Intraperitoneal and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Ovarian Cancer.

OPINION STATEMENT: In our clinical practice, we have shifted away from the use of adjuvant normothermic intraperitoneal (IP) chemotherapy, particularly following the publication of GOG 252. Our decision is rooted in the accumulating evidence indicating a lack of demonstrable superiority, alongside the recognized toxicities and logistical challenges associated with its administration. This strategic departure is also influenced by the rising utilization of maintenance therapies such as bevacizumab and PARP inhibitors, which present viable alternatives for improving patient outcomes. Our utilization of hyperthermic IP chemotherapy (HIPEC) is currently reserved for a specific cohort of patients, mirroring the patient population studied in the OVHIPEC-1 trial. Specifically, our HIPEC protocol applies to patients presenting with newly diagnosed stage IIIC high-grade epithelial ovarian cancer who are deemed ineligible for primary debulking surgery. Patients must exhibit at least stable disease with neoadjuvant platinum-based chemotherapy, maintain a favorable performance status (ECOG score 0-1), possess good nutritional reserves (with no evidence of protein-calorie malnutrition and an albumin level exceeding 3.5), and not have chronic kidney disease. When HIPEC is planned, it is administered at the time of interval debulking surgery, contingent upon the attainment of optimal surgical outcomes (< 1 cm of residual disease). Our HIPEC protocol adheres to the original OVHIPEC-1 trial guidelines, employing cisplatin at a dosage of 100 mg/m2. We administer at least two antiemetics, antihistamines, and sodium thiosulfate to mitigate known side effects. Postoperatively, patients are admitted to the general surgical floor, reserving the intensive care unit for those in critical condition. We follow Enhanced Recovery After Surgery principles, incorporating early ambulation and feeding into our postoperative care strategy. We have encountered encouraging results with this approach, with most patients having largely uncomplicated postoperative courses and resuming adjuvant chemotherapy within 3 to 4 weeks of surgery.

Timing and duration of bevacizumab treatment and survival in patients with recurrent ovarian, fallopian tube, and peritoneal cancer: a multi-institution study.

Bevacizumab has demonstrated significant benefit in recurrent ovarian, fallopian tube and peritoneal cancer (OC), but its optimal position within the sequence of systemic therapies remains controversial. Since rebound progression after bevacizumab has been observed in other cancers, and because bevacizumab is incorporated in several regimens used in the recurrent setting, the duration of treatment may impact survival. We sought to identify whether earlier bevacizumab exposure is associated with prolonged bevacizumab therapy and survival by conducting a multi-institution retrospective study of recurrent OC patients treated with bevacizumab from 2004-2014. Multivariate logistic regression identified factors associated with receiving more than six bevacizumab cycles. Overall survival by duration and ordinal sequence of bevacizumab therapy were evaluated using logrank testing and Cox regression. In total, 318 patients were identified. 89.1% had stage III or IV disease; 36% had primary platinum resistance; 40.5% received two or fewer prior chemotherapy regimens. Multivariate logistic regression demonstrated that primary platinum sensitivity (Odds Ratio (OR) 2.34, p = 0.001) or initiating bevacizumab at the first or second recurrence (OR 2.73, p < 0.001) were independently associated with receiving more than six cycles of bevacizumab. Receiving more cycles of bevacizumab was associated with improved overall survival whether measured from time of diagnosis (logrank p < 0.001), bevacizumab initiation (logrank p < 0.001), or bevacizumab discontinuation (logrank p = 0.017). Waiting one additional recurrence to initiate bevacizumab resulted in a 27% increased hazard of death (Hazard Ratio (HR) 1.27, p < 0.001) by multivariate analysis. In conclusion, patients with primary platinum sensitive disease who received fewer prior lines of chemotherapy were able to receive more cycles of bevacizumab, which was associated with improved overall survival. Survival worsened when bevacizumab was initiated later in the ordinal sequence of therapies.

Society of Gynecologic Oncology Journal Club: Controversial conversations in gynecologic cancer - Navigating maintenance therapy for homologous recombinant proficient ovarian cancer.

