Is venous thromboprophylaxis necessary in patients undergoing minimally invasive surgery for a gynecologic malignancy?

Objectives

Current recommendations for the use of venous thromboprophylaxis in patients undergoing minimally invasive surgery (MIS) for a gynecologic malignancy are derived from patients undergoing open surgery. Our objective was to determine the 30-day prevalence of symptomatic venous thromboembolism (VTE) after laparoscopic gynecologic oncology procedures in patients who received no thromboprophylaxis.

Methods

Between January 2006 and September 2013, women who underwent MIS for endometrial, cervical or ovarian cancer at a single institution were included. Data on patient demographics, diagnosis, comorbidities, perioperative characteristics, use of thromboprophylaxis, and diagnosis of VTE were collected retrospectively.

Results

Of the 419 patients who underwent MIS for a gynecologic cancer, 352 (84%) received no VTE prophylaxis. At least a total laparoscopic hysterectomy (simple or radical) or pelvic lymph node dissection was performed in 95% of these patients. The median length of surgery was 137 min and 95% of patients were discharged home within 1 day of surgery. The rate of VTE in the 352 untreated patients was 0.57% (1 pulmonary embolism and 1 deep vein thrombosis). There were no VTE diagnosed within 30 days of surgery in the 67 patients who received anticoagulant thromboprophylaxis.

Conclusion

The rate of VTE is low in patients undergoing minimally invasive surgery for a gynecologic malignancy despite no VTE prophylaxis. The benefits of routine use of VTE prophylaxis in this population are questionable.     

Small volume stage 1B1 cervical cancer: Is radical surgery still necessary?

Objective

Current surgical treatment of FIGO stage 1B1 cervical cancer is radical surgery. However, several reports have shown that for small tumours a more conservative approach can be as effective in terms of survival, whilst at the same time reducing the morbidity associated with removing the parametrium. The objective of our study was to report survival and obstetric outcomes following conservative management of small-volume stage 1B1 disease.

Methods

All patients with FIGO stage 1B1 cancer and estimated tumour volume of less than 500 mm³ in a loop biopsy specimen were included in the study, irrespective of other histological characteristics. A second loop biopsy was performed to rule out residual disease in 79% of patients.

Results

Sixty two women were identified with a median age of 35 years (range 27-67). Median tumour length was 9.75 mm (7.2-20) and median depth of invasion was 1.55 mm (0.3-5). Thirty five women (56.4%) were treated with loop biopsy, whilst 27 (45.6%) had simple hysterectomy. Fifty seven women (92%) had pelvic lymphadenectomy and one positive node was recorded. After a median follow up of 56 months (16-132) no recurrence was noted. Seven full term pregnancies have been achieved. There were no preterm deliveries or mid-term miscarriages.

Conclusion

Cervical loop biopsy or simple hysterectomy combined with negative pelvic lymphadenectomy for small-volume stage 1B1 cervical cancer offers excellent prognosis in terms of survival. Postoperative morbidity is reduced and obstetric outcomes may be improved. Should these results be verified by further prospective studies, radical surgery for these women may be avoided.     

Pathology slide review in gynecologic oncology: routine or selective?

OBJECTIVE: The aims of this study were to assess the cost/benefit ratio for interinstitution pathology consultation (IPC) and to identify the types of specimens with little or no risk of diagnostic error in order to reduce the cost. METHODS: All gynecologic oncology referrals having IPC from 1993 to 1998 were reviewed. Each case was evaluated by comparing both the original and the consulted pathology reports. A discrepancy was major if it led to treatment alteration. A minor discrepancy was defined as differences without clinical consequences. Consultation error was determined by comparison with the final diagnosis and clinical data obtained from the records. The cost per review was adjusted to 1998 dollars for all cases over the 5-year study period. Statistical data were obtained by Fisher's exact test and Pearson's correlation test. RESULTS: Five hundred sixty-nine pathology specimens from 498 patients were analyzed in this study. The major discrepancy rate was 6.5% and the minor discrepancy rate was 12.5%. Cytological specimens accounted for no major discrepancy and 13 minor discrepancies compared to 37 major and 58 minor discrepancies in histological specimens. The difference was statistically significant (P = 0.003). Consultation errors occurred in 5 cases with no alteration of clinical care. By excluding cervical and vaginal smears and cervical biopsy specimens in cases with clinically gross tumors, the cost can be reduced by 25% with no detriment to the clinical management. CONCLUSIONS: The types of specimens that do not need consultative pathology review include (1) cervical biopsy specimens in those patients with gross tumors and (2) cervical and vaginal smears.     

Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers

Objective

The objective of this study was to evaluate gynecologic oncology provider (GOP) practices regarding weight loss (WL) counseling, and to assess their willingness to initiate weight loss interventions, specifically bariatric surgery (WLS).

Methods

Members of the Society of Gynecologic Oncology were invited to complete an online survey of 49 items assessing knowledge, attitudes, and behaviors related to WL counseling.

Results

A total of 454 participants initiated the survey, yielding a response rate of 30%. The majority of respondents (85%) were practicing GOP or fellows. A majority of responders reported that > 50% of their patient population is clinically obese (BMI ≥ 30). Only 10% reported having any formal training in WL counseling, most often in medical school or residency. Providers who feel adequate about WL counseling were more likely to offer multiple WL options to their patients (p < .05). Over 90% of responders believe that WLS is an effective WL option and is more effective than self-directed diet and medical management of obesity. Providers who were more comfortable with WL counseling were significantly more likely to recommend WLS (p < .01). Approximately 75% of respondents expressed interest in clinical trials evaluating WLS in obese cancer survivors.

Conclusions

The present study suggests that GOP appreciate the importance of WL counseling, but often fail to provide it. Our results demonstrate the paucity of formal obesity training in oncology. Providers seem willing to recommend WLS as an option to their patients but also in clinical trials examining gynecologic cancer outcomes in women treated with BS.     

Is fetal analgesia necessary during prenatal surgery?

Fetal pain and fetal anesthesia are still matter of debate: some authors hypothesize that several intrauterine endocrine neuroinhibitors (ENIn) anesthetize the fetus, keeping it in a constant state of sleep, and making pharmacological fetal anesthesia useless for fetal surgery, while others argue fetal pain is possible and shoud be prevented with fetal anesthesy.

Aim: To retrieve evidences about fetal pain, fetal arousability and about the level of sedation induced by the ENIn, in order to assess the necessity of direct fetal anesthesia during prenatal fetal surgery.

Methods: We performed a careful literature review (1990–2016) on fetal arousability, and on the possibility that ENIn at the average fetal blood levels induce actual anesthesia. We retrieved the papers that fulfilled the research criteria, with particular attention to the second half of pregnancy, the period when most fetal surgery is performed.

Results: Fetuses are awake about 10% of the total time in the last gestational weeks, and they can be aroused by external stimuli. ENIn have not an anesthetic effect at normal fetal values, but only when they areartificialy injected at high doses; their blood levels in the last trimester of average pregnancies are not dissimilar either in the fetus or in the mother.

Conclusions: During the second half of the pregnancy, external stimuli can awake the fetuses, although they spend most of the time in sleeping state; the presence of ENIn is absolutely not enough to guarantee an effective anesthesia during surgery. Thus, direct fetal analgesia/anesthesia is mandatory, though further studies on its possible drawbacks are necessary.     

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly

OBJECTIVE: The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure. METHODS: The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years). RESULTS: Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001). CONCLUSION: The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.     

Preoperative quality of life and surgical outcomes in gynecologic oncology patients: A new predictor of operative risk?

Objective

Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients.

Methods

We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores.

Results

Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30 days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01–.1.21) and HR (OR 1.11, 95%CI 1.03–1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16).

Conclusion

Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk.     

Are there indications for cryogenically preserving ovarian tissue in gynecologic oncology?

