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.

Accuracy of preoperative cross-sectional imaging in cervical cancer patients undergoing primary radical surgery.

OBJECTIVE: We aim to describe the false negative (FN) and false positive (FP) rates of preoperative cross-sectional imaging (PCI) prior to radical surgery for cervical cancer. METHODS: A retrospective cohort study of patients who underwent radical hysterectomy for early-stage cervical cancer from January 2010 until December 2017 at a single tertiary care center was performed. Patients were included if they underwent preoperative PCI and radical surgery. Patient demographics and clinicopathologic information were recorded from medical record review. Descriptive statistics were used. RESULTS: Overall, 106 patients met inclusion criteria. Eighty-four percent (89/106) of patients had no suspicion for metastatic disease on PCI, while 16% (17/106) had suspicion for metastatic disease. Of the 89 without suspicion for metastatic disease on PCI, 16% (14/89) had a false negative study with metastatic disease identified on final surgical pathology. False negative rates by modality were 16% (11/70) for PET/CT and 6% (2/33) for diagnostic CT. Of the 17 cases with suspicion for metastatic disease on imaging, 53% (9/17) were false positive studies with no metastatic disease identified histologically. False positive rates by modality were 7% (5/70) for PET/CT and 12% (4/33) for diagnostic CT. CONCLUSION: PCI is a tool to help identify patients who are optimal candidates for radical surgery. In this sample, the false negative rate was 16%, and false positive rate was 53% for PCI among women who underwent primary radical surgery. Further study is needed to explore preoperative testing that may more accurately identify optimal surgical candidates.

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.

Prenatal Contraceptive Counseling by Video.

OBJECTIVE: Effective postpartum contraception can improve interpregnancy intervals. Opportunities exist for counseling and education during prenatal care. Few studies have assessed the use of multimedia as a tool to improve long-acting reversible contraception (LARC) use postpartum. The objective of this study was to evaluate whether LARC-focused video counseling during prenatal care increases uptake of postpartum LARC and overall contraception use. METHODS: In this randomized controlled trial, women receiving their prenatal care at a university-based resident clinic were randomized to receive LARC FIRST video contraceptive counseling along with routine prenatal care or routine prenatal care alone. All of the participants received information regarding access to free LARC methods in the postpartum period. The primary outcome was LARC uptake by 12 weeks postpartum. Secondary outcomes included overall contraception use at 12 weeks postpartum, postpartum visit attendance, and acceptability of video counseling. RESULTS: LARC use at 12 weeks postpartum rose from an estimated 6% preintervention to 39.4% (13/33) in the video group compared with 29.4% (10/34) of the control group. The difference between groups was not statistically significant. Although overall contraceptive use (72.7% vs 54.8%) and postpartum visit attendance (91% vs. 76.5%) were higher in the video group relative to the control group, these differences were not statistically significant. Participants overwhelmingly liked the video (95.2%, 41/42) and believed viewing it was a good use of their appointment time (92%, 38/42). CONCLUSIONS: LARC use increased 32% across the entire study cohort; however, video-based contraceptive counseling did not increase LARC uptake at 12 weeks postpartum compared with routine prenatal care alone. Patients viewing the video reported high levels of acceptability and improved contraceptive knowledge. Video counseling may be a useful adjunct in many clinical settings.

The effect of distance traveled on disease outcomes in gestational trophoblastic neoplasia.

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.

The Role of Obesity in the Development and Management of Gynecologic Cancer.

IMPORTANCE: Endometrial cancer is the most common gynecologic malignancy, with an estimated 54,000 new cases and 10,000 deaths in the United States in 2015. The obesity epidemic directly contributes to the escalating prevalence of chronic diseases, including obesity-related cancers. Patient body weight and nutritional status markedly impact perioperative oncologic care, chemotherapy administration, recurrence risk, and survivorship goals. OBJECTIVES: The objective of this review is to explore the association between obesity and the development, treatment, and survival outcomes of gynecologic cancers. EVIDENCE ACQUISITION: A systematic literature review was performed utilizing PubMed and ClinicalTrials.gov. CONCLUSIONS AND RELEVANCE: Caring for obese women with gynecologic cancers presents unique challenges. A coordinated multidisciplinary and system effort is required to address the prevention and treatment of obesity, as the sequela of this disease is a clear risk factor for the development of gynecologic malignancy and other comorbidities. Health care providers must be ready to address this worldwide health problem.

Malignant Brenner tumor of the ovary: Case series and review of treatment strategies.

Malignant Brenner tumor (MBTs) is a rare histological subtype of epithelial ovarian cancer, accounting for <0.05% of all ovarian neoplasms. As such, current evidence on the treatment of MBTs is predominantly limited to case studies and small case series. To add to existing literature, we performed a retrospective review of 10 cases of MBT diagnosed and treated at a single institution between 1999 and 2018. For the 10 cases included in our cohort, the median age was 64 and the median tumor stage was IIa/IIb. All patients underwent either a primary or interval debulking surgery and achieved an R0 resection per classifications set by the Union for International Cancer Control (UICC). Lymph node dissections were performed on 6 patients and found no evidence of positive nodal disease. 7 patients received platinum-based adjuvant chemotherapy and experienced a median progression-free survival (PFS) of 37 months. Recurrent disease was varied in terms of locoregional versus distant spread, and these patients had largely suboptimal responses to salvage chemotherapy with doxorubicin, gemcitabine, and eribulin. Sites of metastatic disease included the liver, lungs, bone, and brain. While there is no consensus for the optimal treatment of this rare disease, MBTs seem to respond well to adjuvant platinum-taxane treatment after complete surgical resection, consistent with the current management approach of other epithelial ovarian cancers. Recurrent disease is considerably more difficult to manage, and clinicians may consider a wider avenue of treatment options to include hormonal, biologic, and radiation therapies.

Epstein-Barr Virus-Induced Mononucleosis as an Imitator of Severe Preeclampsia.

Background In pregnancy, conditions presenting with hematologic abnormalities, transaminitis, and proteinuria pose diagnostic challenges in pregnancy. Case We present the case of an 18-year-old woman, G1P0, at 33 weeks' gestation with fever of unknown cause, who developed progressively elevated liver enzymes, proteinuria, and thrombocytopenia, due to Epstein-Barr virus (EBV) infection. Conclusion Acute infection with EBV should be included in the differential diagnosis of preeclampsia with severe features, particularly in the setting of fever. Supportive treatment and observation may prevent iatrogenic preterm birth.