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To evaluate the impact of frailty on postoperative complications following cytoreductive surgery (CRS) with hyperthermic intra-peritoneal chemotherapy (HIPEC) in women with advanced or recurrent gynecologic cancer.An IRB-approved single-institution prospective registry was queried for women who underwent CRS with HIPEC for advanced or recurrent gynecologic cancer from 1/1/2014-12/31/2020. Frailty was defined as a modified Frailty Index (mFI) score of ≥2. Logistic regression was used to assess the impact of mFI upon the rate of moderate or higher (≥ grade 2) Accordion postoperative complications.Of 141 women, 81.6% (n = 115) were non-frail with mFI of 0-1 and 18.4% (n = 26) were frail with mFI ≥2. The incidence of ≥ grade 2 complications was 21.2% (n = 14) for mFI = 0, 26.5% (n = 13) for mFI = 1, 64.7% (n = 11) for mFI = 2 and 100.0% (n = 9) for patients with mFI ≥3. The incidence of re-operation (1.7% vs. 11.5%, p = 0.044), ICU admission (13.2% vs. 34.6%, p = 0.018), acute kidney injury (6.3% vs. 30.8%, p = 0.001), and respiratory failure (0.9% vs. 19.2%, p0.001) were significantly lower amongst non-frail vs. frail women. On multivariable analysis, mFI ≥2 was associated with significantly increased ≥ grade 2 complications versus mFI of 0-1 (OR 9.4, 95% CI 3.3, 26.4, p0.001). Age (OR 1.04, 95% CI 1.00, 1.09, p = 0.07), surgical indication (recurrent vs. primary) (OR 0.71, 95% CI 0.30, 1.7, p = 0.44) and Surgical Complexity Score of Intermediate or High vs. Low (OR 1.5, 95% CI 0.67, 3.5, p = 0.31) were not associated with ≥grade 2 complications.Frailty, defined by the modified frailty index, is predictive of ≥grade 2 postoperative complications following CRS with HIPEC in women with gynecologic cancer. Frailty screening before CRS with HIPEC may assist patient selection and improve postoperative outcomes.

Objective(s) To identify recurrence patterns and outcomes in women with advanced or recurrent epithelial ovarian cancer (EOC) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Methods This is an IRB-approved single-institution cohort study of women who underwent CRS+HIPEC for advanced or recurrent EOC followed in a prospective registry from 1/12/2014–3/1/2020. Recurrence locations were defined as pelvic, upper abdominal (UA) and/or extra-peritoneal (EP). Univariate analysis assessed associations between recurrence location, progression-free survival (PFS), and overall survival (OS). Results In total, 92 women with EOC underwent interval (56.5%; n=52) or recurrent CRS+HIPEC (43.5%; n=40). For interval CRS+HIPEC, recurrence locations were pelvic in 50.0% (n=15), UA in 23.3% (n=7) and EP in 56.7% (n=17); 40.0% (n=12) were EP alone. Similarly, for recurrent CRS+HIPEC, recurrence locations were pelvic (22.5%, n=9), UA (5.0%, n=2) and EP (60.0%, n=24); 66.7% (n=20) were EP alone. For both interval and recurrent CRS+HIPEC, median PFS was 10.5 vs. 13.0 months for pelvic and UA vs. EP only recurrences (p=0.02). Similarly, median OS was 29.2 months for pelvic and UA and not reached for EP only (p=0.05). For interval CRS+HIPEC, there was no difference in median PFS (10.6 vs. 11.7 months, p=0.68) and OS (27.1 vs. 24.8 months, p=0.96) for pelvic and UA vs EP alone. However, for recurrent CRS+HIPEC, pelvic and UA sites of recurrence were associated with reduced PFS (10.0 vs. 18.1 months, p=0.03) and OS (33.6 months vs. not reached, p=0.02) vs. EP only. Conclusions In women with advanced or recurrent EOC undergoing CRS+HIPEC, one-half of patients experience their first recurrence outside of the peritoneal cavity. Providers must be aware of the risk of EP failure in patients treated with CRS+HIPEC.

