Publications by authors named "Emily M Ko"

71 Publications

Impact of surgical approach on prevalence of positive peritoneal cytology and lymph-vascular invasion in patients with early-stage endometrial carcinoma: a National Cancer Database study.

Int J Gynecol Cancer 2021 Apr 14. Epub 2021 Apr 14.

Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: To investigate the prevalence of positive peritoneal cytology and lymph-vascular invasion by surgical approach among patients with early stage endometrioid endometrial carcinoma undergoing hysterectomy.

Methods: The National Cancer Database was accessed and patients with FIGO stage I endometrioid endometrial carcinoma (with no history of another tumor diagnosed) who underwent simple hysterectomy (open or minimally invasive) between January 2010 and December 2015 and had available data on the presence of lymph-vascular invasion and/or status of peritoneal cytology were selected for further analysis. The impact of a surgical approach on the odds of lymph-vascular invasion and positive peritoneal cytology was calculated after controlling for tumor grade, size, and depth of myometrial invasion.

Results: A total of 74 732 patients who met the inclusion criteria were identified. The rate of minimally invasive hysterectomy was 75.7%. Data on peritoneal cytology status and lymph-vascular invasion were available for 50 185 and 71 641 patients, respectively. A higher proportion of patients who had minimally invasive hysterectomy had positive peritoneal cytology (4.4% vs 2.3%, p<0.001), and presence of lymph-vascular invasion (10.4% vs 9.2%, p<0.001). After controlling for tumor size, tumor grade, and disease substage, the performance of minimally invasive surgery was associated with higher odds of positive peritoneal cytology (OR 2.08, 95% CI 1.83 to 2.37) and presence of lymph-vascular invasion (OR 1.33, 95% CI 1.25 to 1.41). After controlling for confounders there was no difference in survival between open and minimally invasive surgery groups (HR 0.93, 95% CI 0.85 to 1.004).

Conclusions: Minimally invasive surgery may be associated with a higher incidence of positive peritoneal cytology and lymph-vascular invasion among patients with early stage endometrioid endometrial cancer. There was no difference in overall survival between patients who had laparotomy or minimally invasive surgery.
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http://dx.doi.org/10.1136/ijgc-2021-002445DOI Listing
April 2021

The impact of sentinel lymph node sampling versus traditional lymphadenectomy on the survival of patients with stage IIIC endometrial cancer.

Int J Gynecol Cancer 2021 Apr 14. Epub 2021 Apr 14.

Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: To investigate the survival of patients with lymph node positive endometrial carcinoma by type of surgical lymph node assessment.

Methods: Patients diagnosed between January 2012 and December 2015 with endometrial carcinoma and uterine confined disease and nodal metastases on final pathology who underwent minimally invasive hysterectomy were identified in the National Cancer Database. Patients who had sentinel lymph node biopsy alone or underwent systematic lymphadenectomy were selected. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log rank test. A Cox model was constructed to evaluate survival after controlling for confounders.

Results: A total of 1432 patients were identified: 1323 (92.4%) and 109 (7.6%) underwent systematic lymphadenectomy and sentinel lymph node biopsy only, respectively. The rate of adjuvant treatment was comparable between patients who had sentinel lymph node biopsy alone and systematic lymphadenectomy (83.5% vs 86.6%, p=0.39). However, patients who had sentinel lymph node biopsy were less likely to receive chemotherapy alone (13.6% vs 36.6%, p<0.001) and more likely to receive radiation therapy alone (19.8% vs 5.4%, p<0.001) compared with patients who had systematic lymphadenectomy. There was no difference in overall survival between patients who had sentinel lymph node biopsy alone and systematic lymphadenectomy (p=0.27 from log rank test), and 3 year overall survival rates were 82.2% and 79.4%, respectively (p>0.05). After controlling for confounders, there was no difference in survival between the systematic lymphadenectomy and sentinel lymph node biopsy alone groups (hazard ratio 0.82, 95% confidence interval 0.46 to 1.45).

Conclusions: Performance of sentinel lymph node biopsy alone was not associated with an adverse impact on survival in patients with lymph node positive endometrial cancer.
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http://dx.doi.org/10.1136/ijgc-2021-002450DOI Listing
April 2021

Mutational spectrum in clinically aggressive low-grade serous carcinoma/serous borderline tumors of the ovary-Clinical significance of BRCA2 gene variants in genomically stable tumors.

Gynecol Oncol 2021 Mar 24. Epub 2021 Mar 24.

Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada. Electronic address:

Objective: The mutational spectra of low-grade serous carcinomas (LGSCs) and serous borderline tumors (SBTs) of the ovary are poorly characterized. We present 17 cases of advanced or recurrent LGSC/SBT patients who underwent molecular profiling.

Methods: Thirteen LGSCs and four SBTs underwent targeted gene panel testing by massively parallel sequencing. Microsatellite stability and tumor mutation burdens (TMBs) were determined based on panel sequencing data.

Results: The mean TMB was 5.2 mutations/megabase (range 3-10) in 14 cases. Twelve of twelve (12/12) cases were microsatellite stable. Clear driver mutations were identified in 11 cases, namely KRAS (5/17), BRAF (2/17), NRAS (2/17) and ERBB2 (2/17). Five cases harbored BRCA2 alterations (allele fractions: 44-51%), including two classified as likely benign/benign variants, and three classified as variants of uncertain significance (VUSs), with two variants being confirmed to be germline. The three BRCA2 VUSs were missense variants that were assessed to be of unlikely clinical significance, based on family cancer history and expected impact on protein function. Two patients received PARP inhibitors during their disease course, with neither of the patients demonstrating appreciable response.

Conclusions: The mutational spectra in 17 clinically aggressive SBT/LGSC cases demonstrate genomically stable tumors, frequently driven by the RTK/RAS/MAPK pathway. While BRCA2 variants were identified, our data demonstrate BRCA2 gene variants are at most VUSs and of dubious clinical significance, in contrast to disease-associated BRCA1/2 variants that may be identified in high-grade serous carcinoma. Germline testing and PARP inhibitors are thus expected to provide limited benefit to patients with LGSC/SBTs.
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http://dx.doi.org/10.1016/j.ygyno.2021.03.019DOI Listing
March 2021

Outcomes of sentinel lymph node mapping for patients with FIGO stage I endometrioid endometrial carcinoma.

