RESUMEN
BACKGROUND: Age and ethnicity are among several factors that influence overall survival (OS) in ovarian cancer. The study objective was to determine whether ethnicity and age were of prognostic significance in women enrolled in a clinical trial evaluating the addition of bevacizumab to front-line therapy. METHODS: Women with advanced stage ovarian, primary peritoneal, or fallopian tube cancer were enrolled in a phase III clinical trial. All women had surgical staging and received adjuvant chemotherapy with one of three regimens. Cox proportional hazards models were used to evaluate the relationship between OS with age and race/ethnicity among the study participants. RESULTS: One-thousand-eight-hundred-seventy-three women were enrolled in the study. There were 280 minority women and 328 women over the age of 70. Women age 70 and older had a 34% increase risk for death when compared to women under 60 (HR = 1.34; 95% CI 1.16-1.54). Non-Hispanic Black women had a 54% decreased risk of death with the addition of maintenance bevacizumab (HR = 0.46, 95% CI:0.26-0.83). Women of Asian descent had more hematologic grade 3 or greater adverse events and a 27% decrease risk of death when compared to non-Hispanic Whites (HR = 0.73; 95% CI: 0.59-0.90). CONCLUSIONS: Non-Hispanic Black women showed a decreased risk of death with the addition of bevacizumab and patients of Asian ancestry had a lower death rate than all other minority groups, but despite these clinically meaningful improvements there was no statistically significant difference in OS among the groups.
Asunto(s)
Inhibidores de la Angiogénesis/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Bevacizumab/uso terapéutico , Carcinoma Epitelial de Ovario/tratamiento farmacológico , Quimioterapia Adyuvante/métodos , Etnicidad/estadística & datos numéricos , Neoplasias Quísticas, Mucinosas y Serosas/tratamiento farmacológico , Neoplasias Ováricas/tratamiento farmacológico , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/patología , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Asiático/estadística & datos numéricos , Carboplatino/administración & dosificación , Carcinoma Endometrioide/tratamiento farmacológico , Carcinoma Endometrioide/patología , Carcinoma Epitelial de Ovario/patología , Neoplasias de las Trompas Uterinas/tratamiento farmacológico , Neoplasias de las Trompas Uterinas/patología , Femenino , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Quísticas, Mucinosas y Serosas/patología , Neoplasias Ováricas/patología , Paclitaxel/administración & dosificación , Neoplasias Peritoneales/tratamiento farmacológico , Neoplasias Peritoneales/patología , Pronóstico , Modelos de Riesgos Proporcionales , Tasa de Supervivencia , Población Blanca/estadística & datos numéricosRESUMEN
OBJECTIVE: To assess quality of life (QOL) in patients who developed lower-extremity lymphedema (LLE) after radical gynecologic cancer surgery on prospective clinical trial GOG 244. METHODS: The prospective, national, cooperative group trial GOG-0244 determined the incidence of LLE and risk factors for LLE development, as well as associated impacts on QOL, in newly diagnosed patients undergoing surgery for endometrial, cervical, or vulvar cancer from 6/4/2012-11/17/2014. Patient-reported outcome (PRO) measures of QOL (by the Functional Assessment of Cancer Therapy [FACT]), body image, sexual and vaginal function, limb function, and cancer distress were recorded at baseline (within 14 days before surgery), and at 6, 12, 18, and 24 months after surgery. Assessments of LLE symptoms and disability were completed at the time of lower limb volume measurement. A linear mixed model was applied to examine the association of PROs/QOL with a Gynecologic Cancer Lymphedema Questionnaire (GCLQ) total score incremental change ≥4 (indicative of increased LLE symptoms) from baseline, a formal diagnosis of LLE (per the GCLQ), and limb volume change (LVC) ≥10%. RESULTS: In 768 evaluable patients, those with a GCLQ score change ≥4 from baseline had significantly worse QOL (p < 0.001), body image (p < 0.001), sexual and vaginal function (p < 0.001), limb function (p < 0.001), and cancer distress (p < 0.001). There were no significant differences in sexual activity rates between those with and without LLE symptoms. CONCLUSIONS: LLE is significantly detrimental to QOL, daily function, and body image. Clinical intervention trials to prevent and manage this chronic condition after gynecologic cancer surgery are needed.
