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We conducted a multi-institutional observational study to investigate whether maintenance hormone therapy following primary treatment of low-grade advanced-stage ovarian cancer (LGSOC) is associated with an overall survival advantage. We included patients with histologically confirmed stage III or IV LGSOC diagnosed between Jan 1, 2004, and Dec 31, 2019, treated in Commission on Cancer-accredited cancer programs in the US. Patients who received hormone therapy within six months of diagnosis were matched to controls who did not initiate hormone therapy during this timeframe by risk-set propensity score matching. The primary outcome was the risk of death from any cause within five years of initiation of HT or observation. There were 296 patients who initiated maintenance hormone therapy within six months of diagnosis and 2805 potential controls. Patients who received hormone therapy were more often treated in academic medical centers (55% vs. 44%), diagnosed later in the study period (62% vs. 23% diagnosed in 2018–2019), and frequently received no chemotherapy during initial treatment (45% vs. 17%). After risk set propensity score matching, we identified 225 patients treated with HT and 225 untreated controls who were otherwise similar with respect to measured covariates. In the matched cohort, hormone therapy was associated with a reduction in the risk of death (hazard ratio 0.60; 95% CI 0.38–0.94), corresponding to a 60-month survival of 75% compared with 65%. Following primary management of LGSOC, maintenance hormone therapy was associated with improved overall survival compared with observation. • Hormone maintenance therapy for low-grade serous carcinoma has increased substantially since 2004. • Hormone maintenance therapy for low-grade serous carcinoma is associated with an overall survival benefit. • An ongoing trial will assess the therapeutic benefit of hormone therapy in patients with low-grade serous carcinoma. [ABSTRACT FROM AUTHOR]

Objectives To investigate the utility of para-aortic lymph node dissection among women undergoing radical hysterectomy and pelvic lymph adenectomy for FIGO Stage IA2-IB2 cervical cancer using the National Cancer Database (NCDB). Methods We identified patients with stage IA2-IB2 squamous cell, adenosquamous, or adenocarcinoma of the cervix diagnosed 2011–2014 in the NCDB. The primary outcome was the negative predictive value of histologically assessed pelvic lymph node status for para-aortic lymph node status among women undergoing pelvic and para-aortic lymph node dissection. We calculated probability of para-aortic lymph node metastasis conditional on pelvic lymph node status. Finally, we compared overall survival between patients undergoing para-aortic lymph node dissection and those in whom this procedure was omitted. Results A total of 3212 patients met study inclusion criteria, of whom 994 (30.9%) underwent para-aortic lymph node dissection. In this group, the risk of isolated para-aortic metastasis was 0.11%. The negative predictive value of surgically assessed pelvic lymph nodes to predict para-aortic lymph node status was 99.9% (95% CI 99.9–99.9). Among 93 patients with pelvic lymph node metastasis, 18 (19.4%) had concurrent para-aortic lymph node metastasis. There was no difference in overall survival between women undergoing pelvic and para-aortic lymph node dissection compared with those undergoing pelvic lymphadenectomy only ( p  = 0.69). Conclusions In patients undergoing radical hysterectomy and pelvic lymphadenectomy for stage IA2-IB2 cervical cancer, para-aortic lymph node dissection is not warranted based on the low risk of isolated metastatic disease, and lack of survival benefit associated with the procedure. [ABSTRACT FROM AUTHOR]

Objective Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients. Methods MEDLINE was searched for studies on menopause management published in English through December of 2016. Results Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking. Conclusions Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer. [ABSTRACT FROM AUTHOR]

Background To evaluate the usage of concurrent chemo-radiotherapy (C-CRT) for the treatment of locally advanced cervical cancer. Methods Patients with locally invasive cervical carcinoma diagnosed between January 1, 2004 and December 31, 2012 from the National Cancer Database (NCDB) were included. Outcomes for patients undergoing radiation therapy only, ‘RT alone’ group were compared to those receiving chemotherapy concurrent with radiation ‘C-CRT group’. Trends in utilization of C-CRT and factors associated with the deviation from standard of care were explored. Lastly, the effect of hospital volume on utilization of C-CRT was investigated. Results A total of 18,164 patients undergoing definitive radiation therapy were available for analysis. Utilization of C-CRT increased from 72.4% in 2004 to 84.3% in 2012 (p-trend < 0.001). After adjusting for patient, tumor, and treatment factors, a multivariable logistic regression model revealed increasing age, African-American race, Charlson-comorbidity index of ≥ 2, Medicaid insurance status, uninsured status, and Stage I disease were each independently associated with the lack of C-CRT. After adjusting for patient characteristics, low volume hospitals were noted to have overall significantly lower rates and greater variation in C-CRT administration. Patients in ‘RT alone’ group had an overall worse survival rate (adjusted-HR 1.47, 95%CI 1.4–1.56). Conclusion Rates of C-CRT administration varied significantly across hospitals in the United States. Hospitals with a high case volume had higher rates and more consistent patterns of C-CRT administration. Furthermore, we identified independent factors, all of which represent noteworthy health disparities, associated with lower rates of C-CRT administration. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Uterine papillary serous carcinoma (UPSC) represents a distinct subtype of endometrial cancer. UPSC is less common than endometrioid carcinoma (ECC) but accounts for a disproportionate number of uterine cancer related deaths. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis, management, and outcome of patients with UPSC. Methods: MEDLINE was searched for all research articles published in English between January 1, 1967–January 1, 2012 which reported on patients diagnosed with UPSC. Given the rarity of this tumor, studies were not limited by design or number of reported patients. Results: UPSC represents a histologically aggressive subtype of endometrial cancer. It commonly presents with extra uterine disease involvement which can be identified by comprehensive surgical staging. Optimal cytoreduction and systemic platinum/taxane-based adjuvant therapy appear to confer a survival advantage. Conclusions: UPSC is a biologically distinct entity, different from ECC. Future studies should explore the role of targeted therapies in the management of UPSC. [Copyright &y& Elsevier]

Abstract: Objective: Different histologic types of epithelial ovarian cancer may represent different diseases with unique clinical and molecular characteristics. Clear cell carcinoma (CCC) of the ovary has been reported as having a worse prognosis than high grade serous epithelial ovarian cancer (EOC). This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis, management, and outcome of patients with ovarian CCC. Methods: MEDLINE was searched for all research articles published in English between January 01, 1977 and January 30, 2012 which reported on patients diagnosed with ovarian CCC. Given the rarity of this tumor, studies were not limited by design or number of reported patients. Results: Ovarian CCC tumors represent 5–25% of ovarian cancers. Its histologic diagnosis can be challenging, resulting often times in misclassification of these tumors. Ovarian CCC tends to present at earlier stages and has been associated with endometriosis, ARID1A and PIK3CA mutations. When compared to stage-matched controls, patients with early-stage ovarian CCCs may have a better prognosis than patients with high-grade serous tumors. For those with advanced stage disease, high-grade serous histology confers a better prognosis than ovarian CCC. Patients with Stage IC–IV have a relatively poor prognosis and efforts should center in discovery of more effective treatment strategies. Conclusions: Ovarian CCC is a biologically distinct entity, different from high-grade serous EOC. Future studies should explore the role of targeted therapies in the management of ovarian CCC. [Copyright &y& Elsevier]

Abstract: Objective: To assess the safety and efficacy of pegylated liposomal doxorubicin (PLD), carboplatin, plus bevacizumab in patients with ovarian, fallopian tube, or primary peritoneal cancer. Methods: Patients with platinum-sensitive, recurrent disease received PLD 30mg/m2 and carboplatin area under the curve (AUC) 5 on Day 1 plus bevacizumab 10mg/kg on Days 1 and 15 of every 28-day cycle, for a maximum of 10cycles. The primary endpoint was objective response rate (ORR) [complete+partial response]; additional endpoints were safety, duration of response, progression-free survival (PFS), and time to progression (TTP). Results: Of the 54 patients enrolled, 15 (27.8%) completed the study treatment as planned. Intent-to-treat (all enrolled patients) ORR was 72.2% (95% CI: 58.4, 83.5). Median duration of response was 11.9months (95% CI: 9.3, not estimable) and median TTP was 13.9months (95% CI: 11.4, 16.0). PFS was virtually the same as TTP. Three (5.6%) patients discontinued therapy due to disease progression, and another 3 (5.6%) patients discontinued therapy due to serious adverse events (Grade 4 thrombocytopenia, Grade 3 small/large intestinal obstruction/small intestinal perforation, and Grade 3 abdominal abscess). Fifty (92.6%) patients had ≥1 adverse event of interest, most commonly neutropenia (42.6%), hypertension (37.0%), stomatitis (37.0%), proteinuria (37.0%), and palmar–plantar erythrodysesthesia (27.8%). No appreciable decreases in left-ventricular ejection fraction were observed. Conclusion: Most patients responded to PLD, carboplatin, and bevacizumab combination therapy. The safety profile was consistent with the known toxicities of these agents. These findings present a potential treatment option for women with ovarian, fallopian tube, or primary peritoneal cancer. [Copyright &y& Elsevier]

