Lesley B. Conrad

Role of minimally invasive surgery in gynecologic oncology: An updated survey of members of the Society of Gynecologic Oncology

Objectives To evaluate the current patterns of use of minimally invasive surgical procedures, including traditional, robotic-assisted, and single-port laparoscopy, by Society of Gynecologic Oncology (SGO) members and to compare the results to those of our 2004 and 2007 surveys. Methods The Society of Gynecologic Oncology members were surveyed through an online or mailed-paper survey. Data were analyzed and compared with results of our prior surveys. Results Four hundred six (32%) of 1279 SGO members responded. Eighty-three percent of respondents (n = 337) performed traditional laparoscopic surgery (compared with 84% in 2004 and 91% in 2007). Ninety-seven percent of respondents performed robotic surgery (compared with 27% in 2007). When respondents were asked to indicate procedures that they performed with the robot but not with traditional laparoscopy, 75% indicated radical hysterectomy and pelvic lymphadenectomy for cervical cancer. Overall, 70% of respondents indicated that hysterectomy and staging for uterine cancer was the procedure they most commonly performed with a minimally invasive approach. Only 17% of respondents who performed minimally invasive surgery performed single-port laparoscopy, and only 5% of respondents indicated that single-port laparoscopy has an important or very important role in the field. Conclusions Since our prior surveys, we found a significant increase in the overall use and indications for robotic surgery. Radical hysterectomy or trachelectomy and pelvic lymphadenectomy for cervical cancer and total hysterectomy and staging for endometrial cancer were procedures found to be significantly more appropriate for the robotic platform in comparison to traditional laparoscopy. The indications for laparoscopy have expanded beyond endometrial cancer staging to include surgical management of early-stage cervical and ovarian cancers, but the use of single-port laparoscopy remains limited.

Make new friends but keep the old: Minimally invasive surgery training in gynecologic oncology fellowship programs

Objectives To evaluate the role of minimally invasive surgery (MIS) in gynecologic oncology fellowship training and fellows’ predictions of their use of MIS in their future practice. Methods All fellows-in-training in American Board of Obstetrics and Gynecology–approved training programs were surveyed in 2012 through an online or mailed-paper survey. Data were analyzed and compared to results of a similar 2007 survey. Results Of 172 fellows, 69 (40%) responded. Ninety-nine percent of respondents (n = 68) indicated that MIS was either very important or important in gynecologic oncology, a proportion essentially unchanged from 2007 (100%). Compared to 2007, greater proportions of fellows considered laparoscopic radical hysterectomy and node dissection for cervical cancer (87% vs 54%; P < 0.0001) and trachelectomy and staging for cervical cancer (83% vs 32%; P < 0.0001) appropriate for MIS. Of the respondents, 92% believed that maximum or some emphasis should be placed on robotic-assisted surgery and 89% on traditional laparoscopy during fellowship training. Ten percent rated their fellowship training in laparoendoscopic single-site surgery as very poor; 44% said that the question was not applicable. Most respondents (60%) in 2012 performed at least 11 procedures per month, whereas most respondents (45%) in 2007 performed 6 to 10 procedures per month (P = 0.005). All respondents at institutions where robotic surgery was used were allowed to operate at the robotic console, and 63% of respondents reported that in robotic-assisted surgery cases when a fellow sat at the robot, the fellow performed more than 50% of the case at the console. Conclusions These findings indicate that MIS in gynecologic oncology is here to stay. Fellowship programs should develop a systematic approach to training in MIS and in individual MIS platforms as they become more prevalent. Fellowship programs should also develop and apply an objective assessment of minimum proficiency in MIS to ensure that programs are adequately preparing trainees.

Management of Persistent Postpartum Hemorrhage Caused by Inner Myometrial Lacerations.

BACKGROUND: Postpartum hemorrhage management must involve rapid recognition of the source of bleeding. Inner myometrial laceration is an uncommonly recognized cause; most cases are demonstrated only by evaluation of peripartum hysterectomy specimens. The exact cause of this laceration is unknown; however, it can be identified by uterine cavity exploration and managed with conservative surgery that preserves fertility. CASE: Postpartum hemorrhage caused by inner myometrial lacerations is presented. We explored the uterine cavity through laparotomy and uterine hysterotomy to identify and repair the source of bleeding. CONCLUSION: In persistent hemorrhage that fails initial interventions, inner myometrial laceration should be considered. Uterine cavity exploration with laparotomy incision and hysterotomy to directly visualize the source are essential steps to manage postpartum hemorrhage while avoiding maternal morbidity, peripartum hysterectomy, and potential mortality.

