Fertility-sparing Surgery for Patients with Cervical, Endometrial, and Ovarian Cancers.

OBJECTIVE: Nearly 10% of the 1.3 million women living with a gynecologic cancer are aged <50 years. For these women, although their cancer treatment can be lifesaving, it's also life-altering because traditional surgical procedures can cause infertility and, in many cases, induce surgical menopause. For appropriately selected patients, fertility-sparing options can reduce the reproductive impact of lifesaving cancer treatments. This review will highlight existing recommendations as well as innovative research for fertility-sparing treatment in the 3 major gynecologic cancers. TABULATION, INTEGRATION, AND RESULTS: For early-stage cervical cancers, fertility-sparing surgeries include cold knife conization, simple hysterectomy with ovarian preservation, or radical trachelectomy with placement of a permanent cerclage. In locally advanced cervical cancer, ovarian transposition before radiation therapy can help preserve ovarian function. For endometrial cancers, fertility-sparing treatment includes progestin therapy with endometrial sampling every 3 to 6 months. After cancer regression, progestin therapy can be halted to allow attempts to conceive. Hysterectomy with ovarian preservation can also be considered, allowing for fertility using assisted reproductive technology and a gestational carrier. For ovarian cancers, fertility-sparing surgery includes unilateral salpingo-oophorectomy or bilateral salpingo-oophorectomy (with lymphadenectomy and staging depending on tumor histology). With higher-risk histology or higher early-stage disease, adjuvant chemotherapy is recommended-however, this carries a 3% to 10% risk of ovarian failure. Use of oocyte or embryo cryopreservation in patients with early-stage ovarian malignancy remains an area of ongoing research. CONCLUSION: Overall, fertility-sparing management of gynecologic cancers is associated with acceptable rates of progression-free survival and overall survival and is less life-altering than more radical surgical approaches.

The addition of metformin to progestin therapy in the fertility-sparing treatment of women with atypical hyperplasia/endometrial intraepithelial neoplasia or endometrial cancer: Little impact on response and low live-birth rates.

OBJECTIVE: Our objectives were 1) to compare the efficacy of progestin therapy combined with metformin (Prog-Met) to Prog alone as primary fertility sparing treatment in women with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) or early-stage endometrioid carcinoma (EC), and 2) to analyze the proportion of women achieving live birth following treatment. METHODS: A retrospective cohort study of all reproductive-aged women with AH/IN or EC treated with Prog ± Met from 1999-2018 was conducted. Complete response (CR) was assessed and Kaplan-Meier analysis used to calculate time to CR. Comparison of potential response predictors was performed with multivariable Cox regression models. RESULTS: Ninety-two women met criteria; 59% (n = 54) were treated for AH/EIN and 41% (n = 38) for EC. Their median age, body mass index, and follow up time was 35 years, 37.7 kg/m2, and 28.4 months, respectively. Fifty-eight women (63%) received Prog and 34 (37%) received Prog-Met. Overall, 79% (n = 73) of subjects responded to treatment with a CR of 69% (n = 63). There was no difference in CR (p = 0.90) or time to CR (p = 0.31) between the treatment cohorts. Overall, 22% experienced a disease recurrence. On multivariable analysis, EC histology was the only covariate associated with a decreased Prog response (HR 0.48; p = 0.007). Only 17% of the cohort achieved a live-birth pregnancy, the majority of which required assisted reproductive technologies (81%) and occurred in the Prog treatment group. CONCLUSIONS: Our study does not support the use of Prog-Met therapy for treatment of AH/EIN or EC. Additionally, fewer than 20% of women achieved a live-birth pregnancy during the study period, with most requiring ART.

Laparoscopic splenectomy for secondary cytoreduction of ovarian cancer in a woman with localized splenic recurrence.

OBJECTIVE/BACKGROUND: Laparoscopic splenectomy is a potential surgical option for the treatment of isolated gynecologic cancer recurrence to the spleen [1-7]. The purpose of this video is to demonstrate a step-by-step approach for laparoscopic splenectomy in the setting of recurrent, oligometastatic ovarian cancer. METHODS: We present the case of a 47-year-old female with recurrent, platinum-sensitive high-grade serous ovarian cancer. A computer tomographic scan demonstrated an isolated 1.5 × 1.0 cm recurrence in the splenic hilum. A laparoscopic secondary cytoreduction with splenectomy was planned. The surgical procedure was recorded via the video camera tower, and the key steps for a laparoscopic splenectomy were identified and highlighted. RESULTS: The indications for secondary cytoreductive surgery, the appropriate candidates for minimally invasive surgery, patient positioning principles to set the surgeon up for success, and left upper quadrant anatomy are reviewed. In the surgical case and in the setting of hilar disease, the technique and rationale for ligating the major splenic ligaments in a particular order are reviewed. The procedure for isolating and ligating the dominant vascular structures - the splenic artery and vein - are reviewed. Finally, perioperative and oncologic outcomes, including an estimated blood loss of 100 cc, operative time of 3 h, a disease-free interval and "no evidence of disease" status after chemotherapy at 14 months, are emphasized. CONCLUSIONS: In this video, both anatomical references and the surgical technique for a laparoscopic splenectomy in the setting of recurrent ovarian cancer are illustrated. We demonstrate that laparoscopic splenectomy is feasible and safe with proper patient selection and positioning as well as meticulous surgical technique.

Pre-operative core muscle index in combination with hypoalbuminemia is associated with poor prognosis in advanced ovarian cancer.

