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Benchmarking , Procedimentos Cirúrgicos em Ginecologia , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/normas , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/normas , Procedimentos Cirúrgicos em Ginecologia/métodos , Neoplasias dos Genitais Femininos/cirurgia , Indicadores de Qualidade em Assistência à SaúdeRESUMO
Introduction: Over the last decade there has been a transition from traditional laparoscopy to robotic surgery for the treatment of endometrial cancer. A number of gynecological oncology surgical fellowship programmes have adopted robot-assisted laparoscopy, but the effect of training on complications and survival has not been evaluated. Our aim was to assess the impact of a proficiency-based progression training curriculum in robot-assisted laparoscopy on peri-operative and survival outcomes for endometrial cancer. Methods: This is an observational cohort study performed in a tertiary referral and subspecialty training center. Women with primary endometrial cancer treated with robot-assisted laparoscopic surgery between 2015 and 2022 were included. Surgery would normally include a hysterectomy and salpingo-oophorectomy with some form of pelvic lymph node dissection (sentinel lymph nodes or lymphadenectomy). Training was provided according to a training curriculum which involves step-wise progression of the trainee based on proficiency to perform a certain surgical technique. Training cases were identified pre-operatively by consultant surgeons based on clinical factors. Case complexity matched the experience of the trainee. Main outcome measures were intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and 5-year disease-free and disease-specific survival for training versus non-training cases. Mann-Witney U, Pearson's chi-squared, multivariable regression, Kaplan-Meier and Cox proportional hazard analyses were performed to assess the effect of proficiency-based progression training on peri-operative and survival outcomes. Results: Training cases had a lower BMI than non-training cases (30 versus 32 kg/m2, p = 0.013), but were comparable in age, performance status and comorbidities. Training had no influence on intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and median 5-year disease-free and disease-specific survival. Operating time was longer in training cases (161 versus 137 min, p = < 0.001). The range of estimated blood loss was smaller in training cases. Conversion rates, critical care unit-admissions and lymphoedema rates were comparable. Discussion: Proficiency-based progression training can be used safely to teach robot-assisted laparoscopic surgery for women with endometrial cancer. Prospective trails are needed to further investigate the influence of distinct parts of robot-assisted laparoscopic surgery performed by a trainee on endometrial cancer outcomes.
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For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.
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OBJECTIVE: The peritoneal cancer index quantitatively assesses cancer distribution and tumor burden in the peritoneal cavity. The aim of this study is to evaluate the association between the peritoneal cancer index and completeness of surgical cytoreduction for ovarian cancer and to identify a cut-off above which complete cytoreduction is unlikely. METHODS: This is a single-center prospective cohort observational study. A total of 100 consecutive patients who underwent ovarian cancer surgery were included. Peritoneal cancer index scores prior to and after surgery were calculated, and a cut-off value for incomplete cytoreduction was identified using a receiver operator characteristic (ROC) curve. Surgical complexity, blood loss, length of surgery, and complications were analyzed and associations with the peritoneal cancer index score were evaluated. RESULTS: The overall median peritoneal cancer index score was 9.5 (range 0-36). The median age of the patients was 61 years (range 24-85). The most common stage was III (13% stage II, 53% stage III, 34% stage IV) and the most common histologic sub-type was high-grade serous (76% high-grade serous, 8% low-grade serous, 5% clear cell, 4% serous borderline, 2% endometrioid, 2% adult granulosa cell, 2% adenocarcinoma, 1% carcinosarcoma). Complete cytoreduction was achieved in 82% of patients, with a median score of 9 (range 0-30). The remaining 18% had a median score of 28.5 (range 0-36). The best predictor of incomplete cytoreduction was the peritoneal cancer index score, with an area under the curve (AUC) of 0.928 (95% CI 0.85 to 1.00). ROC curve analysis determined a peritoneal cancer index cut-off score of 20. Major complications occurred in 15% of patients with peritoneal cancer index scores >20 and in 2.5% of patients with scores ≤20, which was statistically significant (p=0.014). CONCLUSIONS: In our study we found that a peritoneal cancer index score of ≤20 was associated with a high likelihood of complete cytoreduction. Incorporating the peritoneal cancer index into routine surgical practice and research may impact treatment plans.
