Validation of the Safety and Efficacy of Apixaban as Postoperative Thromboembolism Prophylaxis for Patients with Gynecologic Malignancies.

BACKGROUND: Venous thromboembolism is a preventable complication of gynecologic cancer surgery that leads to postoperative morbidity and mortality. This study compared apixaban with enoxaparin to identify whether apixaban had the same safety and efficacy for patients undergoing gynecologic cancer surgery. METHODS: The study identified patients with a gynecologic malignancy who underwent surgery and were prescribed apixaban at discharge between June 2020 and April 2023. International Classification of Diseases 10 codes were used to identify patients who had a thromboembolism within 90 days or a bleeding event within 60 days after surgery. The rates of events for patients prescribed apixaban were compared with those for a historical cohort of patients who received enoxaparin. Fisher's exact tests were used to compare categorical variables, and t tests were used to compare continuous variables. A logistic regression was performed to compare the odds of thromboembolism between the two groups. RESULTS: Baseline patient characteristics differed in terms of body mass index (BMI), race, route of surgery, and type of cancer. Of the 490 patients in the apixaban cohort, 12 (2.4%) had a thromboembolism compared with 3 (2.1%) of the 138 patients in the enoxaparin group (adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI] 0.30-4.70; p > 0.999). The odds ratio was adjusted for BMI, age, and route of surgery. A bleeding event occurred for 1 (0.2%) of the 490 patients in the apixaban group and for 1 (0.7%) of the 138 patients in the enoxaparin group. CONCLUSIONS: This validation study showed that apixaban is a safe and effective method of postoperative venous thromboembolism prophylaxis. The data provide support to previous data and guideline updates recommending the use of apixaban for postoperative prophylaxis.

Prognostic value of isolated tumor cells in sentinel lymph nodes in low risk endometrial cancer: results from an international multi-institutional study.

OBJECTIVE: The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. METHODS: Patients with SLNs-isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan-Meier methods. RESULTS: 494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs-isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1-3.0) and 2.6 years (IQR 0.6-4.2) in the SLN-isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN-isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. CONCLUSIONS: Patients with SLNs-isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs-isolated tumor cells was not associated with worse overall survival.

Delay in adjuvant chemotherapy administration for patients with FIGO stage I epithelial ovarian carcinoma is associated with worse survival; an analysis of the National Cancer Database.

OBJECTIVE: The administration of adjuvant chemotherapy within 42 days from surgery is one of the proposed quality measures for patients with epithelial ovarian cancer (EOC). The aim of the present study was to evaluate the impact of chemotherapy delay in the survival of patients with stage I EOC. METHODS: The National Cancer Database was accessed, and patients diagnosed between 2004 and 2015 with FIGO stage I EOC who received multi-agent chemotherapy were identified. Overall survival (OS) was compared between patients who received chemotherapy <6 weeks and 6-12 weeks from surgery with the log-rank test following generation of Kaplan-Meier curves. Cox model was constructed to control for a priori selected confounders. RESULTS: A total of 8549 patients who received adjuvant chemotherapy at a median 35 days from surgery (interquartile range 19) were identified; 67.7% received adjuvant chemotherapy <6 weeks from surgery while 32.3% experienced a delay. Patients who experienced a delay were more likely to have comorbidities (18.4% vs 14.9%, p < 0.001), and be managed in non-academic facilities (57.1% vs 53.2%, p = 0.001). Patients who experienced a delay had worse OS compared to those who did not, p < 0.001; 5-year OS rates 85.7% and 89.7%, respectively. For patients with high-grade serous tumors, those who experienced a delay had a 5-yr OS of 81.9% compared to 88.6% for those who did not, p < 0.001. After controlling for age, race, presence of comorbidities, insurance status, tumor histology and grade, performance of lymphadenectomy and substage, chemotherapy delay was associated with worse survival (HR: 1.25, 95% CI: 1.10, 1.42). CONCLUSIONS: For patients with early stage EOC administration of adjuvant chemotherapy within 6 weeks from surgery was associated with better overall survival, especially for those with stage IC disease.