Gynecol Oncol 2021 Mar 23. Epub 2021 Mar 23.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: Investigate the overall survival of patients with FIGO stage I endometrioid endometrial carcinoma who underwent sentinel lymph node biopsy (SLNBx).

Methods: Patients diagnosed between 2012 and 2015 with pathological stage I endometrioid endometrial carcinoma who underwent minimally invasive hysterectomy and had at least one month of follow-up were identified in the National Cancer Database (NCDB). Patients who underwent SLNBx or systematic lymphadenectomy (LND) (defined as at least 20 lymph nodes removed) were selected. Overall survival (OS) was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders.

Results: A total of 13,010 patients with endometrioid endometrial carcinoma who met the inclusion criteria were identified; 9861 (75.8%) and 3149 (24.2%) patients had systematic LND and SLNBx, respectively. Patients who had LND were more likely to receive radiation therapy (27.4% vs 19.3%, p < 0.001) and chemotherapy (13% vs 8.7%, p < 0.001) compared to those who had SLNBx. After controlling for patient age, race, insurance status, depth of myometrial invasion, tumor grade, tumor size, presence of lymph-vascular invasion and receipt of radiation therapy, the performance of SLNBx was not associated with worse survival (HR: 0.99, 95% CI: 0.80, 1.21). For high-intermediate risk patients (based on GOG-99 criteria) after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.07, 95% CI: 0.80, 1.44). For intermediate risk patients who did not receive external beam radiation therapy or chemotherapy after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.58, 95% CI: 0.94, 2.65).

Conclusions: SLNBx had no negative impact on the survival of patients with FIGO stage I endometrioid endometrial carcinoma who undergo hysterectomy.
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http://dx.doi.org/10.1016/j.ygyno.2021.03.018DOI Listing
March 2021

Is there a benefit of performing an omentectomy for clinical stage I high-grade endometrial carcinoma?

Surg Oncol 2021 Feb 13;37:101534. Epub 2021 Feb 13.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Objectives: Routine omentectomy is generally not performed in patients with endometrial cancer unless there is evidence of gross omental metastases. The aim of the current study was to evaluate the role of omentectomy in the staging of clinical stage I high-grade endometrial carcinoma and its impact on overall survival.

Methods: Patients in the National Cancer Database who presented between 2010 and 2015 with clinical stage I serous, clear cell, carcinosarcoma, or grade 3 endometrioid carcinoma and underwent hysterectomy with lymphadenectomy were selected. Patients who did and did not receive an omentectomy were identified and clinico-pathological characteristics were compared. Overall survival was evaluated for patients diagnosed between 2010 and 2014 who had at least one month of follow-up following generation of Kaplan-Meier curves and comparison with the log-rank test. A Cox model was constructed to control for confounders.

Results: A total of 9097 patients were identified, and 36.3% underwent an omentectomy. Patients who underwent omentectomy were more likely to be managed in academic institutions (50% vs. 44%, p < 0.001). They were also more likely to have an open surgery (48.2% vs. 27.2%, p < 0.001) and receive adjuvant chemotherapy (54.7% vs. 38.2%, p < 0.001). There was no difference in overall survival between patients who did and did not undergo omentectomy, p = 0.61; the 3-year OS rates were 82.3% and 82.2%, respectively. After controlling for confounders, the performance of an omentectomy was not associated with better survival (hazard ratio [HR]: 0.94, 95% confidence intervals [CI]: 0.84, 1.05).

Conclusions: Routine omentectomy may not be associated with a survival benefit for patients with clinical stage I high-grade endometrial carcinoma.
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http://dx.doi.org/10.1016/j.suronc.2021.101534DOI Listing
February 2021

Oncologic outcomes of uterine preservation for pre-menopausal patients with stage II epithelial ovarian carcinoma.

Int J Gynecol Cancer 2021 Mar;31(3):480-483

Division of Gynecologic Oncology, Penn Medicine, Philadelphia, Pennsylvania, USA.

Objective: Fertility-sparing surgery is rarely offered for patients with stage II epithelial ovarian carcinoma. The aim of the present study was to evaluate the overall survival of pre-menopausal patients with stage II epithelial ovarian carcinoma who did not undergo hysterectomy.

Methods: The National Cancer Database was accessed, and patients aged ≤40 years without a history of another tumor diagnosed between 2004 and 2015 with a pathological stage II epithelial ovarian carcinoma, who underwent lymphadenectomy and received multi-agent chemotherapy, were identified. Overall survival was compared with the log-rank test after generation of Kaplan-Meier curves. A Cox model was constructed to control for tumor histology.

Results: A total of 185 patients met the inclusion criteria. The rate of uterine preservation was 24.3% (45 patients). Patients who did not undergo hysterectomy were younger (median 32 vs 37 years, p<0.001) and less likely to have high-grade tumors compared with those who underwent hysterectomy. The two groups were comparable in terms of presence of co-morbidities and performance of adequate lymphadenectomy (p>0.05). Median follow-up of the present cohort was 62.3 months (95% CI 53.6 to 71.0) and a total of 22 deaths occurred. There was no difference in overall survival between patients who did and did not undergo hysterectomy (p=0.50; 5-year overall survival rates 87.5% and 91.4%, respectively). After controlling for tumor histology, grade and substage, omission of hysterectomy was not associated with worse survival (HR 0.69, 95% CI 0.22 to 2.12).

Conclusions: Uterine preservation was not associated with worse survival in this cohort of pre-menopausal patients with stage II epithelial ovarian carcinoma.
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http://dx.doi.org/10.1136/ijgc-2020-001747DOI Listing
March 2021

Dysregulated transcriptional responses to SARS-CoV-2 in the periphery.

Nat Commun 2021 02 17;12(1):1079. Epub 2021 Feb 17.

Durham Veterans Affairs Medical Center, Durham, NC, USA.

