Targeted Ovarian Cancer Education for Hispanic Women: A Pilot Program in Arizona.

In disadvantaged populations, including Hispanics, there is a deficit in understanding of cancer risk factors, symptoms, prevention, and treatment. The objective of this study was to assess ovarian cancer knowledge in a population of Hispanic women in Arizona, identify deficiencies, and to evaluate the utility of an educational program developed specifically for this community's needs. A de novo questionnaire about ovarian cancer was distributed to Hispanic women enrolled in family literacy programs at Mesa Public Schools. Following this assessment, a video educational program was developed, with emphasis on areas of greatest knowledge deficits, and post-intervention assessment administered. Chi square, Wilcoxon rank sum, and Kruskal-Wallis tests were used for analysis. 167 questionnaires were completed in the pretest group and 102 in the post-intervention group. Between groups, there were no differences in age (p = 0.49), education (p = 0.68), or annual income (p = 0.26). In the pretest group, 45 % of questions were answered correctly versus 84 % in the post-test group (p < 0.01). 24.2 % of the initial respondents correctly identified ovarian cancer symptoms versus 85.6 of post-test respondents (p < 0.01). With the program, there was an increase in the number of correct post-test responses for each question and symptom (p < 0.01), except those about hereditary risk of ovarian cancer (p = 0.62) and pelvic anatomy (p = 0.16). Following identification of an ovarian cancer knowledge deficit in this cohort of Hispanic women, an educational tool targeting specific deficiencies successfully increased cancer knowledge and awareness of symptoms. Similar efforts in this and other minority populations should be continued.

Challenges of pelvic imaging in obese women.

Obesity is a major global health concern affecting all ages, socioeconomic groups, and countries. Although men have higher rates of overweight, women have higher rates of obesity. In the United States, more than 60% of women are overweight or obese, with slightly more than one-third considered frankly obese. Obesity is a major risk factor for noncommunicable diseases such as diabetes mellitus, cardiovascular disease, hypertension, stroke, and specific cancers. Obesity is associated with increased mortality for all cancers, with the highest death rates occurring in the heaviest women. Obesity can contribute to missed diagnoses, nondiagnostic results of imaging studies, imaging examination cancellation because of weight or girth restrictions, scheduling of inappropriate examinations, and increased radiation dose exposure. The utility of the clinical examination is often limited in the obese woman, which results in an even greater reliance on imaging; however, the obese woman may experience a lowered quality of and less access to medical imaging. Recognition of equipment limitations, imaging artifacts, optimization techniques, and appropriateness of modality choices is critical to providing good patient care to this health-challenged group. The clinical indication, the patient's weight, and the body diameters are three key factors to consider when choosing the most appropriate examination. Familiarity with the optimization of imaging techniques across all modalities is important to convert potentially suboptimal examinations into diagnostic-quality studies. The aim of this review is to identify key areas in which obesity affects the imaging care of women with pelvic conditions and to outline strategies to address these areas.

Survival and reproductive outcomes in women treated for malignant ovarian germ cell tumors.

OBJECTIVE: The objective of this study is to review all malignant germ-cell tumors (MOGCTs) treated at our institution, focusing on reproductive outcomes and menstrual function of patients treated with fertility-sparing surgery and adjuvant chemotherapy. METHODS: We performed a retrospective chart review of patients treated for MOGCTs between January 1, 1979 and March 31, 2008. Charts of identified patients were abstracted and data were collected. Patients who had fertility-sparing surgery were contacted and a telephone questionnaire was performed to gather reproductive and menstrual history. RESULTS: Forty patients were treated for MOGCTs at our institution. Mean age at the time of diagnosis was 26.5years (range, 10-48years). Histologic subtypes were: immature teratoma (52.5%), dysgerminoma (27.5%), yolk sac tumor (10.0%), mixed germ cell tumor (7.5%), and choriocarcinoma (2.5%). Thirty-five percent of tumors were FIGO stages II-IV. Twenty-seven patients (67.5%) were treated with chemotherapy postoperatively, 23 (85%) of whom received bleomycin, etoposide and cisplatin (BEP). There were three recurrences, but no deaths. Fertility-sparing surgery was performed in 22 patients (55%), 16 of whom received adjuvant chemotherapy. Fourteen of these patients were contacted. Of the 10 remaining patients desiring pregnancy, 8 (80%) had 11 successful spontaneous pregnancies, one required in-vitro fertilization, and the other required donor egg in-vitro fertilization, resulting in 14 live births. All 14 patients had normal menstrual cycles within one year of completing chemotherapy. CONCLUSIONS: Overall survival was 100% among patients with both local and advanced MOGCTs, including those who underwent fertility-sparing surgery. Fertility-sparing surgery plus adjuvant chemotherapy appeared to have little or no effect on fertility or menstrual cycles.

