Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches

Study ObjectiveTo describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingA tertiary academic center in Boston, Massachusetts.PatientsAll women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016.InterventionsBaseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted.Measurements and Main ResultsDuring the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17–2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001).ConclusionMyomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.     

Phase II Study of Systemic High-dose Methotrexate and Intrathecal Liposomal Cytarabine for Treatment of Leptomeningeal Carcinomatosis From Breast Cancer

Metastatic breast cancer frequently leads to brain metastases and, less commonly, leptomeningeal carcinomatosis (LC). Once cerebrospinal fluid involvement occurs, the prognosis is poor. There are limited treatment options available, but none offer significant survival benefit. Methotrexate, given systemically at high doses (3.5-8 gm/m²), achieves cytotoxic concentrations in the CSF and has been shown to prolong survival in patients with LC. Intrathecal liposomal cytarabine has been shown to increase time to neurologic progression in patients with breast cancer and LC. The combination of these 2 agents in LC has not been studied extensively. Here, we present the results of the phase II study with this combination showing promising efficacy and very good tolerability.     

Radiologic Considerations and Standardization of Malignant Pleural Mesothelioma Imaging Within Clinical Trials: Consensus Statement from the NCI Thoracic Malignancy Steering Committee – International Association for the Study of Lung Cancer – Mesothelioma Applied Research Foundation Clinical Trials Planning Meeting

Detailed guidelines pertaining to radiological assessment of malignant pleural mesothelioma are currently lacking due to the rarity of the disease, complex morphology, propensity to invade multiple planes simultaneously, and lack of specific recommendations within the radiology community about assessment, reporting, and follow-up. In March 2017, a multidisciplinary meeting of mesothelioma experts was co-sponsored by the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and the Mesothelioma Applied Research Foundation. One of the outcomes of this conference was the foundation of detailed, multidisciplinary consensus imaging and management guidelines. Here, we present the recommendations for radiologic assessment of malignant pleural mesothelioma in the setting of clinical trial enrollment. We discuss optimization of imaging parameters across modalities, standardized reporting, and response assessment within clinical trials.     

Determinants of Guideline-Based Treatment in Patients With cT1 Bladder Cancer

IntroductionClinical T1 (cT1) bladder cancer is associated with high rates of recurrence, upstaging, and progression. Guidelines recommend that these patients be treated with adjuvant intravesical Bacillus Calmette-Guérin immunotherapy (BCG) or upfront radical cystectomy (RC). We analyzed the National Cancer Database (NCDB) to identify demographic and clinical determinants of guideline-based treatment (GBT) and RC.Patients and MethodsWe identified 47,694 patients in the NCDB with cT1 bladder cancer diagnosed in 2004-2013. Those who did not receive any treatment or underwent primary chemotherapy were excluded. Mixed effects logistic regression adjusted for facility-level variation was used to identify factors associated with receipt of GBT.ResultsThe median age of the cohort was 72 years (interquartile range, 63-79). Of the patients, 22.4% were female, 5.1% were African American, and 2.7% had variant histology. Nearly one-third of patients received GBT: 11,453 (24%) were initially treated with BCG and 3320 (7%) were initially treated with RC. Recent year of diagnosis (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.52-1.85; P < .001), treatment at an academic center (OR, 2.42; 95% CI, 2.27-2.59; P < .001), and private insurance status (OR, 1.41; 95% CI, 1.19-1.66; P < .001) were associated with increased odds of GBT. Of patients who received GBT, variant histology (OR, 5.89; 95% CI, 4.65-7.47; P < .001), and recent year of diagnosis (OR, 1.89; 95% CI, 1.50-2.39; P < .001) were associated with greater odds of RC.ConclusionThere is low treatment-guideline compliance for patients with cT1 disease. However, there appears to be a temporal trend toward increased use of GBT. Efforts should be made to understand why many cT1 bladder cancer patients do not receive GBT.