Objective(s) To evaluate the incidence and associated risk factors for anastomotic failure following interval debulking surgery (IDS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in women with advanced ovarian cancer. Methods We performed a retrospective cohort study in women with stage III/IV high-grade ovarian cancer treated with neoadjuvant chemotherapy followed by IDS with colorectal resection and HIPEC from 2017 to 2020. These patients were compared to a historical control cohort who underwent IDS with colorectal resection without HIPEC from 2009 to 2016. Data was collected for demographics, surgical variables, and perioperative outcomes. The univariate analysis compared progression-free survival and overall survival. Results 61 women were identified; 21 (34.4%) underwent IDS with HIPEC from 2017 to 2020, and 40 underwent IDS alone from 2009 to 2016. None of the patients who had IDS with HIPEC had protective ileostomy, compared to 10.0% of those who received had IDS alone (n = 4)(p = 0.29). The cumulative incidence of anastomotic leak rate was 8.2% (n = 5). There was no significant difference in anastomotic leak rate for women who underwent IDS with HIPEC (9.5%, n = 2) versus without HIPEC (7.5%, n = 3) (p = 0.99). While there was no difference in PFS (12.2 vs. 13.3 months, log-rank p = 0.31), OS (9.4 vs. 40.6 months, log-rank p = 0.013) was significantly decreased following postoperative anastomotic leak. Conclusions In this retrospective series of women with advanced ovarian cancer, HIPEC was not associated with increased risk for anastomotic leak at the time of IDS with colorectal resection and reanastomosis. While further study is needed, HIPEC alone should not preclude colorectal resection or dictate practices for colonic diversion in IDS.

Highlights • In this small series, HIPEC is well tolerated in patients with advanced USC. • HIPEC at IDS is associated with favorable PFS and OS in advanced USC. • Further investigation of HIPEC in women with advanced USC is warranted., Objective(s) To investigate the efficacy and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of iterval debulking surgery (IDS) in women with advanced uterine serous carcinoma (USC) following neoadjuvant chemotherapy (NACT). Methods An IRB-approved single-institution prospective registry was queried to identify women with incidentally identified USC at the time of IDS + HIPEC for high-grade serous carcinoma. Patient demographic, oncologic, and surgical outcomes data were recorded. Univariate analysis determined progression-free survival (PFS) and overall survival (OS). Results In total, seven patients were found to have advanced USC after undergoing IDS + HIPEC, with a median age of 64.5 years. The majority had stage IV, (n = 6, 85.7%), MMR proficient (n = 5, 71.4%), p53 mutant (n = 6, 85.1%) USC. The median pre-operative CA125 was 24.0U/mL. HIPEC regimen was cisplatin (n = 3, 42.9%) or cisplatin with paclitaxel (n = 4, 57.1%). All patients underwent optimal cytoreduction, with 71.4% (n = 5) having no gross residual disease. Accordion post-operative complications were mild in 14.3% (n = 1), moderate in 57.1% (n = 4) and severe in 14.3% (n = 1); 14.3% (n = 1) had no complications. The median length of stay was 6.5 days (IQR 4–8 days) with a median time to chemotherapy of 33.0 days. The median PFS was 14.0 months (95% CI 3.5–20.8 months), and the median OS was 27.0 months (95% CI 5.1- not reached). Conclusions In this small, prospective series, we demonstrate that IDS + HIPEC is well tolerated in patients with USC and is associated with favorable PFS and OS following NACT. Further prospective investigation is needed to validate these promising findings in larger, heterogeneous cohorts of women with advanced USC who are not candidates for primary surgical management.

ObjectiveTo evaluate perioperative outcomes in elderly versus non-elderly women with advanced or recurrent epithelial ovarian cancer undergoing surgery with hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsA single-institution prospective registry was analyzed for women with ovarian cancer who underwent surgery with HIPEC from January 2014 to December 2020. Elderly age was defined as ≥65 years at surgery. Complications were defined according to the Accordion scale. Univariate and multivariable analysis was used to compare progression-free survival and overall survival.ResultsOf 127 women who underwent surgery with HIPEC, 33.1% (n=42) were ≥65 and 17.3% (n=22) were ≥70 years old. The median age for non-elderly and elderly patients were 55.7±8.3 versus 72.0±5.4 years, respectively (pConclusionsIn this prospective registry of women with ovarian cancer, perioperative morbidity is not increased for non-elderly versus elderly patients following surgery with HIPEC. While age should not exclude patients from surgery with HIPEC, additional research is needed regarding oncologic benefits in elderly women.

