Minimally invasive surgery for suspected early-stage ovarian cancer; a cost-effectiveness study.

OBJECTIVE: While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses. DESIGN: Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management. METHODS: The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings. MAIN OUTCOME MEASURES: The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs). RESULTS: MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses. CONCLUSION: MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses. TWEETABLE ABSTRACT: MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Impact of incorporating an algorithm that utilizes sentinel lymph node mapping during minimally invasive procedures on the detection of stage IIIC endometrial cancer.

OBJECTIVE: To determine whether the frequency of cases diagnosed with stage IIIC endometrial cancer is affected by the incorporation of a modified surgical lymph node assessment. METHODS: Since 2008, we have increasingly utilized a modified nodal assessment using an algorithm that incorporates SLN mapping. For this analysis, we identified all cases of newly diagnosed endometrial cancers undergoing a minimally invasive staging procedure not requiring conversion to laparotomy from 1/1/08 to 12/31/10. Procedures were categorized as standard, modified, and hysterectomy only. Differences were based on time period: 2008 (Y1), 2009 (Y2), and 2010 (Y3). Appropriate statistical tests were used. RESULTS: We identified a total of 507 cases. The distribution of cases was 143 (Y1), 190 (Y2), and 174 (Y3). Tumor grade (P=0.05) and high-risk histologies (P=0.8) did not differ during the 3 time periods. A standard staging procedure was performed in the following cases: Y1 (93/143; 65%), Y2 (66/166; 35%), and Y3 (40/164; 23%) (P<0.001). Median operative times were as follows: Y1 (218 min), Y2 (198 min), and Y3 (176.5 min) (P<0.001). The median numbers of total lymph nodes removed among cases with at least 1 node retrieved were: Y1 (20); Y2 (10); Y3 (7) (P<0.001). Cases diagnosed as stage IIIC were as follows: Y1 (10/143; 7%), Y2 (15/166; 7.9%), and Y3 (13/164; 7.5%) (P=1.0). CONCLUSIONS: The incorporation of a modified staging approach utilizing the SLN mapping algorithm reduces the need for standard lymphadenectomy and does not appear to adversely affect the rate of stage IIIC detection.

Anterior pelvic exenteration with total vaginectomy for recurrent or persistent genitourinary malignancies: review of surgical technique, complications, and outcome.

OBJECTIVE: To describe the surgical technique, complications, and outcomes after anterior pelvic exenteration with total vaginectomy (AETV) for recurrent or persistent genitourinary malignancies. METHODS: We reviewed the medical records of all patients who underwent AETV between 12/2002 and 07/2011. Relevant demographic, clinical, and pathological information was collected. Postoperative complications and rates of readmission and reoperation (up to 180 days after surgery) were examined, and preliminary survival data were obtained. RESULTS: We identified 11 patients who underwent AETV. The median age at the time of the surgery was 55 years (range, 36-71). The median tumor size was 0.9 cm (range, microscopic - 4). Primary tumor sites included: cervix, 6; uterus, 3; vagina, 1; and urethra, 1. Complete surgical resection with negative pathologic margins was achieved in all 11 patients. Major postoperative complications occurred in 4 patients (36%). Six patients (55%) required readmission to the hospital. No operative mortalities were observed, and none of the patients required a re-operation. With a median follow-up after the procedure of 25 months (range, 6-95), none of the patients developed a pelvic recurrence. Ten patients (91%) were alive without evidence of disease and one patient (9%) developed a pancreatic recurrence. CONCLUSION: AETV sparing the rectosigmoid and anus is feasible in highly selected patients with central pelvic recurrences. Compared to previously reported studies on total pelvic exenteration, data from this case series suggest that AETV may be associated with a lower rate of complications without compromising the oncologic outcome, while also preserving rectal function.

Extended pelvic resections for recurrent or persistent uterine and cervical malignancies: an update on out of the box surgery.