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Neoplasias Ovarianas , Neoplasias Peritoneais , Adulto , Humanos , Feminino , Adulto Jovem , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos de Citorredução , Estudos Prospectivos , Neoplasias Peritoneais/cirurgia , Estudos Retrospectivos , Carcinoma Epitelial do Ovário/cirurgia , Neoplasias Ovarianas/patologiaRESUMO
OBJECTIVE: To compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional 'straight stick' laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy. DESIGN: Multicentre prospective observational cohort study. SETTING: Patients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020. PARTICIPANTS: 275 patients recruited with 159 RALS, 73 CLS eligible for analysis. OUTCOME MEASURES: Primary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018-2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS. RESULTS: No difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI -£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI -0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of -£188 (95% CI -£1321 to £827) and QALY difference of 0.0024 (95% CI -0.0008 to 0.0057). CONCLUSIONS: Findings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.
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Neoplasias dos Genitais Femininos , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Feminino , Análise Custo-Benefício , Medicina Estatal , Qualidade de Vida , Estudos Prospectivos , Inglaterra , Histerectomia/métodos , Laparoscopia/métodos , Anos de Vida Ajustados por Qualidade de VidaRESUMO
The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.
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Ginecologia , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Robótica/métodos , Procedimentos Cirúrgicos em Ginecologia , Complicações Pós-Operatórias , Laparoscopia/métodosRESUMO
BACKGROUND: The Global Gynecological Oncology Surgical Outcomes Collaborative (GO SOAR) has developed a network of gynecological oncology surgeons, surgical departments, and other interested parties that have the long-term ability to collaborate on outcome studies. Presented is the protocol for the GO SOAR2 study. PRIMARY OBJECTIVES: To compare survival following interval and delayed cytoreductive surgery, between delayed cytoreductive surgery and no surgery (chemotherapy alone); and international variations in access to cytoreductive surgery for women with stage III-IV epithelial ovarian cancer. STUDY HYPOTHESES: There is no difference in survival following interval and delayed cytoreductive surgery; there is poorer survival with no surgery compared with delayed cytoreductive surgery; and there are international disparities in prevalent practice and access to cytoreductive surgery in women with stage III-IV epithelial ovarian cancer. TRIAL DESIGN: International, multicenter, mixed-methods cohort study. Participating centers, will review medical charts/electronic records of patients who had been consecutively diagnosed with stage III-IV ovarian cancer between January 1, 2006 and December 31, 2021. Qualitative interviews will be conducted to identify factors determining international variations in prevalent practice and access to cytoreductive surgery. MAJOR INCLUSION/EXCLUSION CRITERIA: Inclusion criteria include women with stage III-IV epithelial ovarian cancer, undergoing interval (after 3-4 cycles of chemotherapy) or delayed (≥5 cycles of chemotherapy) cytoreductive surgeries or no cytoreductive surgery (≥5 cycles of chemotherapy alone). PRIMARY ENDPOINTS: Overall survival (defined from date of diagnosis to date of death); progression-free survival (defined from date of diagnosis to date of first recurrence); facilitator/barriers to prevalent practice and access to cytoreductive surgery. SAMPLE SIZE: In order to determine whether there is a difference in survival following interval and delayed cytoreductive surgery and no surgery, data will be abstracted from 1000 patients. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: It is estimated that recruitment will be completed by 2023, and results published by 2024. TRIAL REGISTRATION: NCT05523804.