SARS-CoV-2 infection has been shown to trigger a wide spectrum of immune responses and clinical manifestations in human hosts. Here, we sought to elucidate novel aspects of the host response to SARS-CoV-2 infection through RNA sequencing of peripheral blood samples from 46 subjects with COVID-19 and directly comparing them to subjects with seasonal coronavirus, influenza, bacterial pneumonia, and healthy controls. Early SARS-CoV-2 infection triggers a powerful transcriptomic response in peripheral blood with conserved components that are heavily interferon-driven but also marked by indicators of early B-cell activation and antibody production. Interferon responses during SARS-CoV-2 infection demonstrate unique patterns of dysregulated expression compared to other infectious and healthy states. Heterogeneous activation of coagulation and fibrinolytic pathways are present in early COVID-19, as are IL1 and JAK/STAT signaling pathways, which persist into late disease. Classifiers based on differentially expressed genes accurately distinguished SARS-CoV-2 infection from other acute illnesses (auROC 0.95 [95% CI 0.92-0.98]). The transcriptome in peripheral blood reveals both diverse and conserved components of the immune response in COVID-19 and provides for potential biomarker-based approaches to diagnosis.
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http://dx.doi.org/10.1038/s41467-021-21289-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889643PMC
February 2021

Lymphadenectomy is associated with an increased risk of postoperative venous thromboembolism in early stage endometrial cancer.

Gynecol Oncol 2021 Apr 4;161(1):130-134. Epub 2021 Feb 4.

Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objectives: In patients undergoing surgery for early stage endometrial cancer, we sought to evaluate the effect of lymphadenectomy (LND), as well as surgical route, on the risk of postoperative venous thromboembolism (VTE).

Methods: The Surveillance, Epidemiology, and End Results cancer registries (2000-2013) linked to Medicare claims follow up from 1999 to 2014 was accessed to identify those with stage I-II endometrioid endometrial cancer who underwent hysterectomy. Performance of LND, 90-day incidence of postoperative VTE, open vs minimally invasive surgery (MIS), demographics, comorbidities, grade, and stage were collected. A washout period of 12 months with no prior VTE was required. t-test, Chi square test, univariate and multivariable Poisson regression with robust variance estimator were used.

Results: A total of 15,101 patients had hysterectomy for early stage endometrial cancer. LND was performed in 9004 (60%) patients. VTE was found in 486 patients. There were 346 VTEs (3.8%) in the LND group vs 140 (2.3%) in those without LND (RR = 1.67, p < 0.0001). Adjusting for age, stage, grade, comorbidities and surgical approach, LND remained a significant risk for VTE (RR = 1.7, p < 0.001). In those who underwent MIS, LND was associated with a two-fold increase in the risk of VTE (p = 0.0008) (adjusted RR = 1.99, p = 0.0014) and had a statistically comparable rate of VTE when compared to the open surgical approach (p = 0.054).

Conclusions: LND is associated with an increased 90-day risk of postoperative VTE in patients undergoing surgery for early stage endometrial cancer. The need for extended postoperative VTE prophylaxis in patients undergoing LND via MIS needs further exploration.
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http://dx.doi.org/10.1016/j.ygyno.2021.01.030DOI Listing
April 2021

Impact of past surgical history on perioperative outcomes in gynecologic surgery.

Gynecol Oncol 2021 Apr 9;161(1):20-24. Epub 2021 Jan 9.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA 19104, United States of America. Electronic address:

Objective: We sought to determine if past surgical history is associated with perioperative outcomes for patients undergoing hysterectomy.

Methods: A retrospective cohort study was conducted at a single, tertiary, academic health system of women who underwent hysterectomy from May 2016 - May 2017. Past surgical history (PSH) involving any abdominal or pelvic surgery, baseline demographics and perioperative outcomes were collected. For purposes of analyses, PSH was defined using three algorithms: 1) any prior abdominopelvic surgery, 2) having had abdominopelvic surgeries likely to cause adhesive disease, 3) anatomic location of prior PSH (none; pelvic; abdominal; or abdominal+pelvic). Descriptive, bivariable and multivariable analyses were performed.

Results: 1256 patients underwent hysterectomy. In adjusted analyses, PSH defined by any prior abdominopelvic surgery was associated with length of stay (LOS) (2.1 days (95%CI 1.9, 2.2) vs. 1.8 (95%CI 1.6, 2.0), (p=0.02)). PSH of procedures likely to cause adhesive disease was associated with greater estimated blood loss (EBL) (243.2 mL (95%CI 208.1, 278.3) vs. 189.0 (95%CI 1734, 204.7), (p=0.01)), longer LOS (2.5 days (95%CI 2.2, 2.8) vs. 1.9 (95%CI 1.7, 2.0), (p<0.01)), and more readmissions (OR 2.4, 95%CI 1.3, 4.5) (p<0.01). PSH defined by anatomic location revealed a trend (p=0.07) towards greater EBL in those with prior pelvic or abdominal+pelvic surgery compared to none or abdominal only, whereas LOS, readmissions and operative times did not differ. Increased total number of prior open surgeries was associated with operative time (p<0.0001), EBL (p<0.0001), hospital LOS (p<0.0001) and readmission (p=0.026).

Conclusions: Prior abdominopelvic surgery is associated with worse perioperative outcome measures in women undergoing hysterectomy.
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http://dx.doi.org/10.1016/j.ygyno.2020.12.027DOI Listing
April 2021

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer.

Int J Gynecol Cancer 2021 Jan 26;31(1):40-44. Epub 2020 Nov 26.

Division of Gynecologic Oncology, Penn Medicine, Philadelphia, Pennsylvania, USA.

Objective: A retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomy METHODS: Patients diagnosed between January 2012 and December 2015 with vulvar squamous cell carcinoma of less than 4 cm in size, with invasion of at least 1 mm, who underwent sentinel lymph node biopsy, lymphadenectomy, or both were identified from the National Cancer Database. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test for patients who had at least 1 month of follow-up. A Cox model was constructed to control for confounders.

