Gynecologic Oncology Surgeons Research Articles

Germline BRCA1 and BRCA2 Mutations in Ovarian Cancer

To estimate the frequency of BRCA1 and BRCA2 germline mutations in women with nonmucinous epithelial ovarian carcinoma unselected for a family history of breast or ovarian cancer. From 2004 to 2009, women undergoing surgical staging for nonmucinous epithelial ovarian carcinoma, including fallopian tube and primary peritoneal carcinoma, were invited to participate in tumor banking and genetic counseling for BRCA1 and BRCA2 mutations. Pathology and family history obtained by the gynecologic oncology surgeon and genetic counselors were reviewed. Of 131 women fulfilling entry criteria, germline BRCA1 and BRCA2 mutations were found in 20% (26/131) and were exclusively associated with high-grade serous histology (26/103 [25%]). Restricting BRCA1 and BRCA2 testing to women with family histories of hereditary breast and ovarian cancer, as ascertained by the surgeon, missed 14 mutation carriers, lowering detection rates to 9% (12/131) or 11.6% (12/103) if only considering the patients with high-grade serous histology. This improved to 16% (21/131) or 20.4% (21/103) when ascertained by the genetic counselor; however, 5 of 26 (19%) mutation carriers did not have a family history of hereditary breast or ovarian cancer. Germline BRCA1 and BRCA2 mutations in ovarian (pelvic) cancer are associated with high-grade serous histology. The high incidence (25%) of germline BRCA1 and BRCA2 mutations specific to the high-grade serous subtype suggests that genetic assessment of all women diagnosed with high-grade serous ovarian (pelvic) carcinoma will improve detection rates and capture mutation carriers otherwise missed by referral based on family history alone. II.

Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: is using the robot beneficial?

ObjectiveTo compare the outcomes of total laparoscopic to robotic approach for hysterectomy and all indicated procedures after controlling for surgeon and other confounding factors.MethodsRetrospective chart review of all consecutive cases of total laparoscopic and da Vinci robotic hysterectomies between August 2007 and July 2009 by two gynecologic oncology surgeons. Our primary outcome measure was operative procedure time. Secondary measures included complications, conversion to laparotomy, estimated blood loss and length of hospital stay. A mixed model with a random intercept was applied to control for surgeon and other confounders. Wilcoxon rank-sum, chi-square and Fisher's exact tests were used for the statistical analysis.ResultsThe 124 patients included in the study consisted of 77 total laparoscopic hysterectomies and 47 robotic hysterectomies. Both groups had similar baseline characteristics, indications for surgery and additional procedures performed. The difference between the mean operative procedure time for the total laparoscopic hysterectomy group (111.4 minutes) and the robotic hysterectomy group (150.8 minutes) was statistically significant (p=0.0001) despite the fact that the specimens obtained in the total laparoscopic hysterectomy group were significantly larger (125 g vs. 94 g, p=0.002). The robotic hysterectomy group had statistically less estimated blood loss than the total laparoscopic hysterectomy group (131.5 mL vs. 207.7 mL, p=0.0105) however no patients required a blood transfusion in either group. Both groups had a comparable rate of conversion to laparotomy, intraoperative complications, and length of hospital stay.ConclusionTotal laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy when performed by trained surgeons.

