Enhanced recovery after surgery (ERAS) is an evidence-based and multidisciplinary perioperative care pathway and a surgical quality improvement initiative, which has been shown to promote patient ...mobilization, reduce complication rates after surgery, decrease hospital length of stay and reduce costs, if carefully implemented. There is an increasing interest across Canada to implement enhanced recovery after surgery recommendations. Several Canadian institutions have succeeded in implementing an official ERAS protocol. However, it can be challenging to start such a program because it requires multidisciplinary effort and the buy-in of many stakeholders. Because the ERAS approach has been shown to decrease the stress of surgery through its objective to maintain patients' normal physiology as far as possible, any patient undergoing surgery could benefit from the approach. The ERAS approach can be broken down into 3 main components: preoperative, intraoperative and postoperative. However, enhanced recovery begins with optimizing a patient's physical status before surgery.
To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure.
An Israel Gynecologic Oncology ...Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups.
There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p = 0.53), disease-specific survival (93.4% vs. 91.7%; p = 0.5), and overall survival (86.2% vs. 80.6%; p = 0.22).
Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.
To assess the impact of a fertility-sparing approach on disease recurrence in women with advanced borderline ovarian tumors.
Historic cohort study.
A tertiary referral center for gynecological ...oncology patients and a university teaching hospital.
Consecutive patients with advanced borderline ovarian tumors defined as stage IC and above, treated at a single institution during a span of 30 years.
Data on surgical approach (e.g., fertility sparing, ovarian conserving) as well as histopathology, disease stage, CA-125 level, and use of chemotherapy were collected from the medical records, and their impact on disease recurrence was assessed.
Recurrence-free interval. Its association with the type of surgery and with other clinical and pathological features was assessed using the Kaplan Meier and Cox proportional hazards methods.
Fifty-nine patients with advanced disease were identified. Median follow-up was 55.3 months. Mean age at diagnosis was 35 years. Most of the tumors (51, 84.4%) had serous histology. Twenty-seven patients (45.8%) developed recurrences and 6 (10%) died of their disease. Mean time to recurrence was 30.6 months. Of 44 women ≤40 years, 33 (75%) had a fertility-sparing procedure. Fertility preservation was not associated with disease recurrence. A total of 34 pregnancies and 26 live births were documented among 21 patients attempting conception.
Borderline ovarian tumors carry a favorable prognosis, even at an advanced stage. Fertility preservation was not found to be associated with an increased risk of relapse in young patients with advanced disease, and may be reasonably considered.
There is little data regarding the optimal approach to advanced epithelial ovarian cancer (EOC) with isolated extra-peritoneal disease in the cardiophrenic lymph nodes. This study assessed whether ...the prognosis and surgical outcomes are affected by the treatment approach among these patients.
This retrospective cohort study included patients with advanced EOC, who were treated 2012-2020. Computed tomography scans were reviewed for disease extent and the presence of enlarged supradiaphragmatic nodes (SDLN). Demographic, clinical and oncologic data were recorded. Characteristics and outcomes of patients with and without enlarged SDLN were evaluated, and outcomes of patients with enlarged SDLN who underwent upfront surgery and neoadjuvant chemotherapy were compared.
Among 71 women, 47 (66%) had enlarged supradiaphragmatic lymph nodes. Groups had similar baseline characteristics. Among 47 women who had enlarged SDLN. There was no significant difference in progression free survival among patients who had upfront cytoreduction compared to those who received neoadjuvant chemotherapy. Only one asymptomatic chest recurrence was observed.
Patients with enlarged SDLN have comparable outcomes with either upfront surgery or neoadjuvant chemotherapy. Moreover, the frequency of chest recurrences in patients presenting with enlarged SDLN is exceedingly low.
Data on the outcome of stage IIA1 cervical cancer is limited, as these tumors comprise a small percentage of early tumors. NCCN guidelines suggest consideration of surgical management for small ...tumors with vaginal involvement. Our objective was to evaluate the risk of adjuvant radiotherapy in stage IIA1 cervical cancer and its associated features, in order to improve selection of patients for surgical management.
