Dermoid cyst management and outcomes: a review of over 1000 cases at a single institution.

BACKGROUND: Mature cystic teratomas represent nearly 60% of benign ovarian neoplasms across all age groups. OBJECTIVE: This study aimed to update existing descriptive studies of ovarian teratomas, including the epidemiology, rate of torsion or malignancy, and treatment modalities in a large modern cohort of patients. STUDY DESIGN: This was a retrospective cross-sectional study of all pathology-confirmed cases of ovarian teratoma that underwent surgery at 1 tertiary care institution from 2004 to 2015. Patient demographics, ovarian cyst characteristics, surgical approach and timing, rate of spillage, and surgical complications were examined. RESULTS: A total of 1054 cases of ovarian teratoma were identified during the study period. There were 113 cases (10.7%) of bilateral teratoma. The mean age at diagnosis was 38 years. The average cyst size was 6.26 cm. The overall rate of torsion was 5.6%, with a higher rate of torsion with increasing cyst size. More than 70% of cases were treated with minimally invasive surgery, which was associated with decreased perioperative complications but an increased risk of cyst spillage. Among 394 patients with cyst spillage, only 1 patient developed chemical peritonitis. The malignant transformation rate of mature cystic teratoma in this cohort was 1.1%. This cohort included 100 pregnant women with mature teratoma. Pregnant patients were more likely to have minimally invasive surgery in the first trimester of pregnancy and more likely to undergo laparotomy in the second or third trimester of pregnancy. CONCLUSION: Similar rates of bilaterality, torsion, malignant transformation, and struma ovarii in ovarian teratomas were found in this large modern cohort compared with previous literature. Most cases of ovarian teratoma can be managed laparoscopically, which is associated with a lower surgical complication rate. Despite the increased risk of cyst spillage with a minimally invasive approach, chemical peritonitis is a rare complication.

Inhibition of AXL and VEGF-A Has Improved Therapeutic Efficacy in Uterine Serous Cancer.

Endometrial cancer remains the most prevalent gynecologic cancer with continued rising incidence. A less common form of this cancer is uterine serous cancer, which represents 10% of endometrial cancer cases. However, this is the most aggressive cancer. The objective was to assess whether inhibiting the receptor tyrosine kinase AXL with AVB-500 in combination with bevacizumab would improve response in uterine serous cancer. To prove this, we conducted multiple angiogenesis assays including tube formation assays and angiogenesis invasion assays. In addition, we utilized mouse models with multiple cells lines and subsequently analyzed harvested tissue through immunohistochemistry CD31 staining to assess microvessel density. The combination treatment arms demonstrated decreased angiogenic potential in each assay. In addition, intraperitoneal mouse models demonstrated a significant decrease in tumor burden in two cell lines. The combination of AVB-500 and bevacizumab reduced tumor burden in vivo and reduced morphogenesis and migration in vitro which are vital to the process of angiogenesis.

Enhanced recovery after surgery protocols improve time to return to intended oncology treatment following interval cytoreductive surgery for advanced gynecologic cancers.

OBJECTIVE: The objective of this study was to determine whether the implementation of an enhanced recovery after surgery (ERAS) protocol is associated with earlier return to intended oncology treatment following interval cytoreductive surgery for advanced gynecologic cancers. METHODS: Participants comprised consecutive patients (n=278) with a preoperative diagnosis of stage IIIC or IV ovarian cancer, divided into those that received treatment before versus after implementation of an ERAS protocol at our institution. All patients received at least three cycles of neoadjuvant chemotherapy with a platinum based regimen and underwent interval cytoreduction via laparotomy with the intent to deliver additional cycles of chemotherapy postoperatively. The primary outcome was defined as the timely return to intended oncologic treatment, defined as the percentage of patients initiating adjuvant chemotherapy within 28 days postoperatively. RESULTS: The study cohorts included 150 pre-ERAS patients and 128 post-ERAS patients. Median age was 65 years (range 58-71). Most patients (211; 75.9%) had an American Society of Anesthesiologists score of 3, and the median operative time was 174 min (range 137-219). Median length of stay was 4 days (range 3-5 days) in the pre-ERAS cohort versus 3 days (range 3-4) in the post-ERAS cohort (p<0.0001). At 28 days after operation, 80% of patients had resumed chemotherapy in the post-ERAS cohort compared with 64% in the pre-ERAS cohort (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36 to 3.84; p=0.002). In multivariate logistic regression analysis, the ERAS protocol was the strongest predictor of timely return to intended oncology treatment (OR 10.18, 95% CI 5.35 to 20.32). CONCLUSION: An ERAS protocol for gynecologic oncology patients undergoing interval cytoreductive surgery is associated with earlier resumption of adjuvant chemotherapy.

The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. METHODS: To improve the quality of ERAS reporting, ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. RESULTS: The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. CONCLUSIONS: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.

Sonographic evaluation for intra-abdominal hemorrhage after cesarean delivery.

PURPOSE: To evaluate whether intra-abdominal hemorrhage is visible on a modified focused assessment with sonography for trauma (FAST) examination in stable obstetrics patients after a nonemergent cesarean delivery. METHODS: This was a prospective observational study of patients who underwent nonemergent cesarean delivery at a single institution. Patients provided written informed consent to participate in the study preoperatively and underwent a modified FAST examination in the recovery room within 2 hours of completion of surgery. A sonographic examination was considered positive for hemorrhage if an anechoic pocket consistent with free fluid was present. RESULTS: One hundred patients underwent suprapubic and bilateral upper-quadrant sonographic evaluations. The mean (±SD) time of the evaluation was 74.2 ± 36 minutes after the end of surgery. Among the 100 sonographic examinations of each upper quadrant, 194 (97.0%) were negative, 5 (2.5%) were indeterminate, and 1 (0.5%) was positive for fluid. All suprapubic sonographic examinations were considered inadequate. CONCLUSIONS: Sonographic evaluation immediately after cesarean delivery is feasible in most patients and was overwhelmingly negative for intra-abdominal hemorrhage in a group of patients who did not require reoperation or unexpected blood transfusion.