Atlas of procedures in Laparoscopic Hysterectomy

This atlas is distinguished from other publications in that there are abundant figures which the author drew himself, and it also contains full color photographs and videos taken during surgical procedures. This is a 210-page book with two accompanying DVDs of live surgical footage. The author is Seong Nyeon Bae from Seoul St. Mary's Hospital; famous for gynecologic oncologic surgery as well as one of the leading cancer institutions in Korea. The book is composed of eight parts that deals with pelvic anatomy, various types of hysterectomy procedures, and especially gyneco-oncologic laparoscopy, including nerve-sparing radical hysterectomy and lymph node dissection. The author has made it clear that the aim of the atlas is to provide updated review of pelvic anatomy and procedures in various hysterectomies. The author has also kindly indicated all the anatomic landmarks in the photographs, which will be instructive to readers. Most of the laparoscopic procedures are covered with clear and concise instructions, as well as abundant photographs in a step by step format, providing bilateral surgical procedures. It is very helpful to visualize real surgical fields in these high-quality pictures. From each picture to the next picture, the surgical procedures are chained to each other, presenting a beautiful completion of surgical procedures. The two complementary DVDs are also a great appendix, providing over five and a half hours of video clips. In conclusion, this book will serve as an informative guidance for gynecologic oncology surgeons who wish to be experts in laparoscopic procedures. I strongly recommend this atlas not only to surgical trainees but also senior practitioners who seek useful teaching aid for their colleagues.

Innovative laparoscopic surgery in gynecologic oncology

Minimally invasive surgery has been performed since the early 1990s, and gynecologic oncology surgeons continue to improve their skills for this procedure. Advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Laparoscopy has significant benefits in selected oncologic patients and may be a more useful technique than the abdominal approach. The benefits of laparoscopy include less postoperative pain, less blood loss, shorter length of hospital stay, and a shorter recovery period with no significant increase in complications or morbidity. With emerging data, it appears that the risk of cancer recurrence does not increase with a minimally invasive approach. The incorporation of laparoscopic pelvic and para-aortic lymphadenectomy has expanded the types of procedures performed for the management of certain gynecologic malignancies. New techniques, including hand-assisted laparoscopic procedures and extraperitoneal lymph node dissections, are expanding the role of laparoscopy in the treatment of all gynecologic malignancies.

Splenectomy in patients with advanced or recurrent ovarian cancer: Open and laparoscopic surgical techniques and clinical outcomes

In patients with advanced ovarian cancer, survival is improved when optimal tumor-reductive surgery is performed at the time of initial diagnosis [1–3]. To perform optimal tumorreductive surgery in patients with advanced ovarian cancer, it is often necessary to perform a splenectomy. Recently, Magtibay et al. [4] reported the largest series to date evaluating morbidity and mortality in patients who had undergone splenectomy as part of primary or secondary cytoreductive surgery for ovarian cancer. In that study, which included 112 patients, the most common indication for splenectomy (in 46% of patients) was tumor involvement. Thirteen percent of patients had intraoperative trauma to the spleen as the sole indication for splenectomy. Two percent of the patients in the series required reoperation to address postoperative hemorrhage. The overall perioperative mortality rate was 5%; however, none of the deaths were directly related to splenectomy. This study by Magtibay et al. [4], taken together with previous, smaller studies, indicates that splenectomy in women with advanced or recurrent ovarian cancer can be performed safely. The objective of this article is to describe in detail the surgical technique for performing open splenectomy and total laparoscopic splenectomy as performed by gynecologic oncology surgeons at The University of Texas M. D. Anderson Cancer Center.

Front-Line Treatment of Epithelial Ovarian Cancer

Epithelial ovarian cancer is the leading cause of death among the gynecologic malignancies. Over the past decade, advances in the field of ovarian carcinoma have brought an improvement in survival. This article focuses on the front-line management of ovarian cancer. While management of this disease is multidisciplinary and access to a trained gynecologic oncology surgeon is important, this article summarizes the most important advances from the medical oncologists’ perspective. It also reviews the current standard of care based on disease stage, as well as areas of investigation in the front-line treatment of ovarian cancer.

Recurrent ovarian carcinoma: Is there a place for surgery?

The role of cytoreductive surgery is well established in patients with primary ovarian carcinoma. Minimal residual disease translates to improved response to adjuvant treatment and prolonged survival. For close clinical follow-up, different approaches may be helpful in detecting recurrent disease, including regular physical/pelvic examination, serial CA-125 levels, and imaging studies using computerized tomography, magnetic resonance imaging, or positron emission testing. At recurrence, those patients with a good performance status, a good response to primary therapy, and a macronodular tumor distribution pattern may be candidates for a secondary cytoreductive procedure. Data suggests that secondary cytoreduction is superior to chemotherapy alone in patients who have a significant disease-free interval (6 to 12 months). Survival after secondary cytoreduction is optimized with cytoreduction to microscopic disease, yet there is a recognized risk of surgical morbidity. Therefore, a strong relationship between the gynecologic oncology surgeon and the patient is key to obtaining appropriate informed consent and relaying appropriate outcome expectations. Semin. Surg. Oncol. 19:62–68, 2000. © 2000 Wiley-Liss, Inc.

