Surgery For Uterine Cancer Research Articles

Achievements, Investigations in Gynecologic Oncology Explored

Achievements, Investigations in Gynecologic Oncology Explored

Race-based disparities in loss of functional independence after hysterectomy for uterine cancer.

Racial disparities in uterine cancer-related outcomes have been reported. The goal of this study was to determine if race, pre-operative body mass index (BMI), and medical comorbidities are predictors of loss of functional independence after hysterectomy for uterine cancer. Loss of independence was defined as a change from pre-operative functional independence, to a post-operative requirement of discharge to a post-care facility, or death within the first 30days following uterine cancer surgery. Demographic factors, comorbidities, BMI, intra-operative and post-operative outcomes, and discharge status were abstracted from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Statistical analyses included multivariable logistic regression and Wald tests for interaction. A total of 4005 patients had uterine cancer and were functionally independent pre-operatively. After adjusting for clinical features and comorbidities, Black women were not significantly more likely to lose functional independence than non-Black women. However, a significant interaction (OR=1.17, p<0.001) was found between race and BMI for loss of functional independence. Interaction plots revealed worsening functional outcomes for Black women with BMI >40 but not in non-Blacks. The interaction suggests a 17% increased odds of losing independence for each unit of BMI difference for Black uterine cancer patients, or 170% increased odds of losing independence for a 10-point increase in BMI, given a linear association. To reduce the likelihood of losing post-operative functional independence, Black, high-BMI patients with or at risk for uterine cancer may especially benefit from weight loss or interventions to optimize physical function.

Abstract 3726: Race-based disparities in loss of functional independence after uterine cancer

Abstract Introduction Racial disparities in uterine cancer-related outcomes have been reported. Black uterine cancer patients are more likely to have worse clinical outcomes, which are not fully explained by number of comorbidities. Few studies have investigated the factors that may influence functional independence following surgery for uterine cancer. The goal of this study was to determine if race, preoperative body mass index (BMI) and medical comorbidities are predictors of loss of functional independence. Method: Data from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) were used. All patients were identified by post-operative ICD-9 code. Functional independence was defined as: the patient not requiring assistance from another person for any activities of daily living preoperatively. Loss of independence was defined as requiring discharge to a post-care facility or death, in the immediate postoperative period following hysterectomy. Demographic factors, comorbidities, BMI, intraoperative and postoperative outcomes and discharge status were captured within 30 days of surgery. Statistical analyses included multivariate logistic regression and Wald tests for interaction. Results: 4115 patients were identified with a diagnosis of uterine cancer and were functionally independent preoperatively: 310 (7.5%) were Black and 3805 (92.5%) were non-black. Compared with non-black, Black uterine cancer patients were notable for greater BMI (median 35.4 vs. 32.3, P&amp;lt;0.001), more likely to have one or more comorbidities (76.9% vs. 59.8%, P&amp;lt;0.001), and longer operative time (179.9 mins vs. 159.5 mins, P&amp;lt;0.001). After adjusting for BMI, age, number of comorbidities, pre-operative conditions, major complications, disseminated cancer and days of hospitalization prior to surgery, Black women were not significantly more likely to lose functional independence during the postoperative period than non-Black women. However, a significant interaction (OR 1.14 per 1-unit BMI increase, P&amp;lt;0.001) was found between Black and BMI on loss of functional independence. Interaction plots revealed worse functional outcomes per unit increase in BMI for Black women but not in non-Blacks. Conclusions: The significant interaction between Black race and BMI suggests a 14% increased odds of losing functional independence for each unit of BMI increase for Black uterine cancer patients, meaning that a 10-point increase in BMI would confer a 140% increase in odds of losing functional independence. Black uterine cancer patients with high BMIs may especially benefit from weight loss or interventions to optimize physical function and comorbidity profiles prior to and following surgery, in order to reduce the likelihood of losing functional independence after surgery. Together these efforts may improve disease specific as well as overall health outcomes in Black women with uterine cancer. Citation Format: Lorraine Dean, Xiaochen Zhang, Nawar Latif, Ashley Haggerty, Robert Giuntoli, Sarah Kim, David Shalowitz, Caitlin Stashwick, Mark Morgan, Emily Ko, Kathryn Schmitz. Race-based disparities in loss of functional independence after uterine cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3726. doi:10.1158/1538-7445.AM2015-3726

Cost-effectiveness analysis of robotically assisted laparoscopy for newly diagnosed uterine cancers.

