Impact of tumour histology on survival in advanced cervical carcinoma: an NRG Oncology/Gynaecologic Oncology Group Study.

BACKGROUND: Based primarily on studies concerning early-stage tumours (treated surgically), and locally advanced disease (treated with chemoradiation), the prognosis for women with adenocarcinoma (AC) or adenosquamous (AS) carcinoma has been reported to be poorer than those with squamous cell carcinoma (SCCA) of the cervix. It is unclear whether differences in prognosis also persist in the setting of recurrent or metastatic disease treated using chemotherapy doublets with or without bevacizumab. METHODS: Cases were pooled from three Gynaecologic Oncology Group randomised phase III trials of chemotherapy doublets. Pearson's test was used to evaluate response rate (RR) of AC/AS vs SCCA, Kaplan-Meier method to estimate progression-free survival (PFS) and overall survival (OS), and Cox proportional hazards model to estimate the impact of histology on PFS and OS. RESULTS: Of 781 evaluable patients, 77% (N=599) had SCCA and 23% (N=182) AC/AS. There were no significant differences in RRs between histologic subgroups. The adjusted hazard ratio (HR) for death for SCCA vs AC/AS was 1.13 (95% CI 0.93, 1.38 P=0.23). When comparing SC/AS (N=661, 85%) to AC alone (N=120, 15%), the adjusted HR for death was 1.23 (95% CI 0.97, 1.57, P=0.09). CONCLUSIONS: AC/AS and SCCA have similar survival in recurrent or metastatic cervical carcinoma when treated with chemotherapy doublets.

Sonographic Diagnosis and Management With Delayed Hysterectomy of Two Cesarean Scar Pregnancies That Developed Into Placenta Percreta: Two Case Reports.

Approximately two-thirds of the patients with a cesarean scar pregnancy (CSP) will develop placenta accreta spectrum (PAS). PAS occurs when the placenta attaches too deeply to the uterine wall, and sometimes, the placenta can extend beyond the uterus, invading surrounding organs. PAS is commonly managed with a cesarean hysterectomy, and these deliveries are often complicated by maternal and fetal morbidity and mortality. However, delaying hysterectomy and using chemotherapeutic agents may be a safe and beneficial alternative. We describe the case of a 32 -year-old G3P2002 with a history of two prior cesarean sections (CS) who was referred to our Maternal Fetal Medicine department due to the concern of a gestational sac embedded in the anterior uterine wall in the cesarean scar. Magnetic resonance imaging (MRI) findings at 33 weeks confirmed that the patient had developed placenta percreta extending into the sigmoid colon. We also describe the case of a 30-year-old G6P4104 with a history of four prior CS who was referred to our department for concern of a pregnancy complicated by CSP. This patient had an MRI performed at 23 weeks that showed placenta percreta invading the bladder. Patients one and two were managed with a staged procedure, with CS followed by a delayed laparoscopic and abdominal hysterectomy, respectively, to minimize bowel and bladder injury. After the CS, the patients subsequently received a five-day course of intravenous (IV) etoposide 100mg/m2, and at six weeks postpartum, the patients had a hysterectomy, both showing resolution of the placenta invasion into the surrounding organs on postpartum MRI and confirmed by tissue pathology reports. Our cases present the challenge in diagnosis and management of the most severe presentation of PAS that varies from the generally accepted management recommendations. Delayed hysterectomy with chemotherapy can be a reasonable, conservative surgical approach in the most severe types of PAS. As in our cases, this management could improve maternal and fetal morbidity and mortality.

Primary radiation therapy for medically inoperable patients with clinical stage I and II endometrial carcinoma.

