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Fumagalli D, De Vitis LA, Caruso G, Occhiali T, Palmieri E, Guillot BE, Pappalettera G, Langstraat CL, Glaser GE, Reynolds EA, Fruscio R, Landoni F, Mariani A, Grassi T. Low-Volume Metastases in Apparent Early-Stage Endometrial Cancer: Prevalence, Clinical Significance, and Future Perspectives. Cancers (Basel) 2024; 16:1338. [PMID: 38611016 PMCID: PMC11011093 DOI: 10.3390/cancers16071338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer (EC) is the most diagnosed gynecologic malignancy, and its incidence and mortality are increasing. The prognosis is highly dependent on the disease spread. Surgical staging includes retroperitoneal evaluation to detect potential lymph node metastases. In recent years, systematic lymphadenectomy has been replaced by sentinel lymph node (SLN) biopsy and ultrastaging, allowing for the detection of macrometastases, micrometastases, and isolated tumor cells (ITCs). Micrometastases and ITCs have been grouped as low-volume metastases (LVM). The reported prevalence of LVM in studies enrolling more than one thousand patients with apparent early-stage EC ranges from 1.9% to 10.2%. Different rates of LVM are observed when patients are stratified according to disease characteristics and their risk of recurrence. Patients with EC at low risk for recurrence have low rates of LVM, while intermediate- and high-risk patients have a higher likelihood of being diagnosed with nodal metastases, including LVM. Macro- and micrometastases increase the risk of recurrence and cause upstaging, while the clinical significance of ITCs is still uncertain. A recent meta-analysis found that patients with LVM have a higher relative risk of recurrence [1.34 (95% CI: 1.07-1.67)], regardless of adjuvant treatment. In a retrospective study on patients with low-risk EC and no adjuvant treatment, those with ITCs had worse recurrence-free survival compared to node-negative patients (85.1%; CI 95% 73.8-98.2 versus 90.2%; CI 95% 84.9-95.8). However, a difference was no longer observed after the exclusion of cases with lymphovascular space invasion. There is no consensus on adjuvant treatment in ITC patients at otherwise low risk, and their recurrence rate is low. Multi-institutional, prospective studies are warranted to evaluate the clinical significance of ITCs in low-risk patients. Further stratification of patients, considering histopathological and molecular features of the disease, may clarify the role of LVM and especially ITCs in specific contexts.
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Affiliation(s)
- Diletta Fumagalli
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
| | - Luigi A. De Vitis
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giuseppe Caruso
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Emilia Palmieri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, , Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Roma, Italy
| | - Benedetto E. Guillot
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giulia Pappalettera
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Carrie L. Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Gretchen E. Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Evelyn A. Reynolds
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Tommaso Grassi
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
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Kalogera E, Nevala WK, Finnes HD, Suman VJ, Schimke JM, Strand CA, Kottschade LA, Kudgus RA, Buhrow SA, Becher LR, Geng L, Glaser GE, Grudem ME, Jatoi A, Klampe CM, Kumar A, Langstraat CL, McWilliams RR, Wahner Hendrickson AE, Weroha SJ, Yan Y, Reid JM, Markovic SN, Block MS. A Phase I trial of Nab-Paclitaxel/Bevacizumab (AB160) Nano-Immunoconjugate Therapy for Gynecologic Malignancies. Clin Cancer Res 2024:742012. [PMID: 38530846 DOI: 10.1158/1078-0432.ccr-23-3196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/13/2024] [Accepted: 03/21/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE AB160 is a 160 nm nano-immunoconjugate consisting of nab-paclitaxel (ABX) nanoparticles non-covalently coated with bevacizumab (BEV) for targeted delivery into tissues expressing high levels of VEGF. Preclinical data showed that AB160 resulted in greater tumor targeting and tumor inhibition compared to sequential treatment with ABX then BEV. Given individual drug activity, we investigated the safety and toxicity of AB160 in patients with gynecologic cancers. PATIENTS AND METHODS A 3+3 phase I trial was conducted with 3 potential dose levels in patients with previously treated endometrial (EC), cervical (CC), and platinum-resistant ovarian cancer (OC) patients to ascertain the recommended Phase II dose (RP2D). AB160 was administered intravenously on Days 1, 8 and 15 of a 28-day cycle (ABX 75-175 mg/m2, BEV 30-70 mg/m2). Pharmacokinetic analyses were performed. RESULTS No dose-limiting toxicities (DLTs) were seen among the 3 DLs tested. Grade 3/4 toxicities included neutropenia, thromboembolic events, and leukopenia. DL2 (ABX 150 mg/m2, BEV 60 mg/m2) was chosen as the RP2D. Seven of the 19 patients with measurable disease (36.8%) had confirmed partial responses (95% CI: 16.3%-61.6%). Pharmacokinetic analyses demonstrated that AB160 allowed 50% higher paclitaxel dosing and that paclitaxel clearance mirrored that of therapeutic antibodies. CONCLUSIONS The safety profile and clinical activity of AB160 supports further clinical testing in patients with gynecologic cancers; the RP2D is DL2 (ABX 150 mg/m2, BEV 60 mg/m2).
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Affiliation(s)
| | | | | | | | | | - Carrie A Strand
- Mayo Clinic College of Medicine, Rochester, MN, United States
| | | | | | | | | | - Liyi Geng
- Mayo Clinic, Rochester, MN, United States
| | | | | | | | | | | | | | | | | | | | - Yiyi Yan
- Mayo Clinic, Rochester, MN, United States
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Chauhan S, Langstraat CL, Fought AJ, McGree ME, Cliby WA, Kumar A. Relationship between frailty and nutrition: Refining predictors of mortality after primary cytoreductive surgery for ovarian cancer. Gynecol Oncol 2024; 180:126-131. [PMID: 38091771 DOI: 10.1016/j.ygyno.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE We aimed to examine the interplay between frailty and nutritional status on 90-day mortality after primary cytoreductive surgery (PCS) for ovarian cancer (OC). METHODS Patients with OC who underwent PCS from 1/2/2006-4/30/2018 at a single institution were identified. Frailty index (FI) includes 30 items and is calculated summing across all the item scores and dividing by the total; frailty was defined as FI ≥0.15. Nutritional status was considered impaired when preoperative serum albumin was <3.5 g/dL. Logistic regression was used to analyze the association between FI (continuous) and albumin status (binary) and 90-day postoperative mortality. RESULTS A total of 533 patients (mean age, 64.4 years) were included, the majority were stage IIIC disease and serous histology. Albumin was <3.5 g/dL in 87 patients (16.3%) and 113 patients (21.2%) were considered frail. Median FI was 0.07 (IQR 0.03, 0.13). Postoperative 90-day mortality occurred in 24 patients (4.5%). Mortality within 90 days was higher amongst patients with low albumin (12/87, 13.8%), regardless of frailty status (13.8% [9/65] non-frail and 13.6% [3/22] frail patients). Ninety-day mortality in patients with normal albumin (n = 446) was over twice as likely in frail versus non-frail patients (5.5% [5/91] vs. 2.0% [7/355], respectively, p = 0.08). A model to assess 90-day mortality that included both FI and low albumin significantly improved the overall discrimination compared to low albumin alone (AUC 0.76 vs. 0.68 p = 0.03). CONCLUSION Our findings suggest that frailty and nutrition are both related to 90-day mortality. Preoperative interventions to improve functional and nutritional characteristics are needed.
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Affiliation(s)
- Shruti Chauhan
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Angela J Fought
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Schivardi G, Casarin J, Habermann EB, Bews KA, Langstraat CL, Cliby W, Cucinella G, De Vitis LA, Ramirez PT, Aletti GD, Mariani A, Multinu F. Practice patterns and complications of hysterectomy for invasive cervical cancer after the Laparoscopic Approach to Cervical Cancer trial. Am J Obstet Gynecol 2024; 230:69.e1-69.e10. [PMID: 37690596 DOI: 10.1016/j.ajog.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND After the publication of the Laparoscopic Approach to Cervical Cancer trial, the standard surgical approach for early-stage cervical cancer is open radical hysterectomy. Only limited data were available regarding whether the change to open abdominal hysterectomy observed after the Laparoscopic Approach to Cervical Cancer trial led to an increase in postoperative complication rates as a consequence of the decrease in the use of the minimally invasive approach. OBJECTIVE This study aimed to analyze whether there was a correlation between the publication of the Laparoscopic Approach to Cervical Cancer trial and an increase in the 30-day complications associated with surgical treatment of invasive cervical cancer. STUDY DESIGN Data from the American College of Surgeons National Surgical Quality Improvement Program were used to compare the results in the pre-Laparoscopic Approach to Cervical Cancer period (January 2016 to December 2017) vs the results in the post-Laparoscopic Approach to Cervical Cancer period (January 2019 to December 2020). The rates of each surgical approach (open abdominal or minimally invasive) hysterectomy for invasive cervical cancer during the 2 periods were assessed. Subsequently, 30-day major complication, minor complication, unplanned hospital readmission, and intra- or postoperative transfusion rates before and after the publication of the Laparoscopic Approach to Cervical Cancer trial were compared. RESULTS Overall, 3024 patients undergoing either open abdominal hysterectomy or minimally invasive hysterectomy for invasive cervical cancer were included in the study. Of the patients, 1515 (50.1%) were treated in the pre-Laparoscopic Approach to Cervical Cancer period, and 1509 (49.9%) were treated in the post-Laparoscopic Approach to Cervical Cancer period. The rate of minimally invasive approaches decreased significantly from 75.6% (1145/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 41.1% (620/1509) in the post-Laparoscopic Approach to Cervical Cancer period, whereas the rate of open abdominal approach increased from 24.4% (370/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 58.9% (889/1509) in the post-Laparoscopic Approach to Cervical Cancer period (P<.001). The overall 30-day major complications remained stable between the pre-Laparoscopic Approach to Cervical Cancer period (85/1515 [5.6%]) and the post-Laparoscopic Approach to Cervical Cancer period (74/1509 [4.9%]) (adjusted odds ratio, 0.85; 95% confidence interval, 0.61-1.17). The overall 30-day minor complications were similar in the pre-Laparoscopic Approach to Cervical Cancer period (103/1515 [6.8%]) vs the post-Laparoscopic Approach to Cervical Cancer period (120/1509 [8.0%]) (adjusted odds ratio, 1.17; 95% confidence interval, 0.89-1.55). The unplanned hospital readmission rate remained stable during the pre-Laparoscopic Approach to Cervical Cancer period (7.9% per 30 person-days) and during the post-Laparoscopic Approach to Cervical Cancer period (6.3% per 30 person-days) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.58-1.04)]. The intra- and postoperative transfusion rates increased significantly from 3.8% (58/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 6.7% (101/1509) in the post-Laparoscopic Approach to Cervical Cancer period (adjusted odds ratio, 1.79; 95% confidence interval, 1.27-2.53). CONCLUSION This study observed a significant shift in the surgical approach for invasive cervical cancer after the publication of the Laparoscopic Approach to Cervical Cancer trial, with a reduction in the minimally invasive abdominal approach and an increase in the open abdominal approach. The change in surgical approach was not associated with an increase in the rate of 30-day major or minor complications and unplanned hospital readmission, although it was associated with an increase in the transfusion rate.