Abstract: Objective: Carcinosarcoma of the ovary is a rare tumor with a grim prognosis. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis, management, and outcome of patients with ovarian carcinosarcoma (OCS). Methods: MEDLINE was searched for all research articles published in English between January 1, 1981 and August 30, 2011 which reported on patients diagnosed with carcinosarcoma of the ovary. Given the rarity of this tumor, studies were not limited by design or number of reported patients. Results: Patients with OCS generally present with advanced stage disease, and symptoms similar to those of patients with epithelial ovarian cancer (EOC). Retrospective studies have shown that cytoreductive surgery improves outcomes in patients with OCS. Similarly, platinum-based chemotherapy appears to be active in the treatment of OCS. Conclusions: Ovarian carcinosarcomas are rare and aggressive tumors, associated with a poor prognosis. The mainstay of treatment remains cytoreductive surgical effort for metastatic disease followed by platinum-based chemotherapy. The role of targeted therapies may be promising in the treatment of OCS. [Copyright &y& Elsevier]

Abstract: Objective: Disparities occur in the incidence and mortality of cervical cancer among minority women in the US. Screening lowers cervical cancer incidence. Screening rates are lower for minority women than for White women in the US. This study sought to identify demographic, risk factor, and perception of the role of Pap smears between Latinas and non-Latinas. Methods: A written survey was administered to 150 Latinas and 150 non-Latinas attending a colposcopy unit. Data on demographics, risk factors, screening rates, knowledge about cervical cancer screening, and perceived barriers to participation in screening programs were collected. Results: A total of 140 Latinas and 146 non-Latinas completed the survey. Marital status and health insurance status were similar in the two groups. 30% of Latinas and 73.3% of non-Latinas reported completing college (p <0.0001). Only 55.7% of Latinas were employed, compared to 82.2% of non-Latinas (p <0.0001). 21% of Latinas and 53.4% of non-Latinas reported an annual income greater than $35,000 (p <0.0001). Among Latinas, women with 1–5 lifetime Pap smears were less likely to have completed college than those with more than 5 lifetime Pap smears (OR=2.11; 95% CI 1.05–4.22) and to have an annual income of less than $ 35,000 (OR=3.81; 95% CI 1.64–8.87). Latinas were less likely to have ≥6 lifetime sexual partners, use tobacco, and have a history of sexually transmitted infections. Latinas more commonly reported fear of test results (OR, 0.04; 95% CI 0.02–0.09) and inability to communicate with their provider in Spanish (p <0.0001) as barriers to screening than the non-Latina respondents. Conclusions: Several of the barriers limiting access to cervical cancer screening programs are also present among screened Latinas undergoing further evaluation for abnormal Pap smears. [Copyright &y& Elsevier]

: ObjectiveThe aim of this study was to evaluate the utility of combined positron emission tomography/computed tomography (PET/CT) for identifying ovarian cancer tumor masses ≥1 cm in patients with clinically occult recurrent disease by conventional CT imaging.: MethodsTwenty-two patients with epithelial ovarian cancer, rising serum CA125 levels, and negative or equivocal conventional CT imaging ≥6 months after primary therapy underwent combined PET/CT imaging followed by surgical reassessment. Fisher''s exact test was used to measure the ability of PET/CT to predict macroscopic disease ≥1 cm.: ResultsThe median patient age was 55 years, and 91% of patients had FIGO Stage IIIC/IV disease. The median increase in serum CA125 was 24 U/ml (range 10 to 330 U/ml). Conventional CT was reported as negative (n = 15) or equivocal (n = 7) in all cases. Eighteen patients were ultimately found to harbor recurrent ovarian cancer measuring ≥1 cm at the time of surgery, with a median maximal tumor diameter of 2.3 cm (range 1.5 to 3.2 cm). The overall patient-based accuracy of PET/CT in detecting recurrent disease ≥1 cm was 81.8%, with a sensitivity of 83.3% and positive predictive value of 93.8% (P = 0.046). Of patients with recurrent ovarian cancer ≥1 cm, complete cytoreduction to no gross residual tumor was accomplished in 72.2%.: ConclusionPET/CT imaging demonstrates high sensitivity and positive predictive value in identifying potentially resectable, macroscopic recurrent ovarian cancer among patients with biochemical evidence of recurrence and negative or equivocal conventional CT findings. In appropriately selected patients, early identification of macroscopic recurrent disease may facilitate complete surgical cytoreduction. [Copyright &y& Elsevier]

Abstract Objectives To determine whether perioperative red blood cell transfusion (PRBCT) affects infection, thrombosis, or survival rates in epithelial ovarian cancer (EOC) patients undergoing neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS). Methods Demographics, operative characteristics, and outcome data were abstracted from records of stage IIIC-IV EOC patients managed with NACT-IDS from 01/2010–07/2015. Associations of PRBCT with morbidity and oncologic outcomes were evaluated. Results Of 270 patients, 136 (50.4%) received PRBCT. Patients with preoperative anemia and higher estimated blood loss (EBL) were more likely to undergo PRBCT (OR,95%CI 1.80, 1.02–3.17) and (OR,95%CI 1.00, 1.002–1.004), respectively. There were no significant differences in PRBCT based on patient age, Charlson Comorbidity Index, or stage. When compared to low complexity operations, patients with moderate and high complexity surgeries were more likely to receive PRBCT (OR,95%CI 1.81, 1.05–3.09) and (OR,95%CI 2.25, 1.13–4.50), respectively. On univariate analysis, PRBCT was associated with intraabdominal infection (OR,95%CI 8.31, 1.03–67.41), but not wound complications (OR,95%CI 1.57, 0.76–3.23) or venous thromboembolism/pulmonary embolism (VTE/PE) (OR,95%CI 2.02, 0.49–8.23). After adjusting for surgical complexity and preoperative anemia, PRBCT was not independently associated with intraabdominal infection (OR,95%CI 7.66, 0.92–63.66), wound complications (OR,95%CI 1.70, 0.80–3.64), or VTE/PE (OR,95%CI 2.15, 0.51–9.09). When comparing patients undergoing PRBCT versus those who did not, there were no significant differences in median progression-free survival (PFS) or median overall survival (OS) on univariate analysis after adjusting for age, stage and residual disease. Conclusions Among patients undergoing NACT-IDS, intraabdominal infection, wound complication and VTE/PE rates are similar, regardless of PRBCT. PRBCT does not impact PFS or OS. Highlights • After interval cytoreduction, thrombosis rates are not affected by transfusion. • Infection and wound complication rates are similar, regardless of transfusion. • After interval cytoreduction, transfusion does not impact survival. [ABSTRACT FROM AUTHOR]

To describe trends in neoadjuvant chemotherapy (NACT) use for low-grade serous ovarian carcinoma (LGSOC) and to quantify associations between NACT and extent of cytoreductive surgery. We identified women treated for stage III or IV serous ovarian cancer in a Commission on Cancer accredited program between January 2004–December 2020. Regression models were developed to evaluate trends in NACT use for LGSOC, to identify factors associated with receipt of NACT, and to quantify associations between NACT and bowel or urinary resection at the time of surgery. Demographic and clinical factors were used for confounder control. We observed 3350 patients who received treatment for LGSOC during the study period. The proportion of patients who received NACT increased from 9.5% in 2004 to 25.9% in 2020, corresponding to an annual percent change of 7.2% (95% CI 5.6–8.9). Increasing age (rate ratio (RR) 1.15; 95% CI 1.07–1.24), and stage IV disease (RR 2.66; 95% CI 2.31–3.07) were associated with a higher likelihood of receiving NACT. For patients with high-grade disease, NACT was associated with a decrease in likelihood of bowel or urinary surgery (35.3% versus 23.9%; RR 0.68, 95% CI 0.65–0.71). For LGSOC, NACT was associated with a higher likelihood of these procedures (26.6% versus 32.2%; RR 1.24, 95% CI 1.08–1.42). NACT use among patients with LGSOC has increased from 2004 to 2020. While NACT was associated with a lower rate of gastrointestinal and urinary surgery among patients with high-grade disease, patients with LGSOC receiving NACT were more likely to undergo these procedures. • NACT use for patients with advanced LGSOC has substantially increased from 2004 to 2020. • Increasing age, later calendar year of diagnosis and stage IV disease are associated with receiving NACT. • In patients with HGSOC, NACT is associated with lower rates of bowel or urinary procedures at the time of interval surgery. • Conversely, in LGSOC, NACT is associated with higher rates of bowel or urinary procedures at the time of interval surgery. [ABSTRACT FROM AUTHOR]