OBJECTIVE: To determine the outcomes associated with primary radiation therapy for medically inoperable, clinical stage I and II, endometrial adenocarcinoma (EAC). METHODS: A multi-institution, retrospective chart review from January 1997 to January 2009 was performed. Overall survival (OS), disease-specific survival (DSS), progression-free survival (PFS) and time to progression (TTP) were assessed using the Kaplan-Meier method. Disease-specific survival was analyzed using a competing risks approach. RESULTS: Seventy-four patients were evaluable. The median age and BMI were 65 years (range 36-92 years) and 46 kg/m(2) (range 23-111 kg/m(2)), respectively. 85.1% had severe systemic disease, most frequently cardiopulmonary risk and morbid obesity. With a mean follow-up of 31 months, 13 patients (17.6%) experienced a recurrence. The median PFS and OS were 43.5 months and 47.2 months, respectively. Overall, 35 women died, including 4 women who died of unknown cause. Of the remaining 31 women, 7 patients (9.5%) died of disease, while 24 died of other causes (32.4%). The hazard ratio comparing the risk of death due to other causes to the risk of death due to disease was 3.4 (95% CI 1.4-9.4, p=0.003). Among patients who are alive three years after diagnosis, 14% recurred and the conditional recurrence estimate did not exceed 16%. CONCLUSIONS: Primary radiation therapy for clinical stage I and II EAC is a feasible option for medically inoperable patients and provides disease control, with fewer than 16% of surviving patients experiencing recurrence.

Minimally invasive surgery versus laparotomy in women with high grade endometrial cancer: a multi-site study performed at high volume cancer centers.

OBJECTIVE: The study aim was to compare outcomes in women with high-grade endometrial cancer (EC) who underwent surgical staging via minimally invasive surgery (MIS) versus laparotomy. METHODS: This is a retrospective, multi-institutional cohort study of patients with high-grade EC who were comprehensively surgically staged by either MIS or laparotomy. Demographic, surgical variables, complications, and survival were analyzed. RESULTS: Three hundred and eighty-three patients met criteria: 191 underwent laparotomy and 192 MIS (65% robotic, 35% laparoscopy). Subgroups were well matched by age (mean 66 years), stage, body mass index, histology and adjuvant therapies. Median operative time was longer in the MIS group (191 vs. 135 min; p<.001). However, the MIS cohort had a higher mean lymph node count (39.0 vs. 34.0; p=.03), shorter hospital stay (1 vs. 4 days) and significantly fewer complications (8.4% vs. 31.3%; p<.001). There was no significant difference in lymph node count with laparoscopic versus robotic staging. With a median follow-up time of 44 months, progression-free (PFS) and overall survival were not significantly different between the surgical cohorts. On multivariable analysis, stage, treatment were associated with PFS. CONCLUSIONS: Women with high grade endometrial cancers staged by minimally invasive techniques experienced fewer complications and similar survival outcomes compared to those staged by laparotomy. As this population is elderly and most will receive adjuvant therapies, minimization of surgical morbidity is of interest. When managed by expert laparoscopists or robotic surgeons, a high-risk histologic subtype is not a contraindication to minimally invasive surgery in women with apparent early-stage disease.

Sexual function after intracavitary vaginal brachytherapy for early-stage endometrial carcinoma.

OBJECTIVE: To describe the effects of intracavitary brachytherapy (IVB) on sexual function and quality of life of women with early-stage endometrial cancer. METHODS: Women with International Federation of Gynecology and Obstetrics stage I to stage II endometrial cancer treated surgically with or without IVB were identified and mailed questionnaires. Quality of life and sexual function were measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the cervical cancer disease-specific module. Pertinent data from prior surgery and radiation treatments were abstracted retrospectively. Linear transformation of the survey subscale scores was conducted per European Organization for Research and Treatment of Cancer guidelines. RESULTS: Sixteen women in the IVB arm and 53 in the surgery-alone group completed the survey. Of the sexually active patients, 33% of the IVB patients and 42% of the surgery-alone patients felt their vagina was dry during sexual activity (P = 0.804) and 17% versus 20% felt their vagina was short (P = 0.884). Seventeen percent of patients in the IVB group felt their vagina was tight compared to 29% in the surgery-alone group (P = 0.891) and 0% versus 14% of patients reported pain during intercourse (P = 0.808). There was no statistically significant difference in sexual/vaginal functioning, sexual worry, or sexual enjoyment between the 2 groups. CONCLUSIONS: Although both groups report vaginal changes that may affect sexual function, the patients treated with IVB reported similar outcomes on a sexual function questionnaire compared to patients treated with surgery alone.

