Contemporary Incidence of Medical Inoperability in Clinical Stage I Endometrial Cancer.

BACKGROUND: Minimally invasive surgical (MIS) staging is the standard treatment approach for clinical stage I endometrial cancer. Historical rates of inoperability in endometrial cancer are approximately 10%. Given surgical and medical advancements against increasing population obesity, we aimed to describe a contemporary incidence of medical inoperability in clinical stage I endometrial cancer. PATIENTS AND METHODS: Patients diagnosed with clinical stage I endometrial cancer of any histology from April 2014 to December 2018 were included in this retrospective cohort study. The primary outcome, medical inoperability, was defined as (1) patients deemed inoperable by a gynecologic oncologist at initial consultation, (2) patients deemed inoperable during preoperative clearance, or (3) an aborted hysterectomy. Fisher's exact or χ2, and Student's t-test or Wilcoxon rank sum test were used, as appropriate, for data analysis. Multivariable logistic regression was also employed. RESULTS: Overall, 767 patients were included, of which 4.6% (35/767) were determined to be inoperable. The inoperable group had a higher body mass index (52.7 vs. 33.9, p < 0.001), and increased rates of diabetes (62.8%, 22/35 vs. 27.1%, 199/732, p < 0.001), coronary artery disease (31.4%, 11/35 vs. 7.1%, 52/732, p < 0.001), and hypertension (94.3%, 33/35 vs. 70.2%, 514/732, p < 0.001). Of those with attempted surgical staging, hysterectomy was aborted intraoperatively in 0.68% (5/737). The overall complication rate was 11.6% (86/737). CONCLUSIONS: With maximal surgical effort and MIS, hysterectomy is possible in > 95% of patients with newly diagnosed endometrial cancer treated at a high-volume center. Complication rates were comparable to other trials evaluating the safety of MIS staging for endometrial cancer.

Is a 'guideline-compliant' primary cesarean delivery associated with a modified risk for maternal and neonatal morbidity?: a clinical evaluation of the 2014 ACOG/SMFM obstetric care consensus statement.

BACKGROUND: It is currently unknown whether primary CDs performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement guidelines ("guideline-compliant") are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the guidelines ("guideline-noncompliant"). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD. METHODS: A retrospective cohort study of all primary CDs at one tertiary referral center in the calendar year following publication of the Consensus Statement. Logistic regression was performed to calculate the risk of adverse maternal and neonatal outcomes for guideline-compliant primary CDs, when compared to guideline-noncompliant and guideline-not addressed, and when adjusted for maternal age, BMI, hypertension, gestational age at delivery, insurance carrier, and provider practice. RESULTS: Eight hundred twenty-seven primary CDs were included during the study period, of which 34.8, 26.0, and 39.2% were guideline compliant, guideline-noncompliant, and guideline-not addressed. No statistically significant differences in the frequency of adverse maternal outcomes across these three groups were observed with the exception of maternal ICU admission, which was significantly associated with a guideline-not addressed primary CD (p = 0.0002). No statistical difference in rates of NICU admissions, 5 min APGAR < 5, or umbilical artery cord pH < 7 were observed between guideline-compliant and guideline-noncompliant primary CDs. CONCLUSION: Women undergoing guideline-compliant primary CDs were not significantly more likely to experience a maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs.

Sarcopenia as a predictor of survival and chemotoxicity in patients with epithelial ovarian cancer receiving platinum and taxane-based chemotherapy.

OBJECTIVES: Severe skeletal muscle loss (sarcopenia) is associated with poor cancer outcomes, including reduced survival and increased treatment toxicity. Our goal was to evaluate if sarcopenia was associated with worse survival outcomes and chemotoxicity in EOC patients undergoing primary platinum and taxane-based chemotherapy. METHODS: EOC patients diagnosed between 06/2000 and 02/2017 who received treatment with platinum and taxane-based chemotherapy were included. CT abdominal images closest to the time of diagnosis were retrospectively evaluated for skeletal muscle area at the 3rd lumbar vertebrae. Measurements were obtained with use of TomoVision® radiological software (SliceOmatic - version 5.0, Quebec, Canada). Sarcopenia was defined as Skeletal Muscle Index (SMI) ≤ 41. Data analysis included Kaplan-Meier plots to assess survival, and unpaired t-tests were used to compare the means by groups. RESULTS: 201 EOC patients were evaluated. Sixty-four percent (128/201) met criteria for sarcopenia (SMI ≤ 41) at time of diagnosis. The mean overall survival did not differ between patients with SMI > 41 and SMI ≤ 41 (36.5 vs 40.8 months, p = 0.4, respectively). No difference in frequency of dose reduction, dose delay, hospital admissions, changes in regimen, blood transfusion, or toxicity was noted. There was no difference in distribution of toxicity grade. CONCLUSION: Sarcopenia was not associated with worse survival outcomes or chemotoxcity in EOC patients receiving first-line platinum and taxane-based chemotherapy in this cohort. Future prospective studies should focus on interventions to prevent or reverse sarcopenia and possibly increase ovarian cancer survival, performance status, and quality of life.