Management of metastatic high-risk gestational trophoblastic neoplasia: FIGO stages II-IV: risk factor score > or = 7.

OBJECTIVE: To evaluate treatment of metastatic high-risk gestational trophoblastic neoplasia (GTN), including durable complete response rates to chemotherapy, factors affecting response to therapy, and overall survival. STUDY DESIGN: Forty women with metastatic high-risk GTN (International Federation of Gynecology and Obstetrics [FIGO] stages II-IV, score > or = 7) completed treatment between 1986 (when EMA-CO became the standard chemotherapy for high-risk disease) and 2009, including 26 who were treated primarily and 14 who were treated secondarily. Patients who had incomplete responses or developed resistance to EMA-CO or other methotrexate-containing regimens were treated with drug combinations employing etoposide and a platinum agent with or without bleomycin or ifosfamide. Adjuvant radiotherapy and surgery were used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively. RESULTS: The overall survival rate was 90% (36 of 40): 92% (24/26) for primary treatment and 86% (12/14) for secondary treatment. Twenty-one patients (53%) had durable complete clinical responses to initial treatment, 15 patients (37%) developed resistance to initial chemotherapy but were subsequently placed into lasting remission with platinum-based chemotherapy with or without surgery and 4 patients (10%) died of widespread metastatic disease. Durable complete clinical response to initial chemotherapy was significantly influenced by FIGO stage (II and III, 63%, vs. IV, 31%, p = 0.05) and risk factor score (< 12, 71%, vs. > or = 12, 32%, p < 0.02). Survival was also significantly associated with both FIGO stage (II and III, 100%, vs. IV, 69%, p < 0.01) and score (< 12, 100%, vs. > or = 12, 79%, p < 0.05). CONCLUSION: The use of EMA-CO chemotherapy as primary treatment and platinum-based chemotherapy along with surgical excision of resistant disease as secondary treatment for patients with metastatic high-risk GTN resulted in a survival rate of 90%. All patients who died had FIGO stage IV and risk factors scores > or = 12.

An outpatient intraperitoneal chemotherapy regimen for advanced ovarian cancer.

OBJECTIVES: To assess the feasibility, associated toxicities, and reasons for early cessation of an outpatient intraperitoneal (IP) chemotherapy regimen for treatment of advanced ovarian cancer following optimal cytoreductive surgery. METHODS: Between January 2006 and December 2007, 42 patients with stages IIC-IV epithelial ovarian, tubal, or primary peritoneal cancer who had residual disease <1 cm after cytoreductive surgery were treated with an outpatient IP chemotherapy protocol. Patients received intravenous (IV) docetaxel 75 mg/m(2) and IP cisplatin 75-100 mg/m(2) on day 1, followed by IP paclitaxel 60 mg/m(2) on day 8, with the intent to treat patients every 21 days for 6 cycles of chemotherapy. Charts were abstracted for demographic, chemotherapy, and toxicity-related data. RESULTS: The median age of the 42 patients was 59 years (range 33-70) and the majority of patients had epithelial ovarian cancer (80%), FIGO stage IIIC (83%), and papillary serous histology (74%). Of an intended 252 IP chemotherapy cycles, 172 (68%) were administered. Twenty-nine patients (69%) completed >or=4 cycles and 12 (29%) received all 6 IP cycles. Common grade 3/4 toxicities by patient included neutropenia (43%), infection (21.5%), and gastrointestinal effects (14%). There was one treatment-related death. Reasons for discontinuation were largely chemotherapy (43%) or port (37%) related. CONCLUSIONS: With supportive measures, such as scheduled hydration and granulocyte colony-stimulating factors, outpatient administration of IP chemotherapy was feasible. This regimen resulted in few hospitalizations or treatment delays and demonstrated less toxicity than previously reported IP chemotherapy regimens. Port-related complications were a leading cause of IP chemotherapy discontinuation.