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Affiliation(s)
- Gabriella Schivardi
- Department of Gynecology, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy; Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN
| | - Jvan Casarin
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN; Department of Obstetrics and Gynecology, Women and Children Hospital, University of Insubria, Varese, Italy
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Katherine A Bews
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | | | - William Cliby
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN
| | | | - Luigi A De Vitis
- Department of Gynecology, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy; Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX
| | - Giovanni D Aletti
- Department of Gynecology, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy; Department of Hematology and Oncology, University of Milan, Milano, Italy
| | - Andrea Mariani
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN
| | - Francesco Multinu
- Department of Gynecology, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy; Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN.
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Mushtaq A, Woodrum DA, Thompson SM, Bjarnason H, Bendel E, Tran N(BV, Langstraat CL. Vaginal stenosis treatment using computed tomography and fluoroscopy guidance. AJOG Glob Rep 2023; 3:100257. [PMID: 37701754 PMCID: PMC10493260 DOI: 10.1016/j.xagr.2023.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis. CASE We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation. INTERVENTION A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency. CONCLUSION This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.
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Affiliation(s)
- Aliza Mushtaq
- Department of Radiology, Mayo Clinic, Rochester, MN (Drs Mushtaq, Woodrum, Thompson, Bjarnason, and Bendel)
| | - David A. Woodrum
- Department of Radiology, Mayo Clinic, Rochester, MN (Drs Mushtaq, Woodrum, Thompson, Bjarnason, and Bendel)
| | - Scott M. Thompson
- Department of Radiology, Mayo Clinic, Rochester, MN (Drs Mushtaq, Woodrum, Thompson, Bjarnason, and Bendel)
| | - Haraldur Bjarnason
- Department of Radiology, Mayo Clinic, Rochester, MN (Drs Mushtaq, Woodrum, Thompson, Bjarnason, and Bendel)
| | - Emily Bendel
- Department of Radiology, Mayo Clinic, Rochester, MN (Drs Mushtaq, Woodrum, Thompson, Bjarnason, and Bendel)
| | | | - Carrie L. Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN (Dr Langstraat)
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Shafa A, Watkins AB, McGree ME, Weroha SJ, Wahner Hendrickson AE, Block MS, Langstraat CL, McBane RD, Bakkum-Gamez JN, Kumar A. Incidence of venous thromboembolism in patients with advanced stage ovarian cancer undergoing neoadjuvant chemotherapy: Is it time for thromboprophylaxis? Gynecol Oncol 2023; 176:36-42. [PMID: 37442024 DOI: 10.1016/j.ygyno.2023.06.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/11/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES Our objectives were to determine the incidence, timing, and risk factors for venous thromboembolisms (VTEs) in patients with advanced stage epithelial ovarian cancer (EOC) who received neoadjuvant chemotherapy (NACT). We explored the utilization of direct-acting oral anticoagulants (DOACs) for VTE treatment. METHODS This retrospective cohort study included patients with advanced stage EOC receiving NACT followed by interval cytoreductive surgery (ICS) at a single institution. Risk factors were compared between patients with versus without VTE between EOC diagnosis and 180 days after ICS. Bleeding complications were compared between patient who received a DOAC versus non-DOAC. RESULTS VTE cases occurred amongst 33 of the 154 (21.4%) patients with 4 (2.6%) concurrent with EOC diagnosis, 9 (5.8%) between EOC diagnosis and NACT start, 13 (8.4%) between NACT start and ICS, and 7 (4.5%) within 180 days after ICS. There were no statistically significant differences in risk factors assessed (age, body mass index, functional status, histology, Khorana score, and smoking history) between patients with versus without VTE. Eleven patients (33.3%) received a DOAC for VTE treatment. There were no significant differences in number of intraoperative blood transfusions (p = 0.38), blood loss (p = 0.95), or bleeding complications (p = 0.53) between patients treated with a DOAC versus a non-DOAC. CONCLUSION There is a high incidence of VTE events (21.4%) in patients with advanced stage EOC undergoing NACT. Two-thirds of the VTEs may have been prevented with thromboprophylaxis as they occurred between EOC diagnosis and ICS. These data support consideration of thromboprophylaxis in all patients with advanced stage EOC undergoing NACT.
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Affiliation(s)
- Anousheh Shafa
- Mayo Clinic, Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN, United States of America
| | - A Brooke Watkins
- Mayo Clinic, Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN, United States of America
| | - Michaela E McGree
- Mayo Clinic, Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Rochester, MN, United States of America
| | - S John Weroha
- Mayo Clinic, Department of Oncology, Rochester, MN, United States of America
| | | | - Matthew S Block
- Mayo Clinic, Department of Oncology, Rochester, MN, United States of America
| | - Carrie L Langstraat
- Mayo Clinic, Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN, United States of America; Mayo Clinic, Department of Oncology, Rochester, MN, United States of America
| | - Robert D McBane
- Mayo Clinic, Department of Cardiovascular Disease, Rochester, MN, United States of America
| | - Jamie N Bakkum-Gamez
- Mayo Clinic, Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN, United States of America
| | - Amanika Kumar
- Mayo Clinic, Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN, United States of America.
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Warring SK, Narasimhulu DM, Kumar A, Langstraat CL, Weaver AL, McGree ME, Cliby WA. Next Steps Toward Reducing Surgical Morbidity After Complex Cytoreductive Surgery in Fit Surgical Patients. J Gynecol Surg 2023. [DOI: 10.1089/gyn.2022.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Affiliation(s)
- Simrit K. Warring
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanika Kumar
- Division of Gynecologic Oncology, and Rochester, Minnesota, USA
| | | | - Amy L. Weaver
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
| | - Michaela E. McGree
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
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Tanyi JL, Randall LM, Chambers SK, Butler KA, Winer IS, Langstraat CL, Han ES, Vahrmeijer AL, Chon HS, Morgan MA, Powell MA, Tseng JH, Lopez AS, Wenham RM. A Phase III Study of Pafolacianine Injection (OTL38) for Intraoperative Imaging of Folate Receptor-Positive Ovarian Cancer (Study 006). J Clin Oncol 2023; 41:276-284. [PMID: 36070540 DOI: 10.1200/jco.22.00291] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/06/2022] [Accepted: 08/02/2022] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The adjunctive use of intraoperative molecular imaging (IMI) is gaining acceptance as a potential means to improve outcomes for surgical resection of targetable tumors. This confirmatory study examined the use of pafolacianine for real-time detection of folate receptor-positive ovarian cancer. METHODS This phase III, open-label, 11-center study included subjects with known or suspected ovarian cancer, scheduled to undergo cytoreductive surgery. The objectives were to confirm safety and efficacy of pafolacianine (0.025 mg/kg IV), given ≥ 1 hour before intraoperative near-infrared imaging to detect macroscopic lesions not detected by palpation and normal white light. RESULTS From March 2018 through April 2020, 150 patients received a single infusion of pafolacianine (safety analysis set); 109 patients with folate receptor-positive ovarian cancer comprised the full analysis set for efficacy. In 33.0% of patients (95% CI, 24.3 to 42.7; P < .001), pafolacianine with near-infrared imaging identified additional cancer on tissue not planned for resection and not detected by white light assessment and palpation, exceeding the prespecified threshold of 10%. Among patients who underwent interval debulking surgery, the rate was 39.7% (95% CI, 27.0 to 53.4; P < .001). The sensitivity to detect ovarian cancer was 83%, and the patient false-positive rate was 24.8%. Investigators reported achieving complete R0 resection in 62.4% (68 of 109) of patients. Drug-related adverse events were reported by 30% of patients (45 of 150) and most commonly included nausea, vomiting, and abdominal pain. No drug-related serious adverse events or deaths were reported. CONCLUSION This phase III study of pafolacianine met its primary efficacy end point, identifying additional cancers not otherwise identified or planned for resection. Pafolacianine may offer an important real-time adjunct to current surgical approaches for ovarian cancer.
