Splenectomy at the time of primary or interval cytoreductive surgery for epithelial ovarian carcinoma: A review of outcomes.

OBJECTIVES: We describe post-operative complications after cytoreductive surgery with and without splenectomy for Stage III or IV epithelial ovarian cancer, and identify areas for quality improvement in post-splenectomy care. METHODS: All patients with ovarian cancer cytoreductive surgery from 2008 to 2018 were identified using an institutional database Gynecologic Oncology Longitudinal Data Collection and Utilization Program (GOLD CUP). We compared patients who had and did not have splenectomy as part of cytoreductive surgery by demographics, comorbidities, stage, operative and post-operative data, readmission rates, progression free survival, overall survival and death from disease. Quality metrics reported include receipt of post-splenectomy education handouts and encapsulated-organism vaccines. Statistical analysis was completed in STATA SE 16.0. RESULTS: We identified 47 patients who underwent splenectomy and 454 who did not during primary or interval cytoreductive surgery. Final stage was IIIB in 1 (2.1%), IIIC in 26 (55.3%), IVA in 7 (14.9%), and IVB in 13 (27.7%) patients. Those with splenectomy had significantly higher stage. Surgery duration and hospital length of stay were longer and blood transfusion more common after splenectomy, but there were no differences in post-operative infection, readmission, or overall survival. Pancreatic leaks were seen in 4/47 (8.5%) patients. Post-splenectomy vaccinations were documented in 42/47 (89.4%) patients. Only 2/47 (4.3%) received post-splenectomy discharge instructions and 3/7 (42.9%) received aspirin for platelets 1 million or more. CONCLUSIONS: While splenectomy adds morbidity, it continues to offer benefit in those patients who can achieve optimal cytoreduction. Areas for quality improvement in post-splenectomy care include receipt of vaccinations, patient discharge information, and timely pancreatic fistula management.

A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited.

OBJECTIVE: To perform an updated Markov modeling to assess the optimal age for bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy for benign indication. METHODS: We performed a literature review that assessed hazard ratios (HRs) for mortality by disease, age, hysterectomy with or without BSO, and estrogen therapy use. Base mortality rates were derived from national vital statistics data. A Markov model from reported HRs predicted the proportion of the population staying alive to age 80 years by 1-year and 5-year age groups at time of surgery, from age 45 to 55 years. Those younger than age 50 years were modeled as either taking postoperative estrogen or not; those 50 and older were modeled as not receiving estrogen. Computations were performed with R 3.5.1, using Bayesian integration for HR uncertainty. RESULTS: Performing salpingo-oophorectomy before age 50 years for those not taking estrogen yields a lower survival proportion to age 80 years than hysterectomy alone before age 50 years (52.8% [Bayesian CI 40.7-59.7] vs 63.5% [Bayesian CI 62.2-64.9]). At or after age 50 years, there were similar proportions of those living to age 80 years with hysterectomy alone (66.4%, Bayesian CI 65.0-67.6) compared with concurrent salpingo-oophorectomy (66.9%, Bayesian CI 64.4-69.0). Importantly, those taking estrogen when salpingo-oophorectomy was performed before age 50 years had similar proportions of cardiovascular disease, stroke, and people living to age 80 years as those undergoing hysterectomy alone or those undergoing hysterectomy and salpingo-oophorectomy at age 50 years and older. CONCLUSION: This updated Markov model argues for the consideration of concurrent salpingo-oophorectomy for patients who are undergoing hysterectomy at age 50 and older and suggests that initiating estrogen in those who need salpingo-oophorectomy before age 50 years mitigates increased mortality risk.

Pathologic findings and clinical outcomes in women undergoing risk-reducing surgery to prevent ovarian and fallopian tube carcinoma: A large prospective single institution experience.

OBJECTIVES: Risk-reducing salpingo-oophorectomy (RRSO) is recommended for women at increased risk of ovarian, fallopian tube (FT), and peritoneal carcinoma (collectively OC). We describe rates of occult neoplasia in the largest single-institution prospective cohort of women undergoing RRSO, including those with mutations in non-BRCA homologous repair (HRR) genes. METHODS: Participants undergoing RRSO enrolled in a prospective tissue bank between 1999 and 2017. Ovaries and FTs were serially sectioned in all cases. Participants had OC susceptibility gene mutations or a family history suggesting OC risk. Analyses were completed in Stata IC 15.1. RESULTS: Of 644 women, 194 (30.1%) had mutations in BRCA1, 177 (27.5%) BRCA2, 27 (4.2%) other HRR genes, and 15 (2.3%) Lynch Syndrome-associated genes. Seventeen (2.6%) had occult neoplasms at RRSO, 15/17 (88.2%) in the FT. Of BRCA1 carriers, 14/194 (7.2%) had occult neoplasia, 8/194 (4.1%) invasive. One PALB2 and two BRCA2 carriers had intraepithelial FT neoplasms. Occult neoplasm occurred more frequently in BRCA1/2 carriers ≥45 years of age (6.5% vs 2.2%, chi square, p = .04), and 211/371 (56.9%) BRCA1/2 carriers had surgery after guideline-recommended ages. Four in 8 (50%) invasive and 2/9 (22%) intraepithelial neoplasms had positive pelvic washings. None with intraepithelial neoplasms developed recurrence or peritoneal carcinoma. CONCLUSIONS: BRCA1 carriers have the highest risk of occult neoplasia at RRSO, and the frequency increased with age. Women with BRCA1/2 mutations often have RRSO beyond recommended ages. One PALB2 carrier had FT intraepithelial neoplasia, a novel finding. Serial sectioning is critical to identifying occult neoplasia and should be performed for all risk-reducing surgeries.

