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Is intraoperative gross evaluation of the uterus in patients with complex atypical hyperplasia and endometrial adenocarcinoma reliable?
Abstracts / Gynecologic Oncology 141 (2016) 2–208
OF
doi:10.1016/j.ygyno.2016.04.123
92 - Featured Poster Session Hybrid models of care between high and low volume centers and associations with uterine cancer treatment and survival K.M. Doll, K. Meng, W.R. Brewster, P.A. Gehrig, A.M. Meyer. University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
DP
Objectives: Initial treatment of endometrial cancer (EC) involves surgical resection including removal of pelvic and para-aortic lymph nodes. Attempts have been made to identify preoperative and intraoperative markers to determine which patients are at an increased risk of lymph node metastasis and thus need surgical staging. The goal of this study is to assess the reliability of intraoperative uterine evaluation compared with final pathologic measurements in patients with EC. Methods: After obtaining institutional review board approval, a prospective study was conducted of women who underwent surgery for biopsy-proven complex atypical hyperplasia (CAH) or EC between March 2015 and September 2015. Demographics, preoperative biopsy results, procedure, intraoperative and final pathologic evaluation of lesion size, myometrial invasion, and lower uterine segment/cervical involvement were abstracted. The level of agreement between intraoperative and final pathologic evaluation of tumor involvement of the uterus was determined using κ statistics and intraclass correlation coefficients (ICC). Results: Eighty-six patients with a preoperative diagnosis of CAH or EC were included—29 (33.7%) with CAH and 57 (66.3%) with EC. Mean age was 62 ± 10.5 years, and mean body mass index (BMI) was 38 ± 10.7. The majority of women were white (69%). Seventy (81.4%) patients underwent a laparoscopic or robotic hysterectomy, and 16 (18.6%) underwent an exploratory laparotomy. Seventy-one (82.6%) patients had EC and 15 (17.4%) patients had CAH on final pathology. There was a strong correlation between the intraoperative estimated size of the lesion and the final pathologic assessment (ICC 0.85, mean 3.8 cm, range 0–20 cm, P b .0001). However, there was fair correlation between intraoperative estimation of myometrial invasion and moderate correlation between lower uterine segment/cervical involvement compared with final pathologic evaluation (κ = 0.37 and 0.51, respectively). Conclusions: Estimated intraoperative evaluation of tumor size correlated strongly with final pathology whereas myometrial invasion and lower uterine segment/cervical involvement had moderate agreement at best. Therefore, intraoperative evaluation is inconsistent when determining the extent of disease and may not be an acceptable method for determining the need for surgical staging.
possible lymphadenectomy were recruited for this study. Each patient received intravenous fluorescein dye approximately 5 minutes before uterine artery ligation. After the hysterectomy, the uterus was taken to pathology, bivalved, and the most suspicious areas excised as a transverse section incorporating the endometrium and myometrium. Using a Wood lamp, a measurement of the tumor specimen (nonfluorescent) was compared with the full-thickness specimen. Frozen section analysis of the most suspicious area and gross inspection were conducted, values of which were compared with the final pathology finding. Pearson correlation coefficient was used to compare results between the groups. Results: The correlation between depth of invasion predicted by fluorescein and final pathology findings was high (r = 0.8765; P b .05) and was comparable to the frozen section correlation with final pathology (r = .8707; P b .05). When patients were categorized as having either less than 50% or more than 50% invasion, Χ2 analysis revealed fluorescein to be significantly predictive of final pathology (P = .01). Conclusions: These results suggest that a rapid and inexpensive test in the operating room can help identify patients who require lymphadenectomy for EC.
