Comparison of the Contracted Accordion, Expanded Accordion, and Clavien-Dindo complication grading scales after ovarian cancer cytoreduction

OBJECTIVE

To compare the ability of current complication reporting scales (Contracted Accordion Scale, Expanded Accordion Scale, Clavien-Dindo Scale) to reflect the severity of patient outcomes after cytoreductive surgery for ovarian cancer.

METHODS

We included all patients undergoing primary debulking surgery for stage IIIC/IV ovarian cancer from 2006 to 2016 at two expert centers for ovarian cancer. Complications within 30 days of surgery were graded according to three scales. Outcomes included length of stay, mortality (90-day), and delayed initiation of chemotherapy (>42 days after surgery). Correlations were assessed using the Spearman rank correlation, and comparisons between groups were evaluated using the Wilcoxon rank-sum test and the χ² test.

RESULTS

Among the 892 patients, 185 (20.7%) patients had a grade 3 or higher complication per all scales. Patients with grade 3 or higher complications (compared with those with none, grade 1 or grade 2) had longer length of stay, higher 90-day mortality, and delayed initiation of chemotherapy. The expanded scales (Expanded Accordion Scale and Clavien Dindo Scale) provided a more refined characterization of outcome compared with the Contracted Accordion Scale. However, mortality was actually found to be as high as 25.0% for grade 5 complications using the Expanded Accordion Scale. Patients with organ failure or requiring an invasive procedure had significantly worse outcomes than those without either complication, highlighting the importance of separating these events.

CONCLUSIONS

All three scales demonstrated general correlation with important outcomes after ovarian cancer surgery. However, the expanded scales (Clavien Dindo Scale and Expanded Accordion Scale) used important events commonly encountered after cytoreductive surgery, provided a more refined view of the severity of complications, and should be used in reporting outcomes in ovarian cancer.

Validation of a risk-based algorithm to reduce poor operative outcomes after complex surgery for ovarian cancer

OBJECTIVE

We developed an algorithm that identifies patients at high risk of morbidity/mortality after cytoreductive surgery for advanced ovarian cancer. We have previously shown that the Mayo triage algorithm reduces operative mortality internally, followed by validation using an external low complexity national dataset. However, validation in a higher complexity surgical setting is required before widespread acceptance of this approach, and this was the goal of our study.

METHODS

We included patients who underwent debulking surgery (including primary or interval debulking surgery) for stage IIIC/IV ovarian cancer between October 2011 and November 2019 (SCORPION trial patients until May 2016 and non-trial patients thereafter) at Fondazione Policlinico A Gemelli, Italy. Using the algorithm, we classified patients as either high-risk or triage-appropriate and compared 30-day grade 3+ complications and 90-day mortality using a χ2 test or Fisher's exact test.

RESULTS

A total of 625 patients were included. The mean age was 58.7±11.4 years, 73.6% (n=460) were stage IIIC, and 63.0% (n=394) underwent primary debulking surgery. Surgical complexity was intermediate or high in 82.6% (n=516) of patients (95.7% (n=377) for primary surgery and 60.2% (n=139) for interval surgery), and 20.3% (n=127) were classified as high-risk. When compared with triage-appropriate patients, high-risk patients had (1) a threefold higher rate of 90-day mortality (6.3% vs 2.0%, p=0.02); (2) a higher likelihood of 90-day mortality following a grade 3+ complication (25.9% vs 10.0%, p=0.05); and (3) comparable rates of grade 3+ complications (21.3% vs 16.1%, p=0.17).

CONCLUSION

The evidence-based triage algorithm identifies patients at high risk of morbidity/mortality after cytoreductive surgery. Triage high-risk patients are poor candidates for surgery when complex surgery is required. This algorithm has been validated in heterogeneous settings (internal, national, and international) and degree of surgical complexity. Risk-based decision making should be standard of care when planning surgery for patients with advanced ovarian cancer, whether primary or interval surgery.