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Affiliation(s)
- Janos L Tanyi
- Hospital of the University of Pennsylvania, Abramson Cancer Center, West Pavilion, Philadelphia, PA
| | - Leslie M Randall
- Virginia Commonwealth University Health, Massey Cancer Center, Richmond, VA
| | | | | | | | | | - Ernest S Han
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | | | - Mark A Morgan
- Hospital of the University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA
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9
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Yalon M, Shahi M, Esquivel A, Cleary SP, Langstraat CL, VanBuren WM. A Rare Case of Tumefactive Endomyometriosis of the Liver. J Minim Invasive Gynecol 2022; 29:1287-1290. [PMID: 36103971 DOI: 10.1016/j.jmig.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/22/2022] [Accepted: 09/06/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Mariana Yalon
- Department of Radiology, Mayo Clinic, Rochester, Minnesota.
| | - Maryam Shahi
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Sean P Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, Minnesota
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10
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Garzon S, Grassi T, Mariani A, Kollikonda S, Weaver AL, McGree ME, Petersen IA, Weroha SJ, Glaser GE, Langstraat CL, Amarnath SR, AlHilli MM. Not all stage I and II endometrial cancers are created equal: Recurrence-free survival and cause-specific survival after observation or vaginal brachytherapy alone in all subgroups of early-stage high-intermediate and high-risk endometrial cancer. Gynecol Oncol 2022; 167:444-451. [PMID: 36244826 DOI: 10.1016/j.ygyno.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate recurrence-free survival (RFS) and cause-specific survival (CSS) after observation or vaginal brachytherapy (VB) alone in all subgroups of early-stage high-intermediate (HIR) and high-risk endometrial cancer (EC). METHODS We identified patients with stage I HIR (GOG-249 criteria) and stage II endometrioid EC, and stage I and II non-endometrioid EC who underwent surgery at Mayo Clinic and Cleveland Clinic between 1999 and 2016. Three-year RFS and CSS after observation or VB only were estimated in 16 subgroups defined by risk factors. RESULTS Among 4156 ECs, we identified 447 (10.8%) stage I endometrioid HIR, 52 (1.3%) stage II endometrioid, 350 (8.4%) stage I non-endometrioid, and 17 (0.4%) stage II non-endometrioid ECs; observation or VB alone was applied in 349 (78.1%), 24 (46.2%), 187 (53.4%), and 2 (11.8%) patients, respectively. After observation or VB, stage I HIR endometrioid EC subgroups with <2 factors among grade 3, LVSI, or stage IB had a 3-year CSS >95% (lower 95% confidence intervals limit: 89.8%), whereas subgroups with ≥2 factors had poorer outcomes. No EC-related deaths after 3 years were reported in 97 stage IA non-endometrioid ECs without myometrial invasion. Stage II ECs had poor outcomes regardless of histology. CONCLUSIONS Observation or VB only may be sufficient in stage I endometrioid HIR ECs with <2 factors among grade 3, LVSI, or IB and in stage IA non-endometrioid ECs without myometrial invasion. Stratification of early-stage HIR and high-risk ECs into risk subgroups potentially alleviates the overtreatment and undertreatment risk and should be considered in future research.
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Affiliation(s)
- Simone Garzon
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Tommaso Grassi
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Andrea Mariani
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Swapna Kollikonda
- Department of Gynecology and Obstetrics, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - S John Weroha
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Gretchen E Glaser
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | | | - Sudha R Amarnath
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mariam M AlHilli
- Department of Subspecialty Care for Women's Health, Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, OH, USA.
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11
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Warring SK, Cope AG, Youssef Y, Burnett TL, Langstraat CL, Behm KT, Khan Z. Excision of Deep Endometriosis of the Rectosigmoid: Individualizing Care to the Presenting Pathology. J Minim Invasive Gynecol 2022; 29:1037. [PMID: 35752391 DOI: 10.1016/j.jmig.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
Affiliation(s)
| | - Adela G Cope
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, MN
| | - Youssef Youssef
- Obstetrics & Gynecology, Hurley Medical Center/Michigan State University, Flint, MI
| | - Tatnai L Burnett
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, MN
| | - Carrie L Langstraat
- Obstetrics & Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Zaraq Khan
- Obstetrics & Gynecology, Hurley Medical Center/Michigan State University, Flint, MI
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12
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Cope AG, Lazaro-Weiss JJ, Willborg BE, Lindstrom ED, Mara KC, Destephano CC, Vetter MH, Glaser GE, Langstraat CL, Chen AH, Martino MA, Dinh TA, Salani R, Green IC. Surgical Science - Simbionix Robotic Hysterectomy Simulator: Validating a New Tool. J Minim Invasive Gynecol 2022; 29:759-766. [PMID: 35123040 DOI: 10.1016/j.jmig.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To gather validity evidence for and determine acceptability of Surgical Science - Simbionix Hysterectomy Modules for the DaVinci Xi console simulation system and evaluate performance benchmarks between novice and experienced or expert surgeons. DESIGN Prospective education study (Messick validity framework) SETTING: Multi-center, academic medical institutions PARTICIPANTS: Residents, fellows, and faculty in Obstetrics and Gynecology were invited to participate at 3 institutions. Participants were categorized by experience level: less than 10 hysterectomies (novice), 10 to 50 hysterectomies (experienced), and greater than 50 hysterectomies (expert). A total of 10 novice, 10 experienced, and 14 expert surgeons were included. INTERVENTIONS Participants completed 4 simulator modules (ureter identification, bladder flap development, colpotomy, complete hysterectomy) and a qualitative survey. Simulator recordings were reviewed in duplicate by educators in minimally invasive gynecologic surgery using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) rating scale. MEASUREMENTS AND MAIN RESULTS Most participants felt the simulator realistically simulated robotic hysterectomy (64.7%) and that feedback provided by the simulator was as or more helpful than feedback from previous simulators (88.2%) but less helpful than feedback provided in the OR (73.5%). Participants felt this simulator would be helpful for teaching junior residents. Simulator-generated metrics correlated with GEARS performance for bladder flap and ureter identification modules in multiple domains including total movements and total time for completion. GEARS performance for the bladder flap module correlated with experience level (novice vs experienced/expert) in domains of interest and total score but did not consistently correlate for the other procedural modules. Performance benchmarks were evaluated for the bladder flap module for each GEARS domain and total score. CONCLUSION The modules were well received by participants of all experience levels. Individual simulation modules appear to better discriminate between novice and experienced/expert users than overall simulator performance. Based on these data and participant feedback, use of individual modules in early residency education may be helpful for providing feedback and may ultimately serve as one component of determining readiness to perform robotic hysterectomy.
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Affiliation(s)
- Adela G Cope
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Jose J Lazaro-Weiss
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Brooke E Willborg
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA; Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anita H Chen
- Department of Obstetrics and Gynecology, Mayo Clinic, Jacksonville, Florida, USA
| | - Martin A Martino
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Tri A Dinh
- Department of Obstetrics and Gynecology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ritu Salani
- Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, California, USA
| | - Isabel C Green
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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13
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Colon-Otero G, Zanfagnin V, Hou X, Foster NR, Asmus EJ, Wahner Hendrickson A, Jatoi A, Block MS, Langstraat CL, Glaser GE, Dinh TA, Robertson MW, Camoriano JK, Butler KA, Copland JA, Weroha SJ. Phase II trial of ribociclib and letrozole in patients with relapsed oestrogen receptor-positive ovarian or endometrial cancers. ESMO Open 2021; 5:e000926. [PMID: 33109627 PMCID: PMC7592247 DOI: 10.1136/esmoopen-2020-000926] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/25/2020] [Accepted: 09/23/2020] [Indexed: 11/25/2022] Open
Abstract
Objective We describe a phase II clinical trial of the combination of ribociclib and letrozole for treatment of relapsed oestrogen receptor (ER)-positive ovarian cancer (OC) and endometrial cancer (EC). The primary endpoint was the proportion of patients alive, progression-free survival (PFS), and still on treatment at 12 weeks (PFS12), with 45% or greater considered positive. Methods Patients with measurable, relapsed ER-positive OC or EC (platinum-sensitive or resistant) were eligible and treated with 400 mg of oral ribociclib and 2.5 mg of oral letrozole daily. Patient-derived xenografts (PDXs) were created from imaging-guided tumour biopsies. Results Forty patients (20 OC and 20 EC) were enrolled. A PFS12 of 55% was observed in the EC cohort and 50% in the OC cohort. A PFS greater or equal to 24 weeks (PFS24) was seen in 20% (4/20) of the OC cohort and 35% (7/20) of the EC cohort. The greatest benefit was seen in low-grade serous OC (LGSOC) (3/3, 100% PFS24) and grades 1 and 2 EC (5/11, 45% PFS24). All three LGSOC patients obtained at least a partial response lasting for over 2 years, with two of the three patients still on treatment. PDX tumour engraftment was feasible in 45% of patients. Positive survival effects of the combination of ribociclib and letrozole were observed in two of three EC PDX models. Conclusion Ribociclib and letrozole have promising clinical activity in relapsed ER-positive OC and EC, particularly in LGSOC and relapsed ER-positive grade 1 and 2 EC. Generation of PDX models is feasible with positive survival effects observed in EC models. Trial registration number ClinicalTrials.gov registry (NCT02657928).