Results: A total of 1583 patients were identified; 304 patients (19.2%) underwent sentinel lymph node biopsy alone. Sentinel lymph node biopsy utilization increased 13.9% between 2012 and 2015. Patients who underwent sentinel node biopsy alone were less likely to have comorbidities compared with those undergoing lymphadenectomy only or sentinel node biopsy with lymphadenectomy (25.3% vs 32.9% vs 31.9%, p=0.042), had smaller tumors (median 1.6 vs 2.0 vs 2.0 cm, p<0.001), and were less likely to have positive lymph nodes (11% vs 19.6% vs 28.1%, p<0.001). There was no difference in 3 year overall survival between the three groups (86.3% vs 82.1% vs 77.9%, p=0.26). After controlling for age, race, insurance, comorbidities, lymph node metastases, and tumor size, sentinel lymph node biopsy alone was not associated with worse overall survival compared with lymphadenectomy (HR 0.86, 95% CI 0.57 to 1.32). The sentinel node only group had shorter inpatient stays compared with lymphadenectomy only (median 1 vs 2 days, p<0.001) and a lower rate of unplanned readmission (1.7% vs 5.0%, p=0.010).

Conclusions: The utilization of sentinel lymph node biopsy is increasing in the management of vulvar cancer and is associated with superior perioperative outcomes without impacting overall survival.
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http://dx.doi.org/10.1136/ijgc-2020-001934DOI Listing
January 2021

Lymphadenectomy for early-stage mucinous ovarian carcinoma.

Int J Gynecol Cancer 2021 Jan 26;31(1):104-109. Epub 2020 Nov 26.

Obstetrics and Gynecology, Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objectives: There is evidence to suggest that the rate of lymph node metastases in patients with ovarian mucinous tumors is rare. The objective of this study was to investigate the prevalence of regional lymph node metastases among patients with apparent stage IA and IC mucinous ovarian carcinoma.

Methods: A retrospective cohort study was performed and included patients from the National Cancer Database with apparent stage IA and IC mucinous ovarian tumors who underwent surgery between January 1, 2004 and December 31, 2015. Data collected included demographics, surgical procedures, and pathologic characteristics. The primary outcome was the effect of tumor stage, grade, and size on the risk of lymph node metastases. Categorical and continuous variables were compared using the χ and Mann-Whitney U tests, respectively.

Results: A total of 4379 patients were identified: 3088 and 1213 with stage IA and IC disease, respectively, with an additional 78 patients who were stage I Not Otherwise Specified (NOS). Lymphadenectomy was performed in 70.6% of patients with stage IA and 70.3% of patients with stage IC cancers. Stratifying by grade, 68.4%, 71.3%, and 72.8% of patients with grades 1, 2, and 3 tumors underwent a lymphadenectomy, respectively. Furthermore, lymphadenectomy was performed in 64.9% of patients with tumors <10 cm and 72.4% with tumors >10 cm. Lymph node metastases were identified in 1.2% and 1.6% of patients with stage IA and IC disease, respectively (p=0.063). Additionally, metastases were present in 0.6% of patients with grade 1 tumors, 1.1% of patients with grade 2 tumors, and 5.3% of patients with grade 3 tumors (p<0.001). Lastly, 0.9% of patients with tumors <10 cm and 1.4% of patients with tumors >10 cm had lymph node metastases (p=0.19).

Conclusions: Among patients with mucinous ovarian carcinoma, lymph node metastases are rare. However, metastases are significantly more common in patients with higher grade tumors. These factors may be considered when making decisions regarding the need for lymphadenectomy in early-stage mucinous ovarian tumors.
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http://dx.doi.org/10.1136/ijgc-2020-001817DOI Listing
January 2021

An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery.

Gynecol Oncol 2021 Jan 24;160(1):3-9. Epub 2020 Nov 24.

Gynecologic Oncology, University of Pennsylvania, United States of America.

Objective: To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.

Methods: This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.

Results: Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.

Conclusions: Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.
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http://dx.doi.org/10.1016/j.ygyno.2020.10.030DOI Listing
January 2021

Survival following minimally invasive radical hysterectomy for patients with cervical carcinoma and tumor size ≤2 cm.

Am J Obstet Gynecol 2021 03 28;224(3):317-318.e2. Epub 2020 Oct 28.

Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, 3400 Spruce St., 1 West Gates, Philadelphia, PA 19104.

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http://dx.doi.org/10.1016/j.ajog.2020.10.044DOI Listing
March 2021

Emergency department utilization by patients with gynecologic cancer in the United States.

Int J Gynecol Cancer 2021 Apr 12;31(4):585-593. Epub 2020 Oct 12.

Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.

Introduction: Payment reform will give oncologists increasing responsibility for how patients with cancer meet unexpected care needs.

Objective: To differentiate how patients with gynecologic cancers use emergency care, and to assess the characteristics associated with potentially avoidable treat-and-release visits.

Methods: We performed a retrospective cohort study using the Nationwide Emergency Department Sample, a stratified sample of visits in United States hospital-based emergency departments, from 2010 to 2014. Visits by patients with a diagnosis of gynecologic cancer were selected. Sample weights were applied to calculate national estimates of care patterns and trends. Associations with treat-and-release disposition were assessed with weighted logistic regression.

Results: In the study period, patients with gynecologic cancer made an estimated 370 104 annual emergency department visits (95% CI 351 997 to 388 211). A total of 50.2% of patients were treated and released, 48% were admitted, 1.6% were transferred, and 0.1% died. These visits corresponded to over US$1.27 billion in annual charges, with an average charge of US$3428 per visit (95% CI 3348 to 3509). Driven by growing treat-and-release utilization, annual visits increased, while admission rates fell over time. Patients with cervical cancer represented the plurality (36%) of visits; they were relatively younger, of lower socioeconomic status, and had fewer co-morbidities. Models for treat-and-release disposition did not vary significantly across different cancer populations. In the all-cancer model, increased odds of treat-and-release disposition was associated with cervical cancer diagnosis, younger age, lesser Elixhauser co-morbidity, Medicare coverage (OR=1.19; p<0.001), Medicaid coverage (OR=1.25; p<0.001), uninsured status (OR=1.70; p<0.001), and weekend visits. Visits in the northeast, at urban hospitals, and in winter months showed decreased odds of treat-and-release disposition.

Discussion: Patients with gynecologic cancers have been using the emergency department at increasing rates, primarily driven by treat-and-release visits that did not result in admission or death. Patients with cervical cancer have higher rates of treat-and-release utilization and may over-use emergency department care.
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http://dx.doi.org/10.1136/ijgc-2020-001520DOI Listing
April 2021

Patterns of use and outcomes of sentinel lymph node mapping for patients with high-grade endometrial cancer.

