Abstract Background While advances in minimally invasive surgery have made laparoscopic staging technically feasible in stage I epithelial ovarian cancer, the practice remains controversial due to an ...absence of randomized trials and lack of high-quality observational studies demonstrating equivalent outcomes. Objective This study seeks to evaluate the association of laparoscopic staging with survival among women with clinical stage I epithelial ovarian cancer. Study Design We used the National Cancer Data Base to identify all women who underwent surgical staging for clinical stage I epithelial ovarian cancer diagnosed from 2010-2012. The exposure of interest was planned surgical approach (laparoscopy versus laparotomy) and the primary outcome was overall survival. The primary analysis was based on intention-to-treat: all women whose procedures were initiated laparoscopically were categorized as having had a planned laparoscopic procedure regardless of subsequent conversion to laparotomy. We used propensity methods to match patients who underwent planned laparoscopic staging with similar patients who underwent planned laparotomy based on observed characteristics. We compared survival among the matched cohorts using the Kaplan-Meier method and Cox regression. We compared extent of lymphadenectomy using the Wilcoxon rank-sum test. Results Among 4,798 eligible patients, 1,112 (23.2%) underwent procedures which were initiated laparoscopically, of which 190 (17%) were converted to laparotomy. Women who underwent planned laparoscopy were more frequently white, privately insured, from wealthier zip codes, received care in community cancer centers, and had smaller tumors that were more frequently of serous, and less often of mucinous histology than those who underwent staging via planned laparotomy. After propensity score matching, time to death did not differ between patients undergoing planned laparoscopic versus open staging (Hazard Ratio=0.77, 95%CI=0.54-1.09; p=0.13). Planned laparoscopic staging was associated with a slightly higher median lymph node count (14 versus 12, p=0.005). Planned laparoscopic staging was not associated with time to death after adjustment for receipt of adjuvant chemotherapy, histological type and grade, and pathologic stage (Hazard Ratio 0.82, 95% CI 0.57-1.16). Conclusion Surgical staging via planned laparoscopy versus laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract Laparoendoscopic single-site surgery is a logical advance in the evolution of minimally invasive surgery and is being utilized to perform increasingly complex procedures. We report its use ...for completion of radical hysterectomy as treatment for cervical cancer.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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 31.4 months in women with UCCC, compared to 145 months in patients with OCCC (p = 0.04). UCCC women had a median overall survival of 39.5 months, compared to 155.8 months in patients with OCCC (p = 0.002). In the multivariate Cox regression model, age > 55 years 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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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 36 months, compared with 12 months for patients who underwent a suboptimal surgical effort ( p = 0.001), and a disease-free survival (DFS) of 21 months vs. 10 months ( 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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective. Patients with early-stage neuroendocrine cervical carcinoma (NECC) have a high mortality rate despite aggressive therapy. The rarity of this tumor precludes initiation of a randomized, ...prospective trial. We reviewed our experience in early stage disease and performed a meta-analysis of the literature to identify prognostic factors and determine optimal multimodality therapy.
Methods. Eleven women with International Federation of Gynecology and Obstetrics (FIGO) early stage (IB–IIA) NECC were treated with surgery and chemotherapy at our institutions between 1978 and 1998. Administration of radiation therapy was recorded, but not required for inclusion in this study. A gynecologic pathologist reviewed all histopathologic sections. Medical records were retrospectively reviewed and clinical data obtained. Twenty-three early-stage NECC patients who were similarly treated during the study interval were identified by a Medline search of the English literature and included in the analysis. The Kaplan–Meier method and log-rank test were used for survival analysis.
Results. The overall 2-year survival rate for the 34 patients was 38%. The median age was 37 years (range, 20–75 years). Median cervical tumor diameter was 3.2 cm (range 0.5–11.0 cm). Lymphovascular space invasion was present in 21 (78%) of 27 patients (7 unknown). Fifteen (52%) of twenty-nine had lymph node metastases (5 unknown). Fifteen patients received postoperative platinum/etoposide (PE), seven received vincristine/adriamycin/cyclophosphamide (VAC), two received alternating cycles of VAC and PE, and ten received other chemotherapy regimens. Twenty women were treated with radiation therapy. The presence of lymph node metastases was a poor prognostic factor (P < 0.001). PE and VAC chemotherapy was associated with increased survival (P < 0.01).
Conclusion. NECC is a highly lethal variant of cervical cancer. The presence of lymph node metastases is the most important prognostic variable. Postoperative VAC or PE appears most likely to improve chances for survival.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To investigate the relationship of age and tumors associated with endometriosis and outcome of different histologies of epithelial ovarian cancer arising from endometriosis.