One of the essential goals of ovarian tissue cryopreservation is to preserve the fertility of young women who will be undergoing sterilizing anticancer treatments, as cryopreservation of sperm serves in men. However, maturation of gametes after thawing has not yet been realized in humans and pregnancies have only been obtained in animal models. It is nonetheless possible today to cryopreserve the ovarian tissue of patients who have nothing to lose as their follicular reserve would in any case be destroyed or severely depleted by cancer treatment. In gynecologic oncology, ovarian tissue cryopreservation may be performed when curative or prophylactic ovariectomy must be undergone, or when chemotherapy with high-dose alkylating agents is planned, particularly in cases requiring chemotherapy combined with pelvic radiation. These clinical situations may be encountered in young women and especially in girls with early-onset forms of ovarian, cervical, uterine, or vaginal cancers. These situations, nevertheless, remain rare as gynecological cancers occur most often in the post-menopausal woman.     

Trends among gynecologic oncology inpatient deaths: is end-of-life care improving?

OBJECTIVE: The objective was to describe trends over time in key factors surrounding end-of-life care on a gynecologic oncology service at a tertiary cancer center. METHODS: Patients with gynecologic cancers who were hospitalized and died at our institution between 1992 and 1997 were identified using institutional databases. The study group consisted of 176 patients. For analysis, patients were divided into two groups: those who died between 1992 and 1994 and those who died between 1995 and 1997. Data were abstracted from medical records regarding the interval between placement of do-not-resuscitate (DNR) orders and death; the interval between the patient's being informed of her terminal-stage disease and death; the types of interventions performed near the end-of-life; and other factors related to end-of-life care. RESULTS: The average patient age on last admission to the hospital was 56 years, and the most common disease sites were ovary (47%), cervix (30%), and uterus (17%). Most deaths (82%) occurred on medical or surgical units, with the remainder occurring in the intensive care unit (12%) or emergency room (6%). The average interval between placement of DNR orders and death was longer among patients who died in 1995-1997 than among patients who died in 1992-1994 (49.6 days vs 19.2 days, P = 0.027). The average annual number of deaths (42.0 vs 16.7, P = 0.061) and the average length of hospital stay (13.3 vs 8.8 days; P = 0.079) decreased between 1992-1994 and 1995-1997, but the differences did not reach statistical significance. Changes between patients who died in 1992-1994 and those who died in 1995-1997 in the interval between the last cycle of chemotherapy and death (87 days and 49 days, respectively; P = 0.29), the proportion of patients with a DNR order on admission (39 and 45%, respectively; P = 0.59), the proportion of patients admitted for terminal care only (22 and 19%, respectively; P = 0.47), and the proportion of patients who died awaiting transfer to hospice (32 and 22%, respectively; P = 0.24) likewise did not reach statistical significance. CONCLUSIONS: Our data indicate that discussions about DNR orders are occurring earlier in relation to terminal events. However, we could not detect significant changes in the other outcome measures we studied. Major opportunities remain for further enhancements in the realm of advance planning for end-of-life care. Educational opportunities should be offered to physicians regarding communicating with patients about disease progression and end-of-life decision-making.     

Is aortic lymphadenectomy necessary in the management of endometrial carcinoma?

OBJECTIVE: To evaluate the role of aortic lymphadenectomy in the management of endometrial carcinoma. METHODS: Clinical notes of 163 patients with endometrial carcinoma were reviewed. All patients had peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy with or without aortic lymphadenectomy. RESULTS: Seventy-five (46.0%) patients had pelvic lymphadenectomy alone whereas 88 (54.0%) had both pelvic and aortic lymphadenectomy. Thirty-five (21.5%) patients had nodal metastases with positive pelvic and aortic nodes in 26 (16.0%) and 24 (27.3%) patients, respectively. Isolated aortic metastases were found in 17 cases (19.3%). Among 35 patients with nodal metastases, recurrence developed in 15 (42.9%) patients and all except one died within five to 50 months. The remaining patients had a median disease-free period of 55 months (13-93 months). The recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases, and all those who recurred died of disease within seven to 28 months. CONCLUSIONS: Our data suggest that aortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. After surgical removal and adjuvant radiotherapy, patients with nodal metastases achieved a better survival chance.