Educating Obstetrics and Gynecology Residents on Transgender Patients: A Survey of Program Directors.

OBJECTIVE: To describe education on transgender health provided by obstetrics and gynecology residency programs and to identify the facilitators and barriers to providing this training. METHODS: We conducted a cross-sectional survey to evaluate transgender health education in residency among a representative sample of 100 of the 236 obstetrics and gynecology residency programs listed in the 2015 Electronic Residency Application Service catalogue. We compared programs that did and did not offer transgender education on demographics, presence and type of transgender education offered, and reasons for and barriers to offering transgender health education using χ or Fisher's exact testing. RESULTS: We found that 31 out of 61 (51%, 95% CI 38-64%) programs completing the survey offered transgender health education in residency. Compared with programs that offered no education, residency programs offering education were more likely to report that transgender health education was very important (19/31, 61% [95% CI 42-78%] vs 7/30, 23% [95% CI 9-42%]), resident interest (20/31, 64% [95% CI 45-81%] vs 11/30, 37% [95% CI 20-56%]), and the presence of a transgender population requesting services (28/31 or 90% [95% CI 74-98%] vs 16/30 or 53% [95% CI 34-72%]). Among the 31 programs that offered transgender health education, 30 (97%; 95% CI 83-99%) provided formal didactic sessions and 20 (64%; 95% CI 45-81%) offered health screening for both male-to-female and female-to-male transgender patients, but 17 (55%; 95% CI 36-73%) did not offer gender-affirming hormone therapy. Among the 30 programs that did not currently offer transgender health education, 24 (80%; 95% CI 61-92%) planned to establish a transgender education program in the next year. CONCLUSION: Our survey of obstetrics and gynecology residency programs highlights the interest in transgender health education for a systemically underserved population of patients.

Treatment of recurrent granulosa cell tumor with metformin and letrozole, a case report.

•Cytotoxic chemotherapy has questionable efficacy against granulosa cell tumor.•Aromatase inhibitors may provide alternative treatment for granulosa cell tumors.•Metformin may be a beneficial adjunct in treating recurrent granulosa cell tumors.

Metastases from lung adenocarcinoma within a leiomyoma: A case report.

BACKGROUND: Pulmonary adenocarcinoma rarely spreads to the gynecologic tract, and has not been fully reported to metastasize within a leiomyoma. CASE: A 47 year-old woman with recurrent pulmonary adenocarcinoma was incidentally found to have a positron emission tomography (PET) avid pelvic mass at the time of restaging. She was also noted to be anemic, and reported significant vaginal bleeding. She was taken for an uncomplicated hysterectomy. She was unexpectedly found to have adenocarcinoma within a leiomyoma, consistent with metastasis from her primary pulmonary adenocarcinoma. CONCLUSION: We report one of the first cases of pulmonary adenocarcinoma metastatic to a uterine leiomyoma. A personal history of cancer should always be considered in patients presenting with symptomatic leiomyoma.

Plasma 25-hydroxyvitamin D3, folate and vitamin B12 biomarkers among international colorectal cancer patients: a pilot study.

Vitamin D and folate are associated with decreased colorectal cancer risk and their association with colorectal cancer prognosis is under investigation. We assessed the levels of plasma 25-hydroxyvitamin D3 (25(OH)D3), folate and vitamin B12 in an international pilot study in order to determine variability of these biomarkers based on geographical location. Plasma 25(OH)D3, folate and vitamin B12 concentrations were measured in 149 invasive, newly diagnosed colorectal cancer cases from Heidelberg (Germany), Seattle (WA, USA), and Tampa (FL, USA) and in ninety-one age- and sex-matched controls. Their associations with potential predictors were assessed using multivariate linear regression analyses. Plasma 25(OH)D3, folate and vitamin B12 concentrations differed by location. Other predictors were season for 25(OH)D3 and tumour stage (vitamin B12). Season-corrected average 25(OH)D3 concentrations were higher in Heidelberg (31·7 ng/ml; range 11·0-83·0 ng/ml) than in Seattle (23·3 ng/ml; range 4·0-80·0 ng/ml) and Tampa (21·1 ng/ml; range 4·6-51·6 ng/ml). In Heidelberg, a strong seasonal variation was observed. Folate (11·1 ng/ml) and vitamin B12 (395 pg/ml) concentrations in Heidelberg were lower than those in Seattle (25·3 ng/ml and 740 pg/ml, respectively) and Tampa (23·8 ng/ml and 522 pg/ml, respectively). Differences in plasma 25(OH)D3 and folate concentrations between Heidelberg and the US sites were observed, probably reflecting variation in outdoor activities and sun-avoidance behaviour during summer as well as in folic acid fortification and supplement use. Intra-site differences at each study location were greater than between-location variability, suggesting that individual health behaviours play a significant role. Nevertheless, the intra-site differences we observed may be due to chance because of the limited sample size. Our pilot study illustrates the value of an international cohort in studying colorectal cancer prognosis to discern geographical differences in a broad range of exposures.