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1.
Gynecol Oncol ; 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32247602

RESUMO

OBJECTIVE: We previously reported an algorithm that identifies women at high risk of postoperative morbidity & mortality (M/M) as a tool to triage between neoadjuvant chemotherapy and primary surgery for epithelial ovarian cancer (EOC). We sought to independently validate its performance using multicenter data. METHODS: Women who underwent surgery for stage IIIC/IV EOC between 1/1/2014 and 12/31/2017 were identified from the National Surgical Quality Improvement Program database and classified as "high risk" or "triage appropriate" using our algorithm. Outcomes were compared between triage appropriate and high-risk women using the chi-square test. RESULTS: 1777 women met inclusion criteria; the mean age was 62.6 years and 81.9% had stage IIIC disease. Nationally, the surgical complexity scores were low (69.8% low, 25.2% intermediate and 5.0% high). "High risk" women had 2-fold higher rate of severe 30-day complication or death (6.2% vs 3.5%; p = 0.01), a 3-fold higher rate of 30-day mortality (1.4% vs 0.5%; p = 0.08), and a higher risk of death following a severe complication (11.1% vs. 0%, p = 0.11). A sensitivity analysis excluding women with unknown albumin who didn't meet other high risk criteria showed similar results: severe 30-day complications or death (6.2% vs 3.5%; p = 0.02) and 30-day mortality (1.4% vs 0.3%; p = 0.04) for "high risk" vs "triage appropriate" women. CONCLUSIONS: Primary cytoreductive surgery to minimal residual disease remains the goal for EOC. We verify that our algorithm can identify women at risk of M/M using national multicenter data, despite a low complexity surgical setting and using 30-day mortality (vs. 90-day). Objective surgical risk assessment for ovarian cancer should be standard of care and can be incorporated into practice using the Mayo triage algorithm.

2.
Gynecol Oncol ; 2020 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-32268952

RESUMO

OBJECTIVE: To assess the incidence, treatment, and outcomes in patients with invasive vulvar extramammary Paget's disease (EMPD) in a national cohort of patients. METHODS: Patients from the Surveillance, Epidemiology and End Results (SEER) database with diagnoses of vulvar EMPD from 1992 to 2016 were included. Demographic, treatment, and outcome data were analyzed. RESULTS: A total of 1268 cases of invasive EMPD were identified. Of those, 69.6% had localized disease, 12.0% regional disease, 1.3% distant disease, and 17.1% were unstaged. The annual incidence of invasive vulvar EMPD was 0.36 per 100,000 person years: rates have increased >2-fold since 1992 (1992: 0.19 per 100,000 person years to 0.50 per 100,000 person years in 2016). Most patients underwent primary surgery (n = 1034; 81.5%). Five-year cancer specific survival (CSS) was 95.5% and was associated with stage. Compared to patients with localized disease, patients with distant metastases had dramatically worse CSS (HR: 85.8 (31.8-248) p < 0.0001). Synchronous cancers (diagnosed within one calendar year of EMPD diagnosis year) were observed in 35 cases (2.8%), and 195 patients (15.4%) developed a secondary malignancy (diagnosed >one year from year of EMPD diagnosis year). The most common synchronous breast, gastrointestinal tract, melanoma and the most common secondary cancers were breast, gastrointestinal tract and genitourinary tract. CONCLUSIONS: The incidence of invasive vulvar EMPD has increased over time. CSS is excellent for localized disease, but those with metastatic disease are in need of novel therapies. Approximately 15% will develop a secondary malignancy, indicating that patients with invasive vulvar EMPD should undergo site specific preventative health screens during recurrence surveillance.

3.
Gynecol Oncol ; 156(2): 451-458, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31780236

RESUMO

OBJECTIVE: To examine the effect of robotic-assisted surgery implementation for treatment of endometrial cancer in the United States on 30-day clinical outcomes and costs. METHODS: We retrospectively reviewed data of adult patients who underwent total hysterectomy for endometrial cancer in the US hospitals in Premier Healthcare Database between January 1, 2008 and September 30, 2015. We conducted trend analyses comparing the proportions of surgical approaches with the associated clinical outcomes and costs over the study period using Mann-Kendall tests. Clinical outcomes and costs of robotic-assisted surgery, laparoscopic and open surgery have been compared after propensity score 1:1 matching in the most recent 3 years (January 1, 2013-September 30, 2015). RESULTS: Of a total of 35,224 patients, use of robotic-assisted surgery increased from 9.48% to 56.82% while open surgery decreased from 70.4% to 28.1% over the study period. A 2.5% decrease in major complications (P < .001), a 2.9% decrease in minor complications (P = .001), and a 2.0% decrease 30-day readmissions (P = .001) was observed across all surgical approaches. Perioperative 30-day total cost slightly decreased from US $11,048 to US $10,322 (P = .08). Among propensity-score matched patients, robotic-assisted surgery was associated with shorter hospitalization than open surgery (median [interquartile range], 2.0 [2.0-3.0] vs 4.0 [3.0-6.0] days) and laparoscopic surgery (2.0 [2.0-3.0] vs 3.0 [2.0-4.0] days), fewer 30-day complications (20.1% vs 33.7%) (all P < .001), and comparable perioperative 30-day total costs (median [interquartile range], US $12,200 [US $9,509-US $16,341] vs US $12,018 [US $8,996-US $17,162]; P = .34) with open surgery. CONCLUSION: Robotic-assisted surgery facilitated the widespread diffusion of a minimally invasive approach nationally for endometrial cancer, with reduction of perioperative morbidity and no increase in overall treatment-related 30-day costs at national level.