A Living, Interactive Systematic Review and Network Meta-analysis of First-line Treatment of Metastatic Renal Cell Carcinoma

CONTEXT

Identifying the most effective first-line treatment for metastatic renal cell carcinoma (mRCC) is challenging as rapidly evolving data quickly outdate the existing body of evidence, and current approaches to presenting the evidence in user-friendly formats are fraught with limitations.

OBJECTIVE

To maintain living evidence for contemporary first-line treatment for previously untreated mRCC.

EVIDENCE ACQUISITION

We have created a living, interactive systematic review (LISR) and network meta-analysis for first-line treatment of mRCC using data from randomized controlled trials comparing contemporary treatment options with single-agent tyrosine kinase inhibitors. We applied an advanced programming and artificial intelligence-assisted framework for evidence synthesis to create a living search strategy, facilitate screening and data extraction using a graphical user interface, automate the frequentist network meta-analysis, and display results in an interactive manner.

EVIDENCE SYNTHESIS

As of October 22, 2020, the LISR includes data from 14 clinical trials. Baseline characteristics are summarized in an interactive table. The cabozantinib + nivolumab combination (CaboNivo) is ranked the highest for the overall response rate, progression-free survival, and overall survival, whereas ipilimumab + nivolumab (NivoIpi) is ranked the highest for achieving a complete response (CR). NivoIpi, and atezolizumab + bevacizumab (AteBev) were ranked highest (lowest toxicity) and CaboNivo ranked lowest for treatment-related adverse events (AEs). Network meta-analysis results are summarized as interactive tables and plots, GRADE summary-of-findings tables, and evidence maps.

CONCLUSIONS

This innovative living and interactive review provides the best current evidence on the comparative effectiveness of multiple treatment options for patients with untreated mRCC. Trial-level comparisons suggest that CaboNivo is likely to cause more AEs but is ranked best for all efficacy outcomes, except NivoIpi offers the best chance of CR. Pembrolizumab + axitinib and NivoIpi are acceptable alternatives, except NivoIpi may not be preferred for patients with favorable risk. Although network meta-analysis provides rankings with statistical adjustments, there are inherent biases in cross-trial comparisons with sparse direct evidence that does not replace randomized comparisons.

PATIENT SUMMARY

It is challenging to decide the best option among the several treatment combinations of immunotherapy and targeted treatments for newly diagnosed metastatic kidney cancer. We have created interactive evidence summaries of multiple treatment options that present the benefits and harms and evidence certainty for patient-important outcomes. This evidence is updated as soon as new studies are published.

Sequencing chemotherapy before radiotherapy for women with stage IIIC endometrial cancer

OBJECTIVE

It is unclear how to best sequence adjuvant chemotherapy and radiotherapy for advanced endometrial cancer. We studied the outcomes for women treated with chemotherapy before radiotherapy in a chemotherapy-first (chemotherapy for 6 cycles followed radiotherapy) or 'sandwich' approach (chemotherapy for 3 cycles followed by radiotherapy and subsequently chemotherapy for 3 cycles).

METHODS

Women with stage IIIC endometrial cancer and no gross residual disease treated with chemotherapy before radiotherapy between April 2003 and April 2016 were included. The Kaplan-Meier method was used to estimate recurrence and survival. We performed a meta-analysis of endometrial cancer trials comparing chemotherapy and radiotherapy versus radiotherapy alone.

