Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist.

Answer questions and earn CME/CNE Sexual concerns are prevalent in women with cancer or cancer history and are a factor in patient decision making about cancer treatment and risk-reduction options. Physical examination of the female cancer patient with sexual concerns, regardless of the type or site of her cancer, is an essential and early component of a comprehensive evaluation and effective treatment plan. Specialized practices are emerging that focus specifically on evaluation and treatment of women with cancer and sexual function problems. As part of a specialized evaluation, oncologists and their patients should expect a thorough physical examination to identify or rule out physical causes of sexual problems or dysfunction. This review provides oncology professionals with a description of the physical examination of the female cancer patient with sexual function concerns. This description aims to inform anticipatory guidance for the patient and to assist in interpreting specialists' findings and recommendations. In centers or regions where specialized care is not yet available, this review can also be used by oncology practices to educate and support health care providers interested in expanding their practices to treat women with cancer and sexual function concerns. CA Cancer J Clin 2016;66:241-263. © 2016 American Cancer Society.

Patient reported improvement in sexual health outcomes following care in a sexual health clinic for women with cancer.

PURPOSE: Sexual health concerns are common among female cancer survivors. Few data exist regarding patient-reported outcomes following interventions in this population. We aimed to determine patient-reported adherence and impact of interventions provided in an academic specialty clinic for treatment of sexual health problems. METHODS: A cross-sectional quality improvement survey regarding sexual problems, adherence with recommended therapies, and improvement following intervention was administered to all women seen at the Women's Integrative Sexual Health (WISH) program at the University of Wisconsin-Madison between November 2013 and July 2019. Descriptive and Kruskal-Wallis tests were used to explore differences between groups. RESULTS: Two hundred twenty women (median age at first visit = 50 years, 53.1% breast cancer) were identified; N =113 surveys were completed (response rate = 49.6%). The most common presenting complaints were pain with intercourse (87.2%), vaginal dryness (85.3%), and low libido (82.6%). Menopausal women were more likely than premenopausal women to present with vaginal dryness (93.4% vs. 69.7%, p = .001) and pain with intercourse (93.4% vs. 76.5%, p = .02). Nearly all women adhered to recommendations for vaginal moisturizers/lubricants (96.9-100%) and vibrating vaginal wands (82.4-92.3%). A majority found recommended interventions helpful regardless of menopausal status or cancer type and reported persistent improvement. Nearly all women had improvement in understanding sexual health (92%) and would recommend the WISH program to others (91%). CONCLUSION: Women with cancer report integrative sexual health care to address sexual problems that are helpful and result in long-term improvement. Patients are overall highly adherent to recommended therapies, and nearly all would recommend the program to others. IMPLICATIONS FOR CANCER SURVIVORS: Dedicated care to address sexual health in women after cancer treatment improves patient-reported sexual health outcomes across all cancer types.

Obesity and "obesity-related" cancers: are there body mass index cut-points?

BACKGROUND: Despite compelling links between excess body weight and cancer, body mass index (BMI) cut-points, or thresholds above which cancer incidence increased, have not been identified. The objective of this study was to determine if BMI cut-points exist for 14 obesity-related cancers. SUBJECTS/METHODS: In this retrospective cohort study, patients 18-75 years old were included if they had ≥2 clinical encounters with BMI measurements in the electronic health record (EHR) at a single academic medical center from 2008 to 2018. Patients who were pregnant, had a history of cancer, or had undergone bariatric surgery were excluded. Adjusted logistic regression was performed to identify cancers that were associated with increasing BMI. For those cancers, BMI cut-points were calculated using adjusted quantile regression for cancer incidence at 80% sensitivity. Logistic and quantile regression models were adjusted for age, sex, race/ethnicity, and smoking status. RESULTS: A total of 7079 cancer patients (mean age 58.5 years, mean BMI 30.5 kg/m2) and 270,441 non-cancer patients (mean age 43.8 years, mean BMI 28.8 kg/m2) were included in the study. In adjusted logistic regression analyses, statistically significant associations were identified between increasing BMI and the incidence of kidney, thyroid, and uterine cancer. BMI cut-points were identified for kidney (26.3 kg/m2) and uterine (26.9 kg/m2) cancer. CONCLUSIONS: BMI cut-points that accurately predicted development kidney and uterine cancer occurred in the overweight category. Analysis of multi-institutional EHR data may help determine if these relationships are generalizable to other health care settings. If they are, incorporation of BMI into the screening algorithms for these cancers may be warranted.