Objective Ovarian carcinosarcoma (OCS) is a rare malignancy accounting for only 1–4% of all ovarian cancers. The treatment of OCS is largely based on data from small case series and management of other histologic subtypes of epithelial ovarian cancer. We reviewed the literature pertinent to the pathology, pathogenesis, diagnosis, and management of women with OCS. Methods MEDLINE was searched in English for literature on OCS, focusing on the past 30 years. Given the rarity of this tumor, studies were not limited by design or number of reported patients. Results Molecular, epidemiologic, genetic, and histologic data indicate that most OCS are monoclonal. Patients with OCS generally present with advanced stage disease. Most of the available retrospective studies support the role of cytoreductive surgery in the management of OCS, with optimal debulking associated with improved survival. Platinum-based chemotherapy is the current accepted adjuvant treatment. Given the limited data regarding the management of recurrent OCS, patients are usually treated similarly to women diagnosed with other subtypes of epithelial ovarian cancer. Conclusion OCS represent a rare and aggressive histologic subtype of epithelial ovarian cancer. The goal of surgery is comprehensive staging in patients with early-stage disease and optimal cytoreduction patients with advanced-stage tumors. Platinum-based chemotherapy is the mainstay of adjuvant systemic treatment. Future studies are needed in order to elucidate the molecular basis for OCS and to evaluate the role of targeted therapy in its management. [ABSTRACT FROM AUTHOR]

Objectives To examine the underlying indications, timing, and risk factors associated with unplanned hospital readmissions after major surgery for a gynecologic malignancy. Methods This is a retrospective database cohort study utilizing the National Surgical Quality Improvement Program database (NSQIP). The association between risk factors with respect to 30-day unplanned readmission was modeled using logistic regression. Timing of readmission and the primary reason of readmission was abstracted from the database. Results Overall, the unplanned readmission rate was 6.5% (832/12,804). On multivariate analysis, operative time ≥ 3 h (OR 1.39, p < 0.001), open abdominal surgery (OR 2.2, p < 0.001), any complication prior to discharge (OR 1.6, p < 0.001), two or more additional surgical procedures (OR 1.34, p = 0.003), or cervical cancer as the site of primary disease (OR 1.30, p = 0.05) were noted to be independent predictors of readmission. To provide a convenient calculation of overall probability of readmission, we developed a nomogram of factors significantly predicting readmission. Overall, infections were a cause of 45% of the readmissions. Surgical Site Infections were the most common reason, accounting for 29.2% of all readmissions. A majority of the readmissions (approximately 75%) were within two weeks of discharge from the hospital. Conclusions Efforts to reduce readmission rates should focus on identifying patients at a high risk of readmission and reducing surgical site infections. Additionally, prospective evaluation of interventions targeted at reducing readmissions should focus on the first two weeks after discharge from the hospital. [ABSTRACT FROM AUTHOR]

To evaluate utilization of sentinel lymph node biopsy (SLNB) for early-stage vulvar cancer at minority-serving hospitals and low-volume facilities. Between 2012-2018, individuals with T1b vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients undergoing SLNB or inguinofemoral lymph node dissection (IFLD). Multivariable logistic regression, adjusted for patient, facility, and disease characteristics, was used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. Of the 3,532 patients, 2,406 (68.1%) underwent lymph node evaluation, with 1,704 (48.2%) undergoing IFLD and 702 (19.8%) SLNB. In a multivariable analysis, treatment at minority-serving hospitals (OR 0.39, 95% CI 0.19–0.78) and low-volume hospitals (OR 0.44, 95% CI 0.28–0.70) were associated with significantly lower odds of undergoing SLNB compared to receiving care at non-minority-serving and high-volume hospitals, respectively. While SLNB utilization increased over time for the entire cohort and stratified subgroups, use of the procedure did not increase at minority-serving hospitals. After controlling for patient and tumor characteristics, SLNB was not associated with worse OS compared to IFLD in patients with positive (HR 1.02, 95% CI 0.63–1.66) or negative (HR 0.92, 95% CI 0.70–1.21) nodal pathology. For patients with early-stage vulvar cancer, treatment at minority-serving or low-volume hospitals was associated with significantly decreased odds of undergoing SLNB. Future efforts should be concentrated toward ensuring that all patients have access to advanced surgical techniques regardless of where they receive their care. • The uptake of sentinel lymph node biopsy for early-stage vulvar cancer remains low, though is increasing over time. • Patients receiving care at minority-serving or low-volume hospitals were less likely to undergo sentinel lymph node biopsy. • Escalation of sentinel lymph node biopsy use was most evident in low-volume hospitals. • Sentinel lymph node biopsy was not associated with worse overall survival compared to full groin dissection. [ABSTRACT FROM AUTHOR]

Purpose. To characterize the patterns of primary surgical care for ovarian cancer in a statewide population according to annual surgeon and hospital case volume.Methods. The Maryland hospital discharge database was accessed for annual surgeon and hospital ovarian cancer case volume for the time intervals: 1990–1992, 1993–1995, 1996–98, and 1999–2000. Annual surgeon case volume was categorized as low (≤4), intermediate (5–9), or high (≥10). Annual hospital case volume was categorized as low (≤9), intermediate (10–19), or high (≥20). Logistic regression models were used to evaluate for significant trends in case volume distribution over time and factors associated with access to high-volume care.Results. Overall, 2417 cases were performed by 531 surgeons at 49 hospitals. The distribution according to annual surgeon case volume was low (56.3%), intermediate (9.2%), and high (34.5%). Between 1993 and 2000, there was no significant increase in the proportion of cases performed by high-volume surgeons (OR = 1.03, 95% CI = 0.81–1.33, P = 0.79). Access to high-volume surgeons was positively associated with care at high-volume hospitals and negatively associated with residence ≥50 miles from a high-volume hospital. The overall hospital volume case distribution was low (49.6%), intermediate (27.6%), and high (22.8%). There was a statistically significant decrease in access to high-volume hospitals between 1990 and 1998 (OR = 0.39, 95% CI = 0.30–0.50, P < 0.0001).Conclusion. A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted.Condensed abstract. A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted. [Copyright &y& Elsevier]

The objective of this study was to determine the proportion of patients with a pre-invasive endometrial lesion who meet Mayo criteria for lymph node dissection on final pathology to determine if the use of sentinel lymph node biopsy in patients with pre-invasive lesions would be warranted. All women who underwent hysterectomy for a pre-invasive endometrial lesion (atypical hyperplasia or endometrial intra-epithelial neoplasia) between 2009 and 2019 were included for analysis. Relevant statistical tests were utilized to test the associations between patient, operative, and pathologic characteristics. 141 patients met inclusion criteria. 51 patients (36%) had a final diagnosis of cancer, the majority (96%) of which were Stage IA grade 1 endometrioid carcinomas. Seven patients (5%) met Mayo criteria on final pathology (one grade 3, seven size >2 cm, one >50% myoinvasive). Three of these seven patients had lymph nodes assessed of which 0% had metastases. Six of these patients had frozen section performed, and 2 met (33%) Mayo criteria intraoperatively. Of the seven patients in the overall cohort that had lymph node sampling, six had a final diagnosis of cancer and none had positive lymph nodes. Of the 51 patients with cancer, only 10 had cancer diagnosed using frozen section, and only two met intra-operative Mayo criteria. Age > 55 was predictive of meeting Mayo criteria on final pathology (p = 0.007). No patients experienced a cancer recurrence across a median follow up of 24.3 months. Atypical hyperplasia and endometrial intra-epithelial neoplasia portend low risk disease and universal nodal assessment is of limited value. • Among our cohort of patients with AH/EIN, 5% met Mayo criteria on final pathology. • No patients were found to have positive lymph nodes or subsequent nodal recurrence. • AH/EIN portend low risk disease and universal nodal assessment is of limited value. [ABSTRACT FROM AUTHOR]