The Society of Gynecologic Oncology (SGO) Journal Club is an open forum to review pertinent studies relevant to controversial topics in the management of gynecologic cancers. On August 3rd, 2022, SGO hosted a Journal Club focused on the role of maintenance therapy for homologous recombinant proficient (HRP) patients with ovarian cancer. Navigating optimal therapies has become more complex with the emergence of new clinical trial data and the evolving understanding of how to classify ovarian cancers as HRP. Our speakers, Drs. Susan Modesitt, Barbara Norquist and Rodney Rocconi presented Gynecologic Oncology Group (GOG) 218 (Burger et al., 2011), the VITAL Trial (Rocconi et al., 2021), and the PRIMA study (Gonzalez-Martin et al., 2019). We asked our experts to discuss their opinions and interpretations on the application of these data to current clinical practice. Poll questions were presented to the audience for a pre- and post-webinar comparison (Table 1). Results of the poll questions are shown in Table 1.

Uterine lavage identifies cancer mutations and increased TP53 somatic mutation burden in individuals with ovarian cancer.

Current screening methods for ovarian cancer (OC) have failed to demonstrate a significant reduction in mortality. Uterine lavage combined with TP53 ultra-deep sequencing for the detection of disseminated OC cells has emerged as a promising tool, but this approach has not been tested for early-stage disease or non-serous histologies. In addition, lavages carry multiple background mutations, the significance of which is poorly understood. Uterine lavage was collected preoperatively in 34 patients undergoing surgery for suspected ovarian malignancy including 14 patients with benign disease and 20 patients with OC (6 non-serous and 14 high grade serous-like (serous)). Ultra-deep duplex sequencing (~3000x) with a panel of common OC genes identified the tumor mutation in 33% of non-serous (all early stage) and in 79% of serous cancers (including four early stage). In addition, all lavages carried multiple somatic mutations (average of 25 mutations per lavage), more than half of which corresponded to common cancer driver mutations. Driver mutations in KRAS, PIK3CA, PTEN, PPP2R1A and ARID1A presented as larger clones than non-driver mutations and with similar frequency in lavages from patients with and without OC, indicating prevalent somatic evolution in all patients. Driver TP53 mutations, however, presented as significantly larger clones and with higher frequency in lavages from individuals with OC, suggesting that TP53-specific clonal expansions are linked to ovarian cancer development. Our results demonstrate that lavages capture cancer cells, even from early-stage cancers, as well as other clonal expansions and support further exploration of TP53 mutation burden as a potential OC risk factor.

The optimal management of brain metastases from gestational trophoblastic neoplasia.

INTRODUCTION: Gestational trophoblastic diseases and neoplasias (GTDs and GTNs) comprise a spectrum of diseases arising from abnormally proliferating placental/trophoblastic tissue following an antecedent molar or non-molar pregnancy. These can spread to the brain hematogenously in about 10% of patients, mostly in high-risk disease. The optimal management of patients with brain metastases from GTN is unclear, with multiple systemic regimens under use and an uncertain role for radiotherapy. AREAS COVERED: Here, we review the epidemiology, workup, and treatment of GTN with central nervous system (CNS) involvement. Literature searches in PubMed and Google Scholar were conducted using combinations of keywords such as 'gestational trophoblastic disease,' 'gestational trophoblastic neoplasia,' 'choriocarcinoma,' and 'brain metastases.' EXPERT OPINION: Systemic therapy is the frontline treatment for GTN with brain metastases, and radiotherapy should only be considered in the context of a clinical trial or for resistant/recurrent disease. Surgery has a limited role in palliating symptoms or relieving intracranial pressure/bleeding. Given the highly specialized care these patients require, treatment at a high-volume referral center with multidisciplinary collaboration likely leads to better outcomes. Randomized trials should be conducted to determine the best systemic therapy option for GTN.

Pembrolizumab with low-dose carboplatin for recurrent platinum-resistant ovarian, fallopian tube, and primary peritoneal cancer: survival and immune correlates.