RESULTS

A total of 102 patients were included. The mean (SD) age was 63.8 (10.6) years; 84 patients received the chemotherapy-first approach and 18 patients received the 'sandwich' approach. Pelvic and para-aortic nodes were removed in 99% and 88.2%, respectively. Among all the patients, we observed 1 pelvic (1%), 1 para-aortic (1%), and 5 vaginal (4.9%) recurrences. At 3 years, for the 'sandwich' and chemotherapy-first approaches, the vaginal recurrence was 11.8% and 4.2%, pelvic recurrence was 0% and 1.5%, para-aortic recurrence was 0% and 1.2%, distant recurrence was 42.9% and 24.4%, and overall survival was 70.3% and 81.7%, respectively. With 'chemotherapy before radiotherapy' 94.9% completed 4+ chemotherapy cycles (vs 71-90% reported in the literature for 'radiotherapy before chemotherapy'). In a meta-analysis of endometrial cancer trials, distant recurrence rates were reduced with 4+ chemotherapy cycles but not with 3 cycles (p=0.01).

CONCLUSION

Chemotherapy before radiation sequencing for stage IIIC endometrial cancer was associated with a high proportion of patients completing 4+ chemotherapy cycles and low locoregional lymphatic recurrence rate, despite delaying radiotherapy until after 3-6 cycles of chemotherapy and not administering concurrent cisplatin.

Frailty is a determinant of suboptimal chemotherapy in women with advanced ovarian cancer

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.

Less guessing, more evidence in identifying patients least fit for cytoreductive surgery in advanced ovarian cancer: A triage algorithm to individualize surgical management

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.

External beam radiotherapy versus vaginal brachytherapy in patients with stage II endometrial cancer: a systematic review and meta-analysis

Objective

The choice of adjuvant treatment for women with stage II endometrial cancer is challenging, given the known increase in morbidity with external beam radiation compared with vaginal brachytherapy, and the lack of consensus on its benefits. We summarized the evidence on survival and recurrence for stage II endometrial cancer, defined as cervical stromal invasion, after adjuvant postoperative external beam radiotherapy and vaginal brachytherapy.

Methods

We searched the MEDLINE, EMBASE, CENTRAL, and Scopus databases from inception to January 2019 to identify studies that compared adjuvant postoperative external beam radiotherapy with or without vaginal brachytherapy and vaginal brachytherapy alone in stage II endometrial cancer. Our primary outcome was the locoregional recurrence rate, defined as recurrence in the pelvis or vagina. Secondary outcomes included the rate of recurrence at any site, distant recurrence rate, vaginal recurrence rate, pelvic recurrence rate, and 5 year overall survival. Study selection, assessment, and data abstraction were performed by an independent set of reviewers. Random effects models were used to synthesize quantitative data.

Results

We included 15 cohort studies reporting data on 1070 women. Most women with stage II endometrial cancer (848/1070, 79.3%) were treated with external beam radiotherapy with or without vaginal brachytherapy. Subgroup analysis was stratified by whether >90% of the women included underwent pelvic lymph node assessment (sampling or full dissection). Locoregional recurrence (pelvic and vaginal recurrence) was significantly reduced with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (14 studies (n=1057); odds ratio (OR) 0.33 (95% confidence interval (CI) 0.16 to 0.68); I2=5%) regardless of pelvic lymph node assessment. Most women (81.8%) who recurred locoregionally had a least one uterine risk factor (grade 3 tumor, myometrial invasion >50%, or lymphovascular invasion). There was no difference in overall survival with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (five studies (n=463); OR 0.78 (95% CI 0.34 to 1.80); I2=48%).

Conclusions

External beam radiotherapy with or without vaginal brachytherapy decreased the locoregional recurrence threefold for stage II endometrial cancer, regardless of pelvic lymph node assessment. Most women who suffered recurrence locoregionally had a least one high risk factor. Vaginal brachytherapy alone may be sufficient therapy for node negative stage II endometrial cancer without uterine risk factors, while those with uterine risk factors should be considered for external beam radiotherapy with or without vaginal brachytherapy to improve locoregional control.

Using evidence to direct quality improvement efforts: Defining the highest impact complications after complex cytoreductive surgery for ovarian cancer

OBJECTIVE

We sought to identify postoperative complications with the greatest impact on patient-centric outcomes to serve as high yield QI targets in ovarian cancer (OC) surgery.