Our goal was to pragmatically describe patient reported outcomes (PROs) in a typical clinic population of vulvar cancer patients, as prior studies of vulvar cancer PROs have examined clinical trial participants. A prospective PRO program was implemented in the Gynecologic Oncology clinic of a tertiary academic institution in January 2018. Vulvar cancer patients through September 2019 were administered the European Organization for the Research and Treatment of Cancer Quality of life Questionnaire, the Patient Reported Outcome Measurement Information System Instrumental and Emotional Support Scales, and the Functional Assessment of Cancer Therapy-Vulvar questionnaire. Binary logistic regressions were performed to determine adjusted odds ratios for adverse responses to individual questions by insurance, stage, age, time since diagnosis, recurrence, radiation, and surgical radicality. Seventy vulvar cancer patients responded to PROs (85.4% response rate). Seventy-one percent were > 1 year since diagnosis, 61.4% had stage I disease, and 28.6% recurred. Publicly insured women had less support and worse quality of life (QOL, aOR 4.15, 95% CI 1.00–17.32, p = 0.05). Women who recurred noted more interference with social activities (aOR 4.45, 95% CI 1.28–15.41, p = 0.019) and poorer QOL (aOR 5.22 95% CI 1.51–18.10, p = 0.009). There were no major differences by surgical radicality. Those >1 year since diagnosis experienced less worry (aOR 0.17, 95% CI 0.04–0.63, p = 0.008). Surgical radicality does not affect symptoms or QOL in vulvar cancer patients, whereas insurance, recurrence, and time since diagnosis do. This data can improve counseling and awareness of patient characteristics that would benefit from social services referral. • In a typical clinic population of vulvar cancer patients, quality of life is lower compared to clinical trial populations. • Vulvar cancer patients with public insurance have less emotional and instrumental support and worse quality of life. • Vulvar cancer recurrence is a major predictor of poor quality of life, while radicality of surgery is not. • Oncologists should perform an appropriately radical surgery to prevent recurrence, as this may benefit quality of life. [ABSTRACT FROM AUTHOR]

To determine whether neoadjuvant chemotherapy (NACT) disproportionately benefits obese patients. Data were collected from stage IIIC-IV ovarian cancer patients treated between 01/2010–07/2015. We performed univariate/multivariate logistic regression analyses with post-operative infection, readmission, any postoperative complication, and time to chemotherapy as outcomes. An interaction term was included in models, to determine if the effect of NACT on post-operative complications was influenced by obesity status. Of 507 patients, 115 (22.6%) were obese and 392 (77.3%) were non-obese (obese defined as BMI ≥30). Among obese patients undergoing primary debulking surgery (PDS) vs. NACT, rates of postoperative infection were 42.9% vs. 30.8% (p = 0.12), 30-day readmission 30.2% vs. 11.5% (p < 0.02), and any post-operative complication were 44.4% vs 30.8% (p = 0.133). Among non-obese patients undergoing PDS vs. NACT, rates of post-operative infection were 20.0% vs. 12.9% (p = 0.057), 30-day readmission 16.9% vs. 9.2% (p = 0.02), and any post-operative complication were 19.4% vs 28% (p = 0.044). Obesity was associated with post-operative infection (OR 2.3; 95%CI 1.22–4.33), 30-day readmission/reoperation (OR 2.27; 95%CI 1.08–3.21) and the development of any post-operative complication (OR 2.1; CI 1.13–3.74). However, there was not a significant interaction between obesity and NACT in any of the models predicting post-operative complications. The decision to use NACT should not be predicated on obesity alone, as the reduction in post-operative complications in obese patients is similar to non-obese patients. • Obese patients do not disproportionately benefit from NACT with respect to post-op morbidity. • While obese patients disproportionately suffer post-operative complications, NACT does not mitigate this effect. • The decision to use NACT versus PDS should not be predicated on obesity alone. [ABSTRACT FROM AUTHOR]

Abstract Objective Identify the major factors that drive standardized cost in providing surgical care for women with ovarian cancer, characterize the magnitude of variation in resource utilization between centers, and to investigate the relationship between resource utilization and quality of care provided. Methods Retrospective cohort study of hospitals across the United States reporting to the Premier Database who cared for patients with ovarian cancer diagnosed between 2007 and 2014. The primary outcome was standardized total cost of the index hospitalization. To assess the relationship between hospital standardized costs and patient outcomes, we identified four measures of quality: 1) complications, 2) re-operation, 3) length of stay > 15 days, and 4) unplanned readmission. Results The study population included 15,857 patients treated at 226 hospitals. The median standardized cost for hospitalizations was $13,267 (IQR = $3342). Reoperation was associated with 49% increase (95% CI = 43%–56%), and having minor complication was associated with 10% (95% CI = 8%–12%) increase in standardized cost, a moderate complication was associated with 36% (95% CI = 33%–38%) increase, and a major complication was associated with 83% (95% CI = 76%–89%) increase. The average risk-adjusted hospital standardized costs for hospitals in the highest resource use quartiles was 56% higher than the average hospital costs for hospitals in the lowest quartile ($10,826 vs. $16,933). The largest variation was in operating room standardized cost (45.5% of the total variation in operating room cost is explained by differences in hospital practices) and supplies (41.7%). Conclusions We identified significant variation in standardized costs among women who underwent surgery for ovarian cancer, operating room and supply costs are the largest drivers of variation. Highlights • We identified significant variation in resource utilization among hospitals who treat women for ovarian cancer. • Operating room and supply costs are the largest drivers of variation. • Operating room costs were the fastest growing component of total costs. • We found a significant association between high costs and lower quality of care. [ABSTRACT FROM AUTHOR]

Objectives To examine the relationship between volume of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing primary debulking surgery (PDS). For patients that did not undergo a complete surgical resection (CSR), a surrogate for volume of residual disease was used to assess oncologic outcomes. Methods Medical records of patients with FIGO stage IIIC and IV epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing PDS between January 2010 and November 2014 were reviewed. Patient demographics, operative characteristics, residual disease, anatomic site of residual disease and outcome data were collected. Among patients who did not undergo CSR, but had ≤1 cm of residual disease, the number of anatomic sites (single location vs. multiple locations) with residual disease was utilized as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival (PFS) and overall survival (OS) was evaluated. Results Of 240 patients undergoing PDS, 94 (39.2%) had CSR, 41 (17.1%) had ≤1 cm of residual disease confined to a single anatomic location (≤1 cm-SL), 67 (27.9%) had ≤1 cm of residual disease in multiple anatomic locations (≤1 cm-ML) and 38 (15.8%) were sub-optimally (SO) debulked. Median PFS for CSR, ≤1 cm-SL, ≤1 cm-ML and SO-debulked were: 23, 19, 13 and 10 months, respectively ( p  < 0.001). Median OS for CSR, ≤1 cm-SL, ≤1 cm-ML and SO-debulked were: Not yet reached, 64, 50 and 49 months, respectively ( p  = 0.001). Conclusions Following PDS, CSR and ≤ 1 cm-SL patients have the best prognosis. In contrast, despite being considered “optimally debulked”, ≤1 cm-ML patients have survival similar to those SO-debulked. [ABSTRACT FROM AUTHOR]

Objective Admissions to intensive care units (ICU) are costly, but are necessary for some patients undergoing radical cancer surgery. When compared to primary debulking surgery (PDS), neoadjuvant chemotherapy (NACT) with interval debulking surgery, is associated with less peri-operative morbidity. In this study, we compare rates, indications and lengths of ICU stays among ovarian cancer patients admitted to the ICU within 30 days of cytoreduction, either primary or interval. Methods A retrospective chart review was performed of patients with stage III-IV ovarian cancer who underwent surgical cytoreduction at two large academic medical centers between 2010 and 2014. Chi square tests, Student t -tests, and Mann- U Whitney tests were used. Results A total of 635 patients were included in the study. There were 43 ICU admissions, 7% of patients. Compared to NACT, a higher percentage of PDS patients required ICU admission, 9.4% vs 3.9% of patients (P = 0.004). ICU admission indications did not vary between PDS and NACT patients. NACT patients admitted to the ICU had comparable mean surgical complexity scores to those PDS patients admitted to the ICU, 6.2 (95%CI 5.3–7.1) vs 4.5 (95%CI 3.1–6.0) (P = 0.006). Length of ICU admission did not vary between groups, PDS 2.7 days (95%CI 2.3–3.2) vs 3.5 days (95%CI 1.5–5.6) for NACT (P = 0.936). Conclusions The rate of ICU admissions among patients undergoing PDS is higher than for NACT. Among patients admitted to the ICU, indications for admission, length of stay and surgical complexity were similar between patients treated with NACT and PDS. [ABSTRACT FROM AUTHOR]

