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Diggs A, Sia TY, Huang Y, Gockley A, Melamed A, Khoury-Collado F, St Clair C, Hou JY, Hershman DL, Wright JD. Utilization and outcomes of adjuvant therapy for stage II and III uterine leiomyosarcoma. Gynecol Oncol 2022; 166:308-316. [PMID: 35660331 DOI: 10.1016/j.ygyno.2022.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 04/05/2022] [Revised: 05/17/2022] [Accepted: 05/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The optimal adjuvant therapy for uterine leiomyosarcoma (uLMS) remains uncertain. We analyzed the utilization of adjuvant chemotherapy and radiation therapy for stage II and III uLMS and explored the association between use of adjuvant therapy and survival. METHODS Patients with stage II or III uLMS treated from 2004 to 2016 and recorded in the National Cancer Database were identified. Multivariable regression models were fit to estimate predictors of use of either adjuvant radiation therapy or chemotherapy. To analyze the impact of chemotherapy on all-cause mortality, an inverse probability of treatment weighted (IPTW) propensity score method was used to account for measured confounders, and the receipt of radiation therapy was adjusted in the outcome model. The process was repeated to analyze the impact of radiation therapy on all-cause mortality by using an IPTW propensity score method and adjusting for the receipt of adjuvant chemotherapy. RESULTS A total of 890 patients were identified. Adjuvant chemotherapy use increased from 62.2% in 2010 to 70.4% in 2016, whereas radiation usage decreased from 26.7% in 2010 to 10.4% in 2016. Patients with stage III (vs. stage II) disease were less likely to receive radiation therapy. After propensity score weighting, chemotherapy was associated with a 30% decreased risk of all-cause mortality in stage III patients (HR 0.70, 95% CI 0.45-0.98) but had no effect on mortality for stage II patients (HR 0.93, 95% CI 0.70-1.20). Radiation therapy was associated with a 26% decreased risk of mortality for stage II tumors (HR 0.74; 95% CI, 0.53-0.99) and a 57% decrease in mortality for stage III disease (HR 0.43, 95% CI 0.18-0.99). CONCLUSIONS Among women with stage II-III uLMS, use of chemotherapy is increasing while use of radiation therapy is decreasing. Radiation therapy is associated with improved survival in both stage II and III disease, while there was no association between use of adjuvant chemotherapy and survival in stage II patients.
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Affiliation(s)
- Alexandra Diggs
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; New York Presbyterian Hospital, United States of America
| | - Tiffany Y Sia
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Yongmei Huang
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Allison Gockley
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Alexander Melamed
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Fady Khoury-Collado
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Caryn St Clair
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - June Y Hou
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Dawn L Hershman
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Jason D Wright
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America.
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Overton E, Booker WA, Mourad M, Moroz L, Nhan Chang CL, Breslin N, Syeda S, Laifer-Narin S, Cimic A, Chung DE, Weiner DM, Smiley R, Sheikh M, Mobley DG, Wright JD, Gockley A, Melamed A, St Clair C, Hou J, D'Alton M, Khoury Collado F. Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum. Am J Obstet Gynecol MFM 2022; 4:100657. [PMID: 35597402 DOI: 10.1016/j.ajogmf.2022.100657] [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: 02/08/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado).
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Leslie Moroz
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Chia-Ling Nhan Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Noelle Breslin
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sbaa Syeda
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sherelle Laifer-Narin
- Department of Diagnostic Radiology, Columbia University, New York, NY (Dr Laifer-Narin)
| | - Adela Cimic
- Department of Anatomic Pathology, Columbia University, New York, NY (Dr Cimic)
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - David M Weiner
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - Richard Smiley
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - Maria Sheikh
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - David G Mobley
- Division of Interventional Radiology, Columbia University, New York, NY (Dr Mobley)
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Allison Gockley
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Caryn St Clair
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - June Hou
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Fady Khoury Collado
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
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Sia TY, Huang Y, Gockley A, Melamed A, Khoury-Collado F, St Clair C, Hou JY, Tergas AI, Hershman DL, Wright JD. Trends in ovarian conservation and association with survival in premenopausal patients with stage I leiomyosarcoma. Gynecol Oncol 2021; 161:734-740. [PMID: 33810881 DOI: 10.1016/j.ygyno.2021.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/24/2021] [Accepted: 03/26/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To explore trends of ovarian conservation (OCN) over time in young women with early stage leiomyosarcoma (LMS) and examine the association between OCN and survival. METHODS Patients under the age of 50 who were diagnosed with stage I LMS who underwent hysterectomy with and without oophorectomy between 2010 and 2016 were identified in the National Cancer Database (NCDB). Performance of oophorectomy vs. OCN was determined using surgery codes. Trends of OCN were reported. Multivariable regression models were fit to estimate predictors of OCN. An inverse probability of treatment weighted propensity score method was used to examine the association between all-cause mortality and OCN. RESULTS Overall, 225 patients (28%) underwent OCN. Rates of OCN decreased from 41.2% (2010) to 14.3% (2016); this finding was consistent across age groups: <35, 35-39, 40-44, and 45-49 years. Race, insurance, and stage did not affect performance of OCN. Women with poorly differentiated tumors were less likely to undergo OCN compared to well-differentiated tumors (aRR 0.59; 95% CI 0.40-0.86). After propensity score weighting, there was no association between OCN and mortality (HR 1.19, 95% CI 0.80-1.77). Five-year survival for the OCN group was 67.1% (95% CI 59.8-75.2%) compared to 72.2% for the oophorectomy group (95% CI 67.2-77.5%). CONCLUSIONS OCN for early stage LMS in premenopausal women has decreased over time. There was no association between OCN and mortality among women with stage I LMS. OCN should be considered in premenopausal women with stage I LMS given the health benefits.
