Contemporary outcomes of surgical aortic valve replacement in patients referred for a transcatheter approach

OBJECTIVES

The purpose of this study is to examine which patients referred to our structural valve clinic for potential transcatheter aortic valve replacement (TAVR) are receiving surgical aortic valve replacement (SAVR) whether due to unsuitable anatomy for TAVR versus other reasons.

METHODS

Individuals referred for TAVR from January 2019 to March 2022, who ultimately underwent SAVR were examined, retrospectively. Patients were divided into 2 surgical groups: TAVR was technically unsuitable (SAVR-TU) and those in which TAVR was technically feasible (SAVR-TF).

RESULTS

215 patients referred for TAVR underwent SAVR with 61 (28.4%) patients in the SAVR-TU group and 154 (71.6%) in the SAVR-TF group. The SAVR-TU group were more commonly female (52.5% vs 23.4%, p < 0.0001), had a higher incidence of stroke at baseline (9.8% vs 2.0%, p = 0.017) were frailer (5-m gait 5.2 s vs 4.7 s, p = 0.0035), and had a higher Society of Thoracic Surgery risk score (2.2 vs 1.7, p = 0.04). In the SAVR-TU group, unsuitability for TAVR was due to inadequate aortic root anatomy (86.9%), and poor peripheral access (6.6%). In the SAVR-TF group, the most common reasons for SAVR referral were concomitant coronary artery disease (42.9%), bicuspid aortic valve disease (16.9%), and concomitant aortic aneurysm (10.4%). Overall, in-hospital mortality was 1.4% with no difference between both groups. One-year survival was 96.7%.

CONCLUSION

Despite a higher trend of aortic stenosis being treated with TAVR, higher risk patients unsuitable for TAVR can have SAVR with excellent outcomes. Moreover, patients with AS and concomitant other pathology should be evaluated for cardiac surgery.

Efficacy of del Nido cardioplegia in adult cardiac procedures with prolonged aortic crossclamp time

OBJECTIVE

Equivalent myocardial protection and clinical outcomes have been shown with the use of del Nido cardioplegia (DC) compared with blood cardioplegia (BC) in adult isolated coronary artery bypass grafting and valve patients. However, its safety and efficacy in cardiac procedures with aortic crossclamp times >90 minutes is still unknown.

METHODS

From May 2014 to September 2019, 2506 adult patients at our center underwent cardiac surgery requiring prolonged aortic crossclamp time defined as 90 minutes or longer. Myocardial protection was achieved with BC in 1955 patients and DC in 551 patients. Two surgeons used DC exclusively and 5 used blood exclusively over the study period. BC was delivered anterograde and retrograde whereas DC was delivered anterograde only. Propensity score matching of several preoperative characteristics, including primary cardiac pathology, yielded 526 well matched pairs. Emergency and reoperative cases were included. Troponin T levels were drawn at 12 hours postoperative in all patients. Clinical data were extracted from our local Society of Thoracic Surgeons database. Subgroup analyses were performed on the basis of crossclamp time stratification.

RESULTS

For the propensity score-matched cohort, the median crossclamp time was longer in the BC compared with the DC group (114 [interquartile range (IQR), 100-145] minutes for DC vs 153 [IQR, 122-200] minutes for BC; P < .0001) whereas intraoperative peak glucose was higher with BC (173 [IQR, 147-200] g/dL for DC vs 197 [IQR, 171-228] g/dL for BC; P < .001). In addition, perioperative mortality (3.4% vs 3.0%; P = .7273), stroke (3.2% vs 2.1%; P = .2504), renal failure (6.5% vs 4.6%; P = .1767), atrial fibrillation (34% vs 31.4%, P = .3575), intra-aortic balloon pump use (5.3% vs 4.6%, P = .5694), and extracorporeal membrane oxygenation use (3.0% vs 2.9%, P = .8596) did not differ between DC and BC. Postoperative troponin T levels were 0.53 (IQR, 0.30-0.96) ng/mL and 0.62 (IQR, 0.38-1.07) ng/mL for DC and BC, respectively (P = .0024). Subgroup analysis revealed higher troponin T levels with DC for crossclamp times between 150 and 180 minutes. Survival rates at 1, 2, and 5 years were 93.3%, 91.1%, and 78.7% for DC and 94.5%, 91.8%, and 81.5% for BC, respectively (P = .5140).

CONCLUSIONS

In adult cardiac surgical procedures with aortic crossclamp times >90 minutes, comparable myocardial protection, perioperative mortality and morbidity, and distant survival were observed with the use of DC compared with BC. Higher troponin levels were seen in DC patients with crossclamp times between 150 and 180 minutes, but this was not associated with increased mortality.

Del Nido Cardioplegia in Ascending Aortic Surgery

Del Nido cardioplegia offers equivalent myocardial protection and clinical outcomes to blood cardioplegia in adult isolated CABG and valve patients, but the safety and efficacy of del Nido in complex cases with prolonged aortic cross-clamp times is still unknown. 443 patients at our center underwent replacement of the ascending aorta using either del Nido (n = 182) or blood (n = 261) cardioplegia. Two surgeons used del Nido exclusively and 6 used blood exclusively over the study period. Propensity matching of preoperative characteristics yielded 172 well matched pairs. Emergency and reoperative cases were included. Clinical data were extracted from our local database. Troponin levels were drawn at 12 hours postop in all patients. Rates of perioperative mortality (4.7% vs 5.2%), stroke (5.8% vs 7.0%), renal failure (11.6% vs 12.2%), atrial fibrillation (36.0% vs 31.4%), intra-aortic balloon pump insertion (2.3% vs1.2%), and extra corporeal membrane oxygenation use (4.7% vs 4.1%) did not differ between blood and del Nido groups. Postop Troponin T levels were 0.50[0.35, 0.86] ng/mL and 0.40[0.20, 0.70] ng/mL for blood and del Nido, respectively (P < 0.0001). Postop echocardiography was available in 333 of 344 (96.8%) patients, and there was no difference in change in EF from pre- to postop between blood 0.0[-6.0, 5.0]% and del Nido 0.0 [-6.0, 3.5]% (P = 0.201). Subgroup analysis of patients with aortic cross-clamp time greater than 180 minutes (blood = 77, del Nido = 27) revealed no difference in troponins, ejection fraction, or clinical outcomes. Five-year survival was 85.9[76.8, 91.7]% and 79.8[71.2, 86.1]% for blood and del Nido, respectively (P = 0.151). In ascending aortic surgery with prolonged operative times, no differences were observed in myocardial protection or clinical outcomes with the use of del Nido cardioplegia compared to blood cardioplegia.