Clinical outcomes in patients with COVID-19 and gynecologic cancer: A society of gynecologic oncology COVID-19 and gynecologic cancer registry study.

OBJECTIVES: Patients with gynecologic malignancies may have varied responses to COVID-19 infection. We aimed to describe clinical courses, treatment changes, and short-term clinical outcomes for gynecologic oncology patients with concurrent COVID-19 in the United States. METHODS: The Society of Gynecologic Oncology COVID-19 and Gynecologic Cancer Registry was created to capture clinical courses of gynecologic oncology patients with COVID-19. Logistic regression models were employed to evaluate factors for an association with hospitalization and death, respectively, within 30 days of COVID-19 diagnosis. RESULTS: Data were available for 348 patients across 7 institutions. At COVID-19 diagnosis, 125 patients (36%) had active malignancy. Delay (n = 88) or discontinuation (n = 10) of treatment due to COVID-19 infection occurred in 28% with those on chemotherapy (53/88) or recently receiving surgery (32/88) most frequently delayed. In addition to age, performance status, diabetes, and specific COVID symptoms, both non-White race (adjusted odds ratio (aOR) = 3.93, 95% CI 2.06-7.50) and active malignancy (aOR = 2.34, 95% CI 1.30-4.20) were associated with an increased odds of hospitalization. Eight percent of hospitalized patients (8/101) died of COVID-19 complications and 5% (17/348) of the entire cohort died within 30 days after diagnosis. CONCLUSIONS: Gynecologic oncology patients diagnosed with COVID-19 are at risk for hospitalization, delay of anti-cancer treatments, and death. One in 20 gynecologic oncology patients with COVID-19 died within 30 days after diagnosis. Racial disparities exist in patient hospitalizations for COVID-19, a surrogate of disease severity. Additional studies are needed to determine long-term outcomes and the impact of race.

Safety of ovarian preservation for premenopausal patients with FIGO stage I grade 2 and 3 endometrioid endometrial adenocarcinoma.

OBJECTIVE: To investigate the utilization and outcomes of ovarian preservation for premenopausal patients with International Federation of Gynecology and Obstetrics (FIGO) stage I grade 2 and 3 endometrioid endometrial carcinoma undergoing hysterectomy. METHODS: The National Cancer Database was accessed; patients aged ≤45 years diagnosed between January 2004 and December 2015 with FIGO stage I grade 2 or 3 endometrioid endometrial carcinoma, who underwent hysterectomy with or without bilateral salpingo-oophorectomy and had at least 1 month of follow-up, were identified. Overall survival was assessed following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected variables. RESULTS: A total of 2941 patients who met the inclusion criteria were identified; 200 (6.8%) patients did not undergo bilateral salpingo-oophorectomy. Rate of ovarian preservation was comparable between patients with grade 2 (n=163, 6.6%) and grade 3 (n=37, 7.7%) tumors (p=0.38). Patients who did not undergo bilateral salpingo-oophorectomy were younger (median 39 vs 41 years, p<0.001) and less likely to undergo surgical lymph node assessment (52% vs 76.2%, p<0.001). There was no difference in overall survival between patients who did and did not undergo bilateral salpingo-oophorectomy (p=0.94); 5 year overall survival rates were 96.6% and 97%, respectively. After controlling for confounders, including tumor grade, ovarian preservation was not associated with worse overall survival (HR 0.92, 95% CI 0.47 to 1.84). CONCLUSIONS: For patients with grade 2 and 3 FIGO stage I endometrioid carcinoma undergoing hysterectomy, ovarian preservation is rarely performed while no clear detrimental effect on overall survival was found.

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer.

