Women undergoing treatment for gynecologic malignancies have multiple risk factors for developing fractures, including surgically-induced menopause, cytotoxic chemotherapy, and radiation therapy. The ...incidence of fracture among women treated for gynecologic cancers is estimated to be as high as 20%, however there is limited data regarding the rate of and risk factors for fracture in this population. The objective of this study was to evaluate the incidence of fracture and characteristics of patients with fracture among women undergoing treatment for gynecologic malignancies.
This was a single-institution retrospective cohort study of patients who received surgery, chemotherapy, hormonal therapy, and/or radiation for the treatment of cervical, uterine, and/or vulvar cancer between January 2012 and December 2014. Data on patient demographics, comorbidities, cancer therapies, and risk factors for fracture were manually extracted from patients’ medical records.
Of the 469 women included in the analysis, most (93.8%) were White or African American (3.6%), with a mean age of 58.2 (SD=13.7) years at the time of cancer diagnosis. The mean BMI was 34.8 (SD=9.8) kg/m2. Most (70.4%) patients were menopausal prior to cancer treatment and 16.4% underwent surgically-induced menopause. The majority (69.7%) of patients had a diagnosis of uterine cancer, followed by cervical cancer (16.8%) and vulvar cancer (8.5%). One third (33.7, n=158) received neoadjuvant or adjuvant chemotherapy and 28.4% (n=133) underwent adjuvant radiation. The mean pre- and post-treatment risk of major osteoporotic fracture by FRAX score was 6.9% (SD=5.7) and 8.5% (SD=6.5). Only 20 patients (4.3%) had a DXA scan performed prior to cancer treatment. The proportion of post-treatment fracture within the first two years following treatment was 3.6% (n=17). Of these, most (88.2%, n=15) were diagnosed by x-ray (n=9, 54.8%), followed by MRI (n=4, 23.5%) and CT (n=2, 11.8%). Patients with post-treatment fractures tended to be older at time of treatment (61.9 vs 57.6 years), current tobacco users (47.1% vs 14.1%), and postmenopausal prior to cancer therapy (100% vs 69.7%). Patients with post-treatment fractures also tended to have one or more comorbidity (100% vs 89.4%), have cervical cancer (41.2% vs 15.9%), and to have undergone radiation treatment (64.7% vs 27.4%) as well as chemotherapy treatment (70.6% vs 32.7%).
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Our findings indicate the rate of fracture in the first two years following treatment for gynecologic malignancies is approximately 3.6%. Few women undergo bone mineral density screening prior to cancer treatment. Women with cervical cancer who are postmenopausal with multiple co-morbidities prior to treatment who receive chemotherapy and/or radiation are at higher risk. The mean post-treatment FRAX of 8.5% suggests that many patients may benefit from bone mineral density testing and risk stratification for osteoporosis following cancer therapy.
Gynecologic oncologists have the unique opportunity of caring for patients in a broad range of surgical and medical settings. With increasing awareness of the opioid epidemic and the various factors ...that contribute to chronic opioid use, gynecologic oncologists must also better understand how to best address acute postoperative pain without unknowingly placing patients at risk for opioid misuse. This article examines the use of opioids in the acute surgical setting and provides clinical guidelines and various strategies to reduce opioid misuse.
•The current opioid crisis is relevant to gynecologic oncology patients in the acute surgical setting.•Surgical pain management planning should include preoperative risk factor identification and postoperative pain education.•More effective pain relief can be achieved when multimodal analgesia is used.•Restrictive opioid prescribing guidelines should be used postoperatively whenever possible.
Endometrial intraepithelial neoplasia, also known as complex atypical hyperplasia, is a precancerous lesion of the endometrium associated with a 40% risk of concurrent endometrial cancer at the time ...of hysterectomy. Although a majority of endometrial cancers diagnosed at the time of hysterectomy for endometrial intraepithelial neoplasia are low risk and low stage, approximately 10% of patients ultimately diagnosed with endometrial cancers will have high-risk disease that would warrant lymph node assessment to guide adjuvant therapy decisions. Given these risks, some physicians choose to refer patients to a gynecologic oncologist for definitive management. Currently, few data exist regarding preoperative factors that can predict the presence of concurrent endometrial cancer in patients with endometrial intraepithelial neoplasia. Identification of these factors may assist in the preoperative triaging of patients to general gynecology or gynecologic oncology.
To determine whether preoperative factors can predict the presence of concurrent endometrial cancer at the time of hysterectomy in patients with endometrial intraepithelial neoplasia; and to describe the ability of preoperative characteristics to predict which patients may be at a higher risk for lymph node involvement requiring lymph node assessment at the time of hysterectomy.