Objectives: To investigate progression-free survival (PFS) and peri-operative outcomes in women with EOC undergoing interval debulking surgery (IDS) with hyperthermic intraperitoneal chemotherapy (HIPEC) with paclitaxel/cisplatin (PC) vs single-agent cisplatin (C). Methods: This study was an Institutional Review Board approved, a single-institution cohort study of women with stage III or IV high-grade EOC treated from 1/1/2017-3/1/2020, followed in a prospective HIPEC registry with at least six months of follow-up. HIPEC regimen was administered at primary surgeon's discretion: C alone (80-100mg/m2 for 90 minutes) or P (135-175mg/m2 for 90 minutes) with C (80-100mg/m2 for 45 minutes) in a perfusate of normal saline at 41-43C degrees for 90 minutes, as previously described.3 PFS was defined as months from HIPEC date to recurrence. A Log-rank test was performed for PFS between PC vs. C. A p-value of Results: In total, 54 eligible patients underwent IDS with HIPEC following 3-4 cycles of NACT with carboplatin and paclitaxel were identified from a prospectively maintained HIPEC registry. Patients underwent HIPEC with C (51.9%, n=28) or PC (n=26; 48.1%). All patients underwent optimal cytoreduction to less than 1cm of residual disease. There were no differences in patient demographics, including age (67.4 vs 63.3 years, p=0.10), race (p=0.99), medical co-morbidities (p > 0.05), and pre-operative American Society of Anesthesiologists (ASA) score (III or IV - 64.3% vs 80.8%, p=0.18) for those who received C vs. PC. Additionally, the majority of patients had stage III disease (77.8% vs 76.9%, p=0.87) and serous histology (100.0% vs 92.3%, p=0.23). There were no differences in operative time (6.0 hours vs 5.3 hours, p=0.11) or surgical procedures performed, including small bowel (3.6% vs 3.8%, p=0.99) and large bowel resection (17.9% vs 23.1%, p=0.63). Notably, no differences in the Accordion postoperative adverse events were appreciated (None – 42.9% vs 42.3%; Mild – 25.0% vs 38.5%; Moderate – 21.4% vs 7.7%; Severe – 7.1% vs 11.5%; Death – 3.6% vs 0.0%; p=0.46). Additionally, there was no difference in need for blood transfusion (50.0% vs 57.7%, p=0.57), intra-operative vasopressor use (75.0% vs 92.3%, p=0.14) or ICU admission (7.1% vs 26.9%, p=0.07) The median PFS for the entire cohort was 15.7 months. However, when stratified by treatment regimen, PFS was 10.9 vs 22.2 months for C vs PC, respectively (HR 0.38, 95% CI 0.18, 0.81, p=0.009) (Figure). Conclusions: In this analysis of a prospective HIPEC registry, we demonstrate that PC is associated with a significantly improved PFS compared to C, without increased postoperative morbidity in patients with optimally cytoreduced stage III/IV EOC undergoing IDS with HIPEC. While further study is ongoing regarding overall survival benefit, consideration should be given for incorporation of P with C at the time of IDS with HIPEC. Download : Download high-res image (145KB) Download : Download full-size image