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Procedimentos Cirúrgicos de Citorredução , Neoplasias Ovarianas , Humanos , Feminino , Carcinoma Epitelial do Ovário/tratamento farmacológico , Estudos de Coortes , Procedimentos Cirúrgicos de Citorredução/métodos , Neoplasias Ovarianas/tratamento farmacológico , Resultado do Tratamento , Estudos Multicêntricos como AssuntoRESUMO
PURPOSE: After risk-reducing salpingo-oophorectomy (RRSO), BRCA1/2 pathogenic variant (PV) carriers have a residual risk to develop peritoneal carcinomatosis (PC). The etiology of PC is not yet clarified, but may be related to serous tubal intraepithelial carcinoma (STIC), the postulated origin for high-grade serous cancer. In this systematic review and individual patient data meta-analysis, we investigate the risk of PC in women with and without STIC at RRSO. METHODS: Unpublished data from three centers were supplemented by studies identified in a systematic review of EMBASE, MEDLINE, and the Cochrane library describing women with a BRCA-PV with and without STIC at RRSO until September 2020. Primary outcome was the hazard ratio for the risk of PC between BRCA-PV carriers with and without STIC at RRSO, and the corresponding 5- and 10-year risks. Primary analysis was based on a one-stage Cox proportional-hazards regression with a frailty term for study. RESULTS: From 17 studies, individual patient data were available for 3,121 women, of whom 115 had a STIC at RRSO. The estimated hazard ratio to develop PC during follow-up in women with STIC was 33.9 (95% CI, 15.6 to 73.9), P < .001) compared with women without STIC. For women with STIC, the five- and ten-year risks to develop PC were 10.5% (95% CI, 6.2 to 17.2) and 27.5% (95% CI, 15.6 to 43.9), respectively, whereas the corresponding risks were 0.3% (95% CI, 0.2 to 0.6) and 0.9% (95% CI, 0.6 to 1.4) for women without STIC at RRSO. CONCLUSION: BRCA-PV carriers with STIC at RRSO have a strongly increased risk to develop PC which increases over time, although current data are limited by small numbers of events.
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Neoplasias da Mama , Cistadenocarcinoma Seroso , Neoplasias das Tubas Uterinas , Neoplasias Ovarianas , Neoplasias Peritoneais , Cistadenocarcinoma Seroso/patologia , Neoplasias das Tubas Uterinas/genética , Neoplasias das Tubas Uterinas/prevenção & controle , Neoplasias das Tubas Uterinas/cirurgia , Feminino , Heterozigoto , Humanos , Mutação , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/prevenção & controle , Ovariectomia/efeitos adversos , Neoplasias Peritoneais/genética , Neoplasias Peritoneais/prevenção & controle , Salpingo-Ooforectomia/efeitos adversosRESUMO
PURPOSE: The aim of the present study is to investigate the prognostic significance of nutritional risk factors and sarcopenia on the outcome of patients with recurrent gynaecological malignancies treated by pelvic exenteration. METHODS: We retrospectively evaluated muscle body composite measurements based on pre-operative CT scans, nutritional risk factors as assessed by a validated pre-operative questionnaire, and clinical-pathological parameters in 65 consecutive patients with recurrent gynaecological malignancies, excluding ovarian cancer, treated by pelvic exenteration at the Royal Marsden Hospital London. Predictive value for postoperative morbidity was investigated by logistic regression analyses. Relevant parameters were included in uni- and multivariate survival analyses. RESULTS: We found only (1) low muscle attenuation (MA)-an established factor for muscle depletion-and (2) moderate risk for malnutrition to be independently associated with shorter overall survival (p = 0.006 and p = 0.008, respectively). MA was significantly lower in overweight and obese patients (p = 0.04). Muscle body composite measurements were not predictive for post-operative morbidity. CONCLUSION: The study suggests that pre-operative low MA and moderate risk for malnutrition are associated with shorter survival in patients with recurrent gynaecological malignancies treated with pelvic exenteration. Further studies are needed to validate these findings in larger cohorts.