Gynecol Oncol 2020 12 29;159(3):732-736. Epub 2020 Sep 29.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.ygyno.2020.09.023DOI Listing
December 2020

Perioperative outcomes and disparities in utilization of sentinel lymph node biopsy in minimally invasive staging of endometrial cancer.

Gynecol Oncol 2020 12 25;159(3):758-766. Epub 2020 Sep 25.

Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: To assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes.

Methods: Retrospective cohort study of the National Cancer Database, selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression.

Results: Among 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; OR = 0.53; 95%CI 0.39-0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; OR = 0.49; 95%CI 0.32-0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; OR = 0.51; 95%CI 0.40-0.64; OR = 0.39; 95%CI 0.28-0.55), and unplanned readmission (overall rate 2.3%; OR = 0.52; 95%CI 0.33-0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND.

Conclusion: We identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes.
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http://dx.doi.org/10.1016/j.ygyno.2020.09.032DOI Listing
December 2020

Risk of Persistent Opioid Use following Major Surgery in Matched Samples of Patients with and without Cancer.

Cancer Epidemiol Biomarkers Prev 2020 Nov 28;29(11):2126-2133. Epub 2020 Aug 28.

USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: The opioid crisis has reached epidemic proportions, yet risk of persistent opioid use following curative intent surgery for cancer and factors influencing this risk are not well understood.

Methods: We used electronic health record data from 3,901 adult patients who received a prescription for an opioid analgesic related to hysterectomy or large bowel surgery from January 1, 2013, through June 30, 2018. Patients with and without a cancer diagnosis were matched on the basis of demographic, clinical, and procedural variables and compared for persistent opioid use.

Results: Cancer diagnosis was associated with greater risk for persistent opioid use after hysterectomy [18.9% vs. 9.6%; adjusted OR (aOR), 2.26; 95% confidence interval (CI), 1.38-3.69; = 0.001], but not after large bowel surgery (28.3% vs. 24.1%; aOR 1.25; 95% CI, 0.97-1.59; = 0.09). In the cancer hysterectomy cohort, persistent opioid use was associated with cancer stage (increased rates among those with stage III cancer compared with stage I) and use of neoadjuvant or adjuvant chemotherapy; however, these factors were not associated with persistent opioid use in the large bowel cohort.

Conclusions: Patients with cancer may have an increased risk of persistent opioid use following hysterectomy.

Impact: Risks and benefits of opioid analgesia for surgical pain among patients with cancer undergoing hysterectomy should be carefully considered.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0628DOI Listing
November 2020

Utilization and survival outcomes of sequential, concurrent and sandwich therapies for advanced stage endometrial cancers by histology.

Gynecol Oncol 2020 11 14;159(2):394-401. Epub 2020 Aug 14.

The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX 77030, United States of America. Electronic address:

Objective: To determine the impact on overall survival (OS) of different modalities of adjuvant therapy for the treatment of stage III endometrial cancer (EC), by histology.

Methods: Stage 3 endometrioid (EAC), serous (SER), clear cell (CC), and carcinosarcoma (CS) patients who underwent primary surgical staging from 2000 to 2013 were identified in SEER-Medicare. Adjuvant therapy was defined by a 4-arm comparator grouping (none; RT only; CT only; combination RT), as well as by an 8-arm comparator grouping (none; RT only; CT only; concurrent CT-RT; concurrent CT-RT then CT; Serial CT-RT; serial RT-CT; sandwich). Modality of RT and CT were analyzed using Kaplan-Meier estimates, log rank tests, and multivariable cox modeling.

Results: Of 2870 cases identified (1798 EAC, 606 SER, 118 CC, 348 CS), 31.5% received no adjuvant therapy. The remainder received RT or CT alone, concurrent RT-CT, serial or sandwich modalities. OS differed by adjuvant therapy in adjusted and unadjusted models, when combining all histologies, and when stratifying by histology using both the 4-arm, and 8-arm comparator analyses (log rank p < .05, all). By histology, in adjusted analyses, sandwich modality had the greatest improvement in OS for endometrioid, but pairwise comparisons did not identify a superior chemotherapy-based regimen. For serous and clear cell, the greatest improvement in OS was seen with concurrent RT-CT, and for carcinosarcoma, CT alone.

Conclusions: OS for advanced EC significantly differs by histology and mode of adjuvant therapy. Future studies should evaluate the efficacy of combination-based adjuvant therapy versus chemotherapy alone, by histologic subtype and molecular signature.
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http://dx.doi.org/10.1016/j.ygyno.2020.07.105DOI Listing
November 2020

Impact of Medicaid expansion on women with gynecologic cancer: a difference-in-difference analysis.

Am J Obstet Gynecol 2021 02 7;224(2):195.e1-195.e17. Epub 2020 Aug 7.

Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA.

Background: Women with gynecologic cancer face socioeconomic disparities in care that affect survival outcomes. The Affordable Care Act offered states the option to expand Medicaid enrollment eligibility criteria as a means of improving timely and affordable access to care for the most vulnerable. The variable uptake of expansion by states created a natural experiment, allowing for quasi-experimental methods that offer more unbiased estimates of treatment effects from retrospective data than the traditional regression adjustment.

Objective: To use a quasi-experimental, difference-in-difference framework to create unbiased estimates of impact of Medicaid expansion on women with gynecologic cancer.

Study Design: We performed a quasi-experimental retrospective cohort study from the National Cancer Database files for women with invasive cancers of the uterus, ovary and fallopian tube, cervix, vagina, and vulva diagnosed from 2008 to 2016. Using a marker for state Medicaid expansion status, we created difference-in-difference models to assess the impact of Medicaid expansion on the outcomes of access to and timeliness of care. We excluded women aged <40 years owing to the suppression of the state Medicaid expansions status in the data and women aged ≥65 years owing to the universal Medicare coverage availability. Our primary outcome was the rate of uninsurance at diagnosis. Secondary outcomes included Medicaid coverage, early-stage diagnosis, treatment at an academic facility, and any treatment or surgery within 30 days of diagnosis. Models were run within multiple subgroups and on a propensity-matched cohort to assess the robustness of the treatment estimates. The assumption of parallel trends was assessed with event study time plots.

