Oncologic outcomes in older women with endometrial carcinoma (≥70 years).

Data are limited in the management of elderly women with endometrial cancer as they are under-represented in clinical trials. The aim of this study was to evaluate the outcomes of women ≥70 years who underwent hysterectomy. One hundred and twenty-one patients met the inclusion criteria. The median age among the cohort was 75 years (range: 70-91), and 52% underwent robotic surgery. The five-year overall survival (OS) rate was 67%. The five-year cumulative incidence of recurrence was 19%. Based on univariate analysis, white race, lower ASA score, higher pre-operative and post-operative haematocrit, lower estimated blood loss, stage I and robotic surgery were associated with improved OS. On multivariable analysis, ASA score, preoperative haematocrit, estimated blood loss and stage were associated with survival.Survival rates among older women were low and disease recurrence was high. Robotic surgery was safe and appeared to improve perioperative outcomes in older women with endometrial cancer.Impact StatementWhat is already known on this subject? Endometrial cancer is the most common gynaecologic cancer with an overall survival above 90%. Surgery is the cornerstone of treatment. With an ageing population, an increased incidence of endometrial cancer is also expected. Increased frailty and comorbid conditions may prevent this population from undergoing surgery; consequently, these patients are often undertreated for a potentially curable disease.What do the results of this study add? Older women with endometrial cancer have low survival rates and high disease recurrence rates. Elderly women can tolerate robotic surgery to reduce the risk of adverse events.What are the implications of these findings for clinical practice and/or further research? It is important to develop best practices to optimise patients for minimally invasive surgery. The benefits of robotic surgery may encourage patients and surgeons to partake in this approach. A multidisciplinary approach with geriatric evaluation may improve post-operative care and survival. Future clinical trials should include elderly women.

Survival After Minimally Invasive Surgery in Older Women With Endometrial Carcinoma.

BACKGROUND/AIM: To analyze the impact of minimally invasive surgery for endometrial cancer on overall survival among age >65. PATIENTS AND METHODS: We examined women who underwent hysterectomy from 2010 to 2015 from the U.S. National Cancer Data Base (NCDB). We evaluated the impact of surgical approach on survival. RESULTS: Of 243,601 endometrial cancer cases, 42,458 met the inclusion criteria. Laparoscopic approach was associated with improved survival by 14% (HR=0.86; 95%CI=0.80-0.92; p<0.001) and robotic approach was associated with improved survival by 12% (HR=0.88; 95%CI=0.83-0.93; p<0.0001), compared to the open approach. Similarly, the weighted adjusted 5-year overall survival was 73.1% (95%CI=72%-74.2%), 76.4% (95%CI=75.1-77.7%), and 75.5% (95%CI=74.7-76.4%) for open, laparoscopic, and robotic approaches, respectively (p<0.001). CONCLUSION: Minimally invasive surgery improved overall survival in women over 65 years with endometrial cancer.

Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

AIM: Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. PATIENTS AND METHODS: We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. RESULTS: A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. CONCLUSION: Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Incidence of venous thromboembolism after robotic-assisted hysterectomy in obese patients with endometrial cancer: do we need extended prophylaxis?

Robotic surgery for gynecologic malignancy is associated with a lower rate of venous thromboembolism (VTE) than laparotomy. Obese patients represent a particularly high-risk group for VTE, but prior studies tend to focus on patients with a much lower BMI and without extended VTE prophylaxis. Our objective was to examine the role of extended thromboprophylaxis in obese patients who underwent robotic-assisted surgery for endometrial cancer. We conducted a retrospective cohort study of obese patients (BMI ≥ 35 kg/m2) who underwent robotic surgery for newly diagnosed endometrial cancer. The primary outcome measured was the occurrence of a VTE event within the 30-day postoperative period. The Farrington-Manning score test was used for equivalence analysis with a 5% margin. Secondary outcomes were perioperative complications. One hundred thirty-two robotic cases for endometrial cancer met our criteria. One hundred twenty-one (92%) received preoperative pharmacologic thromboprophylaxis, and 100% used pneumatic compression devices. Ninety-three percent and 90% received preoperative pharmacologic prophylaxis in the extended and no extended group, respectively (p-value = 0.7). Seventy patients (54%) received 4-week extended prophylaxis. Estimated blood loss was similar in both groups (75 mL vs 60 mL, p-value = 0.6). Perioperative complications and readmissions were similar between the two groups. There were no VTE events during hospital stay. One patient in the group that did not receive extended prophylaxis developed a VTE in the 30-day postoperative period (1.6%), versus 0% in the group that did receive extended prophylaxis (p-value = 0.1). The risk of VTE was low. The absence of extended VTE prophylaxis did not significantly increase the risk for VTE in obese patients with newly diagnosed endometrial cancer who underwent robotic-assisted surgery.