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Neoplasias de los Genitales Femeninos/cirugía , Linfedema/fisiopatología , Linfedema/psicología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Pierna/patología , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/psicología , Estudios Prospectivos , Calidad de VidaRESUMEN
OBJECTIVES: To evaluate the incidence and risk factors for lymphedema associated with surgery for gynecologic malignancies on GOG study 244. METHODS: Women undergoing a lymph node dissection for endometrial, cervical, or vulvar cancer were eligible for enrollment. Leg volume was calculated from measurements at 10-cm intervals starting 10 cm above the bottom of the heel to the inguinal crease. Measurements were obtained preoperatively and postoperatively at 4-6 weeks, and at 3-, 6-, 9-, 12-, 18-, and 24- months. Lymphedema was defined as a limb volume change (LVC) ≥10% from baseline and categorized as mild: 10-19% LVC; moderate: 20-40% LVC; or severe: >40% LVC. Risk factors associated with lymphedema were also analyzed. RESULTS: Of 1054 women enrolled on study, 140 were inevaluable due to inadequate measurements or eligibility criteria. This left 734 endometrial, 138 cervical, and 42 vulvar patients evaluable for LVC assessment. Median age was 61 years (range, 28-91) in the endometrial, 44 years (range, 25-83) in the cervical, and 58 years (range, 35-88) in the vulvar group. The incidence of LVC ≥10% was 34% (n = 247), 35% (n = 48), and 43% (n = 18), respectively. The peak incidence of lymphedema was at the 4-6 week assessment. Logistic regression analysis showed a decreased risk with advanced age (p = 0.0467). An exploratory analysis in the endometrial cohort showed an increased risk with a node count >8 (p = 0.033). CONCLUSIONS: For a gynecologic cancer, LVC decreased with age greater than 65, but increased with a lymph node count greater than 8 in the endometrial cohort. There was no association with radiation or other risk factors.
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Neoplasias de los Genitales Femeninos/cirugía , Linfedema/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Neoplasias de los Genitales Femeninos/diagnóstico , Neoplasias de los Genitales Femeninos/epidemiología , Humanos , Incidencia , Pierna/patología , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/estadística & datos numéricos , Linfedema/etiología , Linfedema/patología , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Regresión , Factores de RiesgoRESUMEN
BACKGROUND: Sentinel lymph node (SLN) biopsy is increasingly used in endometrial cancer staging; however, success of the technique is variable, and the learning curve needs to be better understood. Success is defined as identification of a SLN specimen containing nodal tissue in bilateral hemi-pelvises. OBJECTIVE: To assess the learning curve of surgeons at an academic institution in performing successful SLN mapping and biopsy during robotic staging for endometrial cancer. METHODS: After institutional review board approval, patients who underwent staging with robotic SLN mapping using indocyanine green at a single academic program between July 2012 and December 2017 were identified. Demographic, pathologic, and surgical data were retrospectively collected from the medical records. Descriptive and comparative statistics were performed. Surgeon rates of successful bilateral SLN mapping and removal of lymphoid-containing SLN specimens were compared. A logistic model was used to analyze the probability of successful SLN mapping and removal of lymph node-containing tissue with increasing number of procedures performed. RESULTS: Three hundred and seventeen patients met the eligibility criteria. Most had early-stage, low-grade endometrial cancer. A total of 194 (61%) patients had successful bilateral mapping. Among seven surgeons, a plateau in rates of successful bilateral mapping was achieved after 40 cases. No linear correlation was seen between the number of surgeries performed and the rate of removal of lymph node-containing tissue among surgeons. Each additional 10 procedures performed was associated with a 5% and an 11% increase in the odds of successful SLN mapping and removal of lymph node-containing tissue, respectively. DISCUSSION: The successful removal of lymph node-containing specimens appears to be a surgeon-specific phenomenon. The plateau of the learning curve for successful bilateral mapping seems to be reached at around 40 cases. These first 40 cases offer a time for auditing of individual rates of SLN mapping and removal to identify surgeons who may benefit from procedure-specific remediation.
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Neoplasias Endometriales/patología , Neoplasias Endometriales/cirugía , Curva de Aprendizaje , Biopsia del Ganglio Linfático Centinela/educación , Oncología Quirúrgica/educación , Centros Médicos Académicos , Adulto , Anciano , Anciano de 80 o más Años , Ensayos Clínicos como Asunto , Colorantes , Femenino , Humanos , Verde de Indocianina , Modelos Logísticos , Persona de Mediana Edad , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Ganglio Linfático Centinela/patología , Ganglio Linfático Centinela/cirugía , Biopsia del Ganglio Linfático Centinela/métodos , Cirujanos/educación , Oncología Quirúrgica/métodosRESUMEN
OBJECTIVE: To explore whether patient-reported lymphedema-related symptoms, as measured by the Gynecologic Cancer Lymphedema Questionnaire (GCLQ), are associated with a patient-reported diagnosis of lymphedema of the lower extremity (LLE) and limb volume change (LVC) in patients who have undergone radical surgery, including lymphadenectomy, for endometrial, cervical, or vulvar cancer on Gynecologic Oncology Group (GOG) study 244. METHODS: Patients completed the baseline and at least one post-surgery GCLQ and LVC assessment. The 20-item GCLQ measures seven symptom clusters-aching, heaviness, infection-related, numbness, physical functioning, general swelling, and limb swelling. LLE was defined as a patient self-reported LLE diagnosis on the GCLQ. LVC was measured by volume calculations based on circumferential measurements. A linear mixed model was fitted for change in symptom cluster scores and GCLQ total score and adjusted for disease sites and assessment time. RESULTS: Of 987 eligible patients, 894 were evaluable (endometrial, 719; cervical, 136; vulvar, 39). Of these, 14% reported an LLE diagnosis (endometrial, 11%; cervical, 18%; vulvar, 38%). Significantly more patients diagnosed versus not diagnosed with LLE reported ≥4-point increase from baseline on the GCLQ total score (p < 0.001). Changes from baseline were significantly larger on all GCLQ symptom cluster scores in patients with LLE compared to those without LLE. An LVC increment of >10% was significantly associated with reported general swelling (p < 0.001), heaviness (p = 0.005), infection-related symptoms (p = 0.002), and physical function (p = 0.006). CONCLUSIONS: Patient-reported symptoms, as measured by the GCLQ, discerned those with and without a patient-reported LLE diagnosis and demonstrated predictive value. The GCLQ combined with LVC may enhance our ability to identify LLE.
