Does Radical Hysterectomy for Clinically Apparent Stage II Endometrial Cancer Affect Risk of Local Recurrence?

OBJECTIVE: Compare recurrence-free survival (RFS) and morbidity between radical hysterectomy (RH) and simple hysterectomy (SH) for clinically diagnosed stage II endometrial cancer. METHODS: A multicentre, retrospective study, from 2000 to 2015, involving patients with endometrial cancer with cervical involvement preoperatively and stromal invasion on final pathology. Wilcoxon rank-sum test, Fisher exact test, Kaplan-Meier survival functions, and Cox proportional hazards models were used for analysis. RESULTS: Ninety of 1613 patients had clinical stage II endometrial cancer; 57 underwent RH and 33 underwent SH, with no difference in adjuvant treatment or morbidity. About half of patients (51%) had pathologic stage III-IV disease. Mean follow-up was 3.3 and 3.8 years for SH and RH, respectively. Thirty-three percent of patients with RH and SH experienced a recurrence. Most recurrences were distant: 90% with SH and 79% with RH. There was no difference in RFS between groups (2-year: SH 65% vs. RH 75%; 5-year: SH 54% vs. RH 63%; P = 0.72). Controlling for stage, adjuvant treatment, and margin status, RH was not associated with RFS (HR 0.62; 95% CI 0.28-1.35). Among 44 patients with pathologic stage II disease, 7 had a recurrence (4 SH and 3 RH); 6 of 7 had distant recurrences. CONCLUSIONS: Fifty-one percent of patients with clinical stage II endometrial cancer had advanced disease on final pathology, highlighting the importance of surgical staging. RH was not associated with RFS or reduced morbidity. Most recurrences were distant. Although RH could be performed to achieve negative surgical margins, SH may be sufficient for central, small tumours given the high risk of advanced disease and distant recurrence. Research efforts should further elucidate the ideal management of these patients.

Same-Day Discharge Among Patients With Obesity Undergoing Laparoscopic Gynaecologic Oncology Surgery.

OBJECTIVES: To determine the likelihood of same-day discharge (SDD) among patients with obesity undergoing laparoscopic gynaecologic oncology surgery and identify predictors of SDD. METHODS: We conducted a retrospective cohort study of gynaecologic oncology patients who underwent laparoscopic procedures between January 2012 and June 2016. Patients were categorized as non-obese, obese class I/II and obese class III (BMI <30, 30-39.9, and ≥40 kg/m2, respectively). We used univariate and multivariable logistic regression to identify variables associated with SDD. RESULTS: Of 496 patients, 288 were non-obese, 161 were obese class I/II, and 47 were obese class III. Overall, 182 patients (36.7%) were discharged same day; 44% of these were non-obese, 30% class I/II and 15% class III. On multivariable analysis, we found negative predictors for SDD to be obesity (OR 0.54; P = 0.03), procedure length (OR 0.51; P < 0.01), and higher American Society of Anesthesiologists (ASA) score (OR 0.63; P < 0.01), while we found being pre-booked for SDD (OR 9.16; P <0.01) was a positive predictor of SDD. Among all patients with obesity, only procedure length (OR 0.47; P < 0.01) and being pre-booked for SDD (OR 9.67; P < 0.01) were associated with SDD when we controlled for BMI, ASA score, intraoperative complications, type of surgery, and surgical start time. Patients discharged same day were less likely to present to the emergency department within 30 days of surgery (OR 0.48; P = 0.01). CONCLUSION: Among the study cohort and after controlling for potential confounders, women with class I, II, and III obesity had a much lower likelihood of SDD than non-obese women. The only significant predictors of SDD among patients with obesity were duration of procedure and pre-booking for SDD. Further study is needed to identify strategies to improve SDD rates among patients with obesity.

Patterns of recurrence and impact on survival in patients with clear cell ovarian carcinoma.