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Neoplasias dos Genitais Femininos , Desnutrição , Neoplasias Ovarianas , Exenteração Pélvica , Sarcopenia , Carcinoma Epitelial do Ovário/cirurgia , Doença Crônica , Feminino , Neoplasias dos Genitais Femininos/complicações , Neoplasias dos Genitais Femininos/cirurgia , Humanos , Desnutrição/etiologia , Recidiva Local de Neoplasia/patologia , Neoplasias Ovarianas/cirurgia , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/complicaçõesRESUMO
PURPOSE: Preoperative nodal staging is important for planning treatment in cervical cancer and endometrial cancer, but remains challenging. We compare nodal staging accuracy of 18F-ethyl-choline-(FEC)-PET/CT, 18F-fluoro-deoxy-glucose-(FDG)-PET/CT, and diffusion-weighted-MRI (DW-MRI) with conventional morphologic MRI. EXPERIMENTAL DESIGN: A prospective, multicenter observational study of diagnostic accuracy for nodal metastases was undertaken in 5 gyne-oncology centers. FEC-PET/CT, FDG-PET/CT, and DW-MRI were compared with nodal size and morphology on MRI. Reference standard was strictly correlated nodal histology. Eligibility included operable cervical cancer stage ≥ 1B1 or endometrial cancer (grade 3 any stage with myometrial invasion or grade 1-2 stage ≥ II). RESULTS: Among 162 consenting participants, 136 underwent study DW-MRI and FDG-PET/CT and 60 underwent FEC-PET/CT. In 118 patients, 267 nodal regions were strictly correlated at histology (nodal positivity rate, 25%). Sensitivity per patient (n = 118) for nodal size, morphology, DW-MRI, FDG- and FEC-PET/CT was 40%*, 53%, 53%, 63%*, and 67% for all cases (*, P = 0.016); 10%, 10%, 20%, 30%, and 25% in cervical cancer (n = 40); 65%, 75%, 70%, 80% and 88% in endometrial cancer (n = 78). FDG-PET/CT outperformed nodal size (P = 0.006) and size ratio (P = 0.04) for per-region sensitivity. False positive rates were all <10%. CONCLUSIONS: All imaging techniques had low sensitivity for detection of nodal metastases and cannot replace surgical nodal staging. The performance of FEC-PET/CT was not statistically different from other techniques that are more widely available. FDG-PET/CT had higher sensitivity than size in detecting nodal metastases. False positive rates were low across all methods. The low false positive rate demonstrated by FDG-PET/CT may be helpful in arbitration of challenging surgical planning decisions.
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Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Neoplasias do Colo do Útero , Imagem de Difusão por Ressonância Magnética , Feminino , Fluordesoxiglucose F18 , Humanos , Imageamento por Ressonância Magnética/métodos , Estadiamento de Neoplasias , Tomografia por Emissão de Pósitrons/métodos , Estudos Prospectivos , Compostos Radiofarmacêuticos , Tomografia Computadorizada por Raios X/métodos , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias do Colo do Útero/cirurgiaRESUMO
OBJECTIVE: Adolescents and young adults with cancer face unique psychosocial and practical issues. However, patients across this group encounter different life experiences, cancer diagnoses and treatment settings given the tailored services for patients ages 15 to 24. Here, we qualitatively explore the psychosocial experiences and practical challenges of young adults (YAs) with cancer diagnosed between ages 25 and 39 in the United Kingdom. METHODS: We invited YAs diagnosed with cancer in the 5 years prior to enrolment at participating sites to take part in semi-structured interviews or focus groups. Transcripts were analysed using inductive thematic analysis. Two YA patients reviewed the results to ensure robustness. RESULTS: Sixty-five YAs with varied diagnoses participated. Participants struggled to balance work, childcare and financial solvency with treatment. The halt in family and work life as well as changes in image and ability threatened participants' identity and perceived 'normality' as a YA, however, these also stimulated positive changes. YAs experienced social isolation from friends and family, including children. Many struggled to cope with uncertainty around treatment outcomes and disease recurrence. CONCLUSION: The disruption of family and work life can lead to age-specific issues in YAs diagnosed with cancer. Age-tailored psychological and practical services must be considered.