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Affiliation(s)
- Tiffany Y Sia
- Columbia University Irving Medical Center, New York, NY, United States of America
| | - Yongmei Huang
- Columbia University Irving Medical Center, New York, NY, United States of America
| | - Allison Gockley
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Alexander Melamed
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Fady Khoury-Collado
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Caryn St Clair
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - June Y Hou
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Ana I Tergas
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Dawn L Hershman
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Jason D Wright
- Columbia University Irving Medical Center, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America.
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5
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Tobias CJ, Chen L, Melamed A, St Clair C, Khoury-Collado F, Tergas AI, Hou JY, Hur C, Ananth CV, Neugut AI, Hershman DL, Wright JD. Association of Neoadjuvant Chemotherapy With Overall Survival in Women With Metastatic Endometrial Cancer. JAMA Netw Open 2020; 3:e2028612. [PMID: 33295973 PMCID: PMC7726635 DOI: 10.1001/jamanetworkopen.2020.28612] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Although primary debulking surgery (PDS) is often considered the criterion standard for treatment of stage IV endometrial cancer, PDS is associated with significant morbidity and poor survival. Neoadjuvant chemotherapy (NACT) has been proposed as an alternative treatment strategy. OBJECTIVE To determine the use of and outcomes associated with NACT for women with stage IV endometrial cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the National Cancer Database to identify women with stage IV endometrial cancer treated from January 1, 2010, to December 31, 2015. The cohort was limited to women aged 70 years or younger with minimal comorbidity (comorbidity score = 0). Women were stratified based on receipt of NACT or PDS. A propensity score analysis with inverse probability weighting was performed to balance the clinical characteristics of the groups. Survival was examined using flexible parametric Royston-Parmer models to account for time-varying hazards associated with use of NACT. An intention-to-treat (ITT) analysis was performed, as was a per-protocol (PP) analysis that included only women who received treatment with both chemotherapy and surgery (in either sequence). Data were analyzed from March 15, 2018, to July 20, 2018. MAIN OUTCOMES AND MEASURES Use of NACT and overall survival. RESULTS Of a total of 4890 women (median age, 60 years [interquartile range, 54-65 years]) with stage IV endometrial cancer, NACT was used in 952 women (19.5%). Use of NACT increased from 106 of 661 women (16.0%; 95% CI, 13.2%-18.8%) in 2010 to 224 of 938 women (23.9%; 95% CI, 21.2%-26.6%) in 2015 (P < .001). In a multivariate model, more recent year of diagnosis (risk ratio [RR], 1.42; 95% CI, 1.21-1.79 for 2015 vs 2010), stage IVB disease (RR, 1.31; 95% CI, 1.03-1.67 for stage IVB vs IVA), and serous histology (RR, 1.38; 95% CI, 1.13-1.69 for serous vs endometrioid histology) were associated with use of NACT. In a propensity score-balanced cohort, use of NACT displayed a time-varying association with survival. In the ITT analysis, use of NACT was associated with decreased mortality for the first 3 months after diagnosis (hazard ratio [HR] at 2 months, 0.81; 95% CI, 0.66-0.99). After 4 months, the survival curves crossed, and receipt of NACT was associated with increased mortality (HR at 6 months, 1.23; 95% CI, 1.09-1.39). In the PP analysis, use of NACT was associated with decreased mortality for the first 8 months after diagnosis (HR at 6 months, 0.79; 95% CI, 0.63-0.98). After 9 months, the survival curves crossed, and receipt of NACT was associated with increased mortality (HR at 12 months, 1.22; 95% CI, 1.04-1.43). CONCLUSIONS AND RELEVANCE The results of this cohort study suggest that women treated with PDS are at increased risk of early death but have a more favorable long-term prognosis. In contrast, results suggest that women treated with NACT, particularly if they ultimately undergo surgery, may have superior survival in the short term. Based on these findings, NACT may be appropriate for select patients with advanced uterine serous carcinoma.
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Affiliation(s)
- Claire J. Tobias
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
| | - Ling Chen
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Alexander Melamed
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Caryn St Clair
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Fady Khoury-Collado
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Ana I. Tergas
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - June Y. Hou
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Chin Hur
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Cande V. Ananth
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey
| | - Alfred I. Neugut
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Dawn L. Hershman
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Jason D. Wright
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- New York-Presbyterian Hospital, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
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