Mary Gordinier

Adnexal masses in pregnancy: Surgery compared with observation

OBJECTIVE: To estimate whether the delay of surgery impacts the risk of adverse maternal and fetal outcomes in patients diagnosed with an adnexal mass during pregnancy. METHODS: A review was performed of pregnant patients diagnosed with an adnexal mass 5 cm or greater in diameter. Data collected included age, gravity/parity, gestational age at diagnosis, and presenting symptoms. Ultrasound examinations were evaluated for mass size and complexity. Pregnancy outcome, complications, and surgical pathology were reviewed. RESULTS: Between 1990 and 2003, 127,177 deliveries were performed at our institution. An adnexal mass 5 cm in diameter or greater was diagnosed in 63 (0.05%) patients. Pathologic diagnosis was available for 59 (94%) patients. The remaining 4 patients were lost to follow-up and excluded from the analysis. Antepartum surgery was performed in 17 patients (29%): 13 because of ultrasound findings that suggested malignancy and 4 secondary to ovarian torsion. The remaining patients were observed, with surgery performed in the postpartum period or at time of cesarean delivery. The majority of masses were dermoid cysts (42%). Four patients were diagnosed with ovarian cancer (6.8% of masses, 0.0032% of deliveries), and one patient (1.7%) had a tumor of low malignant potential. Antepartum surgery due to ultrasound findings that caused concern was performed on all 5 women diagnosed with a malignancy or borderline tumor, compared with 12 (22%) of the patients with benign tumors (P < .01). CONCLUSION: In select cases, close observation is a reasonable alternative to antepartum surgery in patients with an adnexal mass during pregnancy. LEVEL OF EVIDENCE: II-3

Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy

OBJECTIVE The objective of this study was to investigate the cause of groin recurrence in patients with vulvar cancer who had negative nodes in their superficial inguinal lymphadenectomy (SIL) specimens. METHODS The records of patients with vulvar cancer treated at M. D. Anderson Cancer Center between 1986 and 1997 were reviewed to identify patients with squamous histology, clinical and surgical stage I or II, depth of invasion greater than 1 mm, and primary treatment consisting of radical wide excision and SIL. One hundred four patients met these criteria. Among these, nine experienced recurrent disease that involved one or both of the groins. All of the original hematoxylin and eosin (H&E)-stained slides were reviewed by one pathologist (AM). Then, each paraffin block containing nodal tissue was recut at 40 microm intervals to obtain five sections for H&E staining and two unstained sections to be used for cytokeratin immunostaining if necessary. RESULTS The median age at diagnosis and primary surgery was 65 years and the median depth of invasion was 4 mm. Seven patients underwent bilateral, and two underwent unilateral, groin dissections. The median number of lymph nodes removed per groin was seven. The median time to recurrence was 22 months. A total of 785 additional H&E-stained slides were prepared and examined at 100x and 400x magnification. No micrometastases were identified, and there were no other suspicious findings. Therefore, immunohistochemical staining was not performed. At recurrence, one patient had a biopsy only, and eight had attempted surgical resection. In two patients, tumor was identified in fibroadipose tissue only; no lymph nodes were identified. Among the other six patients, the median number of lymph nodes resected at the time of the recurrence was five (range 1 to 10). At last report, six patients had died and three were alive and free of disease. Median follow-up for survivors was 63 months (range 42 to 71). CONCLUSION These data strongly suggest that groin relapse in patients with negative nodes on SIL is caused by metastatic disease in unresected inguinal nodes. SIL as performed on the patients in this study did not eliminate all sites of nodal metastasis.

The effects of a course in cadaver dissection on resident knowledge of pelvic anatomy: An experimental study

Objective To determine whether a course in cadaver dissection can significantly increase resident knowledge of pelvic anatomy beyond that of current educational practices. Methods Thirteen first-and second-year residents were randomly assigned to a cadaver dissection course (seven) or a control group (six). The dissection group performed dissections with instruction, using a dissection guide designed specifically for the course. The control group received study references on pelvic anatomy and protected study time. Each participant took a practical and written examination at the beginning and end of the study. Results The two groups did not differ statistically in their scores on the pre-test. Both groups improved on the posttest, but the dissection group scored nearly 50% higher on the test than did the controls. The two groups differed significantly on the post-test, adjusted for pre-test performance (P < .01). In their evaluation of the course, participants from the dissection group emphasized its educational value and urged that it be offered to residents as a regular part of their training. Conclusion Dissection of a human cadaver provides a valuable experience, allowing participants to gain a greater understanding of surgical anatomy and surgical procedures in a no-risk, unhurried setting. Residents who participated in a cadaver dissection course designed specifically for their needs showed a statistically significant increase in knowledge compared with those without this experience. Both objectively and subjectively, a cadaver dissection course is an excellent tool for instructing gynecology residents.

