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We aimed to evaluate the feasibility and tolerability of hyperthermic intraperitoneal carboplatin (HIPEC-carboplatin) following secondary cytoreduction for recurrent, platinum-sensitive ovarian cancer.In a single institution prospective, pilot study, ten patients underwent secondary cytoreductive surgery followed by HIPEC-carboplatin at 1000 mg/m(2). Consolidation (6 cycles) was with platinum-based regimens. Adverse and quality of life were measured throughout treatment.Twelve patients were enrolled of which 2 were excluded (one each for extra-abdominal disease indentified before surgery and suboptimal cytoreduction). All 10 remaining patients received prescribed HIPEC-carboplatin. There were no intra-operative complications or AEs attributable to HIPEC-therapy. Grade 1/2 nausea was the most common post-operative toxicity (6/10 patients). Two patients had grade 4 post-operative neutropenia and thrombocytopenia but only one experienced transient treatment delay. The median hospital stay was 5.5 days. 69/70 (98%) of planned chemotherapy doses were ultimately delivered with 1 patient electively forgoing her final treatment. At a median (range) follow-up of 16 (6-23) months, three patients have recurred at 8, 14, and 16 months from surgery. The median disease-free and overall survivals have not been reached. Fact-O scores were significantly lower following surgery (126 vs. 108, p.01), but improved by completion of therapy (108 vs. 113, p=0.27).HIPEC-carboplatin at 1000 mg/m(2) following optimal cytoreduction for ovarian cancer is feasible. Surgical complications were not observed, and post-operative AEs were largely within expected ranges. Consolidation using standard platinum-based regimens was feasible following HIPEC-carboplatin, and preliminary survival data suggests efficacy. Further investigation of HIPEC-carboplatin in the setting of debulkable cancer recurrence is warranted.

Objective This study was undertaken to evaluate the integrity of the loop-to-strand knot when tied with square and nonidentical sliding knots. Study design The synthetic absorbable monofilament suture poliglecaprone 25 in 0 and 2-0 suture gauges was used in this experiment. For each suture gauge, 3 groups of knots were tested: (1) single strand-to-single strand, flat square knot, (2) loop-to-single strand, flat square knot, and (3) loop-to-single strand, nonidentical sliding knot. All knots were tied with 6 throws. The proportion of knots becoming untied was compared among the 3 groups for each suture gauge. Ultimate load required to untie or break knots within each group was also evaluated. Results The loop-to-strand knot performed well in both suture gauges tested as long as it was tied with a flat square knot. The loop-to-strand knot tied with a nonidentical sliding knot had an unacceptably high failure rate. Conclusion The loop-to-strand termination of a continuous suture may be acceptable when tied with a 6-throw flat square knot but not acceptable if tied with sliding knots.

Objective The study was performed to test the knot integrity of parallel and nonidentical sliding knots with the use of monofilament suture. Study design We investigated the proportion of parallel sliding knots that become untied compared with nonidentical sliding knots in four different monofilament suture configurations: group A, 6 throws, 0-0 gauge; group B, 10 throws, 0-0 gauge; group C, 6 throws, 2-0 gauge; group D, 10 throws, 2-0 gauge. Each combination was tested 20 times, for a total of 160 knots. Results The nonidentical sliding knot untied 40% of the time in group A compared with 0% for the parallel knot (P = .003). In the other 6-throw group, group C, 45% of the nonidentical knots became untied compared with 0% of the parallel knots (P = .001). There were no significant differences in the proportions of untying for each knot type in the 10-throw groups. Conclusion Parallel sliding knots demonstrate superior knot integrity compared with nonidentical sliding knots with monofilament suture. The addition of throws to the nonidentical knot improves its knot security.

Subpubic cartilaginous cysts were initially described in 1996 with few reports to date.We describe a 62-year-old woman with a history of breast cancer who presented with a painful, fixed, vulvar mass. MRI revealed an 18 x 10 x 12 mm3 mass extending from the anterior portion of the symphysis pubis without bony involvement. Excision was performed. Histologically, the mass consisted of fibrocartilage with extensive degenerative changes, compatible with a subpubic cartilaginous cyst. Over 24 months later, there has been no recurrence.Subpubic cartilaginous cyst is a rare, benign lesion occurring on the vulva and should be considered in the differential diagnosis of a painful, superior vulvar mass.