Evolution of the Gynecologic Oncology Group protocols in the treatment of epithelial ovarian cancer.

This chapter reviews some of the sentinel Gynecologic Oncology Group (GOG) ovarian trials, describes their rationale, provides summary tables for reference, and is organized into early ovarian cancer (GOG 1, 7601, 7602, 95, 157, 175, 212), advanced ovarian cancer optimal (2, 25, 52, 104, 114, 158, 172, 182, 178, 212, 252), and suboptimal disease (3, 22, 47, 97, 111, 162, 182, 218, 252, 262).

Cervical cancer survival for patients referred to a tertiary care center in Kentucky.

OBJECTIVES: To identify prognostic factors influencing cervical cancer survival for patients referred to a tertiary care center in Kentucky. METHODS: A cohort study was performed to assess predictive survival factors of cervical cancer patients referred to the University of Kentucky from January 2001 to May 2010. Eligibility criteria included those at least 18 years-old, cervical cancer history, and no prior malignancy. Descriptive statistics were compiled and univariable and multivariable Cox proportional hazard analysis were performed. RESULTS: 381 patients met entry criteria. 95% were Caucasian (N=347) and 66% (N=243) lived in Appalachian Kentucky. The following covariates showed no evidence of a statistical association with survival: race, body mass index, residence, insurance status, months between last normal cervical cytology and diagnosis, histology, tumor grade, and location of primary radiation treatment. After controlling for identified significant variables, stage of disease was a significant predictor of overall survival, with estimated relative hazards comparing stages II, III, and IV to stage I of 3.09 (95% CI: 1.30, 7.33), 18.11 (95% CI: 7.44, 44.06), and 53.03(95% CI: 18.16, 154.87), respectively. The presence of more than two comorbid risk factors and unemployment was also correlated with overall survival [HR 4.25 (95% CI: 1.00, 18.13); HR 2.64 (95% CI 1.29, 5.42), respectively]. CONCLUSIONS: Residence and location of treatment center are not an important factor in cervical cancer survival when a tertiary cancer center can oversee and coordinate care; however, comorbid risk factors influence survival and further exploration of disease comorbidity related to cervical cancer survival is warranted.

A black raspberry extract inhibits proliferation and regulates apoptosis in cervical cancer cells.

OBJECTIVE: Cervical cancer is the second most common female cancer worldwide, and it remains a challenge to manage preinvasive and invasive lesions. Food-based cancer prevention entities, such as black raspberries and their derivatives, have demonstrated a marked ability to inhibit preclinical models of epithelial cancer cell growth and tumor formation. Here, we extend the role of black raspberry-mediated chemoprevention to that of cervical carcinogenesis. METHODS: Three human cervical cancer cell lines, HeLa (HPV16-/HPV18+, adenocarcinoma), SiHa (HPV16+/HPV18-, squamous cell carcinoma) and C-33A (HPV16-/HPV18-, squamous cell carcinoma), were treated with a lyophilized black raspberry ethanol extract (RO-ET) at 25, 50, 100 or 200µg/ml for 1, 3 and 5days, respectively. Cell proliferation was measured by WST1 (tetrazolium salt cleavage) assays. Flow cytometry (propidium iodide and Annexin V staining) and fluorescence microscopy analysis were used to measure apoptotic cell changes. RESULTS: We found that non-toxic levels of RO-ET significantly inhibited the growth of human cervical cancer cells, in a dose-dependent and time-dependent manner to a maximum of 54%, 52% and 67%, respectively (p<0.05). Furthermore, cell growth inhibition was persistent following short-term withdrawal of RO-ET from the culture medium. Flow cytometry and fluorescence microscopy demonstrated RO-ET-induced apoptosis in all cell lines. CONCLUSION: Black raspberries and their bioactive components represent promising candidates for future phytochemical-based mechanistic pathway-targeted cancer prevention strategies.