Cytoreduction and intraperitoneal heated chemotherapy for the treatment of endometrial carcinoma recurrent within the peritoneal cavity

Our experience with hyperthermic intraperitoneal chemotherapy (IPHC) in conjunction with surgical resection for endometrial cancer recurrent within the abdominal cavity was reviewed. Eligible patients underwent exploratory laparotomy with the aim of resecting disease to ≤5 mm maximum dimension followed immediately by intraperitoneal perfusion of cisplatin (100 mg/m2) heated to 41–43°C (105.8–109.4°F) for 1.5 h. Data for analysis was extracted from retrospective chart review. Five patients underwent surgery and IPHC between September 2002 and January 2005 for abdomino-pelvic recurrence. Original stage and histology were 1A papillary serous (1), 1C endometrioid with clear cell features (1), and 1B endometrioid (3). Mean age was 61 (41–75) years, mean prior laparotomies were 1.4 (1–2), and mean chemotherapy agent exposure was 1.6 (0–4). Mean time from initial treatment to surgery and IPHC was 47 (29–66) months. Mean length of surgery was 9.8 (7–11) h after which three patients had no residual disease and two had ≤5 mm disease. The mean duration of hospital stay was 12.6 (6–20) days. Postoperative surgical complications included wound infection with septicemia in one patient. Mean maximum postoperative serum creatinine was 1.02 (0.6–1.70) mg/dL. There was no ototoxicity or neuropathy and no perioperative mortality. No patients have been lost to follow-up. Two are living disease free at 28 and 32 m and two are living with disease at 12 and 36 m. One patient died at 3 m without evidence of cancer. Two patients who had no residual macroscopic disease at the end of surgery are alive at 32 and 36 m. The combination of IPHC with surgery for recurrent endometrial carcinoma is relatively well tolerated. The unexpectedly long survival seen in this cohort supports a phase II trial of IPHC with cisplatin for recurrent endometrial cancer.

Dyspnea during Thalidomide Treatment for Advanced Ovarian Cancer

OBJECTIVE: To detail the dyspnea encountered in women receiving thalidomide as therapy for advanced ovarian cancer. CASE SUMMARIES: Eight of 18 (44%) patients with recurrent ovarian cancer developed dyspnea while receiving thalidomide 200 mg daily as part of a prospective Phase II study. Dyspnea was evaluated with pulse oximetry, chest X-ray and, if indicated, spiral computed tomography scan. Four patients had abnormal chest X-ray findings (1 pleural effusion, 1 pneumonia, 2 mild congestive heart failure), and one of these patients also had a pulmonary embolus. The other 4 patients had no objective test findings to explain their dyspnea. Five patients had resolution of symptoms when thalidomide was discontinued and, when the drug was resumed at a 50% dose reduction, experienced no further shortness of breath. DISCUSSION: While dyspnea in association with thalidomide has not previously been reported as a common adverse event, it was a frequent complaint of patients receiving this drug as part of a Phase II study. Comorbid conditions causing dyspnea were evaluated since they are common in this patient population; however, half of our patients had no objective evidence of such conditions. The Naranjo probability scale indicated a probable relationship between dyspnea and thalidomide therapy in the patients with no objective evidence of comorbidity. We advocate discontinuation of thalidomide until symptoms have resolved, at which time reintroduction of thalidomide at a reduced dose may be considered. CONCLUSIONS: Patients receiving thalidomide may develop dyspnea as an adverse effect of the drug. In selected patients, thalidomide may be safely reintroduced once symptoms resolve.

Embryonal rhabdomyosarcoma of the uterine cervix in a 41-year-old woman treated with radical hysterectomy and adjuvant chemotherapy

BACKGROUND Cervical embryonal rhabdomyosarcoma (ERMS) mostly affects young girls. The current treatment protocols are based on trials done on patients under 21 years old. ERMS in women over 40 is rare, and studies on treatment and outcome are limited. CASE We report a case of a 41 year-old woman with cervical ERMS who was treated with radical hysterectomy followed by chemotherapy. She is currently disease-free. CONCLUSION Cervical ERMS in women over the age of 40 can be treated using protocols established for the pediatric population.

Retraction of an intraperitoneal chemotherapy port: a case report and literature review

Delivery of chemotherapy directly into the peritoneal cavity is becoming part of the standard frontline management of patients with optimally cytoreduced ovarian carcinoma. Traditionally, the peritoneal access devices used for this have had relatively high complication rates including infection, blockage, leakage, and difficulties with port access. In order to reduce the risk of infection, we have been using a Bard 9.6F silastic infusaport that does not have a Dacron cuff to secure it into the tissues of the anterior abdominal wall. It has the added advantage of being more easily removed at the end of treatment. We report a case of spontaneous retraction of such a port out of the peritoneal cavity into the subcutaneous tissues. This complication associated with a silastic cuffless port is presented to raise awareness of this possible complication and suggest ways of preventing it.

