Development and Validation of an Algorithm to Identify Endometrial Adenocarcinoma in US Administrative Claims Data.

BACKGROUND: Endometrial adenocarcinoma is the most prevalent type of endometrial cancer. Diagnostic codes to identify endometrial adenocarcinoma in administrative databases, however, have not been validated. OBJECTIVE: To develop and validate an algorithm for identifying the occurrence of endometrial adenocarcinoma in a health insurance claims database. METHODS: To identify potential cases among women in the HealthCore Integrated Research Database (HIRD), published literature and medical consultation were used to develop an algorithm. The algorithm criteria were at least one inpatient diagnosis or at least two outpatient diagnoses of uterine cancer (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 182.xx) between 1 January 2010 and 31 August 2014. Among women fulfilling these criteria, we obtained medical records and two clinical experts reviewed and adjudicated case status to determine a diagnosis. We then estimated the positive predictive value (PPV) of the algorithm. RESULTS: The PPV estimate was 90.8% (95% CI 86.9-93.6), based on 330 potential cases of endometrial adenocarcinoma. Women who fulfilled the algorithm but who, after review of medical records, were found not to have endometrial adenocarcinoma, had diagnoses such as uterine sarcoma, rhabdomyosarcoma of the uterus, endometrial stromal sarcoma, ovarian cancer, fallopian tube cancer, endometrial hyperplasia, leiomyosarcoma, or colon cancer. CONCLUSIONS: An algorithm comprising one inpatient or two outpatient ICD-9-CM diagnosis codes for endometrial adenocarcinoma had a high PPV. The results indicate that claims databases can be used to reliably identify cases of endometrial adenocarcinoma in studies seeking a high PPV.

Primary endodermal sinus tumor of the endometrium presenting as "recurrent" endometrial adenocarcinoma.

BACKGROUND: Primary endodermal sinus tumor of the endometrium is an extremely rare malignancy with few reports in the world literature. CASE: A case of primary endodermal sinus tumor of the endometrium is presented. The case is unusual in several aspects: it occurred in a patient with a history of breast cancer and long-standing tamoxifen use, and was diagnosed only after presenting as an apparent unexpected recurrence of endometrial adenocarcinoma. The tumor recurred despite initial cytoreductive surgery and combination chemotherapy. CONCLUSION: Rare types of endometrial cancers may present as unexpected recurrences of previously resected endometrial adenocarcinomas. Appropriate therapy depends on obtaining sufficient tissue to establish an accurate diagnosis to ensure selection of proper chemotherapeutic agents.

Papanicolaou smears are of little value in the post-treatment surveillance of patients with ovarian epithelial cancer.

275 consecutive patients with ovarian epithelial cancer had routine brush vaginal vault cytology performed as part of routine post-treatment surveillance for recurrent disease screening. No patient with stage I or II disease (75 patients total) developed either recurrent vaginal vault disease or had an abnormal Pap smear indicating recurrent adenocarcinoma or even atypical glandular cells of undetermined significance (AGCUS). Of the 200 patients with stage III or IV disease there were four vaginal vault recurrences (three macroscopic, one microscopic); all of these recurrences had recurrent disease elsewhere and none were detected on the basis of Papanicolaou smear alone. Papanicolaou smear may be safely omitted as part of any post-treatment surveillance protocol for patients with ovarian epithelial cancers.

Meigs syndrome and "false positive" preoperative serum CA-125 levels: analysis of ten cases.

Ten patients with Meigs syndrome operated on by the author were evaluated to determine the possible relationship between elevated preoperative serum CA-125 levels and tumor size and/or ascites.

Endometrial cancer in women 45 years of age or younger.

OBJECTIVE: The clinical characteristics and outcomes of endometrial cancer in women 45 years of age or younger evaluated and treated at the community hospital level are presented. METHODS: A series of 500 consecutive women with endometrial cancer operated on by the author over a nine-year period of time was used to identify women 45 years of age or younger and compared to older patients from the author's data base. RESULTS: Although the majority of patients presented with clinical stage I disease, 30% of women 45 years of age or younger had occult metastatic disease and 5.0% had clear cell or papillary serous histology, similar to the older patient population. In addition, survival was similar in both groups of patients. Serum CA-125 was useful in identifying patients with possible occult metastatic disease in the group of women 45 years old or younger. CONCLUSION: Patients 45 years of age or younger with uterine cancer are not ipso facto a "lower risk" group of patients; efforts to preserve fertility should be balanced against a thorough effort to identify those individuals at higher risk for occult metastases.