4.
Gynecol Oncol ; 156(2): 278-283, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31785863

RESUMO

OBJECTIVE: We sought to identify postoperative complications with the greatest impact on patient-centric outcomes to serve as high yield QI targets in ovarian cancer (OC) surgery. METHODS: Women undergoing complex CRS (defined as cytoreductive surgery with colon resection) for OC between January 1, 2012 and 12/31/2016 were identified from the National Surgical Quality Improvement Program (NSQIP) database. We determined the population attributable fraction (PAF) to quantify the contribution of each major complication towards adverse outcomes. PAF represents the burden of adverse outcomes that could be eliminated if the corresponding complication was prevented. Organ space surgical site infection (SSI) was used as a surrogate for anastomotic leak (AL). RESULTS: A total of 1434 women met inclusion criteria. Any adverse clinical outcome (composite of death, reoperation, or end organ dysfunction) occurred in 9.1% of women, and AL was the largest contributor to adverse clinical outcomes [PAF = 33.4% (95%CI: 22.3%-45.6%)]. The rates of increased resource utilization were as follows; prolonged hospitalization in 23.7%, non-home discharge in 10.7% and unplanned readmission in 14.8% of women. AL was the largest contributor to prolonged hospitalizations [PAF = 75.7% (95%CI: 51.4%-90.0%)] and readmissions [PAF = 17.1% (95%CI: 11.5%-22.6%)]; while transfusion was the largest contributor to non-home discharge [PAF = 22.8% (95%CI: 0.7%-42.4%)]. By comparison, the impact of other complications, including those targeted by the Surgical Care Improvement Project (SCIP), such as incisional SSI, venous thromboembolism, myocardial infarction, and urinary infection, was small. CONCLUSIONS: Anastomotic leak is the largest contributor to adverse clinical outcomes and increased resource utilization after complex cytoreductive surgery. Quality improvement efforts to reduce AL and its impact should be of highest priority in OC surgery.

5.
Clin Obstet Gynecol ; 63(1): 74-79, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31725415

RESUMO

Treatment for patients with advanced ovarian cancer includes a combination of platinum-based chemotherapy and maximally cytoreductive surgery. The 2 options for initial treatment include upfront surgery followed by adjuvant chemotherapy or neoadjuvant chemotherapy followed by interval surgery. Deciding between which approach is a on the basis of several factors: (1) resectability of disease; (2) patient factors such as age, albumin, and body mass index; (3) patient wishes; and (4) overall functional status. Research is needed to further refine these approaches and create a patient-focused treatment plan which includes novel factors such as molecular subtype of disease and frailty and sarcopenia.

6.
Gynecol Oncol ; 156(1): 62-69, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31776037

RESUMO

OBJECTIVES: To compare survival after nodal assessment using a sentinel lymph node (SLN) algorithm versus comprehensive pelvic and paraaortic lymphadenectomy (LND) in serous or clear cell endometrial carcinoma, and to compare survival in node-negative cases. METHODS: Three-year recurrence-free survival (RFS) and overall survival were compared between one institution that used comprehensive LND to the renal veins and a second institution that used an SLN algorithm with ultra-staging with inverse-probability of treatment weighting (IPTW) derived from propensity scores to adjust for covariate imbalance between cohorts. RESULTS: 214 patients were identified (118 SLN cohort, 96 LND cohort). Adjuvant therapy differed between the cohorts; 84% and 40% in the SLN and LND cohorts, respectively, received chemotherapy ± radiation therapy. The IPTW-adjusted 3-year RFS rates were 69% and 80%, respectively. The IPTW-adjusted 3-year OS rates were 88% and 77%, respectively. The IPTW-adjusted hazard ratio (HR) for the association of surgical approach (SLN vs LND) with progression and death was 1.46 (95% CI: 0.70-3.04) and 0.44 (95% CI: 0.19-1.02), respectively. In the 168 node-negative cases, the IPTW-adjusted 3-year RFS rates were 73% and 91%, respectively. The IPTW-adjusted 3-year OS rates were 88% and 86%, respectively. In this subgroup, IPTW-adjusted HR for the association of surgical approach (SLN vs LND) with progression and death was 3.12 (95% CI: 1.02-9.57) and 0.69 (95% CI: 0.24-1.95), respectively. CONCLUSION: OS was not compromised with the SLN algorithm. SLN may be associated with a decreased RFS but similar OS in node-negative cases despite the majority receiving chemotherapy. This may be due to differences in surveillance.


