Less is more: Clinical utility of postoperative labs following minimally invasive hysterectomy for endometrial cancer
BACKGROUND:With the increasing rates of same day discharge following minimally invasive surgery for endometrial cancer, the need for and value of routine postoperative testing is unclear. OBJECTIVE:To determine whether routine postoperative labs following minimally invasive hysterectomy for endometrial cancer leads to clinically significant changes in postoperative care. STUDY DESIGN/METHODS:This is a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for endometrial cancer by a gynecologic oncologist between June 2014-2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory testing was computed using hospital-level cost data. RESULTS:Of the 649 women included in the analysis, the majority (91.4%) were white, with a mean age of 61 years, and mean body mass index of 38.0 kg/m2. The most common comorbidities were diabetes (31.9%, n=207), chronic pulmonary disease (7.9%, n=51), and congestive heart failure (3.2%, n=21). Median operative time was 151 minutes (range 61-278 minutes) and median estimated blood loss was 100 mL (range 10-1500 mL). Most patients (68.6%, n=445) underwent lymphadenectomy. All patients had post-operative labs ordered: 100% complete blood count, 99.7% chemistry, 62.9% magnesium, 46.8% phosphate, 37.4% calcium, and 1.2% liver function tests. Twenty-six patients (4.0%) had a change in management due to postoperative lab results. Of these 26 women, 88% experienced a change in clinical status that would have otherwise prompted testing. Only three (0.5% of entire cohort) were asymptomatic: one received a blood transfusion for asymptomatic anemia and the other two, who did not carry a diagnosis of diabetes, had interventions for hyperglycemia. On univariable analysis, peripheral and cerebrovascular disease, diabetes with end organ damage, and a Charlson Comorbidity Index of â‰¥ 3 were associated with increased odds of change in management; these were not significant on multivariable analysis. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $292,000. CONCLUSIONS:Routine postoperative labs are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for endometrial cancer and may increase cost without providing a discernable clinical benefit. In the setting of strict post-operative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for endometrial cancer.
Who will be readmitted? Evaluation of the laparoscopic hysterectomy readmission score in a gynecologic oncology population undergoing robotic-assisted hysterectomy
OBJECTIVES/OBJECTIVE:The laparoscopic hysterectomy readmission score (LHRS) was created to identify patients for whom same day discharge (SDD) after minimally invasive hysterectomy (MIH) may not be advisable and includes diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery, and any postoperative complication prior to discharge. We evaluated the performance of the score at predicting readmission in a gynecologic oncology population, and additionally sought to determine if any factors known prior to surgery could replace those that are not known until the time of surgery (operative time and postoperative complication). METHODS:This was a single-institution retrospective cohort study of women undergoing robotic hysterectomy by a gynecologic oncologist in 2018. Associations between pre-operative, operative and post-operative factors and 30-day readmission, SDD and postoperative complications were assessed using logistic regression. RESULTS:The 30-day readmission rate among the 423 women in the cohort was 4.5% and 1.9% in those undergoing SDD. Readmission rates by LHRS were: score 1 (4.9%), score 2 (7.8%), score 3 (13.6%), score 4 (16.7%). Patients with a LHRS of â‰¥3 had higher odds of readmission compared to those with a lower score (OR 4.20, pÂ =Â 0.02). Infectious morbidity accounted for the majority of postoperative complications, emergency room visits and readmissions. We did not identify preoperative factors to replace the intra- and post-operative factors used in the score. CONCLUSIONS:The readmission rate following MIH is low, and a LHRS of â‰¥3 is associated with increased risk of readmission. Our findings support the applicability of the LHRS to a gynecologic oncology population; addressing risk factors for postoperative infection or closer follow up for patients with a LHRS â‰¥3 could reduce postoperative readmissions.
PARP Inhibitors in Gynecologic Cancers: What Is the Next Big Development?
PURPOSE OF REVIEW:Conventional and novel applications of Poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors (PARPi) are reviewed in the context of recently published clinical trials and preclinical data supporting rapidly expanding uses of this class of chemotherapy. RECENT FINDINGS:PARPi block a pathway of DNA repair and target defects in homologous recombination repair (HRR), a pathway responsible for high-fidelity repair of double-strand breaks in DNA. BRCA1/2 proteins are essential to this pathway. Approximately 15-30% of women with ovarian cancer will have a germline or somatic BRCA mutation, and PARPi have shown promise in this population in a variety of settings. With growing understanding of the HRR pathway and its role in gynecologic malignancies, the potential applications of PARPi continue to expand. While the role of PARPi in gynecologic malignancies is most established in ovarian cancer, there are also promising applications in uterine and cervical cancer. We review current indications for PARPi use and promising applications of these medications in gynecologic malignancies.