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Affiliation(s)
| | | | - Xiaonan Hou
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan R Foster
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Erik J Asmus
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aminah Jatoi
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew S Block
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Gretchen E Glaser
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tri A Dinh
- Department of Medical & Surgical Gynecology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Matthew W Robertson
- Department of Medical & Surgical Gynecology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - John K Camoriano
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Kristina A Butler
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - John A Copland
- Department of Cancer Biology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - S John Weroha
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Zivanovic O, Chi DS, Zhou Q, Iasonos A, Konner JA, Makker V, Grisham RN, Brown AK, Nerenstone S, Diaz JP, Schroeder ED, Langstraat CL, Paroder V, Lakhman Y, Soldan K, Su K, Gardner GJ, Andikyan V, Guo J, Jewell EL, Long Roche K, Troso-Sandoval T, Lichtman SM, Moukarzel LA, Dessources K, Abu-Rustum NR, Aghajanian C, Tew WP, Beumer J, Sonoda Y, O'Cearbhaill RE. Secondary Cytoreduction and Carboplatin Hyperthermic Intraperitoneal Chemotherapy for Platinum-Sensitive Recurrent Ovarian Cancer: An MSK Team Ovary Phase II Study. J Clin Oncol 2021; 39:2594-2604. [PMID: 34019431 PMCID: PMC8330970 DOI: 10.1200/jco.21.00605] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The purpose of this phase II study was to evaluate hyperthermic intraperitoneal chemotherapy (HIPEC) with carboplatin for recurrent ovarian cancer during secondary cytoreductive surgery. MATERIALS AND METHODS Patients were intraoperatively randomly assigned to carboplatin HIPEC (800 mg/m2 for 90 minutes) or no HIPEC, followed by five or six cycles of postoperative IV carboplatin-based chemotherapy, respectively. Based on a binomial single-stage pick-the-winner design, an arm was considered winner if ≥ 17 of 49 patients were without disease progression at 24 months post-surgery. Secondary objectives included postoperative toxicity and HIPEC pharmacokinetics. RESULTS Of 98 patients, 49 (50%) received HIPEC. Complete gross resection was achieved in 82% of the HIPEC patients and 94% of the standard-arm patients. Bowel resection was performed in 37% of patients in the HIPEC arm compared with 65% in the standard (P = .008). There was no perioperative mortality and no difference in use of ostomies, length of stay, or postoperative toxicity. At 24 months, eight patients (16.3%; 1-sided 90% CI, 9.7 to 100) were without progression or death in the HIPEC arm and 12 (24.5%; 1-sided 90% CI, 16.5 to 100) in the standard arm. With a medium follow-up of 39.5 months, 82 patients progressed and 37 died. The median progression-free survival in the HIPEC and standard arms were 12.3 and 15.7 months, respectively (hazard ratio, 1.54; 95% CI, 1 to 2.37; P = .05). There was no significant difference in median overall survival (52.5 v 59.7 months, respectively; hazard ratio, 1.39; 95% CI, 0.73 to 2.67; P = .31). These analyses were exploratory. CONCLUSION HIPEC with carboplatin was well tolerated but did not result in superior clinical outcomes. This study does not support the use of HIPEC with carboplatin during secondary cytoreductive surgery for platinum-sensitive recurrent ovarian cancer.
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Affiliation(s)
- Oliver Zivanovic
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Dennis S. Chi
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Qin Zhou
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Alexia Iasonos
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Jason A. Konner
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Vicky Makker
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Rachel N. Grisham
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Amy K. Brown
- Hartford Healthcare Cancer Institute, Hartford, CT
| | | | | | | | | | - Viktoriya Paroder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Yulia Lakhman
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Krysten Soldan
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Katy Su
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Ginger J. Gardner
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Vaagn Andikyan
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Elizabeth L. Jewell
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Kara Long Roche
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Stuart M. Lichtman
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Lea A. Moukarzel
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Kimberly Dessources
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Nadeem R. Abu-Rustum
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Carol Aghajanian
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - William P. Tew
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Jan Beumer
- UPMC Hillman Cancer Center, Pittsburgh, PA
| | - Yukio Sonoda
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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Tanyi JL, Chon HS, Morgan MA, Chambers SK, Han ES, Butler KA, Langstraat CL, Powell MA, Randall LM, Vahrmeijer AL, Winer IS, Wenham RM. Phase 3, randomized, single-dose, open-label study to investigate the safety and efficacy of pafolacianine sodium injection (OTL38) for intraoperative imaging of folate receptor positive ovarian cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5503] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5503 Background: Pafolacianine sodium is under investigation as an adjunct to visual inspection and palpation by providing intra-operative imaging of folate receptor positive (FR+) ovarian cancer. Since complete resection (R0) is the strongest predictor of overall survival, methods to enhance detection of lesions are expected to benefit patient outcomes. Methods: For this phase 3, randomized, multicenter, single dose, open-label pivotal trial (NCT03180307), patients with ovarian cancer who were scheduled to undergo cytoreductive surgery were recruited from 11 sites in the US and Netherlands from March 2018 through April 2020. The study objectives were to confirm efficacy and safety of pafolacianine sodium (0.025 mg/kg i.v., ≥1 h prior to imaging) in combination with intraoperative near-infrared fluorescence (NIRF) imaging to detect additional lesions not detected by palpation and normal white light alone. Results: Pafolacianine sodium was administered to 150 total patients (safety analysis set); 109 patients comprised the full analysis set for efficacy analyses. Patients had primarily serous adenocarcinoma (n = 72; 68.6%) and advanced stage disease (n = 83; 76.1%). In 33% of patients (36 of 109), NIRF imaging with pafolacianine sodium identified additional lesions that were not planned for resection and were not detected by normal white light and palpation ( P < 0.001, 95% CI [0.243, 0.427]). Among patients who underwent interval debulking surgery, the rate was higher, at 39.7% of patients (23 of 58; 95% CI [0.270, 0.534]). At the individual lesion level, the accuracy of pafolacianine sodium with NIRF to detect ovarian cancer is reflected by sensitivity of 83% (95% CI [73.9, 89.4]) and a false positive rate of 32.7% (95% CI [25.6, 40.7]). Investigators reported achieving complete resection (R0) in 62.4% (68 of 109) of patients. Drug-related adverse events (AEs) were reported by 30% of patients (45 out of 150). The most frequently reported drug-related AEs were nausea (18.0%), vomiting (5.3%), and abdominal pain (4.7%). Infusion reactions at the time of the procedure were mostly (96%) mild or moderate in severity; 89% resolved within 24 hours of onset. No drug-related serious AEs or deaths were reported. Conclusions: This phase 3 trial of pafolacianine sodium with NIRF imaging met its primary endpoint, intraoperatively identifying additional cancer not planned for resection in a statistically significant number of patients. Therefore, pafolacianine sodium may offer a novel real-time adjunct to current surgical imaging practice in ovarian cancer surgery. Clinical trial information: NCT03180307.
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Affiliation(s)
- Janos Laszlo Tanyi
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Hye Sook Chon
- Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | | | | | | | | | - Matthew A. Powell
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Singh P, Bentall AJ, Langstraat CL, Swanson AA, Deziel PJ, Huang Y, Razonable RR. A rare manifestation of CMV disease in a kidney transplant recipient. Transpl Infect Dis 2021; 23:e13527. [PMID: 33237608 DOI: 10.1111/tid.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Prince Singh
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Andrew J Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Amy A Swanson
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Deziel
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Yajue Huang
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
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17
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Narasimhulu DM, Thannickal A, Kumar A, Weaver AL, McGree ME, Langstraat CL, Cliby WA. Appropriate triage allows aggressive primary debulking surgery with rates of morbidity and mortality comparable to interval surgery after chemotherapy. Gynecol Oncol 2020; 160:681-687. [PMID: 33390326 DOI: 10.1016/j.ygyno.2020.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Morbidity and mortality (M/M) after primary debulking surgery (PDS) is often cited as a rationale for neoadjuvant chemotherapy and interval debulking surgery (IDS). We tested if using an evidence-based algorithm to identify patients fit for surgery would reduce M/M after PDS to that seen after IDS. METHODS We included women who underwent PDS or IDS for advanced epithelial ovarian cancer (EOC) (1/2012-7/2016) guided by the use of a prospective triage algorithm. Outcomes were compared after applying inverse-probability of treatment weighting (IPTW) to adjust for covariate imbalance. RESULTS Of 334 included patients, 232 (69.5%) underwent PDS and 102 (30.5%) were triaged to IDS. Relative to IDS group, PDS patients were younger (63.9 vs 67.5 years, P=0.01), were less likely to have low albumin (16.8% vs. 32.4%, P<0.001), had longer median operative times (315 vs 263 min, P <0.001), more high complexity surgeries and fewer low complexity surgeries (27.2% vs. 11.8% and 18.5% vs 36.3% respectively, P<0.001). The rates of the following outcomes were comparable for PDS and IDS, respectively: successful cytoreduction (complete, 62.5% vs 66.7%, P=0.47 and optimal, 95.3% vs 98.0%, P=0.36), 30-day grade 3+ complications (IPTW-adjusted 18.3% vs. 12.9%, P=0.22), 90-day mortality (IPTW-adjusted, 2.2% vs. 3.8%, P=0.42), length of hospitalization (P=0.29), and postoperative chemotherapy delivery (P=0.83). 3-year overall survival was higher for PDS group (IPTW-adjusted 64.1% vs. 42.6%, P=0.001). CONCLUSIONS Use of our validated triage strategy allowed us to offer 70% of women with advanced EOC PDS surgery. Despite more complex surgery, M/M after this approach is low and comparable to IDS, with similar rates of complete resection and superior OS. Use of a validated triage system should be utilized when considering PDS vs neoadjuvant chemotherapy.