Objectives: We sought to create a laparoscopic-based model to predict the ability to perform a minimally invasive (MIS) cytoreductive surgery in advanced epithelial ovarian cancer patients who have received neoadjuvant chemotherapy (NACT). Methods: A total of 50 women with at least a partial response by RECIST 1.1 criteria to NACT were enrolled in a multi-institutional prospective pilot study (MIID-SOC trial- NCT03378128). Each patient underwent laparoscopic evaluation of 43 abdominopelvic sites followed by primary surgeon dictated surgical approach, either continue laparoscopically (MIS) or laparotomically. However, if the procedure was to continued MIS, the placement of a hand-assist port for manual palpation was mandated as to emulate a laparotomic approach and all 43 sites were re-evaluated. A total of 2 patients could not be evaluated by laparoscopy because of dense adhesions, 2 patients did not undergo cytoreductive surgery as the laparoscopy deemed the patient unresectable, and 1 patient withdrew consent prior to surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each site to predict resectability via the MIS approach. Based on statistical probability of each factor predicting cytoreductive approach, 10 abdominopelvic sites were selected for inclusion in the final model. Each parameter was assigned a numeric value based on the strength of statistical association and a total predictive index score (PIV) was assigned for each patient. Receiver operating characteristic curve analysis (ROC-AUC) was used to assess the ability of the model to predict the MIS surgical approach. Statistical significance was evaluated using Fisher's exact test. Download : Download high-res image (76KB) Download : Download full-size image Results: A total of 28 patients (61%) underwent MIS cytoreductive surgery. All patients had an optimal cytoreductive surgery ( Download : Download high-res image (432KB) Download : Download full-size image Conclusions: In this model, a PIV of

Objective To determine peri-operative outcomes in women with advanced epithelial ovarian cancer (EOC) undergoing interval debulking surgery (IDS) with hyperthermic intraperitoneal chemotherapy (HIPEC) via minimally invasive interval debulking surgery (MIS) or laparotomy (LAP). Methods A single institution, retrospective cohort study was performed in women with EOC who underwent IDS with HIPEC from 2017 to 2019 via MIS or LAP. Peri-operative outcomes were compared using univariate analysis. Results In total, 50 eligible women were identified; ten (20.0%) underwent MIS + HIPEC and 40 (80.0%) LAP + HIPEC. The median age of patients in the MIS group was 71.1 vs. 64.2 years in LAP (p = 0.031). There was no significant difference in pre-operative complete radiographic response following NACT (p = 0.18). Notably, there was no difference in the rate of R0 resection (70.0% vs. 77.5%; p = 0.39). There was no significant difference in ICU admission, estimated blood loss, operative time, or use of vasopressors between the cohorts. Similarly, there was no difference in 30-day adverse events for MIS vs. LAP, but length of stay was decreased for those who underwent minimally invasive procedures (3 vs. 4 days, p = 0.016). Time to initiation of chemotherapy following surgery was not significantly different between groups (26.2 days vs 32.0 days, p = 0.090). With median follow-up of 15.1 months, there was no difference in recurrence free survival (median 15.0 vs 17.2 months log-rank, p = 0.30) for MIS vs. LAP. Conclusions In this retrospective cohort study, we demonstrate that in women with advanced EOC, HIPEC with MIS at the time of IDS following NACT is feasible. Our institutional experience demonstrates similar rates of R0 cytoreduction, compared to LAP. An MIS approach should not prevent surgeons from utilizing HIPEC where indicated for management of advanced EOC., Highlights • When comparing MIS and LAP at time of HIPEC, no differences are observed in adverse perioperative outcomes. • MIS was associated with shorter hospitalization and with no significant difference in the rate of R0 resections. • Patient candidacy for an MIS IDS should not prevent surgeons from utilizing HIPEC in appropriate candidates.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) may be used to treat peritoneal based malignancies, such as epithelial ovarian cancer (EOC). Despite results of clinical trials supporting an increasing indication for HIPEC in EOC, concerns have existed regarding morbidity and challenges with initiating HIPEC at an institutional level. The objective of this review is to describe evidence-based recommendations to guide implementation of a HIPEC program, following our experience at a high-volume tertiary care center. Establishing a HIPEC program requires building a multi-disciplinary team, including gynecologic oncologists, anesthesia, nursing, perfusionists and pharmacists. Team members require education regarding HIPEC protocols, toxic waste and spill management, and personal protective equipment (PPE). Required equipment includes chemotherapy certified PPE and a HIPEC pump which is connected to inflow and outflow catheters placed within the peritoneal cavity. During the procedure, 3–6 L of a hyperthermic perfusate, composed of a isotonic crystalloid vehicle and the chemotherapy of choice, is infused through the peritoneal cavity with goal temperature of 41–43 °C. Prior to HIPEC infusion, surgical teams must communicate with anesthesia and pharmacy. In patients receiving HIPEC with cisplatin, furosemide and mannitol should be administered one hour prior to chemotherapy to ensure adequate diuresis. Sodium thiosulfate may also be considered for renal protection (van Driel et al., n.d. [3]). We utilize a multi-agent pre-medication protocol prior to HIPEC infusion to reduce hypersensitivity reactions, renal toxicity and post-operative nausea and vomiting. Limited data exists to support the optimal regimen for HIPEC at the time of CRS in women with EOC. From our experience, we favor use of cisplatin 100 mg/m2 alone or in combination with paclitaxel 135–175 mg/m2 with 90 min of total perfusion time. Close attention to temperature and glycemic control is essential during the procedure, as electrolyte derangements including hyperglycemia, lactic acidosis and hypokalemia may occur. Continuous patient monitoring and proactive management of abnormalities that arise during HIPEC is imperative to decrease patient morbidity and mortality.