The Society of Gynecologic Oncology wellness curriculum pilot: A groundbreaking initiative for fellowship training.

OBJECTIVES: Trainee well-being is a core component of ACGME program requirements and the SGO has recognized the high incidence of burnout among gynecologic oncologists and its negative impact. To foster a culture of wellness throughout the SGO community we sought to engage current fellows along with fellowship directors in a structured didactic program designed to teach wellness. We evaluated the feasibility of and preliminary responses to a pilot curriculum designed to teach skills that promote wellness and prevent burnout. METHODS: The SGO Wellness Taskforce developed a curriculum with topics based on established evidence as well as specialty specific stressors such as end of life discussions. Faculty leaders from 15 pilot-sites attended a full-day training course and then taught four modules over four months. Interactive modules engaged fellows through reflective writing, guided discussion, and multimedia presentations. Fellows completed the Perceived Stress Scale pre- and post-implementation and provided feedback regarding attitudes toward wellness and the individual modules. Faculty curriculum leaders completed surveys regarding their attitudes toward the curriculum as well as their trainees' reactions. RESULTS: Among 73 participating gynecologic oncology fellows, 95% (69/73) and 52/73 (71%) completed the pre-and post-surveys, respectively. Only 34/73 (49%) respondents reported that there was wellness programming at their institution prior to the initiation of the SGO curriculum. At institutions where such programming was available, 35% (12/34) reported not utilizing them. Fifty-five (80%) fellows had PSS scores greater than 12 compared to 39 (75%) post-intervention. After the curriculum, the percentage of fellows comfortable discussing wellness topics increased from 63 to 74%. Prior to the curriculum, 75% felt they could identify symptoms of burnout or psychosocial distress. This increased to 90% post-intervention. The modules were well received by fellows, and the time spent addressing wellness was widely appreciated. CONCLUSIONS: A structured curriculum to promote wellness among gynecologic oncology fellows is feasible and was associated with observed decreased reported stress among fellows at participating programs. This curriculum addresses ACGME requirements regarding trainee well-being, and showed potential for more programmatic, nationwide implementation. Fellowship culture change was not directly measured, but may have been one of the most significant positive outcomes of the wellness program. Further longitudinal studies will be necessary to understand the natural course of fellow burnout and the impact of structured wellness programming.

Using simple radiologic measurements to anticipate surgical challenge in endometrial cancer: a prospective study.

OBJECTIVES: To determine if linear measurements of adiposity from pre-operative imaging can improve anticipation of surgical difficulty among endometrial cancer patients. METHODS: Eighty patients with newly diagnosed endometrial cancer were enrolled. Routine pre-operative imaging (MRI or CT) was performed. Radiologic linear measurements of the following were obtained: anterior-to-posterior skin distance; anterior skin to anterior edge of L5 distance (total anterior); anterior peritoneum to anterior edge of L5 distance (visceral obesity); and posterior edge of L5 to posterior skin distance (total posterior). Surgeons completed questionnaires quantifying preoperative anticipated operative difficulty and postoperative reported operative difficulty. The primary objective was to assess for a correlation between linear measurements of visceral fat and reported operative difficulty. RESULTS: Seventy-nine patients had questionnaires completed, preoperative imaging obtained, and surgery performed. Univariate analysis showed all four linear measurements, body mass index, weight, and anticipated operative difficulty were associated with increased reported operative difficulty (P< 0.05). Multivariate analysis demonstrated that body mass index and linear measurements visceral obesity and total posterior were independently associated with increased reported operative difficulty (P< 0.05). Compared with body mass index, the visceral obesity measurement was more sensitive and specific for predicting increased reported operative difficulty (visceral obesity; sensitivity 54%, specificity 91 %; body mass index; sensitivity 38%, specificity 89%). A difficulty risk model combining body mass index, visceral obesity, and total posterior demonstrated better predictive performance than any individual preoperative variable. CONCLUSIONS: Simple linear measurements of visceral fat obtained from preoperative imaging are more predictive than body mass index alone in anticipating surgeon-reported operative difficulty. These easily obtained measurements may assist in preoperative decision making in this challenging patient population.

Abuse, cancer and sexual dysfunction in women: A potentially vicious cycle.