A change in the balance between personal and professional life among female gynecologic oncologists

Background: Female representation in gynecologic oncology has increased over the last two decades. Our objective was to compare work-life balance issues faced by female gynecologic oncologists between 1998 and 2015. Material/Methods: We conducted a cross-sectional survey of physician members of the Society of Gynecologic Oncology. A survey sent to female gynecologic oncologists in 1998 was expanded, piloted with 10 volunteers, and administered in electronic format (DatStat Illume) in February 2015. There were 75 fixed response questions regarding 4 domains: demographics, mentoring issues, work-life balance, and caregiving responsibilities. We compared 2015 responses to the 1998 aggregate survey data. Data were analyzed using Stata 10 (Statacorp, College Station TX) with Chi-square/Fisher’s exact tests using aggregate data functions. Results: 172 of 643 female gynecologic oncologists (26.7% response rate) completed the 2015 survey. The historical comparison group included 82 females (56.2% response rate). While more women in 2015 versus 1998 reported starting a family during residency or fellowship (57.7% vs. 36.0%, p<0.009), 42% still waited until after training. More than half (55.9%) of respondents in 2015 said the timing of becoming a parent led to some or a great deal of relationship stress compared to only 20% in 1998 (p<0.0001). The majority of divorces were in fellowship for both groups with 8 (50.0%) in 2015 compared to 5 (45.5%) in 1998 (p=0.8). In 2015, 5 (83.4%) women divorced after fellowship and felt their career had a moderate to great influence on their divorce. Conclusions: Despite changes in work-life balance and caregiving responsibilities in female gynecologic oncologists between 1998 and 2015, challenges still exist today. Correspondence to: Ashley R Stuckey, Women and Infants Hospital, 101 Dudley St, Providence, RI 02905, USA, Tel: (401) 453-7520; Fax: (401) 453-7529; E-mail: astuckey@wihri.org

Current Mentorship Practices in Gynecologic Oncology [20P]

INTRODUCTION: Our objective was to describe mentoring practices among gynecologic oncologists. METHODS: We conducted a cross-sectional survey of gynecologic oncology physician members of the Society of Gynecologic Oncology. A survey sent to female gynecologic oncologists in 1998 was expanded, piloted, and administered electronically (DataStat Illume). Our 2015 instrument contained 75 fixed response questions in 4 domains: Demographics; Mentoring issues; Work-life Balance; Caregiving Responsibilities. Data was analyzed using Chi-square/Fishers exact test (Stata 10). RESULTS: We had a 22% response rate (268 of 1246), comprised of 64% women and 36% men. Fifty percent were between the ages of 30–40. 54% were in academic practice and 21% in fellowship. The majority (50%) reported currently having a mentor. Most (54%) had a male mentor, but 25% had both a male and female mentor. 41% of women had only a male mentor, while only 8% of men had only a female mentor. Most classified their mentor as academic (86%), but 29% reported a personal mentor. More women than men felt that it was somewhat important, important or very important that a mentor be the same gender (68.6% vs 41.7%, P<.001). Whether it was important that a mentor have children also differed between genders (37.5% of men vs 64.5% of women, P<.001). Formal mentoring programs were uncommon (28%). The majority (58%) also served as mentors themselves. CONCLUSION: The majority of gynecologic oncologists both receive and provide mentorship, despite few formal programs. Women placed greater value on having a mentor of the same gender and with children.

Cross-sensitivity between paclitaxel and docetaxel in a women's cancers program

2052 Background: Taxanes are used to treat both breast and gynecologic cancers. The incidence of severe hypersensitivity reactions (S-HSR) to paclitaxel (P) is estimated to be 2% or lower, especially with the use of steroids and anti-histamines. For those who develop a S-HSR to paclitaxel, docetaxel (D) has been employed as an alternative agent but the presence of cross-sensitivity has not been documented. We sought to define the presence of S-HSR to D following a P S-HSR in women treated for breast or gynecologic cancers. Methods: Patients treated with either P or D between 11/1999 and 8/2004 were identified through our pharmacy database. Records were reviewed and data collected on those patients who had a S-HSR to P, D, or both, defined as symptoms for which drug was discontinued. Data collected included type of cancer, type of reaction, dates of treatment, and time interval between taxane therapy. Characteristics were compared using Fisher’s exact test or Chi Square for categorized variables. Results: ...