Objective The utility of adjuvant therapy for women with uterine confined leiomyosarcoma remains uncertain. We sought to identify trends, analyze efficacy, and assess survival impact of adjuvant therapy in this patients. Methods We performed an observational cohort study of 1030 women with early stage leiomyosarcoma from the 2008–2014 National Cancer Database. Multi-nominal logistic regression was used to identify trends in receipt of adjuvant treatment. Demographic and clinical characteristics were compared. Kaplan-Meier curves were used to estimate survival. Results There were 547 who (53.1%) received observation, 79 (7.7%) received radiation alone, 340 (33.0%) received chemotherapy alone, and 64 (6.2%) received chemoradiation. Patients were more likely to be observed if tumor size was 5 cm, and LVSI with worsened survival, with the strongest predictor of mortality being the presence of LVSI. With a median survival of 61.9 months, there was no difference in estimated overall survival at 1 and 3 years based on receipt of adjuvant treatment as compared to observation (p=0.500). Conclusion Although women with uterine confined leiomyosarcoma experience high recurrence rates and poor survival outcomes, adjuvant treatment does not appear to confer a survival benefit.

Introduction Hyperthermic intraperitoneal chemotherapy following cytoreductive surgery (CRS) is a treatment strategy that has been evaluated in recurrent ovarian cancer. The aim of this study was to examine if survival was similar regardless of platinum sensitivity. Methods A retrospective study of women with recurrent platinum sensitive or resisteant epithelial ovarian cancer who were treated with cytoreductive surgery (CRS) and HIPEC between the years 2010–2018 was performed. Recurrence free (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Results Thirty-five (72.9 %) were platinum sensitive (PS) and 13 (27.1 %) were platinum resistant (PR). The complete cytoreduction (R0) rate was higher in the PS patients as compared to PR (85.7 % vs 53.8 %; p = 0.017). Median follow-up was 16.9 (range, 11.7–34.5) months. The median recurrence free survival in the patients who had a R0 resection was 22.3 months in PS and 11.1 months in PR patients (p = 0.017), respectively. Median overall survival was 26.9 months in the PR patients, while it had not been reached in the PS patients. In the patients with PS recurrence, the mean treatment free interval (TFI) prior to HIPEC was 1.6 years and following HIPEC, 40 % of those patients were recurrence free at 2 years. In the patients with PR recurrence, the mean TFI prior to HIPEC was 4.6 months and following HIPEC, 61.5 % of those patients had a longer TFI, with a mean increase of 10.1 months. Conclusion Although surgery is not considered standard treatment in PR ovarian cancer, in carefully selected patients, surgery with HIPEC could extend the treatment-free interval.

