Patient perspectives of telemedicine in gynecologic oncology during COVID.

Objectives: Healthcare rapidly expanded the use of telemedicine during the COVID- 19 pandemic. Research regarding telemedicine benefits and patient perspectives during COVID are limited. The aim of this study was to determine how the pandemic impacted patient perspectives and value of telemedicine in gynecologic oncology. Methods: A cross-sectional survey was distributed to patients presenting for an appointment to the gynecologic oncology ambulatory clinic. The survey assessed patient demographics, frequency of technology use, and preferences of telemedicine use in their care. Descriptive statistics were generated and Pearson's chi square and analysis of variance (ANOVA) were used for statistical analysis. Results: 116 patients completed the survey. Respondent age range was 20-70 years old. Most respondents (80 %) had a cancer diagnosis. Nearly all (91 %) patients had access to online medical records via an online portal. Increased use of technology was not associated with agreeing to a telemedicine visit. Only 36 % stated they would feel comfortable with a telemedicine visit with a gynecologic oncologist. Patients were more willing to agree to video rather than telephone visits (41.8 % vs 24.5 %). The pandemic did not affect patient comfort level with telemedicine. Conclusions: Despite increased use and overall favorable impression, patients were not more eager to participate in telemedicine during the pandemic. Patients are open to incorporating telemedicine more often in follow up settings.

Robotic virtual reality simulation plus standard robotic orientation versus standard robotic orientation alone: a randomized controlled trial.

OBJECTIVE: The objective of this study was to compare the effect of virtual reality simulation training plus robotic orientation versus robotic orientation alone on performance of surgical tasks using an inanimate model. METHODS: Surgical resident physicians were enrolled in this assessor-blinded randomized controlled trial. Residents were randomized to receive either (1) robotic virtual reality simulation training plus standard robotic orientation or (2) standard robotic orientation alone. Performance of surgical tasks was assessed at baseline and after the intervention. Nine of 33 modules from the da Vinci Skills Simulator were chosen. Experts in robotic surgery evaluated each resident's videotaped performance of the inanimate model using the Global Rating Scale (GRS) and Objective Structured Assessment of Technical Skills-modified for robotic-assisted surgery (rOSATS). RESULTS: Nine resident physicians were enrolled in the simulation group and 9 in the control group. As a whole, participants improved their total time, time to incision, and suture time from baseline to repeat testing on the inanimate model (P = 0.001, 0.003, <0.001, respectively). Both groups improved their GRS and rOSATS scores significantly (both P < 0.001); however, the GRS overall pass rate was higher in the simulation group compared with the control group (89% vs 44%, P = 0.066). CONCLUSIONS: Standard robotic orientation and/or robotic virtual reality simulation improve surgical skills on an inanimate model, although this may be a function of the initial "practice" on the inanimate model and repeat testing of a known task. However, robotic virtual reality simulation training increases GRS pass rates consistent with improved robotic technical skills learned in a virtual reality environment.

Placental site trophoblastic tumor presenting as an intramural mass with negative markers: an opportunity for novel diagnosis and treatment with robotic hysterectomy.

A patient presented with persistent levels of quantitative human chorionic gonadotropin despite therapy with methotrexate. A dilation and curettage procedure did not provide a pathologic diagnosis. Gestational trophoblastic disease was suspected, but serum biomarkers were unable to provide a pre-operative diagnosis. A mass was found in the uterus by ultrasound and subsequent computed tomography scans. There was no evidence of extrauterine disease, but the uterine mass was continuous with the endometrial cavity, evoking the suspicion of an invasive endometrial mass. The patient underwent robotic hysterectomy for both therapy and diagnosis of suspected gestational trophoblastic disease (GTD). The final pathologic diagnosis was placental site trophoblastic tumor. The robotic approach allows for a minimally invasive surgical procedure with thorough examination of the pelvic cavity and adnexae and does not require a uterine manipulator which may be contra-indicated in the setting of uterine GTD. For patients with suspected persistent uterine GTD who are otherwise candidates for minimally invasive surgery, a robotic procedure offers advantages when compared to traditional laparoscopy or vaginal hysterectomy.

ERCC5 is a novel biomarker of ovarian cancer prognosis.