Robotic surgery in gynecologic oncology: impact on fellowship training.

OBJECTIVES: To report the impact of a new robotic surgery program on the surgical training of gynecologic oncology fellows over a 12 month period of time. METHODS: A robotic surgery program was introduced into the gynecologic oncology fellowship program at Northwestern University Feinberg School of Medicine in June 2007. A database of patients undergoing surgical management of endometrial and cervical cancer between July 2007 and July 2008 was collected and analyzed. Changes in fellow surgical training were measured and analyzed. RESULTS: Fellow surgical training for endometrial and cervical cancer underwent a dramatic transition in 12 months. The proportion of patients undergoing minimally invasive surgery increased from 3.3% (4/110 patients) to 43.5% (47/108 patients). Fellow training transitioned from primarily an open approach (94.4%) to a minimally invasive approach (11% laparoscopic, 49% robotic, 40% open) for endometrial cancer stagings, and from an open approach (100%) to an open (50%) and robotic (50%) approach for radical hysterectomies. Fellow participation in robotic procedures increased from 45% in the first 3 months to 72% within 6 months, and 92% by 12 months. The role of the fellow in robotic cases transitioned from bedside assistant to console operator within 3 months. CONCLUSIONS: Fellow surgical training underwent a dramatic change with the introduction of a robotic surgery program. The management of endometrial and cervical cancer was impacted the most by robotics. Robotic surgery broadened fellowship surgical training, but balanced surgical training and standardized fellow training modules remain challenges for fellowship programs.

FIGO stage IIIC endometrial carcinoma: prognostic factors and outcomes.

OBJECTIVES: Investigate the clinicopathologic characteristics, nodal distribution, and postoperative treatment of patients with FIGO stage IIIC endometrial carcinoma and determine patterns of recurrence and survival. METHODS: A retrospective review of 85 patients who underwent surgical staging with lymph node dissection at a single institution between 1979 and 2005 was performed. Data collected from patient charts included demographics, treatment, recurrence and survival. Variables were compared using the log-rank and X2 tests, and multivariate analysis was performed. RESULTS: Of 1487 patients who underwent surgical staging for endometrial cancer, 104 (7.0%) were diagnosed with stage IIIC disease and 85 of these were analyzed. Stage was determined by positive pelvic lymph nodes (PLN) in 54 patients, and positive para-aortic lymph nodes (PaLN)+/-PLN in 31 patients. With a median follow up of 50 months, 5-year overall survival (OS) was 61.3%, recurrence-free survival (RFS) was 58.0%, and disease-specific survival (DSS) was 71.9%. Median OS, RFS and DSS were 131 months, 131 months, and not attained, respectively. Five-year OS and RFS with positive PaLN were 48.8% and 44.4% respectively, compared to 69.7% and 65.6% with positive PLN only. On multivariate analysis, age, non-endometrioid histology, and >50% invasion were significantly associated with OS; age and non-endometrioid histology were associated with RFS. Disease recurred in 21 patients (24.7%): 15 distant, 4 abdominal, 1 para-aortic, and 1 pelvic. Disease recurred outside the field of radiation in all patients. CONCLUSIONS: Endometrial cancer patients with FIGO stage IIIC had a 5-year OS of 61.3%, a RFS of 58.0% and a DSS of 71.9% in this series. Because of the high proportion of distant sites of recurrence (71.4%), recurrence outside the radiation field (100%), and mortality after recurrence (86.3%), multimodality therapy should be considered.

The role of adjuvant radiation in endometrial cancer.

Endometrial cancer treatment ideally begins with a staging procedure including abdominopelvic washing, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymph node evaluation. Recommendations for postoperative adjuvant radiotherapy are determined by recurrence risk. Patients who have undergone staging and have early stage I disease and an absence of high-risk features for recurrence generally are treated with surgery alone. Intermediate-risk patients--those with high-risk stage I disease and some stage II patients--may benefit from adjuvant radiation therapy. Several randomized trials show that radiation therapy improves locoregional control among intermediate-risk patients. The optimal type of radiation therapy, whether vaginal brachytherapy or whole-pelvic radiation therapy, remains undetermined, though treatment decision can be guided by risk factors not encompassed by the current staging system. Patients with high-risk stage II disease and stage III disease generally receive external-beam radiotherapy, often in combination with chemotherapy. Chemotherapy alone in advanced-stage patients is a consideration, given the results of the Gynecologic Oncology Group (GOG)-122 trial.