e17570 Background: In 2010, Nout et al. reported on PORTEC-2, which randomized patients with high intermediate risk (HIR) endometrial cancer to adjuvant vaginal brachytherapy or pelvic radiotherapy or observation, and showed that vaginal brachytherapy was non-inferior in terms of locoregional control and was deemed the adjuvant treatment of choice for these patients. We sought to evaluate the adherence to and the oncologic outcomes of the PORTEC-2 regimen. Methods: We utilized the SEER database to identify patients who met PORTEC-2 inclusion criteria. All patients underwent surgery followed by either vaginal brachytherapy (VBT) or whole pelvic radiotherapy (WPRT). Inclusion criteria were patients with the following characteristics: grade 1 with ≥ 50% myometrial invasion (MI), grade 2 with any invasion, and grade 3 with < 50% MI. Patients were excluded if any lymph nodes were examined or involved, if they received any chemotherapy, or had any missing values for any of the variables. HIR endometrial adenocarcinoma was defined as the presence of 2 of the following: age > 60, grade 3, and ≥50% myometrial invasion. Radiation status was extracted from the SEER Radiation/Chemotherapy database. Outcomes were overall death, cancer specific death and total survival months per SEER’s standard definitions. Variables are reported as median and interquartile range (IQR) or number (%). Mean survival was calculated using Kaplan Meier analysis and Mantel-Cox rank test was done to test for statistical significance between the study groups. Cox regression analysis was performed, and hazard ratios (HR) were calculated. Statistical analysis was performed using SPSS v. 22.0. Results: Between 2005- 2015, 571 patients met PORTEC-2 inclusion criteria of whom 349 (61.1%) and 222 (38.9%) received WPRT and VBT, respectively. We showed that the rate of VBT was significantly increased from 85 (27.4%) between 2005-2010 to 137 (52.5%) between 2011-2015 (p < 0.001). There was no difference in grade and myometrial invasion between the study groups. Kaplan Meier analysis showed a 22.5 and 16.3 month improvement in overall and cancer specific survival in subjects who underwent VBT as compared to WPRT, respectively (p < 0.001 for both). Cox regression analysis revealed a 36% and 66% decrease in the hazard of overall and cancer specific death, respectively, in the VBT group as compared to WPRT group (Overall death: HR = 0.64, 95% CI: 0.45-0.91, p = 0.012; Cancer specific death: HR = 0.34, 95% CI: 0.16-0.73, p = 0.006). Conclusions: Administration of vaginal brachytherapy following surgery has become significantly more popular after publication of the PORTEC-2 results in 2010. Our study shows a significant decrease in both overall and cancer related death and an increase in survival with VBT over WPRT in patients with HIR endometrial cancer.

Highlights • Cisplatin induced nephrotoxicity can occur days after administration. • Hyperthermic intraperitoneal chemotherapy with cisplatin for ovarian cancer is increasing in utilization. • Sodium thiosulfate can be used following cisplatin induced nephrotoxicity for treatment.

In patients with early-stage cervical cancer, radical hysterectomy and pelvic lymphadenectomy is the gold standard. However, this disease commonly affects women of childbearing age; thus an option to spare fertility is ideal. This option came to fruition in the early 90s when the Dargent procedure or radical trachelectomy was first reported. The procedure has subsequently been modified as technology has improved and now may be performed via minimally invasive techniques. Additionally, with the advent of the sentinel lymph node procedure, the morbidity in this usually young patient population has continued to improve. There is a multitude of data to show that oncologic outcomes, concerning recurrence and mortality, are comparable to radical hysterectomy, as well as obstetrical outcomes are favorable. Data to support its acceptance within the gynecologic oncology community has led to radical trachelectomy being implemented into governing body guidelines and should be offered to appropriate candidates with early-stage cervical cancer who wish to preserve fertility.

ObjectiveThe objective of this study was to assess the scope of intestinal surgery training across gynecologic oncology fellowships in the United States and identify factors associated with perceived preparedness to perform intestinal surgery independently.Materials/MethodsAn institutional review board–approved survey was distributed to Society of Gynecologic Oncology fellows and candidate members within the first 3 years of practice. Questions addressed demographics, operative experience, preparedness and plans for performing intestinal surgery, and attitudes toward gynecologic oncologists (GOs) performing intestinal surgery. Responses were analyzed using descriptive statistics as well as univariate and multivariate analyses.ResultsOf 374 Society of Gynecologic Oncology members invited, 108 (29%) responded, including 38 fellows (35%) and 53 recent graduates (49%). Fifteen (14%) reported more than 3 years of practice and were excluded. Most participants (96%) received intestinal surgery training from GOs, and 64% reported that all faculty routinely performed intestinal surgery. Most participants (81%) believed GOs should perform intestinal procedures, whereas only 58% felt prepared and 59% planned to perform intestinal procedures independently. Fellows who performed more than 10 intestinal diversion procedures, participated directed in intestine-related intraoperative consultations, or reported that all faculty performed intestinal surgery were more likely to feel prepared to perform intestinal surgery independently. Sex, training region, intended practice environment, and fellowship curriculum were not associated with preparedness to perform intestinal surgery.ConclusionsAlmost half of gynecologic oncology fellows and recent graduates in the United States do not feel prepared to perform intestinal procedures independently after fellowship. Increased volume and direct involvement of fellows in intestinal surgery may improve preparedness for performing intestinal surgery after fellowship.