Objective Surgical cytoreduction has been postulated to affect survival by increasing the efficacy of chemotherapy in ovarian cancer. We hypothesized that women with high-grade serous ovarian cancer, which usually responds to chemotherapy, would derive greater benefit from complete cytoreduction than those with histologic subtypes that are less responsive to chemotherapy, such as mucinous and clear cell carcinoma. Methods We conducted a retrospective cohort study of patients who underwent primary cytoreductive surgery and adjuvant chemotherapy for stage IIIC or IV epithelial ovarian cancer from 2011 to 2013 using data from the National Cancer Database. We constructed multivariable models to quantify the magnitude of associations between residual disease status (no residual disease, ≤ 1 cm, or > 1 cm) and all-cause mortality by histologic type among women with clear cell, mucinous, and high-grade serous ovarian cancer. Because 26% of the sample had unknown residual disease status, we used multiple imputations in the primary analysis. Results We identified 6,013 women with stage IIIC and IV high-grade serous, 307 with clear cell, and 140 with mucinous histology. The association between residual disease status and mortality hazard did not differ significantly among histologic subtypes of ovarian cancer (p for interaction = 0.32). In covariate adjusted models, compared to suboptimal cytoreduction, cytoreduction to no gross disease was associated with a hazard reduction of 42% in high-grade serous carcinoma (hazard ratio [HR] = 0.58, 95% confidence interval [CI] = 0.49–0.68), 61% in clear cell carcinoma (HR = 0.39, 95% CI = 0.22–0.69), and 54% in mucinous carcinoma (HR = 0.46, 95% CI = 0.22–0.99). Conclusions We found no evidence that surgical cytoreduction was of greater prognostic importance in high-grade serous carcinomas than in histologies that are less responsive to chemotherapy. [ABSTRACT FROM AUTHOR]

Objective Most ovarian cancer patients present with advanced-stage disease, disseminated in the peritoneal cavity. Standard treatment involves surgical resection of all visible tumor, followed by delivery of systemic therapy. Patients with advanced-stage disease may be candidates for intraperitoneal (IP) chemotherapy following surgical debulking. Recent clinical trials have created controversy regarding the benefits of this approach. Previous clinical trials report that patients with microscopic residual disease respond best to IP therapy. The goal of this study was to determine the relationship between tumor size and the efficacy of continuous chemotherapy. Methods Small and large ovarian cancer spheroids (derived from UCI101 and A2780 cell lines) were exposed to short-term high (modeling an IP injection, “IP”) or prolonged, low cisplatin concentrations (modeling an implanted device, “device”), which have been previously shown to be less toxic. Spheroid diameter was measured at various time points via image analysis and used to quantify tumor shrinkage over the course of treatment. Results We show that “IP” doses more effectively shrink large spheroids when the same cumulative dose is administered with both treatments, but that both regimens similarly treat small spheroids. We also demonstrate that higher cumulative “device” doses are most effective at shrinking large spheroids. Conclusions These results support the hypothesis that intratumoral drug distribution following IP treatment is diffusion-controlled. An implanted device that continuously delivers low doses of IP chemotherapy would, therefore, be maximally effective against microscopic tumors. [ABSTRACT FROM AUTHOR]

Purpose To examine patterns of care and survival for Hispanic women compared to white and African American women with high-grade endometrial cancer. Methods We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear cell carcinoma and papillary serous carcinoma between 2003 and 2011. The effect of treatment on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Results 43,950 women were eligible. African American and Hispanic women had higher rates of stage III and IV disease compared to white women (36.5% vs. 36% vs. 33.5%, p < 0.001). African American women were less likely to undergo surgical treatment for their cancer (85.2% vs. 89.8% vs. 87.5%, p < 0.001) and were more likely to receive chemotherapy (36.8% vs. 32.4% vs. 32%, p < 0.001) compared to white and Hispanic women. Over the entire study period, after adjusting for age, time period of diagnosis, region of the country, urban or rural setting, treating facility type, socioeconomic status, education, insurance, comorbidity index, pathologic stage, histology, lymphadenectomy and adjuvant treatment, African American women had lower overall survival compared to white women (Hazard Ratio 1.21, 95% CI 1.16–1.26). Conversely, Hispanic women had improved overall survival compared to white women after controlling for the aforementioned factors (HR 0.87, 95% CI 0.80–0.93). Conclusions Among women with high-grade endometrial cancer, African American women have lower all-cause survival while Hispanic women have higher all-cause survival compared to white women after controlling for treatment, sociodemographic, comorbidity and histopathologic variables. [ABSTRACT FROM AUTHOR]

Objective Neoadjuvant chemotherapy and interval debulking surgery for the treatment of advanced ovarian cancer has remained controversial, despite the publication of two randomized trials comparing this modality with primary cytoreductive surgery. This study describes temporal trends in the utilization of neoadjuvant chemotherapy and interval debulking surgery in clinical practice in the United States. Methods We completed a time trend analysis of the National Cancer Data Base. We identified women with stage IIIC and IV epithelial ovarian cancer diagnosed between 2004 and 2013. We categorized subjects as having undergone one of four treatment modalities: primary cytoreductive surgery followed by adjuvant chemotherapy, neoadjuvant chemotherapy followed by interval debulking surgery, surgery only, and chemotherapy only. Temporal trends in the frequency of treatment modalities were evaluated using Joinpoint regression, and χ 2 tests. Results We identified 40,694 women meeting inclusion criteria, of whom 27,032 (66.4%) underwent primary cytoreductive surgery and adjuvant chemotherapy, 5429 (13.3%) received neoadjuvant chemotherapy and interval surgery, 5844 (15.4%) had surgery only, and 2389 (5.9%) received chemotherapy only. The proportion of women receiving neoadjuvant chemotherapy and surgery increased from 8.6% to 22.6% between 2004 and 2013 ( p < 0.001), and adoption of this treatment modality occurred primarily after 2007 (95%CI 2006–2009; p = 0.001). During this period, the proportion of women who received primary cytoreductive surgery and chemotherapy declined from 68.1% to 60.8% ( p < 0.001), and the proportion who underwent surgery only declined from 17.8% to 9.9% ( p < 0.001). Conclusion Between 2004 and 2013 the frequency of neoadjuvant chemotherapy and interval surgery increased significantly in the United States. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to determine if outcomes of patients with ovarian carcinosarcoma (OCS) differ from those of women with high-grade papillary serous ovarian carcinoma (HG-PSOC) when compared by stage and treatment modalities. Methods The National Cancer Database was queried to identify patients with OCS and HG-PSOC diagnosed between 2003 and 2011. Demographic and clinical data were compared, and the impact of tumor histology on survival was analyzed using the Kaplan–Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Results The final study group consisted of 45,153 women. 2886 (6.39%) had OCS and 42,267 (93.61%) had HG-PSOC. The mean age at diagnosis was 65.43 (± 12.21) years for women with OCS and 61.52 (± 12.6) years for HG-PSOC (P < 0.001). African-American women had higher rate of OCS relative to white non-hispanic women (7.84% vs. 6.37%; P = 0.002). Overall, women with OCS had a worse five-year survival rate, 26.63% [95% Confidence Interval (CI) = 24.86%–28.53%] vs. 43.61% (95% CI = 43.07%–44.17%). This difference persisted for each FIGO disease stage I–IV, with five-year survival consistently worse for women with OCS compared to those with HG-PSOC. Over the entire study period and after adjusting for histology, age, period of diagnosis, SEER registry, marital status, stage, surgery, radiotherapy, and lymph node dissection, carcinosarcoma histology was associated with decreased survival. Conclusion OCS is associated with a poor prognosis compared to HG-PSOC. This difference was noted across all FIGO stages. [ABSTRACT FROM AUTHOR]

Objective Evaluate rates of chemotherapy and radiotherapy delivery in the treatment of uterine serous carcinoma, and compare clinical outcomes of treated and untreated patients. Methods The National Cancer Database was queried to identify patients diagnosed with uterine serous carcinoma between 2003 and 2011. The impact of chemotherapy on survival was analyzed using the Kaplan–Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Results A total of 13,752 patients met the study eligibility criteria. Stage I, II, III, and IV disease accounted for 4355 (31.7%), 1023 (7.4%), 3484 (25.3%), and 2451 (17.8%) of the study population, respectively. 2439 (17.7%) women had unknown stage. Chemotherapy was administered in 4290 (35.4%) patients, radiotherapy to 1673 (12.2%), adjuvant chemo-radiation to 2915 (21.2%), and 4874 (35.4%) of women did not receive adjuvant therapy during the study period. Utilization of chemotherapy became more frequent over time. Over the entire study period, after adjusting for age, period of diagnosis, race, facility location, facility type, insurance provider, socioeconomic status, comorbidity index, lymph node dissection, treatment modality, and stage, there was an association between treatment modality and survival, with the lowest hazard ratio in patients that received chemo-radiation. After adjusting for the same factors in women with stages I and II, chemo-radiation was associated with improved survival compared to patients that received no treatment. Radiotherapy or chemotherapy alone was not associated with improved survival. Conclusion Utilization of chemotherapy is increased in this population over the study period from 2003–2012 and more importantly that survival, particularly in advanced stage patients, is improving. [ABSTRACT FROM AUTHOR]