PURPOSE: To identify a biomarker of ovarian cancer response to chemotherapy. PATIENTS AND METHODS Study: participants had epithelial ovarian cancer treated with surgery followed by platinum-based chemotherapy. DNA and RNA were isolated from frozen tumors and normal DNA was isolated from matched peripheral blood. A whole-genome loss of heterozygosity (LOH) analysis was performed using a high-density oligonucleotide array. Candidate genomic areas that predicted enhanced response to chemotherapy were identified with Cox proportional hazards methods. Gene expression analyses were performed through microarray experiments. Candidate genes were tested for independent effects on survival using Cox proportional hazards models, Kaplan-Meier survival curves, and the log-rank test. RESULTS: Using a whole-genome approach to study the molecular determinants of ovarian cancer response to platinum-based chemotherapy, we identified LOH of a 13q region to predict prolonged progression-free survival (PFS; hazard ratio, 0.23; P = .006). ERCC5 was identified as a candidate gene in this region because of its known function in the nucleotide excision repair pathway, the unique DNA repair pathway that removes platinum-DNA adducts. We found LOH of the ERCC5 gene locus and downregulation of ERCC5 gene expression to predict prolonged PFS. Integration of genomic and gene expression data shows a correlation between 13q LOH and ERCC5 gene downregulation. CONCLUSION: ERCC5 is a novel biomarker of ovarian cancer prognosis and a potential therapeutic target of ovarian cancer response to platinum chemotherapy.

Hereditary ovarian cancer--assessing risk and prevention strategies.

Hereditary ovarian cancers are almost entirely attributable to mutations in BRCA1/2 or the genes of DNA mismatch repair. Identifying individuals at risk requires a complete family history and evidence-guided genetic testing. Screening of women at increased risk for ovarian cancer can be considered in those not wishing prophylactic surgery and typically should include a twice-annual pelvic examination, serum CA-125 measurement, and transvaginal sonography. Patients must understand that these measures have not been conclusively proven to improve early detection or long-term survival. In all mutation carriers who have completed or do not desire childbearing, prophylactic bilateral salpingo-oophorectomy must be strongly considered.

Hyperandrogenism, mediated by obesity and receptor polymorphisms, promotes aggressive epithelial ovarian cancer biology.

OBJECTIVE: Epidemiologic data suggest that aberrant androgen homeostasis may promote aggressive epithelial ovarian cancer biology. Hyperandrogenism results from both obesity and expression of polymorphic androgen receptor (AR) allelotypes harboring short cytosine-adenine-guanine (CAG) repeat sequences; both have been shown to independently correlate with poor overall survival in ovarian cancer. We have hypothesized that the combination of these factors further manifests an aggressive ovarian cancer phenotype. METHODS: Genotype analysis of the AR CAG polymorphism was performed on 81 patients with papillary serous epithelial ovarian cancer. Medical records were reviewed for body mass index (BMI), clinico-pathologic factors, and survival. Data were examined using the Fishers exact test, Kaplan-Meier survival, and Cox regression analyses. RESULTS: Overweight or obese women (BMI > or = 25) with a short AR allele (< or = 19 CAG repeats) demonstrated statistically shorter progression-free survival (9 months) when compared to underweight or ideal body weight women (BMI < 25) and a long AR allele (> 19 CAG repeats; 26 months, p=0.0002). Overweight/obese women with a short AR allele also demonstrated shorter overall survival (34 months) when compared to underweight/ideal body weight women with a long AR allele (59 months, p=0.036). On multivariate analyses, the combination of a short AR allele and BMI > 25 was an independent poor prognostic factor after controlling for age, stage, grade, optimal cytoreduction, and AR allele length and BMI independently (p=0.05). CONCLUSION: These data provide further evidence that suggest that hyperandrogenism promotes an aggressive epithelial ovarian cancer phenotype.

Characterization of CSOC 882, a novel immortalized ovarian cancer cell line expressing EGFR, HER2, and activated AKT.