Recurrent ovarian carcinoma: is there a place for surgery?

The role of cytoreductive surgery is well established in patients with primary ovarian carcinoma. Minimal residual disease translates to improved response to adjuvant treatment and prolonged survival. For close clinical follow-up, different approaches may be helpful in detecting recurrent disease, including regular physical/pelvic examination, serial CA-125 levels, and imaging studies using computerized tomography, magnetic resonance imaging, or positron emission testing. At recurrence, those patients with a good performance status, a good response to primary therapy, and a macronodular tumor distribution pattern may be candidates for a secondary cytoreductive procedure. Data suggests that secondary cytoreduction is superior to chemotherapy alone in patients who have a significant disease-free interval (6 to 12 months). Survival after secondary cytoreduction is optimized with cytoreduction to microscopic disease, yet there is a recognized risk of surgical morbidity. Therefore, a strong relationship between the gynecologic oncology surgeon and the patient is key to obtaining appropriate informed consent and relaying appropriate outcome expectations.

Ovarian carcinoma metastases to gastrointestinal tract appear to spread like colon carcinoma: implications for surgical resection.

To profile the incidence of mesenteric lymph node metastases in patients with ovarian carcinoma and metastases to the gastrointestinal tract in order to determine the optimal technique for surgical debulking. The slides and charts of all patients with ovarian carcinoma who had undergone bowel resection were retrospectively reviewed and follow-up information was obtained. Of 100 separate bowel resections 44% had penetration of metastases to the muscularis, 18% had invasion through the submucosa, 4% had mucosal perforation, and two patients had clinical perforation. Fifty-five percent of all resections demonstrated lymph-vascular space invasion (LVSI). In the 33 specimens which included pathologic analysis of mesenteric lymph nodes, 79% had positive LVSI, which correlated with the presence of mesenteric lymph node metastases (P = 0.05) but not histologic grade (P = 0.20). When surgery was performed for secondary debulking, the frequency of mesenteric node metastasis was higher (P = 0.15). There was a trend for patients with positive mesenteric nodes to fail sooner (median survival, 20 months vs 32 months). Because ovarian carcinoma metastases to the gastrointestinal tract are frequently associated with metastases to mesenteric lymph nodes, gynecologic oncology surgeons may wish to consider resection of the mesentery in a wedge fashion similar to current standards of resection for primary bowel carcinoma in cases in which a bowel resection is being performed with the intent to debulk to zero visible residual disease.

Selective pelvic and periaortic lymphadenectomy does not increase morbidity in surgical staging of endometrial carcinoma

OBJECTIVE: The objective of this study was to retrospectively assess whether there was increased morbidity associated with the addition of selective pelvic and periaortic lymphadenectomy to hysterectomy in patients with endometrial carcinoma. STUDY DESIGN: From 1977 through 1988, 196 patients undergoing selective pelvic and periaortic lymphadenectomy plus hysterectomy were compared with 104 patients who underwent hysterectomy alone for endometrial adenocarcinoma. RESULTS: Only after adjusting for covariates was selective pelvic and periaortic lymphadenectomy associated with a higher estimated blood loss, which increased linearly with weight and was higher for black than for white women. The transfusion rate was similar for the two groups (selective pelvic and periaortic lymphadenectomy 6%, hysterectomy 10%). The mean blood loss was significantly different among the four gynecologic oncology surgeons (range 343 to 652 ml). The operating time primarily depended on patient weight and race, surgeon, and estimated blood loss. Postoperative hospital stay increased significantly with age, surgeon, wound infections, thrombotic events, and serious complications. Selective pelvic and periaortic lymphadenectomy had no effect on wound infections, which were directly related to operating time. Seventy-five (38%) of the selective pelvic and periaortic lymphadenectomy group and 19 (18%) of the hysterectomy group ( p < 0.01) received whole-pelvic radiation with no difference in bowel complications (selective pelvic and periaortic lymphadenectomy 2/75, hysterectomy 1/19). The risk of serious complications was associated only with increasing age. CONCLUSION: Selective pelvic and periaortic lymphadenectomy in patients with endometrial carcinoma does not significantly add to morbidity from hysterectomy, which is related primarily to other factors such as patient weight, age, and race; operating time; and surgeon.