To assess the direct costs of three surgical approaches in uterine cancer and the cost-effectiveness of incorporating robot-assisted surgery. A cost system that allocates the actual cost of resources used to treat each patient, as opposed to borrowing cost data from a billing system, was used to determine direct costs for patients who underwent surgery for uterine cancer from 2009 to 2010. These costs included all aspects of surgical care up to 6 months after discharge. Total amortized direct costs included the capital cost of three dual-console robotic platforms with 5 years of service contracts. Nonamortized costs were also calculated (excluded capital costs). Modeling was performed to estimate the mean cost of surgical care for patients presenting with endometrial cancer from 2007 to 2010. Of 436 cases (132 laparoscopic, 262 robotic, 42 laparotomy), total mean amortized direct costs per case were $20,489 (laparoscopy), $23,646 (robot), and $24,642 (laparotomy) (P<.05 [robot compared with laparoscopy]; P=.6 [robot compared with laparotomy]). Total nonamortized costs per case were $20,289, $20,467, and $24,433, respectively (P=.9 [robot compared with laparoscopy]; P=.03 [robot compared with laparotomy]). The planned surgical approach in 2007 was laparoscopy, 68%; robot, 8%; and laparotomy, 24% compared with 26%, 64%, and 9%, respectively, in 2010 (P<.001). The modeled mean amortized direct costs per case were $21,738 in 2007 and $22,678 in 2010 (+$940). Nonamortized costs were $21,298 in 2007 and $20,573 in 2010 (-$725). Laparoscopy is least expensive when including capital acquisition costs. Laparoscopy and robotic surgery are comparable if upfront costs are excluded. There is cost neutralization with the robot when it helps decrease laparotomy rates.

The wait time creep: Changes in the surgical wait time for women with uterine cancer in Ontario, Canada, during 2000–2009

ObjectiveUterine cancer is a major cancer of women, with outcomes potentially worsening with delayed diagnosis or hysterectomy, the main treatment. Yet cancer surgery wait times are not reported by cancer site. This study sought to examine changes in wait times for uterine cancer surgery between 2000 and 2009 and to identify predictors of longer surgery wait times. MethodsPopulation-based retrospective analysis of a cohort of uterine cancer patients diagnosed between April 2000 and March 2009. Using linked administrative data, all cases in which a patient had hysterectomy following diagnosis were identified. Wait time was defined as days from diagnosis of uterine cancer (day 0) to hysterectomy. Regression analysis was used to examine the relationship between covariates and wait time. ResultsWait times increased steadily between 2000 and 2006 from a median of 34 to 54days, followed by a plateau until 2009—during which patients waited a median of between 53 and 55days for surgery after diagnosis. Overall, 55% of patients had a wait time longer than 6weeks after diagnosis. Predictors of a wait time greater than 6weeks included older age, region, lower income, later year of diagnosis, surgery by a gynaecologic oncologist, non-sarcoma histology group and having surgery in a teaching hospital. ConclusionOver half of uterine cancer patients waited longer than the recommended 6weeks for surgery. Future reporting of cancer wait times by each disease site regularly would help to identify progress to reduce wait times and opportunities for improvement.