The Effects of a Pain Management-Focused Mobile Health Behavior Intervention on Older Adults' Self-efficacy, Satisfaction with Functioning, and Quality of Life: a Randomized Pilot Trial

BACKGROUND

This report investigates the impact of a remote physical activity intervention on self-efficacy, satisfaction with functioning, and health-related quality of life (HRQOL) as assessed by the SF-36 in obese older adults with chronic pain. The intervention was group-mediated in nature and based in social cognitive theory and mindfulness-based relapse prevention.

METHODS

Participants (N = 28; 70.21 ± 5.22 years) were randomly assigned to receive either the active intervention, which focused on reducing caloric intake and increasing steps across the day or to a waitlist control condition.

RESULTS

Over 12 weeks, intervention participants reported a moderate, positive improvement in self-efficacy for walking relative to control. They also reported large magnitude improvements in satisfaction for physical functioning as well as improvements on pain and the physical functioning subscales of the SF-36.

CONCLUSIONS

These findings expand on previous research showing similar effects in response to structured exercise, this time via a protocol that is likely to be scalable and sustainable for many older adults. Additional work on larger and more diverse samples is warranted.

Racial Disparities in Mitral Valve Surgery: A Statewide Analysis

OBJECTIVE

Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.

METHODS

All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.

RESULTS

A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.

CONCLUSIONS

Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

Relationships between respiratory sinus arrhythmia and stress in college students

The purpose of this study was to examine the relationships between university students' respiratory sinus arrhythmia (RSA) profiles and both retrospective and momentary ratings of stress. Participants were undergraduate students enrolled in an introductory health science course (N = 64). Participants provided RSA data at rest (tonic) and following an orthostatic challenge (phasic), completed the 10-item Perceived Stress Scale (PSS), and completed 6 daily ecological momentary assessments (EMA) of stress for 1 week. Higher tonic RSA was associated with lower perceived stress assessed via PSS and average EMA responses. Those with higher tonic RSA did not differ in their experience of stress across the week, whereas those with lower tonic RSA experienced increased stress across the week, and these trajectories varied as a function of phasic responses. These findings suggest a need for greater emphasis on behavioral strategies for maintaining and enhancing autonomic nervous system health among college students.

Empowered with Movement to Prevent Obesity & Weight Regain (EMPOWER): Design and methods

Promoting lasting weight loss among older adults is an important public health challenge. Participation in physical activity aids in weight loss and is important for the maintenance of physical function and quality of life. However, traditional intensive lifestyle interventions place a focus on discrete bouts of structured activity, leaving much of the remainder of the day for sedentary behavior. Structured exercise and weight loss programs often produce short-term weight loss that is typically followed by weight regain, and older adults are more likely to regain weight as fat mass rather than lean mass. Preliminary evidence suggests a focus on day-long movement intended to minimize time spent sitting produces better short-term weight loss and weight maintenance. Herein we describe the design and methods for a three-arm randomized controlled trial comparing mHealth-supported weight loss (WL) + structured exercise (EX); WL + a novel daily movement intervention (SitLess); and WL + EX + SitLess. Older adults (N = 180) will be randomly assigned to one of the three interventions, each comprised of a 6-month intensive phase; a 3-month transition phase; and a 9-month maintenance phase. The primary aim of the study is to determine whether the addition of SitLess to a traditional intensive lifestyle intervention comprised of dietary weight loss and structured exercise produces a larger 18-month reduction in body weight relative to WL + EX and WL + SitLess.

Replacing sedentary time with sleep, light, or moderate-to-vigorous physical activity: effects on self-regulation and executive functioning

Recent attention has highlighted the importance of reducing sedentary time for maintaining health and quality of life. However, it is unclear how changing sedentary behavior may influence executive functions and self-regulatory strategy use, which are vital for the long-term maintenance of a health behavior regimen. The purpose of this cross-sectional study is to examine the estimated self-regulatory and executive functioning effects of substituting 30 min of sedentary behavior with 30 min of light activity, moderate-to-vigorous physical activity (MVPA), or sleep in a sample of older adults. This study reports baseline data collected from low-active healthy older adults (N = 247, mean age 65.4 ± 4.6 years) recruited to participate in a 6 month randomized controlled exercise trial examining the effects of various modes of exercise on brain health and function. Each participant completed assessments of physical activity self-regulatory strategy use (i.e., self-monitoring, goal-setting, social support, reinforcement, time management, and relapse prevention) and executive functioning. Physical activity and sedentary behaviors were measured using accelerometers during waking hours for seven consecutive days at each time point. Isotemporal substitution analyses were conducted to examine the effect on self-regulation and executive functioning should an individual substitute sedentary time with light activity, MVPA, or sleep. The substitution of sedentary time with both sleep and MVPA influenced both self-regulatory strategy use and executive functioning. Sleep was associated with greater self-monitoring (B = .23, p = .02), goal-setting (B = .32, p < .01), and social support (B = .18, p = .01) behaviors. Substitution of sedentary time with MVPA was associated with higher accuracy on 2-item (B = .03, p = .01) and 3-item (B = .02, p = .04) spatial working memory tasks, and with faster reaction times on single (B = -23.12, p = .03) and mixed-repeated task-switching blocks (B = -27.06, p = .04). Substitution of sedentary time with sleep was associated with marginally faster reaction time on mixed-repeated task-switching blocks (B = -12.20, p = .07) and faster reaction time on mixed-switch blocks (B = 17.21, p = .05), as well as reduced global reaction time switch cost (B = -16.86, p = .01). Substitution for light intensity physical activity did not produce significant effects. By replacing sedentary time with sleep and MVPA, individuals may bolster several important domains of self-regulatory behavior and executive functioning. This has important implications for the design of long-lasting health behavior interventions. Trial Registration clinicaltrials.gov identifier NCT00438347.