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Affiliation(s)
- Deepa M Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aneesa Thannickal
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amy L Weaver
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Moynagh MR, Dowdy SC, Welch B, Glaser GE, Schmitz JJ, Jatoi A, Langstraat CL, Block MS, Kurup AN, Kumar A. Image-guided tumor ablation in gynecologic oncology: Review of interventional oncology techniques and case examples highlighting a collaborative, multidisciplinary program. Gynecol Oncol 2020; 160:835-843. [PMID: 33388156 DOI: 10.1016/j.ygyno.2020.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/23/2020] [Indexed: 01/20/2023]
Abstract
As interventional oncology services within radiology mature, image-guided ablation techniques are increasingly applied to recurrent gynecologic malignancies. Ablation may be performed using thermal techniques like cryoablation, microwave ablation, or radiofrequency ablation, as well as non-thermal ones, such as focused ultrasound or irreversible electroporation. Feasibility and approach depend on tumor type, size, number, anatomic location, proximity of critical structures, and goals of therapy. Current indications include local control of limited metastatic disease or palliation of painful bone metastases refractory or unsuitable to conventional therapies. Technical aspects of these procedures, including methods to protect nearby critical structures are presented through illustrative examples. Cases amenable to image-guided ablation include, but are not limited to, hepatic or pulmonary metastases, musculoskeletal metastases, retroperitoneal nodal metastases, pelvic side wall disease, abdominal wall disease, and vaginal or vulvar tumors. Protective maneuvers, such as hydro-displacement of bowel, neuromonitoring, and retrograde pyeloperfusion through ureteral stents, permit safe ablation despite close proximity to vulnerable nerves or organs. Image-guided ablation offers an alternative modality to achieve local tumor control without the risks associated with surgery or systemic treatment in appropriately selected patients. A multidisciplinary approach to use of image-guided ablation includes collaboration between gynecologic oncology, interventional radiology, anesthesia, urology and radiation oncology teams allowing for appropriate patient-centered case selection. Long-term follow up and additional studies are needed to determine the oncologic benefits of such techniques.
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Affiliation(s)
- Michael R Moynagh
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Sean C Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Brian Welch
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - John J Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Aminah Jatoi
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Matthew S Block
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - A Nicholas Kurup
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States of America.
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Narasimhulu DM, McGree ME, Weaver AL, Jatoi A, LeBrasseur NK, Glaser GE, Langstraat CL, Block MS, Kumar A. Frailty is a determinant of suboptimal chemotherapy in women with advanced ovarian cancer. Gynecol Oncol 2020; 158:646-652. [PMID: 32518016 DOI: 10.1016/j.ygyno.2020.05.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/27/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the relationship between frailty and chemotherapy delivery among women with epithelial ovarian cancer (EOC). METHODS We included women who underwent primary debulking surgery (PDS) for stage IIIC/IV EOC between 1/2/2003 and 12/30/2011, received adjuvant chemotherapy at our institution, and had data available to calculate a frailty deficit index. Frailty was defined as a frailty deficit index ≥0.15. Relative dose intensity (RDI) of chemotherapy was calculated as the percentage of the standard dose that was administered, and compared between frail and non-frail using the Wilcoxon rank-sum test. RESULTS Failure to receive chemotherapy following PDS was twice as common among frail vs. non-frail women (26.7% vs 14.2%, p = 0.001). Of the 169 women who received chemotherapy at our institution, 17.2% (29/169) were frail. Frail women were older (mean, 67.9 vs 62.3 years, p = 0.01), had higher BMI (mean, 29.6 vs 25.7 kg/m2, p = 0.003), and were less likely to complete 6 cycles of chemotherapy (75.9 vs. 93.6%, p = 0.008). Using an RDI cutoff of 85%, frail women were less likely to have adequate doses of carboplatin (15.8 vs. 66.2%, p < 0.001) and paclitaxel (57.9 vs. 80.5%, p = 0.07) despite no differences in dose delays (34.5 vs. 42.1%), dose reductions (65.5 vs. 68.6%), and severe neutropenia (44.8 vs. 39.3%). After adjusting for age, frailty was associated with shorter progression-free (HR 1.58, 95% CI: 0.99-2.50) and overall survival (HR 2.14, 95% CI: 1.35-3.41). CONCLUSION Frail women with EOC were less likely to receive chemotherapy or the optimal dose of chemotherapy after PDS despite no evidence of treatment-related toxicity. Frail EOC patients demonstrated shorter progression-free and overall survival. Further studies are needed to explore the association between frailty, chemotherapy, and survival.
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Affiliation(s)
- Deepa Maheswari Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Amy L Weaver
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Aminah Jatoi
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Nathan K LeBrasseur
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, United States
| | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States; Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States; Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Matthew S Block
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States; Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States.
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Zivanovic O, Chi D, Zhou Q, Iasonos A, Makker V, Grisham RN, Konner JA, Diaz JP, Brown AK, Langstraat CL, Paroder V, Soldan K, Su K, Gardner GJ, Jewell EL, Long K, Tew WP, Lichtman SM, Sonoda Y, O'Cearbhaill RE. A randomized phase II trial of secondary cytoreductive surgery (SCS) +/- carboplatin hyperthermic intraperitoneal chemotherapy (HIPEC) in patients (pts) with recurrent platinum-sensitive ovarian cancer (EOC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.6016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6016 Background: The role of HIPEC for recurrent EOC is not well defined. The aim of this phase II study was to determine the proportion of pts without evidence of disease progression at 24 months post SCS +/- intraoperative carboplatin HIPEC. Methods: After SCS to ≤ 0.5 cm residual visible disease pts were intraoperatively randomized to carboplatin HIPEC (800mg/m2 for 90 minutes) or no HIPEC. The HIPEC arm received 5 additional and the standard arm received 6 postoperative cycles of IV platinum-based chemotherapy without maintenance treatment. Based on an exact binomial single stage “pick the winner” design, each arm is considered “winner” if ≥ 17/49 pts are without evidence of disease progression at 24 months post SCS. Secondary objectives include postoperative grade ≥ 3 toxicity and complications within 4 weeks post SCS, and pharmacokinetics of carboplatin HIPEC. Results: Of 98 pts, 49 (50%) were randomized to the HIPEC arm. The arms were well balanced for age, stage, histology, BRCA mutation status, prior chemotherapy, and disease-free interval. Complete gross SCS was achieved in 94% of the standard and 82% of the HIPEC arm (p = 0.12). Bowel resection was performed more frequently in the standard (65%) compared to the HIPEC arm (37%; p = 0.008). Median operative time was shorter in the standard (296 minutes) compared to the HIPEC arm (475 minutes; p < 0.001). There was no perioperative mortality and no difference in use of ostomies, length of stay or postoperative toxicity. At a median follow-up of 27.7 months (range: 8.8-81.8 months) 70 of 98 pts progressed and 26 died with a median progression free survival (PFS) of 14.3 months (12.1-16 months) and a median overall survival (OS) of 55.2 months (47.7-not reached). At 24 months post SCS 32 pts progressed within 24 months in the standard versus 35 in the HIPEC arm. There was no statistically significant difference in median PFS (15.4 vs 12.3 months, p = 0.173) or median OS (69.2 vs 53.1 months, p = 0.317) between arms. These are preliminary efficacy estimates as 83/98 pts have a minimum of 24 months follow-up. Conclusions: The HIPEC arm did not reach the predefined “winner” endpoint; the standard arm is still undetermined as 6 pts did not reach 24 months follow-up. No perioperative mortality, and no increased perioperative morbidity or toxicity was seen with HIPEC. SCS with carboplatin HIPEC followed by 5 cycles of platinum-based chemotherapy was not superior to SCS without HIPEC followed by 6 cycles of platinum-based chemotherapy. Clinical trial information: NCT01767675.