We identified cases of ...epithelial ovarian cancers with clear cell, endometrioid, or mixed clear cell and endometrioid histologies from January 2001 to March 2009. Tumors were classified as either "arising in" endometriosis, "associated with" endometriosis or "controls" (not associated with endometriosis). We collected information regarding patient demographics, past medical history, presentation at diagnosis, treatment, and outcome.
Of 140 patients identified, 42 (30.0%) had clear cell, 92 (65.7%) had endometrioid, and 6 (4.3%) had mixed. Of those, 28.6% of tumors were associated with endometriosis (n = 40), 37.1% were arising in endometriosis (n = 52), and 34.3% were controls (n = 48). Premenopausal women had tumors that were more likely arising from or associated with endometriosis as compared to tumors in postmenopausal women (p = 0.005). Premenopausal patients were also more likely to present with early stage disease as compared to postmenopausal women (80.4% vs. 63.6%, p = 0.04) and better overall survival (p < 0.008). Survival analyses of the entire cohort showed that improved survival was associated with stage (p < 0.001), grade (p < 0.001), endometrioid histology (p < 0.005), and with tumors associated with or arising in endometriosis (p < 0.04). Multivariate analysis controlling for menopausal status showed the presence of endometriosis was no longer associated with a survival advantage (p = 0.08).
The association with endometriosis does appear, at least in endometrioid tumors, to provide a survival benefit. Overall, menopausal status, stage, and grade are more powerful variables associated with improved survival.
The incidence of adnexal masses in pregnancy is estimated to be 1% to 4%. In select cases, surgical intervention is required. Recent studies have demonstrated that laparoscopy during pregnancy is ...safe and confers many advantages over laparotomy. Herein we present a series of nine cases collected prospectively that demonstrate the feasibility, safety, and putative benefits of laparoendoscopic single-site surgery for treatment of adnexal masses in pregnant women.
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Background: Cure rates for patients with advanced stage ovarian cancer have not changed over the last four decades likely due to inability to eradicate residual cancer cells after frontline ...therapy. Identifying clinically undetectable minimal residual disease (MRD) after frontline therapy by second look laparoscopy (SLL) has potential to a) uncover mechanisms of chemoresistance, b) identify MRD-specific therapeutic targets, and c) allow for earlier intervention with investigational therapies. The objective of this study is to describe the initial safety and feasibility of SLL and illustrate clinical pathologic correlates. Methods: This IRB-approved observational, single-center study includes patients with epithelial high-grade ovarian cancer with complete CA-125 and radiologic response after frontline treatment who underwent SLL from 4/2017-12/2022. Patients were subsequently offered standard of care or investigational maintenance therapy options based on homologous recombination deficiency (HRD) and MRD status. Summary statistics described the study population, chi-square tests compared categorical variables, and progression free survival (PFS) based on MRD status was estimated using Kaplan-Meier method and compared using log rank test. Results: 64 patients underwent SLL with a median of 8 biopsies (range 1-16). The majority of patients had stage III-IV disease (89%), and high-grade serous histology (89%). Approximately half (52%) of patients underwent neoadjuvant chemotherapy (NACT) with interval tumor reductive surgery (TRS). MRD was present in 28 patients (44%), and the presence of MRD was associated with a worse PFS (HR 3.1, 95% CI 1.5-6.3; 9.2 vs 24.6 months; P=0.002). MRD was more frequent among NACT recipients compared to those who underwent primary TRS (61% vs 26%, P=0.005), those with HRD negative tumors (63% vs 22%, P=0.003), and those with R1 versus R0 resections (71% vs 35%, P=0.012). Of patients with MRD, 20 patients (71%) received bevacizumab until progression as part of a clinical trial (NCT02884648), 3 (11%) received bevacizumab off trial, 4 (14%) received a PARP inhibitor (all HRD positive) and 1 received other therapy. There was one (1.6%) intraoperative complication requiring conversion to laparotomy. Conclusions: SLL is feasible, overall safe, and detected MRD in 44% of ovarian cancer patients who were in radiologic and CA-125 remission after frontline therapy. MRD rates were higher in patients who received NACT and HRD negative patients, and PFS was significantly longer in patients without residual disease. MRD rate by SLL may have utility as an early surrogate for efficacy in trials evaluating novel frontline investigational therapies. Knowledge of MRD status in this patient population enables interventional, observational, and translational investigations, as well as personalized prognostic counseling.
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