Radical abdominal versus laparoscopic hysterectomy for stage IB cervical cancer: what's the point?

OBJECTIVE: To evaluate surgical morbidity and length of stay for type III radical abdominal hysterectomy performed in the private practice setting, and to compare these results with currently available data on laparoscopic radical hysterectomy. METHODS AND MATERIALS: One hundred seventy-five consecutive type III radical abdominal hysterectomies performed by the author in a uniform fashion over a ten-year period for patients with stage IB cervical cancer were evaluated. All surgeries were performed in private community hospitals in New Jersey. RESULTS: Type III radical abdominal hysterectomy performed in the private setting using the author's protocol resulted in lower surgical morbidity, equivalent hospital stay and resumption of normal activities, and much shorter operating times than laparoscopic radical hysterectomy. CONCLUSION: Laparoscopic radical hysterectomy provides no surgical or financial advantage over radical abdominal hysterectomy when the latter is performed in the private practice setting; results from laparoscopic surgery are inferior with respect to morbidity.

Abdominal sacral colpopexy in patients with gynecologic cancer: report of 25 cases with long-term follow-up and literature review.

OBJECTIVE: The aim of this study was to evaluate abdominal sacral colpopexy performed in conjunction with radical pelvic surgery for gynecologic cancer. METHODS: Over a 9-year period from 1990 to 1999 25 patients with invasive gynecologic cancer and concomitant uterovaginal or vaginal vault prolapse underwent surgery. These patients were compared to a series of 50 patients with no history of gynecologic cancer who underwent abdominal sacral colpopexy during the same period. RESULTS: All surgeries were performed without intraoperative complication. There was one failed vault suspension in each group and no postoperative mesh complications as a result of radical pelvic surgery or postoperative radiation or chemotherapy. CONCLUSION: Abdominal sacral colpopexy may be safely performed along with radical pelvic surgery for gynecologic cancer without an increase in intra- or postoperative morbidity even if patients require chemotherapy or radiation therapy after surgery.

Chronic abdominal pain secondary to omental J-flap: report of two patients.

Two patients with a history of stage IB cervical cancer who had undergone prior radical abdominal hysterectomy, omental J-flap placement, and postoperative whole pelvic radiation therapy required subsequent exploratory laparotomy with resection of omental J-flap for treatment of chronic abdominal pain 5 and 2 years, respectively, following J-flap placement. Issues relating to this unusual possible long-term complication of omentoplasty are discussed.

Laparoscopy using the left upper quadrant approach.

STUDY OBJECTIVE: To describe a technique of laparoscopy and multiport operative pelviscopy using left upper quadrant primary port insertion. DESIGN: Retrospective evaluation (Canadian Task Force classification II-2). SETTING: Private gynecologic oncology practice. PATIENTS: Ninety women with a history of gynecologic cancer and at least one laparotomy. INTERVENTIONS: Laparoscopy and operative pelviscopy. MEASUREMENTS AND MAIN RESULTS: The procedure was performed using the left upper quadrant as a single entry site for the Veress needle and primary laparoscopy port. In 88 women it was performed without complication. One woman experienced transverse colon injury from primary port insertion, which was repaired immediately by laparotomy. A second patient had a rectosigmoid injury that required temporary colostomy at laparotomy. CONCLUSION: Operative laparoscopy using the left upper quadrant approach seems to be safe in patients with advanced gynecologic malignancy. (J Am Assoc Gynecol Laparosc 6(3):323-325, 1999)

Routine retroperitoneal drainage is not required for uncomplicated pelvic lymphadenectomy for uterine cancer.