BACKGROUND: Anti-programmed death 1 (PD1)/programmed cell death ligand 1 (PD-L1) therapies have shown modest activity as monotherapy in recurrent ovarian cancer. Platinum chemotherapies induce T-cell proliferation and enhance tumor recognition. We assessed activity and safety of pembrolizumab with carboplatin in recurrent platinum-resistant ovarian cancer. PATIENTS AND METHODS: This phase I/II, single-arm clinical trial studied concurrent carboplatin and pembrolizumab in recurrent platinum-resistant ovarian, fallopian tube, and primary peritoneal cancer. Primary platinum refractory patients were excluded. Patients were treated after progression on subsequent non-platinum systemic therapy after becoming platinum resistant or refractory. Pembrolizumab 200 mg was given on day 1 and carboplatin area under the curve 2 on days 8 and 15 of a 3-week cycle until progression. Imaging was assessed by blinded independent review. PD-L1 expression was assessed by immunohistochemistry. Flow cytometry on peripheral blood mononuclear cells was performed for CD3, CD4, CD8, PD1, CTLA4 and Ki67. RESULTS: The most common treatment-related adverse events were lymphopenia (18%) and anemia (9%) with most being grade 1 or 2 (93%). Of 29 patients treated, 23 patients were evaluable for best objective response: 10.3% (95% CI 2.2 to 27.4) had partial response (PR), 51.7% (95% CI 32.5 to 70.6) had stable disease (SD). 56.5% of patients had decreases in target lesions from baseline. All PD-L1-positive patients achieved PR (3/7, 42.8%) or SD (4/7, 57.2%). Median progression-free survival was 4.63 months (95% CI 4.3 to 4.96). Median OS was 11.3 months (95% CI 6.094 to 16.506). Peripheral CD8+PD1+Ki67+ T cells expanded after 3 (p=0.0015) and 5 (p=0.0023) cycles. CTLA4+PD1+CD8+ T cells decreased through the course of treatment up to the 12th cycle (p=0.004). When stratified by ratio of peripheral CD8+PD1+Ki67+ T cells to tumor burden at baseline, patients with a ratio ≥0.0375 who had a significantly longer median OS of 18.37 months compared with those with a ratio <0.0375 who had a median OS of 8.72 months (p=0.0099). No survival advantage was seen with stratification by tumor burden alone (p=0.24) or by CD8+PD1+Ki67+ T cells alone (p=0.53). CONCLUSIONS: Pembrolizumab with carboplatin was well-tolerated and active in recurrent platinum-resistant ovarian cancer. A ratio of peripheral T-cell exhaustion to radiographic tumor burden may identify patients more likely to benefit from this chemoimmunotherapy. TRIAL REGISTRATION NUMBER: NCT03029598.

Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations, part II.

In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. This manuscript, Part II in a two-part series, includes specific recommendations on treatment of recurrent disease, post treatment surveillance and survivorship, considerations for younger women, and special situations. Part I covered histopathology and molecular pathology, risk factors, presentation and diagnostic approach, surgical approach and adjuvant therapy.

Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations.

INTRODUCTION: In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. Despite these advances, the incidence of endometrial cancer as well as the deaths attributable to the disease have continued to rise; from 1987 to 2014 there has been a 75% increase in cases and almost 300% increase in endometrial cancer deaths. Fortunately, since then, there has been progress in the treatment of patients with endometrial cancer with increased utilization of molecular pathology, greater understanding of genetic predisposition, enhanced methods for lymph node assessment, a broader understanding of the efficacy of radiation and chemotherapy, and a more efficient approach to survivorship and surveillance. The purpose of this document is to present a comprehensive review of this progress. MANUSCRIPT DEVELOPMENT PROCESS: The authors reviewed the available evidence, contributed to the development of this manuscript, provided critical review of the guidelines, and finalized the manuscript recommendations. The review was also presented to and approved by the Society of Gynecologic Oncology (SGO) Clinical Practice Committee, SGO Publications Committee, and the SGO board members prior to submission for publication. The recommendations for this manuscript were developed by a panel of gynecologic oncologists who were members of the SGO Clinical Practice and Education Committees. Panelists reviewed and considered evidence from current uterine cancer literature. The terminology used in these guidelines was adopted from the ASCCP management guidelines [1] using a two-part rating system to grade the strength of recommendation and quality of evidence (Table 1). The rating for each recommendation is given in parentheses.

The association between HIV infection and cervical cancer presentation and survival in Uganda.