We conducted a retrospective cohort study of women undergoing hysterectomy for pathologically confirmed endometrial intraepithelial neoplasia from January 2004 to December 2015. Patient demographics, imaging, pathology, and outcomes were recorded. The “Mayo criteria” were used to determine patients requiring lymphadenectomy. Unadjusted associations between covariates and progression to endometrial cancer were estimated by 2-sample t-tests for continuous covariates and by logistic regression for categorical covariates. A multivariable model for endometrial cancer at the time of hysterectomy was developed using logistic regression with 5-fold cross-validation.
Of the 1055 charts reviewed, 169 patients were eligible and included. Of these patients, 87 (51.5%) had a final diagnosis of endometrial intraepithelial neoplasia/other benign disease, whereas 82 (48.5%) were ultimately diagnosed with endometrial cancer. No medical comorbidities were found to be strongly associated with concurrent endometrial cancer. Patients with endometrial cancer had a thicker average endometrial stripe compared to the patients with no endometrial cancer at the time of hysterectomy (15.7 mm; standard deviation, 9.5) versus 12.5 mm; standard deviation, 6.4; P = .01). An endometrial stripe of ≥2 cm was associated with 4.0 times the odds of concurrent endometrial cancer (95% confidence interval, 1.5–10.0), controlling for age. In all, 87% of endometrial cancer cases were stage T1a (Nx or N0). Approximately 44% of patients diagnosed with endometrial cancer and an endometrial stripe of ≥2 cm met the “Mayo criteria” for indicated lymphadenectomy compared to 22% of endometrial cancer patients with an endometrial stripe of <2 cm.
Endometrial stripe thickness and age were the strongest predictors of concurrent endometrial cancer at time of hysterectomy for endometrial intraepithelial neoplasia. Referral to a gynecologic oncologist may be especially warranted in endometrial intraepithelial neoplasia patients with an endometrial stripe of ≥2 cm given the increased rate of concurrent cancer and potential need for lymph node assessment.
To investigate themes, quality, and reliability of gynecologic cancer-related content on the social media application TikTok.
TikTok was systematically searched for the 100 most popular posts for ...ovarian cancer (OC), endometrial cancer (EC), cervical cancer (CC), vulvar cancer (VC), and gestational trophoblastic disease (GTD) in August 2022. Data was collected for demographics, tone, and themes. Educational videos were rated for quality and reliability utilizing the modified DISCERN scale. Relationships between content demographics, disease sites, and themes were assessed.
As of August 2022, the top five hashtags for each gynecologic cancer on TikTok had 466.7 million views. 430 of the top 500 posts were eligible for inclusion (OC: n = 86, CC: n = 93, EC: n = 98, GTD: n = 63, VC: n = 90). The majority of creators (n = 323, 75.1%) were White, 33 (7.7%) were Black, 20 (4.6%) were Asian/Pacific Islander (API), 10 (2.3%) were South Asian, 20 (4.7%) were Hispanic/Latino/a, 24 (5.5%) were unable to determine. Eleven central themes were identified, with significant differences when analyzed by disease site and race. The median DISCERN score for all posts was 1.0, indicating poor educational quality and reliability. When compared by race, South Asian/API posters received the highest scores (3, IQR 2.5) versus Black (2: IQR 3), Hispanic/Latino/a (2: IQR 0), and White posters (1, IQR 2) (p = 0.0013).
Gynecologic cancer-related content on TikTok is of poor educational quality, and racial disparities in gynecologic cancer extend to social media. Opportunities exist to create more diverse content to support racial and cultural experiences in gynecologic cancer treatment.
•Gynecologic cancer content on TikTok is prevalent, with high user engagement.•Significant differences exist across disease sites and races in regards to engagement statistics and thematic content.•Content related to gynecologic cancers on TikTok is of poor quality.•Significant differences in content reliability exist when stratified by race of the content creator.•Opportunity exists to create diverse and inclusive content to support racial/cultural experiences in gynecologic cancer.
To determine the association of pre-treatment neutrophil-to-lymphocyte ratio (NLR) with progression-free survival (PFS) and overall survival (OS) for patients with recurrent endometrial cancer (EC) ...treated with immunotherapy.
Recurrent EC patients treated with immunotherapy alone or in combination from 2016 to 2021 were included. Demographics, pre-treatment laboratory results, pathologic data, response at first radiographic assessment, and cancer outcomes were obtained from the medical record. Kaplan-Meier curves were generated to compare PFS and OS stratified by NLR.