OBJECTIVE: Only a small number of comprehensively characterized immortalized ovarian cancer cell lines are available for laboratory studies on ovarian cancer. We describe a new ovarian cancer cell line that arose from primary culture of a stage IC, grade III ovarian carcinoma, designated CSOC 882. METHODS: We characterized CSOC 882 by karyotyping, growth modeling, immunohistochemical staining, immunoblotting, drug sensitivity testing, and xenografting in nude mice. RESULTS: CSOC 882 possessed an abnormal tetraploid karyotype including loss of one copy of chromosomes 2, 17, 19, and 21, and deletion of 8p21. Growth of CSOC 882 was best modeled using the logistic growth equation revealing an average doubling time of 31 h. CSOC 882 cells expressed vimentin, cytokeratin, p53, BRCA1, EGF receptor, HER2, androgen receptor, estrogen receptor alpha, and progesterone receptor, while no evidence of estrogen receptor beta or factor VIII was observed. Some but not all CSOC 882 cells were positive for CA125 reflecting the primary tumor, which had patchy CA125 staining. Drug sensitivity assays demonstrated that CSOC 882 was more sensitive to cisplatin and carboplatin than SKOV3 and HCC1937 while CSOC 882 and SKOV3 were both sensitive to paclitaxel unlike HCC1937. CSOC 882 xenografts retained the original characteristics of vimentin, cytokeratin, and factor VIII labeling. CONCLUSIONS: CSOC 882 is an immortalized cell line that has survived more than 130 passages in culture and retained molecular features of the primary tumor from which it was derived. Compared to the most common ovarian carcinoma cell lines, CSOC 882 is a unique resource for genetic and cellular research on ovarian cancer.

Effect of obesity on survival in epithelial ovarian cancer.

BACKGROUND: Epidemiologic studies suggest that obese women are more likely to die of ovarian cancer than those of ideal body weight, but it is not known whether increased incidence, comorbidities common to obese women, or altered tumor biology is responsible for this difference. The current study attempted to determine the influence of excess body weight on ovarian cancer survival, disease progression, and clinicopathologic factors. METHODS: The records of patients undergoing surgery for epithelial ovarian cancer at Cedars Sinai Medical Center between January 1, 1996 and June 30, 2003 were reviewed for height, weight, age, comorbidities, and treatment-specific details. Statistical analyses included the Fisher exact test, Kaplan-Meier survival, and Cox regression analyses. RESULTS: In all, 216 patients were identified. Eight percent were underweight (body mass index [BMI] < 18.5), 50% were ideal body weight (18.5 /= 30). Age, comorbidities including coronary artery disease and venous thromboembolism, and rates of optimal surgical cytoreduction were similar among BMI strata. Diabetes and hypertension were more common in obese women. Ten (29%) of the obese patients had International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, compared with 19 (10%) of the patients with BMI < 30 (P = .01). In a subcohort of 149 patients with Stage III or IV disease, a significant trend was identified favoring increased BMI as an independent negative factor for disease-free (P = .02) and overall (P = .02) survival. CONCLUSIONS: Obese patients were more likely to have disease limited to the ovaries. For patients with advanced stage disease, obesity was independently associated with both shorter time to recurrence and shorter overall survival. These findings suggest an effect of excess body weight on tumor biology, and studies are under way to elucidate the molecular and hormonal mechanisms underlying these clinical observations.

Adenocarcinoma of the uterine cervix with choriocarcinomatous metastasis.

BACKGROUND: Nongestational choriocarcinoma, in very rare instances, has been described as a component of other malignancies with a tendency for a very poor prognosis. CASE: A 55 year old woman was diagnosed with adenocarcinoma of the cervix, and incompletely treated with only external beam radiation. Adjuvant radical hysterectomy demonstrated no residual tumor, but the patient developed a tumor metastasis mimicking a pulmonary artery thrombus which by histology and immunohistochemistry was pure choriocarcinoma. While chemotherapy was successful in achieving a complete remission, the patient succumbed to complications of her pulmonary metastasis. CONCLUSION: Choriocarcinomatous dedifferentiation of cervical adenocarcinoma is extremely rare, with only one other case reported in the literature. While the prognosis for patients with such a tumor is generally poor, aggressive combination chemotherapy may be of benefit in some.

Correlation of cyclooxygenase-2 (COX-2) and aromatase expression in human endometrial cancer: tissue microarray analysis.