Our objective was to determine how HIV infection impacts cervical cancer stage at presentation and overall survival (OS) among Ugandan women. This was a prospective study of 149 women diagnosed with cervical cancer from 2013 to 2015 at the Uganda Cancer Institute. Poisson regression models were fit to calculate prevalence ratios (PR) for the association between HIV infection and late stage at cancer diagnosis. The association between HIV infection and OS after cervical cancer diagnosis was evaluated using Cox proportional hazards models. The cohort included 53 HIV-positive and 96 HIV-negative participants. Median age at diagnosis was 44 years for HIV-positive and 54 years for HIV-negative participants. Seventy-seven percent of HIV-positive participants received antiretroviral therapy. Median baseline CD4 count was 373 cells/mm3 for HIV-positive participants versus 926 cells/mm3 for HIV-negative participants. Thirty-two percent of HIV-positive participants were diagnosed with late stage cervical cancer (III-IV) versus 39% of HIV-negative participants. No association was found between late stage at cancer diagnosis and HIV infection (PR adjusted for age, parity and transport cost 1.0, 95%CI 0.6-1.8). Most women presenting for care received cancer treatment, though almost half who received radiotherapy did not complete treatment. The median OS was 13.7 months for HIV-positive participants and 24.3 months for HIV-negative participants. After adjusting for age and stage, HIV infection was weakly associated with OS (HR 1.3, 95%CI 0.8-2.2). In Uganda, cervical cancer is often incompletely treated and survival remains poor. HIV infection was not associated with cervical cancer stage at diagnosis, but may be weakly associated with shorter survival.

Pilot study of a condensed communication skills workshop for gynecologic oncology fellows.

In gynecologic oncology (GO) fellowship, devoting sufficient time to learning communication skills can be challenging due to required time and logistics. A two day workshop was previously piloted at a single institution with GOs and found to be beneficial. We sought to implement that curriculum in a condensed form. We conducted two four-hour sessions with 4 GO fellows at a single institution over 4 months. Sessions consisted of a didactic in communication skills led by faculty with VitalTalk™ training, followed by application with a simulated patient. Cases were developed and previously used in a two-day workshop at another institution. Fellows were surveyed prior to both sessions and after the second session. Perceived confidence was assessed on a Likert scale (1 to 5). An improvement was defined by an increase of ≥1 in Likert score. All fellows reported that the educational quality of the sessions was "excellent," that the time in between sessions was "just right," allowing them to apply skills learned in the first session prior to the second. After both sessions, at least three of the four fellows reported an improvement in confidence in nearly 50% (10/21) of the communication topics assessed. GO fellows perceived improvements in communication skills with condensed half-day training seminars.

Intraperitoneal ports placed at the time of bowel resection for treatment of ovarian cancer: Complications and surgical outcomes.

OBJECTIVES: To determine if intraperitoneal (IP) ports placed concurrently with bowel resection during surgical treatment of ovarian cancer is associated with more complications than those ports placed without concurrent bowel resection. METHODS: The medical records of all patients who had an IP port placed at our institution between 2005 and 2016 were reviewed. Two groups were analyzed: IP ports placed with bowel resection (IP-BR) and those without (IP). RESULTS: Of 306 patient charts reviewed, 31% had a surgery with IP port placement and concurrent bowel resection (IP-BR). Demographics were similar except for mean BMI (25.6 IP-BR vs 27.4 IP, p = 0.007). More IP-BR patients had stage IIIC disease (83.3% IP-BR vs 56.9% IP, p ≤0.01). Patients were cytoreduced to R0 in 48.7% IP-BR vs 56.4% IP (p = 0.253). For adjuvant treatment, IV chemotherapy was administered before IP chemotherapy in 90.4% IP-BR (median 2 cycles), and 50.3% IP, (median 2 cycles, p < 0.01). Ultimately 80.2% IP-BR (median 4 cycles) and 77.8% IP (median 5 cycles) received IP chemotherapy (p = 0.65). Rates of total IP port complications were similar (19.2% IP-BR vs 23.2% IP, p = 0.397), including IP port infections (0% IP-BR vs 0.7% IP, p = 0.5). Eleven percent of IP-BR patients had a bowel complication (e.g. obstruction or perforation) while IP port was in situ vs 2.7% IP (p = 0.01). Only 2.7% IP-BR and 6% IP discontinued IP chemotherapy due to IP port complication (p = 0.3). CONCLUSIONS: Patients who have IP ports placed concurrently with a bowel resection do not appear to have more complications, nor lower rates of IP chemotherapy administration.

Patterns and duration of primary and recurrent treatment in ovarian cancer patients with germline BRCA mutations.