Assuntos
Adenocarcinoma de Células Claras/cirurgia , Algoritmos , Cistadenocarcinoma Seroso/cirurgia , Neoplasias do Endométrio/cirurgia , Linfonodos/patologia , Linfonodos/cirurgia , Adenocarcinoma de Células Claras/patologia , Idoso , Estudos de Coortes , Cistadenocarcinoma Seroso/patologia , Neoplasias do Endométrio/patologia , Feminino , Humanos , Excisão de Linfonodo/métodos , Metástase Linfática , Linfonodo Sentinela/patologia , Biópsia de Linfonodo Sentinela/métodos , Resultado do Tratamento
7.
Gynecol Oncol ; 155(2): 177-185, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31604668

RESUMO

OBJECTIVES: To compare survival and progression outcomes between 2 nodal assessment approaches in patients with nonbulky stage IIIC endometrial cancer (EC). METHODS: Patients with stage IIIC EC treated at 2 institutions were retrospectively identified. At 1 institution, a historical series (2004-2008) was treated with systematic pelvic and para-aortic lymphadenectomy (LND cohort). At the other institution, more contemporary patients (2006-2013) were treated using a sentinel lymph node algorithm (SLN cohort). Outcomes (hazard ratios [HRs]) within the first 5 years after surgery were compared between cohorts using Cox models adjusted for type of adjuvant therapy. RESULTS: The study included 104 patients (48 LND, 56 SLN). The use of chemoradiotherapy was similar in the 2 cohorts (46% LND vs 50% SLN), but the use of chemotherapy alone (19% vs 36%) or radiotherapy alone (15% vs 2%) differed. Although there was evidence of higher risk of cause-specific death (HR, 2.10; 95% CI, 0.79-5.58; P = 0.14) and lower risk of para-aortic progression (HR, 0.27; 95% CI, 0.05-1.42; P = 0.12) for the LND group, the associations did not meet statistical significance. The risk of progression was not significantly different between the groups (HR, 1.27; 95% CI, 0.60-2.67; P =0 .53). In parsimonious multivariable models, high-risk tumor characteristics and nonendometrioid type were independently associated with lower cause-specific survival and progression-free survival. CONCLUSIONS: In EC patients with nonbulky positive lymph nodes, use of the SLN algorithm with limited nodal dissection does not compromise survival compared with LND. Aggressive pathologic features of the primary tumor are the strongest determinants of prognosis.


Assuntos
Neoplasias do Endométrio/cirurgia , Excisão de Linfonodo/métodos , Idoso , Algoritmos , Progressão da Doença , Intervalo Livre de Doença , Neoplasias do Endométrio/patologia , Feminino , Humanos , Metástase Linfática , Invasividade Neoplásica , Estadiamento de Neoplasias , Estudos Retrospectivos , Linfonodo Sentinela/patologia , Resultado do Tratamento
8.
Gynecol Oncol ; 155(1): 21-26, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31409487

RESUMO

OBJECTIVE: To compare two published risk stratification models (Milwaukee Model vs. Mayo Criteria) to predict lymphatic dissemination (LD) in endometrioid endometrial cancer (EC). METHODS: Patients with stage I-III EC undergoing surgery from 1/1/2004-9/30/2013 were retrospectively reviewed and classified as low-risk vs at-risk for LD using two independent risk models. LD was defined as positive nodes at surgery or lymph node recurrence within 2 years of surgery after negative lymph node dissection (LND) or when LND was not performed. False positive (FP) and false negative (FN) rates for each risk model were calculated. RESULTS: Among 1103 patients, 81 (7.3%) had LD (72 positive LN and 9 LN recurrences), and most (90.2%) had stage I EC. The Milwaukee Model yielded a low at-risk rate for LD (38.1%) but a high FN rate (13.6%, 95% CI 7.0-23.0). The traditional Mayo Criteria using a cut-off of 2 cm for tumor diameter (TD) had a higher at-risk rate for LD (69.5%) but a FN rate of 0% (95% CI, 0-4.5). Modifying the Mayo Criteria using a TD cutoff of ≤3 cm identified fewer women at-risk (56.8% vs. 69.5%) and had a lower FP rate (53.6% vs. 67.1%), but had a higher FN rate (3.7%, 95% CI, 0.8-10.4). CONCLUSIONS: The Milwaukee Model had the lowest at-risk rate of LD but an unacceptable FN rate. Modifying the Mayo Criteria by increasing the TD cutoff from the traditional ≤2 cm to ≤3 cm would spare an estimated 13.5% of patients LND, but the accompanying FN rate is unacceptably high. The traditional Mayo Criteria for low-risk EC remains the most sensitive in determining which patients LND can be omitted.