A Microfluidic Chip Enables Isolation of Exosomes and Establishment of Their Protein Profiles and Associated Signaling Pathways in Ovarian Cancer
Because of limits on specificity and purity to allow for in-depth protein profiling, a standardized method for exosome isolation has yet to be established. In this study, we describe a novel, in-house microfluidic-based device to isolate exosomes from culture media and patient samples. This technology overcomes contamination issues because sample separation is based on the expression of highly specific surface markers CD63 and EpCAM. Mass spectrometry revealed over 25 exosome proteins that are differentially expressed in high-grade serous ovarian cancer (HGSOC) cell lines compared with normal cells-ovarian surface epithelia cells and fallopian tube secretory epithelial cells (FTSEC). Top exosome proteins were identified on the basis of their fold change and statistical significance between groups. Ingenuity pathway analysis identified STAT3 and HGF as top regulator proteins. We further validated exosome proteins of interest (pSTAT3, HGF, and IL6) in HGSOC samples of origin-based cell lines (OVCAR-8, FTSEC) and in early-stage HGSOC patient serum exosome samples using LC/MS-MS and proximity extension assay. Our microfluidic device will allow us to make new discoveries for exosome-based biomarkers for the early detection of HGSOC and will contribute to the development of new targeted therapies based on signaling pathways that are unique to HGSOC, both of which could improve the outcome for women with HGSOC. SIGNIFICANCE: A unique platform utilizing a microfluidic device enables the discovery of new exosome-based biomarkers in ovarian cancer.
Role of Olaparib as Maintenance Treatment for Ovarian Cancer: The Evidence to Date
PARP inhibitors have shown significant promise in the treatment of ovarian cancer. Olaparib is a PARP inhibitor that has been approved for maintenance for BRCA-mutated ovarian cancer in the recurrent and front-line setting as well as for treatment of BRCA-mutated ovarian cancer in patients who have received multiple prior lines of chemotherapy. In this review, we focus on the use of olaparib in the maintenance setting including the evidence to date, ongoing research, and future directions.
Project ESCUCHE: A Spanish-language Radio-based Intervention to Increase Science Literacy
Project ESCUCHE was developed to evaluate the potential to increase science literacy among Spanish-language radio listeners. In collaboration with community partners, we developed a 10-week culturally applicable science and health curriculum delivered through Spanish-language radio. Science literacy was assessed before and after the intervention. Among the 51 participants, 70% were female, 76% were > 35 years old, 60% reported some college education, and 90% preferred speaking in Spanish versus English. The majority of participants (>94%) demonstrated adequate baseline functional health literacy, and 70% reported listening to all ten of the radio programs. Participants demonstrated significant increases in science knowledge post intervention (mean score before intervention 68.4% and after intervention 77%). This improvement was consistent across gender, education level, age, and baseline functional health literacy. Radio has the potential to be an effective method of engaging the Spanish-speaking community to improve science literacy. The results from the ESCUCHE program add to the groundwork for further exploration of how radio programming and other media platforms can be used to impact health.
Participation in global health delivery: Survey results from the Society of Gynecologic Oncology
â€¢Gynecologic oncologists face multiple barriers in participating in global health.â€¢Several barriers may be addressed at the institutional level.â€¢Most global health experiences involved direct patient care, while only a small proportion involved research.â€¢Gynecologic oncologists receive little structured training in global health.
Impact of Cystectomy on Ovarian Reserve: Review of the Literature
Ovarian cysts are common in the reproductive age. Pathologic cysts such as endometriomas and dermoids often require surgical intervention if symptomatic. Laparoscopic cystectomy is the first-line treatment for these cysts and is associated with better pain control and less recurrence than drainage or cyst ablation procedures. There has been an emerging concern about the effect of ovarian cystectomy on ovarian reserve with some evidence of short-term and long-term reduction in ovarian reserve. Certain cyst characteristics (endometrioma pathology, large cyst size, bilateral presentation) are associated with a greater decline in ovarian reserve after cystectomy. The impact of surgery on ovarian reserve can be minimized by selecting the appropriate surgery for the patient, careful tissue handling, and limited use of electrosurgery. Patients should be counseled on the risks of surgery on reproductive potential, and the management plan should be individualized to the patient's symptoms and reproductive goals.
Vaginal cuff dehiscence and evisceration: a review of the literature
PURPOSE OF REVIEW:Vaginal cuff dehiscence and evisceration are rare but potentially serious complications of hysterectomy. In this article, we review the incidence, risk factors, management, and preventive measures for dehiscence based on available literature. RECENT FINDINGS:Identifying risk factors for dehiscence is challenging because studies lack comparison groups and most studies are largely underpowered to draw concrete conclusions. SUMMARY:High-quality data on cuff dehiscence after hysterectomy are limited. Potentially modifiable risks that optimize vaginal wound healing, minimize vaginal cuff strain, and minimize cuff infection should be optimized.
Evaluating the Teaching Methods of a Community Health Worker Training Curriculum in Rural Guatemala