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Neoplasias de los Genitales Femeninos/epidemiología , Linfedema/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Neoplasias de los Genitales Femeninos/patología , Neoplasias de los Genitales Femeninos/cirugía , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Humanos , Pierna/patología , Linfedema/etiología , Linfedema/patología , Persona de Mediana Edad , Autoinforme , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Cervical excision procedures are essential to the care of cervical dysplasia and malignancy. We sought to determine whether learner involvement in cervical excision procedures affects the quality of excision specimen. MATERIALS AND METHODS: A retrospective cohort study of cervical cancer patients diagnosed from July 1, 2000, to July 1, 2015, was performed. We included patients who had (1) a cervical excision procedure, either loop electrosurgical excision procedure or cold knife cone, and (2) pathologic information available. Primary outcome was the margin status of the specimen; secondary outcome was the size of the excision specimen including both width and depth. The exposure of interest was trainee participation, defined as resident physicians under the supervision of either a gynecologist or gynecologic oncologist. Descriptive statistics and general linear models were used for analysis. RESULTS: Ninety-four patients were identified. Overall, 58% (n = 54) of procedures were performed with trainee involvement. There was no difference in age, body mass index, or specimen width between trainee-performed and nontrainee-performed excisions. There was no significant difference in the status of margins with or without a trainee [44/57 (77%) and 29/37 (78%), respectively, p = .89]. There was a statistically significant difference in median specimen depth between trainee-performed and nontrainee-performed cases (15.4 mm vs 12 mm, p < .02). When adjusting for age, body mass index, excision type, indication, presence of trainee, and type of supervising physician, only the indication and type of excision were associated with greater depth of excision, (p < .01). CONCLUSIONS: Trainee involvement in cervical excision procedures does not alter the quality of excision specimen.
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Márgenes de Escisión , Preceptoría/métodos , Calidad de la Atención de Salud , Procedimientos Quirúrgicos Operativos/educación , Neoplasias del Cuello Uterino/cirugía , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
STUDY OBJECTIVE: To confirm the safety and feasibility outcomes of robotic radical parametrectomy and pelvic lymphadenectomy and compare the clinicopathological features of women requiring adjuvant treatment with the historical literature. DESIGN: Retrospective cohort study and review of literature (Canadian Task Force classification II-2). SETTING: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill. PATIENTS: All patients who underwent robotic radical parametrectomy with upper vaginectomy (RRPV), and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy at our institution between January 2007 and December 2015. INTERVENTIONS: RRPV and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy. We also performed a literature review of the literature on radical parametrectomy after occult cervical carcinoma. MEASUREMENTS AND MAIN RESULTS: Seventeen patients with invasive carcinoma of the cervix discovered after extrafascial hysterectomy underwent RRPV with bilateral pelvic lymphadenectomy. There were 2 intraoperative complications, including 1 bowel injury and 1 bladder injury. One patient required a blood transfusion of 2 units. Three patients underwent adjuvant treatment with chemoradiation with radiation-sensitizing cisplatin. One of these patients had residual carcinoma on the upper vagina, 1 patient had positive parametria and pelvic nodes, and 1 patient had positive pelvic lymph nodes. No patients experienced recurrence, and 1 patient died from unknown causes at 59.4 months after surgery. We analyzed 15 studies reported in the literature and found 238 women who underwent radical parametrectomy; however, no specific preoperative pathological features predicted outcomes, the need for adjuvant treatment, or parametrial involvement. CONCLUSION: RRPV is a feasible and safe treatment option. As reflected in the literature, RRPV can help avoid empiric adjuvant chemoradiation; however, no pathological features predict the need for adjuvant treatment after surgery.