METHODS

Women undergoing complex CRS (defined as cytoreductive surgery with colon resection) for OC between January 1, 2012 and 12/31/2016 were identified from the National Surgical Quality Improvement Program (NSQIP) database. We determined the population attributable fraction (PAF) to quantify the contribution of each major complication towards adverse outcomes. PAF represents the burden of adverse outcomes that could be eliminated if the corresponding complication was prevented. Organ space surgical site infection (SSI) was used as a surrogate for anastomotic leak (AL).

RESULTS

A total of 1434 women met inclusion criteria. Any adverse clinical outcome (composite of death, reoperation, or end organ dysfunction) occurred in 9.1% of women, and AL was the largest contributor to adverse clinical outcomes [PAF = 33.4% (95%CI: 22.3%-45.6%)]. The rates of increased resource utilization were as follows; prolonged hospitalization in 23.7%, non-home discharge in 10.7% and unplanned readmission in 14.8% of women. AL was the largest contributor to prolonged hospitalizations [PAF = 75.7% (95%CI: 51.4%-90.0%)] and readmissions [PAF = 17.1% (95%CI: 11.5%-22.6%)]; while transfusion was the largest contributor to non-home discharge [PAF = 22.8% (95%CI: 0.7%-42.4%)]. By comparison, the impact of other complications, including those targeted by the Surgical Care Improvement Project (SCIP), such as incisional SSI, venous thromboembolism, myocardial infarction, and urinary infection, was small.

CONCLUSIONS

Anastomotic leak is the largest contributor to adverse clinical outcomes and increased resource utilization after complex cytoreductive surgery. Quality improvement efforts to reduce AL and its impact should be of highest priority in OC surgery.

Uterine Tachysystole with Prolonged Deceleration Following Nipple Stimulation for Labor Augmentation

Breast stimulation for inducing uterine contractions has been reported in the medical literature since the 18th century. The American college of Obstetricians and Gynecologists (ACOG) has described nipple stimulation as a natural and inexpensive nonmedical method for inducing labor. We report on a 37 year old P2 with a singleton pregnancy at 40 weeks gestation who developed tachysystole with a prolonged deceleration after nipple stimulation for augmentation of labor. Initial resuscitative measures, including oxygen by mask, a bolus of intravenous fluids and left lateral positioning, did not restore the fetal heart rate to normal. After the administration of Terbutaline 250 mcg subcutaneously, the tachysystole resolved and the fetal heart rate recovered after five minutes of bradycardia. Most trials of nipple stimulation for induction or augmentation of labor have had small study populations, and no conclusions could be drawn about the safety of nipple stimulation, though its use is widespread. While there have been a few reports of similar complications during nipple stimulation for contraction stress testing, there are no previous reports of tachysystole with sustained bradycardia following nipple stimulation for labor augmentation. In this report, we draw attention to the dangers of nipple stimulation so that providers will be aware of this potential complication.

50% dextrose versus normal saline as distension media during cystoscopy for assessment of ureteric patency

OBJECTIVE

To compare the visualization of ureteric jets when using 50% dextrose (D50) as opposed to normal saline (NS) as distension media during cystoscopy.

STUDY DESIGN

Cross sectional study.

METHODS

Two patients each had two cystoscopy videos recorded at the time of a ureteric jet; one using NS and the other using D50 resulting in two sets of paired videos (four videos). A fifth cystoscopy video was recorded, as a control, at a time when there was no ureteric-jet. Fifty participants including attending physicians, residents and medical students were recruited at an academic-affiliated community hospital. Participants were blinded to the medium used and viewed each of the five videos. Participants assessed each video for presence of a ureteric-jet, ease of interpretation, and compared the paired D50 and NS videos for clarity of ureteric-jets.

MAIN OUTCOME MEASURES

Participant's assessment of clarity of the ureteric jets when D50 was used as compared to when NS was used in the paired videos.