OBJECTIVE: A retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomy METHODS: Patients diagnosed between January 2012 and December 2015 with vulvar squamous cell carcinoma of less than 4 cm in size, with invasion of at least 1 mm, who underwent sentinel lymph node biopsy, lymphadenectomy, or both were identified from the National Cancer Database. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test for patients who had at least 1 month of follow-up. A Cox model was constructed to control for confounders. RESULTS: A total of 1583 patients were identified; 304 patients (19.2%) underwent sentinel lymph node biopsy alone. Sentinel lymph node biopsy utilization increased 13.9% between 2012 and 2015. Patients who underwent sentinel node biopsy alone were less likely to have comorbidities compared with those undergoing lymphadenectomy only or sentinel node biopsy with lymphadenectomy (25.3% vs 32.9% vs 31.9%, p=0.042), had smaller tumors (median 1.6 vs 2.0 vs 2.0 cm, p<0.001), and were less likely to have positive lymph nodes (11% vs 19.6% vs 28.1%, p<0.001). There was no difference in 3 year overall survival between the three groups (86.3% vs 82.1% vs 77.9%, p=0.26). After controlling for age, race, insurance, comorbidities, lymph node metastases, and tumor size, sentinel lymph node biopsy alone was not associated with worse overall survival compared with lymphadenectomy (HR 0.86, 95% CI 0.57 to 1.32). The sentinel node only group had shorter inpatient stays compared with lymphadenectomy only (median 1 vs 2 days, p<0.001) and a lower rate of unplanned readmission (1.7% vs 5.0%, p=0.010). CONCLUSIONS: The utilization of sentinel lymph node biopsy is increasing in the management of vulvar cancer and is associated with superior perioperative outcomes without impacting overall survival.

Trends in the surgical management of malignant ovarian germcell tumors.

OBJECTIVE: To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests. RESULTS: A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p > 0.05). CONCLUSIONS: Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.

Effect of bilateral salpingo-oophorectomy on the overall survival of premenopausal patients with stage I low-grade endometrial stromal sarcoma; a National Cancer Database analysis.

OBJECTIVES: Investigate the prevalence of bilateral salpingo-oophorectomy (BSO) for women ≤50 years with early stage low-grade endometrial stromal sarcoma (LGESS) and its impact on overall survival (OS). METHODS: Women ≤50 years, diagnosed with stage I LGESS and managed with hysterectomy between 2004 and 2015 were identified from the National Cancer Database. Patient demographics were recorded and compared with the chi-square test. OS for patients diagnosed between 2004 and 2014 with at least one month of follow-up was assessed using Kaplan-Meier curves, and compared with the log-rank test. RESULTS: A total 743 patients with a median age of 44 years met the inclusion criteria. Use of radiatiotherapy (9%), chemotherapy (0.8%) and hormonal therapy (11%) was infrequent. BSO was performed in 541 (72.8%) patients. Patients who had ovarian preservation (OP) were younger (median age 43 vs 45 years, p < 0.001), less likely to have comorbidities (6.9% vs 12.4%, p = 0.034), or undergo LND (30.7% vs 44.4%, p = 0.001). There were no differences between the two groups in terms of substage or patient race. Five year OS rates for patients who did (n = 490) and did not (n = 191) undergo BSO were 96.2% and 97.1% and there was no difference in OS, p = 0.50. Even after controlling for presence of comorbidities performance of BSO was not associated with better survival (HR: 1.28, 95% CI: 0.51, 3.19). CONCLUSIONS: Ovarian function was preserved in approximately one third of women ≤50 years with stage I LGESS with no clear detriment to overall survival. As BSO is associated with long term health effects in this patient population OP could be considered in selected women with stage I LGESS.

Ovarian Sertoli-Leydig and granulosa cell tumor: comparison of epidemiology and survival outcomes.