Objective To determine feasibility and efficacy of administering docetaxel and carboplatin chemotherapy followed by pelvic radiotherapy and then consolidation chemotherapy in patients with advanced or recurrent endometrial cancer. Methods Patients with surgically staged III–IV (excluding IIIA from positive cytology alone) endometrial cancer or biopsy confirmed recurrent disease were eligible. Treatment consisted of 3 cycles of docetaxel (75mg/m 2 ) and carboplatin (AUC 6) on a q21 day schedule followed by involved field irradiation (45Gy)±brachytherapy and three additional cycles of docetaxel and carboplatin. Kaplan–Meier (KM) methods estimated overall survival (OS) and progression free survival (PFS). Results Forty-two patients enrolled, 7 did not complete therapy. 95% (39/41) had primary disease. Median age=58years (range: 21–81years). 78% (32/41)=endometrioid histology. Stages=10 IIIA, 21 IIIC, 1 IVA, 7 IVB, (recurrent=1 IC, 1 IIA). There were 23 non-hematologic and 14 grade 3 and 16 grade 4 hematologic toxicities. Seven patients died following treatment with a median follow-up of 28months (range: 7–70months). KM estimates and 95% confidence intervals for OS at 1year were 95% (82–99%), at 3years 90% (75–96%), and at 5years 71% (45–86%). Of the 39 with primary disease, 11 progressed or died within 5years of study enrollment. KM estimates and 95% confidence intervals for PFS at 1year were 87% (72–94%), at 3years 71% (51–83%), and at 5years 64% (42–80%). Conclusions "Sandwiching" radiation between chemotherapy for advanced or recurrent endometrial cancer merits further development based on the reported PFS and OS.

We sought to determine if patient age influenced chemotherapy completion rate, complication rate, or progression free survival (PFS) among patients who received intraperitoneal (IP) chemotherapy for epithelial ovarian, fallopian tube, or primary peritoneal cancers.Charts for patients receiving IP chemotherapy between January 2006 and September 2009 were reviewed at three institutions. Primary outcomes included completion rate of planned IP chemotherapy, complication rate, and PFS. Completion rates were categorized as 0-49%, 50-99%, or 100% of planned treatments were delivered. The tolerability of IP versus intravenous (IV) chemotherapy was also compared among patients ≥ 70 years.One hundred nine patients receiving IP chemotherapy were identified, 86 were70 years and 23 were ≥ 70 years. All patients received IP cisplatin and paclitaxel in combination with IV paclitaxel or docetaxel. Patients ≥ 70 years old were less likely to complete all planned cycles of IP chemotherapy than the younger cohort (OR = 0.33, 95% CI 0.13-0.83, p = 0.01), but there was no significant association between age and complication rate or PFS (p = 0.82 and p = 0.68, respectively). Optimally debulked patients ≥ 70 years receiving IV chemotherapy completed more cycles than patients ≥ 70 receiving IP chemotherapy (p0.01).Although elderly patients appear to tolerate fewer cycles of IP chemotherapy, they do not have higher objective complication rates or impaired PFS compared to younger patients. Age alone should not limit access to IP chemotherapy.

Objective We sought to evaluate the outcomes and feasibility associated with delivering sequential chemotherapy and radiation in advanced stage endometrial cancer. Methods We conducted a retrospective analysis of patients treated at the University of Minnesota with sequential chemotherapy and radiation for advanced stage endometrial cancer from 1999 to 2007. Inclusion criteria were endometrial cancer patients treated with comprehensive surgical staging followed by adjuvant therapy consisting of sequential chemotherapy, radiation, and consolidation chemotherapy in a "sandwich" fashion. Progression free survival (PFS) and overall survival (OS) were calculated by Kaplan–Meier (KM) method. Results Twenty-three patients met entry criteria and were included in the analysis. The median age was 57 years (range 28–78). The majority of patients were stage III (78%) and the most common histologic type was serous (52%). The combination of a taxane and carboplatin was administered in 100% of cases. All planned cycles of chemotherapy were completed (100%) with the majority being prescribed six cycles (82%). Of the 23 patients, 5 progressed of which 3 died during the follow up period. The KM estimate of 1, 3, and 5 year PFS is 100%, 80%, and 74%, respectively. The KM estimate for 1, 3, and 5 year OS is 100%, 88% and 79%, respectively. Conclusion Adjuvant therapy delivered in a "sandwich" fashion was feasible, well-tolerated and resulted in excellent long-term progression free and overall survival. A prospective study is currently ongoing at our institution.