Effects of a DVD-delivered exercise program on patterns of sedentary behavior in older adults: a randomized controlled trial

INTRODUCTION

In the present study, we examined the influence of a home-based, DVD-delivered exercise intervention on daily sedentary time and breaks in sedentary time in older adults.

METHODS

Between 2010 and 2012, older adults (i.e., aged 65 or older) residing in Illinois (N = 307) were randomized into a 6-month home-based, DVD-delivered exercise program (i.e., FlexToBa; FTB) or a waitlist control. Participants completed measurements prior to the first week (baseline), following the intervention period (month 6), and after a 6 month no-contact follow-up (month 12). Sedentary behavior was measured objectively using accelerometers for 7 consecutive days at each time point. Differences in daily sedentary time and breaks between groups and across the three time points were examined using mixed-factor analysis of variance (mixed ANOVA) and analysis of covariance (ANCOVA).

RESULTS

Mixed ANOVA models revealed that daily minutes of sedentary time did not differ by group or time. The FTB condition, however, demonstrated a greater number of daily breaks in sedentary time relative to the control condition (p = .02). ANCOVA models revealed a non-significant effect favoring FTB at month 6, and a significant difference between groups at month 12 (p = .02).

CONCLUSIONS

While overall sedentary time did not differ between groups, the DVD-delivered exercise intervention was effective for maintaining a greater number of breaks when compared with the control condition. Given the accumulating evidence emphasizing the importance of breaking up sedentary time, these findings have important implications for the design of future health behavior interventions.

Robotic radical hysterectomy

Robotic radical hysterectomy is increasingly being utilized in the treatment of cervical cancer and initial studies are promising. Compared to open radical hysterectomy, robotic radical hysterectomy is expected to result in decreased pain, infection, length of stay, and adhesions and quicker return to activity. Prospective randomized controlled trials are needed to compare robotic, laparoscopic and open radical hysterectomy for the treatment of cervical cancer.

Immunohistochemical evaluation is not prognostic for recurrence in fully staged high-risk endometrial cancer

The objective of this study was to determine the prognostic significance of common immunohistochemical pathologic risk factors in fully staged high-risk endometrial cancers. Sixty-two of 265 consecutive endometrioid adenocarcinomas were considered high risk for recurrence because of deep myometrial invasion and poor differentiation (stage IC, G3), cervical metastasis (stage II), ovarian metastasis (stage IIIA) or lymph node metastasis (stage IIIC). All patients underwent complete surgical staging with bilateral pelvic and aortic lymphadenectomy. Expression of estrogen receptors, progesterone receptors, p53, HER-2/neu, c-myc, bcl-2, FVIII, and Ki-67 were analyzed by immunohistochemistry using commercially available monoclonal antibodies. A general linear model multiple regression analysis was used to determine if any of the immunostains, along with grade or stage, were predictors of recurrence. Mean age was 68 years and mean weight 188 pounds. Sixty-eight percent of patients had associated medical illness. The majority of tumors were poorly differentiated (44%) and were stage IIIC (29%). Mean follow-up was 4.3 years. Fourteen patients (22%) developed tumor recurrence. Using multiple regression analysis, none of the immunostains were predictive for recurrence (P = 0.19-.96). Only stage and grade were predictive of tumor recurrence (P = 0.04,.02). We conclude that in completely staged high risk endometrial cancer, commonly used immunohistochemical risk factors are not predictive for recurrence.

Immunohistochemical evaluation is not prognostic for recurrence in fully staged high-risk endometrial cancer

Abstract.

Fanning J, Brown S, Phibbs G, Kramer T, Zaher A. Immunohistochemical evaluation is not prognostic for recurrence in fully staged high-risk endometrial cancer.

The objective of this study was to determine the prognostic significance of common immunohistochemical pathologic risk factors in fully staged high-risk endometrial cancers. Sixty-two of 265 consecutive endometrioid adenocarcinomas were considered high risk for recurrence because of deep myometrial invasion and poor differentiation (stage IC, G3), cervical metastasis (stage II), ovarian metastasis (stage IIIA) or lymph node metastasis (stage IIIC). All patients underwent complete surgical staging with bilateral pelvic and aortic lymphadenectomy. Expression of estrogen receptors, progesterone receptors, p53, HER-2/neu, c-myc, bcl-2, FVIII, and Ki-67 were analyzed by immunohistochemistry using commercially available monoclonal antibodies. A general linear model multiple regression analysis was used to determine if any of the immunostains, along with grade or stage, were predictors of recurrence. Mean age was 68 years and mean weight 188 pounds. Sixty-eight percent of patients had associated medical illness. The majority of tumors were poorly differentiated (44%) and were stage IIIC (29%). Mean follow-up was 4.3 years. Fourteen patients (22%) developed tumor recurrence. Using multiple regression analysis, none of the immunostains were predictive for recurrence (P = 0.19-.96). Only stage and grade were predictive of tumor recurrence (P = 0.04, .02). We conclude that in completely staged high risk endometrial cancer, commonly used immunohistochemical risk factors are not predictive for recurrence.

Long-term survival of intermediate risk endometrial cancer (stage IG3, IC, II) treated with full lymphadenectomy and brachytherapy without teletherapy

OBJECTIVES

The aim of this study was to determine long-term survival and late complications of intermediate risk endometrial cancer (Stage IG3, IC, and II) treated with full lymphadenectomy and brachytherapy without teletherapy.