RO
90 - Featured Poster Session Is intraoperative gross evaluation of the uterus in patients with complex atypical hyperplasia and endometrial adenocarcinoma reliable? B.Q. Smith, J.D. Boone, E.D. Thomas, T.B. Turner, G. McGwin, C.A. Leath III, W.K. Huh. University of Alabama at Birmingham, Birmingham, AL, USA
39
CO
doi:10.1016/j.ygyno.2016.04.122
RR
EC
TE
Objectives: High-risk uterine cancer (UC) rates are increasing, and centralization is key to alleviating disparities in care. As cancer care is centralized in high-volume (HV) centers, patients may interact with HV centers for all (HV-All), a portion (HV-Hybrid), or none (LV) of their care. Neither the frequency of these referral care models nor their impact on outcomes is known. Methods: The North Carolina Central Cancer Registry (NCCCR) was used to identify all UC cases from 2004 to 2009, which were linked to insurance claims using the Integrated Information Cancer Surveillance System. Sites of care were defined by UC surgery volume (HV ≥ 50). Demographic and histologic data were obtained from the NCCCR and clinical data from claims, using ICD-9 and CPT codes. Bivariate statistics were used to compare care model groups, modified Poisson regression to evaluate the receipt of surgical staging and chemotherapy, and Cox models and KM curves to explore crude survival differences. Results: A total of 1,964 women had UC linked to insurance claims. Mean age was 67 (± 12) years, 328 (17%) were racial/ ethnic minorities, and 618 (31%) resided in nonmetropolitan counties. Stage was 73% (n = 1,473) localized, 19% (n = 378) regional, 5% (n = 105) distant, and less than 1% (n = 8) unknown, with 66% (n = 1,287) low-risk and 34% (n = 677) grade 3 histology. For initial surgery, 73% (n = 1,519) were performed at HV centers. Lymphadenectomy was performed in 71% (n = 1,388) of all cases, and in 498 (74%) of 677 patients with grade 3. In adjusted models, LV centers were less likely to perform lymphadenectomy (RR 0.73, 95% CI 0.66–0.80) with a trend toward decreased chemotherapy for type 2 patients (RR 0.73, 95% CI 0.51–1.05). Among type 2 patients receiving chemotherapy, 62% (n = 92) were in HV-All, 27% (n = 40) HV-Hybrid, and 11% LV (n = 17) models. HV-All patients experienced lowest mortality (Fig. 1) while a 50% greater risk of mortality was seen in both HVHybrid (RR 1.5, 95% CI 0.9–2.6) and LV (RR 1.5, 95% CI 0.7–3.2) patients.
UN
91 - Featured Poster Session A quick and inexpensive alternative to frozen section for diagnosing myometrial invasion in endometrial cancer A.F. Burnetta, B. Stoneb, K.K. Zorna, C.M. Quicka. aUniversity of Arkansas for Medical Sciences, Little Rock, AR, USA, bJohns Hopkins University, Baltimore, MD, USA Objectives: Depth of myometrial invasion is an important determinant for performing lymphadenectomy in endometrial cancer. Frozen section of the uterus correlates with final pathology 87% to 92% of the time but is associated with increased time and expense. We have developed a technique that can be used in the operating room immediately after the uterus is removed, which accurately predicts the depth of endometrial cancer invasion. Methods: Fifteen women with endometrial cancer who were undergoing hysterectomy and bilateral salpingo-oophorectomy with
OF
doi:10.1016/j.ygyno.2016.04.123
92 - Featured Poster Session Hybrid models of care between high and low volume centers and associations with uterine cancer treatment and survival K.M. Doll, K. Meng, W.R. Brewster, P.A. Gehrig, A.M. Meyer. University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
DP
Objectives: Initial treatment of endometrial cancer (EC) involves surgical resection including removal of pelvic and para-aortic lymph nodes. Attempts have been made to identify preoperative and intraoperative markers to determine which patients are at an increased risk of lymph node metastasis and thus need surgical staging. The goal of this study is to assess the reliability of intraoperative uterine evaluation compared with final pathologic measurements in patients with EC. Methods: After obtaining institutional review board approval, a prospective study was conducted of women who underwent surgery for biopsy-proven complex atypical hyperplasia (CAH) or EC between March 2015 and September 2015. Demographics, preoperative biopsy results, procedure, intraoperative and final pathologic evaluation of lesion size, myometrial invasion, and lower uterine segment/cervical involvement were abstracted. The level of agreement between intraoperative and final pathologic evaluation of tumor involvement of the uterus was determined using κ statistics and intraclass correlation coefficients (ICC). Results: Eighty-six patients with a preoperative diagnosis of CAH or EC were included—29 (33.7%) with CAH and 57 (66.3%) with EC. Mean age was 62 ± 10.5 years, and mean body mass index (BMI) was 38 ± 10.7. The majority of women were white (69%). Seventy (81.4%) patients underwent a laparoscopic or robotic hysterectomy, and 16 (18.6%) underwent an exploratory laparotomy. Seventy-one (82.6%) patients had EC and 15 (17.4%) patients had CAH on final pathology. There was a strong correlation between the intraoperative estimated size of the lesion and the final pathologic assessment (ICC 0.85, mean 3.8 cm, range 0–20 cm, P b .0001). However, there was fair correlation between intraoperative estimation of myometrial invasion and moderate correlation between lower uterine segment/cervical involvement compared with final pathologic evaluation (κ = 0.37 and 0.51, respectively). Conclusions: Estimated intraoperative evaluation of tumor size correlated strongly with final pathology whereas myometrial invasion and lower uterine segment/cervical involvement had moderate agreement at best. Therefore, intraoperative evaluation is inconsistent when determining the extent of disease and may not be an acceptable method for determining the need for surgical staging.