PURPOSE: To investigate the epidemiology, clinico-pathological characteristics and outcomes of patients diagnosed with malignant ovarian Sertoli-Leydig cell tumors (SLCTs) in comparison to granulosa cell tumors (GCTs). METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were accessed and patients diagnosed with a malignant SLCT and GCT between 1988 and 2013 were selected. Demographic and clinico-pathological characteristics were compared using the Mann-Whitney and chi-square tests. Overall (OS) and cancer-specific survival (CSS) rates were estimated with the Kaplan-Meier method and compared with the log-rank test. Cox hazard models were constructed to control for confounders. RESULTS: A total of 175 and 1361 patients diagnosed with SLCT and GCT, respectively, were identified. Compared to patients with GCT, those with SLCT were younger (median age 32 vs. 51 years, p < 0.001) and more likely to present with larger tumors (median size 15 vs 9.5 cm, p < 0.001) confined to the ovary (77.5% vs 69.2%, p = 0.031). Patients with SLCTs had worse CSS compared to those with GCTs, p < 0.001 (5-year rate was 76.2% vs 90.7%). After controlling for the presence of extra-ovarian disease and tumor size (≤ 10 vs > 10 cm), SCLTs were associated with a worse cancer-specific mortality compared to GCTs. CONCLUSIONS: SLCTs are extremely rare, commonly arise in premenopausal patients. They are associated with a poorer prognosis compared to GCT.

Adjuvant chemotherapy for stage I ovarian clear cell carcinoma: Patterns of use and outcomes.

OBJECTIVE: The aim of this study was to investigate the patterns of use and outcomes of adjuvant chemotherapy for patients diagnosed with FIGO stage I ovarian clear cell carcinoma (OCCC). METHODS: A cohort of patients diagnosed between 2004 and 2015 with OCCC was drawn from the National Cancer Database. Those with stage I disease who had primary surgery and underwent systematic lymphadenectomy (defined as at least 10 lymph nodes removed) were selected for further analysis. Factors associated with the administration of adjuvant chemotherapy were investigated with multivariate logistic regression. Overall survival (OS) was evaluated using Kaplan-Meier curves for patients diagnosed between 2004 and 2014, while comparisons were made with the log-rank test. Multivariate Cox analysis was performed to control for possible confounders. RESULTS: A total of 2325 patients met the inclusion criteria. Median age was 55 years. The majority were White (86.6%). Adjuvant chemotherapy was administered to 1839 (79.1%) patients. Hospital type and location, patient age, disease sub-stage, and year of diagnosis were independently associated with the administration of chemotherapy. Patients who received adjuvant chemotherapy (n = 1629) had better OS than those who did not (n = 443), (5-year OS rates 89.2% vs 82.6%, p < 0.001). After controlling for disease sub-stage, age, race, hospital type and medical comorbidities, adjuvant chemotherapy was associated with better overall survival (HR: 0.59, 95% CI: 0.45, 0.78). CONCLUSIONS: Adjuvant chemotherapy could be associated with a survival benefit for patients with stage I OCCC.

Successful Treatment of Estrogen Excess in Primary Bilateral Macronodular Adrenocortical Hyperplasia with Leuprolide Acetate.

Primary bilateral macronodular adrenocortical hyperplasia (PBMAH) is an uncommon cause of adrenal Cushing syndrome (CS) in which cortisol and occasionally other steroid hormones can be secreted under the influence of aberrantly expressed G-protein coupled receptors (GPCRs) in the adrenal cortex. We describe the unique case of a 64-year-old postmenopausal female with PBMAH whose adrenal lesions expressed luteinizing hormone receptors (LHr). She presented initially with CS and underwent right adrenalectomy; a few years later she presented with macromastia and mastodynia, possibly due to estrogen excess from her remaining left adrenocortical masses. Testing before and after treatment with quarterly leuprolide acetate therapy and immunohistochemistry on tissue and targeted sequencing of the genes of interest were performed. Tissue from the patient's right adrenal was tested for P450 aromatase (CYP19A1) and LHr expression; both were expressed throughout the hyperplastic cortex, although expression was more intense in the adenomatous areas. Targeted sequencing revealed a pathogenic PDE11A mutation, as well as variants in the ARMC5 and INHA genes. PDE11A expression was decreased in the adenoma but there was no loss of heterozygosity for the PDE11A locus. Because of the clinical presentation and LHr expression, quarterly leuprolide acetate therapy was started. Shortly after initiation of therapy, the patient reported decreased breast size and pain; she remains well controlled to date, after 10 years of treatment. This is the first description of a patient with PBMAH presenting with severe macromastia and mastodynia from what appears to be excess estrogen production from her adrenal tumor. The patient had a long-lasting response to chronic leuprolide acetate treatment, showing that drug therapy exploiting the aberrant receptor expression in PBMAH is possible even in the absence of cortisol overproduction.