OBJECTIVE: To update our report on the outcome of patients who underwent extended pelvic resection (EPR) for recurrent or persistent uterine and cervical malignancies. METHODS: We reviewed the records of all patients who underwent EPR between 6/2000 and 07/2011. EPR was defined as an en-bloc resection of a pelvic tumor with sidewall muscle, bone, major nerve, and/or major vascular structure. Complications up to 180 days post surgery were analyzed. Survivals were estimated using the Kaplan-Meier method. RESULTS: We identified 22 patients. Median age at the time of EPR was 58 years (range, 36-74). Median tumor diameter was 5.4 cm (range, 1.5-11.2). Primary tumor sites included: uterus, 13; cervix, 7; synchronous uterus/cervix, 1; and synchronous uterus/ovary, 1. The EPR structures were: muscle, 13; nerve, 10; bone, 8; vessel, 5. Complete gross resection with microscopically negative margins (R0 resection) was achieved in 17 patients (77%). There were no perioperative mortalities. Major postoperative complications occurred in 14 patients (64%). The two most common morbidities were pelvic abscesses and peripheral neuropathies. Median follow-up time was 28 months (range, 6-99). The 5-year overall survival (OS) for the entire cohort was 34% (95% CI, 13-57). For the 17 patients who had an R0 resection, the 5-year OS was 48% (95% CI, 19-73). In patients with positive pathologic margins (n=5), the 5-year OS was 0%. CONCLUSION: EPR was associated with prolonged survival when an R0 resection was achieved. The high rate of postoperative complications remains a hallmark of these procedures and properly selected patients should be extensively counseled preoperatively.

Sentinel lymph node mapping for endometrial cancer improves the detection of metastatic disease to regional lymph nodes.

OBJECTIVE: To compare the incidence of metastatic cancer cells in sentinel lymph nodes (SLN) vs. non-sentinel nodes in patients who had lymphatic mapping for endometrial cancer and to determine the contribution of metastases detected on ultrastaging to the overall nodal metastasis rate. METHODS: All patients who underwent lymphatic mapping for endometrial cancer were reviewed. Cervical injection of blue dye was used in all cases. Sentinel nodes were examined by routine hematoxylin and eosin (H&E), and if negative, by standardized institutional pathology protocol that included additional sections and immunohistochemistry (IHC). RESULTS: Between 09/2005 and 03/2010, 266 patients with endometrial cancer underwent lymphatic mapping. Sentinel node identification was successful in 223 (84%) cases. Positive nodes were diagnosed in 32/266 (12%) patients. Of those, 8/266 patients (3%) had the metastasis detected only by additional section or IHC as part of SLN ultrastaging. Excluding the 8 cases with positive SLN on ultrastaging only, 24/801 (2.99%) SLN and 30/2698 (1.11%) non-SLN were positive for metastatic disease (p=0.0003). CONCLUSION: Using a cervical injection for mapping, metastatic cells from endometrial cancer are three times as likely to be detected in SLN than in the non-sentinel nodes. This finding strongly supports the concept of lymphatic mapping in endometrial cancer to fine tune the nodal dissection topography. By adding SLN mapping to our current surgical staging procedures we may increase the likelihood of detecting metastatic cancer cells in regional lymph nodes. An additional benefit of incorporating pathologic ultrastaging of SLN is the detection of micrometastasis, which may be the only evidence of extrauterine spread.

Lymphatic mapping in endometrial cancer: a literature review of current techniques and results.

The objective of this study was to review available literature pertaining to lymphatic mapping in endometrial cancer. We reviewed all published series of lymphatic mapping in endometrial cancer available through a PubMed search. Techniques used for identification of sentinel lymph nodes fell into three main categories in relation to the site of injection: 1) uterine subserosal, 2) cervical, and 3) endometrial via hysteroscopy. High detection rates may be achieved in all three categories. The use of both radiolabeled technetium and blue dye has been reported. A combination of cervical and uterine corpus injections appears feasible and less technically demanding than hysteroscopic injections. Immunohistochemistry staining of sentinel nodes coupled with step-serial section may improve the detection of micrometastasis in sentinel nodes. Meaningful sensitivity and false-negative rates cannot be calculated from current series due to their small numbers. The role of lymphatic mapping in endometrial carcinoma and the optimal injection site remains to be determined. A combination of cervical and uterine fundal injections may result in acceptable detection rates. Large-scale validation trials requiring complete pelvic and para-aortic lymphadenectomy are needed to evaluate its role in future clinical practice.

Fetal clavicle length throughout gestation: a nomogram.