RESULTS

All 100 observations of the two D50 videos with jets identified the presence of a jet; for the NS videos, 96/100 observations identified a jet, 2/100 did not identify a jet and 2/100 were unsure. 48/50 observations of the video with no jet were correct, while 2/50 were unsure. Participants rated the ureteric-jets to be clearer in videos with D50 (86% vs 14%, P<0.001); and had difficulty interpreting cystoscopy videos with NS (62% vs 2%, OR: 80, 95% CI: 10.2-627.6).

CONCLUSION

Participants preferred the clarity of the ureteric-jet when 50% dextrose was used as the distension medium during cystoscopy as compared to normal saline.

Healthcare Workers' Attitudes Toward Patients With Ebola Virus Disease in The United States

Healthcare worker's willingness to care for Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, they were strongly influenced by concerns about potentially exposing families and friends to Ebola virus disease.

Background. We assessed healthcare workers' (HCWs) attitudes toward care of patients with Ebola virus disease (EVD).

Methods. We provided a self-administered questionnaire-based cross-sectional study of HCWs at 2 urban hospitals.

Results. Of 428 HCWs surveyed, 25.1% believed it was ethical to refuse care to patients with EVD; 25.9% were unwilling to provide care to them. In a multivariate analysis, female gender (32.9% vs 11.9%; odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4–7.7), nursing profession (43.6% vs 12.8%; OR, 2.7; 95% CI, 1.4–5.2), ethical beliefs about refusing care to patients with EVD (39.1% vs 21.3%; OR, 3.71; 95% CI, 2.0–7.0), and increased concern about putting family, friends, and coworkers at risk (28.2% vs 0%; P = .003; OR, 11.1) were independent predictors of unwillingness to care for patients with EVD. Although beliefs about the ethics of refusing care were independently associated with willingness to care for patients with EVD, 21.3% of those who thought it was unethical to refuse care would be unwilling to care for patients with EVD. Healthcare workers in our study had concerns about potentially exposing their families and friends to EVD (90%), which was out of proportion to their degree of concern for personal risk (16.8%).

Conclusion. Healthcare workers' willingness to care for patients with Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, although they were strongly influenced by those beliefs. Healthcare workers may be balancing ethical beliefs about patient care with beliefs about risks entailed in rendering care and consequent risks to their families. Providing a safe work environment and measures to reduce risks to family, perhaps by arranging child care or providing temporary quarters, may help alleviate HCW's concerns.

Torsion of an iatrogenic parasitic fibroid related to power morcellation for specimen retrieval

Parasitic fibroids are generally diagnosed incidentally at the time of surgery performed for symptomatic uterine fibroids. Torsion of a parasitic fibroid causing severe acute onset pain is extremely rare. We report a torsed parasitic fibroid in a patient who underwent hysterectomy using power morcellation for specimen retrieval. A 40-year-old patient with a history of laparoscopic supracervical hysterectomy 8 years prior presented with severe abdominal pain. She was diagnosed with degenerating parasitic fibroids on magnetic resonance imaging and was managed conservatively. Surgery was performed 3 days later for persistent pain, and the parasitic fibroid was found to have undergone torsion. Torsed ischemic fibroids can undergo necrosis and gangrene and can potentially cause life-threatening coagulopathy and peritonitis. Awareness of this potential complication will reduce errors in diagnosis and facilitate timely management.

Endometrial osseous metaplasia: an unusual cause of infertility

Osseous metaplasia of the endometrium is a rare disorder associated with the presence of bone in the uterine endometrium. Most patients with this condition presenting with infertility do so owing to the presence of a foreign body in the endometrium. We report a case of a 38-year-old woman who presented with secondary infertility due to osseous metaplasia in the endometrial cavity. She conceived spontaneously after hysteroscopic removal of the bony fragments from the uterus. Uterine osseous metaplasia is a rare cause of infertility that can be easily managed by hysteroscopic removal of the bony fragments, which results in return of fertility.