Assuntos
Carcinoma Endometrioide/patologia , Carcinoma Endometrioide/cirurgia , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Linfonodos/patologia , Linfonodos/cirurgia , Estudos de Coortes , Reações Falso-Negativas , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Pessoa de Meia-Idade , Modelos Estatísticos , Gradação de Tumores , Estadiamento de Neoplasias , Estudos Retrospectivos , Risco , Biópsia de Linfonodo Sentinela
9.
Gynecol Oncol ; 155(1): 58-62, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31402165

RESUMO

OBJECTIVE: To evaluate the impact of an evidence-based triage algorithm to decide between primary debulking surgery (PDS) and neoadjuvant chemotherapy followed by interval debulking surgery (NACT/IDS) for advanced epithelial ovarian cancer (EOC). METHODS: Surgical morbidity and mortality (M/M) after PDS for stage IIIC-IV EOC at Mayo Clinic after implementation of the triage algorithm (contemporary cohort, 2012-July 2016) were compared to that of a historic PDS cohort (2003-2011). RESULTS: Mean age of the 232 women who met inclusion criteria in the contemporary cohort was 63.9 years. We observed a 71% decrease in 90-day mortality from 8.9% to 2.6% (P = 0.002) between the contemporary and historic cohorts. Accordion grade 3+ postoperative complications within 30 days after surgery decreased from 22.3% to 18.3% (P = 0.19). Among those with a grade 3+ complication, 90-day mortality rates decreased from 28.3% in the historic cohort to 2.4% in the contemporary cohort (P < 0.001) suggesting patients were better able to tolerate complex surgery. When compared to the historic PDS cohort, oncologic outcomes were also improved in the contemporary PDS cohort. Complete as well as optimal (residual disease ≤1 cm) cytoreduction rates increased (45.5% vs. 62.5% and 84.5% vs. 95.3%, respectively, P < 0.001), and the proportion of women starting chemotherapy within 42 days of surgery increased (57.4% vs. 69.8%, P = 0.001). Three-year overall survival was 53% in the historic cohort and 66% in the contemporary cohort (P < 0.001). CONCLUSIONS: Use of the Mayo triage algorithm for EOC was associated with reduced 90-day mortality after PDS and improved oncologic outcomes. Surgical risk assessment is a critical aspect of treatment planning in the primary management of EOC and should be incorporated into practice.


Assuntos
Algoritmos , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/cirurgia , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/cirurgia , Triagem/métodos , Idoso , Carcinoma Epitelial do Ovário/mortalidade , Carcinoma Epitelial do Ovário/patologia , Quimioterapia Adjuvante , Estudos de Coortes , Procedimentos Cirúrgicos de Citorredução , Feminino , Humanos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Ovarianas/mortalidade , Estudos Retrospectivos , Análise de Sobrevida
10.
Gynecol Oncol ; 154(3): 495-504, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31204077

RESUMO

OBJECTIVE: This study is designed to identify genes and pathways that could promote metastasis to the bowel in high-grade serous ovarian cancer (OC) and evaluate their associations with clinical outcomes. METHODS: We performed RNA sequencing of OC primary tumors (PTs) and their corresponding bowel metastases (n = 21 discovery set; n = 18 replication set). Differentially expressed genes (DEGs) were those expressed at least 2-fold higher in bowel metastases (BMets) than PTs in at least 30% of patients (P < .05) with no increased expression in paired benign bowel tissue and were validated with quantitative reverse transcription PCR. Using an independent OC cohort (n = 333), associations between DEGs in PTs and surgical and clinical outcomes were performed. Immunohistochemistry and mouse xenograft studies were performed to confirm the role of LRRC15 in promoting metastasis. RESULTS: Among 27 DEGs in the discovery set, 21 were confirmed in the replication set: SFRP2, Col11A1, LRRC15, ADAM12, ADAMTS12, MFAP5, LUM, PLPP4, FAP, POSTN, GRP, MMP11, MMP13, C1QTNF3, EPYC, DIO2, KCNA1, NETO1, NTM, MYH13, and PVALB. Higher expression of more than half of the genes in the PT was associated with an increased requirement for bowel resection at primary surgery and an inability to achieve complete cytoreduction. Increased expression of LRRC15 in BMets was confirmed by immunohistochemistry and knockdown of LRRC15 significantly inhibited tumor progression in mice. CONCLUSIONS: We identified 21 genes that are overexpressed in bowel metastases among patients with OC. Our findings will help select potential molecular targets for the prevention and treatment of malignant bowel obstruction in OC.


