous carcinoma (UPSC) at three Southern California hospitals were identified from tumor registry databases. Data for analysis were collected from hospital charts, office records, and tumor registry files.nnnRESULTSnOf the 100 patients diagnosed with UPSC, 16 had noninvasive lesions. Twelve underwent a comprehensive surgical staging procedure with omental resection. Six of these 12 women were found to have disease beyond the uterine corpus, including 4 with adnexal involvement, 3 with omental disease, 2 with cervical extension, 1 with pelvic lymph node involvement, and 3 with positive washings. Three women were found to have positive cytology and metastases in more than one location. Of the 12 patients, 1 of the 6 with stage IA disease had distant recurrence and 4 of the 6 with stage II-IV disease recurred. Of the remaining 4 patients who underwent a staging procedure without pathologic omental assessment, 1 was found to have cervical extension. In these 4 women, 1 with stage IA disease recurred.nnnCONCLUSIONnThe typical patterns of spread and prognostic factors for endometrioid carcinoma of the uterus do not apply to UPSC. In our series, omental assessment was necessary to detect the 25% of patients with stage IVB disease due to omental involvement. Thus, women with noninvasive UPSC should undergo a comprehensive staging procedure including omental sampling to determine the extent of disease.

Survival outcomes in patients with recurrent ovarian cancer who were treated with chemoresistance assay–guided chemotherapy

OBJECTIVEnThe purpose of this study was to determine the outcome of patients with recurrent ovarian carcinoma after extreme drug resistance assay-directed therapy.nnnSTUDY DESIGNnFifty women who were treated with chemotherapy based on extreme drug resistance assay guidance were compared with 50 well-balanced control subjects who were treated empirically.nnnRESULTSnIn the platinum-sensitive group, patients with extreme drug resistance-directed therapy had an overall response rate of 65% compared with 35% in the patients who were treated empirically (P=.02). The overall and progression-free median survival were 38 and 15 months in the extreme drug resistance assay group compared with 21 and 7 months in the control group, respectively (P=.005, overall; P=.0002, progression free). In the platinum-resistant group, there was no improved outcome in the patients who underwent assay-guided therapy. In multivariate analysis, platinum-sensitive disease, extreme drug resistance-guided therapy and early stage of disease were independent predictors for improved survival.nnnCONCLUSIONnIn this retrospective analysis, our results indicate an improved outcome in patients with recurrent ovarian carcinoma who have platinum sensitive disease and who underwent extreme drug resistance-directed chemotherapy. Randomized, prospective, controlled trials are needed.

Stages III and IV invasive epithelial ovarian carcinoma in younger versus older women: what prognostic factors are important?

OBJECTIVE To compare the survival rates in younger (45 years or younger) and older women (over 45) diagnosed with advanced-stage invasive epithelial ovarian cancer. Clinical and pathologic factors responsible for survival differences between the two groups were also determined. METHODS All younger women with advanced-stage epithelial ovarian carcinoma diagnosed between 1984 and 2001 were identified from tumor registry databases at two hospitals. Patients with borderline tumors were excluded. An older group of comparable controls was selected for comparison. Kaplan–Meier and Cox proportional hazards analyses were used to determine the predictors for survival. RESULTS Of 104 women with advanced-stage epithelial ovarian carcinoma, 52 were 45 or younger and the rest were over 45. The 5-year survival rate and median survival in younger patients were 48% and 54 months, compared with 22% and 34 months in the older women (P = .003). Younger women had significantly better performance status than older patients, and survival remained significantly better in younger women based on Kaplan–Meier analysis stratified by performance status (0 versus 1 to 2, P = .02). Furthermore, overall survival was significantly better in younger women after stratification by stage (III versus IV, P = .002) and by cytoreductive surgery (optimal versus suboptimal, P = .003). Multivariable analysis demonstrated that all these factors remained as significant independent prognostic factors for survival. CONCLUSION Younger women with advanced-stage invasive epithelial ovarian cancer have significantly improved survival rates relative to older patients. Age, performance status, stage of disease, and extent of cytoreductive surgery are important independent prognostic factors for survival.

Vaginal hysterectomy as primary treatment of endometrial cancer in medically compromised women

Objective To study the survival, rates and patterns of recurrence, and perioperative morbidity in medically compromised women with endometrial cancer treated by primary vaginal hysterectomy. Methods Fifty-one patients with endometrial cancer treated initially by vaginal hysterectomy between 1977 and 1999 were identified at the University of California, Irvine Medical Center and affiliated hospitals. Data were retrieved from hospital and office records. Statistical analysis, including Kaplan-Meier methods, was performed and the disease-specific survival rates were estimated. This study has 80% power to demonstrate a greater than 20% improvement in 5-year survival over historical controls. Results Fifty-one women with uterine carcinoma clinically confined to the uterus underwent primary vaginal hysterectomy with (n = 26) or without (n = 25) salpingo-oophorectomy. Eighty-four percent were obese with a body mass index greater than 27. Additional risk factors for surgical complications included hypertension (57%), diabetes mellitus (27%), and cardiovascular disease (18%). One-third of patients had three or more risk factors. Surgical morbidity included one episode of acute hemorrhage necessitating transfusion and abdominal exploration. Blood transfusions were given to four additional patients. There were no perioperative deaths. Five women recurred and expired at a median of 13 months (range 3–53 months) after surgery. The 3- and 5-year disease-specific survival rates were 91.4% and 88.0%, respectively. Conclusion Vaginal hysterectomy for the initial treatment of early-stage endometrial cancer is associated with a high rate of cure and minimal morbidity. Thus, it may be considered a reasonable alternative to the abdominal approach in medically compromised women.

Modified technique for suprapubic catheter insertion that avoids urinary leakage

When a large bore suprapubic catheter, such as a Foley catheter, is required for postoperative drainage of the bladder, nearly 10% of patients experience urinary leakage. We describe a novel technique involving the tubularization of the bladder during large bore suprapubic catheter placement to prevent urinary leakage while the catheter is in place and after its removal.