Objective Evaluate rates of chemotherapy and radiotherapy delivery in the treatment of uterine carcinosarcoma, and compare clinical outcomes of treated and untreated patients. Methods The National Cancer Database was queried to identify patients diagnosed with uterine carcinosarcoma between 2003 and 2011. The impact of chemotherapy on survival was analyzed using the Kaplan–Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Results A total of 10,609 patients met study eligibility criteria. Stages I, II, III, and IV disease accounted for 2997 (28.2%), 642 (6.1%), 2037 (19.2%), and 1316 (12.4%) of the study population, respectively. Most patients (91.0%) underwent definitive surgery, and lymphadenectomy was performed in 68.7% of the patients. Chemotherapy was administered in 2378 (22.4%) patients, radiotherapy to 2196 (20.7%), adjuvant chemo-radiation to 1804 (17.0%), and 4231 (39.9%) of women did not received adjuvant therapy. Utilization of chemotherapy became more frequent over time. Over the entire study period, after adjusting for race, period of diagnosis, facility location, facility type, insurance provider, stage, age, treatment modality, lymph node dissection, socioeconomic status, and comorbidity index, there was an association between treatment modality and survival. The lowest hazard ratio observed was in patients that received chemo-radiation. The strongest quantitative predictor of death was stage at the time of diagnosis. In addition, surgical treatment, lymph node dissection, most recent time-periods, lower comorbidity index, and higher socioeconomic status were associated with improved survival. Conclusion The overall rates of chemotherapy use have increased over time. Adjuvant chemotherapy and chemo-radiation were associated with improved survival. [ABSTRACT FROM AUTHOR]

Objective: To validate whether Surgical Apgar Score can predict post-operative morbidity in patients undergoing hysterectomies for malignancies. Method: We conducted a retrospective cohort study of consecutive hysterectomies performed for cancer at a single academic institution between 2008 and 2010. The Surgical Apgar Score (SAS) was derived as previously reported. Peri-operative complications were as outlined by the American Board for Obstetrics and Gynecology, and then further subdivided into intra-operative and post-operative events. Univariate and multivariate logistic regressions were utilized. Result: A total of 632 patients were identified. Of our cohort, 64% underwent surgery for cancer arising in the uterus, followed by ovary at 28.6% and cervix at 4%. Median patient age was 60years old with a mean American Society of Anesthesiologists Physical Status Classification System (ASA) score of 2.5 and a median body mass index of 29. Average Surgical Apgar Score was 7.6. As SAS decreased, the risk of peri-operative complications increased (p>0.01). On univariate analysis SAS could predict for both intra-operative and post-operative complications. However, on multivariate analyses SAS could not independently predict for any post-operative complications (OR 1.02, CI 0.47-2.17). In a multivariable model incorporating age, ASA class, SAS >4, disease site, bowel resection and laparotomy, only ASA class and laparotomy were able to predict for postoperative complication events. Conclusions: Low Surgical Apgar Score significantly associates with morbidity in women undergoing hysterectomy for malignancy, but is unable to predict which patients will have postoperative complications. This renders the SAS less helpful for the creation of peri-operative metrics to guide post-operative care. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The objective of this investigation was to evaluate the risk of nodal metastasis in patients with endometrial cancer, using the Mayo criteria, in a population-based analysis. Materials and methods: Data from the SEER registry was reviewed for endometrial cancer cases diagnosed between 1988 and 2010. Patients were considered at low-risk for nodal metastasis if their tumors were histologic grade 1 or 2, myometrial invasion was less than 50%, and tumor size equal to or less than 2cm. Patients not meeting these criteria were considered at high-risk for nodal involvement. Results: The final study group consisted of 19,329 women with surgically staged endometrial cancer. Of these, 1035 (5.3%) had lymph node involvement. Based on Mayo criteria, 4095 (21.1%) patients were found to be at low-risk and 15,234 (78.9%) at high-risk for nodal metastasis. Low-risk features were associated with a 1.4% risk for lymph node metastasis, compared to 6.4% in patients with high-risk features (p<0.001). When myometrial invasion was removed from the analysis, low-risk pathologic features were associated with a 2.4% risk of lymph node metastasis, compared to 10.4% in patients with high-risk features (p<0.001). Conclusions: In a population-based analysis, women with low-risk endometrial cancer, as defined by the Mayo criteria, have a low rate of lymph node metastasis. [Copyright &y& Elsevier]

Abstract: Objective: The aim of this investigation was to compare outcomes of patients with clear cell carcinoma (CCC) and endometrioid carcinoma (EC) of the ovary associated with endometriosis to patients with ovarian papillary serous carcinoma (PSC). Methods: Patients with CCC and EC of the ovary associated with endometriosis were identified and matched by age and stage to PSC controls. Student's t test and chi square test were used to analyze continuous and categorical data. The Kaplan–Meier method was used for survival analysis. Results: 67 cases associated with endometriosis were identified, of which 45 were arising in endometriosis. Cases were matched to 134 PSC controls. 27 patients with tumors associated with endometriosis presented at stage I (40.3%), 27 at stage II (40.3%), ten at stage III (14.9%) and three at stage IV (4.5%). There was no difference in rate of optimal cytoreduction or response to chemotherapy in cases vs. PSC controls. There was a significant increase in synchronous endometrial cancer in tumors associated with endometriosis compared to PSC (25.4% vs. 3.7%; P<0.001). 18 cases (26.9%) had recurrent disease vs. 55 (41%) controls (P=0.03). The 5-year disease-free survival (DFS) and overall survival (OS) of patients with tumors associated with endometriosis compared to PSC controls were 75% vs. 55% (P=0.03) and 85% vs. 77% (P=0.2), respectively. Conclusions: Patients with tumors associated with endometriosis had a higher rate of synchronous endometrial cancer. Cases also demonstrated a lower rate of recurrence and improved 5year DFS; however, this did not translate into a difference in OS. [Copyright &y& Elsevier]

Abstract: Objectives: The aim of this study is to compare response to chemotherapy and survival between patients with transitional call carcinoma of the ovary (TCCO) and papillary serous ovarian cancer (PSOC). Methods: We identified women with both pure and mixed TCCO who were treated between 2000 and 2010. Each case was matched to two women with PSOC by age, grade, stage, and year of diagnosis. Correlation between categorical variables was assessed with chi square test. The Kaplan–Meier survival analysis was used to generate overall survival data (OS). Factors predictive of outcome were compared using the log-rank test and Cox proportional hazards model. Results: Eighty-one women diagnosed with TCCO were selected as cases and compared to 162 controls. Women with TCCO had a lower rate of platinum resistance compared to controls (9% vs. 25%; p=0.01). When multivariate logistic regression was used to control for other factors independently associated with platinum resistance, patients with TCCO had a significantly lower risk of platinum resistance compared to PSOC. Median progression-free survival was not significantly different (27months vs. 22months; p=0.15) for women with TCCO and PSOC, respectively. Median OS, however, was significantly different at 83months vs. 52months for the TCCO and PSOC groups, respectively (p=0.01). A Cox proportional hazards model identified optimal cytoreduction, transitional cell histology, age, stage, and platinum and paclitaxel chemotherapy as independent predictors of OS. Conclusions: Patients with TCCO are less likely to demonstrate resistance to platinum chemotherapy and have improved overall survival when compared to patients with PSOC. [Copyright &y& Elsevier]

Abstract: Objective: To describe the role of immediate re-exploration in patients with inadvertently morcellated uterine leiomyosarcoma (ULMS) and smooth muscle tumors of uncertain malignant potential (STUMP). Methods: All patients with ULMS/STUMP who were managed or referred to the participating institutions from January 2005 to January 2012 following minimally invasive gynecology surgery with morcellation were detected through the pathology database. The diagnosis was confirmed by gynecologic-pathologists following post-surgery pathology review. Results: Twenty-one patients with the diagnosis of ULMS (N=15) and STUMP (N=6) after morcellation were identified. The median age of occurrence was 46years (range, 25–58years). Median follow-up duration was 27months (range, 1.8–93.1months). None of the 21 patients had documented evidence of extra-uterine disease at the time of original surgery. Ultimately 12 patients were immediately re-explored to complete staging. The median time to the staging surgery was 33days (range 15–118days). Two (28.5%) out of seven patients with presumed stage I ULMS and one (25%) out of four patients with presumed stage I STUMP had significant findings of disseminated intraperitoneal disease detected at immediate surgical re-exploration. One of the 8 patients with confined early ULMS and STUMP at the second surgery had intraperitoneal recurrence, while the remaining 7 patients have had no recurrence and remain disease free. Conclusion: Surgical re-exploration is likely to show findings of disseminated peritoneal sarcomatosis in a significant number of patients diagnosed with ULMS after a morcellation procedure. Findings from re-exploration can contribute to the knowledge of natural history of morcellated ULMS/STUMP and allow for accurate prognostication. [Copyright &y& Elsevier]

