Surgical Findings and Outcomes in Premenopausal Breast Cancer Patients Undergoing Oophorectomy: A Multicenter Review From the Society of Gynecologic Surgeons Fellows Pelvic Research Network.

STUDY OBJECTIVE: To describe the procedures performed, intra-abdominal findings, and surgical pathology in a cohort of women with premenopausal breast cancer who underwent oopherectomy. DESIGN: Multicenter retrospective chart review (Canadian Task Force classification II-3). SETTING: Nine US academic medical centers participating in the Fellows' Pelvic Research Network (FPRN). PATIENTS: One hundred twenty-seven women with premenopausal breast cancer undergoing oophorectomy between January 2013 and March 2016. INTERVENTION: Surgical castration. MEASUREMENTS AND MAIN RESULTS: The mean patient age was 45.8 years. Fourteen patients (11%) carried a BRCA mutations, and 22 (17%) carried another germline or acquired mutation, including multiple variants of uncertain significance. There was wide variation in surgical approach. Sixty-five patients (51%) underwent pelvic washings, and 43 (35%) underwent concurrent hysterectomy. Other concomitant procedures included midurethral sling placement, appendectomy, and hysteroscopy. Three patients experienced complications (transfusion, wound cellulitis, and vaginal cuff dehiscence). Thirteen patients (10%) had ovarian pathology detected on analysis of the surgical specimen, including metastatic tumor, serous cystadenomas, endometriomas, and Brenner tumor. Eight patients (6%) had Fallopian tube pathology, including 3 serous tubal intraepithelial cancers. Among the 44 uterine specimens, 1 endometrial adenocarcinoma and 1 multifocal endometrial intraepithelial neoplasia were noted. Regarding the entire study population, the number of patients meeting our study criteria and seen by gynecologic surgeons in the FPRN for oophorectomy increased by nearly 400% from 2013 to 2015. CONCLUSION: Since publication of the Suppression of Ovarian Function Trial data, bilateral oophorectomy has been recommended for some women with premenopausal breast cancer to facilitate breast cancer treatment with aromatase inhibitors. These women may be at elevated risk for occult abdominal pathology compared with the general population. Gynecologic surgeons often perform castration oophorectomy in patients with breast cancer as an increasing number of oncologists are using aromatase inhibitors to treat premenopausal breast cancer. Our data suggest that other abdominal/pelvic cancers, precancerous conditions, and previously unrecognized metastatic disease are not uncommon findings in this patient population. Gynecologists serving this patient population may consider a careful abdominal survey, pelvic washings, endometrial sampling, and serial sectioning of fallopian tube specimens for a thorough evaluation.

Laparoscopic Posterior Versus Lateral Transversus Abdominis Plane Block in Gynecology.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane (TAP) block is a safe and effective type of regional anesthesia technique used in laparoscopic gynecologic surgery to minimize postoperative pain. Our study aimed to compare the analgesic effects of the posterior versus lateral approaches to laparoscopic-assisted TAP block in minimally invasive gynecologic surgery. METHODS: We performed a randomized controlled trial with 82 patients allocated to either posterior (n = 38) or lateral (n = 44) TAP block groups. Laparoscopic-assisted posterior or lateral TAP block was administered using liposomal bupivacaine mixture. All subjects were asked to fill out a questionnaire, which included postoperative pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h, as well as narcotic utilization postoperatively. Both groups were compared for postoperative pain scores, opioid consumption, perioperative, and demographic characteristics. RESULTS: A total of 67 patients were analyzed in our study (n = 33 in posterior arm, n = 34 in lateral arm). Demographic characteristics including race, body mass index, comorbidities, American Society of Anesthesiologists classification, pre-operative diagnosis, complication rates, length of stay, and estimated blood loss were comparable between the two groups. The distribution of different operative procedures was similar between the two groups. There was no statistically significant difference in pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h postoperatively between the two groups. However, patients receiving posterior TAP had a significant reduction in narcotic intake (p = 0.0009). CONCLUSION: Laparoscopic-assisted TAP block is a safe and effective option for regional analgesia in laparoscopic gynecologic surgery. Posterior TAP block may help to reduce narcotic usage postoperatively.

Pseudovascular Invasion: Minimally Invasive Surgery for Endometrial Cancer.

BACKGROUND AND OBJECTIVES: To determine if the use of an intrauterine manipulator is associated with an increased incidence of pseudovascular invasion on pathologic evaluation of hysterectomy specimens for endometrial cancer and to assess the possible implications of pseudovascular space invasion in the treatment of endometrial cancer. METHODS: We performed a retrospective cohort study of patients with early stage (I/II) endometrial cancer who underwent minimally invasive surgical staging. The following data were abstracted: race, body mass index, grade, age, stage, histology, presence or absence of lymphovascular space invasion (LVSI), peritoneal cytology, and adjuvant treatment. Slides were blindly reviewed by a gynecologic pathologist. RESULTS: Of the104 patients meeting eligibility criteria, 74 cases were reviewed in detail (the study was terminated early based on the results of an interim analysis). Patients in the no-manipulator group were older (P = .02) and had a higher stage 1B/II (P = .01) than patients in the manipulator group. No difference was found in the incidence of pseudovascular invasion between the manipulator and the no-manipulator groups (P = .86). Subgroup analysis showed no association of pseudovascular invasion with tumor grade (P = .79). Five patients were identified to have pseudovascular invasion misdiagnosed as true LVSI-4 had endometrioid and 1 had serous histology. Of these, 3 were in the manipulator group. Two received adjuvant radiotherapy which they not have gotten, absent reported lymphovascular invasion. CONCLUSION: The use of a uterine manipulator does not appear to increase the rate of pseudovascular invasion in our limited data set. Misdiagnosis of pseudovascular invasion as LVSI can result in risk migration of patients with potential for harm from unwarranted adjuvant therapy.