possible lymphadenectomy were recruited for this study. Each patient received intravenous fluorescein dye approximately 5 minutes before uterine artery ligation. After the hysterectomy, the uterus was taken to pathology, bivalved, and the most suspicious areas excised as a transverse section incorporating the endometrium and myometrium. Using a Wood lamp, a measurement of the tumor specimen (nonfluorescent) was compared with the full-thickness specimen. Frozen section analysis of the most suspicious area and gross inspection were conducted, values of which were compared with the final pathology finding. Pearson correlation coefficient was used to compare results between the groups. Results: The correlation between depth of invasion predicted by fluorescein and final pathology findings was high (r = 0.8765; P b .05) and was comparable to the frozen section correlation with final pathology (r = .8707; P b .05). When patients were categorized as having either less than 50% or more than 50% invasion, Χ2 analysis revealed fluorescein to be significantly predictive of final pathology (P = .01). Conclusions: These results suggest that a rapid and inexpensive test in the operating room can help identify patients who require lymphadenectomy for EC.
RO
90 - Featured Poster Session Is intraoperative gross evaluation of the uterus in patients with complex atypical hyperplasia and endometrial adenocarcinoma reliable? B.Q. Smith, J.D. Boone, E.D. Thomas, T.B. Turner, G. McGwin, C.A. Leath III, W.K. Huh. University of Alabama at Birmingham, Birmingham, AL, USA
39
CO
doi:10.1016/j.ygyno.2016.04.122
RR
EC
TE
Objectives: High-risk uterine cancer (UC) rates are increasing, and centralization is key to alleviating disparities in care. As cancer care is centralized in high-volume (HV) centers, patients may interact with HV centers for all (HV-All), a portion (HV-Hybrid), or none (LV) of their care. Neither the frequency of these referral care models nor their impact on outcomes is known. Methods: The North Carolina Central Cancer Registry (NCCCR) was used to identify all UC cases from 2004 to 2009, which were linked to insurance claims using the Integrated Information Cancer Surveillance System. Sites of care were defined by UC surgery volume (HV ≥ 50). Demographic and histologic data were obtained from the NCCCR and clinical data from claims, using ICD-9 and CPT codes. Bivariate statistics were used to compare care model groups, modified Poisson regression to evaluate the receipt of surgical staging and chemotherapy, and Cox models and KM curves to explore crude survival differences. Results: A total of 1,964 women had UC linked to insurance claims. Mean age was 67 (± 12) years, 328 (17%) were racial/ ethnic minorities, and 618 (31%) resided in nonmetropolitan counties. Stage was 73% (n = 1,473) localized, 19% (n = 378) regional, 5% (n = 105) distant, and less than 1% (n = 8) unknown, with 66% (n = 1,287) low-risk and 34% (n = 677) grade 3 histology. For initial surgery, 73% (n = 1,519) were performed at HV centers. Lymphadenectomy was performed in 71% (n = 1,388) of all cases, and in 498 (74%) of 677 patients with grade 3. In adjusted models, LV centers were less likely to perform lymphadenectomy (RR 0.73, 95% CI 0.66–0.80) with a trend toward decreased chemotherapy for type 2 patients (RR 0.73, 95% CI 0.51–1.05). Among type 2 patients receiving chemotherapy, 62% (n = 92) were in HV-All, 27% (n = 40) HV-Hybrid, and 11% LV (n = 17) models. HV-All patients experienced lowest mortality (Fig. 1) while a 50% greater risk of mortality was seen in both HVHybrid (RR 1.5, 95% CI 0.9–2.6) and LV (RR 1.5, 95% CI 0.7–3.2) patients.
UN
91 - Featured Poster Session A quick and inexpensive alternative to frozen section for diagnosing myometrial invasion in endometrial cancer A.F. Burnetta, B. Stoneb, K.K. Zorna, C.M. Quicka. aUniversity of Arkansas for Medical Sciences, Little Rock, AR, USA, bJohns Hopkins University, Baltimore, MD, USA Objectives: Depth of myometrial invasion is an important determinant for performing lymphadenectomy in endometrial cancer. Frozen section of the uterus correlates with final pathology 87% to 92% of the time but is associated with increased time and expense. We have developed a technique that can be used in the operating room immediately after the uterus is removed, which accurately predicts the depth of endometrial cancer invasion. Methods: Fifteen women with endometrial cancer who were undergoing hysterectomy and bilateral salpingo-oophorectomy with