METHODS

Two-hundred sixty-five consecutive patients underwent surgical staging for endometrial cancer consisting of hysterectomy, oophorectomy, and bilateral pelvic and periaortic lymphadenectomy. Sixty-six patients had intermediate risk endometrial cancer (Stage IG3, IC, and II) and received postoperative brachytherapy without teletherapy. Mean age was 68 years and mean weight was 188 lb. Seventy-seven percent had associated medical illness.

RESULTS

At a mean follow-up of 4.4 years, Kaplan-Meier estimated 5-year progression free survival is 97%. Two patients (3%) developed distant recurrence (abdomen, lungs) with no vaginal or pelvic recurrence. Major complications occurred in 6% of patients.

CONCLUSIONS

Complete lymphadenectomy with brachytherapy without teletherapy for intermediate risk endometrial cancer results in excellent progression-free survival and minimal major morbidity.

Early postoperative feeding after major gynecologic surgery: evidence-based scientific medicine

Postoperative gastrointestinal care after major gynecologic surgery has evolved considerably over the last decade. According to evidence-based scientific medicine, the following conclusions can be drawn: (1) Postoperative colonic stasis occurs after major abdominal surgery and persists for approximately 3 days (classes I and IIA). (2) Elective postoperative nasogastric decompression after major abdominal surgery is unnecessary (class I). (3) Early feeding after major gynecologic surgery results in emesis but does not increase the incidence of aspiration pneumonia, dehiscence, or intestinal leaks and decreases hospital stay (class I). (4) Slow advancement of postoperative diet after major gynecologic surgery is probably unnecessary (class III). (5) After major abdominal gynecologic surgery, there appear to be minimal medical benefits (decreased infection rate) of early postoperative feeding (class III). (6) After radical hysterectomy, postoperative bowel stimulation decreases length of hospital stay (class IIA).

Survival after multimodality treatment for stage IIIC endometrial cancer

OBJECTIVE

Our purpose was to review our results of multimodality treatment of lymph node metastasis in endometrial cancer (stage IIIC).

STUDY DESIGN

All patients underwent surgical staging for endometrial cancer with complete pelvic and aortic lymphadenectomy. All macroscopic nodal metastases were resected. Patients with microscopic nodal metastasis received adjuvant teletherapy, whereas those with macroscopic nodal metastasis received chemotherapy (carboplatin AUC 5 and paclitaxel 135 mg/m2 every 3 weeks for 6 courses) followed by teletherapy.

RESULTS

Twenty-one patients had stage IIIC disease, and one had stage IVB (inguinal nodal metastasis). Sixty-four percent of tumors were poorly differentiated. Fifty-five percent of patients had pelvic nodal metastasis only and 41% had macroscopic nodal metastasis. At a median follow-up of 3.8 years, 32% of patients had recurrence, all extrapelvic. Overall mean survival was 48 months and progression-free survival was 40 months. Overall survival for microscopic nodal metastasis was >60 months versus 35 months for macroscopic metastasis. Overall survival for pelvic nodal metastasis was 53 months versus 42 months for aorticinguinal metastasis. There were no complications from lymphadenectomy, a 22% chemotherapeutic toxicity, and a 14% radiation toxicity.

CONCLUSION

Our surgical, chemotherapeutic, and radiation treatment protocol for stage IIIC endometrial cancer produced minimal toxicity and good survival.

Prospective analysis of a fever evaluation algorithm after major gynecologic surgery

OBJECTIVE

We performed a prospective trial to evaluate the feasibility, accuracy, and safety of a postoperative fever algorithm that is based on symptoms and physical examination in an attempt to decrease the random use of urine cultures, blood cultures, and chest radiographs.

STUDY DESIGN

Our fever algorithm consisted of assessing all febrile postoperative patients for signs and symptoms of infection. If none were present, no tests were ordered.

RESULTS

Twenty-eight of 105 consecutive patients (27%) had postoperative fever after major gynecologic surgery. Three of 28 febrile patients (11%) were evaluated with tests according to the algorithm. Two of 28 febrile patients (7%) were evaluated in violation of the algorithm. Four febrile patients (14%) had documented infections. Two patients had infections within the first 30 days after discharge. Compared with our previous retrospective review, significantly fewer febrile patients were evaluated with testing with a significantly increased yield of positive test results.

CONCLUSIONS

Our postoperative fever evaluation algorithm that is based on symptoms and physical examination is feasible, is safe, decreases random testing, and increases the yield of positive test results.

Surgical stapling technique for radical hysterectomy: survival, recurrence, and late complications

OBJECTIVE

The aim of this study was to conduct a long-term follow-up of the surgical stapling technique of radical hysterectomy to determine survival, recurrence, and late complications.

METHODS

One hundred consecutive eligible patients treated with the surgical stapling technique of radical hysterectomy were prospectively evaluated.

RESULTS

Median operative time was 3.2 h. Median blood loss was 500 ml. There was an 18% acute postoperative complication rate and a 10% long-term complication rate. There was a 6% recurrence rate and a 92% disease-free survival.

CONCLUSION

The surgical stapling technique of radical hysterectomy results in acceptable survival, recurrence, and complication rates, which appear similar to those of the traditional type of radical hysterectomy, while operative time and blood loss appear to be reduced.

Cisplatin-paclitaxel-cyclophosphamide with G-CSF in primary advanced epithelial ovarian cancer

INTRODUCTION

In an attempt to increase survival, we performed a prospective trial of high-dose cisplatin-paclitaxel-cyclophosphamide with granulocyte colony-stimulating factor (G-CSF) for three cycles followed by carboplatin-paclitaxel for three cycles after cytoreduction of primary advanced epithelial ovarian cancer.