Stage I, grade 3 endometrioid adenocarcinoma of the endometrium: an analysis of clinical outcomes and patterns of recurrence.

OBJECTIVE: To study patterns of recurrence and survival outcomes in patients with surgical stage I, grade 3 endometrioid adenocarcinoma of the endometrium (EA) treated with various treatment modalities. METHODS: A retrospective multi-institutional study of surgical stage I, grade 3 EA patients diagnosed between 1988 and 2006 was performed. Demographic, clinicopathologic, treatment and outcome data were collected. After surgery, patients were treated with either observation or radiotherapy (vaginal brachytherapy, whole pelvic or both). RESULTS: One hundred seventy-six patients were collected with a median age of 68 years. Twenty-six (15%) were stage IA, 96 (54%) IB and 54 (31%) IC. Sixty-one patients (35%) had lymphovascular space invasion (LVSI) and a mean of 18.9 lymph nodes (LNs) was removed. Seventy-eight patients (44%) were observed while 98 (56%) were treated with radiotherapy, the majority (n=51) receiving brachytherapy. After a median follow-up of 58 months, 20 recurrences (11%) were noted. Ninety percent of recurrences occurred in Stage IB/IC patients. The median time to recurrence was 22.5 months (5-74.5) and 80% of recurrences were extra-pelvic. There was no significant difference in recurrence based upon treatment modality or LVSI. Majority of recurrences were not salvaged as 75% (12/16) died of their disease with a median time of recurrence to death of 8 months. CONCLUSIONS: Patients with stage IB/IC, grade 3 endometrioid adenocarcinoma have a significant risk for extra-pelvic recurrence. Most patients will not be salvaged and will succumb to their disease, suggesting that current loco-regional adjuvant treatment strategies are not optimal and evaluation of more systemic therapies is warranted.

Risk of malignancy in sonographically confirmed septated cystic ovarian tumors.

OBJECTIVE: To determine the risk of malignancy in septated cystic ovarian tumors. MATERIALS: 1319 (4.4%) of 29,829 women were identified by transvaginal sonography (TVS) as having a complex cystic ovarian tumor with septations without solid areas or papillary projections and were placed on long-term ultrasound surveillance for ovarian malignancy. RESULTS: These 1319 patients had a total of 2870 septated cystic ovarian tumors. 2288 tumors (79.7%) had a septal width <2 mm and 582 (20.3%) had a septal width >or=2 mm. 2286 tumors (79.6%) were <5 cm in diameter and 584 (20.4%) were>or=5 cm in diameter. 1114 septated cystic tumors (38.8%) resolved spontaneously (mean duration to resolution-12 months) and 1756 (61.2%) tumors persisted. 128 patients underwent surgical tumor removal within 3 months of ultrasound. Most common histopathology was: serous cystadenoma (75), mucinous cystadenoma (13), and endometrioma (10). One patient had an ovarian tumor of borderline malignancy (Stage IB). There were no cases of ovarian cancer. Patients were followed from 4 to 252 months (mean-77 months). One patient developed papillary morphology in the contralateral ovary 3.2 years after detection of a septated ovarian cyst and had epithelial ovarian cancer in that ovary and in the omentum (Stage IIIC disease). The remaining patients are all free of ovarian neoplasia after a total of 7642 follow-up years. CONCLUSIONS: Septated cystic ovarian tumors without solid areas or papillary projections have a low risk of malignancy and can be followed sonographically without surgery.

Is there a high-risk subgroup of stage I epithelial ovarian cancer that is most likely to benefit from 6 versus 3 cycles of adjuvant chemotherapy?