Background In response to the critical shortage of liposomal doxorubicin (Doxil®) in the United States, the Food and Drug Administration (FDA) approved temporary importation of doxorubicin hydrochloride liposome (Lipodox®). The objective was to compare toxicity and clinical activity of Lipodox® with Doxil®. Methods Recurrent ovarian cancer patients who received Lipodox® were compared 3:1 to matched control Doxil® patients who had received Doxil®. Patients were matched based on age, stage, dose, platinum sensitivity, and prior treatments from an existing de-identified database. Patients receiving combination regimens were excluded. Results The data from 40 Lipodox® patients was compared to 120 matched control Doxil® patients. In this study, 17 (42.5%) of the Lipodox® patients were switched to Doxil®. The overall response rate Lipodox® was 4.3% (1/23) compared to 18% (20/111) in matched control Doxil® patients. In the platinum-sensitive patients, 100% progressed in the Lipodox® group compared to 78.4% in matched control Doxil® patients. The mean time to progression was 4.1 ± 2.8 months for Lipodox® and 6.2 ± 7.2 months in control Doxil®s ( p = 0·25). Toxicity was similar in the Lipodox® group and control Doxil® group. Conclusion Lipodox® for treatment of recurrent ovarian cancer did not appear to have equivalent efficacy compared to Doxil®. A prospective clinical study is warranted before Lipodox® can be deemed equivalent substitution for Doxil®.

Stercoral perforation of the colon, though rare, is associated with high mortality. Review of the literature identified only three prior cases reported during pregnancy. We report a case on a multiparous female presenting at 31 weeks of gestation with acute abdominal pain. Computed tomography suggested a sigmoid colon perforation. An urgent exploratory laparotomy was performed where feculent peritonitis and a stercoral perforation of the sigmoid colon was confirmed. A cesarean delivery and sigmoid colectomy with descending end colostomy was performed. While the newborn had an uncomplicated course, the mother developed an intra-abdominal abscess requiring operative management.

BACKGROUND Anastomotic leak after colorectal surgery is a significant cause of morbidity and mortality. The aim of this study was to evaluate the impact of a reinforced colo-colonic anastomosis with tissue adhesive, 2-octylcyanoacrylate (2-OCA), on the integrity of anastomotic healing as measured by anastomotic bursting pressure. METHODS Sixty-eight female Sprague-Dawley rats underwent a rectosigmoid colon transection and a sutured end-to-end anastomosis followed by randomization to receive no further intervention or reinforcement with the tissue adhesive, 2-OCA. After seven postoperative days, a macroscopic assessment of the anastomosis, mechanical assessment to determine anastomotic bursting pressure, and a detailed semi-quantitative histopathologic healing assessment were performed. RESULTS Thirty-four animals were randomized to each group. Study characteristics did not differ between the groups. There was also no difference in the degree of adhesions present postoperatively. Although there was no difference between the net proximal and distal luminal areas in the two groups (0.37 cm2versus 0.55 cm2, P = 0.26), the 2-OCA group exhibited evidence of stricture in 15% of anastomoses as compared with 3% in the suture-only group (P