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Neoplasias , Adaptação Psicológica , Adolescente , Adulto , Criança , Grupos Focais , Humanos , Neoplasias/terapia , Pesquisa Qualitativa , Incerteza , Adulto JovemAssuntos
Neoplasias do Endométrio/patologia , Linfonodo Sentinela/patologia , Neoplasias do Colo do Útero/patologia , Neoplasias Vulvares/patologia , Consenso , Neoplasias do Endométrio/diagnóstico por imagem , Feminino , Humanos , Guias de Prática Clínica como Assunto , Linfonodo Sentinela/diagnóstico por imagem , Biópsia de Linfonodo Sentinela/métodos , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias Vulvares/diagnóstico por imagemRESUMO
BACKGROUND: We have assessed the impact of introducing robotics for a stage 1b cervical cancer service on laparotomy rates, complications, and costs. METHODS: Data were collected prospectively from 90 consecutive patients who had a radical hysterectomy between 1 April 2010 and 31 December 2017. RESULTS: There were 37 women before the first robotic procedure and 53 after. The laparotomy rate reduced from 75% (9/12) in 2010 to 0% (0/18) in 2017. The length of stay reduced from 6 days (range 3-39) to 3 days (range 1-15) (P < 0.0001). The complication rate before robotics was 68% (25/37) compared with 45% (24/53) afterwards (P = 0.0493). The blood transfusion rate reduced from 43% (16/37) to 11% (6/53) (P = 0.0007). There were no differences between the total costs before and after the introduction of robotics or between each route. CONCLUSIONS: In this series, introducing robotics for cervical carcinoma reduced hospital stay and complications. No cost differences were demonstrated.
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Histerectomia/economia , Histerectomia/métodos , Procedimentos Cirúrgicos Robóticos , Neoplasias do Colo do Útero/economia , Neoplasias do Colo do Útero/cirurgia , Adulto , Idoso , Feminino , Custos de Cuidados de Saúde , Humanos , Pessoa de Meia-Idade , Modelos Econômicos , Estudos Prospectivos , Resultado do Tratamento , Reino UnidoRESUMO
BACKGROUND: Evidence has been systematically assessed comparing robotic with standard laparoscopy for treatment of endometrial cancer. METHODS: A search of Medline, Embase and Cochrane databases was performed until 30th October 2016. RESULTS: Thirty-six papers including 33 retrospective studies, two matched case-control studies and one randomized controlled study were used in a meta-analysis. Information from a further seven registry/database studies were assessed descriptively. There were no differences in the duration of surgery but days stay in hospital were shorter in the robotic arm (0.46 days, 95%CI 0.26 to 0.66). A robotic approach had less blood loss (57.74 mL, 95%CI 38.29 to 77.20), less conversions to laparotomy (RR = 0.41, 95%CI 0.29 to 0.59), and less overall complications (RR = 0.82, 95%CI 0.72 to 0.93). A robotic approach had higher costs ($1746.20, 95%CI $63.37 to $3429.03). CONCLUSION: A robotic approach has favourable clinical outcomes but is more expensive.
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Neoplasias do Endométrio/cirurgia , Laparoscopia/instrumentação , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Laparotomia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Robótica , Resultado do TratamentoRESUMO
The aim of this study was to compare the financial and clinical outcomes in robotic-assisted laparoscopic surgery for primary endometrial cancer between obese and nonobese women. The hospital finance department assessed the total admission costs for robotic surgery for endometrial cancer in 54 women. This included a subanalysis for costs over nine areas (ward and clinics, drugs and pharmacy, medical staff, theaters, blood products, imaging, pathology, rehabilitation therapy, and high dependency costs). Furthermore, a prospective collection of morbidity and surgical outcome data was performed. The study group included 21 nonobese and 33 obese women (body mass index >30). Obese women were more likely to stay for more than one night in hospital (20/33 [60.6%] compared to 4/21 [19.0%], P=0.032) and to have high dependency care (25/33 [75.8%] compared to 10/21 [47.6%], P=0.032). Theater time was on average 35 min longer (95% confidence interval [CI] 5-65 min, P=0.0252). Both the groups were comparable for comorbidities except for the presence of diabetes being present in the obese group (13/33 [39.4%] compared to 0/21 [0.0%], P=0.007). There were six Clavien-Dindo grade II complications in the obese group and two in the nonobese group. The average overall costs were £1,852 greater (95% CI £431-£3,277, P=0.012) in the obese group. Diabetes and hypertension were associated with increased costs, but obesity was the only independent variable. In conclusion, greater resource should be allocated to obese women undergoing primary surgery for endometrial cancer.