Assuntos
Carcinoma Epitelial do Ovário/genética , Carcinoma Epitelial do Ovário/patologia , Neoplasias Intestinais/genética , Neoplasias Intestinais/secundário , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/patologia , Animais , Linhagem Celular Tumoral , Estudos de Coortes , Feminino , Técnicas de Silenciamento de Genes , Xenoenxertos , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Proteínas de Membrana/genética , Camundongos , Camundongos Nus , RNA Neoplásico/genética , Transcriptoma , Regulação para Cima
11.
Gynecol Oncol ; 154(1): 60-64, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31126637

RESUMO

OBJECTIVE: This study aimed to determine the prevalence of occult pelvic lymph node metastasis in patients with endometrial cancer (EC) with isolated paraaortic dissemination who underwent pelvic and paraaortic lymphadenectomy. METHODS: From 2004 to 2008, patients undergoing surgery for EC at our institution were prospectively treated according to a validated surgical algorithm relying on intraoperative frozen section. For the current study, we re-reviewed pathologic slides obtained at the time of diagnosis and performed ultrastaging of all negative pelvic lymph nodes to assess the prevalence of occult pelvic lymph node metastasis. RESULTS: Of 466 patients at risk for lymphatic dissemination, 394 (84.5%) underwent both pelvic and paraaortic lymphadenectomy. Of them, 10 (2.5%) had isolated paraaortic metastasis. Pathologic review of hematoxylin-eosin-stained slides identified 1 patient with micrometastasis in 1 of 18 pelvic lymph nodes removed. Ultrastaging of 296 pelvic lymph nodes removed from the 9 other patients (median [range], 32 [20-50] nodes per patient) identified 2 additional cases (1 with micrometastasis and 1 with isolated tumor cells), for a total of 3/10 patients (30%) having occult pelvic dissemination. CONCLUSIONS: Ultrastaging and pathologic review of negative pelvic lymph nodes of patients with presumed isolated paraaortic metastasis can identify occult pelvic dissemination and reduce the prevalence of true isolated paraaortic disease. In the era of the sentinel lymph node (SLN) algorithm for EC staging, which incorporates ultrastaging of the SLNs removed, these findings demonstrate that use of the SLN algorithm can further mitigate the concern of missing cases of isolated paraaortic dissemination.


Assuntos
Neoplasias do Endométrio/patologia , Linfonodos/patologia , Idoso , Aorta , Neoplasias do Endométrio/epidemiologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Itália/epidemiologia , Excisão de Linfonodo , Linfonodos/cirurgia , Metástase Linfática , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prevalência
12.
Gynecol Oncol ; 154(1): 72-76, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31000471

RESUMO

OBJECTIVE: Treatment planning requires accurate estimation of surgical complexity (SC) and residual disease (RD) at primary debulking surgery (PDS) for advanced ovarian cancer (OC). We sought to independently validate two published computed tomography (CT) prediction models. METHODS: We included stage IIIC/IV OC patients who underwent PDS from 2003 to 2011. Two prediction models which included imaging and clinical variables to predict RD > 1 and any gross RD, respectively, were applied to our cohort. Two radiologists scored CTs. Discrimination was estimated using the c-index and calibration were assessed by comparing the observed and predicted estimates. RESULTS: The validation cohort consisted of 276 patients; median age of the cohort was 64 years old and majority had serous histology. The validation and model development cohorts were similar in terms of baseline characteristics, however the RD rates differed between cohorts (9.4% vs 25.4% had RD >1 cm; 50.7% vs. 66.6% had gross RD). Model 1, the model to predict RD >1 cm, did not validate well. The c-index of 0.653 for the validation cohort was lower than reported in the development cohort (0.758) and the model over-predicted the proportion with RD >1 cm. The second model to predict gross RD had excellent discrimination with a c-index of 0.762. CONCLUSIONS: We are able to validate a CT model to predict presence of gross RD in an independent center; the separate model to predict RD >1 cm did not validate. Application of the model to predict gross RD can help with clinical decision making in advanced ovarian cancer.


