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Use of an ureteroileocecal appendicostomy urinary reservoir in patients with recurrent pelvic malignancies treated with radiation

Bochner, Bernard H; McCreath, Wayne A; Aubey, Janice James; Levine, Douglas A; Barakat, Richard R; Abu-Rustum, Nadeem; Poynor, Elizabeth; Wong, Douglas; Chi, Dennis S
OBJECTIVE: Evaluation of a modified right colon urinary reservoir in a heavily radiated patient population undergoing pelvic exenteration. METHODS: A retrospective chart review was performed on all patients with recurrent gynecologic, colorectal, and urological tumors who underwent total pelvic or anterior exenteration and urinary diversion from 3/01 to 7/03 using an ureteroileocecal appendicostomy urinary reservoir. RESULTS: Fourteen patients were identified over the study interval. The mean age of the patients was 53 years (range, 22-78 years). All patients received external beam, intracavitary, or a combination of both radiation treatment modalities to the pelvis preoperatively. Eight patients received intraoperative radiation therapy (IORT) at a mean dose of 16.25 Gy (range, 12.5-17.5 Gy). The primary sites of disease were as follows: cervix, five; prostate, three; uterus, two; colon/rectum two; and one each for vulva and bladder. Complete stomal continence was achieved in all patients after a median follow-up of 10 months (range, 2-31 months). Two patients experienced a traumatic disruption of the stomal-skin anastomosis in the early postoperative period (postoperative days 7 and 14). One late complication related to the ureterointestinal anastomosis was observed and consisted of an anastomotic stricture managed conservatively. One patient experienced an entero-pouch fistula following re-exploration for an acute postoperative hemorrhage. CONCLUSION: The early outcomes using the ureteroileocecal appendicostomy urinary reservoir in heavily radiated patients demonstrate the technical feasibility of this design as both minimal early stoma and ureterointestinal complications may occur. Longer postoperative follow-up will be required to address the late outcomes of this procedure and its ultimate use in this population.
PMID: 15262132
ISSN: 0090-8258
CID: 1934122

Primary vaginal melanoma: a critical analysis of therapy

Miner, Thomas J; Delgado, Ruby; Zeisler, Jonathan; Busam, Klaus; Alektiar, Kaled; Barakat, Richard; Poynor, Elizabeth
BACKGROUND: Primary vaginal melanoma is a rare and highly malignant disease. The impact of therapy on outcomes is poorly understood. METHODS: Records of all patients treated for primary vaginal melanoma at Memorial Sloan-Kettering Cancer Center from 1977 to 2001 were reviewed. Survival analysis was performed based on appropriate patient, tumor, and treatment variables. Pathologic materials were reviewed to confirm the original diagnosis and examine appropriate clinicopathologic features. RESULTS: Thirty-five women were treated for vaginal melanoma; the primary treatment selected was surgical for 69% (24) and radiotherapy for 31% (11) of the patients. Surgical removal of the tumor was achieved in 92% (22) of the 24 patients selected for surgical therapy. At operation, radical excision with en bloc removal of involved pelvic organs was performed in 50% (12) of the 24 patients, a wide excision was performed in 42% (10), and a total vaginectomy was performed in 8% (2). Elective pelvic lymph node dissection was performed in 74% (26) of the 35 cases. Lymph node metastasis was found in only 8% (2) of these 26 patients. The overall median survival was 20 months. Primary surgical therapy was associated with longer overall survival (25 vs. 13 months; P =.039). Recurrence-free survival was not associated with the extent of surgery. None of the examined clinicopathologic features were associated with survival differences. CONCLUSIONS: The prognosis is poor for patients with primary vaginal melanoma. Improved clinical outcomes were associated with surgical removal of gross disease whenever possible. Because of the low rate of lymph node metastasis, elective pelvic lymph node dissection is not obligatory. In cases of surgically unresectable disease, primary radiation therapy is indicated.
PMID: 14699031
ISSN: 1068-9265
CID: 1934132

Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using the argon-beam coagulator: pilot data and comparison to laparotomy

Abu-Rustum, Nadeem R; Gemignani, Mary L; Moore, Kathleen; Sonoda, Yukio; Venkatraman, Ennapadam; Brown, Carol; Poynor, Elizabeth; Chi, Dennis S; Barakat, Richard R
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.
PMID: 14599873
ISSN: 0090-8258
CID: 1934142

Transperitoneal laparoscopic pelvic and para-aortic lymph node dissection using the argon-beam coagulator and monopolar instruments: an 8-year study and description of technique

Abu-Rustum, Nadeem R; Chi, Dennis S; Sonoda, Yukio; DiClemente, Michael J; Bekker, Genia; Gemignani, Mary; Poynor, Elizabeth; Brown, Carol; Barakat, Richard R
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.
PMID: 12798719
ISSN: 0090-8258
CID: 1934152

Quality of life in women at risk for ovarian cancer who have undergone risk-reducing oophorectomy

Robson, Mark; Hensley, Martee; Barakat, Richard; Brown, Carol; Chi, Dennis; Poynor, Elizabeth; Offit, Kenneth
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.
PMID: 12713992
ISSN: 0090-8258
CID: 1934162

Retrospective analysis of carboplatin and paclitaxel as initial second-line therapy for recurrent epithelial ovarian carcinoma: application toward a dynamic disease state model of ovarian cancer

Dizon, Don S; Hensley, Martee L; Poynor, Elizabeth A; Sabbatini, Paul; Aghajanian, Carol; Hummer, Amanda; Venkatraman, Ennapadam; Spriggs, David R
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.
PMID: 11870166
ISSN: 0732-183x
CID: 1934172

The role of laparoscopy in second-look evaluations for ovarian cancer

Husain A; Chi DS; Prasad M; Abu-Rustum N; Barakat RR; Brown CL; Poynor EA; Hoskins WJ; Curtin JP
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
PMID: 11136568
ISSN: 0090-8258
CID: 36628

Ovarian hyperstimulation and oophorectomy following accidental daily clomiphene citrate use over three consecutive months [Case Report]

Sills ES; Poynor EA; Moomjy M
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
PMID: 11099879
ISSN: 0890-6238
CID: 25519

Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies

Husain, A; Curtin, J; Brown, C; Chi, D; Hoskins, W; Poynor, E; Alektiar, K; Barakat, R
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.
PMID: 10926804
ISSN: 0090-8258
CID: 634982

Clinicopathologic features of BRCA-linked and sporadic ovarian cancer

Boyd J; Sonoda Y; Federici MG; Bogomolniy F; Rhei E; Maresco DL; Saigo PE; Almadrones LA; Barakat RR; Brown CL; Chi DS; Curtin JP; Poynor EA; Hoskins WJ
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
PMID: 10807385
ISSN: 0098-7484
CID: 36629