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Histerectomía/métodos , Escisión del Ganglio Linfático/métodos , Peritoneo/cirugía , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/cirugía , Vagina/cirugía , Colpotomía/efectos adversos , Colpotomía/métodos , Femenino , Humanos , Histerectomía/efectos adversos , Escisión del Ganglio Linfático/efectos adversos , Ganglios Linfáticos/patología , Metástasis Linfática , Recurrencia Local de Neoplasia/cirugía , Pelvis/cirugía , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversosRESUMEN
OBJECTIVE: To determine if preoperative hypoalbuminemia is associated with postoperative wound complications among patients with vulvar cancer. METHODS: The National Surgical Quality Improvement Program database was queried for cases of vulvar cancer undergoing vulvectomy with or without lymphadenectomy (LND) from 2008 to 2013. Primary outcome was major wound complication. Secondary outcome was minor wound complication. Hypoalbuminemia was defined as albumin<3.5g/dL. Descriptive statistics and multivariable logistic regression were used for analysis. RESULTS: Of 777 vulvar cancer patients, 514 (66.2%) had vulvar surgery alone and 263 (30.3%) had a LND. Median age was 66 (range 20-90) and median BMI was 28.9kg/m(2) (range 14.3-65.5). The incidence of wound complication was 10.4% (81/777) with 48 minor and 39 major complications. There was no difference in major wound complications when a LND was performed (p=1.0). Preoperative albumin was recorded in 429 patients (55.2%). Patients with hypoalbuminemia were more likely to have a major wound complication (OR 2.9 95% CI 1.1-7.3, p=0.02), even after adjusting for BMI, age, preoperative hematocrit, and diabetes (aOR 2.7 95% CI 1.1-7.1, p=0.04). In bivariable analysis, age, diabetes, and BMI were not associated with wound complication. Patients with a wound infection had 10 times the odds of being readmitted within 30days (OR 9.5, 95% CI 4.9-18.4, p<0.01). CONCLUSIONS: Low preoperative albumin is associated with major postoperative wound complications in women undergoing surgery for vulvar cancer. When obtaining informed consent, patients with low albumin should be counseled regarding higher risks of postoperative wound complication.
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Hipoalbuminemia/patología , Infección de la Herida Quirúrgica/sangre , Neoplasias de la Vulva/sangre , Neoplasias de la Vulva/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Hipoalbuminemia/sangre , Persona de Mediana Edad , Infección de la Herida Quirúrgica/patología , Neoplasias de la Vulva/patología , Adulto JovenRESUMEN
BACKGROUND: Gestational trophoblastic neoplasia is a rare gynecological malignancy often treated at tertiary referral centers. Patients frequently travel long distances to obtain care for gestational trophoblastic neoplasia, which may affect cancer outcomes in these patients. OBJECTIVE: We examined the association between distance traveled to obtain care and disease burden at time of presentation as well as recurrence. STUDY DESIGN: We performed a retrospective cohort analysis of all patients diagnosed with gestational trophoblastic neoplasia from January 1995 to June 2015 at a high-volume tertiary referral center. Patients were included if they met International Federation of Gynecology and Obstetrics 2000 criteria for postmolar gestational trophoblastic neoplasia or had choriocarcinoma, placental-site trophoblastic tumor, or epithelioid trophoblastic tumor. Sixty patients were identified. Disease burden at presentation was examined using both the World Health Organization prognostic score and International Federation of Gynecology and Obstetrics. Patients who traveled more than 50 miles were considered long-distance travelers based on previous literature on the effect of distance traveled on cancer outcomes. Demographic, clinical, and pathological data were obtained by chart review. Bivariable comparisons were performed using the χ(2) test or Fisher exact test for categorical variables. The t test or Wilcoxon rank-sum test was used to compare continuous variables when normally or not normally distributed. RESULTS: Most patients presented at stage I (61%) with low-risk gestational trophoblastic neoplasia (70%). Median distance to care was 40 miles (range, 4-384). Eighteen patients (30%) had no insurance and 42 (70%) had either private or public insurance. Patients traveling more than 50 miles for care were more likely to have high-risk gestational trophoblastic neoplasia (46% vs 19%, P = .03), but there was no difference in recurrence (13% vs 11%, P = .89). Patients with high-risk gestational trophoblastic neoplasia lived 63 miles farther (92 vs 28 miles, P < .001) than patients with low-risk gestational trophoblastic neoplasia. Long-distance travelers had a longer period between antecedent pregnancy and gestational trophoblastic neoplasia diagnosis (10 weeks vs 4.5 weeks, P = .009) and were more likely to receive multiagent chemotherapy (86% vs 61%, P = .03). CONCLUSION: In this cohort, long distance traveled to obtain care for gestational trophoblastic neoplasia was associated with an increased risk of presenting with high-risk disease and requiring multiagent chemotherapy for treatment. Patients with high-risk gestational trophoblastic neoplasia traveled nearly 100 miles to obtain care. There may be a delay in diagnosis in women traveling more than 50 miles to obtain care; however, we found no difference in recurrence risk for long-distance travelers.