More than 30% of women have a history of abuse. Women with cancer may be at substantially increased risk for abuse, but this issue is rarely discussed in the course of oncology care. Women with a history of abuse who present for cancer care commonly have a high prevalence of co-morbid illness. Sexual dysfunction, a highly prevalent but under-recognized condition among women of all ages, is also more common among both women with a history of abuse and women with cancer. Although common after cancer, sexual dysfunction, like abuse, can be stigmatizing and often goes undiagnosed and untreated. This review first examines the literature for evidence of a relationship between any history of abuse and cancer among women, addressing two questions: 1) How does abuse promote or create risk for developing cancer? 2) How does cancer increase a woman's susceptibility to abuse? We then examine evidence for a relationship between abuse and female sexual dysfunction, followed by an investigation of the complex relationship between all three factors: abuse, sexual dysfunction and cancer. The literature is limited by a lack of harmonization of measures across studies, retrospective designs, and small and idiosyncratic samples. Despite these limitations, it is imperative that providers integrate the knowledge of this complex relationship into the care of women with cancer.

Preoperative obstructive sleep apnea screening in gynecologic oncology patients.

BACKGROUND: Women with a gynecologic cancer tend to be older, obese, and postmenopausal, characteristics that are associated with an increased risk for obstructive sleep apnea. However, there is limited investigation regarding the condition's prevalence in this population or its impact on postoperative outcomes. In other surgical populations, patients with obstructive sleep apnea have been observed to be at increased risk for adverse postoperative events. OBJECTIVE: We sought to estimate the prevalence of obstructive sleep apnea among gynecologic oncology patients undergoing elective surgery and to investigate for a relationship between obstructive sleep apnea and postoperative outcomes. STUDY DESIGN: Patients referred to an academic gynecologic oncology practice were approached for enrollment in this prospective, observational study. Patients were considered eligible for study enrollment if they were scheduled for a nonemergent inpatient surgery and could provide informed consent. Enrolled patients were evaluated for a preexisting diagnosis of obstructive sleep apnea. Those without a prior diagnosis were screened using the validated, 4-item STOP questionnaire (ie, Snore loudly, daytime Tiredness, Observed apnea, elevated blood Pressure). All patients who screened positive for obstructive sleep apnea were referred for polysomnography. The primary outcome was the prevalence of women with obstructive sleep apnea or those who screened at high risk for the condition. Secondary outcomes examined the correlation between body mass index (kg/m2) with obstructive sleep apnea and assessed for a relationship between obstructive sleep apnea and postoperative outcomes. RESULTS: Over a 22-month accrual period, 383 eligible patients were consecutively approached to participate in the study. A cohort of 260 patients were enrolled. A total of 33/260 patients (13%) were identified as having a previous diagnosis of obstructive sleep apnea. An additional 66/260 (25%) screened at risk for the condition using the STOP questionnaire. Of the patients who screened positive, 8/66 (12%) completed polysomnography, all of whom (8/8 [100%]) were found to have obstructive sleep apnea. The prevalence of previously diagnosed obstructive sleep apnea or screening at risk for the condition increased as body mass index increased (P < .001). Women with untreated obstructive sleep apnea and those who screened at risk for the condition were found to have an increased risk for postoperative hypoxemia (odds ratio, 3.5; 95% confidence interval, 1.8-4.7; P = .011) and delayed return of bowel function (odds ratio, 2.1; 95% confidence interval, 1.3-4.5; P = .009). CONCLUSION: The prevalence of obstructive sleep apnea or screening at risk for the condition is high among women presenting for surgery with a gynecologic oncologist. Providers should consider evaluating a patient's risk for obstructive sleep apnea in the preoperative setting, especially when risk factors for the condition are present.

Surgical outcomes among elderly women with endometrial cancer treated by laparoscopic hysterectomy: a NRG/Gynecologic Oncology Group study.