Trends in Hospital Volume and Patterns of Referral for Women With Gynecologic Cancers

To estimate trends in hospital volume and referral patterns for women with uterine and ovarian cancer. The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged 65 years or older with ovarian and uterine cancer who underwent surgery from 2000 to 2007. "Volume creep," when a greater number of patients undergo surgery at the same hospitals, and "market concentration," when a similar overall number of patients undergo a procedure but at a smaller number of hospitals, were analyzed. Among 4,522 patients with ovarian cancer, mean hospital volume increased from 3.1 cases during 2000-2001 to 3.4 cases during 2006-2007 (P=.62) suggesting minimal volume creep. Similarly, there was little evidence of market concentration. In 2000-2001, 37.8% of women were treated at the top decile by volume hospitals compared with 41.4% in 2006-2007 (P=.14). In 2006-2007, 201 (63.2%) of the hospitals had an ovarian cancer surgery volume of two or fewer cases. Among 9,908 women with uterine cancer, the mean hospital volume increased slightly from 4.5 in 2000-2001 to 5.4 in 2006-2007 (P=.10). The percentage of patients treated at the top decile by volume of hospitals increased from 40.4% in 2000-2001 to 44.7% in 2006-2007 (P<.001). In 2006-2007, 243 (49.3%) of the hospitals had a uterine cancer surgery volume of two or fewer cases. There have been only modest changes in the referral patterns of women with ovarian and uterine cancer. A large number of hospitals have a very low procedural volume.

Endoscopic submucosal dissection of multiple flat adenomas in the radiated rectum

We report a case of multiple flat adenomas and cancer of the rectum that occurred 15 years after pelvic irradiation following surgery for uterine cancer. Adenoma borders were diagnosed accurately by magnifying chromoendoscopy, leading to their adequate excision using endoscopic submucosal dissection. This enabled minimal dissection of the irradiated pelvis that would have otherwise been difficult. Furthermore, our approach probably helped minimize loss of bowel function, thereby preserving the patient's quality of life as much as possible. Pathology of the resected specimens revealed thickened walls of the submucosal layer vessels, indicating chronic radiation proctitis. Pelvic irradiation of the bowel carries a high risk of causing flat adenomas and cancer. Close and long-term surveillance may be useful in such cases, using not only conventional colonoscopy but also chromoendoscopy with indigo carmine dye spray and magnifying endoscopy.

Port-site recurrence in a patient undergoing robot-assisted gynecologic cancer surgery for endometrial cancer — A case report

► First case of port-site metastasis after robotic staging surgery for uterine cancer. ► Changes to robotic surgical technique to reduce risk of port-site recurrence. ► Further areas of investigation worth examining in this aspect of robotic surgery.

Ectopic Intrapulmonary Thyroid Tissue Mimicking Metastatic Tissue

Ectopic intrapulmonary thyroid is extremely rare, with only about two cases reported in the literature. These cases were found either during the work-up of a solitary pulmonary nodule or at autopsy. Here, we report a case of ectopic intrapulmonary thyroid mimicking multiple pulmonary metastases from an endometrioid adenocarcinoma of the uterus. A 50-year-old woman presented with dysmenorrhea and menorrhagia. Endometrial curettage of the uterus revealed an endometrioid adenocarcinoma. During the staging, multiple pulmonary nodules were found. To exclude the possibility of lung metastases of the endometrioid adenocarcinoma from the uterus, video-assisted thoracic surgery (VATS) with wedge resection was performed for the largest nodule. The histopathology for that nodule was entirely consistent with normal thyroid tissue. The patient underwent surgery for uterine cancer and was discharged without further adjuvant chemotherapy. The remaining intrapulmonary nodules were unchanged in size on a serial computed tomography scan. In this patient, pulmonary metastases were initially considered the most likely cause of the multiple pulmonary nodules, but the diagnosis of the ectopic intrapulmonary thyroid was ultimately made based on VATS-wedge resection for the largest pulmonary nodule. The patient was able to avoid any unnecessary systemic chemotherapy. Ectopic intrapulmonary thyroid is extremely rare but can be confused with pulmonary metastases from other sites. We are unaware of similar cases in the literature.