The objectives of this study were to describe the patterns and duration of primary and recurrent treatment in patients with ovarian cancer (OC) harboring germline BRCA1 and BRCA2 (BRCA) mutations. A retrospective review of BRCA mutation carriers with advanced, high-grade OC diagnosed between 2004 and 2014 with at least 3 years of follow-up (or until death) was undertaken. Descriptive statistics were calculated and a Swimmer's Plot used to depict disease course. Forty BRCA mutation carriers (26 BRCA1, 14 BRCA2) were identified. Mean age was 54 (range 32-77). All had cytoreductive surgery and received platinum chemotherapy. Median platinum-free interval was 11.9 months (IQR 3.6-21.9). Among 28 patients who recurred, median number of treatment lines was 4 (IQR 3-6), with a median of 2 (IQR 2-3) platinum lines. On average, patients who recurred spent 32% (IQR 20-43%) of their time after diagnosis receiving cytotoxic chemotherapy and 54% (IQR 42-67%) of the time on some cancer-directed therapy, including maintenance. Median overall survival was 79.1 months from diagnosis and 25.4 months after first recurrence. In conclusion, beyond first-line therapy, there was treatment and outcome heterogeneity for BRCA-mutated OC. After OC diagnosis, patients spent close to half their life on treatment.

Post-diagnosis use of antihypertensive medications and the risk of death from ovarian cancer.

OBJECTIVE: To examine associations between post-diagnosis use of antihypertensive (AH) medications including thiazide diuretics (TDs), angiotensin converting enzyme inhibitors (ACEIs), beta blockers (BBs) [both non-selective (NSBBs) and selective (SBBs)] and calcium channel blockers (CCBs) and ovarian cancer-specific survival. METHODS: This cohort study used SEER-Medicare data on 2195 women 66+ years of age who were diagnosed with ovarian cancer during 2007-2012 and who survived for at least 12 months. Use of an AH class was defined as two or more fills during the year after diagnosis. Ovarian cancer-specific death was assessed starting one year after diagnosis and continued through the end of 2013. Associations between AH use and ovarian cancer-specific mortality were assessed using Cox proportional hazard models, comparing users of a given class of AH to non-AH users. RESULTS: Overall, 718 (33%), 690 (31%), 521 (24%), 154 (7%) of women used a TD, ACEI, BB, or CCB, respectively, with some women (48%) using more than one class of drug. Ovarian cancer-specific mortality was found to be lower among women who used an ACEI (adjusted hazard ratio [aHR] 0.76, 95% confidence interval [CI] 0.63-0.92), a TD (aHR 0.82, 95%CI 0.68-0.99), or a NSBB (aHR 0.60, 95%CI 0.43-0.83), but no such association was seen in women who took a SBB or CCB. CONCLUSION: We observed that women who took certain forms of an AH medication during the year following a diagnosis of ovarian cancer were thereafter at a relatively reduced risk of dying from their disease. However, the potential for residual confounding by disease severity argues for a cautious interpretation.

Use of Statin Medications Following Diagnosis in Relation to Survival among Women with Ovarian Cancer.

BACKGROUND: It has been suggested that the likelihood of survival among women with ovarian cancer could be increased by postdiagnosis statin use. This study examines the potential association between postdiagnosis statin use and cancer-specific mortality among women with ovarian cancer. METHODS: This cohort study used SEER-Medicare data on women ≥66 years of age diagnosed with ovarian cancer during 2007 to 2012 who were enrolled in Medicare parts A, B, and D during the year after diagnosis. Statin use was defined as two or more fills for a statin during the year after diagnosis. Ovarian cancer-specific death was assessed starting 1 year after diagnosis. Marginal structural Cox models were used, adjusting for the inverse probability of treatment weighting and censoring weighting. Treatment weights and censoring weights were calculated using logistic regression models with a priori-defined covariates. RESULTS: Among 2,195 women with ovarian cancer, 489 (22%) used statins within 1 year after their diagnosis. Over a mean follow-up of 2.2 years, 796 (36%) women died from ovarian cancer. The adjusted HR for ovarian cancer mortality comparing statin users to nonusers was 0.74 (95% confidence interval, 0.61-0.91). CONCLUSIONS: Findings from this and prior work suggest statin use following a diagnosis with ovarian cancer is associated with a lower risk of cancer death. IMPACT: Because, in most women, statin administration has limited side effects, a randomized trial of statins among patients with ovarian cancer may be warranted.

The perceptions of gynecologic oncology fellows on readiness for subspecialty training following OB/GYNRESIDENCY.