Abstract: Introduction: The purpose of this study is to analyze and compare the demographics, treatment, and survival rates in patients with uterine clear cell carcinoma (UCCC) and ovarian clear cell carcinoma (OCCC). Methods: The Surveillance, Epidemiology and End Results (SEER) program data for all 18 registries from 1988 to 2010 was reviewed to identify women with OCCC and UCCC. Demographic and clinical data were compared, and the impact of tumor site on survival was analyzed using the Kaplan–Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Results: The final study group consisted of 5421 women with clear cell histopathology. 3631 (67%) had OCCC and 1790 (33%) had UCCC. The mean age at diagnosis was 56 (±12) years for women with OCCC and 67.7 (±12.0) years for UCCC (P<0.001). Patients with OCCC had a higher rate of late stage disease (38.9% vs. 21.2%; P<0.001). Over the entire study period, after adjusting for known variables, there was no significant difference in cancer specific mortality between UCCC and OCCC, HR 1.05 (0.92–1.19). In the subset analysis by staging, in women with localized disease there was an improved survival in UCCC compared to OCCC. In contrast, in women with distant disease there was an increased mortality in women with UCCC. Conclusion: In the entire population, there was no significant difference in cancer related mortality between the groups. However, in women with localized disease, UCCC had improved survival, but increased mortality in distant disease compared to OCCC. [Copyright &y& Elsevier]

Abstract: Objective: The aims of this study are to determine if outcomes of patients with ovarian carcinosarcoma (OCS) differ from women with high grade papillary serous ovarian carcinoma when compared by stage as well as to identify any associated clinico-pathologic factors. Methods: The Surveillance, Epidemiology, and End Results (SEER) Program data for all 18 registries from 1998 to 2009 was reviewed to identify women with OCS and high grade papillary serous carcinoma of the ovary. Demographic and clinical data were compared, and the impact of tumor histology on survival was analyzed using the Kaplan–Meier method. Factors predictive of outcome were compared using the Cox proportional hazard model. Results: The final study group consisted of 14,753 women. 1334 (9.04%) had OCS and 13,419 (90.96%) had high grade papillary serous carcinoma of the ovary. Overall, women with OCS had a worse five-year, disease specific survival rate, 28.2% vs. 38.4% (P<0.001). This difference persisted for each FIGO disease stages I–IV, with five year survival consistently worse for women with OCS compared with papillary serous carcinoma. Over the entire study period, after adjusting for histology, age, period of diagnosis, SEER registry, marital status, stage, surgery, radiotherapy, lymph node dissection, and history of secondary malignancy after the diagnosis of ovarian cancer, carcinosarcoma histology was associated with decreased cancer-specific survival. Conclusions: OCS is associated with a poor prognosis compared to high grade papillary serous carcinoma of the ovary. This difference was noted across all FIGO stages. [Copyright &y& Elsevier]

Abstract: Objective: Primary debulking surgery (PDS) has historically been the standard treatment for advanced ovarian cancer. Recent data appear to support a paradigm shift toward neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) for a subset of women with advanced ovarian cancer. It remains unresolved whether NACT-IDS increases the risk of platinum resistance. We compared response to chemotherapy in patients that received NACT-IDS vs. PDS. Methods: From our Cancer Registry database we identified patients with stages IIIC and IV epithelial ovarian cancer who underwent treatment from January, 2005 to December, 2010. Standard univariate analyses were performed, as were multivariable analysis with logistic regression. The Kaplan–Meier method was used to generate survival data. Results: The study population consisted of 425 patients, 95 (22.3%) underwent NACT-IDS and 330 (77.6%) PDS. After the initial platinum-based chemotherapy, 42 (44.2%) women in the NACT-IDS group were considered to have platinum resistant disease, compared to 103 (31.2%) in the PDS group (P =0.01). When multivariate logistic regression was used to control for factors independently associated with platinum resistance, NACT-IDS was no longer associated with an initial increased risk. However, in women that had a recurrence and were retreated with platinum-based chemotherapy, 32 (88.8%) in the NACT-IDS group had developed a recurrence within six months and were considered platinum resistant, compared to 62 (55.3%) in the PDS (P <0.001). Conclusion: In women with EOC that have a recurrence and are treated again with platinum-based chemotherapy, NACT-IDS appears to increase the risk of platinum resistance. [Copyright &y& Elsevier]

Abstract: Objective: The purpose of this study is to analyze and compare the demographics, treatment, recurrence, and survival rates in patients with uterine clear cell carcinoma (UCCC) and ovarian clear cell carcinoma (OCCC). Methods: A retrospective review of the Cancer Registry database was performed. All patients with UCCC and OCCC who underwent surgical staging at the two participating institutions, between January, 1995 and December, 2007, were identified. Categorical variables were evaluated by Chi square test. Survival estimates were plotted utilizing the Kaplan–Meier method. Results: Analysis of 41 women with UCCC and 121 with OCCC was performed. In patients with OCCC, 48.4% had localized disease, 18.9% had regional spread, 31.1% had distant metastasis, and in 1.6% spread is unknown; compared to UCCC, 41.5% had localized disease, 12.2% regional spread, and 46.3% distant metastasis (p=0.2). The median progression free survival was 31.4months in women with UCCC, compared to 145months in patients with OCCC (p=0.04). UCCC women had a median overall survival of 39.5months, compared to 155.8months in patients with OCCC (p=0.002). In the multivariate Cox regression model, age>55years old, tumor extension, optimal cytoreduction, and platinum-based chemotherapy were identified as independent predictors of overall survival. UCCC vs. OCCC was not associated with decreased overall survival in multivariate analysis. Conclusion: OCCC and UCCC have the same rate of localized disease, regional spread and distant metastasis. After controlling for age, tumor extension, optimal cytoreduction, and platinum based chemotherapy, UCCC was not associated with decreased overall survival compared to OCCC. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the predictive power of serum CA-125 changes in the management of patients undergoing neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) for a new diagnosis of epithelial ovarian carcinoma (EOC). Methods: Using the Cancer Registry databases from our institutions, a retrospective review of patients with FIGO stage IIIC and IV EOC who were treated with platinum-based NACT-IDS between January 2006 and December 2009 was conducted. Demographic data, CA-125 levels, radiographic data, chemotherapy, and surgical–pathologic information were obtained. Continuous variables were evaluated by Student''s t test or Wilcoxon–Mann–Whitney test. Results: One hundred-three patients with stage IIIC or IV EOC met study criteria. Median number of neoadjuvant cycles was 3. Ninety-nine patients (96.1%) were optimally cytoreduced. Forty-seven patients (47.5%) had resection to no residual disease (NRD). The median CA-125 at diagnosis and before interval debulking was 1749U/mL and 161U/mL, respectively. Comparing patients with NRD v. optimal macroscopic disease (OMD), there was no statistical difference in the mean CA-125 at diagnosis (1566U/mL v. 2077U/mL, p=0.1). There was a significant difference in the mean CA-125 prior to interval debulking, 92 v. 233U/mL (p=0.001). In the NRD group, 38 patients (80%) had preoperative CA-125≤100U/mL compared to 33 patients (63.4%) in the OMD group (p=0.04). Conclusions: Patients who undergo NACT-IDS achieve a high rate of optimal cytoreduction. In our series, after treatment with taxane and platinum-based chemotherapy, patients with a preoperative CA-125 of ≤100U/mL were highly likely to be cytoreduced to no residual disease. [Copyright &y& Elsevier]

Abstract: Introduction: Carcinosarcoma of the ovary is a rare tumor with a grim prognosis. Chemotherapy for these tumors is chosen according to guidelines established for epithelial ovarian cancer (EOC). The purpose of this study is to compare response to chemotherapy and survival in patients with advanced stage carcinosarcoma of the ovary. Methods: We identified women with advanced carcinosarcoma of the ovary who underwent first-line platinum and taxane-based chemotherapy. Each case was matched to two women with serous EOC. Cases and controls were matched by age, stage, and year of diagnosis. The Kaplan–Meier method was used to generate overall survival (OS) data. Factors predictive of outcome were compared using the log-rank test and Cox proportional hazards model. Results: Fifty women treated with first line platinum and taxane-based chemotherapy had advanced carcinosarcoma of the ovary and were selected as cases. The response rates to chemotherapy for cases and controls were 62% and 83% (P =0.03), respectively. Median progression-free survival was 11months (95% CI, 8 to 14months) versus 16months (95% CI, 12 to 21months; P =0.02) and median overall survival was 24months (95% CI, 18 to 29months) versus 41months (95% CI, 33 to 49months; P =0.002) for cases and controls, respectively. Conclusion: Patients with advanced carcinosarcoma of the ovary have a poorer response to platinum and taxane-based first-line chemotherapy and worse survival, compared to patients with serous EOC. Aggressive surgical treatment may play an important role. However, other alternative systemic therapeutic approaches should be sought for patients with carcinosarcoma of the ovary. [Copyright &y& Elsevier]