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Enfermedad Trofoblástica Gestacional/tratamiento farmacológico , Adulto , Costo de Enfermedad , Femenino , Humanos , Embarazo , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria , Adulto JovenRESUMEN
OBJECTIVE: Open radical hysterectomy followed by adjuvant radiation for cervical cancer has been associated with significant rates of morbidity. Radical hysterectomy is now often performed robotically. We sought to examine if the robotic platform decreased the morbidity associated with radical hysterectomy followed by adjuvant radiation. MATERIALS/METHODS: A retrospective cohort of patients with cervical cancer undergoing radical hysterectomy from 1995 to 2013 was evaluated. Complications were assessed using electronic record review and graded. χ tests and Student t tests were used for analysis. RESULTS: Overall, 243 patients underwent radical hysterectomy for cervical cancer. Surgical approach was 43% open and 57% robotic. Eighty-three patients (34.2%) required adjuvant radiation. Overall, radical hysterectomy plus adjuvant radiation was associated with increased risk of complication (29%) compared to radical hysterectomy alone (7%) (P < 0.001). Complications included lymphedema (n = 18), bowel-associated complications (n = 10), and urinary complications (n = 7). There was no difference in time to initiation of radiation between open and robotic surgery (43 vs 47 days; P = 0.33). There was no difference in grade 2/3 complications in patients receiving adjuvant radiation between open and robotic surgery (27.5% vs 27.9%; P = 0.97). Patients undergoing open surgery followed by radiation experienced a trend toward increased adhesion-related complications, such as bowel obstruction and ureteral stricture (10% vs 2.3%; P = 0.19); whereas patients undergoing robotic surgery followed by radiation experienced a trend toward increased lymphedema (19% vs 8%; P = 0.20). CONCLUSIONS: We found no difference in long-term complications between patients who underwent robotic surgery compared to open radical hysterectomy with adjuvant radiation. There may be fewer adhesion-related complications with robotic surgery. However, as many radiation-related complications occur at later time points, continued follow-up to evaluate for potential differences between the 2 groups is necessary.
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Histerectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias del Cuello Uterino/radioterapia , Neoplasias del Cuello Uterino/cirugía , Adulto , Estudios de Cohortes , Femenino , Humanos , Histerectomía/efectos adversos , Persona de Mediana Edad , Estadificación de Neoplasias , Radioterapia Adyuvante , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Neoplasias del Cuello Uterino/patologíaRESUMEN
OBJECTIVE: Robotic gynecological surgery is feasible in obese patients, but there remain concerns about the safety of this approach because the positioning required for pelvic surgery can exacerbate obesity-related changes in respiratory physiology. The objective of our study was to evaluate pulmonary and all-cause complication rates in obese women undergoing robotic gynecological surgery and to assess variables that may be associated with complications. STUDY DESIGN: A retrospective chart review was performed on obese patients (body mass index of ≥30 kg/m(2)) who underwent robotic gynecological surgery at 2 academic institutions between 2006 and 2012. The primary outcome was pulmonary complications and the secondary outcome was all-cause complications. Univariate and multivariate logistic regression analyses were used to determine the associations between patient baseline variables, operative variables, ventilator parameters, and complications. RESULTS: Of 1032 patients, 146 patients (14%) had any complication, whereas only 33 patients (3%) had a pulmonary complication. Median body mass index was 37 kg/m(2). Only age was significantly associated with a higher risk of pulmonary complications (P = .01). Older age, higher estimated blood loss, and longer case length were associated with a higher rate of all-cause complications (P = .0001, P < .0001, and P = .004, respectively). No other covariates were strongly associated with complications. CONCLUSION: The vast majority of obese patients can successfully tolerate robotic gynecological surgery and have overall low complications rates and even lower rates of pulmonary complications. The degree of obesity was not predictive of successful robotic surgery and subsequent complications.
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Enfermedades de los Genitales Femeninos/epidemiología , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Enfermedades Pulmonares/epidemiología , Obesidad/epidemiología , Robótica , Adulto , Anciano , Comorbilidad , Femenino , Enfermedades de los Genitales Femeninos/cirugía , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Inclinación de Cabeza , Humanos , Modelos Logísticos , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: The aim of this study is to report recurrence-free and overall survival for women with endometrial adenocarcinoma who were surgically staged using robotic-assisted laparoscopy. METHODS: A retrospective chart review was performed for all consecutive endometrial adenocarcinoma patients surgically staged with robotic-assisted laparoscopy at the University of North Carolina Hospital from 2005 to 2010. Demographic data, 5-year survival, and recurrence-free intervals were analyzed. Statistical analysis using Chi-square, t-test, and Kaplan-Meier curves were performed with SAS software. Study results were compared to endometrial cancer statistics from the Surveillance Epidemiology and End Results database from the National Cancer Institute. RESULTS: A total of 499 patients were identified and included in the study. Recurrence-free intervals after robotic-assisted surgical staging were 85.2% for stage IA, 80.2% for stage IB, 69.8% for stage II, and 69% for stage III. Projected 5-year survival was 88.7% for all patients included in the study. Nearly 82% of cases were endometrioid adenocarcinoma, with papillary serous, clear cell or mixed histology comprising 17.4% of cases. Median follow up time was 23 months, with a range of 0 to 80 months. Among stage IA, IB, II, and III patients, projected overall survival was 94.2%, 85.9%, 77.4%, and 68.6%, respectively. CONCLUSIONS: The results from this study demonstrate that robotic-assisted surgical staging for endometrial cancer does not adversely affect rates of recurrence or survival. These findings provide further evidence that robotic-assisted laparoscopic surgical staging is not associated with inferior results when compared to laparotomy or traditional laparoscopy.