MATERIALS AND METHODS

Thirty consecutive women with Stage 3 or 4 invasive primary epithelial ovarian cancer were treated with cytoreductive surgery. Postoperatively patients received 100 mg/m(2) of cisplatin, 200 mg/m(2) of paclitaxel, and 500 mg/m(2) of cyclophosphamide IV q 21 days x 3 cycles with 300 microg of G-CSF daily x5 beginning the first day following chemotherapy. This was followed by carboplatin AUC-5 and 135 mg/m(2) of paclitaxel IV q 21 days x3. All administration was outpatient and paclitaxel was administered over 3 h.

RESULTS

Eighty percent of tumors were Stage 3C, 77% were serous, and 60% were Grade 3. Maximum cytoreduction to <2 cm was performed in 96%. Median follow-up is 30 months. Sixty-three percent of patients developed recurrence. Currently 50% of patients are alive with no evidence of disease. Estimated mean survival is 61 months and estimated mean progression-free survival is 29 months. No patient developed thrombocytopenia, neutropenic sepsis, significant neuropathy, or renal toxicity.

CONCLUSION

This treatment regimen resulted in minimal toxicity and, following aggressive cytoreduction, produced good progression-free and overall survival.

National Cancer Data Base/Surveillance Epidemiology and End Results: potential insensitive-measure bias

OBJECTIVES

Abstraction of data from National Cancer Data Base (NCDB)/Surveillance Epidemiology and End Results (SEER) for reasons other than incidence, mortality, and patterns of care has risen. A potential problem with these data is that insensitive-measure bias can exist because of possible inaccuracies in hospital tumor registry staging. The purpose of this study is to assess the accuracy of tumor registry staging from six community hospitals.

METHODS

Staging of 103 consecutive cancers operated on by a gynecologic oncologist (one of the authors) as a surgical consultant to a gynecologist or surgeon was reviewed. Hospital tumor registry staging forms were arbitrarily assigned to be completed by the nongynecologic oncologist versus the gynecologic oncologist by the medical records department. The authors reassessed cancer staging by medical chart review. The tumor registry staging was compared with the actual staging as determined by the authors. Major staging violations were defined as errors that would significantly change stage enough to alter prognosis or change recommended adjuvant treatment. All other violations were defined as minor.

RESULTS

Twenty-eight (27%) cancers were staged by the gynecologic oncologist and 75 (73%) by nongynecologic oncologists. Eighty (78%) cancers were endometrial and 14 (13%) ovarian. Eighty-three (81%) tumors were stage I or II. Major staging violations occurred in 0% of cancers staged by the gynecologic oncologist and 22% (16/75) by a nongynecologic oncologist (P = 0.002). Minor staging violations occurred in 14% (4/28) of cancers staged by the gynecologic oncologist and 42% (32/75) by a nongynecologic oncologist (P = 0. 005). Minor violations were due to omission of histologic subtype and/or grade.

CONCLUSION

The 22% major staging violation rate represents significant insensitive-measure bias. If additional studies produce similar results, abstraction of data from NCDB/SEER for reasons other than incidence, mortality, and patterns of care cannot be accepted as evidence-based scientific medicine.

Prospective trial of early feeding and bowel stimulation after radical hysterectomy

OBJECTIVE

In an attempt to decrease hospital stay we performed a prospective trial of aggressive bowel stimulation and early postoperative feeding after radical hysterectomy.

STUDY DESIGN

In a prospective trial of 20 consecutive patients undergoing class 3 radical hysterectomy, feeding of a clear liquid diet and bowel stimulation with oral 66% sodium phosphate solution (Fleet Phospho-Soda) were instituted on postoperative day 1. Patients were discharged after passage of flatus or stool.

RESULTS

Median time to discharge was 3.5 days. No patient had emesis, ileus, or bowel obstruction. The decrease in hospital stay with respect to those in our previous trial with traditional postoperative feeding and our original study on postoperative bowel stimulation was statistically significant.

CONCLUSION

Aggressive bowel stimulation with Fleet Phospho-Soda and early feeding after radical hysterectomy resulted in early return of bowel function and early discharge without significant intestinal complication.

Gap junctional intercellular communication and connexin 43 expression in ovarian carcinoma

OBJECTIVES

Gap junctions, which are composed of subunits termed connexins, are plasma membrane channels that link the interior of adjacent cells and permit cells to directly exchange small molecules and ions. Loss or dysfunction of gap junctions appears to be important in allowing cancer cells to escape growth regulation. In a previous study we showed that human ovarian surface epithelial cells exhibited extensive gap junctions and expression of connexin 43. These were nearly absent in human ovarian adenocarcinoma cell lines. To ensure that this variation was not artificially produced by culturing techniques, this study evaluated gap junctions and connexin 43 expressions in normal ovaries and in ovarian adenocarcinomas.

STUDY DESIGN

Specimens of normal ovaries and ovarian adenocarcinomas were obtained at the time of surgery and flash-frozen in liquid nitrogen. Connexin 43 immunostaining was performed on all specimens.

RESULTS

Among the 11 normal ovaries an average of 59% of the surface epithelium stained positively for connexin 43. In contrast, among the 10 ovarian adenocarcinomas only 19% of each specimen stained positively for connexin 43 (P =.01).

CONCLUSION

Similar to our studies on human ovarian surface epithelial cells and ovarian adenocarcinoma cell lines, surgical specimens of normal ovary exhibited extensive connexin 43 expression, whereas connexin 43 expression was nearly absent in ovarian adenocarcinomas. It thus appears that the previously reported loss of gap junctions and connexin 43 was actually associated with a neoplastic process, rather than being artificially induced in the laboratory.

Loop electrosurgical excision procedure for partial upper vaginectomy

OBJECTIVES

Partial upper vaginectomy consists of removal of the vaginal apex and is indicated for the diagnosis and treatment of vaginal intraepithelial neoplasia and recurrent cancer. We present a novel surgical approach to partial upper vaginectomy by use of the loop electrosurgical excision procedure.