A recent survey of fellowship program directors (PD) within gynecologic oncology (GO) noted concerns regarding the abilities of incoming fellows. The objective of this study was to evaluate the perceptions of current and former fellows in gynecologic oncology of their readiness for fellowship training. A previously used survey was modified and distributed in 2016 to current and former fellows in GO. The survey explored domains of independent practice, psychomotor ability, clinical evaluation and scholarship. A standard Likert scale was employed and domains/responses were tailored to the subspecialty. A total of 150 current and recently former fellows responded to the survey, for a response rate of 38.7%. Nearly 70% of respondents reported being able to independently perform a hysterectomy when starting fellowship, and nearly 50% felt they could perform lysis of adhesions either without assistance. Although nearly 95% reported having had the opportunity to develop a plan of action for patients on labor and delivery, only 40.7% felt able to independently manage postoperative complications without assistance. Common themes that emerged in the open-ended responses pertained to self-perception of inadequate surgical skills and knowledge specific to gynecologic oncology. Although the majority of current and former fellows in gynecologic oncology report feeling prepared for fellowship, themes noted in the open-ended responses suggest a lack of confidence in surgical skills and clinical knowledge.

Two cases of extragonadal malignant transformation of endometriosis after TAH/BSO for benign indications.

•Extragonadal malignant transformation of endometriosis can occur after oophorectomy.•Endometriosis-associated malignancy can occur in the absence of hormone replacement.•Estrogen and progesterone receptor status can influence treatment strategies.•The role of chemotherapy for malignant transformation of endometriosis is not clear.

Revisiting Minimally Invasive Surgery in the Management of Early-Stage Cervical Cancer.

Minimally invasive surgery (MIS) was previously considered an acceptable alternative to open radical hysterectomy in the management of early-stage cervical cancer (ESCC), but adequately powered, high-quality prospective trials evaluating survival outcomes were lacking. Recently, a large randomized phase III trial, the Laparoscopic Approach to Cervical Cancer (LACC) trial, showed that MIS for ESCC is associated with a higher risk of recurrence and death compared with open surgery. We review the LACC trial findings in depth, as well as a recent National Cancer Database analysis using propensity score weighting that supports the LACC trial findings. Additional studies are needed to better understand the mechanisms explaining the worse survival associated with MIS for ESCC. This review discusses considerations for integrating the findings of the LACC trial into clinical practice. Based on the high-quality evidence now available, open radical hysterectomy should be offered as standard of care for stage IA2-IB1 cervical cancer and patients should be guided appropriately to make informed shared decision-making if they still desire MIS.

Fellow Perceptions of Residency Training in Obstetrics and Gynecology.

OBJECTIVE: To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training. METHODS: A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized. RESULTS: A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident. CONCLUSIONS: The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies.

Combined symptom index and second-generation multivariate biomarker test for prediction of ovarian cancer in patients with an adnexal mass.

OBJECTIVE: To assess the performance of a symptom index (SI) and multivariate biomarker panel in the identification of ovarian cancer in women presenting for surgery with an adnexal mass. STUDY DESIGN: Prospective study of patients seen at a tertiary medical center. Following consent, patients completed an SI and preoperative serum was collected for individual markers (CA 125) and a second-generation FDA-cleared biomarker test (MIA2G). Results for the SI and MIA2G were correlated with operative findings and surgical pathology. Logistic regression modeling was performed to assess the interaction of the SI with MIA2G to determine the risk of malignancy (ROM). RESULTS: Of the 218 patients enrolled, the mean age was 53.6 years (range 18-86). One-hundred and forty-seven patients (67.4%) were postmenopausal. Sixty-four patients (29.4%) had epithelial ovarian cancer or fallopian tube cancer (EOC/FTC) and 17 (7.8%) had borderline ovarian tumors. A positive SI or MIA2G correctly identified 96.1% of patients with EOC/FTC. Using logistic regression, we found that both SI and MIA2G score were significantly associated with ROM (p < 0.001). In a simulation with disease prevalence set at 5%, patients with a negative SI and a MIA2G score of 6 had a ROM of 1.8% whereas patients with the same MIA2G and positive SI had a 10.5% ROM, nearly a 6-fold higher risk. CONCLUSIONS: The combination of a patient-reported symptom index and refined biomarker panel allows for improved accuracy in the assessment for ovarian cancer in patients with an adnexal mass. This strategy could offer a personalized approach to addressing ROM to triage patients with an adnexal mass to appropriate care.