Faculty Bibliography

OBJECTIVE: To determine the percentage of patients with early-stage cervical cancer who may be eligible for fertility preservation with laparoscopic radical vaginal trachelectomy (LRVT). METHODS: We retrospectively reviewed the records of patients who underwent a radical hysterectomy for invasive cervical cancer at our institution from 12/85 to 8/01, before our use of LRVT at Memorial Sloan-Kettering Cancer Center. Institutional eligibility criteria for LRVT were applied. Patients > or =40 years of age were considered ineligible. RESULTS: We identified 435 patients who had undergone radical hysterectomy for cervical cancer; 186 were age < 40 at surgery and constituted our study population. Eighty-nine (48%) patients may have been eligible by our pathologic criteria. In 12 patients, LRVT may have been aborted or altered because of unexpected disease spread. CONCLUSION: A significant number of patients < 40 with early-stage cervical cancer may be pathologically eligible for LRVT and should be counseled on this preoperatively.

OBJECTIVES: Women at risk for ovarian cancer may consider risk-reducing salpingo-oophorectomy (RRSO), and desire information regarding the health consequences of the procedure. We studied women who had undergone RRSO to assess quality of life after the procedure. METHODS: Women (n = 59) undergoing RRSO between 1 January 1997 and 31 July 2000 completed a questionnaire composed of the Symptom Checklist (SCL), the Medical Outcomes Study SF-36 Health Survey, the Center for Epidemiological Studies Depression Scale, the Impact of Events Scale, and the Sexual Functioning Questionnaire-Female. RESULTS: At a mean of 23.8 months after RRSO, overall quality of life was similar to that reported for the general population and for breast cancer survivors. Estrogen deprivation symptoms, particularly vaginal dryness (35.2%) and dyspareunia (27.7%), were commonly bothersome. Genital symptoms resulting in sexual dysfunction were the most significant predictors of satisfaction with surgery. The prevalence of depression (20.4%) was similar to that of the general population, but a significant proportion of the group (20.7%) continued to report significant ovarian cancer-specific worries despite surgery. CONCLUSION: Vaginal symptoms are bothersome to women who have undergone RRSO, but overall health and psychological outcomes are not impaired. Although coital symptoms may not be a direct consequence of RRSO, they are the most important predictors of satisfaction. A proportion of women continue to report worries about ovarian cancer after surgery, and these women are at risk for psychological distress.

OBJECTIVE: The objective was to describe the results, technique, and complications of transperitoneal laparoscopic (LSC) pelvic and aortic lymph node dissection (LND) using the argon-beam coagulator (ABC) and monopolar electrosurgical instruments in women with gynecologic malignancies. METHODS: A retrospective chart review of 114 patients who underwent LSC pelvic and/or aortic LND in addition to other LSC procedures between 1/1994 and 12/2001 was conducted. All intraoperative complications and complications that occurred within the first 30 postoperative days were included. Complications were graded according to an institutional surgical secondary events reference. During the same time period, 89 patients underwent LSC followed immediately by laparotomy that included LND, resulting in a total of 203 cases. These 203 total cases are used as a denominator to determine the etiology of cases converted from LSC to laparotomy. Monopolar electrosurgical instruments or the 10-mm ABC (Conmed) set at 70 W with argon flow of 3-4 L/m min were used for laparoscopic nodal dissection. RESULTS: Sixty-one of 114 (53%) patients underwent pelvic LND, 35 (31%) underwent both pelvic and aortic LND, and 18 (16%) underwent aortic LND only. Mean patient age and body mass index were 53.3 years (range, 16 to 87 years) and 25 (range, 16 to 40), respectively. In addition, the mean number of pelvic and aortic lymph nodes removed was 10.7 (range, 1 to 39) and 5.7 (range, 0 to 21), respectively. The mean estimated blood loss was 151 mL (range, 25 to 600 ml) and the mean hospital stay was 2.8 days (range, 0 to 35 days). Overall, complications occurred in eight (7%) cases. There were no fatal complications, and no patient required conversion to laparotomy due to uncontrollable bleeding from the laparoscopic nodal dissection. Only 17 of 203 (8%) patients required conversion to laparotomy secondary to adhesions and unsatisfactory exposure. CONCLUSION: Laparoscopic pelvic and aortic LND for gynecologic malignancies can be satisfactorily performed in the majority of patients, with only 8% of patients requiring conversion to laparotomy due to adhesions or unsatisfactory exposure. The overall complication rate was 7% and was limited to grade 3 or less.