Does tumor grade influence the rate of lymph node metastasis in apparent early stage ovarian cancer?

PURPOSE: To evaluate the prevalence of regional lymph node (LN) metastasis in patients with non-clear cell epithelial ovarian cancer apparently confined to the ovary, stratified by tumor grade. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was accessed (1988-2014). We identified patients with epithelial ovarian carcinoma of serous, endometrioid and mucinous histology apparently confined to the ovary who underwent extensive lymphadenectomy (defined as at least 20 lymph nodes removed). Demographics, tumor histology, grade and lymph node status were collected. Comparisons were made with Chi square and Mann-Whitney U tests. RESULTS: A total of 1242 women met the inclusion criteria. Endometrioid adenocarcinoma was the most common histology (564 patients (45.4%)) while 443 (35.7%) and 235 (18.9%) patients had serous, and mucinous adenocarcinoma, respectively. The rate of LN metastasis in low-grade serous was 9.0% (6/67) vs. 14.4% (54/376) in high-grade serous histology (OR, 1.71, 95% CI 0.70, 4.14, p = 0.24). In patients with low-grade endometrioid tumors, the rate of LN metastasis was 1.7% (7/407) vs. 5.1% (8/157) observed in those with high-grade tumors (OR: 3.07, 95% CI 1.09, 8.61, p = 0.033). Lastly, the rate of LN metastasis in mucinous histology was 1.7% (3/177) in low-grade vs. 8.6% (5/58) in high-grade tumors (OR: 5.47, 95% CI 1.27, 23.66, p = 0.024). CONCLUSIONS: Regional LN metastasis in apparent stage I low-grade mucinous and endometrioid ovarian tumors is infrequent.

Skeletal maturation in children with Cushing syndrome is not consistently delayed: the role of corticotropin, obesity, and steroid hormones, and the effect of surgical cure.

OBJECTIVE: To assess skeletal maturity by measuring bone age (BA) in children with Cushing syndrome (CS) before and 1-year after transsphenoidal surgery or adrenalectomy, and to correlate BA with hormone levels and other measurements. STUDY DESIGN: This case series conducted at the National Institutes of Health Clinical Center included 93 children with Cushing disease (CD) (43 females; mean age, 12.3 ± 2.9 years) and 31 children with adrenocorticotropic hormone-independent CS (AICS) (22 females, mean age 10.3 ± 4.5 years). BA was obtained before surgery and at follow-up. Outcome measures were comparison of BA in CD vs AICS and analysis of the effects of hypercortisolism, insulin excess, body mass index, and androgen excess on BA. RESULTS: Twenty-six of the 124 children (21.0%) had advanced BA, compared with the expected general population prevalence of 2.5% (P < .0001). Only 4 of 124 (3.2%) had delayed BA. The majority of children (76%) had normal BA. The average BA z-score was similar in the children with CD and those with AICS (0.6 ± 1.4 vs 0.5 ± 1.8; P = .8865). Body mass index SDS and normalized values of dehydroepiandrosterone, dehydroepiandrosterone sulfate, androsteonedione, estradiol, and testosterone were all significantly higher in the children with advanced BA vs those with normal or delayed BA. Fifty-nine children who remained in remission from CD had follow-up BA 1.2 ± 0.3 years after transsphenoidal surgery, demonstrating decreased BA z-score (1.0 ± 1.6 vs 0.3 ± 1.4; P < .0001). CONCLUSION: Contrary to common belief, endogenous CS in children appears to be associated with normal or even advanced skeletal maturation. When present, BA advancement in CS is related to obesity, insulin resistance, and elevated adrenal androgen levels and aromatization. This finding may have significant implications for treatment decisions and final height predictions in these children.