Generation and Characterization of Recombinant Antibody-like ADP-Ribose Binding Proteins

ADP-ribosylation is an enzyme-catalyzed post-translational modification of proteins in which the ADP-ribose (ADPR) moiety of NAD+ is transferred to a specific amino acid in a substrate protein. The biological functions of ADP-ribosylation are numerous and diverse, ranging from normal physiology to pathological conditions. Biochemical and cellular studies of the diverse forms and functions of ADPR require immunological reagents that can be used for detection and enrichment. The lack of a complete set of tools that recognize all forms of ADPR [i.e., mono-, oligo-, and poly(ADP-ribose)] has hampered progress. Herein, we describe the generation and characterization of a set of recombinant antibody-like ADP-ribose binding proteins, in which naturally occurring ADPR binding domains, including macrodomains and WWE domains, have been functionalized by fusion to the Fc region of rabbit immunoglobulin. These reagents, which collectively recognize all forms of ADPR with different specificities, are useful in a broad array of antibody-based assays, such as immunoblotting, immunofluorescent staining of cells, and immunoprecipitation. Observations from these assays suggest that the biology of ADPR is more diverse, rich, and complex than previously thought. The ARBD-Fc fusion proteins described herein will be useful tools for future exploration of the chemistry, biochemistry, and biology of ADP-ribose.

Pre-operative core muscle index in combination with hypoalbuminemia is associated with poor prognosis in advanced ovarian cancer

Age and frailty have been correlated with poor clinical outcomes in cancer. Core muscle index (CMI) and nutritional status are integral in assessing frailty. We explored the effect of pre‐operative serum albumin and body composition on clinical outcomes in patients with epithelial ovarian cancer (EOC).

Defining Sarcopenia in Advanced Ovarian Cancer Patients [15P]

INTRODUCTION: Core muscle index (CMI) and co-morbidities are integral in assessing patient frailty. We explored the effect of age, CMI and Age-Adjusted Charlson Comorbidity Index (ACCI) on postoperative clinical outcomes in patients with epithelial ovarian cancer (EOC). METHODS: Stage III–IV EOC following primary cytoreductive surgery (CRS) from 2007–2005 were included. Computed tomography was used to determine psoas muscle cross-sectional area at L4 (cm2) and normalized for height (m2) to determine the CMI. “Sarcopenia” was defined as below the mean value of CMI. Clinical and survival outcomes were assessed and compared. RESULTS: 104 women underwent primary CRS. Median age was 53 yrs (range 23–77) and median follow-up was 26.5 months (range 1–85). High-grade serous comprised 74% of all histologies. Age 65 and older was significantly associated with worse median overall survival (28 mo v 66 mo, P=.018), but not progression free survival (16 mo v 16 mo, P=.73). Age did not affect short-term morbidity (P=.29). Mean CMI was 4.56±0.13 cm2/m2. There was no association between CMI and survival even when patients 65 yrs and older were excluded. CMI was not a predictor of short-term morbidity. Excluding 65 yrs and older, patients with sarcopenia had a shorter mean hospital stay (P=.005), and sarcopenia was associated with ACCI (P=.008). ACCI did not influence survival or short-term morbidity (P=.06). CONCLUSION: Age is the only frailty index associated with overall survival among patients who are candidates for CRS. Although age, CMI and ACCI did not influence short-term morbidity, sarcopenia was associated with ACCI and shorter hospital stay.

Factors influencing primary treatment of midline vulvar cancers

OBJECTIVES Advanced vulvar cancers involving midline structures pose a therapeutic challenge. Our objectives were to review the management and outcomes, and identify factors influencing primary treatment modality. METHODS Patients with midline vulvar cancers diagnosed from 1985 to 2012 were included in the analysis. Medical records were abstracted for demographics, clinico-pathological findings, treatment, and outcomes. Groin node status was defined by clinical findings or pathology. Survival was analyzed by Kaplan-Meier method and differences by log-rank test and Cox proportional hazards model. Factors influencing treatment modality were evaluated using stepwise logistic regression. RESULTS Forty-two patients were identified. Twenty-one underwent primary radical vulvectomy and 21 underwent primary radiation. Median tumor diameter was 3.4cm (range 2-9cm) for primary radical vulvectomy and 5cm (range 2.3-15cm) for primary radiation. Primary radiation was significantly associated with a tumor diameter ≥5cm (p=0.02), or when 2 or more midline (p=0.008) or 1 or more mucosal structures (p=0.03) were involved. On multivariate analysis, age and tumor diameter were predictors of progression-free survival (PFS) (p=0.02 and p=0.0004, respectively) and overall survival (OS) (p=0.03 and p=0.0005, respectively). Thirty-month OS for primary surgery and primary radiation was 74% and 71% (p=0.78), respectively. There were no differences in PFS or recurrence rates between the two treatment groups. CONCLUSIONS Clinical tumor diameter and the number of midline or mucosal structures involved influence selection of primary treatment modality. Survival outcomes and recurrence rates did not differ between treatment groups. Age and tumor diameter are important prognostic factors for survival.