Intestinal surgery performed on gynecologic cancer patients

A retrospective review covering a 9-year period revealed 113 patients who underwent 157 major bowel procedures during 130 operations performed solely by gynecologic oncology surgeons. Forty-eight percent of the operations were done for tumor cytoreduction, and 33% were performed for a bowel obstruction. Other indications included colostomy closure, fistula repair, resection for multiple enterotomies, temporary diversions, repair of perforated bowel, treatment for severe proctosigmoiditis, management of ureteral stricture, treatment for vulvar necrosis, and resection of an incidental small bowel tumor. Of the 157 procedures, 44% were colostomies, 32% were bowel resections with reanastomosis, 9% were urinary conduits, 6% were intestinal bypass procedures, 5% were colostomy closures, and 4% were ileostomies. Postoperative complications occurred in 32% of the 130 operations. These included wound infection, death, sepsis, fistula formation, urinary tract infection, unexplained febrile morbidity, anastomotic leakage, stomal infarction, adult respiratory distress syndrome, bowel obstruction, deep venous thrombosis, and wound hematoma. Four of the eight deaths were due to tumor progression, three were from sepsis, and one was from adult respiratory distress syndrome. Of the 130 operations, 89 (68%) were associated with no complications. These data support the concept that gynecologic oncology surgeons are able to perform intestinal operations as therapy for gynecologic malignancies with acceptable complication rates. Since a thorough understanding of the natural history of the cancer, familiarity with alternative therapeutic options, and knowledge of the prognosis are important in making operative decisions, and since gynecologic oncologists are technically capable of performing operations on the small bowel and colon, referral of patients with a primary or recurrent gynecologic malignancy or with a subsequent intestinal complication after initial therapy should be directed to the gynecologic oncologist whenever possible.

Two cases of duodenal ulceration in children

Oncovascular surgery is a new term used to define tumor resection with simultaneous reconstruction of the great vessels when the tumor infiltrates or firmly adheres to such vessels. The benefit of oncovascular surgery has been widely described in patients with hepato-biliary-pancreatic cancers, retroperitoneal soft tissue sarcoma, and in other areas of gynecologic oncology, such as the lateral compartment of the pelvis, retroperitoneum, and hepato-biliary-pancreatic region, with an increase in complete resections and without increasing the morbidity and mortality rates. In the latter decades of the past century, several advances and accumulating scientific evidence led gynecologic oncologists to perform more thorough cytoreductive surgeries that included multivisceral resections. But to our knowledge, published studies on the frequency and relevance of vascular surgery in gynecological oncology are scarce. Gynecologic oncologists still do not receive formal training in vascular surgery and additionally, with the current reduction in experience with pelvic and para-aortic lymphadenectomy, as well as other types of radical abdominal and pelvic surgeries, trainees will encounter fewer vascular injuries and the opportunity to deal with a variety of management types required. Well-organized collaboration between each subspecialty with a multidisciplinary approach and adequate pre-operative planning are pivotal. The aim of this review is to pave the way towards the understanding that patients with suspicion of great vessels9 infiltration or encasement by tumor require personalized and specialized treatment with the need to form an oncovascular surgery team, and that it is necessary for gynecologic oncology surgeons to take a step forward in surgical training.