Obesity and perioperative outcomes in endometrial cancer surgery

Obesity is a significant risk factor in developing endometrial cancer. As obesity is becoming more endemic, we wish to evaluate the impact of obesity on perioperative outcomes in patients undergoing uterine cancer surgery. We analyzed our prospective database on patients with endometrial cancer who underwent abdominal hysterectomy and pelvic/aortic lymphadenectomy by one gynecologic oncologist. Information regarding race, age, body mass index (BMI), lymph node counts, staging, and estimated blood loss were analyzed against patient's weight category. Weight category was divided as follows: Normal weight (BMI < 25), overweight (BMI 25 to <30), obese (BMI 30 to <35) and morbid obesity (BMI ≥ 35). Between April 2003 and December 2009, 233 patients were recruited prospectively. This study found no difference in the number of lymph nodes harvested patient (P = 0.0539) or length of hospital stay (P = 0.4234) in patients with a normal BMI versus that of an overweight, obese, or morbidly obese. However, estimated blood loss (P = 0.01) and operative time (P = 0.0015) were greater as BMI increased. African American patients were more morbidly obese than Caucasian patients. Furthermore, younger patients tend to be more obese across all races. Finally, obesity did not affect perioperative complications (P = 0.78). Obesity increases surgical blood loss and operative time. However, obesity does not affect length of hospital stay, number of lymph nodes harvested, or perioperative complications in uterine cancer staging surgery.

Central Tumor Necrosis of a Large Meningioma Following Acute Anemia Caused by Hysterectomy -Case Report-

A 55-year-old woman, with a one-year history of headache, gait disturbance, and slight aphasia, was transferred to our hospital after head injury. Magnetic resonance (MR) imaging and computed tomography revealed a large meningioma with peripheral edema. However, priority was given to previously planned gynecological surgery for uterine cancer. She developed severe anemia after the surgery, followed by consciousness disturbance. MR imaging revealed spontaneous tumor necrosis. The meningioma was totally removed. Her consciousness improved, and she was discharged with no neurological deficit. Patients with large meningioma may suffer deterioration of symptoms due to central tumor necrosis triggered by acute anemia.

Concentration of uterine cancer surgical care among the elderly: A population-based perspective

Objectives. To characterize the primary surgical care and short-term outcomes for uterine cancer in women age ≥ 80 years compared to younger women. Methods. A statewide hospital discharge database was used to identify women that underwent primary surgery for uterine cancer from 1994 to 2005. Logistic regression models were used to evaluate for significant differences in demographic characteristics and short-term outcomes comparing women aged ≥ 80 years with those aged < 80 years. Results. A total of 6181 women were identified, women aged ≥ 80 years comprised 10.6% ( n = 656) of cases. Elderly women were 1.3 times more likely to be managed by high volume surgeons (41% vs. 35%, p = 0.00). The 30-day mortality rate was 4.3 fold higher for the elderly group (4.27% vs. 1.03%, p = 0.00). Among the elderly group, there was a 62% reduction in the risk of 30-day mortality when they were managed at high volume hospitals (95% CI: 0.18–0.80, p = 0.01), and a 44% reduction in the risk of 30-day mortality when management was performed by high volume surgeons (95% CI: 0.21–1.48, p = 0.22). The cost of care among elderly women managed at high volume centers ($10,425 vs. $9454, p = 0.02) and by high volume surgeons ($11,260 vs. $9400, p < 0.00) was higher when compared to the low volume groups. Conclusions. Primary surgical care of elderly women with uterine cancer by high volume providers is associated with better short-term outcomes but increases healthcare expenditure compared to low volume providers. Increased efforts to concentrate the operative care of this patient population in experienced, high volume centers are warranted.