A phase 1 trial of adoptive transfer of vaccine-primed autologous circulating T cells in ovarian cancer.

We have previously shown that vaccination with tumor-pulsed dendritic cells amplifies neoantigen recognition in ovarian cancer. Here, in a phase 1 clinical study ( NCT01312376 /UPCC26810) including 19 patients, we show that such responses are further reinvigorated by subsequent adoptive transfer of vaccine-primed, ex vivo-expanded autologous peripheral blood T cells. The treatment is safe, and epitope spreading with novel neopeptide reactivities was observed after cell infusion in patients who experienced clinical benefit, suggesting reinvigoration of tumor-sculpting immunity.

Known VDR polymorphisms are not associated with bone mineral density measures in pediatric Cushing disease.

Decreased bone mineral density (BMD) has been documented in adults with Cushing disease (CD), and allelic variants of the vitamin D receptor (VDR) gene have been associated with osteopenia. Genetic factors play an important role in bone accrual and its response to various diseases; among them, the most studied are the allelic variants of the VDR gene. There is debate as to whether described variants in the VDR gene have an effect on BMD. In the current study, we sought to analyze whether BMD differences in patients with CD were associated with the Taq1 and Apal VDR allelotypes. The data showed lack of association between BMD and these widely studied VDR polymorphisms, suggesting that the effect of endogenous hypercortisolism on bone in the context of CD does not depend on VDR genotypes.

Role of lymphadenectomy for apparent early stage uterine sarcoma; a comprehensive analysis of the National Cancer Database.

OBJECTIVE: Investigate the role of lymphadenectomy for patients with apparent stage I uterine sarcoma. METHODS: The National Cancer Database was accessed and patients without a history of another tumor diagnosed between 2004 and 2015 with an apparent early stage leiomyosarcoma, adenosarcoma, low-grade endometrial stromal and high-grade endometrial stromal/undifferentiated sarcoma who underwent hysterectomy with or without lymphadenectomy were identified. Overall survival was assessed after stratification by histology with the log-rank test while Cox models were constructed to control for confounders. RESULTS: A total of 6412 patients with apparent early stage uterine sarcoma who underwent hysterectomy were identified; 2820 (44%) underwent lymphadenectomy. Rate of lymph node metastasis was 3.4% (42/1250) for patients with leiomyosarcoma, 2.3% (19/826) for those with adenosarcoma, 4.5% (21/463) for patients with low-grade endometrial stromal sarcoma and 7.9% (22/280) for those with high-grade endometrial stromal/undifferentiated sarcoma, p < 0.001. After controlling for confounders lymphadenectomy was not associated with better survival for patients with adenosarcoma (HR: 0.92, 95% CI: 0.73, 1.17), or low-grade endometrial stromal sarcoma (HR: 1.17, 95% CI: 0.73, 1.87). Patients with leiomyosarcoma who underwent lymphadenectomy had worse survival (HR: 1.15, 95% CI: 1.03, 1.28). Patients with high-grade endometrial stromal/undifferentiated sarcoma who underwent lymphadenectomy had better survival (HR: 0.66, 95% CI: 0.48, 0.89). CONCLUSIONS: Incidence of lymph node metastasis in apparent early stage uterine sarcoma is rare while the performance of lymphadenectomy was not associated with a clear survival benefit for all histologic subtypes except high-grade endometrial stromal/undifferentiated sarcoma.

Gestational Trophoblastic Neoplasia After Human Chorionic Gonadotropin Normalization Following Molar Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations. DATA SOURCES: MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of "gestational trophoblastic disease," "molar pregnancy," and "human chorionic gonadotropin" themes. METHODS OF STUDY SELECTION: Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%). CONCLUSION: Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019116414.

Fertility preserving surgery for high-grade epithelial ovarian carcinoma confined to the ovary.