Assuntos
Carcinoma Epitelial do Ovário/cirurgia , Procedimentos Cirúrgicos de Citorredução/métodos , Modelos Estatísticos , Neoplasias Ovarianas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto Jovem
13.
Gynecol Oncol ; 153(2): 238-241, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30833135

RESUMO

OBJECTIVES: The FIGO staging consensus agreement from 2012 indicates that bowel mucosal invasion for epithelial ovarian cancer (EOC) should be assigned to stage IV disease. Finding no evidence justifying this recommendation, we examined the impact of recto-sigmoid colonic invasion on survival based on depth of invasion. METHODS: Patients having recto-sigmoid resection to achieve complete gross resection for stage IIIC/IV EOC between 2003 and 2011 were included. For this study, mucosal invasion alone was not considered as stage IV. Degree of bowel invasion was defined as: serosal/subserosal vs. muscularis/submucosa/mucosa. Patients with only mesenteric invasion were excluded. Intraperitoneal disease (IP) dissemination patterns were defined as pelvic, lower abdomen, upper abdomen, and miliary disease. Comparisons between groups were evaluated using the log-rank test for progression-free and overall survival (PFS, OS) and the chi-square test for IP dissemination pattern. RESULTS: Eighty-five patients were included with a mean age of 64.5 years. Most cases were serous (87.1%) and stage IIIC (83.5%). There were 53 (62.4%) patients with serosal/subserosal and 32 (37.6%) with muscularis/submucosa/mucosa invasion. Although not statistically significant, PFS and OS both favored cases with deeper invasion (muscularis/submucosa/mucosa vs. serosal/subserosal invasion: median PFS, 33.5 vs. 18.2 months, p = 0.34; median OS, 82.3 vs. 51.5 months, p = 0.46). When comparing patterns of disease dissemination, we observed that patients with serosal/subserosal invasion (vs. those with deeper invasion) tended to have more upper abdominal or miliary disease (67.9% vs. 48.4%, p = 0.08). CONCLUSIONS: Depth of recto-sigmoid colon wall invasion does not have prognostic significance. Our observations do not support assignment to a higher FIGO stage (IV) based solely on this factor.


Assuntos
Carcinoma Epitelial do Ovário/patologia , Procedimentos Cirúrgicos de Citorredução , Mucosa Intestinal/patologia , Neoplasias Ovarianas/patologia , Idoso , Carcinoma Epitelial do Ovário/mortalidade , Carcinoma Epitelial do Ovário/cirurgia , Colo Sigmoide/patologia , Colo Sigmoide/cirurgia , Feminino , Humanos , Mucosa Intestinal/cirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Neoplasias Ovarianas/mortalidade , Neoplasias Ovarianas/cirurgia , Prognóstico , Intervalo Livre de Progressão , Reto/patologia , Reto/cirurgia , Estudos Retrospectivos
14.
Gynecol Oncol ; 153(1): 68-73, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30612784

RESUMO

OBJECTIVES: We sought to examine the relationship between frailty and complicated postoperative courses, including intensive care unit (ICU) admission and non-home discharge, in patients with advanced ovarian cancer (OC) undergoing primary debulking surgery (PDS) for curative intent. METHODS: Patients were identified from a retrospectively collected database at a single institution between 1/1/2003-12/31/2011. A frailty index was derived from 30 items representing comorbidities and activities of daily living, each scored as 0, 0.5, or 1, and calculated as the total summated score divided by the total number of non-missing items. Frailty was defined as an index ≥0.15. Associations with binary outcomes were assessed using logistic regression. RESULTS: A total of 535 patients met inclusion criteria. Frail patients were older, mean age 67.8 versus 63.2 years (p < 0.001), but there was no difference in grade, stage, or serous histology. Almost half of the frail patients (48.9%, 64/131) were admitted to the ICU compared to 20.5% (83/404) of non-frail patients. Frailty remained an independent predictor of 30-day ICU admission (adjusted odds ratio (aOR) 3.20, 95% CI: 2.03-5.06) in a multivariable model including age, preoperative albumin, surgical complexity, and residual disease. Frail patients were also more likely to have a non-home discharge (24.2% vs. 7.0%). Frailty independently predicted non-home discharge (aOR 2.58, 95% CI: 1.35-4.93) after adjusting for age, BMI, and stage. CONCLUSION: Frailty is a measurable, objective clinical syndrome that has impact on postoperative outcomes in advanced OC and should be considered when decision-making about treatments and counseling patients.