OBJECTIVES: The aim of this study was to describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy for stage I cervical cancer using the argon-beam coagulator. METHODS: A retrospective review was performed of patients with FIGO stage IA1-IB1 cervical cancer who underwent a total laparoscopic approach for definitive surgical treatment. Comparison was made to a cohort of 195 patients who were treated with laparotomy. RESULTS: Between 12/2000 and 12/2002, 19 patients were offered the laparoscopic approach. The procedure was completed laparoscopically in 17 patients (89.5%). Two patients, in the beginning of the study, underwent conversion to laparotomy, 1 due to parametrial bleeding and 1 due to pelvic adhesions and cystotomy. Mean age was 42.6 years (range, 30-69 years); mean body mass index was 23.1 (range, 18-30); FIGO stage included IA1 with LVI (2), IA2 (6), IB1 (11). Mean pelvic lymph node count was 25.5 (range, 15-39), and 1 patient (5.3%) had positive nodes. Mean estimated blood loss was 301 cc (range, 75-1500 cc) compared to 693 cc in the laparotomy group (P < 0.01), mean operating time was 371 min (range, 230-600 min) compared to 295 min in the laparotomy group (P < 0.01), and mean hospital stay was 4.5 days (range, 3-11 days) compared to 9.7 days in the laparotomy group (P < 0.01). There were no ureteral injuries or fistula formation. All patients remain clinically disease free at the time of this report. CONCLUSIONS: Total laparoscopic radical hysterectomy with pelvic lymphadenectomy for selected patients with stage I cervical cancer is feasible, safe, and associated with a low morbidity in the pilot phase. Estimated blood loss and postoperative hospitalization appear shorter than historical controls, at the cost of longer operating time. Oncologic outcome requires longer follow-up.

PURPOSE: The majority of patients with epithelial ovarian cancer (EOC) who achieve a complete remission with front-line chemotherapy develop recurrent disease. Carboplatin and paclitaxel are used for patients with platinum-sensitive recurrent disease, although there is little information regarding the response and survival in unselected patients treated with this strategy. We sought to determine the outcomes for patients with EOC treated with carboplatin and paclitaxel at the time of first recurrence. In addition, we sought to define a new paradigm for disease transition in patients with EOC. PATIENTS AND METHODS: Eighty-nine patients were identified who had a complete response to front-line platinum-based chemotherapy for EOC, relapsed 6 months after completion of front-line chemotherapy, and were treated with carboplatin and paclitaxel as second-line therapy. RESULTS: Eighty-four cases were available for analysis of survival end points, and 66 were assessable for response. The median follow-up was 27 months. The overall response rate was 70%. The median progression-free interval for the cohort was 13 months (95% confidence interval [CI], 10.7 to 13.8 months). The 3-year survival rate was 72% (95% CI, 59.4 to 86.1%). Toxicity was limited, and no deaths from treatment were observed. Using this data, it is possible to construct a disease states model of EOC, which provides risk estimates for transitions between clinically distinct categories. CONCLUSION: Re-treatment with carboplatin and paclitaxel is effective as initial therapy in recurrent EOC. This should form the basis of a randomized trial to determine the best agents for initial treatment of relapse from EOC in potentially platinum-sensitive patients.