OBJECTIVE: Despite results from Gynecologic Oncology Group (GOG) 157 showing no statistically significant survival differences in patients treated with 3 versus 6 cycles of carboplatin and paclitaxel, further analysis of GOG 157 data suggested that certain early-stage epithelial ovarian cancers (EOCs) might benefit from extended chemotherapy. We sought to determine those stage I EOC cases at highest risk of failing 3 cycles of therapy. METHODS: All patients with surgical International Federation of Gynecology and Obstetrics stage I EOC operated on at the Mayo Clinic and The Ohio State University between January 1991 and December 2007 were identified through retrospective chart review. A cohort of patients who received 6 cycles of adjuvant carboplatin and paclitaxel chemotherapy was compared with a cohort of patients who received 3 cycles. Disease-free survival and disease-specific survival were primary outcomes analyzed. RESULTS: There were 107 patients who received either 3 or 6 cycles of adjuvant carboplatin and paclitaxel. Among all stage I EOCs, the number of cycles did not influence disease-free survival or disease-specific survival. The highest recurrence rate (7 [46.7%] of 15 cases) was among stage IC cases with fixed tumors and positive cytology and/or surface involvement. Among this cohort, 6 (66.7%) of the 9 patients who received 3 cycles recurred, whereas only 1 (16.7%) of the 6 patients who received 6 cycles recurred (hazard ratio, 5.97; 95% confidence interval [CI], 0.98-114.46; P = 0.05, Cox proportional hazards regression model) for an odds ratio of 3.94. The absolute risk reduction for 6 cycles in this highest risk cohort was 50%. CONCLUSIONS: Patients with stage IC cancer and with fixed tumors and positive cytology and/or tumor surface involvement appear to have a higher risk of recurrence after 3 cycles (compared with 6) of platinum-based chemotherapy. The clinical behavior of this highest risk cohort implies a more aggressive tumor biology, and further understanding of such stage I EOCs is warranted.

Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer.

OBJECTIVE: To evaluate the effect of tumor capsule rupture on disease prognosis in stage I epithelial ovarian cancer. METHODS: All patients with International Federation of Gynecology and Obstetrics stage I epithelial ovarian cancer operated on at the Mayo Clinic and The Ohio State University between January 1991 and December 2007 were identified. Relevant tumor characteristics, procedures performed, adjuvant therapies, and follow-up were recorded and analyzed. Inclusion criteria included comprehensive staging. Cox proportional hazards, Kaplan-Meier estimation, log rank test, and chi test were used for statistical analyses. RESULTS: There were 161 cases that met inclusion criteria. Seventy-four (46%) patients had intact capsules without positive cytology or surface involvement; 61 (38%) had capsule rupture; 33 (20%) had positive cytology; and 22 (14%) had surface involvement. Overall, 22 of 161 (14%) patients recurred and 12 of 161 (7%) patients died of their disease. In univariable analysis, both intraoperative capsule rupture and positive cytologic washings portended worse disease-free survival (hazard ratio [HR] 3.6, 95% confidence interval [CI] 1.5-8.9; P=.004 and HR 5.2, 95% CI 2.1-12.3; P<.001, respectively) and disease-specific survival (HR 4.1, 95% CI 1.3-15.4; P=.018 and HR 5.9, 95% CI 1.8-19.3; P=.005, respectively). In multivariable analysis, capsule rupture (HR 4.2, 95% CI 1.8-10.9; P=.001) and positive cytologic washings (HR 6.4, 95% CI 2.5-16.0; P<.001) remained independent predictors of worse disease-free survival. Disease-free survival and disease-specific survival were shortest for stage IC cases with positive cytology, surface involvement, or both, that also had intraoperative rupture. CONCLUSION: In stage I epithelial ovarian cancer, intraoperative capsule rupture portends a higher risk of disease recurrence and death from disease. Careful intraoperative removal of ovarian masses is important, and recognizing the higher-risk nature of such cases is imperative. LEVEL OF EVIDENCE: III.