Robotic-assisted interval cytoreductive surgery in ovarian cancer: a feasibility study.

OBJECTIVE: The primary objective was to assess the feasibility of robotic-assisted interval cytoreductive surgery for achieving complete cytoreduction for patients with advanced-stage ovarian cancer. The secondary objective was to examine the perioperative outcomes. METHODS: A retrospective study of 12 patients with stage IIIC or IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent interval cytoreductive surgery after neo-adjuvant chemotherapy. RESULTS: Optimal cytoreduction was achieved in 100% of selected patients. Complete cytoreductive surgery was achieved in 75% of patients. The estimated mean blood loss was 100 mL. The median length of hospital stay was 2 days. Perioperative complication and 30-day readmission rates were 8.3% (1 patient). The median follow-up time was 9.5 months. CONCLUSION: Robotic-assisted interval cytoreductive surgery in ovarian cancer is safe and feasible and may be an alternative to standard laparotomy in selected patients.

Germline PALB2, ATM variants in a patient with breast and ovarian cancer at risk for familial cancer syndrome: Is there a role for risk-reducing salpingo-oophorectomy?

A 50-year-old non-Hispanic white Caucasian female was diagnosed with breast cancer and was subsequently found to possess the tumorigenic ataxia telangiectasia mutated (ATM) and PALB2 variants but not the BRCA1 and BRCA2 variants. She visited the gynecologic oncology office for routine counseling about risk-reducing salpingo-oophorectomy (RRSO). Although the patient was asymptomatic, an adnexal mass was discovered in the physical examination performed by palpation. Upon using pre-operative imaging techniques, an 8 cm complex adnexal mass was identified. Her CA-125 level was elevated. She underwent complete cytoreductive surgery. Pathological analysis showed a stage IC clear cell carcinoma of the left ovary; subsequently, she received 6 cycles of adjuvant chemotherapy with a combination of carboplatin and paclitaxel. The patient exhibited no signs ovarian cancer in a follow-up appointment after 32 months of treatment. However, bilateral RRSO is not recommended for patients positive for ATM and PALB2. Breast cancer patients with PALB2 and ATM mutations should extensively discuss the risks and benefits of RRSO in light of current data.

Minimally invasive interval cytoreductive surgery in ovarian cancer: systematic review and meta-analysis.

The introduction of minimally invasive surgery in other gynecologic cancers has shown benefits with similar oncologic outcomes. However, the biology and complexity of surgery for ovarian cancer may preclude this approach for ovarian cancer patients. Our objective is to assess feasibility to achieve complete cytoreductive surgery after neoadjuvant chemotherapy for stage IIIC-IV ovarian cancer patients via minimally invasive surgery. Our data sources include PubMed, Embase, Scopus, Biosis, Clinicaltrials.gov, and the Cochrane Library. Meta-analysis was performed using the random-effects model with DerSimonian and Laird estimator for the amount of heterogeneity to estimate the pooled outcomes. A funnel plot and Egger's regression test were used to test publication bias. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the studies. There were 6 studies (3 prospective, 3 retrospective) that met the criteria for meta-analysis with a total of 3231 patients, 567 were in the minimally invasive group and 2664 in the laparotomy group. Both groups were similar in stage and serous histology. Complete cytoreductive surgery was achieved in 74.50% (95% CI 40.41-97.65%) and 53.10% (95% CI 4.88-97.75%) of patients in the minimally invasive and laparotomy groups, respectively. There was no statistical significant difference between these 2 pooled proportions (p = 0.52). Three studies compared minimally invasive surgery vs laparotomy. No significant difference was observed between the 2 groups in obtaining complete cytoreductive surgery [OR = 0.90 (95% CI 0.70-1.16; p = 0.43)]. A symmetrical funnel plot indicated no publication bias. The pooled proportion for grade > 2 postoperative complications was not significant among the laparoscopy group [3.11% (95% CI 0.00-10.24%; p = 0.15)]. Complete cytoreductive surgery appears feasible and safe with minimally invasive surgery in selected advanced ovarian cancer patients after neoadjuvant chemotherapy.