OBJECTIVE: To investigate the safety of uterine preservation in patients with high-grade epithelial ovarian carcinoma (EOC). STUDY DESIGN: The Surveillance, Epidemiology, and End Results database was accessed (1988-2014) and patients aged < = 45 years, diagnosed with an unilateral high-grade non-clear cell EOC confined to the ovary were selected. Based on surgery codes we determined whether hysterectomy was performed. Overall (OS) and cancer-specific survival (CSS) was estimated calculated following generation of Kaplan-Meier curves and compared using the log-rank test. Cox hazard model was constructed to control for possible confounders. RESULTS: A total of 1039 patients with a median follow-up of 119 months were identified. Rate of uterine preservation was 31.8 %. Patients who had hysterectomy were older (median 41 vs 32 yrs, p < 0.001). Patients with mucinous tumors were less likely to undergo hysterectomy (58.9 %) compared to those with endometrioid (73.9 %) and serous (75.9 %) carcinoma, p < 0.001. There was no difference in CSS between patients who did and did not have hysterectomy, p = 0.70 (5-yr rates were 93.9 % vs 92.2 %, respectively). After controlling for year of diagnosis, tumor histology (serous vs non-serous), disease stage, performance of lymph node dissection (LND) and tumor grade, uterine preservation was not associated with a worse cancer-specific (HR: 1.08, 95 % CI:0.69,1.71) and overall (HR:0.88, 95 % CI: 0.59, 1.32) mortality. CONCLUSION: In this retrospective cohort of patients with unilateral high-grade non-clear cell EOC confined to the ovary, uterine preservation was not associated with a worse prognosis.

Prognostic significance of elevated pre-treatment serum CA-125 levels in patients with stage I ovarian sex cord-stromal tumors.

OBJECTIVE: To investigate the prognostic significance of elevated pre-operative serum CA-125 values for patients with early stage ovarian sex cord - stromal tumors (SCSTs). METHODS: Patients diagnosed between 2004 and 2015 with a SCST were drawn from the U.S National Cancer Database. Those with stage I disease, and normal or elevated CA-125 values were selected for further analysis. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 with Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for known confounders. RESULTS: A total of 1156 patients met the inclusion criteria; 486 (42%) had elevated pre-treatment CA-125 values. Patients with elevated pre-treatment CA-125 (n = 417) had worse OS compared to those with normal values (n = 588), p < 0.001 from log-rank test; 5-yr OS rates were 86.8% and 94.8% respectively. After controlling for patient age (<50 vs > = 50 yrs), the presence of medical co-morbidities, tumor histology (granulosa vs non-granulosa), size (<10 vs > = 10 cm vs unknown) and the performance of lymphadenectomy, elevated pre-treatment CA-125 levels were associated with a worse survival (HR: 1.80, 95% CI: 1.15, 2.82, p = 0.01). CONCLUSIONS: In a large cohort of patients with early stage SCSTs elevated preoperative CA-125 levels were associated with worse survival.

Increased Risk of Breast and Uterine Cancer Among Women With Ovarian Granulosa Cell Tumors.

BACKGROUND/AIM: We evaluated the incidence of uterine and breast cancer among women diagnosed with granulosa cell tumors (GCTs) of the ovary. PATIENTS AND METHODS: The US Surveillance, Epidemiology, and End Results (SEER) database was accessed and patients diagnosed with a GCT and had a known follow-up between 1973-2014 were identified. Personal tumor history was extracted and patients with a previous or subsequent malignant breast or uterine tumor were identified. The expected incidence of breast and uterine cancer was calculated based on the U.S age-specific rate of breast and uterine cancer per 100,000 women. Standardized incidence ratio (SIR) with 95% confidence intervals (95% CI) were calculated for each tumor. RESULTS: A total of 1908 cases of GCT were identified. Seventy- nine (4.14%) and 53 (2.78%) patients were diagnosed with a malignant breast and uterine malignancy. The cumulative expected number of malignant breast and uterine tumors was 27 (1.41%) and 6 (0.31%), respectively. The calculated SIR for breast and uterine malignancies was 2.96 (95%CI=2.34, 3.68) and 8.83 (95%CI=6.61, 11.56), respectively. CONCLUSION: An increased incidence of breast and uterine malignancies among patients diagnosed with GCTs was observed.