The regulation and function of the forkhead transcription factor, Forkhead box O1, is dependent on the progesterone receptor in endometrial carcinoma.

In many type I endometrial cancers, the PTEN gene is inactivated, which ultimately leads to constitutively active Akt and the inhibition of Forkhead box O1 (FOXO1), a member of the FOXO subfamily of Forkhead/winged helix family of transcription factors. The expression, regulation, and function of FOXO1 in endometrial cancer were investigated in this study. Immunohistochemical analysis of 49 endometrial tumor tissues revealed a decrease of FOXO1 expression in 95.9% of the cases compared with the expression in normal endometrium. In four different endometrial cancer cell lines (ECC1, Hec1B, Ishikawa, and RL95), FOXO1 mRNA was expressed at similar levels; however, protein levels were low or undetectable in Ecc1, Ishikawa, and RL95 cells. Using small interfering RNA technology, we demonstrated that the low levels of FOXO1 protein were due to the involvement of Skp2, an oncogenic subunit of the Skp1/Cul1/F-box protein ubiquitin complex, given that silencing Skp2 increased FOXO1 protein expression in Ishikawa cells. Inhibition of Akt in Ishikawa cells also increased nuclear FOXO1 protein levels. Additionally, progestins increased FOXO1 protein levels, specifically through progesterone receptor B (PRB) as determined by using stably transfected PRA-specific and PRB-specific Ishikawa cell lines. Finally, overexpression of triple mutant (Tm) FOXO1 in the PR-specific Ishikawa cell lines caused cell cycle arrest and significantly decreased proliferation in the presence and absence of the progestin, R5020. Furthermore, TmFOXO1 overexpression induced apoptosis in PRB-specific cells in the presence and absence of ligand. Taken together, these data provide insight into the phosphoinositide-3-kinase/Akt/FOXO pathway for the determination of progestin responsiveness and the development of alternate therapies for endometrial cancer.

Weekly topotecan for recurrent platinum resistant ovarian cancer.

OBJECTIVE: To evaluate toxicity, response and progression-free survival of weekly topotecan chemotherapy in women with primary and secondary platinum-resistant epithelial ovarian cancer. METHODS: A retrospective analysis of 69 patients who received weekly topotecan with a median dose of 3.75 on days 1, 8 and 15 of a 28-day cycle treated between November 2002 and May 2005. All patients had recurrent epithelial ovarian, primary peritoneal or tubal cancer with primary or secondary resistance to platinum. Disease response was evaluated by CA-125 levels, physical exam, and when appropriate, imaging studies. Toxicity was evaluated using the NCI Common Toxicity Criteria. RESULTS: Response to topotecan therapy was noted in 14 of 69 patients (20.3%); (complete response 7.3%, and partial response 13%). Stable disease was noted in 23 patients (33.3%) and progression of disease occurred in 31 patients (44.9%). Two patients (2.8%) had significant side effects that warranted discontinuation of therapy. There was no significant difference in response to therapy between patients with primary or secondary platinum resistance. A total of 229 cycles was given with a median of 3 (range 1-12) cycles per patient. Grades 3 and 4 myelosuppression was rare: 1 cycle (0.4%) with grade 3 leukopenia, 16 cycles (7%) with grade 3 or 4 neutropenia, 1 cycle (0.4%) with grade 3 anemia, and 2 cycles (0.9%) with grade 3 thrombocytopenia. No patient was admitted with neutropenic fever. The median progression-free survival for responders was 5.7 months (2-16.75). CONCLUSIONS: Weekly topotecan is a well-tolerated and effective regimen for platinum-resistant ovarian cancer with considerable less hematological toxicity when compared with historical data for the 5-day regimen.

Chemosensitization of endometrial cancer cells through AKT inhibition involves FOXO1.