Surgical Margins After Neoadjuvant Radiation for Locally Advanced Vulvar Carcinoma: What is an Adequate Margin?

OBJECTIVE: We aim to explore whether the surgical tumor free margin is important for overall survival (OS) and local control in patients who undergo neoadjuvant radiation (RT) for vulvar cancer. METHODS: A retrospective review from 2004 to 2021 of patients who underwent RT followed by surgical resection was performed. Patients were categorized into groups based on margin status (no residual disease, >8 mm, close margins defined as 1 to 7 mm, or positive). Local control and OS were analyzed using the Kaplan-Meier with log rank test. Multivariate analysis was performed with cox hazards model. RESULTS: Eighty-three patients were included. A complete pathologic response (pCR) was found in 56% (n=46) of patients. The median follow-up time was 35 months (range: 4 to 216). The median OS for the entire cohort was 46 months (95% CI: 32.3-59.7). Having a pCR improved both OS and disease-free survival (DFS) compared with residual disease by 81 and 91 months, respectively (P<0.001). In the 2 patients with a margin >8 mm, there was no statistical difference in survival between those with close margins (46 vs. 25 mo, P=0.485). Factors that significantly impacted both OS and DFS were depth of invasion (DOI) and LVSI. On multivariate analysis of those with residual disease, there was no difference in OS or DFS by margin status but having a DOI >9 mm showed decreased OS (HR: 3.654; 95% CI: 1.317-10.135). CONCLUSIONS: In this cohort, response to RT, not margin status drives survival and recurrence. Given residual disease, the optimal margin is not clear, as there were only 2 patients with >8 mm margins. A close or positive margin had no impact on OS or local recurrence. A DOI >9 mm significantly impacts both OS and local recurrence even when accounting for other factors.

Can an in-person hands-on applicator-based teaching session improve trainee knowledge and comfort with complex gynecologic brachytherapy?

INTRODUCTION: With the emergence of imaged-based planning and hybrid applicators the complexity of gynecologic brachytherapy has dramatically increased. Despite the known advantages of brachytherapy, notable national declines in utilization of brachytherapy have been documented. Clearly improved education in the sphere of gynecologic brachytherapy is needed. We hypothesize that a hands-on applicator-based training session would improve trainee comfort with gynecologic brachytherapy. METHODS AND MATERIALS: An in-person, applicator-based, hands-on training session was held with trainees from both radiation and gynecologic oncology programs. Trainees practiced assembling and handling applicators while receiving instruction on clinical scenarios in which various applicators are used in gynecologic cancer brachytherapy. Pre- and post-session, participants were administered an objective test of 10 pictorial-based case vignettes to quantify ability to select the correct applicator based on the interpretation of T2-weighted MR images. Participants additionally received a subjective survey to quantify comfort and experience with gynecologic brachytherapy using Likert-type question formatting. RESULTS: A total of 14 trainees participated. Most common case volume experience was 0-10 intracavitary (57%), 0-10 hybrid (71%), and 0-10 interstitial (71%). Pre-session, the most common answer to comfort level was "not comfortable still learning" for all brachytherapy types, and most common answer to largest gap in knowledge was all facets of brachytherapy. Average case-based test score was 3.5/10 pre-session versus 5.3/10 post-session (p = 0.028). Post-session, all respondents reported improved comfort level with brachytherapy. Post-session, most common answer to largest gap in knowledge was applicator/patient selection, and applicator/patient selection was also the largest area of identified improvement. 100% of participants felt repeating the session in the future would be helpful. CONCLUSIONS: Hands-on training with applicators improves both subjective and objective comfort with gynecologic brachytherapy. With 100% of participants requesting to implement this session into resident training, we suggest national opportunities might exist to expand educational processes and improve utilization of complex gynecologic brachytherapy in practice.