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Neoplasias Endometriales/patología , Neoplasias Endometriales/cirugía , Robótica/métodos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Endometriales/mortalidad , Femenino , Humanos , Laparoscopía , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Estudios Retrospectivos , Factores de TiempoRESUMEN
OBJECTIVE: The study goal was to determine whether prior outpatient exposure to hospice discussion altered the inpatient course and end-of-life (EOL) care among patients ultimately discharged to hospice. METHODS: Medical records from January 2009 to June 2012 were reviewed and data were abstracted under an IRB-approved protocol. Hospice discussions were identified in the last outpatient clinical encounter prior to admission. Kaplan-Meier was used to estimate overall survival (OS) and the log-rank test was used to test for differences. RESULTS: There were 89 hospitalizations resulting in discharge to hospice care: 41 women with ovarian (46%), 23 with uterine (29%), 19 with cervical (21.3%), and with 6 vulvar/vaginal (6.7%) cancers. 83 patients (93%) had outpatient clinical encounters prior to admission;18% (15/83) were exposed to a hospice discussion (HD) and 82% (68/83) were not (NHD). Median time from last outpatient encounter was 18 days (range 0-371). NHD patients had longer inpatient length of stay (median 7 days vs. 4 days, p=0.008) and were less likely to receive palliative care consults than the HD patients (65% vs. 93%, p=0.03). Median OS for HD patients was 33 days (95% CI 22d-61 d) vs. 60 days (95% CI 49 d-84 d) for NHD patients (p=0.01). There were no differences detected based on race, ethnicity, or insurance status. CONCLUSIONS: HD patients had significantly shorter OS suggesting that providers were accurate in identifying patients nearing the EOL. Patients exposed to outpatient hospice discussions had a shorter length of stay and increased utilization of palliative care resources.
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Neoplasias de los Genitales Femeninos/psicología , Neoplasias de los Genitales Femeninos/terapia , Hospitales para Enfermos Terminales/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitales para Enfermos Terminales/métodos , Humanos , Persona de Mediana Edad , Pacientes Ambulatorios , Modelos de Riesgos Proporcionales , Análisis de Regresión , Cuidado Terminal/métodos , Cuidado Terminal/psicologíaRESUMEN
OBJECTIVE: To determine the radiographic characteristics of ovarian granulosa cell tumors (GCTs) and to evaluate the use of CA125 levels >35 in combination with imaging as an algorithm for preoperative diagnosis. METHODS: A retrospective analysis of women from two academic medical centers who were diagnosed with ovarian GCT between January 1998 and August 2012 was conducted. Clinical data included tumor appearance on pre-operative imaging and CA125 levels. Ovarian cysts were defined as complex if imaging exhibited multicystic areas, hemorrhagic, solid, or cystic and solid components. A CA125 level >35 was abnormal. RESULTS: One hundred and fifteen women were diagnosed with GCTs, of whom 63 underwent pre-operative imaging. Median age at surgery was 46 years (12-87). Forty women had preoperative ultrasounds, 43 had CT scans and 20 underwent both modalities. GCTs were almost exclusively classified as complex cysts in 62 (98%) cases. The most common morphology was solid and cystic (n=44 (70%)). Forty-four (70%) patients had tumors >10 cm. Forty-two patients had a pre-operative CA125 performed. Eighteen (43%) patients had complex masses and CA125 >35. Twenty-three (55%) had CA125 <35 with a complex mass, and one (2%) had a unilocular cyst with a CA125 >35. CONCLUSIONS: In this study, there was a near equal distribution of patients with complex masses and CA125 levels > or <35. If established strategies to predict malignancy are applied to GCTs, we will frequently fail to make the diagnosis pre-operatively. Additional research is necessary to generate an appropriate algorithm to guide pre-operative referral to a gynecologic oncologist.