Objective: To compare cone specimen size between loop electrosurgical excision procedure (LEEP) and cold knife cone (CKC), and evaluate the association between specimen size and margin status. Methods/materials: A retrospective review was performed of women with adenocarcinoma in situ (AIS) who underwent CKC or LEEP between 1998 and 2013. Specimen size, including length (distance from the external cervical os to the endocervical margin) and volume were compared between LEEP and CKC, and correlated with margin status. Results: Eighty-five patients underwent a total of 136 procedures, including 91 CKCs (67%) and 45 LEEPs (33%), with 27 removed as a single specimen (one-piece LEEP) and 18 as two specimens with an ectocervical specimen and a deeper endocervical top-hat specimen (two-piece LEEP). The two-piece LEEP specimen median length was significantly longer (2.1 cm) versus CKC (1.4 cm, p3) versus CKC (3.4 cm3, p3, pConclusion: Our results suggest that a two-piece LEEP produces a larger specimen size with similar rates of positive margins compared with CKC. Given the decreased cost and morbidity compared with CKC, a two-piece LEEP should be considered in the management of women with AIS.

Objectives Because of the frequent detection of carcinoma in surgical specimens after hysterectomy for endometrial complex atypical hyperplasia (CAH), it has been suggested that patients with a preoperative diagnosis of CAH be referred to gynecologic oncology for potential lymphadenectomy. However, the risk of lymph node metastasis in such patients is unknown. We sought to determine the risk of endometrial cancer and to estimate the risk of lymphatic spread in women with a preoperative diagnosis of CAH. Study design We retrospectively reviewed the medical records of 150 consecutive patients with a preoperative diagnosis of CAH who subsequently underwent hysterectomy. Clinical characteristics and pathologic information were abstracted. Risk of lymphatic spread was modeled using previously published criteria and nomograms. Results Fifty-five of the 150 patients (36.7%) had an incidental endometrial carcinoma at the time of hysterectomy. Among patients with a preoperative office biopsy compared to dilation and curettage, the rate of an incidental finding of cancer was 43.5% and 28.1%, respectively ( p =0.054). Of patients with cancer, 1 (1.8%) had a grade 3 endometrial carcinoma, 4 (7.3%) had lymphovascular space involvement, and 6 (10.9%) had deep (>50%) myometrial invasion. For the 10 patients who underwent lymphadenectomy, one (10%) had lymph node metastases. Based on multiple models, the estimated risk of lymph node spread was 1.6%–2.1% for all women with a preoperative diagnosis of CAH and 4.4%–6.8% for the 55 women with endometrial cancer. Conclusions Given the high rates of underlying endometrial cancer and the potential need for lymphadenectomy, care for patients with a preoperative diagnosis of CAH desiring definitive management with hysterectomy should be referred to a gynecologic oncologist.

Objective Cervical adenocarcinoma in situ (AIS) is increasing in incidence among reproductive-age women. Cervical conization is an alternative to hysterectomy that allows future fertility, however reports regarding the risk of residual AIS and underlying adenocarcinoma are conflicting. The purpose of this study was to determine the outcomes of a large cohort of women treated for AIS. Methods The medical records of 180 women with cervical AIS evaluated at the University of Texas MD Anderson Cancer Center and its outlying clinics between 1983 and 2011 were reviewed for demographic information, treatment history, pathologic findings and outcomes. Results The mean age at diagnosis was 33.8years (range 17.6–76.1years). 172 of the 180 women had at least one cone biopsy performed, with 110 (64.0%) undergoing a cold knife cone (CKC), and 62 (36.0%) undergoing a loop electrosurgical excision procedure (LEEP) as their initial method of treatment. Positive margins were noted in 35.0% of patients undergoing CKC compared with 55.6% undergoing LEEP (p=0.017). 71 patients ultimately underwent hysterectomy with residual disease noted in 10 patients (14.1%), 8 patients (11.3%) with residual AIS and 2 patients (2.8%) with invasive carcinoma. Of the 101 patients who did not undergo hysterectomy, 2 patients (2.0%) developed recurrent AIS at a median of 27.5months (range 18–37months) from the last cone, and none developed invasive carcinoma. Conclusion Patients undergoing conservative management for AIS with cervical conization alone should be monitored closely and counseled regarding the potential risks of residual and recurrent disease, even when negative cone margins are obtained.

► Recurrent invasive adenocarcinoma after definitive therapy for AIS is a rare occurrence. ► Because of its unpredictable nature, AIS requires long-term and close surveillance.