OBJECTIVE: Endometrial cancer is the most common type of gynecologic cancer in the United States. In this study, we propose that inhibition of the AKT pathway sensitizes cells to chemotherapeutic agents by increasing FOXO1 expression. METHODS: Ishikawa and RL95 cells were treated with the AKT inhibitor (API-59CJ-OMe) alone and in combination with carboplatin or paclitaxel. Cells were counted using a hemocytometer and cell cycle analysis done with flow cytometry. Apoptosis was measured with TUNEL and Annexin V/DAPI staining. FOXO1 protein expression and localization was done using immunofluorescent staining of cells. Finally, the adenovirus containing triple mutant FOXO1 was used to overexpress the constitutively active FOXO1 in Ishikawa cells and its effects on cell viability were studied. RESULTS: Treatment with 6 microM API-59CJ-OME resulted in preferential cell death in Ishikawa and RL95 cells compared to another endometrial cancer cell line, ECC1 after 48 h of treatment. API-59CJ-OME treatment of Ishikawa cells resulted in cell cycle arrest in the G2/M phase. The addition of API-59CJ-OME to carboplatin resulted in a synergistic increase in cell death by apoptosis compared to the responses to each agent separately. Treatment with API-59CJ-OME, carboplatin, paclitaxel or the combinations for 24 h increased nuclear expression of FOXO1 in Ishikawa cells. Overexpression of FOXO1 caused 37% of the cells to die within 24 h. Addition of carboplatin to the AD-FOXO1 expressing cells further increased cell death to 71%. CONCLUSIONS: Inhibition of AKT signaling potentiates cell death in Ishikawa and RL95 cells when combined with carboplatin through mechanisms involving FOXO1 activation.

Primary treatment of metastatic high-risk gestational trophoblastic neoplasia with EMA-CO chemotherapy.

OBJECTIVE: To evaluate the efficacy of etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) in the primary treatment of metastatic high-risk gestational trophoblastic neoplasia. STUDY DESIGN: Thirty women with metastatic high-risk gestational trophoblastic neoplasia were treated primarily with EMA-CO between 1986 and 2005. Patients who had incomplete responses or developed resistance to EMA-CO were treated with drug combinations employing etoposide and a platinum agent with or without bleomycin or ifosfamide. Adjuvant surgery and radiotherapy were used in selected patients. Survival, clinical response and factors affecting treatment success were analyzed retrospectively. RESULTS: The overall survival rate was 93.3% (28 of 30). Of the 30 patients treated with EMA-CO, 20 (66.7%) had a lasting clinical response, 8 (26.7%) developed resistance but were subsequently placed in remission with platinum-based chemotherapy, and 2 (6.7%) died of widespread metastatic disease. Clinical complete response to EMA-CO was significantly influenced by human chorionic gonadotropin level (<100,000 mIU/ mL, 82%, vs. > 100,000 mIU/mL, 46%), metastatic site (lung and pelvis, 75%, vs. other, 33%) and International Federation of Gynecology and Obstetrics (FIGO) risk factor score (< 7, 92% vs. >7, 50%). Surgical procedures were performed on 12 patients, and 4 patients received brain irradiation. Eight (80%) of 10 patients who received secondary platinum-based chemotherapy or without surgery were cured. The 2 patients who died had stage IV disease (brain and/or liver metastases) with FIGO scores of 13 and 14. CONCLUSION: Over 93% of 30 patients with metastatic high-risk gestational trophoblastic neoplasia treated initially with the EMA-CO protocol, often in conjunction with brain irradiation, surgical resection of sites of persistent tumor and salvage platinum-based chemotherapy, were cured.

Role of surgery in the management of high-risk gestational trophoblastic neoplasia.

OBJECTIVE: To evaluate the role of surgery in the management of high-risk gestational trophoblastic neoplasia. STUDY DESIGN: Twenty-four (48%) of 50 patients treated with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen as primary or secondary chemotherapy for high-risk gestational trophoblastic neoplasia between 1986 and 2005 underwent 28 adjuvant surgical procedures. The procedures included hysterectomy (17), lung resection (5), salpingectomy (1), uterine wedge resection (1), small bowel resection (1), suturing of the liver or uterus for bleeding (2) and uterine artery embolization (1). RESULTS: Twenty-one (87.5%) of 24 patients who had surgical procedures as part of their treatment for high-risk disease survived. Fifteen (88%) of 17 patients undergoing hysterectomy were cured. Four (80%) of 5 patients who had resistant foci of choriocarcinoma in the lung were cured by pulmonary resection. The patients who had suturing of the uterus, uterine artery embolization, small bowel resection and salpingectomy for bleeding as well as the patient who had uterine wedge resection of resistant choriocarcinoma survived. CONCLUSION: Adjuvant surgical procedures, especially hysterectomy and pulmonary resection for chemotherapy-resistant disease as well as procedures to control hemorrhage, are important components in the management of high-risk gestational trophoblastic neoplasia. Twenty-four (48%) of 50 patients with high-risk gestational trophoblastic neoplasia in this series underwent surgical procedures, and 21 (87.5%) were cured.