Background Despite increasing use of intraperitoneal chemotherapy the optimal delivery strategy and regimen remain undetermined. Catheter-related complications have been reported in 3–34% of cases across a number of platforms and port styles, but few data compare different catheters directly. We sought to evaluate the complication rate of two separate intraperitoneal chemotherapy port delivery systems used within a single practice. Methods We reviewed the medical records of all patients who underwent port placement in our practice (two surgical centers) from January, 2006 through October, 2008. Data extracted included: demographics, medical co-morbidities, port type, timing of placement, intraoperative procedures, reasons for discontinuation of IP chemotherapy, and number of completed cycles. Results We identified 85 patients who had intraperitoneal ports placed. Four patients were excluded from this analysis: 2 declined chemotherapy and 2 were treated at other institutions and follow-up data was insufficient. Fifty-two (64%) of the 81 patients analyzed had a fenestrated port placed, and 29 (36%) had single lumen ports. In 67 cases (83%) the port was placed at the time of initial cytoreductive surgery. In 14 patients (17%) it was placed as a secondary event. The groups were well matched for age, stage, BMI, and medical co-morbidities though the group with single lumen catheters had more antecedent surgeries. We observed no significant difference between patients with single lumen or fenestrated ports with regard to: number of intraperitoneal treatments, catheter-related complications, hematologic outcomes, and rates of discontinuation. Conclusions A low rate of catheter-related complications is observed with both systems. The majority of discontinuations were due to hematologic complications and did not appear to be intrinsic to catheter choice.

The aim of the study was to determine the effectiveness of whole-body [18F]fluoro-2-deoxyglucose positron emission tomography (FDG PET) imaging in properly selecting candidates for radical hysterectomy who are at low risk for subsequent chemoradiation. Retrospective study of 14 women undergoing planned radical hysterectomy and pelvic lymphadenectomy with clinically localized cervical cancer and either negative or inconclusive metastatic nodal disease by PET scan was performed. Pelvic lymph nodes were clearly negative by FDG PET scan in 12 of the 14 women. Two women had focal FDG uptake suspicious, although not definitive, for nodal metastasis, and pelvic nodes were positive at surgery in both. Computed tomography (CT) scan failed to detect nodal disease in either woman. Neither PET nor CT was effective at detecting parametrial disease, and both also failed to detect the primary tumor in some cases. Women with FDG PET scans that are clearly negative for nodal disease are good candidates for radical hysterectomy and are at low risk for subsequent chemoradiation.