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OBJECTIVE: This study aimed to determine the frequency of malignant pathology in a macroscopically normal appendix during surgery for a borderline or malignant mucinous ovarian tumor (MOT). METHODS: Women with borderline and malignant MOT were identified from the pathology database from 2000 to 2014. Women who had a benign MOT and had an appendicectomy were excluded from the study. Data were collected from the electronic patient record and case notes. RESULTS: Of 310 women identified with MOT, 203 patients with benign MOT were excluded. Of the remaining 107 patients, 15 patients with previous appendicectomy were also excluded. The study population consisted of 92 patients. There were 57 (62%) patients with borderline MOT and 35 (38%) patients with malignant MOT. In the borderline subgroup, 40/57 (70%) patients had appendicectomy of whom 8 (20%) had macroscopically abnormal appendices. One patient had pseudomyxoma peritonei secondarily involving the appendix and 7 patients had a histologically normal appendix. Normal histology was found in all macroscopically normal appendices. In the malignant subgroup, 29/35 (83%) patients had an appendicectomy. There were 8 (27.5%) macroscopically abnormal appendices with a malignant pathology in 7 (87.5%) patients and 1 patient had a resolving appendicitis. There were 21 macroscopically normal appendices of which, serrated adenoma was found in 1 (4.8%) patient, whereas the remaining 20 (95.2%) patients had normal histology. CONCLUSIONS: In MOT, an abnormal appearing appendix should be excised. If the appendix is grossly normal, our data do not support performing an appendicectomy as part of a surgical staging procedure.
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Adenocarcinoma Mucinoso/patologia , Adenocarcinoma Mucinoso/cirurgia , Apêndice/patologia , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Adulto , Idoso , Apendicectomia , Apêndice/cirurgia , Feminino , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos RetrospectivosRESUMO
BACKGROUND: We have assessed how the introduction of robotics in a publicly funded endometrial cancer service affects clinical and economic outcomes. METHODS: The study included 196 women. Costs were divided into those for wards, high dependency, staffing, theatres, pharmacy, blood products, imaging, pathology and rehabilitation. Capital depreciation was included. RESULTS: Prior to the introduction of robotics, 78/130 (60.0%) cases were performed open, compared to 17/66 (25.8%) afterwards (p < 0.0001). The median operative time increased 37 min (95% CI 17-55 min; p = 0.0002); the median blood loss was 55 ml lower (95% CI 0-150 ml; p = 0.0181); the stay was 2 days shorter (95% CI 1-3; p < 0.0001). Complications reduced from 64/130 (49.2%) to 19/66 (28.8%) (p = 0.0045). Costs reduced from £11 476 to £10 274 (p = 0.0065). Conversions for 'straight stick' surgery were 18.2% (14/77) compared to 0.0% (0/24) for robotics (p = 0.0164). CONCLUSIONS: Introducing robotics resulted in fewer laparotomies, shorter stays, fewer complications and lower costs.
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Neoplasias do Endométrio/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/economiaRESUMO
OBJECTIVES: To determine the impact on survival of symptomatic and asymptomatic venous thromboembolism (VTE) at time of diagnosis of primary ovarian malignancy. MATERIALS AND METHODS: The clinical records of 397 consecutive cases of primary ovarian malignancy were studied. Clinical, pathological and survival data were obtained. RESULTS AND CONCLUSIONS: Of 397 cases, 19 (4.8%) were found to have VTE at diagnosis, of which 63.2% (n=12) were asymptomatic. VTE was significantly associated with reduced overall median survival (28 vs. 45 months, p=0.004). Decreased survival was associated with symptomatic VTE compared to patients with asymptomatic VTE (21 vs. 36 months, p=0.02) whose survival was similar to that of patients without VTE. Decreased survival remained significant in symptomatic patients after controlling for stage of disease at diagnosis, cytoreductive status and adjuvant chemotherapy use. Overall these data suggest for the first time that symptomatic but not asymptomatic VTE prior to primary treatment of ovarian cancer is an independent adverse prognostic factor.