The 106 patients included in the study were stratified by NLR <6 (n = 77, 72.6%) or NLR ≥6 (n = 29, 27.3%). Most had endometrioid pathology (59%), widely metastatic disease, and 36.8% had received ≥2 treatment lines before initiating immunotherapy. Mismatch repair deficiency (dMMR) was noted in 52 (49.1%) tumors. Most dMMR patients (94.3%) were treated with single-agent pembrolizumab, and most MMR proficient patients (78.7%) were treated with lenvatinb plus pembrolizumab. In the overall cohort, 40.2% (partial response (PR) 29.9%, complete response (CR) 10.4%) of patients with a NLR <6 responded at first radiographic assessment, compared to 31% (PR 27.5%, CR 3.4%) of patients with NLR ≥6 (p 0.691). Kaplan-Meier curves stratified by NLR <6 vs. ≥6 showed no difference in PFS. However, NLR <6 was associated with improved OS (p < 0.05). In the NLR < 6 group, the probability of survival at one year was 69% (95% CI: 58%, 82%), compared to 41% (95% CI: 26%, 67%) for the NLR > 6 group.
Pre-treatment NLR <6 was associated with improved OS for recurrent EC patients treated with immunotherapy. NLR holds promise as a predictive biomarker for survival after immunotherapy treatment for patients with recurrent EC.
•NLR ratio < 6 is associated with improved OS for patients with recurrent endometrial cancer treated with immunotherapy.•This association was observed within both dMMR and pMMR subgroups.•Pretreatment NLR warrants future study as a potential predictive biomarker for response to immunotherapy agents.
To describe outcomes following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. To determine differences in ...the rates of wound complications and positive margins between patients treated by gynecologic oncologists (GO) and those treated by general gynecologic (GYN) surgeons.
Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. Institutional Review Board (IRB) approval was obtained and surgical records were reviewed; patients undergoing “wide local excision, vulva,” “simple partial vulvectomy,” or “destruction of vulvar lesion with excision” were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were collected, and patients were separated by surgeon division (GO or GYN). Patients had follow up documented at least through the postoperative appointment. Surface areas of elliptical specimen were calculated using ‘0.25 x length x width x pi.’ Wound complications and other variables were compared between these groups. All eligible patients were included in the analysis of wound complications. Only patients with pathologic diagnoses of vulvar dysplasia were included in the analysis of margin positivity. Fisher's exact tests and Chi squared tests were used to compare categorical variables and logistic regression models were used for continuous variables. P-values <0.05 were considered statistically significant. JMP 15.2.0 software was used to perform statistical analysis.
Three-hundred thirty-five patients met inclusion criteria over the study period (GO, n=223; GYN, n=112). Patients in the GO group were older (median age 56y versus 40.5y, P<0.01) and more likely to be White (93% versus 75%, P<0.01). Patients in the GO group were more likely to have cardiovascular disease (RR 1.33, 95% CI 1.14-1.55), ASA class 3 or 4 (RR 1.80, 95% CI 1.34-2.43), and have history of malignancy (RR 1.33, 95% CI 1.14-1.54). The distributions of specimen length, surface area, and number of excisions per surgery were not significantly different between the groups. Wound complication occurred in 101/223 (45%) GO patients compared to 40/112 (36%) GYN patients (P=0.11). There were no significant differences specific to wound separation (43% vs 34%, P=0.12), infection (7% vs 5%, P>0.5), or hematoma (1% vs 2%, P>0.5). More patients in the GO group had pathology of high-grade vulvar dysplasia (HSIL) with or without occult carcinoma at the time of WLE (77% vs 40%, P<0.01). Of patients with HSIL, 65/171 (38%) in the GO group had dysplasia present at the margins compared to 23/45 (51%) in the GYN group (RR 0.74, 95% CI 0.53-1.05).
There is renewed interest in optimal management of vulvar surgery.1 WLE is a common procedure done by GO and GYN surgeons. In our study there was a high overall rate (42%) of postoperative wound complication; however, there were no significant differences in complication rates between GO and GYN surgeons. The rate of positive margins following WLE for vulvar dysplasia was also similar between these groups. The trend towards more frequent complications among GO patients may be explained by a population with older age and more comorbidities. It is appropriate for GO or GYN surgeons to perform WLE of the vulva for HSIL, provided the necessary expertise, comfort, and low concern for invasive disease requiring radical excision or lymph node dissection.
To investigate determinants of wound complication following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. ...To determine factors associated with perioperative antibiotic use for WLE of the vulva and whether preoperative intravenous (IV) antibiotics or postoperative topical antimicrobial agents are associated with a decreased risk of wound complication.
Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. IRB approval was obtained and surgical records were reviewed; patients undergoing ‘wide local excision, vulva,’ ‘simple partial vulvectomy,’ or ‘destruction of vulvar lesion with excision’ were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were recorded. Dimensions of specimen and elliptical surface areas were recorded. Patient follow up was documented at least through the postoperative appointment. Patients were separated by receipt of preoperative IV antibiotics or postoperative antimicrobial agents and by postoperative wound complications. Fisher's exact tests and Chi squared tests were used to compare categorical variables between groups and logistic regression models were used for continuous variables. P-values <0.05 were considered statistically significant. JMP 15.2.0 software was used to perform statistical analysis.
Three-hundred thirty-five patients met inclusion criteria over the study period. One-hundred forty-one patients developed a wound complication (42%); this included 134 wound separations (40%), 22 infections (6.6%), and 4 hematomas (1.2%). Thirty-two patients (9.6%) received preoperative IV antibiotics and 42 (12.5%) received postoperative topical antimicrobial agents. Neither IV nor topical antimicrobial agents were associated with a decreased risk of wound complication (RR 0.96, 95% CI 0.62-1.49; RR 0.99, 95% CI 0.66-1.48). Demographics and preoperative characteristics were similar between those who received and did not receive antibiotics. Antibiotic administration was not associated with the maximum length or total surface area of excisions, number of vulvar excisions per surgery, or indication for WLE. Preoperative antibiotic use was similar between the gynecologic oncology and general gynecology divisions (RR 1.23, 95% CI 0.59-2.59). Patients who received IV antibiotics were more likely to be undergoing concurrent hysterectomy or other laparoscopic procedure (RR 12.8, 95% CI 7.87-20.75).
WLE of the vulva is a common procedure among gynecologic oncologists and general gynecologists and carries a high rate of wound complication. Recent ERAS guidelines report low-level evidence to consider preoperative antibiotics for WLE and do not comment on topical antimicrobials.1 In our study neither preoperative antibiotics nor postoperative topical antimicrobials were associated with improved outcomes. Prospective data on this topic is lacking and should be an area of future research. Antibiotic use for WLE-in the absence of concurrent clean-contaminated procedures-appears to be guided by surgeon preference.
To report on the incidence of ovarian metastasis in patients with high grade neuroendocrine tumors of the cervix (NEC) who underwent surgical resection.
This was a single institution retrospective ...chart review. The electronic medical record was searched for all patients with a diagnosis of NEC at The Ohio State University from January 2010 to March 2020. Patients without complete pathologic records were excluded.
From January 2010 to March 2020, 43 patients were identified with NEC. Of those patients, 16 had undergone surgical resection including hysterectomy, bilateral salpingectomy and oophorectomy, and lymph node dissection. Of the 16 patients, zero had evidence of metastatic disease to their ovaries. The median age of patients in our cohort was 35.5 years with a mean age of 40.5 (28-70y). 13 of the 16 patients were considered pre-menopausal at the time of their surgery (defined as age 50 or younger). Of the 16 patients who underwent surgical management, 2 had adjuvant chemotherapy alone, 7 had adjuvant chemotherapy with adjuvant radiotherapy, 2 had adjuvant chemoradiotherapy, and 3 had adjuvant radiation therapy. Of the 16 patients in the study, 13 received neoadjuvant chemotherapy as part of their treatment. For those who had chemotherapy as part of their treatment plan, the most commonly used regimen was cisplatin with etoposide with a median of 3 cycles neoadjuvant and 3 cycles in the adjuvant setting. Based on the FIGO 2018 staging classifications, 6 patients had stage I disease (1 1A2, 2 IB1, 1 IB2, 2 IB3). 10 of the 16 patients had advanced stage disease defined as IIB through IVB (2 IIB, 1 IIIB, 3 IIIC1, 2 IIIC2, 2 IVB).
The incidence of ovarian metastasis in patients with NEC has not been reported in the literature. Here we demonstrate in our limited series that ovarian metastasis in NEC of the cervix is rare. Current practice of ovarian retention in NEC is based on expert opinion and is not standard of care across the field of gynecologic oncology. Our data support that ovarian retention in NEC is safe. Previously published data from our institution demonstrate that 82% of patients with stage I disease had no evidence of disease at time of their last follow up with the use of a multimodality treatment approach (McCann 2013). In our cohort, radiation therapy is often employed in the treatment of NEC. Ovarian retention with transposition out of the radiated field may be a reasonable option for women who would benefit from preservation of ovarian function. Commonly used chemotherapeutic agents were cisplatin with etoposide, both with limited gonadotoxicity. Given the low incidence of ovarian metastasis in NEC, ovarian cryopreservation or oocyte harvesting is a reasonable option for patients who desire the ability to have offspring with the assistance of a surrogate in the future. Further studies with a multi-institutional collaboration to better define the incidence of NEC metastasis to the ovary is necessary.
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