Assuntos
Carcinoma Epitelial do Ovário/fisiopatologia , Carcinoma Epitelial do Ovário/cirurgia , Procedimentos Cirúrgicos de Citorredução/métodos , Fragilidade/fisiopatologia , Cuidados Paliativos/métodos , Cuidados Pós-Operatórios/métodos , Idoso , Carcinoma Epitelial do Ovário/patologia , Comorbidade , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Estadiamento de Neoplasias
15.
Int J Gynecol Cancer ; 29(1): 60-67, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30640685

RESUMO

OBJECTIVE: To explore the factors influencing adoption of the sentinel lymph node (SLN) technique for endometrial cancer staging among gynecologic oncologists. METHODS: A self-administered, web-based survey was sent via email (April 20 through May 21, 2017) to all members of European Society of Gynecologic Oncologists, International Gynecologic Cancer Society, and Society of Gynecologic Oncologists. Surgical and pathologic practices related to SLN and reasons for not adopting this technique were investigated. RESULTS: Overall, 489 attending physicians or consultants in gynecologic oncology from 69 countries responded: 201 (41.1%), 118 (24.1%), and 117 (23.9%) from Europe, the USA, and other countries, respectively (10.8% did not report a country). SLN was adopted by 246 (50.3%) respondents, with 93.1% injecting the cervix and 62.6 % using indocyanine green dye. The National Comprehensive Cancer Network SLN algorithm was followed by 160 (65.0%) respondents (USA 74.4%, Europe 55.4%, other countries 71.4%). However, 66.7% completed a backup lymphadenectomy in high-risk patients. When SLN biopsy revealed isolated tumor cells, 13.8% of respondents recommended adjuvant therapy. This percentage increased to 52% if micrometastases were detected. Among the 243 not adopting SLN, 50.2% cited lack of evidence and 45.3% stated that inadequate instrumentation fueled their decisions. CONCLUSIONS: SLN with a cervical injection is gaining widespread acceptance for staging of endometrial cancer among gynecologic oncologists worldwide. Standardization of the surgical approach with the National Comprehensive Care Network algorithm is applied by most users. Management of isolated tumor cells and the role of backup lymphadenectomy for 'high-risk' cases remain areas of investigation.


Assuntos
Neoplasias do Endométrio/patologia , Ginecologia/normas , Verde de Indocianina , Oncologistas/normas , Linfonodo Sentinela/patologia , Inquéritos e Questionários , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Excisão de Linfonodo , Linfonodo Sentinela/cirurgia , Biópsia de Linfonodo Sentinela
16.
J Minim Invasive Gynecol ; 26(4): 727-732, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30138740

RESUMO

STUDY OBJECTIVE: We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions. DESIGN: Retrospective multi-institution cohort (Canadian Task Force classification II-2). SETTING: Three tertiary cancer referral cancer centers. PATIENTS: Patients with endometrial and vulvar cancer undergoing lymph node evaluation. INTERVENTIONS: Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment. MEASUREMENTS AND MAIN RESULTS: Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins. CONCLUSIONS: Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.


Assuntos
Neoplasias dos Genitais Femininos/diagnóstico , Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/educação , Biópsia de Linfonodo Sentinela/métodos , Cirurgiões , Oncologia Cirúrgica/educação , Abdome/patologia , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Neoplasias dos Genitais Femininos/patologia , Humanos , Excisão de Linfonodo/métodos , Linfonodos/patologia , Pelve/patologia , Estudos Retrospectivos , Linfonodo Sentinela/patologia , Neoplasias Vulvares/patologia , Carga de Trabalho
17.
Gynecol Oncol ; 152(2): 286-292, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30471900

RESUMO

OBJECTIVE: To determine the incidence and risk factors for venous thromboembolism (VTE) within six months after primary debulking surgery (PDS) for epithelial ovarian cancer (EOC). METHODS: In a historical cohort, we estimated the cumulative incidence of clinically diagnosed VTE within 6 months among consecutive women who underwent PDS for EOC at a single institution from 1/1/2003 to 12/31/2011. We evaluated perioperative variables as potential risk factors of VTE within 6 months during the postoperative period using univariate and multivariable Cox proportional hazards models. RESULTS: Among 860 women without an immediate history (past 30 days) of a VTE, the cumulative incidence of VTE was 7.5% (95% CI, 5.7-9.3) by 30 days and 13.8% (95% CI, 11.4-16.2) by 6 months following surgery. Macroscopic residual disease (adjusted HR 1.99 [95% CI 1.35-2.94] vs microscopic), increasing estimated blood loss (1.25 [1.05-1.49] per doubling), longer hospital length of stay (3.00 [1.57-5.75]), and experiencing a cardiac event within 30 postoperative days (2.72 [1.55-4.80]) were independently associated with subsequent VTE within 6 months. In-hospital VTE prophylaxis included heterogeneous approaches; dual prophylaxis did not impact 30-day or 6-month VTE rates. CONCLUSIONS: VTE occurred in 1 in 7 women with EOC within 6 months of PDS-a substantial risk of VTE that extends into the adjuvant chemotherapy period. Novel prophylactic measures should be explored in these women at high risk for VTE.