Results: Our sample included 335,063 women. Among this cohort, 121,449 were from nonexpansion states and 213,614 were from expansion states, with 79,886 posttreatment cases diagnosed after the expansion took full effect in expansion states. The groups had minor differences in demographics, and we found occasional preperiod event study coefficients diverging from the mean, but the outcome trends were generally similar between the expansion and nonexpansion states in the preperiod, satisfying the necessary assumption for the difference-in-difference analysis. In a basic difference-in-difference model, the Medicaid expansion in January 2014 was associated with significant increases in insurance at diagnosis, treatment at an academic facility, and treatment within 30 days of diagnosis (P<.001 for all). In an adjusted model including all states and accounting for variable expansion implementation time, there was a significant treatment effect of Medicaid expansion on the reduction in uninsurance at diagnosis (-2.00%; 95% confidence interval, -2.3 to -1.7; P<.001), increases in early-stage diagnosis (0.80%; 95% confidence interval, 0.2-1.4; P=.02), treatment at an academic facility (0.83%; 95% confidence interval, 0.1-1.5; P=.02), treatment within 30 days (1.62%; 95% confidence interval, 1.0-2.3; P<.001), and surgery within 30 days (1.54%; 95% confidence interval, 0.8-2.3; P<.001). In particular, large gains were estimated for women living in low-income zip codes, Hispanic women, and women with cervical cancer. Estimates from the subgroup and propensity-matched cohorts were generally consistent for all outcomes besides early-stage diagnosis and treatment within 30 days.

Conclusion: Medicaid expansion was significantly associated with gains in the access and timeliness of treatment for nonelderly women with gynecologic cancer. The implementation of Medicaid expansion could greatly benefit women in nonexpansion states. Gynecologists and gynecologic oncologists should advocate for Medicaid expansion as a means of improving outcomes and reducing socioeconomic and racial disparities.
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http://dx.doi.org/10.1016/j.ajog.2020.08.007DOI Listing
February 2021

Adjuvant treatment for patients with FIGO stage I uterine serous carcinoma confined to the endometrium.

Int J Gynecol Cancer 2020 08 15;30(8):1089-1094. Epub 2020 Jul 15.

Division of Gynecologic Oncology, Penn Medicine, Philadelphia, Pennsylvania, USA.

Objectives: The role of adjuvant treatment for early-stage uterine serous carcinoma is not defined. The goal of this study was to investigate the impact of adjuvant treatment on survival of patients with tumors confined to the endometrium.

Methods: Patients diagnosed with stage I uterine serous carcinoma with no myometrial invasion between January 2004 and December 2015 who underwent hysterectomy with at least 10 lymph nodes removed were identified from the National Cancer Database. Adjuvant treatment patterns defined as receipt of chemotherapy and/or radiotherapy within 6 months from surgery were investigated and overall survival was evaluated using Kaplan-Meier curves, and compared with the log-rank test for patients with at least one month of follow-up. A Cox analysis was performed to control for confounders.

Results: A total of 1709 patients were identified; 833 (48.7%) did not receive adjuvant treatment, 348 (20.4%) received both chemotherapy and radiotherapy, 353 (20.7%) received chemotherapy only, and 175 (10.2%) received radiotherapy only. Five-year overall survival rates for patients who did not receive adjuvant treatment (n=736) was 81.9%, compared with 91.3% for those who had chemoradiation (n=293), 85.1% for those who received radiotherapy only (n=143), and 91.0% for those who received chemotherapy only (n=298) (p<0.001). After controlling for age, insurance status, type of treatment facility, tumor size, co-morbidities, and history of another tumor, patients who received adjuvant chemotherapy (HR 0.64, 95% CI 0.42, 0.96), or chemoradiation (HR 0.55, 95% CI 0.35, 0.88) had better survival compared with those who did not receive any adjuvant treatment, while there was no benefit from radiotherapy alone (HR 0.85, 95% CI 0.53, 1.37). There was no survival difference between chemoradiation and chemotherapy only (HR 1.15, 95% CI 0.65, 2.01).

Conclusion: Adjuvant chemotherapy (with or without radiotherapy) is associated with a survival benefit for uterine serous carcinoma confined to the endometrium.
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http://dx.doi.org/10.1136/ijgc-2020-001379DOI Listing
August 2020

Ovarian Sertoli-Leydig and granulosa cell tumor: comparison of epidemiology and survival outcomes.

Arch Gynecol Obstet 2020 08 9;302(2):481-486. Epub 2020 Jun 9.

Department of Obstetrics and Gynecology, Helen O'Dickens Women's Health Center, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.

Purpose: To investigate the epidemiology, clinico-pathological characteristics and outcomes of patients diagnosed with malignant ovarian Sertoli-Leydig cell tumors (SLCTs) in comparison to granulosa cell tumors (GCTs).

Methods: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were accessed and patients diagnosed with a malignant SLCT and GCT between 1988 and 2013 were selected. Demographic and clinico-pathological characteristics were compared using the Mann-Whitney and chi-square tests. Overall (OS) and cancer-specific survival (CSS) rates were estimated with the Kaplan-Meier method and compared with the log-rank test. Cox hazard models were constructed to control for confounders.

Results: A total of 175 and 1361 patients diagnosed with SLCT and GCT, respectively, were identified. Compared to patients with GCT, those with SLCT were younger (median age 32 vs. 51 years, p < 0.001) and more likely to present with larger tumors (median size 15 vs 9.5 cm, p < 0.001) confined to the ovary (77.5% vs 69.2%, p = 0.031). Patients with SLCTs had worse CSS compared to those with GCTs, p < 0.001 (5-year rate was 76.2% vs 90.7%). After controlling for the presence of extra-ovarian disease and tumor size (≤ 10 vs > 10 cm), SCLTs were associated with a worse cancer-specific mortality compared to GCTs.

Conclusions: SLCTs are extremely rare, commonly arise in premenopausal patients. They are associated with a poorer prognosis compared to GCT.
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http://dx.doi.org/10.1007/s00404-020-05633-zDOI Listing
August 2020

Knowledge of endometrial cancer risk factors in a general gynecologic population.

Gynecol Oncol 2020 07 10;158(1):137-142. Epub 2020 May 10.

Division of Gynecologic Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States of America.