Comprehensive surgical staging for endometrial cancer in obese patients: comparing robotics and laparotomy.

OBJECTIVE: To compare adequacy and outcomes of surgical staging for endometrial cancer in obese women by robotics or laparotomy. METHODS: Clinical stage I or occult stage II endometrial cancer patients with body mass indexes (BMIs) of at least 30 (BMI is calculated as weight (kg)/[height (m)]2) were identified undergoing robotic staging and matched 1:2 with laparotomy patients. Patient characteristics, operative times, complications, and pathologic factors were collected. An adequate lymphadenectomy was defined arbitrarily as at least 10 total nodes removed, and adequate pelvic and paraaortic lymphadenectomy was defined as at least six and at least four nodes removed, respectively. RESULTS: A total of 109 patients underwent surgery with the intent of robotic staging and were matched to 191 laparotomy patients. The mean BMI was 40 for each group. The robotic conversion rate was 15.6% (95% confidence interval [CI] 9.5-24.2%). Ninety-two completed robotic patients were compared with 162 matched laparotomy patients. The two groups were comparable regarding total lymph node count (25 +/- compared with 24 +/- 12, P =.45) and the percentage of patients undergoing adequate lymphadenectomy (85% compared with 91%, P=.16) and adequate pelvic (90% compared with 95%, P=.16) and aortic lymphadenectomy (76% compared with 79%, P=.70) for robotic and laparotomy patients, respectively, but there was limited power to detect this difference. The blood transfusion rate (2% compared with 9%, odds ratio [OR] 0.22, 95% CI 0.05-0.97, P=.046), the number of nights in the hospital (1 compared with 3, P<.001), complications (11% compared with 27%, OR 0.29, 95% CI 0.13-0.65 P=.003), and wound problems (2% compared with 17%, OR 0.10, 95% CI 0.02-0.43, P=.002) were reduced for robotic surgery. CONCLUSION: In obese women with endometrial cancer, robotic comprehensive surgical staging is feasible. Importantly, obesity may not compromise the ability to adequately stage patients robotically. LEVEL OF EVIDENCE: II

Paratubal borderline serous tumors.

BACKGROUND: While ovarian borderline tumors are common, their fallopian tube counterparts are extremely rare. We describe the first case of a serous borderline paratubal tumor with a review of the literature on paratubal and tubal low malignant potential tumors. CASE: A 26 year-old woman presented with acute onset of sharp right lower quadrant pain and nausea. Abdominal and pelvic CT revealed 12.5 cm cystic ovarian mass and she was admitted for pain control. On hospital day two, her pain escalated and torsion was suspected; thus, she underwent a diagnostic laparoscopy with right fallopian tube cystectomy and partial salpingectomy. Inspection of the cyst wall demonstrated multiple papillary excrescences and frozen section returned at least borderline fallopian tube neoplasm. After a fertility-sparing comprehensive surgical staging procedure was performed, she was diagnosed with stage IC fallopian tube serous borderline tumor and underwent no further therapy. Currently, she is without evidence of disease recurrence. CONCLUSION: Borderline fallopian tube or paratubal tumors are usually early stage at diagnosis and commonly present in the third decade with pain or are discovered on routine examination. Continued reporting of these tumors is essential to understanding the prognosis and treatment of this rare tumor.

A detailed analysis of the learning curve: robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer.