Abstract: Objective: The aim of this study was to evaluate the survival impact of cytoreductive surgery and other prognostic determinants in patients with stage IIIC and IV uterine papillary serous carcinoma (UPSC). Methods: All patients with FIGO stage IIIC and IV UPSC who underwent surgical staging at the two participating institutions, between January 1, 1995 and December 31, 2007, were identified from the tumor registry database. The Kaplan–Meier method was used to generate overall survival (OS) data. Factors predictive of outcome were compared using the log-rank test and Cox regression analysis. Results: Analysis of 79 patients with stage IIIC–IV disease was performed. Optimal cytoreduction was associated with a median survival of 36months, compared with 12months for patients who underwent a suboptimal surgical effort (p =0.001), and a disease-free survival (DFS) of 21months vs. 10months (p =0.001), respectively. Regression analysis identified stage (HR=2.4, p =0.03), absence of visible residual disease (HR=0.5, p =0.03), and chemotherapy (HR=0.1, p <0.001) as independent predictors of OS. Conclusions: Cytoreduction to no gross residual disease and the use of platinum therapy are associated with a significant survival benefit for patients with stage IIIC–IV UPSC. Recommended management for this group of patients should consist of maximal surgical cytoreduction followed by platinum-based chemotherapy, preferably in combination with paclitaxel. Adjuvant radiation therapy should also be considered. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Endometrioid adenocarcinoma of the endometrium (EEC) is the most common histologic type of endometrial cancer, with stage being the most critical prognostic factor. Cervical involvement (CI), divided into IIA (epithelial involvement) and IIB (stromal invasion), is overall associated with decreased survival (70 vs 90%). However, the impact on prognosis of sub-stages IIA vs IIB is unclear. The purpose of this study was to investigate the prognostic significance of cervical involvement as well as its substaging in patients diagnosed with EEC. Methods: Eighty-one patients treated for stage II EEC were identified (1993–2003) in our institution. They were stratified into Group 1 (46) with available slides for review and Group 2 (35) with information obtained from the pathology report. All pathology reports, for all 81 patients, contained information on cervical glandular and stromal involvement. In Group 1, 1 to 6 slides of cervix (mean 3) were reviewed. Tumors were classified as Stage IIA or IIB according to the most recent FIGO criteria. Stromal invasion (SI) in Group 1 tumors was sub-classified in 4 subgroups based on depth of invasion; A) ≤1 mm; B) >1 mm and ≤3 mm; C) >3 mm and ≤5 mm and D) >5 mm. Other histopathologic parameters evaluated include grade, depth of myometrial invasion (MI), and lymphovascular invasion (LI). Clinical data included age, type of surgery, type of radiation, and survival. Statistical analysis was performed. Results: Patients ranged in age from 33–91 (median 64) years. In Group 1, 11 patients had stage IIA and 35 stage IIB tumors. Depth of SI ranged from 1–12 mm (mean 3.4 mm). The pathologists reviewing the slides in Group 1 agreed with the initial reported description of cervical glandular and stromal involvement. In Group 2, 15 patients had stage IIA and 20 stage IIB tumors with no further information regarding depth of SI. In Group 1, 12 EECs were Grade 1, 29 Grade 2, and 5 Grade 3. Thirty tumors had <50% MI, 15 showed >50% MI and LVI was present in 11. In Group 2, 13 tumors were Grade 1, 13 Grade 2, and 9 Grade 3. Twenty-one had <50% or no MI and 9 showed LVI. Median follow-up was 73 (range 5–210) months. Five- and 10-year survival rates were 83% and 78% for patients with stage IIA and 71% and 65% for stage IIB EECs respectively. By univariate analysis, age, MI, LVI and type of treatment affected survival but not substaging into IIA vs IIB or depth of SI. By multivariate analysis, only age (p =0.001), LVI (p =0.017), and type of treatment (p =0.022) were predictors of survival in stage II EECs. Conclusions: This study showed that the distinction between stage IIA and IIB or depth of SI does not affect survival in patients with EEC. LVI and type of hysterectomy performed were predictors of survival in stage II EECs. Our results suggest that substaging should be eliminated, women with suspect cervical SI should be offered a radical hysterectomy, and that the presence of LVI may be a useful tool in guiding recommendations about the need for adjuvant radiation therapy. [Copyright &y& Elsevier]

Abstract: Objective: Recent scientific advances have lead to the development of a prophylactic, quadrivalent HPV vaccine conferring. We surveyed Latino and non-Latino women directly to examine what motivates them to vaccinate themselves, their daughters, and their sons. Methods: A written survey was administered to 86 Latinas and 141 non-Latinas, ages 18–55, and attending a general medicine, gynecology, or pediatric unit at an academic center. The instrument included questions on demographics, knowledge and attitudes toward the HPV vaccine, attitudes toward HPV vaccination for the respondents'' daughters and/or sons, and the effect of vaccine acceptability on women''s attitudes towards their sexual behavior and cervical cancer screening practices. Results: Acceptance for the HPV vaccine was high, with 73% of non-vaccinated, eligible women stating that they would vaccinate themselves. Cervical cancer prevention was the primary motivation for seeking vaccination. Most respondents reported that vaccination should still be accompanied by cervical cancer screening. Seventy-percent of eligible respondent agreed to vaccinate their daughters (97% of Latino and 68.2% of non-Latino mothers, p =0.0078). Eighty-six percent of eligible participants agreed to vaccinate their sons (92.3% of Latino and 76.9% of non-Latino mothers, p =0.0490). Cervical cancer prevention and anal/penile cancer prevention were the primary motivation reported for accepting the vaccine in their daughters and sons, respectively. Fewer than 20% of eligible respondents cited protection of women against developing cervical cancer as the motivation to vaccinate their son(s). Conclusions: Among vaccine-eligible women, HPV vaccination acceptance for themselves, their daughters, and potentially their sons is high and primarily motivated by cancer prevention for the individual vaccinated. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the usefulness of pre-operative serum CA-125 in the management of women diagnosed with uterine papillary serous carcinoma (UPSC). We hypothesized that elevated pre-operative levels of serum CA-125 correlate with higher disease stage and poorer prognosis. Methods: Patients diagnosed with UPSC and managed in our institution were identified over a period of 10 years, 1995 to 2005. All required information were extracted from their records. The nonparametric test applied for comparison of data included Kruskal Wallis H-test and Man–Whitney U-test. The χ 2 test and Spearman correlation test were used to examine the association of serum CA-125 with different parameters. Receiver operator characteristic curves (ROC) were used to quantify marker performance. Recurrence and survival were analyzed using Kaplan–Meier method. Multivariate analyses were performed with a Cox proportional regression method. Results: A total of 41 patients met the study criteria. Mean pre-operative serum CA-125 levels were significantly higher in patients with stage IV (1150±1297 U/mL), compared with stage III (181±232 U/mL; P <0.001), stage II (22±9; P <0.001), and stage I (14±1; P <0.001). CA-125 correlated strongly with stage (r =0.68, P <0.001). On the ROC, a cut-off of 35 IU/mL provided the best sensitivity and specificity (78% vs. 100% respectively) for extra-uterine disease. Disease free survival (DFS) and overall survival (OS) were longer in patients with CA-125<35 U/mL compared with CA-125≥35 U/mL [median DFS not reached during study vs. 21.2 months (P =0.009), and median OS not reached during study vs. 25 months, (P =0.0001) respectively]. Multivariate regression model showed CA-125 as the only variable associated with survival (P =0.05). Conclusion: Pre-operative serum CA-125 levels correlate with stage of disease in patients with UPSC. This may be important for management planning, prognostication and counseling in these women. [Copyright &y& Elsevier]

Highlights: [•] 85% of cervical cancer cases occur in developing countries where it is the first or second cause of cancer-related death. [•] CONEP is a Central America initiative focused on education and training for the prevention and treatment of gynecologic cancers. [ABSTRACT FROM AUTHOR]