Objectives: To determine knowledge regarding endometrial cancer (EC) risk factors in a general gynecologic patient population.

Study Design: A questionnaire survey regarding health behaviors and knowledge of risk factors of EC was administered to patients presenting for routine gynecologic care at two general gynecologic practices affiliated with a tertiary-care center between August and October 2014. Patient demographics, lifestyle information, and knowledge regarding EC risk factors were assessed. Data were analyzed using univariable and bivariable analyses, Χ tests, Fischer's exact tests, and t-tests.

Results: 231 women responded. Median age was 56 years old (IQR 25-64), and 87% were Caucasian. Median BMI was 24.9 (IQR 22.3-29.2). 24.7% were overweight and 24.3% obese. The majority (69.4%) of patients received a college or graduate degree. Over half of the women (52.1%) did not know that obesity was associated with increased risk of EC. When dichotomized based on obese vs non obese, there was no difference in patients' knowledge of the association between obesity and EC (47% vs 48%, respectively, p = .93). 91% of all respondents reported that their gynecologist or primary care physician had never discussed the risks of EC with them.

Conclusions: Regardless of education level, age or obesity status, the majority of women did not know the common risks of EC. Increased efforts towards educating women regarding obesity and other risk factors of EC are necessary in order to reduce the rising incidence of EC, a predominantly obesity-driven disease. Interventions must include general obstetrician-gynecologists and primary care providers.
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http://dx.doi.org/10.1016/j.ygyno.2020.03.032DOI Listing
July 2020

Performance of lymphadenectomy for apparent early stage malignant ovarian germ cell tumors in the era of platinum-based chemotherapy.

Gynecol Oncol 2020 06 28;157(3):613-618. Epub 2020 Apr 28.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objectives: To investigate the patterns of use and impact of lymphadenectomy (LND) on overall survival (OS) of patients with apparent early stage malignant ovarian germ cell tumors (MOGCTs).

Methods: Patients with apparent stage I MOGCT diagnosed between 2004 and 2015 were drawn from the National Cancer Database. The performance of LND was assessed from the pathology report. OS was evaluated using Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for confounders.

Results: A total of 2774 patients were identified; 1426 (51.4%) underwent LND. The median number of lymph nodes (LN) removed was 9 (range 1-81); 48.3% of patients had at least 10 lymph nodes removed. The rate of regional lymph node metastasis was 10.3% (147 patients). There was no difference in OS, between patients who did (n = 1287) and did not (n = 1210) undergo LND, p = 0.81; 5-yr OS rates were 96.5% and 97.6% respectively. After controlling for patient age, insurance status, histology, presence of medical comorbidities, and receipt of chemotherapy, the performance of LND was not associated with better survival (HR: 1.33, 95% CI: 0.82, 2.14).

Conclusions: While LN metastasis is common in apparent early stage MOGCTs, the performance of LND was not associated with a survival benefit.
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http://dx.doi.org/10.1016/j.ygyno.2020.04.047DOI Listing
June 2020

Effect of bilateral salpingo-oophorectomy on the overall survival of premenopausal patients with stage I low-grade endometrial stromal sarcoma; a National Cancer Database analysis.

Gynecol Oncol 2020 06 27;157(3):634-638. Epub 2020 Apr 27.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objectives: Investigate the prevalence of bilateral salpingo-oophorectomy (BSO) for women ≤50 years with early stage low-grade endometrial stromal sarcoma (LGESS) and its impact on overall survival (OS).

Methods: Women ≤50 years, diagnosed with stage I LGESS and managed with hysterectomy between 2004 and 2015 were identified from the National Cancer Database. Patient demographics were recorded and compared with the chi-square test. OS for patients diagnosed between 2004 and 2014 with at least one month of follow-up was assessed using Kaplan-Meier curves, and compared with the log-rank test.

Results: A total 743 patients with a median age of 44 years met the inclusion criteria. Use of radiatiotherapy (9%), chemotherapy (0.8%) and hormonal therapy (11%) was infrequent. BSO was performed in 541 (72.8%) patients. Patients who had ovarian preservation (OP) were younger (median age 43 vs 45 years, p < 0.001), less likely to have comorbidities (6.9% vs 12.4%, p = 0.034), or undergo LND (30.7% vs 44.4%, p = 0.001). There were no differences between the two groups in terms of substage or patient race. Five year OS rates for patients who did (n = 490) and did not (n = 191) undergo BSO were 96.2% and 97.1% and there was no difference in OS, p = 0.50. Even after controlling for presence of comorbidities performance of BSO was not associated with better survival (HR: 1.28, 95% CI: 0.51, 3.19).

Conclusions: Ovarian function was preserved in approximately one third of women ≤50 years with stage I LGESS with no clear detriment to overall survival. As BSO is associated with long term health effects in this patient population OP could be considered in selected women with stage I LGESS.
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http://dx.doi.org/10.1016/j.ygyno.2020.04.001DOI Listing
June 2020

In Reply.

Obstet Gynecol 2020 05;135(5):1226-1227

Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/AOG.0000000000003848DOI Listing
May 2020

Advanced stage primary mucinous ovarian carcinoma. Where do we stand ?

Arch Gynecol Obstet 2020 04 17;301(4):1047-1054. Epub 2020 Mar 17.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: To evaluate factors associated with survival of patients with advanced stage mucinous ovarian carcinoma (MOC) using a large multi-institutional database.

Methods: Patients diagnosed between 2004 and 2014 with advanced stage (III-IV) MOC were identified within the National Cancer Database. Those without a personal history of another primary tumor who received cancer-directed surgery with a curative intent were selected for further analysis. Overall survival (OS) was evaluated with Kaplan-Meier curves, and compared with the log-rank test. Multivariate Cox analysis was performed to identify independent predictors of survival.

Results: A total of 1509 patients with a median age of 59 years (IQR 20) met the inclusion criteria: stage III (n = 1045, 69.3%) and stage IV disease (n = 464, 30.7%). Patients who received chemotherapy (n = 1065, 70.6%) had better OS compared to those who did not (n = 385, 25.5%), (median OS 15.44 vs 5.06 months, p < 0.001). The type of reporting facility (p = 0.65) and the year of diagnosis (p = 0.27) were not associated with OS. Presence of residual disease was strongly associated with OS (p < 0.001). After controlling for confounders, the administration of chemotherapy (HR 0.63, 95% CI 0.55, 0.72) was associated with better survival.