STUDY DESIGN

A total of 15 consecutive patients with abnormal vaginal cytologic results were treated by the loop electrosurgical excision procedure for partial upper vaginectomy. After submucosal injection of local anesthetic, the loop electrode was used to resect the upper third of the vagina. An iodoform vaginal pack was placed for 24 hours. All patients with high-grade vaginal intraepithelial neoplasia received intravaginal 5-fluorouracil cream postoperatively.

RESULTS

The mean blood loss was 0 mL, and the mean surgical time was 30 minutes. A complication developed in 1 patient (7%). One case of invasive carcinoma was diagnosed. No recurrences have developed in any patients with vaginal intraepithelial neoplasia after hysterectomy.

CONCLUSIONS

The loop electrosurgical excision procedure for partial upper vaginectomy can be performed quickly, with minimal blood loss, minimal complications, and minimal recurrence of neoplasia, and it provides a histologic specimen for evaluation.

Patterns of failure in endometrial carcinoma stage IB grade 3 and IC patients treated with postoperative vaginal vault brachytherapy

OBJECTIVE

The vagina is the most common site of locoregional failure in surgical stage IB, IC, and II (occult) endometrial adenocarcinoma. The objective of this study is to evaluate the therapeutic efficacy of vaginal vault brachytherapy alone for surgical stage I patients with high-risk features.

MATERIALS AND METHODS

The study group consists of high-risk stage I patients with either stage IB grade (G) 3 or any grade IC disease. From February 1991 to August 1997, 124 patients with endometrial carcinoma were treated postoperatively with high-dose-rate vaginal vault brachytherapy as the only adjuvant treatment. All patients were surgically staged. Among them, 38 patients were identified as high risk. Twelve patients had stage IBG3, 14 had ICG1, 9 had ICG2, and 3 had ICG3 disease. The median age was 67 years (range 41 to 86 years). A dose of 21 Gy in three fractions of 7 Gy each was delivered to a prescription depth of 0.5 cm from the surface of the vaginal applicator using high-dose-rate brachytherapy.

RESULTS

The median follow-up was 30 months (range 7 to 91 months). No patient has developed a vaginal or pelvic recurrence. Three patients developed tumor recurrence in the upper abdomen at 11, 18, and 37 months. Two of the three patients with recurrent disease also had history of breast cancer. In one patient, breast cancer was diagnosed 4.8 years prior and in the second 3 years subsequent to the diagnosis of endometrial cancer. The 5-year actuarial overall survival and disease-free survival are 93 and 87%, respectively. There was no treatment-related grade 3 or 4 morbidity observed.

CONCLUSIONS

For patients with surgical stage IBG3 and IC, excellent local control and minimal morbidity has been observed with the selective use of vaginal brachytherapy alone. Further studies and longer follow-up are warranted.

Treatment for early endometrial cancer. Cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of treatment for early endometrial cancer.

STUDY DESIGN

Cost-minimization type of cost-effectiveness analysis with payer costs based on CPT (physician's current procedural terminology) and DRG (disease related group) codes. The six principles of cost-effectiveness analysis were evaluated. We compared the standard treatment protocol of selected lymphadenectomy/selective teletherapy (lymphadenectomy and postoperative teletherapy administered for high-risk tumors) as performed by the majority of gynecologic oncologists vs. an alternate treatment protocol of lymphadenectomy/selective brachytherapy (lymphadenectomy for all tumors, brachytherapy for high-risk tumors and teletherapy reserved for nodal metastasis) as performed by 10-12% of gynecologic oncologists.

RESULTS

In cost-minimization analysis, lymphadenectomy/selective brachytherapy was 12% less expensive than the standard treatment protocol of selective lymphadenectomy/teletherapy.

CONCLUSION

Although only 10-12% of gynecologic oncologists perform lymphadenectomy on all patients, deliver brachytherapy for high-risk tumors and reserve teletherapy for lymph node metastasis, it is a cost-effective treatment strategy for early endometrial cancer.

Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy

INTRODUCTION

Postoperative traditional feeding protocols are not based on scientific studies, but rather on anecdotal evidence. We present the first prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy in an attempt to determine its effect on the length of hospital stay.

METHODS

Twenty consecutive patients undergoing radical hysterectomy were entered onto a prospective trial of aggressive postoperative bowel stimulation, which consisted of 30 cc milk of magnesia p.o. b.i.d. starting on postoperative day 1 and biscolic suppositories q.d. starting on day 2. A clear liquid diet was begun following flatus or bowel movement and patients were discharged 12 h after tolerating a clear liquid diet. Diet was slowly advanced at home.

RESULTS

Median time to flatus was 3 days, bowel movement 3 days, and clear liquid diet 3 days. Median time to discharge was 4 days. No patients developed ileus or bowel obstructions and there were no readmissions for bowel complications. Our median time to discharge of 4 days represents a 50% reduction in hospital stay compared to our previous prospective study using traditional postoperative bowel management (8 days), which was statistically significant at P = 0.001.

CONCLUSION

Aggressive bowel stimulation with milk of magnesia and biscolic suppositories resulted in early return of bowel function and early discharge with no noticeable complications.

Peritoneal fluid urea nitrogen and creatinine reference values

OBJECTIVE

To evaluate urea nitrogen and creatinine levels in peritoneal fluid.

METHODS

We prospectively evaluated 20 consecutive women having radical hysterectomy with lymphadenectomy. On postoperative days 2 and 3, serum, urine, and peritoneal fluid samples were tested for urea nitrogen and creatinine. Using power analysis we calculated an adequate sample size to be 16 patients.

