Reloadable Stapler Use during Peripartum Hysterectomy for Placenta Accreta Spectrum: A Novel Surgical Technique and Case Series.

OBJECTIVE: This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS). STUDY DESIGN: This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center. RESULTS: Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 344/7 ± 11/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta. CONCLUSION: Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140-254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500-5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS. KEY POINTS: · PAS is associated with severe maternal morbidity.. · Decreased operative time and blood loss have many clinical benefits.. · Reloadable stapler use for PAS decreases operative time.. · Reloadable stapler use for PAS decreases operative blood loss..

A case of primary cervical lymphoma in a patient with abnormal uterine bleeding.

Primary lymphoma of the uterine cervix is a rare site of extranodal lymphoma. Many gynecologic oncologists may go their entire career without encountering one. Patients may present with symptoms of abnormal or postmenopausal bleeding, and diagnosis may be challenging as typical office tests such as the pap smear may not detect the abnormal cells. Once a diagnosis is made, management may be debated due to the rarity of the condition and lack of accepted standard treatment. However, most patients respond well to some version of chemotherapy and radiation typically used for standard lymphomas. Prognosis is favorable if the patient is diagnosed early in the disease process.

A brief review of the management of platinum-resistant-platinum-refractory ovarian cancer.

Ovarian cancer, which ranks fifth in cancer deaths among women, is the most lethal gynecologic malignancy. Epithelial ovarian cancer (EOC) is the most common histologic type, with the 5-year survival for all stages estimated at 45.6%. This rate increases to more than 70% in the minority of patients who are diagnosed at an early stage, but declines to 35% in the vast majority of patients diagnosed at advanced stage. Recurrent EOC is incurable. Platinum sensitivity (or lack thereof) is a major determinant of prognosis. The current standard treatment is primary surgery followed by platinum-based chemotherapy. In recurrent platinum-resistant/platinum-refractory EOC, sequential single-agent salvage chemotherapy is superior to multiagent chemotherapy. Multiagent regimens increase toxicity without clear benefit; however, no preferred sequence of single agents is recommended. The impact of targeted therapies and immunotherapies on progression-free survival and overall survival, which remains dismal, is under active investigation. Currently, clinical trials offer the best hope for the development of a new treatment paradigm in this recalcitrant disease.

BAD phosphorylation determines ovarian cancer chemosensitivity and patient survival.

PURPOSE: Despite initial sensitivity to chemotherapy, ovarian cancers (OVCA) often develop drug resistance, which limits patient survival. Using specimens and/or genomic data from 289 patients and a panel of cancer cell lines, we explored genome-wide expression changes that underlie the evolution of OVCA chemoresistance and characterized the BCL2 antagonist of cell death (BAD) apoptosis pathway as a determinant of chemosensitivity and patient survival. EXPERIMENTAL DESIGN: Serial OVCA cell cisplatin treatments were performed in parallel with measurements of genome-wide expression changes. Pathway analysis was carried out on genes associated with increasing cisplatin resistance (EC(50)). BAD-pathway expression and BAD protein phosphorylation were evaluated in patient samples and cell lines as determinants of chemosensitivity and/or clinical outcome and as therapeutic targets. RESULTS: Induced in vitro OVCA cisplatin resistance was associated with BAD-pathway expression (P < 0.001). In OVCA cell lines and primary specimens, BAD protein phosphorylation was associated with platinum resistance (n = 147, P < 0.0001) and also with overall patient survival (n = 134, P = 0.0007). Targeted modulation of BAD-phosphorylation levels influenced cisplatin sensitivity. A 47-gene BAD-pathway score was associated with in vitro phosphorylated BAD levels and with survival in 142 patients with advanced-stage (III/IV) serous OVCA. Integration of BAD-phosphorylation or BAD-pathway score with OVCA surgical cytoreductive status was significantly associated with overall survival by log-rank test (P = 0.004 and P < 0.0001, respectively). CONCLUSION: The BAD apoptosis pathway influences OVCA chemosensitivity and overall survival, likely via modulation of BAD phosphorylation. The pathway has clinical relevance as a biomarker of therapeutic response, patient survival, and as a promising therapeutic target.

Primary retroperitoneal mucinous borderline tumor: a case report.

BACKGROUND: Primary retroperitoneal mucinous borderline tumors are rare. These tumors can be present in women with otherwise normal pelvic anatomy. CASE: A 22-year-old woman with abdominal pain was found to have a large midline mass superior to the uterus with ascites. In surgery, a large mass was arising from the sigmoid mesentery. The pelvis was normal on inspection. Final pathology of the mass revealed borderline tumor (tumor of low malignant potential) and focus of ovarian tissue. CONCLUSION: This is a case report of primary retroperitoneal mucinous borderline tumor. The gynecologic oncologist should be aware of primary retroperitoneal tumors and the differential diagnosis.

Adverse impact of a history of violence for women with breast, cervical, endometrial, or ovarian cancer.

OBJECTIVE: The experience of physical and sexual violence (victimization) is common among U.S. women and is associated with adverse health consequences. The study objectives were to estimate the prevalence of victimization in women with cancer and to examine associations with demographics, cancer screening, and cancer stage. METHODS: From 2004 to 2005, 101 women with breast, cervical, endometrial, or ovarian cancer were interviewed to collect demographics, cancer screening history, health care access/use, and violence history. Chi-square and Fisher exact tests were used test risk-factor associations. A multinomial logistic regression model was used for multivariable analysis. RESULTS: The prevalence of a history of violence was 48.5% (49/101 women), and within that group, 46.9% (23/49) had a positive childhood violence screen, 75.5% (37/49) had a positive adult screen, and 55% (27/49) reported sexual violence at any age. Women with a positive violence screen differed significantly from women with a negative screen in that they were younger (P = .031), more often divorced (P = .012), more likely to smoke (P = .010), more often lacked commercial insurance (P = .036), and had more advanced stage of disease (P = .013), but they did not differ with regard to race, cancer type, education level, alcohol or drug use, or cancer screening compliance. Multivariable analysis revealed that only stage remained significant; women with a history of violence had a 2.6-fold increased chance of diagnosis in later stages (odds ratio 2.61, 95% confidence interval 1.03-6.59). CONCLUSION: A history of violence in breast, ovarian, endometrial, and ovarian cancer patients was extremely common and correlated with advanced stage at diagnosis. LEVEL OF EVIDENCE: II-2.

Factors influencing maternal perception of uterine contractions.

OBJECTIVES: The purpose of this study was to assess factors associated with perception of uterine contractions. STUDY DESIGN: A database of ambulatory uterine activity monitoring was examined. All patients having singleton pregnancies evaluated between March 1997 and March 2002 were eligible for analysis. Data were divided into 4 groups by maternal prepregnancy body mass index (BMI): lean (<20 kg/m(2)), normal (>or=20 to <25 kg/m(2)), overweight (>or=25 to <30 kg/m(2)), and obese (>or=30 kg/m(2)). The percentage of contractions perceived during observation was compared between groups. Variables interrogated included maternal weight and parity. Statistical analysis included t test, analysis of variance (ANOVA), and linear regression. RESULTS: Data from 7808 patients (556,382 hr) were analyzed. A significant reduction in perception of contractions occurred with increasing BMI between each classification, P <.001. A significant reduction in perception of contractions was also noted between nulliparous and multiparous patients at each weight classification, P <.001. CONCLUSION: Obese, nulliparous patients have the greatest difficulty perceiving contractions. Such data may help explain unattended birth or late presentation for care in this group.