Uterine cancer in Maryland: Impact of surgeon case volume and other prognostic factors on short-term mortality

To characterize the patterns of primary surgical care and short term outcomes for uterine cancer according to surgeon and hospital case volume. A statewide hospital discharge database was used to identify women undergoing primary surgery for uterine cancer during 1994-2005. Surgeon case volume was categorized as low (<or=99 cases/12 years), or high (>or=100 cases/12 years). Hospital case volume was categorized as low (<or=199 cases/12 years), or high (>or=200 cases/12 years). Logistic regression models were used to evaluate for significant factors associated with in-hospital death and access to high volume care. Overall, 6,181 cases for uterine cancer were performed by 894 surgeons at 49 hospitals. Low volume surgeons performed 62.4% of the cases. Management by high volume surgeons was associated with a 53% reduction in the risk of the case being managed by different attending physician/surgeon (95% CI 0.38-0.57, p<0.00). In contrast, 90.5% of cases were performed at high volume hospitals. Management by different attending physician/surgeon was associated with a 2.6 increase in the risk of in hospital death (95%CI 1.41-4.79, p=0.00). Surgery performed by high-volume surgeons was associated with a 48% reduction in the risk of in-hospital death (95%CI 0.26-1.00, p=0.05). Surgical management of uterine cancer by high volume surgeons is associated with a decrease risk in in-hospital death. Increased efforts to concentrate the surgical management of uterine cancer by high volume surgeons at high volume centers should be undertaken.

Physical side effects and quality of life during postoperative radiotherapy for uterine cancer. prospective evaluation by a diary card

Objective Adjuvant pelvic radiotherapy (XRT) after radical surgery for uterine cancer may cause various (mainly gastrointestinal) side effects capable of affecting a patient’s lifestyle. This prospective study used a diary card to evaluate toxicity and daily quality of life changes in uterine cancer patients given postoperative pelvic radiotherapy. Methods The self-completed diary card listed 12 items concerning lifestyle changes and side effects. The patients were stratified by age (≤65 vs >65 years). Results Twenty-five patients were evaluable, and a total of 848 days were assessed (82.6% of the 1027 days of XRT). The mean number of daily stools progressively increased during treatment ( P < 0.01). No statistically significant differences were observed in terms of nausea or pain. There was a significant decrease in appetite ( P < 0.01). Vaginal symptom scores did not significantly change during treatment, and no significant differences were found in terms of anxiety, daily activities, or compliance to therapy. The subjective perception of overall well-being and the quality of life score progressively and significantly decreased over time ( P < 0.01). The younger patients had significantly more bowel movements, less appetite, more pain and vaginal burning, less vaginal bleeding, more anxiety, a greater reduction in daily activities and therapeutic compliance, a poorer subjective perception of overall well-being, and a lower quality of life score. Conclusions The use of a diary card may be an adequate means of detecting the extent of treatment-related changes in the lifestyle of uterine cancer patients receiving postoperative radiotherapy.

Incisional hernia in gynecologic oncology patients: a 10-year study

Objective: To evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer. Methods: Over 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics. Results: Four hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19–44] kg/m 2 versus 24 [16–41] kg/m 2; P < .01). The frequencies of diabetes (14.3% versus 4.8%; P < .01), wound sepsis (10.4% versus 1.3%; P < .05), and fascial closure with interrupted sutures (70.1% versus 55.6%; P < .05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m 2 (odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81; P < .01) and wound infection (OR 5.05; 95% CI 1.39, 18.37; P < .01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22; P < .01) and wound infection (OR 8.55; 95% CI 1.54, 47.5; P < .01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65; P < .05) and 8 years (OR 49.52; 95% CI 2.72, 907.14; P < .01), the only significant association was found with diabetes. Conclusion: Late incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

A New Proposal for Radical Hysterectomy

Objective: The authors revised the surgical procedure for radical hysterectomy utilizing detailed observation of the venous system, connective fascial sheets, and neural pathways within the uterine supports. Study design: The anterior, middle, and posterior uterine supports were reclassified into two systems, supporting or fascial and drainage or areoral. Supporting system consisted of the superficial layer of the vesicouterine ligament, fascial part of the Mackenrodt ligament, sacrouterine ligament, and rectovaginal ligament, whereas drainage system consisted of the deep layer of the vesicouterine ligament, vascular part of the Mackenrodt ligament, and the so-called mesoureter. The operative procedure was planned according to the continuity of these ligaments and executed first by excising the fascia and then dissecting the denuded areoral tissue. Results: Among the 15 patients who underwent surgery for uterine cancer during a 2-year period the mean (SD) time required for the operation was 305.5 ± 30.5 min and the mean (SD) total volume of blood loss 592.0 ± 238.2 ml. A mean (SD) period of 14.3 ± 3.8 postoperative days was required until the volume of the residual urine decreased to less than 50 ml. Conclusion: The present operation has been structured more three-dimensionally and systematically than before. Further, safety of the operation was significantly improved including prevention of hemorrhage and preservation of bladder function.