OBJECTIVE: To define the learning curve for robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial carcinoma. METHODS: Patient demographics and segmental operative times on all patients at one institution who underwent robotic comprehensive surgical staging (hysterectomy, pelvic and aortic lymphadenectomy) for endometrial cancer were prospectively collected. Patients were arranged in order based on surgery date and outcomes were compared between quartiles (cases 1-20, 21-40, 41-60, and 61-79). Proficiency was defined as the point at which the slope of the curve becomes less steep for operative times. Efficiency was defined as the point at which the slope is zero. ANOVA or Fisher's exact test was used to compare the procedure times. Locally weighted regression generated smoothed lines that represent operative time over the sequence of the operations. RESULTS: 79 patients were comprehensively staged robotically. While age, the percentage of patients with >/=2 co-morbidities, number of patients with previous laparotomy, EBL, LOS and lymph node counts do not differ between groups, the first 20 patients had a lower BMI compared to the next 20 (27 vs. 34 kg/m(2), P=0.009). Operative times decreased from the first 20 cases to next 20, but was not significantly changed over the next three quartiles. Each component of the procedure has a separate learning curve. CONCLUSIONS: Proficiency for robotic hysterectomy with pelvic-aortic lymphadenectomy for endometrial cancer is achieved after 20 cases; however, the number of procedures to gain efficiency varies for each portion of the case and continues to improve over time.

Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy?

OBJECTIVE: To compare outcomes between robotic versus laparoscopic hysterectomy and lymphadenectomy in patients with endometrial cancer. METHODS: A cohort study was performed by prospectively identifying all patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy and lymphadenectomy from 2006-2008 and retrospectively comparing data using the same surgeons' laparoscopic hysterectomy and lymphadenectomy cases from 1998-2005, prior to our robotic experience. Patient demographics, operative times, complications, conversion rates, pathologic results, and length of stay were analyzed. RESULTS: 181 patients (105 robotic and 76 laparoscopic) met inclusion criteria. There was no significant difference between the two groups in median age, uterine weight, bilateral pelvic or aortic lymph node counts, or complication rates in patients whose surgeries were completed minimally invasively. Despite a higher BMI (34 vs. 29, P<0.001), the estimated blood loss (100 vs. 250 mL, P<0.001), transfusion rate (3% vs. 18%, RR 0.18, 95%CI 0.05-0.64, P=0.002), laparotomy conversion rate (12% vs. 26%, RR 0.47, 95%CI 0.25-0.89, P=0.017), and length of stay (median: 1 vs. 2 nights, P<0.001) were lower in the robotic patients compared to the laparoscopic cohort. The odds ratio of conversion to laparotomy based on BMI for robotics compared to laparoscopy is 0.20 (95% CI 0.08-0.56, P=0.002). The mean skin to skin time (242 vs. 287 min, P<0.001) and total room time (305 vs. 336 min, P<0.001) was shorter for the robotic cohort. CONCLUSION: Robotic hysterectomy and lymphadenectomy for endometrial carcinoma can be accomplished in heavier patients and results in shorter operating times and hospital length of stay, a lower transfusion rate, and less frequent conversion to laparotomy when compared to laparoscopic hysterectomy and lymphadenectomy.

Reclassification of leiomyosarcoma as an extra-gastrointestinal stromal tumor of the gynecologic tract.

Extra-gastrointestinal stromal tumors (EGISTs) are rare, and may have similar histologic appearance to leiomyosarcomas. Thus, these tumors are often misdiagnosed when occurring in gynecologic organs. We present the fourth case of EGIST occurring in the rectovaginal septum and a review of the literature. A 56-year-old woman presented with a rectovaginal mass that was initially diagnosed as leiomyosarcoma and was treated with resection and adjuvant radiation. She presented with recurrence 4 years later and underwent a second resection. After a 5-year disease-free interval, she experienced a second recurrence and after resection was diagnosed with recurrent EGIST. EGISTs are rare but should be considered in the differential diagnosis of spindle-cell neoplasms located in or near the gynecologic tract.

Outpatient platinum-taxane intraperitoneal chemotherapy regimen for ovarian cancer.