Evaluation of Outcomes in Patients With Carcinoma of the Cervix Treated With Concurrent Radiation and Cisplatin Versus Cisplatin/5-FU Compared With Radiation Alone.

OBJECTIVES: The objective of this study was to compare outcomes for patients with cervical cancer treated with radiation concurrently with cisplatin, cisplatin/5-fluorouracil (5-FU), or without chemotherapy. MATERIALS AND METHODS: We reviewed the records of eligible patients with locoregionally confined, stage IB1 through IVA, intact cervical cancer who were treated at Northwestern Memorial Hospital. All patients underwent definitive radiotherapy with combined external beam radiation-the majority with extended-field (62%)-and received low-dose rate brachytherapy. RESULTS: A total of 236 patients were included: 99 had no concurrent chemotherapy, 95 were treated with concurrent cisplatin, and 42 were treated with cisplatin/5-FU. For all patients treated with or without chemotherapy, overall survival at 5 and 10 years was 64% and 59%, respectively. Patients treated with chemotherapy had a superior recurrence-free survival rate of 69% at 5 years versus 49% in patients who did not receive chemotherapy (P=0.09). Twenty-six percent of patients treated with cisplatin alone, 31% of patients treated with cisplatin/5-FU, and 45% of patients who did not receive chemotherapy experienced a disease recurrence. Adenosquamous histology conferred a higher rate of recurrence as compared with adenocarcinoma and squamous cell histologies (54% vs. 34%, respectively; P=0.05). CONCLUSIONS: Cisplatin-based concurrent chemoradiotherapy showed a trend toward improved recurrence-free survival survival in the definitive treatment of nonmetastatic cervical cancer. The addition of 5-FU to cisplatin did not appear to significantly impact survival or recurrence-free survival. Adenosquamous histology was associated with a higher risk of recurrence as compared with other histologic subtypes.

Frozen section analyses as predictors of lymphatic spread in patients with early-stage uterine cancer.

BACKGROUND: Many gynecologic oncologists use intraoperative frozen section (IFS) assessment of histologic grade and depth of myometrial invasion (DOI) as predictors of final grade and stage in women with endometrial cancer. This clinical decision method has never been critically examined. STUDY DESIGN: We retrospectively reviewed charts of patients with a preoperative diagnosis of uterine endometrioid adenocarcinoma and an intraoperative frozen section assessment of histologic grade and depth of myometrial invasion. Intraoperative predictors combining intraoperative frozen section assessment of histologic grade and depth of myometrial invasion were established and compared with final grade and surgical stage. We then modeled the risks of pelvic and paraaortic lymph node metastases for each predictor. RESULTS: There were 129 patients who met inclusion criteria. Thirty-six patients had the IAG1 predictor; 17 (47%) were stage IAG1 on final pathology. Ten patients had the IAG2 predictor; 3 (30%) were stage IAG2 on final pathology. Thirty-four patients had the IBG1 predictor; 18 (53%) were stage IBG1 on final pathology. Forty-nine patients had the IBG2 predictor; 34 (69%) were stage IBG2 on final pathology. Our decision models predict that the IAG1 predictor has a 1% risk of paraaortic and a 2% risk of pelvic lymph node metastases. The IAG2 and IBG1 predictors have a 2% risk of paraaortic and a 4% risk of pelvic lymph node metastases. The IBG2 predictor has a 2% risk of paraaortic and a 6% risk of pelvic lymph node metastases. CONCLUSIONS: The combination of intraoperative frozen section analysis for histologic grade and depth of myometrial invasion does not correlate well with final pathologic grade and stage. Data from our models suggest a significant risk of lymph node spread even for patients with seemingly low-risk disease. Until better markers of lymphatic spread exist, we recommend complete surgical staging of all patients with endometrial cancer.

A comparison of 2 methods of vaginal cuff closure during robotic hysterectomy.