RESULTS

The mean urea nitrogen was 11 mg/dL in serum, 11 mg/dL in peritoneal fluid, and 469 mg/dL in urine. The mean creatinine was .9 mg/dL in serum, 1.0 mg/dL in peritoneal fluid, and 141 mg/dL in urine. Urea nitrogen and creatinine values in peritoneal fluid and serum were essentially identical. Urine urea nitrogen and creatinine values were significantly greater than serum and peritoneal values (47 to 157 times greater) (P < .011). On postoperative days 2 and 3, serial levels of serum, peritoneal fluid, and urine urea nitrogen and creatinine in the same subject showed no significant variation (P ranging from .19 to .31).

CONCLUSION

Normal reference values of urea nitrogen and creatinine in peritoneal fluid are equivalent to serum values and significantly less than urine levels.

Paget's disease of the vulva: prevalence of associated vulvar adenocarcinoma, invasive Paget's disease, and recurrence after surgical excision

OBJECTIVE

Our aim was to determine the prevalence of associated vulvar adenocarcinoma, invasive Paget's disease, and recurrence of Paget's disease of the vulva.

STUDY DESIGN

A retrospective review of tumor and pathology registries at 8 institutions is presented. Patients with recurrent disease were excluded. Histologic slide review was performed.

RESULTS

The median age of the 100 patients was 70 years. The median duration of pruritus before surgery was 2 years. Thirty-four percent of patients experienced a recurrence at a median of 3 years. There was a 12% prevalence of invasive vulvar Paget's disease and a 4% prevalence of associated vulvar adenocarcinoma. One patient died of Paget's disease with associated vulvar adenocarcinoma.

CONCLUSIONS

Paget's disease of the vulva is rarely associated with an underlying vulvar adenocarcinoma or invasive Paget's disease, but there is a high recurrence rate.

Frequency and yield of postoperative fever evaluation

OBJECTIVE

In women undergoing major gynecologic surgery, we wish to determine the frequency and yield of blood culture, urine culture, and chest X-ray evaluation of postoperative fever.

METHODS

A retrospective review of 537 consecutive patients undergoing major gynecologic surgery was performed. In patients who developed postoperative fever, it was determined whether blood culture, urine culture, and/or chest X-ray were performed, and, if so, the frequency of positive results was evaluated.

RESULTS

Two hundred eleven patients (39%) developed postoperative fever. Blood cultures were obtained in 77 of 211 (37%) febrile patients, urine cultures in 106 of 211 (50%) febrile patients, and chest X-ray in 54 of 211 (26%) febrile patients. Zero of 77 blood cultures were positive, 11 of 106 (10%) urine cultures were positive, and 5 of 54 (9%) chest X-rays were positive. Logistic regression revealed that late onset fever predicted for positive urine cultures and early onset fever and advanced age predicted for pneumonia. Eighty percent of patients with pneumonia were symptomatic. In 92% of patients with postoperative fever, no infections or pathologic process were diagnosed.

CONCLUSION

Although postoperative fever is frequently evaluated by blood culture, urine culture, and chest X-ray, evaluation rarely yields positive results.

Frequency and yield of postoperative fever evaluation

OBJECTIVE

In women undergoing major gynecologic surgery, we wish to determine the frequency and yield of blood culture, urine culture, and chest X-ray evaluation of postoperative fever.

METHODS

A retrospective review of 537 consecutive patients undergoing major gynecologic surgery was performed. In patients who developed postoperative fever, it was determined whether blood culture, urine culture, and/or chest X-ray were performed, and, if so, the frequency of positive results was evaluated.

RESULTS

Two hundred eleven patients (39%) developed postoperative fever. Blood cultures were obtained in 77 of 211 (37%) febrile patients, urine cultures in 106 of 211 (50%) febrile patients, and chest X-ray in 54 of 211 (26%) febrile patients. Zero of 77 blood cultures were positive, 11 of 106 (10%) urine cultures were positive, and 5 of 54 (9%) chest X-rays were positive. Logistic regression revealed that late onset fever predicted for positive urine cultures and early onset fever and advanced age predicted for pneumonia. Eighty percent of patients with pneumonia were symptomatic. In 92% of patients with postoperative fever, no infections or pathologic process were diagnosed.

CONCLUSION

Although postoperative fever is frequently evaluated by blood culture, urine culture, and chest X-ray, evaluation rarely yields positive results.

Modified radical vulvectomy without lymphadenectomy under local anesthesia in medically compromised patients

INTRODUCTION

Our objective was to review our experience with vulvar cancer treated with modified radical vulvectomy without lymphadenectomy under local anesthesia and sedation.

METHODS

A retrospective review of surgical case lists revealed five patients who underwent modified radical vulvectomy without lymphadenectomy under local anesthesia with sedation. All patients had significant medical diseases which precluded regional or general anesthesia. Modified radical vulvectomy was performed in standard fashion under sedation and local anesthesia. Inguinal lymphadenectomy was not performed.

RESULTS

Median operative time was 1.5 h and median blood loss was 100 cc. Median diameter of tissue resected was 5 cm and median depth was 5 cm. Median length of hospital stay was 4 days. No patient complained of pain during the operative procedure. At a median follow-up of 2.5 years, there has been one local recurrence.

CONCLUSION

Five patients with symptomatic vulvar cancer who were not candidates for regional or general anesthesia underwent modified radical vulvectomy without lymphadenectomy under local anesthesia with sedation. The procedure was well-tolerated and produced minimal morbidity and adequate short-term local control.

Methotrexate pneumonitis after systemic treatment for ectopic pregnancy

Pneumonitis is an infrequent complication of methotrexate therapy. Described is a case of pneumonitis after treatment of an ectopic pregnancy. A 20-year-old white woman, gravida 3, para 0, ectopic pregnancy 2, was treated for her third ectopic pregnancy with 88 mg (50 mg/m2) of intramuscular methotrexate. Four days later acute dyspnea, tachypnea, fever, patchy infiltrates on chest x-ray films, and a PO2 of 30 mm Hg developed. Respiratory distress resolved over 48 hours. Pneumonitis should be suspected in any patient treated with methotrexate who has unexplained dyspnea.