Assuntos
Carcinoma Epitelial do Ovário/cirurgia , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Tromboembolia Venosa/epidemiologia , Carcinoma Epitelial do Ovário/sangue , Estudos de Coortes , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/métodos , Neoplasias das Tubas Uterinas/sangue , Neoplasias das Tubas Uterinas/cirurgia , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Neoplasias Peritoneais/sangue , Neoplasias Peritoneais/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
18.
Gynecol Oncol ; 152(2): 223-227, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30503050

RESUMO

OBJECTIVE: To evaluate the contribution of molecular subtype to 30-day postoperative complications and 90-day mortality after primary debulking surgery (PDS) in advanced stage high-grade serous ovarian cancer (HGSOC). METHODS: Patients with stages III-IV HGSOC undergoing PDS from 1994 to 2011 with available molecular subtyping were included. Residual disease (RD) status was categorized as 0, 0.1-0.5, 0.6-1.0, or >1 cm. Surgical complexity scores were calculated as high, intermediate, or low as previously published. Postoperative complications were graded according to the modified Accordion classification 0-4 scale; severe was defined as grade ≥3. Molecular subtypes were derived from Agilent 4 × 44k tumor mRNA expression profiles and categorized as mesenchymal (MES) or non-mesenchymal (non-MES). Logistic regression modeling was used to assess associations. RESULTS: Of 329 patients, 68.7% were stage IIIC, 80.5% had RD ≤1 cm, 28.0% had MES subtype, and 19.5% had a grade 3-4 complication; 90-day mortality was 5.8%. In univariate analysis, patients with MES subtype were more likely to have severe complications compared to non-MES (31.5 vs. 14.8%; OR 2.66, 95% CI 1.51-4.69; p < 0.001). MES subtype remained an independent predictor of complications (adjusted OR 2.14, 95% CI 1.17-3.92; p = 0.01) in a multivariable model which included ASA score, preoperative albumin, and surgical complexity. There was no statistical difference in 90-day mortality in patients with MES compared to non-MES subtype (7.6 vs. 5.1%; OR 1.54, 95% CI 0.59-4.05; p = 0.38). CONCLUSIONS: MES subtype is an independent predictor of severe postoperative morbidity and adds to the potential use of pre-operative molecular testing in planning primary treatment of patients with advanced ovarian cancer.


Assuntos
Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Feminino , Perfilação da Expressão Gênica , Humanos , Mesoderma/patologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Valor Preditivo dos Testes , Estudos Retrospectivos
19.
Gynecol Oncol ; 152(2): 368-374, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30448260

RESUMO

OBJECTIVE: Mesenchymal (MES) subtype of high-grade serous ovarian cancer (HGSOC) is associated with worse outcomes including survival and resectability compared with other molecular subtypes. Molecular subtypes have historically been derived from 'tumor', consisting of both cancer and stromal cells. We sought to determine the origins of multiple MES subtype gene signatures in HGSOC. METHODS: Fifteen patients with MES subtype of HGSOC diagnosed between 2010 and 2013 were identified. Formalin-fixed paraffin-embedded (FFPE) blocks from primary surgery were sectioned for immunohistochemistry (IHC) staining of relevant proteins. Eight genes (ACTA2, COL5A1, COL11A1, FAP, POSTN, VCAN, ZEB1 and p-SMAD2) were selected for IHC staining based on their differential expression in MES vs. non-MES subtypes of HGSOC. Slides were scored for intensity and localization and simple statistics were used to compare expression results in cancer vs. stroma and between primary and metastatic sites. RESULTS: COL5A1, VCAN, FAP, and ZEB1 proteins were almost exclusively expressed by stroma as opposed to cancer cells. In addition, stromal expression was dominant for ACTA2, COL11A1, POSTN and p-SMAD2. In general there were minimal differences in expression of proteins between primary and metastatic sites, exceptions being COL5A1 (reduced in metastases) and COL11A1 (increased in metastases). Nuclear p-SMAD2 expression was more common in metastatic stroma. CONCLUSIONS: The existing molecular classification of HGSOC MES subtype reflects a significant stromal contribution, suggesting an important role in HGSOC behavior and thus stroma may be a relevant therapeutic target. Specific patterns of expression indicate that collagens and TGF-ß signaling are involved in the metastatic process.


Assuntos
Cistadenocarcinoma Seroso/patologia , Neoplasias Ovarianas/patologia , Idoso , Cistadenocarcinoma Seroso/genética , Cistadenocarcinoma Seroso/metabolismo , Feminino , Perfilação da Expressão Gênica , Humanos , Imuno-Histoquímica , Mesoderma/patologia , Pessoa de Meia-Idade , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/metabolismo , Células Estromais/patologia
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