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Affiliation(s)
- Oliver Zivanovic
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Dennis Chi
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Vicky Makker
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachel N. Grisham
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Jason A. Konner
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Amy K. Brown
- Hartford Hospital Healthcare Centers, Glatsonbury, CT
| | | | | | | | - Katy Su
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ginger J. Gardner
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Elizabeth Lin Jewell
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Kara Long
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - William P. Tew
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Yukio Sonoda
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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Kalogera E, Suman VJ, Nevala WK, Finnes HD, Schimke J, Strand C, Glaser G, Grudem M, Jatoi A, Klampe C, Kumar A, Langstraat CL, Wahner Hendrickson AE, Weroha SJ, Reid JM, Markovic S, Block MS. A phase I trial of nab-paclitaxel/bevacizumab (AB160) nano-immunoconjugate therapy for metastatic gynecological malignancies: MC1371 (NCT02020707). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e18097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18097 Background: AB160 is a 160 nm nano-immunoconjugate consisting of nab-paclitaxel (NP) nanoparticles non-covalently coated with bevacizumab (BEV) for targeted delivery into tissues expressing high levels of vascular-endothelial growth factor (VEGF). Both taxanes (GOG-0129C, GOG-0126R, GOG-0127V) and BEV (GOG-0229E, AURELIA, GOG-0227C) have demonstrated clinical activity in previously treated metastatic endometrial cancer (EC), ovarian cancer (OC), and cervical cancer (CC), respectively. Methods: A 3+3 phase I trial was conducted in patients with EC, platinum-resistant OC and CC who had prior systemic treatment for metastatic disease to determine the maximum tolerated dose of AB160 administered intravenously on days 1, 8 and 15 of a 28-day cycle. The starting dose level (DL1) was NP at 125 mg/m2 with BEV at 50 mg/m2. There were 2 higher dose levels: DL2 (NP at 150 mg/m2 with BEV at 60 mg/m2) and DL3 (NP at 175 mg/m2 with BEV at 70 mg/m2). Dose limiting toxicities (DLT) included grade (G) 4 neutropenia or anemia, PLT < 25,000, serum creatinine ≥2 times baseline, G2-4 neurologic toxicity or G3-4 non-hematologic toxicities. Disease evaluations were conducted after every 2 treatment cycles using RECIST criteria. Patients were treated until disease progression or intolerability. Samples were collected for pharmacokinetic (PK) studies. Results: Nine women 41 – 74 years of age (median 57) have enrolled (5 with EC and 4 with OC); data are available for the first 8. No DLTs have been observed among the 3 women enrolled on DL1, 3 women on DL2, and 2 women on DL3. All 3 patients on DL3 continue on treatment. The other 6 patients have discontinued due to adverse reactions (3), progression (2), and patient choice (1). The median number of cycles administered is 6 (4-14). The most common severe (G3/4) toxicities include neutropenia (37.5%) and leukopenia (25%). There have been 5 partial responses (62.5%): 1 on DL1 and 2 each on DL2 and DL3. PK evaluation is pending. Conclusions: AB160 therapy is safe and demonstrates promising clinical activity in patients with previously treated metastatic gynecologic malignancies. Further clinical testing is being pursued in this patient population. Clinical trial information: NCT02020707.
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Goldfarb JA, Dinoi G, Mariani A, Langstraat CL. A case of multi-agent drug resistant choriocarcinoma treated with Pembrolizumab. Gynecol Oncol Rep 2020; 32:100574. [PMID: 32395603 PMCID: PMC7210394 DOI: 10.1016/j.gore.2020.100574] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022] Open
Abstract
High-risk multi-agent drug resistant GTN is a life threatening disease. Majority of choriocarcinomas show intense PD-L1 immunoreactivity. Pembrolizumab increases antitumor activity. Effectiveness of Pembrolizumab in treating patients with high-risk multi-agent drug resistant GTN.
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Affiliation(s)
- Jennifer A Goldfarb
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Giorgia Dinoi
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Andrea Mariani
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Carrie L Langstraat
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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Narasimhulu DM, Kumar A, Weaver AL, Langstraat CL, Cliby WA. Less guessing, more evidence in identifying patients least fit for cytoreductive surgery in advanced ovarian cancer: A triage algorithm to individualize surgical management. Gynecol Oncol 2020; 157:572-577. [PMID: 32247602 DOI: 10.1016/j.ygyno.2020.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/20/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We previously reported an algorithm that identifies women at high risk of postoperative morbidity & mortality (M/M) as a tool to triage between neoadjuvant chemotherapy and primary surgery for epithelial ovarian cancer (EOC). We sought to independently validate its performance using multicenter data. METHODS Women who underwent surgery for stage IIIC/IV EOC between 1/1/2014 and 12/31/2017 were identified from the National Surgical Quality Improvement Program database and classified as "high risk" or "triage appropriate" using our algorithm. Outcomes were compared between triage appropriate and high-risk women using the chi-square test. RESULTS 1777 women met inclusion criteria; the mean age was 62.6 years and 81.9% had stage IIIC disease. Nationally, the surgical complexity scores were low (69.8% low, 25.2% intermediate and 5.0% high). "High risk" women had 2-fold higher rate of severe 30-day complication or death (6.2% vs 3.5%; p = 0.01), a 3-fold higher rate of 30-day mortality (1.4% vs 0.5%; p = 0.08), and a higher risk of death following a severe complication (11.1% vs. 0%, p = 0.11). A sensitivity analysis excluding women with unknown albumin who didn't meet other high risk criteria showed similar results: severe 30-day complications or death (6.2% vs 3.5%; p = 0.02) and 30-day mortality (1.4% vs 0.3%; p = 0.04) for "high risk" vs "triage appropriate" women. CONCLUSIONS Primary cytoreductive surgery to minimal residual disease remains the goal for EOC. We verify that our algorithm can identify women at risk of M/M using national multicenter data, despite a low complexity surgical setting and using 30-day mortality (vs. 90-day). Objective surgical risk assessment for ovarian cancer should be standard of care and can be incorporated into practice using the Mayo triage algorithm.
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Affiliation(s)
- Deepa Maheswari Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amy L Weaver
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Casarin J, Song C, Multinu F, Cappuccio S, Liu E, Butler KA, Glaser GE, Cliby WA, Langstraat CL, Ghezzi F, Fu AZ, Mariani A. Implementing robotic surgery for uterine cancer in the United States: Better outcomes without increased costs. Gynecol Oncol 2020; 156:451-458. [DOI: 10.1016/j.ygyno.2019.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 12/11/2022]
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Narasimhulu DM, Kumar A, Weaver AL, McGree ME, Langstraat CL, Cliby WA. Using an evidence-based triage algorithm to reduce 90-day mortality after primary debulking surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2019; 155:58-62. [DOI: 10.1016/j.ygyno.2019.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/25/2019] [Accepted: 08/02/2019] [Indexed: 12/18/2022]
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Tortorella L, Casarin J, Multinu F, Cappuccio S, McGree ME, Weaver AL, Langstraat CL, Keeney GL, Kumar A, Melis GB, Angioni S, Scambia G, Mariani A, Glaser GE. Sentinel lymph node biopsy with cervical injection of indocyanine green in apparent early-stage endometrial cancer: predictors of unsuccessful mapping. Gynecol Oncol 2019; 155:34-38. [DOI: 10.1016/j.ygyno.2019.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 12/27/2022]
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Kilts TP, Glaser GE, Langstraat CL, Kumar A, Weaver AL, Mc Gree ME, Gostout BS, Podratz KC, Dowdy SC, Cliby WA, Mariani A, Bakkum-Gamez JN. Comparing risk stratification criteria for predicting lymphatic dissemination in endometrial cancer. Gynecol Oncol 2019; 155:21-26. [PMID: 31409487 DOI: 10.1016/j.ygyno.2019.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/26/2019] [Accepted: 08/02/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To compare two published risk stratification models (Milwaukee Model vs. Mayo Criteria) to predict lymphatic dissemination (LD) in endometrioid endometrial cancer (EC). METHODS Patients with stage I-III EC undergoing surgery from 1/1/2004-9/30/2013 were retrospectively reviewed and classified as low-risk vs at-risk for LD using two independent risk models. LD was defined as positive nodes at surgery or lymph node recurrence within 2 years of surgery after negative lymph node dissection (LND) or when LND was not performed. False positive (FP) and false negative (FN) rates for each risk model were calculated. RESULTS Among 1103 patients, 81 (7.3%) had LD (72 positive LN and 9 LN recurrences), and most (90.2%) had stage I EC. The Milwaukee Model yielded a low at-risk rate for LD (38.1%) but a high FN rate (13.6%, 95% CI 7.0-23.0). The traditional Mayo Criteria using a cut-off of 2 cm for tumor diameter (TD) had a higher at-risk rate for LD (69.5%) but a FN rate of 0% (95% CI, 0-4.5). Modifying the Mayo Criteria using a TD cutoff of ≤3 cm identified fewer women at-risk (56.8% vs. 69.5%) and had a lower FP rate (53.6% vs. 67.1%), but had a higher FN rate (3.7%, 95% CI, 0.8-10.4). CONCLUSIONS The Milwaukee Model had the lowest at-risk rate of LD but an unacceptable FN rate. Modifying the Mayo Criteria by increasing the TD cutoff from the traditional ≤2 cm to ≤3 cm would spare an estimated 13.5% of patients LND, but the accompanying FN rate is unacceptably high. The traditional Mayo Criteria for low-risk EC remains the most sensitive in determining which patients LND can be omitted.
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Affiliation(s)
- Toni P Kilts
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Gretchen E Glaser
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Carrie L Langstraat
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Amanika Kumar
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, United States
| | - Michaela E Mc Gree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, United States
| | - Bobbie S Gostout
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Karl C Podratz
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - William A Cliby
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Andrea Mariani
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Jamie N Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States.