OBJECTIVE: Tolerance of and complications caused by minimally invasive hysterectomy and staging in the older endometrial cancer population is largely unknown despite the fact that this is the most rapidly growing age group in the United States. The objective of this retrospective review was to compare operative morbidity by age in patients on the Gynecologic Oncology Group Laparoscopic Surgery or Standard Surgery in Treating Patients With Endometrial Cancer or Cancer of the Uterus (LAP2) trial. STUDY DESIGN: This is a retrospective analysis of patients from Gynecologic Oncology Group LAP2, a trial that included clinically early-stage uterine cancer patients randomized to laparotomy vs laparoscopy for surgical staging. Differences in the rates and types of intraoperative and perioperative complications were compared by age. Specifically complications between patients <60 vs ≥60 years old were compared caused by toxicity analysis showing a sharp increase in toxicity starting at age 60 years in the laparotomy group. RESULTS: LAP2 included 1477 patients ≥60 years old. As expected, with increasing age there was worsening performance status and disease characteristics including higher rates of serous histology, high-stage disease, and lymphovascular space invasion. There was no significant difference in lymph node dissection rate by age for the entire population or within the laparotomy or laparoscopy groups. Toxicity analysis showed a sharp increase in toxicity seen in patients ≥60 years old in the laparotomy group. Further analysis showed that when comparing laparotomy with laparoscopy in patients <60 years old vs ≥60 years old and controlling for race, body mass index, stage, grade, and performance status, patients <60 years old undergoing laparotomy had more hospital stays >2 days (odds ratio, 17.48; 95% confidence interval, 11.71-27.00, P < .001) compared with patients <60 years old undergoing laparoscopy. However, when comparing laparotomy with laparoscopy in patients ≥60 years old, in addition to hospital stay >2 days (odds ratio, 12.77; 95% confidence interval, 8.74-19.32, P < .001), there were higher rates of the following postoperative complications: antibiotic administration (odds ratio, 1.63; 95% confidence interval, 1.24-2.14, P < .001), ileus (odds ratio, 2.16; 95% confidence interval, 1.42-3.31, P <0.001), pneumonias (odds ratio, 2.36; 95% confidence interval, 1.01-5.66, P = .048), deep vein thromboses (odds ratio, 2.87; 95% confidence interval, 1.08-8.03, P = .035), and arrhythmias (odds ratio, 3.21; 95% confidence interval, 1.60-6.65, P = .001) in the laparotomy group. CONCLUSION: Laparoscopic staging for uterine cancer is associated with decreased morbidity in the immediate postoperative period in patients ≥60 years old. These results allow for more accurate preoperative counseling. A minimally invasive approach to uterine cancer staging may decrease morbidity that could affect long-term survival.

A phase II evaluation of ixabepilone in the treatment of recurrent/persistent carcinosarcoma of the uterus, an NRG Oncology/Gynecologic Oncology Group study.

BACKGROUND: The primary objectives were to determine the objective response rate (ORR) and safety profile of ixabepilone in women with recurrent or persistent uterine carcinosarcoma (UCS). Secondary objectives included progression-free survival (PFS) and overall survival (OS). Exploratory translational objectives included characterization of class III beta tubulin expression and its association with response, PFS, and OS. METHODS: Patients had measurable disease; up to two prior chemotherapeutic regimens were allowed, but must have included a taxane. Women received ixabepilone 40mg/m2 as a 3hour IV infusion on day 1 of a 21daycycle. Treatment was continued until disease progression or unacceptable toxicity occurred. RESULTS: Forty-two women were enrolled, with 34 eligible and evaluable. Median age was 68years. ECOG performance status was 0 in 56% of women, 38% had received radiation, and 15% had received 2 lines of chemotherapy. Overall ORR was 11.8% (4/34, 90% CI 4.2-25.1%); all were partial responses. Stable disease for at least 8weeks was achieved in 8 patients (23.5%). Median PFS and OS were 1.7mo and 7.7mo, respectively, with a median follow-up of 37mo. Six month PFS was 20.6%. Major grade≥3 toxicities were neutropenia (47%), fatigue (15%), dehydration (15%), hypertension (15%), and hyponatremia (15%); grade 2 peripheral neuropathy was reported in 18%. In this small sample size, class III beta tubulin expression in the primary tumor was not associated with the response to ixabepilone, PFS, or OS. CONCLUSION: In this cohort of women, single agent ixabepilone showed modest but insufficient clinical activity.

Maintaining sexual health throughout gynecologic cancer survivorship: A comprehensive review and clinical guide.