INTRODUCTION: Intraperitoneal (IP) chemotherapy is associated with an improved survival at the expense of increased toxicity in optimally debulked ovarian cancer patients. We describe the toxicity profile of an outpatient regimen of an intravenous (IV) and IP taxane-platinum chemotherapy. METHODS: A chart review of all patients who received IP chemotherapy from December 2005 to May 2008 was performed. Optimally debulked patients after primary surgery for ovarian, primary peritoneal, or fallopian tubal cancer who received IV docetaxel 60 to 70 mg/m and IP cisplatin 80 to 85 mg/m on day 1 and IP paclitaxel 60 to 70 mg/m on day 8 every 21 days were included. Toxicities were recorded using the Common Terminology Criteria for Adverse Events v3.0. RESULTS: Thirty-three patients have completed chemotherapy. Of these, 19 patients (58%) completed all planned cycles of IP chemotherapy and 23 (70%) completed 75% or greater of the planned cycles. Four patients (12%) did not complete 50% or greater of the cycles. A total of 150.5 IP cycles were delivered, with a median number of 4 IP cycles (range, 0.5-7.5) completed. Grades 3 and 4 hematologic toxicities occurred in 21% of patients (n = 7), and 8 patients (24%) experienced grade 3 or 4 nonhematologic events. The overall response rate was 100% (complete response, 91%; partial response, 9.0%) with a progression-free survival of 19 months. CONCLUSIONS: This outpatient regimen of IV and IP platinum-taxane chemotherapy is well tolerated with acceptable toxicity. Importantly, most patients were able to complete all planned cycles of chemotherapy. These findings suggest that continued investigation of methods to decrease the toxicity of the treatment seen in the Gynecologic Oncology Group Protocol 172 is needed and should be studied in future phase 2 IP chemotherapy trials.

Robotic trocar site small bowel evisceration after gynecologic cancer surgery.

BACKGROUND: Trocar site hernia is a known, rare complication after laparoscopic surgery. We describe a case of bowel herniation, evisceration, and bowel obstruction through an 8-mm robotic port site. CASE: A 67-year-old patient with endometrial cancer underwent an uncomplicated robotic hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic lymphadenectomy. Four days later, she presented with symptoms of a small bowel obstruction and was found to have evisceration through a laterally placed 8-mm robotic port site. The bowel was reduced locally and the fascial defect repaired without midline laparotomy or bowel resection. CONCLUSION: Bowel herniation can occur through the fascial defect after placement of an 8-mm robotic port. Continued reporting is needed to accurately gauge the occurrence of this complication.

Robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer.

OBJECTIVE: To report the learning curve and outcomes after our first 105 patients underwent robotic hysterectomy and pelvic-aortic lymphadenectomy for the comprehensive staging of endometrial cancer. METHODS: We prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients who underwent robotic hysterectomy pelvic-aortic lymphadenectomy for clinical stage I or occult stage II endometrial carcinoma. RESULTS: One hundred five patients at The Ohio State University between March 2006 and April 2008 underwent exploration with the intent of robotic hysterectomy pelvic-aortic lymphadenectomy. Ninety-two (87.6%) were completed robotically and 13 (12.4%) were converted. The probability of conversion was 15% (95% confidence interval [CI] 8.4-25.7), 24% (95% CI 12.4-39.9), 35% (95% CI 15.9-59.6), and 48% (95% CI 19.1-77.8) for a body mass index of 40, 45, 50, and 55 kg/m(2), respectively. The median body mass index was 34 kg/m(2) (range 19-58). In patients who underwent a robotic hysterectomy pelvic-aortic lymphadenectomy (n=79, 75%) or a robotic hysterectomy-pelvic lymphadenectomy (n=6, 5.7%), the average operating time from skin opening to closure was 242 minutes (+/-50 minutes). The median estimated blood loss was 99 mL (+/-83 mL). The median number of lymph nodes recovered was 29 (range 9-56), 21 (range 5-40) pelvic nodes and 9 (range 2-21) aortic nodes. The median length of stay was 1 night. After analysis of the data, we determined approximately 20 cases are needed to gain proficiency. CONCLUSION: Early experience demonstrates that robotic hysterectomy pelvic-aortic lymphadenectomy for endometrial cancer is feasible, with approximately 20 procedures needed to gain proficiency. LEVEL OF EVIDENCE: III.