BACKGROUND: The aim of this study was to evaluate the accuracy and safety of laparoscopic second-look operations in patients with ovarian cancer. METHODS: We retrospectively reviewed the medical records of all patients who have undergone laparoscopic second-look procedures for ovarian cancer at our institution. RESULTS: From July 1993 to December 1998, 150 patients underwent laparoscopic second-look operations. The mean age of patients was 53 years (range, 25-78 years). The majority of patients (87%) had Stage III or IV disease at initial surgery; the remainder were Stage II or unstaged. Eighty-two patients (54%) had had optimal cytoreduction at the time of their initial surgery. All patients had completed primary chemotherapy and were clinically disease-free based on imaging studies and CA-125 levels at the time of second look. Sixty-nine patients (46%) were found to have pathologically negative second looks; thus, the rate of positive second-look evaluations was 54%. The rate of conversion to laparotomy was 18/150 (12%). In 3 cases this was secondary to bowel injury; one patient sustained a bladder injury; the remainder of conversions to laparotomy were for secondary cytoreduction. There was only 1 case where the patient was found to have extensive adhesions and laparoscopy was abandoned. The overall rate of major complications was 2.7%. CONCLUSIONS: In our experience, laparoscopy is a safe and accurate method of second-look assessment in patients with ovarian cancer. The incidence of complications is low, particularly in this group of patients, all of whom have undergone prior abdominal surgery. The rate of negative evaluations and the rate of recurrences in patients with negative second looks are equivalent to those described in studies of second-look assessment by laparotomy

OBJECTIVE: The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies. METHODS: We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. RESULTS: Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catheterization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients). CONCLUSIONS: Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.

We describe the longest-known continuous use of clomiphene citrate ever reported in a human. As a result of a pharmacy error, a woman took 50 mg/day clomiphene citrate for three months. The prolonged use of this medication resulted in ovarian hyperstimulation and unilateral oophorectomy for torsion

CONTEXT: Most hereditary ovarian cancers are associated with germline mutations in BRCA1 or BRCA2. Attempts to define the clinical significance of BRCA mutation status in ovarian cancer have produced conflicting results, especially regarding survival. OBJECTIVE: To determine whether hereditary ovarian cancers have distinct clinical and pathological features compared with sporadic (nonhereditary) ovarian cancers. DESIGN AND SETTING: Retrospective cohort study of a consecutive series of 933 ovarian cancers diagnosed and treated at our institution, which is a comprehensive cancer center as designated by the National Cancer Institute, over a 12-year period (December 1986 to August 1998). PATIENTS: The study was restricted to patients of Jewish origin because of the ease of BRCA1 and BRCA2 genotyping in this ethnic group. From the 189 patients who identified themselves as Jewish, 88 hereditary cases were identified with the presence of a germline founder mutation in BRCA1 or BRCA2. The remaining 101 cases from the same series not associated with a BRCA mutation and 2 additional groups (Gynecologic Oncology Group protocols 52 and 111) with ovarian cancer from clinical trials (for the survival analysis) were included for comparison. MAIN OUTCOME MEASURES: Age at diagnosis, surgical stage, histologic cell type and grade, and surgical outcome; and response to chemotherapy and survival for advanced-stage (II and IV) cases. RESULTS: Hereditary cancers were rarely diagnosed before age 40 years and were common after age 60 years, with mean age at diagnosis being significantly younger for BRCA1- vs BRCA2-linked patients (54 vs 62 years; P=.04). Histology, grade, stage, and success of cytoreductive surgery were similar for hereditary and sporadic cases. The hereditary group had a longer disease-free interval following primary chemotherapy in comparison with the nonhereditary group, with a median time to recurrence of 14 months and 7 months, respectively (P<.001). Those with hereditary cancers had improved survival compared with the nonhereditary group (P=.004). For stage III cancers, BRCA mutation status was an independent prognostic variable (P=.03). CONCLUSIONS: Although BRCA-associated hereditary ovarian cancers in this population have surgical and pathological characteristics similar to those of sporadic cancers, advanced-stage hereditary cancer patients survive longer than nonhereditary cancer patients. Age penetrance is greater for BRCA1-linked than for BRCA2-linked cancers in this population