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Colon-Otero G, Weroha SJ, Zanfagnin V, Foster NR, Asmus E, Wahner Hendrickson AE, Jatoi A, Block MS, Langstraat CL, Glaser GE, Dinh T, Robertson M, Camoriano JK, Butler K, Copland JA. Results of a phase 2 trial of ribociclib and letrozole in patients with either relapsed estrogen receptor (ER)-positive ovarian cancers or relapsed ER-positive endometrial cancers. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.5510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5510 Background: Single agent aromatase inhibitor (AI) therapy is associated with limited clinical activity in ovarian cancer (OC) and endometrial cancers (EC). AI therapy was associated with a progression free survival (PFS) at 12 weeks of only 20% in relapsed OC (Bowman et al, 2002) and a median PFS of 1 month in relapsed EC (Rose et al, 2000). In Estrogen Receptor (ER) positive metastatic breast cancer, clinical studies had shown a significant prolongation of PFS with the addition of the cyclin kinase 4/6 inhibitor ribociclib to AI (Hortobagyi et al, 2016). Here, we report the results of a phase 2 clinical trial of the combination of ribociclib and letrozole in patients with relapsed ER positive OC or EC. Objectives: Primary endpoint was the proportion of patients with relapsed ER positive OC or EC alive and progression-free after 12 weeks of therapy (PFS12) with the combination of ribociclib given at a dose of 400 mg orally daily and letrozole 2.5 mg orally daily. A PFS of 45% was considered a favorable result based on the data referenced above from Bowman et al. Methods: Eligibility criteria included patients with relapsed ER positive OC or EC, with measurable disease, not previously treated with ribociclib or AIs. Xenografts were created from CT guided tumor biopsies at baseline to assess feasibility. Results: A total of 40 patients were enrolled (20 with OC and 20 with EC) ) with a median age of 61 years (range: 30-82) and 64.5 (range: 52-75) in the OC and EC groups respectively. Among the OC patients, 17 had high grade serous carcinomas and 3 had low grade serous carcinomas. 11 EC patients had endometrioid cancers (3 with grade 1 tumors) and 9 had high grade serous tumors. Ten out of 20 OC patients and 11/20 EC patients were alive and progression-free at 12 weeks (PFS12 of 50 and 55%, respectively). The most common grade 3 or higher adverse events (occurring in at least 5 pts) were leukopenia (18%), lymphopenia (18%), neutropenia (13%), and fatigue (13%). 34 tumor biopsies were suitable for injection into mice and 44% engrafted. ER expression persisted through multiple passages in mice. Two of three EC PDX models exhibited improved PFS with letrozole/ribociclib compared to letrozole alone. Conclusions: The combination of ribociclib and letrozole is associated with a promising 50% and 55% PFS12 in patients with ER positive relapsed OC or EC respectively. Creation of xenograft tumor models from CT guided biopsies of OC and EC tumors was feasible. Clinical trial information: NCT02657928.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Kristina Butler
- Mayo Clinic School of Graduate Medical Education, Scottsdale, AZ
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Torres D, Kumar A, Bakkum-Gamez JN, Weaver AL, McGree ME, Wang C, Langstraat CL, Cliby WA. Mesenchymal molecular subtype is an independent predictor of severe postoperative complications after primary debulking surgery for advanced ovarian cancer. Gynecol Oncol 2019; 152:223-227. [DOI: 10.1016/j.ygyno.2018.11.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
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Kalogera E, Glaser GE, Kumar A, Dowdy SC, Langstraat CL. Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review. J Minim Invasive Gynecol 2019; 26:288-298. [DOI: 10.1016/j.jmig.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022]
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Kumar A, Wallace SA, Cliby WA, Glaser GE, Mariani A, Leitao MM, Frumovitz M, Langstraat CL. Impact of Sentinel Node Approach in Gynecologic Cancer on Training Needs. J Minim Invasive Gynecol 2018; 26:727-732. [PMID: 30138740 DOI: 10.1016/j.jmig.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/12/2018] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions. DESIGN Retrospective multi-institution cohort (Canadian Task Force classification II-2). SETTING Three tertiary cancer referral cancer centers. PATIENTS Patients with endometrial and vulvar cancer undergoing lymph node evaluation. INTERVENTIONS Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment. MEASUREMENTS AND MAIN RESULTS Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins. CONCLUSIONS Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.
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Affiliation(s)
- Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota.
| | - Sumer A Wallace
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Mario M Leitao
- Department of Gynecologic Oncology (Dr. Leitao), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Frumovitz
- Department of Gynecologic Oncology (Dr. Frumovitz), MD Anderson Cancer Center, Houston, Texas
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
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Tortorella L, Langstraat CL, Weaver AL, McGree ME, Bakkum-Gamez JN, Dowdy SC, Cliby WA, Keeney GL, Sherman ME, Weroha SJ, Mariani A, Podratz KC. Uterine serous carcinoma: Reassessing effectiveness of platinum-based adjuvant therapy. Gynecol Oncol 2018; 149:291-296. [PMID: 29550183 DOI: 10.1016/j.ygyno.2018.02.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/20/2018] [Accepted: 02/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Two randomized trials failed to demonstrate efficacy of platinum-based chemotherapy (PbCT) for uterine serous carcinoma (USC). Our objective was to reassess the value of PbCT for patients with microscopic residuum (R0). METHODS Progression-free survival (PFS) after surgery was analyzed for 409 patients and correlated with adjuvant therapies: vaginal brachytherapy (VBRT), external beam radiotherapy (EBRT), PbCT, or combinations. RESULTS The estimated 5-year PFS for stage I (n=209) USC was 65.1% for observation only; 90.7%, VBRT only; and 91.1%, PbCT±VBRT (85% received VBRT); VBRT significantly (P=.004) impacted PFS, but the added value of PbCT remains uncertain. Of 58 stage IIIC, PbCT-treated patients (±EBRT), 5-year PFS was 33.9%; most failures had a vascular disseminated component. Median PFS for 72 stage IV, PbCT-treated patients was 18.6months for R0; 8.0, R1≤1cm residual disease; and 4.6, R2>1cm (P=.008). The progression rate (PR) during 1 to 2year follow-up for R0 was similar to PR during 0-1year follow-up for R1 (P=.31), suggesting recurrences in patients with R0 disease before 2years are likely platinum resistant. PRs during follow-up were nearly identical for R0≥2years and R1≥1year (P=.95), presumably showing limited numbers of platinum-sensitive tumors. CONCLUSIONS A comparison of PR for patients treated with PbCT for stage IV R0 and R1 disease suggested that a 1-year lag interval precedes clinical recognition of PbCT refractory/resistant R0 disease. Most patients treated with PbCT who had microscopic residuum had recurrences within 2years (across stages), emphasizing the need for more effective therapy.
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Affiliation(s)
- Lucia Tortorella
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Carrie L Langstraat
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA; Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William A Cliby
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gary L Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mark E Sherman
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Andrea Mariani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Karl C Podratz
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Kumar A, Langstraat CL, DeJong SR, McGree ME, Bakkum-Gamez JN, Weaver AL, LeBrasseur NK, Cliby WA. Functional not chronologic age: Frailty index predicts outcomes in advanced ovarian cancer. Gynecol Oncol 2017; 147:104-109. [DOI: 10.1016/j.ygyno.2017.07.126] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 11/27/2022]
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Nitschmann CC, Multinu F, Bakkum-Gamez JN, Langstraat CL, Occhino JA, Weaver AL, Cliby WA, Mariani A, Dowdy SC. Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care. Gynecol Oncol 2017; 145:555-561. [PMID: 28392125 DOI: 10.1016/j.ygyno.2017.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND). METHODS Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores. RESULTS VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08). CONCLUSION Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.
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Affiliation(s)
- C C Nitschmann
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - F Multinu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - J N Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - C L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - J A Occhino
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - A L Weaver
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - W A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - A Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - S C Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Marnach ML, Butler KA, Henry MR, Hutz CE, Langstraat CL, Lohse CM, Casey PM. Oral Progestogens Versus Levonorgestrel-Releasing Intrauterine System for Treatment of Endometrial Intraepithelial Neoplasia. J Womens Health (Larchmt) 2017; 26:368-373. [DOI: 10.1089/jwh.2016.5774] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mary L. Marnach
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Kristina A. Butler
- Division of Pelvic Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Michael R. Henry
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Catherine E. Hutz
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Carrie L. Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Christine M. Lohse
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Petra M. Casey
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
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Gill SE, McGree ME, Weaver AL, Cliby WA, Langstraat CL. Optimizing the treatment of ovarian cancer: Neoadjuvant chemotherapy and interval debulking versus primary debulking surgery for epithelial ovarian cancers likely to have suboptimal resection. Gynecol Oncol 2016; 144:266-273. [PMID: 27916269 DOI: 10.1016/j.ygyno.2016.11.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/11/2016] [Accepted: 11/12/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To: a) identify prognostic factors in patients with epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS), and b) compare post-surgical survival between patients treated with NACT/IDS for presumed unresectable disease and stage IIIC/IV patients who underwent suboptimal primary debulking surgery (PDS). METHODS This was a retrospective study of consecutive stage IIIC or IV patients undergoing IDS after NACT at Mayo Clinic from January 2007 to December 2013. A subset of patients receiving NACT/IDS for the indication of unresectable disease were matched 1:1 on age and stage to a cohort of patients who underwent suboptimal PDS between 2003 and 2011. Hazard ratios and corresponding 95% confidence intervals were estimated from Cox proportional hazards models. RESULTS We identified 87 patients treated with NACT/IDS: the median OS and PFS following surgery was 2.4 and 1.0years, respectively. Factors associated with significantly worse OS were older age (adjusted HR 1.60 per 10-year increase in age, 95% CI 1.18, 2.16) and elevated CA-125 before IDS (adjusted HR 2.30 for CA-125 >35U/mL, 95% CI 1.25, 4.23). Number of adjuvant chemotherapy cycles administered did not have a significant effect on survival. In the matched cohort analysis of presumed unresectable cases undergoing NACT/IDS vs suboptimal PDS cases (n=45 each), the NACT/IDS group had a significant OS advantage (HR 0.53; 95% CI 0.32, 0.88), and fewer patients experienced a 30-day postoperative Accordion grade 3/4 complication (11% vs 36%, P=0.01). CONCLUSIONS Younger age and normalization of CA-125 prior to IDS are associated with improved survival with NACT/IDS. For primary EOC where resection to residual disease of 1cm or less is unlikely, NACT/IDS is associated with improved survival and reduced perioperative morbidity compared to PDS. As these patients are likely best served by NACT/IDS, more reliable predictors of resectability would be valuable.