A retrospective cohort study comparing surgically treated cervical cancer patients with stage IB1 and stage IIA1 disease. Women treated between 2000 and 2015 in ten Israeli medical centers were included. Patient and disease features were compared between stages. The relative risk (Fisher's exact test) of receiving post-operative radiation was calculated and compared for each risk factor. A general linear model (GLM) was used for multivariable analysis.
199 patients were included, of whom 21 had stage IIA1 disease. Most features were comparable for stage IB1 and stage IIA1 disease, although patients with vaginal involvement were more likely to have close surgical margins (23.8% vs 8.5%, p = 0.03). Patients with stage IIA1 disease were more likely to receive radiation after surgery (76% vs. 46%, RR = 1.65 (1.24–2.2), p = 0.011). Vaginal involvement as well as depth of stromal invasion, LVSI and lymph node metastases were independent predictors of radiation on multivariable general linear modeling.
Cervical cancer patients with vaginal involvement are highly more likely to require postoperative radiation. We recommend careful evaluation of these patients before surgical management is offered.
•76% of patients having surgery for stage IIA1 cervical cancer receive adjuvant treatment.•Rates of close and involved surgical margins are high in stage IIA1 cervical cancer.•Tumor stage, depth of invasion, LVSI and lymph node spread are independent predictors of radiation.
Minimally invasive surgery for the treatment of macroscopic cervical cancer leads to worse oncologic outcomes than with open surgery. Preoperative conization may mitigate the risk of surgical ...approach. Our objective was to describe the oncologic outcomes in cases of cervical cancer initially treated with conization, and subsequently found to have no residual cervical cancer after hysterectomy performed via open and minimally invasive approaches. This was a retrospective cohort study of surgically treated cervical cancer at 11 Canadian institutions from 2007 to 2017. Cases initially treated with cervical conization and subsequent hysterectomy, with no residual disease on hysterectomy specimen were included. They were subdivided according to minimally invasive (laparoscopic/robotic (MIS) or laparoscopically assisted vaginal/vaginal hysterectomy (LVH)), or abdominal (AH). Recurrence free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare between cohorts. Within the total cohort, 238/1696 (14%) had no residual disease on hysterectomy specimen (122 MIS, 103 AH, and 13 VLH). The majority of cases in the cohort were FIGO 2018 stage IB1 (43.7%) and underwent a radical hysterectomy (81.9%). There was no statistical difference between stage, histology, and radical vs simple hysterectomy between the abdominal and minimally invasive groups. There were no significant differences in RFS (5-year: MIS/LVH 97.7%, AH 95.8%,
= 0.23) or OS (5-year: MIS/VLH 98.9%, AH 97.4%,
= 0.10), although event-rates were low. There were only two recurrences. In this large study including only patients with no residual cervical cancer on hysterectomy specimen, no significant differences in survival were seen by surgical approach. This may be due to the small number of events or due to no actual difference between the groups. Further studies are warranted.
•Sentinel lymph nodes biopsy method for surgical staging of endometrial cancer is safe and reliable.•Sentinel lymph nodes biopsy is associated with lower rate of external beam pelvic radiation.•The ...survival of patients operated by sentinel lymph nodes method is comparable to patients undergoing full lymphadenectomy.
To compare the rates of post-operative radiotherapy between two methods of lymph nodes assessment during surgical staging for endometrial cancer (EC).
We conducted a comparative study of all consecutive women with endometrial cancer who underwent sentinel lymph node detection and biopsy using blue dye and isotope scan (SLNB) at Kaplan Medical Center and patients from the IGOG database, who underwent staging lymphadenectomy (PLND). The primary outcome was the rate of adjuvant and therapeutic radiation. The secondary outcome was a comparison of disease-free survival (DFS) and overall survival (OS).