Objective. To describe the incidence of retroperitoneal pelvic or paraaortic lymph node metastasis in patients with primary and recurrent ovarian granulosa cell tumors. Methods. At Memorial Sloan-Kettering Cancer Center, we conducted a retrospective chart review of all patients with ovarian granulosa cell tumors managed as inpatients from January 1991 to July 2005. The initial date of diagnosis ranged from 1971 to 2005. Results. We identified 68 patients with a median age of 49 years (mean, 47.5 years; range, 19–78 years). Sixty-four (94%) patients had adult type and 4 (6%) had juvenile granulosa cell tumors. Fifty-three (78%) patients had their initial surgery at another institution and 55 (81%) were incompletely surgically staged at diagnosis due to the absence of pelvic and/or aortic lymph node dissection. Patients were assigned an International Federation of Gynecology and Obstetrics (FIGO) stage that included IA, 39; IC, 15; IIB, 3; IIC, 3; IIIC, 1. In 7 patients, the original stage was not assigned. Only 16 (24%) patients had a pelvic lymph node sampling and 13 (19%) also had a paraaortic lymph node sampling at primary surgery or at restaging surgery performed shortly following initial diagnosis; however, in these cases, lymph nodes were negative for metastasis. The median number of pelvic lymph nodes removed was 10 (mean, 11.6 nodes; range, 0–36 nodes). The median number of paraaortic lymph nodes removed was 4 (mean, 6 nodes; range, 0–19 nodes). Nine of 15 (60%) of patients managed initially at our institution were surgically staged compared to 4 of 53 (7.5%) who were managed initially elsewhere ( P Thirty-four patients with recurrent granulosa cell tumors were managed during the study, 31 (91%) had adult type granulosa cell tumor, and 3 had juvenile histology. Thirty-three of 34 patients who recurred were incompletely surgically staged at the initial operation. Original "clinical" FIGO stage for patients who recurred included IA, 15; IC, 8; IIB, 1; IIC, 3; IIIC, 1; and in 6 patients, the original stage was not available. The median disease-free interval to first recurrence was 63 months (mean,69.4 months; range, 4–170 months). First recurrence sites included pelvis, 24/34 (70%); pelvis and abdomen, 3 (9%); retroperitoneum only, 2 (6%); pelvis and retroperitoneum, 2 (6%); pelvis/abdomen/retroperitoneum, 1(3%); abdomen only, 1 (3%); and bone, 1 (3%). Conclusions. Complete surgical staging was performed in approximately 1/5 women with ovarian granulosa cell tumors; however, in those initially surgically staged, no nodal metastasis was identified. Clinical stage IA disease was the most common original diagnosis in women who recurred, and approximately 15% of first recurrences appear to involve the retroperitoneum.

Objective To compare the safety and efficacy of laparoscopic staging of ovarian or fallopian tube cancers to staging via laparotomy for epithelial ovarian carcinoma. Study design We performed a case-control study of all patients with apparent stage I adnexal cancers who had laparoscopic staging from October 2000 to March 2003. The control group consisted of all patients with apparent stage I epithelial ovarian carcinoma who had staging via laparotomy during the same time period. Results Staging was laparoscopic in 20 patients and via laparotomy in 30. There were no differences in mean age and body mass index. There were also no differences in omental specimen size and number of lymph nodes removed. Estimated blood loss and hospital stay were lower for laparoscopy, but operating time was longer. There were no conversions to laparotomy or complications in the laparoscopic group, compared with 3 minor complications in the laparotomy group. Conclusion In this preliminary analysis, it appears that patients with apparent stage I ovarian or fallopian tube cancer can safely and adequately undergo laparoscopic surgical staging.

Objective: The aim of this study was to describe the feasibility and outcome of laparoscopic risk-reducing salpingo-oophorectomy (RRSO) in patients with a history of breast cancer who previously had undergone a transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. Methods: We performed a retrospective review of patients with a history of breast cancer who had undergone laparoscopic RRSO between February 1995 and April 2002. Patients who had undergone TRAM flap reconstructive surgery were compared with patients who had undergone laparoscopic RRSO without prior reconstructive surgery. Results: We identified 102 patients with a history of breast cancer who were candidates for a laparoscopic RRSO during the study period. One hundred one of these patients underwent the procedure, including 10 patients with a history of TRAM flap breast reconstructive surgery. One patient did not undergo the procedure because she was noted to be hypotensive prior to the procedure from her bowel preparation. There were no differences between the groups with or without prior history of TRAM flap reconstruction with respect to body mass index, prior abdominal surgery, menopausal status, or preoperative ultrasound characteristics. Operatively, there was no difference between the groups with respect to estimated blood loss, hospital stay, and intraoperative and postoperative complication rates. The only noted difference between the two groups was the estimated operating time (TRAM group, 91 min; non-TRAM group, 70 min [ P Conclusions: Laparoscopic RRSO is safe and feasible in patients who have undergone a prior TRAM flap reconstruction.