Assuntos
Doenças Assintomáticas/mortalidade , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/mortalidade , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Distribuição por Idade , Idoso , Causalidade , Comorbidade , Intervalo Livre de Doença , Feminino , Humanos , Incidência , Londres/epidemiologia , Pessoa de Meia-Idade , Neoplasias Ovarianas/terapia , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Avaliação de Sintomas/estatística & dados numéricos , Tromboembolia Venosa/terapiaRESUMO
BACKGROUND: Some guidelines suggest that poor performance status (PS) is a contraindication to 1st line chemotherapy. Poor PS is a known adverse prognostic factor in advanced epithelial ovarian cancer (EOC). We show in this retrospective analysis that 1st line chemotherapy in this patient group is not only safe but is associated with good outcomes. PATIENTS AND METHODS: A retrospective review of 114 patients with stage III/IV EOC, who presented with a PS ≥3 at diagnosis and treated as inpatients with upfront platinum-based chemotherapy between 2000 and 2013, at the Royal Marsden Hospital, was conducted. The association between clinical parameters and the likelihood of completion of chemotherapy and overall survival (OS) was assessed. RESULTS: 66% of patients completed ≥6cycles of platinum-based chemotherapy. Prognostic factors for completion of chemotherapy were improvement of PS during hospital stay (p<0.001) and doublet-chemotherapy with carboplatin/paclitaxel compared to single-agent carboplatin (p=0.004). A negative trend for completion of treatment was seen for patients with low albumin (<25g/l) and low CA125 levels at baseline. The median OS for all patients was 13.1months (95% CI: 10.4-15.8) and 21.2months (95% CI: 16.5-25.8) for those who completed 6cycles of chemotherapy. CONCLUSION: Upfront platinum-based chemotherapy is feasible, beneficial and tolerable for the majority of patients with advanced EOC and poor PS. Guidelines suggesting that best supportive care is the preferred option for poor PS patients with solid tumours should be revised to exclude those with advanced EOC. An aggressive approach utilising neoadjuvant carboplatin plus paclitaxel should be regarded as standard of care.
Assuntos
Adenocarcinoma/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias das Tubas Uterinas/tratamento farmacológico , Neoplasias Císticas, Mucinosas e Serosas/tratamento farmacológico , Neoplasias Epiteliais e Glandulares/tratamento farmacológico , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Peritoneais/tratamento farmacológico , Adenocarcinoma/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carboplatina/administração & dosagem , Carcinoma Epitelial do Ovário , Estudos de Coortes , Neoplasias das Tubas Uterinas/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Císticas, Mucinosas e Serosas/patologia , Neoplasias Epiteliais e Glandulares/patologia , Neoplasias Ovarianas/patologia , Paclitaxel/administração & dosagem , Neoplasias Peritoneais/patologia , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: Primary melanomas originating from the gynaecological tract are rare and aggressive cancers. The 5-year survival is around 10%. The majority of tumours differ from cutaneous melanomas, which arise from the skin, by developing from melanocytes located in mucosal epithelium. The clinical behaviour, prognosis and the biology of mucosal melanomas are distinct from cutaneous melanomas. In this article, we summarize the current management of melanomas of the gynaecological tract (vulva, vagina, ovary and cervix) and discuss the progress in developing new treatments. RECENT FINDINGS: The management of mucosal melanomas has not changed substantially over the last decade and the prognosis remains poor. Surgery remains the primary treatment of choice in all localized melanomas of the genital tract. Radiotherapy and chemotherapy are options but have limited success for the majority of women. Activation of c-KIT occurs in vulvar melanomas. Clinical trials of targeted agents are underway. SUMMARY: As a result of the rarity of gynaecological tract melanomas, challenges associated with their anatomical locations and resistance to conventional radiotherapy and chemotherapy, this group of conditions remain difficult to treat and continue to have a poor prognosis. A greater understanding of the molecular profile of these cancers may provide promising targeted approaches.