Relative value of the wertheim and schauta operations in cancer of the cervix

T HE history of uterine carcinoma surgery encompasses 0nIy a few decades, ahhough it is true that attempts had been made to remove uterine cancers as Iong ago as the end of the eighteenth century. The measures empIoyed at that time consisted of curettage of the cervix, cauterization, and amputation of the cervix. WhiIe these therapeutic efforts were of no definite scientific vaIue, it is worthy of note that even these primitive methods effected occasiona temporary cures, and certain authors reported cases of ten or fifteen years’ standing without recurrences. The rea1 history of uterine cancer surgery began when the three chief dangers of extirpation were recognized: hemorrhage, injury to adjacent organs, and the danger of impIantation of maIignant ceIIs. The profession Iearned how to avoid, or rather prevent, them. This era dawned about the end of the nineteenth century. PeIvic surgeons then began extirpating the uterus invoIved in a malignant process by two different routes; vaginal and abdominal. With the development of surgical asepsis and the progressive improvement in operative technique, both methods have become popuIar in the hands of different operators. Vagina1 removal of the cancerous uterus was favored for a Iong time, particuIarIy during the years when surgeons had a justifiabIe fear of opening the abdomina1 cavity. Thus the vagina1 operation heId sway for a certain period because of its comparativeIy Iow primary mortaIity. With the passing of time, however, it graduaIIy Iost its favored position, because the fact was recognized that simple extirpation of the cancerous uterus is unIikeIy to insure a cure. Appreciation of the significance of the coincident invoIvement of the Iymphatics brought Iaparotomy to the fore, and the Iatter method reached its greatest vogue when Wertheim perfected the technique of radical abdomina1 hysterectomy. Wertheim Iigates the uterine arteries, isoIates the ureters, cIamps the broad Iigaments and excises them compIeteIy, freeing the cervix from the vagina, bIadder and rectum. With speciaIIy designed forceps the upper third of the vagina is cIamped and the amputation made at this IeveI. In the opened infundibuIopeIvic Iigaments, the Iymphatics and Iymph nodes are removed. The Ieading gynecoIogists of the worId adopted this method with enthusiasm, and no peIvic surgeon was considered modern at that time who did not foIIow Wertheim’s technique. Before Iong a mass of statistics was at hand, which was utiIized for a careful evaIuation of the merits of this operation. It soon became apparent that radica1 abdominal hysterectomy is attended by a high primary mortality, and even today it stands at about 13 per cent. In addition to the discouraging mortality in those patients who survive the operation, there is a reIativeIy high incidence of intraperitoneal and extraperitonea1 infection : parametria1 and pararecta1 suppuration, cystitis, fistuIae, embolism, etc. Such resuIts again directed the attention of a number of gynecoIogists toward vagina1 extirpation. Efforts to evoIve a radica1 vagina1 procedure hnaIIy resuIted in certain modifications which cuIminated in the method described by Schauta. By this technique the parametria1 tissue becomes more acces-

Lumbar anesthesia in radical surgery for uterine cancer

M.V. Sokolov (Moscow. Med. Zh., 1925, No. 12) reports useful data on the outcomes of radical surgery for uterine cancer (on. Wertheim) with various types of anesthesia: 21 cases of surgery performed under chloroform anesthesia gave 42.8% of primary mortality, 15 cases where the operation was performed under ether anesthesia - 26.6%, 52 cases of surgery with intravenous hedonal anesthesia - 23.07% and 33 cases with lumbar anesthesia with novocaine - 12.1%.