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Affiliation(s)
- Sarah E Gill
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - William A Cliby
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Kumar A, Moynagh MR, Multinu F, Cliby WA, McGree ME, Weaver AL, Young PM, Bakkum-Gamez JN, Langstraat CL, Dowdy SC, Jatoi A, Mariani A. Muscle composition measured by CT scan is a measurable predictor of overall survival in advanced ovarian cancer. Gynecol Oncol 2016; 142:311-6. [PMID: 27235857 DOI: 10.1016/j.ygyno.2016.05.027] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To assess the impact of muscle composition and sarcopenia on overall survival in advanced epithelial ovarian cancer (EOC) after primary debulking surgery (PDS). METHODS Women with stage IIIC/IV EOC who underwent PDS with curative intent between 1/1/2006 and 12/31/2012 were included. Patient variables and vital status were abstracted. Body composition was evaluated in a semi-automated process using Slice-O-Matic software v4.3 (TomoVision). Skeletal muscle area and mean skeletal muscle attenuation were recorded. Associations with overall survival were evaluated using Cox proportional hazards models and recursive partitioning. RESULTS We identified 296 patients and 132 (44.6%) were classified as sarcopenic. The average mean skeletal muscle attenuation of the entire cohort was 33.4 Hounsfield units (HU). A multivariate model of overall risk of death included histology, residual disease, and mean skeletal attenuation. Among patients without residual disease, overall survival, but not progression free survival was significantly different between patients with low versus high mean skeletal attenuation (median survival, 2.8 vs. 3.3years). Among patients with residual disease, overall survival was significantly different between patients with low versus high mean skeletal attenuation ≥36.40 vs. <36.40 HU (median survival, 2.0 vs. 3.3years). CONCLUSIONS Sarcopenia and low mean skeletal muscle attenuation are common in women undergoing PDS for advanced EOC. These factors are associated with poorer outcomes, and can be used in preoperative risk stratification and patient counseling. Further research into body composition and whether this risk factor can be altered via nutrition or fitness in this population is warranted.
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Affiliation(s)
- Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Francesco Multinu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Phillip M Young
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Jamie N Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Sean C Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aminah Jatoi
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Kumar A, Janco JM, Mariani A, Bakkum-Gamez JN, Langstraat CL, Weaver AL, McGree ME, Cliby WA. Risk-prediction model of severe postoperative complications after primary debulking surgery for advanced ovarian cancer. Gynecol Oncol 2016; 140:15-21. [DOI: 10.1016/j.ygyno.2015.10.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/28/2015] [Accepted: 10/31/2015] [Indexed: 01/31/2023]
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AlHilli MM, Tran CW, Langstraat CL, Martin JR, Weaver AL, McGree ME, Mariani A, Cliby WA, Bakkum-Gamez JN. Risk-scoring model for prediction of non-home discharge in epithelial ovarian cancer patients. J Am Coll Surg 2013; 217:507-15. [PMID: 23816386 DOI: 10.1016/j.jamcollsurg.2013.04.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 04/22/2013] [Accepted: 04/23/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Identification of preoperative factors predictive of non-home discharge after surgery for epithelial ovarian cancer (EOC) may aid counseling and optimize discharge planning. We aimed to determine the association between preoperative risk factors and non-home discharge. STUDY DESIGN Patients who underwent primary surgery for EOC at Mayo Clinic between January 2, 2003 and December 29, 2008 were included. Demographic, preoperative, and intraoperative factors were retrospectively abstracted. Logistic regression models were fit to identify preoperative factors associated with non-home discharge. Multivariable models were developed using stepwise and backward variable selection. A risk-scoring system was developed for use in preoperative counseling. RESULTS Within our cohort of 587 EOC patients, 12.8% were not discharged home (61 went to a skilled nursing facility, 1 to a rehabilitation facility, 1 to hospice, and there were 12 in-hospital deaths). Median length of stay was 7 days (interquartile range [IQR] 5, 10 days) for patients dismissed home compared with 11 days (IQR 7, 17 days) for those with non-home dismissals (p < 0.001). In multivariable analyses, patients with advanced age (odds ratio [OR] 3.75 95% CI [2.57, 5.48], p < 0.001), worse Eastern Cooperative Oncology Group (ECOG) performance status (OR 0.92 [95% CI 0.43, 1.97] for ECOG performance status 1 vs 0 and OR 5.40 (95% CI 2.42, 12.03) for score of 2+ vs 0; p < 0.001), greater American Society of Anesthesiologists (ASA) score (OR 2.03 [95% CI 1.02, 4.04] for score ≥3 vs < 3, p = 0.04), and higher CA-125 (OR 1.28 [95% CI 1.12, 1.46], p < 0.001) were less likely to be discharged home. The unbiased estimate of the c-index was excellent at 0.88, and the model had excellent calibration. CONCLUSIONS Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.
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Affiliation(s)
- Mariam M AlHilli
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Allensworth SK, Langstraat CL, Martin JR, Lemens MA, McGree ME, Weaver AL, Dowdy SC, Podratz KC, Bakkum-Gamez JN. Evaluating the prognostic significance of preoperative thrombocytosis in epithelial ovarian cancer. Gynecol Oncol 2013; 130:499-504. [PMID: 23747328 DOI: 10.1016/j.ygyno.2013.05.038] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/22/2013] [Accepted: 05/25/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Preoperative thrombocytosis has been implicated as a negative prognostic marker for epithelial ovarian cancer (EOC). We assessed whether thrombocytosis is an independent risk factor for EOC recurrence and death. METHODS Perioperative patient characteristics and process-of-care variables (National Surgical Quality Improvement Program (NSQIP)-defined) were retrospectively abstracted from 587 women who underwent EOC staging between 1/2/03-12/29/08. Thrombocytosis was defined as platelet count > 450 × 10(9)/L. Disease-free survival (DFS) and overall survival (OS) were determined using Kaplan-Meier methods. Associations were evaluated with Cox proportional hazards regression and hazard ratios (HR). RESULTS The incidence of preoperative thrombocytosis was 22.3%. DFS was 70.8% and 36.0% at 1 and 3 years. OS was 83.3% and 54.3% at 1 and 3 years. Ascites, lower hemoglobin, advanced disease, and receipt of perioperative packed red blood cell transfusion were independently associated with thrombocytosis. Older age and the presence of coronary artery disease were associated with lower likelihood of thrombocytosis. Overall, thrombocytosis was an independent predictor of increased risk of recurrence. Among early stage (I/II) cases, there was a 5-fold increase in the risk of death and nearly 8-fold risk of disease recurrence independently associated with thrombocytosis. CONCLUSION Preoperative thrombocytosis portends worse DFS in EOC. In early stage disease, thrombocytosis is a potent predictor of worse DFS and OS and further assessment of the impact of circulating platelet-derived factors on EOC survival is warranted. Thrombocytosis is also associated with extensive initial disease burden, measurable residual disease, and postoperative sequelae. Preoperative platelet levels may have value in primary cytoreduction counseling.
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Affiliation(s)
- S K Allensworth
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery Mayo Clinic, Rochester, MN 55905, United States
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Bakkum-Gamez JN, Langstraat CL, Martin JR, Lemens MA, Weaver AL, Allensworth S, Dowdy SC, Cliby WA, Gostout BS, Podratz KC. Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma. Gynecol Oncol 2012; 125:614-20. [PMID: 22370599 DOI: 10.1016/j.ygyno.2012.02.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 02/17/2012] [Accepted: 02/18/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Thorough primary cytoreduction for epithelial ovarian carcinoma (EOC) improves survival. The incidence of postoperative ileus (POI) in these patients may be underreported because of varying POI definitions and the evolving, increasingly complex contemporary surgical approach to EOC. We sought to determine the current incidence of POI and its risk factors in women undergoing debulking and staging for EOC. METHODS We retrospectively identified the records of women who underwent primary staging and cytoreduction for EOC between 2003 and 2008. POI was defined as a surgeon's diagnosis of POI, return to nothing-by-mouth status, or reinsertion of a nasogastric tube. Perioperative patient characteristics and process-of-care variables were analyzed. Univariate analyses were used to identify POI risk factors; variables with P ≤.20 were included in multivariate analysis. RESULTS Among 587 women identified, the overall incidence of POI was 30.3% (25.9% without bowel resection, 38.5% with bowel resection; P=.002). Preoperative thrombocytosis, involvement of bowel mesentery with carcinoma, and perioperative red blood cell transfusion were independently associated with increased POI. Postoperative ibuprofen use was associated with decreased POI risk. Women with POI had a longer length of stay (median, 11 vs 6 days) and increased time to recovery of the upper (7.5 vs 4 days) and lower (4 vs 3 days) gastrointestinal tract (P<.001 for each). CONCLUSIONS The rate of POI is substantial among women undergoing staging and cytoreduction for EOC and is associated with increased length of stay. Modifiable risk factors may include transfusion and postoperative ibuprofen use. Alternative interventions to decrease POI are needed.
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