BACKGROUND AND OBJECTIVES: Age and frailty have been correlated with poor clinical outcomes in cancer. Core muscle index (CMI) and nutritional status are integral in assessing frailty. We explored the effect of pre-operative serum albumin and body composition on clinical outcomes in patients with epithelial ovarian cancer (EOC). METHODS: We identified stage III-IV EOC patients undergoing primary cytoreductive surgery from 2007 to 2015. Data were abstracted from medical records. Body composition measurements were obtained from pre-operative imaging. Psoas muscle cross-sectional area was normalized to height2 to determine CMI. Sarcopenia was defined as CMI below the population mean. The influence of sarcopenia on short-term morbidity was evaluated. Relationships among body composition measurements and albumin were assessed with Spearman correlations. Patient characteristics and body composition measurements between patients with and without sarcopenia were compared with parametric and non-parametric statistical methods. Kaplan-Meier survival curves were compared using log-rank. RESULTS: 102 women met inclusion criteria. Sarcopenia correlated with albumin (P = 0.0002). Sarcopenia was not associated with short-term morbidity or time to recurrence. Sarcopenia was associated with nearly a fourfold increased risk of death when hypoalbuminemia was present (P = 0.02). CONCLUSIONS: Pre-operative sarcopenia in combination with hypoalbuminemia was associated with significantly worse survival.

Long-Term Percutaneous Nephrostomy Management of Malignant Urinary Obstruction: Estimation of Optimal Exchange Frequency and Estimation of the Financial Impact of Patient Compliance.

PURPOSE: To estimate the least costly routine exchange frequency for percutaneous nephrostomies (PCNs) placed for malignant urinary obstruction, as measured by annual hospital charges, and to estimate the financial impact of patient compliance. MATERIALS AND METHODS: Patients with PCNs placed for malignant urinary obstruction were studied from 2011 to 2013. Exchanges were classified as routine or due to 1 of 3 complication types: mechanical (tube dislodgment), obstruction, or infection. Representative cases were identified, and median representative charges were used as inputs for the model. Accelerated failure time and Markov chain Monte Carlo models were used to estimate distribution of exchange types and annual hospital charges under different routine exchange frequency and compliance scenarios. RESULTS: Long-term PCN management was required in 57 patients, with 87 total exchange encounters. Median representative hospital charges for pyelonephritis and obstruction were 11.8 and 9.3 times greater, respectively, than a routine exchange. The projected proportion of routine exchanges increased and the projected proportion of infection-related exchanges decreased when moving from a 90-day exchange with 50% compliance to a 60-day exchange with 75% compliance, and this was associated with a projected reduction in annual charges. Projected cost reductions resulting from increased compliance were generally greater than reductions resulting from changes in exchange frequency. CONCLUSIONS: This simulation model suggests that the optimal routine exchange interval for PCN exchange in patients with malignant urinary obstruction is approximately 60 days and that the degree of reduction in charges likely depends more on patient compliance than exact exchange interval.

History of simulation in medicine: from Resusci Annie to the Ann Myers Medical Center.

Medical and surgical graduate medical education has historically used a halstedian approach of "see one, do one, teach one." Increased public demand for safety, quality, and accountability in the setting of regulated resident work hours and limited resources is driving the development of innovative educational tools. The use of simulation in nonmedical, medical, and neurosurgical disciplines is reviewed in this article. Simulation has been validated as an educational tool in nonmedical fields such as aviation and the military. Across most medical and surgical subspecialties, simulation is recognized as a valuable tool that will shape the next era of medical education, postgraduate training, and maintenance of certification.

Environmental enrichment protects against the acquisition of cocaine self-administration in adult male rats, but does not eliminate avoidance of a drug-associated saccharin cue.

One of the most menacing consequences of drug addiction is the devaluation of natural rewards (e.g. food, sex, work, money, caring for one's offspring). However, evidence also suggests that natural rewards, such as an enriched environment, can devalue drugs of abuse. Thus, this study used a rodent model to test whether exposure to an enriched environment could protect adult rats from acquiring cocaine self-administration and from the resultant drug-induced devaluation of a natural saccharin reward cue. Adult male Sprague-Dawley rats were implanted with intravenous jugular catheters. Rats were then separated into two housing conditions: an enriched condition, including social companions(four/cage) and novel objects (e.g. balls, polyethylene tubes, paper, etc.), and a nonenriched condition where the rats were singly housed with no novel objects. During testing, the rats were given 5-min access to 0.15% saccharin, followed by 1 h to self-administer saline or cocaine (0.167 mg/infusion) on fixed ratio and progressive ratio schedules of reinforcement. The results showed that rats that were singly housed in the nonenriched environment fell into two groups: low drug-takers (n=34) and high drug-takers (n=12). In comparison, only one out of the 22 rats housed in the enriched environment was a high drug-taker. Thus, all rats in the enriched environment, except one, behaved like low drug-takers under the nonenriched condition. As such, these rats self-administered almost no drug on either the fixed ratio or the progressive ratio schedule of reinforcement and were extremely slow to self-administer their first cocaine infusion. Interestingly, despite their very low levels of drug self-administration, low-drug-taking rats housed in the enriched environment continued to avoid intake of the drug-associated saccharin cue. Taken together, these data suggest that the enriched environment itself served as a salient natural reward that reduced cocaine seeking and cocaine taking, but had little impact on avoidance of the cocaine-paired taste cue. The protective effects of the enriched environment were robust and, as such, have important implications for the methods used in the study of drug addiction in animal models and for the prevention, and possibly the treatment, of the disease in adult humans.