BACKGROUND: Patients with recurrent clear cell ovarian cancer have poor prognosis and limited effective systemic treatment options. OBJECTIVES: To characterize patterns of recurrence and compare overall survival and post-recurrence survival parameters in patients with recurrent ovarian clear cell carcinoma. METHODS: Clinical data on patients with ovarian clear cell carcinoma between June 1995 and August 2014 were collected. Patients with clear cell ovarian cancer recurrence were included in this study. Patients with different histologic sub-type, persistent or progressive disease on completion of the initial treatment were excluded. Descriptive statistics, univariate and multivariable analyses, and Kaplan-Meier survival probability estimates were completed. The log-rank test was used to quantify survival differences on univariable analysis. To search for significant covariates related to the overall survival and post-recurrence survival, a univariable Cox proportional hazard model was performed. RESULTS: A total of 209 patients met inclusion criteria. Of these, 61 (29%) patients who were free of disease at completion of the initial treatment had recurrence. Patterns of recurrence were as follows: 38 (62%) patients had multiple-site recurrence, 12 (20%) had single-site recurrence, and 11 (18%) had nodal recurrence only. The median overall survival was 44.7 months (95% CI 33.4 to 64.2) and was significantly associated with pattern of recurrence (p=0.005). The median post-recurrence survival was 18.4 months (95% CI 12.5 to 26.7): 54.4 months (95% CI 11 to 125.5) in single-site recurrence, 13.7 months (95% CI 6.8 to 16.5) in multiple-site recurrence, and 30.1 (95% CI 7.2 to 89) months in nodal recurrence (p=0.0002). In the multivariable analysis, pattern of recurrence was a predictor of post-recurrence survival.Six patients (9.8%) had a prolonged disease-free interval after recurrence (disease-free for more than 30 months after completion of treatment for recurrence). Prolonged recurrences were noted in 4 (33%) of 12 patients with single-site recurrence, 1 (9%) of 11 patients with nodal recurrence, and in 1 (2.7%) of 38 patients with multiple-site recurrence. Three of the six patients with a prolonged disease-free interval after recurrence were treated surgically at the time of recurrence. CONCLUSION: Ovarian clear cell carcinoma predominantly recurs in multiple sites and it is associated with a high mortality rate and short post-recurrence survival. When recurrences are limited to a single site, or only to lymph nodes, the median post-recurrence survival is longer. Disease-free interval after recurrence is longer in patients with single-site recurrence who are treated surgically at the time of recurrence.

Can sentinel lymph node biopsy replace pelvic lymphadenectomy for early cervical cancer?

OBJECTIVE: Evaluate recurrence-free survival (RFS) and short-term morbidity in patients with early cervical cancer who undergo bilateral pelvic lymphadenectomy (BPLND) versus bilateral sentinel lymph node biopsy only (BSLNB) at primary surgery. METHODS: All patients with pathologically confirmed node negative stage IA/IB cervical cancer managed with BPLND or BSLNB were identified in the University of Toronto's prospective cervical cancer database from May 1984-June 2015. Groups were compared with Wilcoxon rank-sum, Chi-square, and Fisher's exact tests. Predictors of RFS were identified with Cox proportional hazard models. Kaplan-Meier survival curves were compared. Statistical significance was p<0.05. RESULTS: 1188 node negative patients were identified, BPLND-1078; BSLNB-110. There was no difference between BPLND and BSLNB in 2 and 5year RFS (95% vs 97% and 92% vs 93% respectively), tumor size, histology, invasion depth, intra-operative complications or short-term morbidity. BPLND was associated with increased surgical time (2.8 vs 2.0h, p<0.001), blood loss (500mL vs 100mL, p<0.001), transfusion (23% vs 0%, p<0.001) and post-operative infection (11% vs 0%, p=0.001). Age, surgery date, stage, LVSI, and radicality of surgery differed between groups. Controlling for age, stage, LVSI, invasion depth and histology, there was no significant difference in RFS between groups. Only invasion depth, LVSI and histology were predictors of RFS. CONCLUSION: A negative BSLNB is not associated with a difference in RFS compared to a negative BPLND. Short-term morbidity may be reduced, however due to the long study period, changes in demographics and surgery may contribute to differences noted.