OBJECTIVE: To compare 2 methods of vaginal cuff closure with regard to safety, ease of use, and postoperative outcome. METHODS: All patients undergoing robotic-assisted total hysterectomy by a gynecologic oncologist from July 1, 2010, to July 1, 2011, at Northwestern Memorial Prentice Women's Hospital were included in a retrospective analysis. Providers used either 2-0 monofilament synthetic absorbable suture to close the vaginal cuff in a running fashion, secured with an absorbable suture clip at the angles and then knotted in the middle, or 2-0 absorbable unidirectional barbed suture with a welded-loop closure in a running fashion. RESULTS: A total of 134 patients underwent robotic-assisted total hysterectomy. The 2-0 tied monofilament closure was used in 58 patients, and the 2-0 barbed knotless closure was used in 76 patients. There were no instances of vaginal cuff dehiscence or vaginal cuff cellulitis. Rates of vaginal spotting and bleeding were comparable between the groups (12.0% spotting in the monofilament suture group vs 13.0% spotting in the barbed suture group). All vaginal cuff bleeding resolved on its own without significant intervention. CONCLUSION: The use of either a 2-0 welded-loop unidirectional barbed suture or a 2-0 monofilament absorbable suture to close the vaginal cuff is safe and well tolerated.

What is integrative oncology and can it help my patients?

Integrative oncology lends itself to the comprehensive practice of gynecologic oncology with multiple tools and interventions that can impact on QoL and survival. However, there remains a paucity of well-designed, well-powered randomized control trials on various CAM modalities for gynecologic cancer patients. The reasons for the lack of level 1 evidence include the nascent state of integrative medicine as a science, the limitations on CAM funding, the relative lack of integration of CAM practitioners into the oncology community, and absence of strict regulation of herbs and supplements by the US FDA. The use of CAM as adjunctive therapies will likely continue given the patient-driven trends to date, and given the evidence for at least safety and potentially efficacy, our patients deserve our willingness to use all possible approaches to improving their outcomes. Continued evolution of our ability to specifically measure and describe QoL will further our ability to hone in on domains most important to patients and their survival and allow practitioners to make patient-specific recommendations. Multimodal programs that include physical activity, stress management, and diet have the potential to address demonstrated deficits in PWB and FWB in ovarian cancer patients which suggests a model of collaborative gynecologic oncology care). Integrative oncology represents a holistic approach to patient care whose goal is maximization of patient quantity and quality of life. Patients can achieve this optimal outcome through the synergy of conventional care, integrative modalities, lifestyle modifications, and supportive care. Refer to Table 4 for a listing of integrated medicine Internet resources.

Dosimetry and toxicity outcomes in postoperative high-dose-rate intracavitary brachytherapy for endometrial carcinoma.

PURPOSE: The optimal dosimetric parameters and planning techniques for high-dose-rate vaginal brachytherapy (HDR-VB) are unclear. Our aim was to evaluate the utility of bladder and rectal dosimetry for patients receiving HDR-VB for postoperative treatment of endometrial carcinoma. MATERIAL AND METHODS: Patients with endometrial cancer who underwent postoperative HDR-VB from January 1, 2004 through December 31, 2010 were included. All patients underwent primary surgery consisting of total hysterectomy and bilateral salpingo-oophrectomy (TH-BSO) with or without lymph node dissection and were treated with HDR-VB without pelvic external beam radiotherapy (EBRT) or chemotherapy. Demographic, pathologic, dosimetric and clinical data were collected. RESULTS: One hundred patients were identified with the majority of patients receiving HDR-VB in 700 cGy × 3 fractions (45%) or 550 cGy x 4 fractions (53%). No plan was altered based on bladder dosimetry at the time of planning. The rate of acute urinary reactions (< 90 days from beginning of RT) grades 1 and 2 were 14% and 2%, respectively. The rate of late urinary reactions (> 90 days after RT) grades 1 and 2 were 7% and 3%, respectively. Dose to the bladder point did not correlate with urinary toxicity. No rectal toxicity was reported by patients receiving HDR-VB. CONCLUSIONS: In the setting of HDR-VB without EBRT, the measured dose to the bladder point does not predict urinary toxicity and is very unlikely to indicate the need to change the treatment plan. The treatment of endometrial carcinoma utilizing HDR-VB alone is associated with very low rates of high-grade acute or late bladder toxicity.