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Antígeno Ca-125/sangre , Tumor de Células de la Granulosa/diagnóstico por imagen , Quistes Ováricos/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Niño , Femenino , Tumor de Células de la Granulosa/sangre , Humanos , Persona de Mediana Edad , Quistes Ováricos/sangre , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Ultrasonografía , Adulto JovenRESUMEN
BACKGROUND: Specimens from aviation accident pilot fatalities are submitted to the Civil Aerospace Medical Institute (CAMI) for toxicological analyses. Trends of fatal amateur-built aircraft accidents and toxicological findings in the associated pilot fatalities have not been examined. METHODS: Fatal amateur-built aircraft accidents that occurred during 1990-2009 were evaluated by retrieving information from the CAMI toxicology database. Probable cause/factor in the amateur-built aircraft mishaps were obtained from the National Transportation Safety Board's (NTSB's) aviation accident database. RESULTS: Of 6309 fatal aviation accidents from which CAMI received postmortem samples, 979 (16%) were related to amateur-built aircraft. There was a decreasing trend in non-amateur-built aircraft accidents, but an increasing trend in amateur-built aircraft accidents. In the 979 accidents, 392 pilots (40%) were positive for ethanol and/or drugs. In these 392 accidents also, the review showed a decreasing trend with non-amateur-built aircraft and an increasing trend with amateur-built aircraft. Percentages of pilots with prescription drugs were 26% for amateur-built aircraft, 16% for non-amateur-built aircraft, and 18% for all aircraft. Ethanol/drug use and medical condition were determined to be a cause/factor in 42 (11%) of the 385 ethanol/ drug-positive amateur-built aircraft accidents investigated by the NTSB. DISCUSSION: Drugs found in the pilots were consistent with commonly used medications in the general population. The contributory role of mechanical malfunction of home-built aircraft cannot be ruled out in the observed increasing trends in their accidents, with or without ethanol and/or drugs. Regardless, the increasing trends of such accidents are of significant concern.
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Accidentes de Aviación , Consumo de Bebidas Alcohólicas/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Accidentes de Aviación/estadística & datos numéricos , Accidentes de Aviación/tendencias , HumanosRESUMEN
IMPORTANCE: Placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT) are rare forms of gestational trophoblastic neoplasia (GTN). These tumors differ from choriocarcinoma as they are monophasic, have slower growth rates, have lower ß-hCG concentrations, and are more chemoresistant. Placental site trophoblastic tumor and ETT can be misdiagnosed, leading to inappropriate management.. OBJECTIVE: The aim of this study was to review the pathogenesis, presentation, pathologic findings, and treatment for PSTT and ETT. EVIDENCE ACQUISITION: A comprehensive literature review was performed identifying relevant research and review articles. Relevant textbook chapters and guidelines were also reviewed. RESULTS: Placental site trophoblastic tumor and ETT can present months to years after any antecedent pregnancy event with abnormal uterine bleeding and an elevated ß-hCG. Tumors are typically confined to the uterus and secrete lower levels of ß-hCG compared with other GTNs. The International Federation of Gynecology and Obstetrics prognostic scoring system does not correlate well with prognosis. These lesions can be misdiagnosed as smooth muscle tumors, metastatic melanoma, and cervical squamous cell carcinoma. However, they can be distinguished by their unique histologic and immunophenotypic features. CONCLUSIONS: Surgery is the mainstay of treatment for early-stage PSTT and ETT. For patients with advanced disease or for those with poor prognostic indicators, such as an antecedent pregnancy interval of greater than 48 months, a multimodal treatment paradigm of surgery and chemotherapy using a high-risk GTN platinum-etoposide containing regimen is recommended. RELEVANCE: Placental site trophoblastic tumor and ETT should be considered in the differential diagnosis in a reproductive age patient presenting with abnormal uterine bleeding and an elevated ß-hCG after any antecedent pregnancy event.
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Enfermedad Trofoblástica Gestacional , Tumor Trofoblástico Localizado en la Placenta , Neoplasias Uterinas , Femenino , Enfermedad Trofoblástica Gestacional/diagnóstico , Enfermedad Trofoblástica Gestacional/tratamiento farmacológico , Humanos , Placenta/patología , Embarazo , Pronóstico , Tumor Trofoblástico Localizado en la Placenta/diagnóstico , Tumor Trofoblástico Localizado en la Placenta/patología , Tumor Trofoblástico Localizado en la Placenta/terapia , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/tratamiento farmacológicoRESUMEN
A diagnosis of myelodysplastic syndrome (MDS) is typically unexpected and can be difficult for patients to grasp. Not only is MDS a complicated disease to understand, which can contribute to stress and anxiety, but it also has an uncertain prognosis, which can be emotionally paralyzing. Not surprisingly, emotional distress and the symptom burden of MDS, including extreme fatigue due to cytopenias, negatively impact a patient's quality of life (QOL). Studies have shown that patient-centered care-including greater physician understanding of the disease burden their patients experience, discussing and establishing agreed-on treatment goals, and including patients in the decision-making process about their care-may help improve patient QOL. To better understand patient and caregiver experiences with MDS and how the disease impacts QOL, a small survey was conducted of patients with MDS or leukemia and their caregivers on an online health network. Among the 30 respondents who completed the survey, four had MDS and one was a caregiver for a patient with MDS. Here we focus on the five MDS respondents and contextualize the findings with personal experiences from a patient and physician perspective. The patient perspective was provided by John Soper, PhD, DABCC, who was diagnosed with MDS in 2019. Dr Soper is a retired board-certified clinical chemist and a member of the MDS Foundation. The physician perspective was provided by Dr Ruben Mesa, Executive Director of the Mays Cancer Center at UT Health San Antonio MD Anderson. The survey responses and the accompanying patient and physician perspectives highlight the importance of open communication between patients and their healthcare provider to better serve those with MDS and improve their QOL.