Four hundred consecutive patients with endometrial carcinoma clinically confined to the corpus and cervix underwent extrafascial hysterectomy and pelvic lymphadenectomy by the author over an eight-year period of time. No patient had retroperitoneal drains, and only one patient (0.25%) developed a pelvic lymphocyst. Routine retroperitoneal drainage may be safely omitted in patients with uterine carcinoma undergoing hysterectomy and staging pelvic lymphadenctomy.

The potential value of preoperative cytobrush papanicolaou smear in clinical stage I endometrial carcinoma.

PURPOSE: Our purpose was to assess the value of preoperative cytobrush Papanicolaou (Pap) smear in patients with uterine cancer clinically confined to the uterine corpus (stage I by previous International Federation of Gynecology and Obstetrics classification). METHODS AND MATERIALS: Over a 6-year period, 300 consecutive women with clinical stage I endometrial cancer were evaluated prospectively by preoperative Cytobrush (Unimar Products, Shelton, CT) Pap smears. RESULTS: A total of 246 patients (82%) had normal preoperative Pap smears. The diagnosis of either adenocarcinoma (24 patients; 8.0%) or atypical glandular cells of undetermined significance (30 patients; 10%) usually was associated with subclinical advanced surgical-stage disease or with the presence of high-risk subtypes, such as clear-cell carcinoma or papillary serous carcinoma. CONCLUSION: Abnormal preoperative cytobrush Pap smear in clinical stage I endometrial cancer should alert clinicians to the possibility of unsuspected occult metastatic disease or the presence of high-risk histological subtypes and should be taken into account in surgical treatment planning.

Ovarian epithelial carcinoma metastatic to the choroid of the eye: prolonged survival with radiation and taxol chemotherapy.

A 64-year-old was diagnosed with a stage 1aII clear cell adenocarcinoma of the ovary in 1986. Initial chemotherapy was with Cisplatinum, Cytoxan, and Adriamycin. A pelvic recurrence developed in 1991 which failed to respond to Carboplatin therapy, and progression of disease with retroperitoneal nodal and choroidal metastases was noted in 1992. Debulking of retroperitoneal disease along with radiotherapy and seventeen cycles of Taxol chemotherapy resulted in a sustained clinical remission for three years until December 1995 when a right pelvic recurrence was noted. The patient underwent resection of disease again and was restarted on Taxol which was continued for six cycles until increasing serum CA-125 and recurrent pelvic disease were noted.

Radical abdominal hysterectomy using the ENDO-GIA stapler: report of 150 cases and literature review.

Over a seven-year period from 1990-1997 150 consecutive patients underwent Type III radical abdominal hysterectomy using the ENDO-GIA stapler on the cardinal and uterosacral ligaments. Compared to prior patients operated on with standard suturing methods, the stapler patients had shorter operating times, lower blood loss and infection rates, and shorter hospital stays without any increase in recurrence rate. The equipment failure rate was 3%. Although not all improvements in surgical and post-operative morbidity are likely due to use of the ENDO-GIA stapler, the use of the stapler clearly lowered operating times, blood loss, surgical morbidity, hospital stay with no adverse effect on patient survival.

CUSA resection of massive recurrent vulvar carcinoma.

The CUSA was employed to resect a massive recurrent vulvar carcinoma involving prior rotational flaps, urethra and rectovaginal septum.

Conservative management of cervical intraepithelial neoplasia 3 during pregnancy: is conization ever indicated?

During an 8-year period, 200 patients with biopsy-proved cervical intraepithelial neoplasia grade 3 (CIN3) of the cervix were evaluated serially both before and after birth with serial Cytobrush cytology, colposcopy, and biopsy. No patient underwent cervical conization, regardless of cytological or colposcopic findings. Ninety percent of patients had postpartum CIN3, 5% had CIN1, and 4.5% showed no evidence of dysplasia. One patient was found to have a stage IA2 invasive squamous cell carcinoma of the cervix on postpartum conization. CIN3 rarely regresses postpartum, but conization may be avoided even in the presence of unsatisfactory colposcopy, discrepancy between Papanicolaou smear and biopsy, or cytological findings consistent with early invasive cervical cancer.