OBJECTIVE: The diagnosis and treatment of gynecologic cancer can cause short- and long-term negative effects on sexual health and quality of life (QoL). The aim of this article is to present a comprehensive overview of the sexual health concerns of gynecologic cancer survivors and discuss evidence-based treatment options for commonly encountered sexual health issues. METHODS: A comprehensive literature search of English language studies on sexual health in gynecologic cancer survivors and the treatment of sexual dysfunction was conducted in MEDLINE databases. Relevant data are presented in this review. Additionally, personal and institutional practices are incorporated where relevant. RESULTS: Sexual dysfunction is prevalent among gynecologic cancer survivors as a result of surgery, radiation, and chemotherapy-negatively impacting QoL. Many patients expect their healthcare providers to address sexual health concerns, but most have never discussed sex-related issues with their physician. Lubricants, moisturizers, and dilators are effective, simple, non-hormonal interventions that can alleviate the morbidity of vaginal atrophy, stenosis, and pain. Pelvic floor physical therapy can be an additional tool to address dyspareunia. Cognitive behavioral therapy has been shown to be beneficial to patients reporting problems with sexual interest, arousal, and orgasm. CONCLUSION: Oncology providers can make a significant impact on the QoL of gynecologic cancer survivors by addressing sexual health concerns. Simple strategies can be implemented into clinical practice to discuss and treat many sexual issues. Referral to specialized sexual health providers may be needed to address more complex problems.

Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients.

OBJECTIVE: SSI rates after gynecologic oncology surgery vary from 5% to 35%, but are up to 45% in patients with diabetes mellitus (DM). Strict postoperative glucose control by insulin infusion has been shown to lower morbidity, but not specifically SSI rates. Our project studied continuous postoperative insulin infusion for 24h for gynecologic oncology patients with DM and hyperglycemia with a target blood glucose of <139 mL/dL and a primary outcome of the protocol's impact on SSI rates. METHODS: We compared SSI rates retrospectively among three groups. Group 1 was composed of patients with DM whose blood glucose was controlled with intermittent subcutaneous insulin injections. Group 2 was composed of patients with DM and postoperative hyperglycemia whose blood glucose was controlled by insulin infusion. Group 3 was composed of patients with neither DM nor hyperglycemia. We controlled for all relevant factors associated with SSI. RESULTS: We studied a total of 372 patients. Patients in Group 2 had an SSI rate of 26/135 (19%), similar to patients in Group 3 whose rate was 19/89 (21%). Both were significantly lower than the SSI rate (43/148, 29%) of patients in Group 1. This reduction of 35% is significant (p = 0.02). Multivariate analysis showed an odd ratio = 0.5 (0.28-0.91) in reducing SSI rates after instituting this protocol. CONCLUSIONS: Initiating intensive glycemic control for 24h after gynecologic oncology surgery in patients with DM and postoperative hyperglycemia lowers the SSI rate by 35% (OR = 0.5) compared to patients receiving intermittent sliding scale insulin and to a rate equivalent to non-diabetics.

Sexual health education in U.S. physician assistant programs.

INTRODUCTION: Since the 1950s, sexual health education in medical schools has been evaluated and reported upon, but there has never been an assessment published about sexual health curricula in U.S. physician assistant (PA) programs. AIM: The aim of this study was to gain better understanding of how PA programs cover sexual health topics. METHODS: Between January and March 2014, 181 accredited PA programs received a mailed survey inquiring about their sexual health curriculum. MAIN OUTCOME MEASURES: The survey assessed general sexual health topics; lesbian, gay, bisexual, transgender (LGBT) topics; teaching methods; and the amount of time spent on sexual health education. RESULTS: A total of 106 programs responded (59%). Ten programs offered a required, discrete course on human sexuality. The majority incorporated training into other coursework, which is consistent with most medical schools. LGBT topics were covered less thoroughly than the general sexual health topics. Total amount of time spent on sexual health topics varied widely among programs, from a minimum of 2-4 hours to a maximum of 60 hours, with a median of 12 hours. CONCLUSIONS: PA programs in the United States appear to compare favorably with the training offered to medical students in regard to time spent on sexual health education. Transgender issues were least well-covered of all the topics queried.

Robotic surgery for early stage cervical cancer: Evolution and current trends.

The management of early stage cervical cancer often includes surgery in the form of radical hysterectomy, radical trachelectomy, or radical parametrectomy. Surgical techniques have evolved to include minimal invasive approaches, and more recently, to include robotic assisted techniques. This review highlights the evolution of surgical management of early cervical cancer and specifically explores robotic assisted radical hysterectomy, radical trachelectomy, radical parametrectomy, and the role of neoadjuvant chemotherapy.

Preoperative Pelvic MRI and Serum Cancer Antigen-125: Selecting Women With Grade 1 Endometrial Cancer for Lymphadenectomy.