There were 138 patients in the SLNB group and 1022 women in the PLND group. The detection rate of SLN was 74% for unilateral detection and 54% for bilateral detection. In the PLND group 57% were high risk patients vs. 47% in SLNB group (p = 0.03). 43% of high-risk patients in the PLND group received adjuvant or therapeutic pelvic radiation vs. 28% of high-risk women in the SLNB arm (p = 0.017). No statistically significant difference in recurrence rates nor in death rates had been observed in the high-risk group patients. The 5-years survival in the high-risk PLND group was 80% and the recurrence rate was 19% vs. 75% 5-year survival and 14% recurrence in high-risk SLNB cohort, log-rank p = 0.82 for survival and long-rank p = 0.25 for recurrence.
Endometrial cancer patients undergoing lymph node assessment by sentinel lymph node biopsy, receive less pelvic radiotherapy.
The current study investigates disease patterns and outcomes in young Israeli epithelial ovarian cancer (EOC) patients and their association with BRCA mutation status.
Consecutive EOC patients ...diagnosed at or below 50 years in a single institution between 1995-2011 were identified. All patients are referred for genetic counseling and testing for the predominant Jewish BRCA mutations: BRCA1-185delAG, BRCA1-5382insC, and BRCA2-6174delT. A comparison between BRCA mutation carriers and non-carriers was undertaken across demographic, pathologic, and clinical features; recurrence and survival were compared using the Kaplan-Meier method and associations with the variables of interest were analyzed using the Cox proportional hazards method.
One hundred eighty-six patients diagnosed with EOC at 50 years or younger were included, with a total follow-up of 1,088 person years. Mean age at diagnosis was 44±5 years. Of 113 patients with documented BRCA testing, 49.6% carried a germline BRCA mutation, compared with 29% in the general Israeli EOC population (p=0.001). BRCA mutation carriers had a higher rate of serous tumors (75% vs. 64%, p=0.040) and higher CA125 levels at diagnosis (median, 401 vs. 157, p=0.001) than non-carriers. No significant association between BRCA mutations and recurrence (hazard ratio HR=1.03; p=0.940) or survival (HR=1.40; p=0.390) was found.
BRCA mutations are encountered in almost 50% of young Israeli ovarian cancer patients; they are associated with serous tumors and high CA125 levels at diagnosis, but are not independently associated with recurrence or survival in this patient population.
Bowel procedures are commonly performed as part of ovarian cancer cytoreduction. The aim of this study was to assess the postoperative complication rates among women with an ovarian malignancy ...undergoing bowel resection/repair at the time of cytoreductive surgery compared with a control group (cytoreductive surgery without bowel resection or repair).
Analysis of 4965 cytoreductive surgeries for suspected ovarian malignancies recorded in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) datasets (2006–2017) was performed. One-way ANOVA, Kruskal-Wallis H and Chi-squared tests were used to evaluate and compare baseline characteristics between the groups and controls. Postoperative surgical site infection rates and other 30-day post-operative outcomes were assessed with multivariable logistic and linear regressions.
8.3% (413/4965) of cytoreductive procedures had an associated repair of enterotomy (small or large bowel), 10.9% (541/4947) had an associated colectomy with primary anastomosis, and 2.1% (104/4965) had an associated colectomy with colostomy. Surgical site infections (SSI, either superficial incisional, deep incisional, organ space or wound dehiscence) were significantly more prevalent in the bowel resection/repair group (16.9% vs 5.7%, p < 0.0001). The odds of surgical infections were 2.67 times higher in patients who underwent a bowel resection or repair after controlling for age, BMI, ASA status, pre-operative weight loss, hypoalbuminemia, NSQIP morbidity score, length and complexity of surgical procedure.
Patients undergoing bowel resection/repair at the time of cytoreductive surgery are at increased risk of surgical site infections, without increased risk of 30-day mortality. Interventions to mitigate the risk of infectious complications in these patients should be evaluated in a prospective fashion.
•21.3% of ovarian cancer cytoreductive surgeries were associated with a bowel resection or repair.•Odds of surgical infections were 2.67 times higher in patients who underwent a bowel procedure.•Primary anastomosis or colostomy creation after bowel resection are associated with similar risks of complication.
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