Prophylactic granulocyte colony-stimulating factor allows escalation of chemotherapeutic dose intensity in advanced epithelial ovarian cancer

BACKGROUND

In an effort to discover an effective regimen for use in Phase III evaluation of the efficacy of dose intensification in advanced ovarian cancer, we performed a Phase II trial of dose intensified cisplatin, etoposide, and ifosfamide with granulocyte colony-stimulating factor (G-CSF).

METHODS

Thirty patients with primary, FiGO Stage 3 or 4, epithelial ovarian cancer underwent intensified cytoreduction followed by cisplatin 105 mg/m2, etoposide 300 mg/m2 and ifosfamide/mesna 3 g/m2, q 28 days x 6 cycles with G-CSF 5 microg/kg q day for 7 days. The dose of etoposide and ifosfamide was escalated 20% in cohorts of three patients.

RESULTS

Intensified cytoreductive surgery was successful in resecting all gross tumor in 24 patients (80%). At the original dose of cisplatin, etoposide, and ifosfamide without G-CSF, 55% of cycles resulted in neutropenia and 38% in thrombocytopenia (dose intensity = 0.8). With the addition of G-CSF, neutropenia developed in 5% of cycles and thrombocytopenia in 38%. At a 20% escalation of etoposide and ifosfamide, neutropenia developed in 17% of cycles and thrombocytopenia in 50% (dose intensity = 1.2). At a 40% escalation of etoposide and ifosfamide, neutropenia developed in 33% of cycles and thrombocytopenia in 83%, which was dose limiting. The remaining 18 patients were treated at a 20% escalation and neutropenia developed in 14% of cycles and thrombocytopenia in 36%. CA125 response was 73%. At a 4.1-year median follow-up, median progression-free survival was 2.6 years and median survival was 3.0 years.

CONCLUSION

In 30 women with primary advanced ovarian cancer, G-CSF allowed a 50% dose escalation of etoposide and ifosfamide from 0.8 to 1.2 dose intensity. The maximum tolerated dose of this regimen is cisplatin 105 mg/m2, etoposide 360 mg/m2, and ifosfamide 3.6 g/m2 with G-CSF.

False positive malignant peritoneal cytology and psammoma bodies in benign gynecologic disease

OBJECTIVE

To determine the incidence of false positive malignant peritoneal cytology and psammoma bodies associated with benign gynecologic disorders.

STUDY DESIGN

Pelvic peritoneal fluid was prospectively collected for cytologic examination from 119 women undergoing laparoscopy for benign conditions (infertility, 67; pelvic pain, 35; elective sterilization, 17). The median age was 30. No patient had laparoscopic gross cancer or histologic evidence of cancer.

RESULTS

The peritoneal cytology of 2 of 119 cases (2%) contained cells with features suggestive of malignancy, and 6 of 119 cases (5%) contained psammoma bodies. Both cases of false positive peritoneal cytology and four of six with psammoma bodies were associated with endometriosis. All cases were followed for a minimum of two years, and no patient had developed cancer.

CONCLUSION

Peritoneal fluid from cases of benign gynecologic disorders, especially endometriosis, can contain psammoma bodies and cells suggestive of malignancy.

Surgical staging and high dose rate brachytherapy for endometrial cancer: limiting external radiotherapy to node-positive tumors

OBJECTIVE

To evaluate the efficacy and morbidity of surgical staging and high dose rate brachytherapy for women with stage I-IIIA endometrial cancer.

METHODS

Sixty consecutive patients underwent surgical staging consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, bilateral pelvic lymphadenectomy, periaortic lymphadenectomy, and omentectomy. High dose rate brachytherapy was delivered postoperatively in three fractions for a total of 2100 cGy. Only patients with nodal metastasis received external radiotherapy.

RESULTS

Twenty-two tumors (37%) were considered high-risk uterine disease because of deep invasion (stage IC), cervical involvement (stage II), positive peritoneal cytology (stage IIIA), or poor differentiation (grade 3). Lymph node metastases were detected in five patients. There was no surgical mortality, and morbidity from surgery and high dose rate brachytherapy was minimal. At a median follow-up of 3 years, there has been one recurrence. The conventional practice of postoperative external radiotherapy was altered in 23 of 60 patients (38%): 22 women with high-risk uterine factors did not receive external radiotherapy, and one patient with low-risk uterine factors (less than 50% myometrial invasion, grade 2) received external radiotherapy because of microscopic pelvic lymph node metastasis.

CONCLUSION

Surgical staging and high dose rate brachytherapy without external radiotherapy for stage I-IIIA endometrial cancer were associated with minimal morbidity and produced excellent survival.

Sequential granulocyte colony-stimulating factor increases cisplatin cytotoxicity in human epithelial ovarian cancer cell lines

BACKGROUND

To determine the effect of granulocyte colony-stimulating factor (G-CSF) on tumor growth and cisplatin cytotoxicity in human epithelial ovarian cancer.

METHODS

Six human epithelial ovarian cancer cell lines were treated with media (control) for 24 hr, G-CSF for 24 hr, cisplatin for 24 hr, simultaneous cisplatin and G-CSF for 24 hr, media (control) for 48 hr, cisplatin for 24 hr and sequential media for 24 hr, cisplatin for 24 hr, and sequential G-CSF for 24 hr. Following incubation, the percentage cell lysis was determined by particle concentration fluorescein immunoassay chemosensitivity assay.

RESULTS

G-CSF resulted in tumor cell growth (7-19%) in three cell lines. Simultaneous G-CSF decreased cisplatin cytotoxicity in five cell lines (7-45%). Sequential G-CSF increased cisplatin cytotoxicity in all six cell lines (5-108%).

CONCLUSIONS

G-CSF may result in ovarian cancer proliferation. Simultaneous G-CSF may decrease cisplatin cytotoxicity, while sequential G-CSF appears to increase cisplatin cytotoxicity.