Conclusion: Advanced stage MOC has an extremely poor prognosis. Patients who received chemotherapy had a small improvement in survival. Every effort to achieve complete gross resection should be performed. Given no improvement in survival outcomes over time, there is an eminent need for novel treatment options.
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http://dx.doi.org/10.1007/s00404-020-05489-3DOI Listing
April 2020

Fertility preserving surgery for high-grade epithelial ovarian carcinoma confined to the ovary.

Eur J Obstet Gynecol Reprod Biol 2020 May 30;248:63-70. Epub 2020 Jan 30.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.

Objective: To investigate the safety of uterine preservation in patients with high-grade epithelial ovarian carcinoma (EOC).

Study Design: The Surveillance, Epidemiology, and End Results database was accessed (1988-2014) and patients aged < = 45 years, diagnosed with an unilateral high-grade non-clear cell EOC confined to the ovary were selected. Based on surgery codes we determined whether hysterectomy was performed. Overall (OS) and cancer-specific survival (CSS) was estimated calculated following generation of Kaplan-Meier curves and compared using the log-rank test. Cox hazard model was constructed to control for possible confounders.

Results: A total of 1039 patients with a median follow-up of 119 months were identified. Rate of uterine preservation was 31.8 %. Patients who had hysterectomy were older (median 41 vs 32 yrs, p < 0.001). Patients with mucinous tumors were less likely to undergo hysterectomy (58.9 %) compared to those with endometrioid (73.9 %) and serous (75.9 %) carcinoma, p < 0.001. There was no difference in CSS between patients who did and did not have hysterectomy, p = 0.70 (5-yr rates were 93.9 % vs 92.2 %, respectively). After controlling for year of diagnosis, tumor histology (serous vs non-serous), disease stage, performance of lymph node dissection (LND) and tumor grade, uterine preservation was not associated with a worse cancer-specific (HR: 1.08, 95 % CI:0.69,1.71) and overall (HR:0.88, 95 % CI: 0.59, 1.32) mortality.

Conclusion: In this retrospective cohort of patients with unilateral high-grade non-clear cell EOC confined to the ovary, uterine preservation was not associated with a worse prognosis.
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http://dx.doi.org/10.1016/j.ejogrb.2020.01.039DOI Listing
May 2020

Surgical and oncologic outcomes of minimally invasive surgery for stage I high-grade endometrial cancer.

Surg Oncol 2020 Sep 17;34:7-12. Epub 2020 Feb 17.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: To evaluate the prevalence and outcomes of minimally invasive surgery for stage I high grade endometrial cancer. We hypothesized that route of surgery is not associated with survival.

Materials: Patients diagnosed between 2010 and 2014, with stage I grade 3 endometrioid, serous, clear cell and carcinosarcoma endometrial carcinoma, who underwent hysterectomy with lymphadenectomy were drawn from the National Cancer Database. Patients converted to open surgery were excluded. Overall survival was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.

Results: A total of 12852 patients were identified. The rate of minimally invasive surgery was 62.2%. An increase in the use between 2010 and 2014 was noted (p < 0.001). Open surgery was associated with longer hospital stay (median 3 vs 1 day, p < 0.001), higher 30-day unplanned re-admission rate (4.5% vs 2.4%, p < 0.001) and 30-day mortality (0.6% vs 0.3%, p = 0.008). There was no difference in overall survival between patients who had open or minimally invasive surgery, p = 0.22; 3-yr overall survival rates were 83.7% and 84.4% respectively. After controlling for patient age, tumor histology, substage, type of insurance, type of reporting facility, receipt of radiation therapy and chemotherapy, extent of lymphadenectomy, the presence of comorbidities and personal history of another tumor, minimally invasive surgery was not associated with a worse survival (hazard ratio: 1.06, 95% confidence interval: 0.97, 1.15).

Conclusions: Minimally invasive surgery for patients with stage I high grade endometrial cancer, was associated with superior short-term outcomes with no difference in overall survival noted.
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http://dx.doi.org/10.1016/j.suronc.2020.02.015DOI Listing
September 2020

Radical hysterectomy is not associated with a survival benefit for patients with stage II endometrial carcinoma.

Gynecol Oncol 2020 05 20;157(2):335-339. Epub 2020 Feb 20.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: To evaluate the role of radical hysterectomy in the management of patients with stage II endometrial carcinoma.

Materials: Patients diagnosed between 2004 and 2015, with stage II (based on the revised FIGO staging) endometrial carcinoma who had hysterectomy and regional lymph node surgery were identified in the National Cancer Database. Those who had radical or modified radical (RH), or total hysterectomy (TH) were selected. Overall survival (OS) was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders.

Results: A total of 7552 patients who met the inclusion criteria were identified. Rate of RH was 10.5%. Those who underwent RH had longer hospital stay (median 3 vs 2 days, p < 0.001) and a higher 90-day (1.6% vs 0.8%, p = 0.05) mortality. There was no difference in OS between patients who had RH (n = 712) and SH (n = 5955) (p = 0.62); 5-year survival rates were 77.4% and 76.9%, respectively. After controlling for patient age (<65, ≥65 years), race (white, black, other/unknown), insurance status, presence of comorbidities, tumor size (<5, ≥5 cm, unknown), histology (endometrioid, non-endometrioid), performance of adequate lymphadenectomy, and receipt of adjuvant chemotherapy and radiation therapy, performance of radical hysterectomy was not associated with better survival (HR: 1.01, 95% CI: 0.85, 1.21).

Conclusions: Radical hysterectomy was not associated with a survival benefit in a cohort of patients with stage II endometrial carcinoma.
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http://dx.doi.org/10.1016/j.ygyno.2020.02.003DOI Listing
May 2020

Trends in the surgical management of malignant ovarian germcell tumors.

Gynecol Oncol 2020 04 31;157(1):89-93. Epub 2020 Jan 31.

Division of Gynecologic Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.

Objective: To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes.

Materials And Methods: Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests.

Results: A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p > 0.05).

Conclusions: Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.
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http://dx.doi.org/10.1016/j.ygyno.2020.01.033DOI Listing
April 2020