OBJECTIVE: The objective of our study was to determine the predictive value of preoperative pelvic MRI and serum cancer antigen-125 (CA-125) evaluation in selecting women with grade 1 endometrial cancer for lymphadenectomy as part of the cancer staging operation. MATERIALS AND METHODS: A new preoperative clinical protocol including MRI and CA-125 evaluation was adopted at our institution in patients with grade 1 endometrioid adenocarcinoma. Lymphadenectomy was considered as part of the surgical staging operation if there was an elevated CA-125 value or a positive MRI finding (≥ 50% myometrial invasion, cervical invasion, abnormal lymph nodes, extrauterine disease, or tumor index ≥ 36 cm). From January 2012 through May 2013, a retrospective analysis was performed of 100 women who underwent preoperative MRI and CA-125 evaluation; we refer to this cohort as the "preoperative study cohort." The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using final surgical pathology and CA-125 results as the reference standard. The rate of metastatic lymph nodes in the preoperative study cohort was determined. From May 2009 through January 2011, a retrospective analysis of a cohort who did not undergo preoperative MRI and CA-125 evaluation was undertaken to compare lymphadenectomy and lymph node metastasis rates before and after implementation of the new protocol; we refer to this cohort as the "historical cohort." RESULTS: The new clinical protocol had sensitivity of 94%, specificity of 91%, PPV of 84%, and NPV of 97%. When histologic grade alone was considered, positive lymph node rates in the preoperative study cohort was 4.0% versus 4.2% in the historical cohort. In the preoperative study cohort, the lymph node metastasis rate increased to 11.1% with a positive MRI finding or elevated CA-125 value. CONCLUSION: Preoperative MRI and CA-125 evaluation identified women for lymphadenectomy with a high NPV.

Uterine rupture disguised by urinary retention following a second trimester induced abortion: a case report.

BACKGROUND: Uterine rupture classically presents with severe abdominal pain, loss of fetal station, vaginal bleeding, and shock. CASE PRESENTATION: We present a case of uterine rupture presenting as significant urinary retention that occurred following a second trimester abortion induced with mifepristone and misoprostol. Uterine rupture was discovered unexpectedly on diagnostic laparoscopy. The uterine rupture was contained by dense adhesions between the omentum and bladder with the previous uterine cesarean hysterotomy scar. CONCLUSION: This case highlights the difficulties in diagnosis of abnormal placentation and an unusual presentation of uterine rupture. This case was managed successfully laparoscopically.

Diminished Utilization of in Vitro Fertilization Following Ovarian Transposition in Cervical Cancer Patients.

OBJECTIVE: To assess subsequent utilization of fertility treatment in reproductive-age women with cervical cancer (CC) who underwent ovarian transposition (OT) to preserve fertility prior to pelvic radiation. STUDY DESIGN: This is a case series of 216 CC patients seen in a comprehensive cancer center. Sixteen patients underwent OT for fertility preservation prior to pelvic radiation. Patients were assessed for utilization of fertility treatment, follicle-stimulating hormone (FSH) levels as a measure of ovarian reserve, and functional assessment of chronic illness therapy-cervix cancer (FACT-CX) to assess quality of life after OT. RESULTS: Of the patients, 94% of patients [corrected] maintained regular menstrual cycles 3 years after ovarian transposition (OT) [corrected] surgery (15/16). When measured (n = 5), serum FSH was normal at baseline and showed a transient elevation at 3 months following chemoradiation, with a return to normal levels at 6 months (means, 6.33 ± 2.94, 48.44 ± 18.63, and 12.52 ± 8.25 mIU/mL, respectively). Only 1 patient in this series attempted fertility treatment (in vitro fertilization) following OT, and she did not become pregnant. FACT-CX indicated that quality of life did not change significantly over the 6 months' duration following OT and chemoradiation therapy. CONCLUSION: OT preserves menstrual cycle regularity without negatively impacting patients' quality of life. The utility of OT as an effective fertility preservation option is hampered by the low utilization rate of in vitro fertilization and lack of ovarian reserve assessment following OT.

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies.