OBJECTIVE: The objective of this study was to compare the prevalence of cyclooxygenase-2 (COX-2), aromatase, and hormone receptor immunohistochemical (IHC) expression to well defined clinical-pathologic prognostic factors in a large group of surgically staged endometrial cancer patients. STUDY DESIGN: A tissue microarray (TMA) was constructed from 336 separate specimens of endometrial cancer. IHC was performed for estrogen (ER) and progesterone (PR) receptor, COX-2, COX-1, and aromatase. RESULTS: The majority of tumors expressed COX-2 (59%) and aromatase (65%). COX-2 staining significantly correlated with aromatase expression ( P < .014) but did not correlate with ER and PR. COX-2 expression was correlated with worsening histologic grade ( P < .026) and approached statistical significance for deep myometrial invasion ( P < .055). After applying multivariate analysis, no single IHC or combination of IHCs correlated with intrauterine poor prognostic factors or advanced stage. Only myometrial invasion >50% (OR 6.98, P < .001) and nonendometrioid histology (OR 4.933, P < .001) were predictive of advanced stage after multivariate analysis. CONCLUSION: COX-2 and aromatase are expressed in the majority of endometrial cancer patients. COX-2 expression was not associated with the great majority of surgical-pathologic prognostic factors. COX-2 expression did significantly correlate with aromatase expression, suggesting that intratumoral production of estrogen in endometrial cancer may be an important mechanism in tumorigenesis.

Surgical staging for patients presenting with grade 1 endometrial carcinoma.

OBJECTIVE: To examine the impact of surgical staging of patients presenting with grade 1 endometrial cancer. METHODS: The charts of all patients who presented for surgery for endometrial cancer between March 1997 and July 2003 were analyzed for demographic data, final tumor histology, grade, stage, and complications. RESULTS: A total of 349 patients underwent surgical management for endometrial cancer. Preoperatively, 181 (52%) were identified with grade 1 disease, with a mean age of 61 years (range 27-89). Surgical staging (pelvic +/- para-aortic lymphadenectomy) was performed in 82% of cases and was omitted only in cases when disease was apparently confined to the endometrium and surgical risk was high. In staged patients, 3.2% had severe surgical complications. There were 2 perioperative mortalities (1 pulmonary emboli and 1 myocardial infarct). In comparison of pre- and postoperative histology, 19% of patients were upgraded, with 15% grade 2, 0.5% grade 3, 2.5% serous or clear cell, and 1% mixed mesodermal tumor. Lymph node metastases were found in 3.9% of patients presenting with grade 1 endometrial cancer, and 10.5% had extrauterine spread (> IIb). High-risk uterine features, including myometrial invasion more than 1/2, grade 3 lesions, high-risk histologic variants, and/or cervical involvement, were found in 26% of the patients. No patients with stage Ia-IIb endometrioid cancer received adjuvant teletherapy or chemotherapy. Four patients with low-risk uterine features were found to have extrauterine disease. Twelve percent of patients received adjuvant therapy, and 17% avoided teletherapy and/or chemotherapy based on surgical staging. CONCLUSION: Surgical staging in patients presenting with grade 1 endometrial cancer significantly impacted postoperative treatment decisions in 29% of patients. Omitting lymphadenectomy in patients presenting with grade 1 endometrial cancer may lead to inappropriate postoperative management.

Morbid obesity and endometrial cancer: surgical, clinical, and pathologic outcomes in surgically managed patients.

OBJECTIVE: To evaluate surgical, clinical, and pathologic outcomes of patients with endometrial cancer managed with primary surgery when stratified by body mass index (BMI). METHODS: A review of 356 consecutive patients undergoing primary surgical management of endometrial carcinoma by a single gynecologic oncology service from 1997 to 2003 was undertaken. Patients were divided into three groups based on preoperative BMI. Data regarding surgical and pathologic outcomes were compared. RESULTS: Twenty-two percent of patients had a BMI >40, 38% were 30-40, and 40% were <30. Overall, 90% underwent some surgical staging, including 93%, 92%, and 81% of those with a BMI <30, 30-40, and >40, respectively. In fully staged patients, a median 23 lymph nodes were removed in all groups, without a significant difference in the number of aortic nodes recovered between the heaviest and lightest groups. Aortic lymphadenectomy was performed in 48% patients with BMI >40 compared with 74% of patients with BMI <30. Intraoperative and postoperative complications were rare and similar between groups. Patients with BMI >40 were more commonly diagnosed with grade 1 tumor than patients with BMI <30. Rates of nodal metastasis were similar between groups and occurred in 11% of patients overall. In those with a BMI >40, extrauterine disease was encountered in 12% of patients. CONCLUSIONS: While surgical staging of morbidly obese patients is difficult, adequate lymphadenectomy can be performed safely; although aortic nodes are less commonly resected in this population. Staging remains important in obese women, as the risk of extrauterine disease, including lymph node metastasis, is similar to that in women with ideal body weight.