To evaluate our experience with malignant mixed mullerian sarcomas of the uterus (MMMT) and the clinical factors affecting survival.The records of 18 women with MMMT who received treatment at our hospital between 1989-2002 were reviewed. We analyzed factors influencing survival such as stage, presence of heterologous components, and post-operative radiation. Survival analysis was performed using Kaplan-Meier survival curve.All women underwent surgical tumor debulking. Eleven women were Stage I, three were Stage II, two were Stage III, and two were Stage IV. Five women had tumors with heterologous elements. As expected, survival was most influenced by stage of disease, with the best overall survival in women with Stage I tumors, P0.001. Cumulative 5-year survival was 60% for Stage I disease, for Stage II, 34%, and 0% for Stage III and Stage IV.The initial stage of women presenting with MMMTs is the most important predictive factor for survival.

Objective The study was undertaken to test the integrity of nonidentical sliding knots made with 3 throws compared with those made with 6 throws with monofilament and braided absorbable suture. Study design The 3 throw nonidentical sliding knot was compared with the 6 throw nonidentical sliding knot in 4 different suture groups. The groups were 0-0 polydioxanone, 2-0 polydioxanone, 0-0 polyglactin 910, and 2-0 polyglactin 910. Knots were tested to failure with a tensiometer. The proportion of 3 throw knots becoming untied was compared with the 6 throw knot within each group. Ultimate load required to break tied knots within each suture group was also evaluated. Results The 3 throw knots had very high rates of knot failure and untied significantly more often than the 6 throw knots. Conclusion The 6 throw nonidentical sliding knot demonstrates superior knot integrity compared with the 3 throw knot with both monofilament and braided absorbable suture.

The authors reviewed the medical records of 44 patients who had been previously treated for cervical carcinoma. In these women, a total of 47 examinations with whole-body [18F]fluoro-2-deoxyglucose (FDG) positron emissiontomography (PET) scans were performed to detect recurrent disease. Twenty-one PET scans were performed in women who had symptoms of recurrence and 26 were in asymptomatic women. In the surveillance group, the time to posttreatment PET scans ranged from 2 to 40 months. In symptomatic women, posttreatment scans were performed from 3 to 80 months after treatment (P = 0.02 for difference). Recurrent disease was detected in 8 (30.8%) asymptomatic and 14 (66.7%) symptomatic patients (P = 0.01). Two asymptomatic women had false-negative PET scans. One patient, whose scan was negative for the presence of disease 3 months after treatment, had persistent disease detected in a cervical biopsy taken at the same time. Another developed a recurrence 4 months after a negative PET scan. A diagnosis of recurrent disease 13 months after a negative scan was not considered a false-negative. The sensitivity of PET scan for detection of recurrent disease among asymptomatic patients was 80.0%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 88.9%. There were 15 positive PET scans reported among symptomatic women. Fourteen of these were confirmed by biopsy or computed tomography (CT), but no disease was found in 1 patient whose PET scan indicated vaginal recurrence. Repeat PET scan at 4 months was negative for disease. Another patient had a pelvic mass detected by PET scan and CT, but because it did not appear to exceed surrounding areas in the FDG uptake, she was not considered positive for recurrence. She was found to have adherent bowel at laparotomy and had no evidence of recurrent disease. All negative findings by PET scan in symptomatic women were confirmed by clinical examination, biopsy, or CT. The sensitivity of PET scan for detection of recurrent disease in symptomatic patients was 100%, specificity was 85.7%, positive predictive value was 93.3%, and negative predictive value was 100%.

Objective The objective of the study was to determine the integrity of flat square knots. Study Design Three sutures were used in both 0 and 2-0 suture gauges: poliglecaprone 25 (Monocryl), polyglactin 910 (Vicryl), and silk. For each, flat square knots were tied with either 3 or 5 throws. Knots were tested to failure. The major outcome measured was the proportion of 3 throw knots untying, compared with that of 5 throw knots. Results There were high rates of untying for the poliglecaprone 25 and for the polyglactin 910 with both suture gauges when tied with only 3 throws. The failure rate decreased significantly when the throws were increased. There was no statistical benefit to increasing the number of throws for silk. Conclusion Knot failure is decreased by increasing the number of throws for poliglecaprone 25 and polyglactin 910. However, there is no advantage to increasing the number of throws from 3 to 5 for silk.