Effectiveness of the risk of malignancy index and the risk of ovarian malignancy algorithm in a cohort of women with ovarian cancer: does histotype and stage matter?

OBJECTIVE: To examine the performance of the Risk of Malignancy Index (RMI) and Risk of Ovarian Malignancy Algorithm (ROMA) by histologic subtype and stage of disease in a cohort of women with ovarian cancer. METHODS: All patients with confirmed ovarian cancer at the Princess Margaret Hospital between February 2011 and January 2013 were eligible for study inclusion. Preoperative cancer antigen 125, human epididymis protein 4, and ultrasound findings were reviewed, and the sensitivity and false-negative rates of the RMI and ROMA were determined by stage of disease and tumor histology. RESULTS: A total of 131 patients with ovarian cancer were identified. High-grade serous (HGS) histology was most frequently associated with stage III/IV disease (n = 46 [72% of stage III/IV]) vs stage I (n = 5 [11% of stage I]; P < 0.0001). Clear cell (CC) and endometrioid (EC) histology presented most commonly with stage I disease (n = 9 [20%] and n = 13 [29% of stage I cases], respectively). Median cancer antigen 125 and human epididymis protein 4 values were significantly higher for HGS than for EC or CC histology. Risk of Malignancy Index II demonstrated the highest sensitivity of the 3 RMI algorithms. All RMIs and ROMA were significantly more sensitive in predicting malignancy in patients with HGS than EC or CC histology. Risk of Malignancy Index II (n = 38) and ROMA (n = 35) exhibited sensitivities of 68% and 54% and false-negative rates of 32% and 46%, respectively, for patients with stage I disease vs sensitivities of 94% and 93% and false-negative rates of 6% and 7% for patients with stage III/IV disease. CONCLUSION: Both RMI and ROMA performed well for the detection of advanced ovarian cancer and HGS histology. These triaging algorithms do not perform well in patients with stage I disease where EC and CC histologies predominate. Clinicians should be cautious using RMI or ROMA scoring tools to triage isolated adnexal masses because many patients with stage I malignancies would be missed.

The rectus abdominus myoperitoneal flap for vaginal reconstruction.

To review the indications, technique and results of the rectus abdominis myoperitoneal (RAMP) flap for vaginal reconstruction from literature and at a single institution. A literature search was conducted of vaginal reconstruction to identify published cases using RAMP flaps. All cases of vaginal reconstruction at Sunnybrook Health Sciences Center (SHSC) from 2007 to 2019 were reviewed. Twenty-one published cases of vaginal reconstruction with RAMP flaps were identified. Eleven had partial longitudinal vaginal defects, 5 had circumferential defects and 5 had unspecified defects. Eight patients with circumferential (N = 3) or unspecified (N = 5) defects developed vaginal stenosis. None of the 11 patients with partial longitudinal defects developed vaginal stenosis and 8 resumed sexual activity. There were 2 cases of donor site hernia and 4 donor site infections, but no flap loss. At SHSC, 5 cases of RAMP flap vaginal reconstruction were identified. Cases 1-3 and 5 had circumferential vaginal defects and Case 4 had a partial longitudinal defect. There were no cases of flap necrosis or donor site hernia. Case 1 died 18 days after pelvic exenteration from bowel ischemia. Case 2 developed a rectovaginal fistula after an anastomotic leak from a low anterior resection. Case 3 had a wound infection and vaginal shortening to 3-4 cm. Cases 4 and 5 had no complications and the vagina appeared normal on exam post-operatively. The literature and our experience support the use of RAMP flaps for reconstruction of partial longitudinal vaginal defects but not circumferential defects where the risk of vaginal stenosis and shortening is high.