OBJECTIVE: To create a nomogram of fetal clavicle length (CL) throughout gestation. METHODS: Cross-sectional study of patients between 14 and 42 weeks' gestation. Inclusion criteria consisted of well-established dates (consistent with early ultrasound), singleton, non-anomalous fetuses, and intact amniotic membranes. Sonographic measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL) and sonographically estimated fetal weight (SEFW). For every case, the average of three separate measurements of the CL was used. The 5th, 50th and 95th centiles were obtained by least squares regression. Pearson's correlation coefficient and associated P-values for the relationships between CL and other biometric measurements were calculated. The data were compared to a nomogram of the CL generated in 1985 from the measurement of 85 fetuses. RESULTS: A total of 623 consecutive patients were studied. In all but three cases, CL was successfully measured. Mean maternal age was 27.7 +/- 6.2 years, median gravidity 3 (range, 1-14) and median parity 1 (range, 0-9). Mean CL (mm) = -75.30 + 32.70*ln(GA) and SD = -0.41 + 0.08328*GA, where ln represents the natural logarithm and GA the gestational age in weeks. Fetal CL correlated significantly and strongly with BPD, HC, AC, HL, FL and the logarithm of SEFW, with Pearson correlation values of 0.973, 0.977, 0.976, 0.979, 0.977 and 0.979, respectively (all P < 0.001). Measurements according to comparable 1985 data were consistently substantially below the present data (smaller CL for any given GA except below 17 weeks' gestation). CONCLUSIONS: We propose a new nomogram of CL, which differs significantly from the previously published nomogram. We suggest that the present data reflect the use of high-resolution ultrasound technology and propose that these data, based on a large number of fetuses, replace the previous nomogram. We also suggest that the '1 mm = 1 week' rule of thumb should no longer be used, since it can be erroneous by as much as 6 weeks.

Cord entanglement of monochorionic diamniotic twins following spontaneous antepartum septostomy sonographically simulating a true knot of the umbilical cord.

Spontaneous antepartum septostomy occurring in monochorionic diamniotic twins is extremely rare. We present a case in which prenatal sonography at 26 weeks' gestation depicted a monochorionic diamniotic twin gestation with concordant fetal growth and findings suggestive of a true knot of the umbilical cord. At Cesarean delivery at 34 weeks' gestation, spontaneous antepartum septostomy with entanglement of the two separate umbilical cords was noted. This case suggests that the differential diagnosis of findings considered consistent with a true knot of the umbilical cord in monochorionic diamniotic twin gestations, should include spontaneous antepartum septostomy and umbilical cord entanglement.

Is fetal cerebral vascular resistance affected by the presence of nuchal cord(s) in the third trimester of pregnancy?

OBJECTIVE: To assess whether fetal cerebral vascular resistance is affected by the presence of nuchal cord(s) in the third trimester. METHODS: A set of 115 patients with well-established dates and singleton, appropriate for gestational age (GA), non-anomalous fetuses with nuchal cord(s) diagnosed with prenatal color Doppler imaging, between 28 and 41 weeks and 115 controls matched for GA, were studied. Patients with hypertension, diabetes and autoimmune conditions were excluded. Doppler indices were obtained from the umbilical artery (UA) and the fetal middle cerebral artery (MCA) upon initial diagnosis of the nuchal cord. RESULTS: Of 115 GA-matched pairs of pregnancies, 103 fetuses had a single nuchal cord and 12 a double nuchal cord. No significant differences were noted in patient age, gravidity, parity, sonographically estimated fetal weight (SEFW), and growth centile at ultrasonographic diagnosis. Mean UA systolic/diastolic ratio (S/D) was 2.28 +/- 0.32 and 2.36 +/- 0.33 (P = 0.03) and UA resistance index (RI) 0.55 +/- 0.06 and 0.57 +/- 0.06 (P = 0.02) among study and controls, respectively. Mean fetal MCA S/D and RI did not differ significantly between the two groups (fetal MCA S/D 5.01 +/- 1.28 and 5.04 +/- 1.71 (P = 0.86), and mean fetal MCA RI 0.78 +/- 0.06 and 0.78 +/- 0.05 (P = 0.88)). No significant differences were noted in GA at delivery, incidence of meconium-stained amniotic fluid, birth weight, mode of delivery, neonatal gender, 1 and 5 minute Apgar scores, or UA pH and base excess, between study and control patients. CONCLUSION: Fetal cerebral vascular resistance is not affected by the presence of nuchal cord(s) in the third trimester of pregnancy.