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BACKGROUND: Nab-paclitaxel is a novel Cremophor®-free nanoparticle of albumin-stabilized paclitaxel, which has favorable efficacy and toxicity characteristics relative to other solvent-based taxanes, such as paclitaxel and docetaxel. METHODS: Eligible patients had platinum- and taxane-resistant ovarian cancer, defined by persistent or progressive disease following primary chemotherapy (n = 5) or recurrence within 6 months of treatment completion (n = 42). All patients had measurable disease, no prior therapy for recurrent disease and Gynecologic Oncology Group performance status of ≤ 2. Treatment was nab-paclitaxel, 100 mg/m² days 1, 8, and 15 on a 28-day schedule. The primary endpoint was Response Evaluation Criteria in Solid Tumors v1.0 response rate, evaluated in a 2-stage design (with power of 0.90 for a RR of 25% and with alpha of 0.05 for RR of 10%). RESULTS: Fifty-one patients were enrolled of which 47 were evaluable; median time from frontline therapy completion to registration was 21 days. Patient demographics include median age: 59 (34-78) years, serous histology: 72%, and high-grade: 81%. EFFICACY: one complete and 10 partial responses were confirmed (23%); 17 patients (36%) had stable disease. The median progression-free survival was 4.5 months (95% CI: 2.2-6.7); overall survival was 17.4 months (95% CI: 13.2-20.8). Seventeen patients (36%) had PFS > 6 months. TOXICITY: there were no grade 4 events; grade 3 events were neutropenia (6), anemia (3), GI (2), metabolic (2), pain (2), and leukopenia (1); neurosensory toxicity was observed as grade 2:5, grade 3:1. CONCLUSIONS: Nab-paclitaxel has noteworthy single-agent activity and is tolerable in this cohort of refractory ovarian cancer patients previously treated with paclitaxel.
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Albúminas/administración & dosificación , Neoplasias de las Trompas Uterinas/tratamiento farmacológico , Nanopartículas/administración & dosificación , Recurrencia Local de Neoplasia/tratamiento farmacológico , Neoplasias Ováricas/tratamiento farmacológico , Paclitaxel/administración & dosificación , Neoplasias Peritoneales/tratamiento farmacológico , Adulto , Anciano , Antineoplásicos Fitogénicos/administración & dosificación , Resistencia a Antineoplásicos , Femenino , Humanos , Persona de Mediana EdadRESUMEN
This review summarizes the current evaluation and management of gestational trophoblastic disease, including evacuation of hydatidiform moles, surveillance after evacuation of hydatidiform mole and the diagnosis and management of gestational trophoblastic neoplasia. Most women with gestational trophoblastic disease can be successfully managed with preservation of reproductive function. It is important to manage molar pregnancies properly to minimize acute complications and to identify gestational trophoblastic neoplasia promptly. Current International Federation of Gynecology and Obstetrics guidelines for making the diagnosis and staging of gestational trophoblastic neoplasia allow uniformity for reporting results of treatment. It is important to individualize treatment based on their risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for patients with high-risk disease. Patients with gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients.
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Enfermedad Trofoblástica Gestacional/terapia , Antineoplásicos/administración & dosificación , Femenino , Enfermedad Trofoblástica Gestacional/clasificación , Enfermedad Trofoblástica Gestacional/diagnóstico , Enfermedad Trofoblástica Gestacional/patología , Procedimientos Quirúrgicos Ginecológicos , Humanos , Embarazo , Terminología como Asunto , Útero/patologíaRESUMEN
IMPORTANCE: Vulvar intraepithelial neoplasia (VIN) represents an increasingly common, yet challenging diagnosis that shares many common risk factors with cervical intraepithelial neoplasia. However, unlike cervical intraepithelial neoplasia, effective screening and treatment strategies are much less defined for patients with VIN. OBJECTIVE: The objective of this article is to review the underlying risk factors leading to the development of VIN, identify special populations at risk for VIN, and outline acceptable treatment strategies. EVIDENCE ACQUISITION: This literature review was performed primarily using PubMed. RESULTS: Vulvar intraepithelial neoplasia can be separated into usual VIN (uVIN) and differentiated VIN (dVIN). The more common uVIN is related to underlying human papillomavirus infection, whereas dVIN occurs in the setting of other vulvar inflammatory conditions such as lichen sclerosis. Differentiated VIN carries a higher risk of progression to invasive malignancy. Extramammary Paget disease is a rare intraepithelial adenocarcinoma unrelated to uVIN and dVIN, although management is similar. CONCLUSIONS AND RELEVANCE: Vulvar intraepithelial neoplasia is a preinvasive neoplasia of the vulva with few robust strategies for surveillance or management. Careful examination with targeted biopsy is warranted for suspicious lesions, and a combination of surgical and medical management can be tailored for individual patient needs.