OBJECTIVE: To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery. METHODS: Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (<3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value. RESULTS: Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels. According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47-2.73, p<0.0001), three or more complications (OR-4.1,CI: 2.31-7.1, p<0.0001), surgical complications (OR-2.39,CI: 1.59-3.58, p<0.0001), thromboembolic complications (OR-2.59,CI: 1.33-5.06, p<0.0001), pulmonary complications (OR-4.06,CI: 2.05-8.03, p<0.0001), or infectious complications (OR-1.84,CI: 1.26-2.69, p<0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51-16.95, p<0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery. In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3g/dl. CONCLUSION: Preoperative albumin levels <3g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.

The role of appendectomy for mucinous ovarian neoplasms.

OBJECTIVE: To determine how frequently the appendix harbors pathology in women having surgery for mucinous neoplasms of the ovary and assess the associated morbidity. STUDY DESIGN: A retrospective chart review of patients operated on at our institution with the diagnosis of a mucinous neoplasm of the ovary or appendix. RESULTS: A total of 327 cases were identified. Of the 309 women with mucinous ovarian neoplasms, 197 (64%) were benign, 68 (22%) low malignancy potential, and 44 (14%) were invasive. Of 155 appendectomies performed, only 1 metastatic low grade mucinous appendiceal tumor was found, but this appendix was grossly abnormal. There was no association between wound complications and appendectomy. CONCLUSION: When a grossly normal appendix is removed during surgery for a mucinous ovarian neoplasm without evidence of pseudomyxoma peritonei, no primary or metastatic mucinous appendiceal tumors are found.

A new diagnostic test for endometrial cancer?: Cytology analysis of sonohysterography distention media.

OBJECTIVE: During saline-infused sonohysterography (SIS), the distension fluid is typically discarded. If cytology analysis could identify those patients with endometrial cancer, many women would be spared from further procedures. METHODS: Thirty consecutive patients with clinical stage I or II endometrial adenocarcinoma were prospectively recruited preoperatively. Saline-infused sonohysterography was performed by instilling 5 mL of saline, withdrawing and sending for analysis. Saline was reinfused until complete SIS images were obtained and sent separately for cytology. RESULTS: Of the 30 women enrolled, SIS was technically successful in 29. Demographics included mean age (60.5 ± 6.99 years), body mass index (35.55 ± 8.18 kg/m), endometrioid histology (76%), and grade (grade 1, 67%). Prestudy diagnostic method included biopsy (70%), dilatation and curettage (17%), and hysteroscopy (10%). Adequate cytology specimens were obtained in 66% of the 5 mL flushes and 72% of the complete SIS collections. Of adequate specimens, the sensitivities to detect endometrial cancer for the 5-mL, complete, and combined fluid samples were 26% (95% confidence interval, 9%-51%), 36% (17%-59%), and 42% (22%-63%). Sensitivity based on the whole study sample (N = 30) was 33% (17%-53%). Statistical significance was not found in the association between a positive test and age, body mass index, grade, diagnostic method, or volume instilled or aspirated. CONCLUSIONS: Most patients with early endometrial cancer can undergo SIS procedures with adequate cytology specimens obtained from distention media. However, the sensitivity is low, and refinements are necessary before utilizing as a diagnostic test. In cases with positive results, the patient may be able to avoid other costly and painful procedures.

Fluorescein Mapping in Vulvar Paget Disease.

BACKGROUND: Vulvar Paget disease often requires extensive and, in some cases, multiple resections to treat. A fluorescein-mapping procedure followed by a staged vulvectomy may be an effective technique to tailor resection and identify clinically occult lesions. TECHNIQUE: We describe a two-step procedure; first, intravenous fluorescein sodium is injected, and the vulva is illuminated with a Wood's lamp. Representative biopsies are obtained and correlated on final pathology with the extent of disease to develop a final plan for excision. Second, using fluorescein to identify the confirmed areas of disease, the appropriate excisional procedure is performed once mapping biopsy pathology is known. EXPERIENCE: We describe our experience with eight patients with vulvar Paget disease undergoing fluorescein mapping biopsies and staged vulvectomy. Using intravenous fluorescein sodium, all patients were found to have Paget disease beyond the visible margins of their gross lesions. No patients experienced a recurrence of Paget disease within a median follow-up time of 32 months, comparable with other directed methods of surgical resection. CONCLUSION: We report a technique for the injection of fluorescein sodium for the visualization of vulvar Paget disease capable of providing accurate surgical margins and identification of occult satellite lesions with a high degree of safety and a favorable cost profile. This staged approach to vulvectomy could offer improved accuracy of resection for vulvar Paget disease with few drawbacks.