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Current utilization of robotic procedures by gynecologic oncologist: A multi-institutional retrospective review of outcomes
ABSTRACTS / Gynecologic Oncology 111 (2008) 373–386
and the formation of the activating synapse displaces MUC 16 from the area of cell to cell contact. It was observed that MUC16 is virtually absent from the interface between the NK cell and the tumor cell when treated with KS-IL2. Conclusions. MUC16/CA125 protects tumor cells from the cells of the innate immune system by providing a steric barrier to immune cell synapse formation. The high affinity of the antibody–antigen interaction coupled with the high affinity Fc– Fc receptor interaction and the activating effects of Immunocytokine KS-IL2 can overcome this barrier making ovarian cancer cells sensitive to NK cell lysis. doi:10.1016/j.ygyno.2008.07.068
9 Effect of robotic surgery on a Gynecologic Oncology Fellowship Training Program A.V. Hoekstra, A. Jairam-Thodla, E. Berry, J.R. Lurain, B.M. Buttin, D.K. Singh, J.C. Schink, M.P. Lowe Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Northwestern University, Chicago, IL, USA Objective. Robotic surgery is increasingly being incorporated into the practice of gynecologic oncology and into some institutions with fellowship programs. The purpose of this study was to analyze the feasibility and evaluate the impact of a new robotic surgery program on the surgical practice management of endometrioid adenocarcinoma of the uterus in a fellowship training program. Methods. In July of 2007, a robotic surgery program was introduced into a fellowship training program. A prospective database of all patients undergoing surgical staging of endometrial cancer at Northwestern University between July and December of 2007 was analyzed. Demographic data and perioperative outcomes were compared between cases performed via laparotomy (LAP), laparoscopy (LSC) and robotassistance (ROB). Variables analyzed included age, body mass index (BMI), stage, grade, operative time, estimated blood loss (EBL), length of hospital stay, and total lymph node count. Proportion of staging surgeries performed with minimally invasive surgery, number of days this cohort of patients spent inpatient, and number of staging surgeries in which the fellow was either first-assist (LAP/LSC) or performed as console operator (ROB) were also evaluated. Results. Thirty-eight patients were identified who underwent surgical staging procedures for endometrioid adenocarcinoma of the uterus, including hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and peritoneal washings at our institution during a six-month period. There were 18 patients in the LAP group, 6 in the LSC group, and 14 in the ROB group. Median age (57 vs. 59 vs. 61; p = 0.74) and BMI (35 vs. 29 vs. 29; p = 0.15) did not differ between the LAP, LSC and ROB groups, respectively. Total lymph node counts (20 vs. 20 vs.
377
17; p = 0.81) also did not differ between the LAP, LSC and ROB groups. The ROB group had shorter median operating time (185 min for ROB vs. 202 min for LAP vs. 281 min for LSC; p = 0.0022), less EBL (50 mL for ROB vs. 400 mL for LAP vs. 125 for LSC; p b 0.0001), shorter median hospital stay than LAP (1 day vs. 4 days; p b 0.0001) and equal hospital stay to LSC (1 day). Minimally invasive surgical staging surgeries increased from b10% (laparoscopy) to 53% (laparoscopy and robotic) after the introduction of the robotic surgery program. Total number of inpatient days for this group of patients decreased from 204 to 96 during the six months before and after the robotic surgery program was established. The fellow-in-training was either firstassist or console operator for 73% of all of the endometrial staging surgeries in the first 3 months after robotic surgery was introduced, increasing to 100% in the following 3-month block. The fellow role transitioned in the latter 3 months from bedside assistant to console operator, performing the hysterectomy and pelvic nodal dissections. Conclusions. The introduction of a robotic surgery program at a fellowship training program is feasible, offering broadened surgical training, improved perioperative patient outcomes, lower complication rates, and decreased hospital census. Robotic surgery dramatically altered our surgical practice management of endometrial cancer from use of laparotomy to a minimally invasive approach within 6 months. High levels of participation in robotic staging procedures as well as continued training in laparoscopic and open techniques for fellows are challenges to be considered by centers. doi:10.1016/j.ygyno.2008.07.071
10 Current utilization of robotic procedures by gynecologic oncologist: A multi-institutional retrospective review of outcomes M.L. Tyndall a, M.P. Lowe b, P.R. Johnson c , S.A. Kamelle c, W.B. Davenport a, J.J. Bringman a, D.H. Chamberlain d, T.D. Tillmanns a a UT HSC, Memphis, TN, USA b Northwestern University Feinberg School of Medicine, Chicago, IL, USA c Aurora Gynecologic Oncology, Milwaukee, WI, USA d UT HSC, Chattanooga, TN, USA Objective. Limited data exists regarding the effectiveness of the da Vinci Robotic Surgical System in the gynecologic oncology community. The primary objective was to report typical patterns of usage, operative details, and complications associated with the use of the da Vinci Robotic Surgical System in gynecologic oncology and to determine whether operative time and estimated blood loss decreased with successive surgeries per surgeon. Methods. This was a multi-institutional retrospective study regarding the utilization of the da Vinci Robotic Surgical System. Five gynecologic oncologists at four geographically separate locations compiled data from 4/2003 to 3/2008. Patient
378
ABSTRACTS / Gynecologic Oncology 111 (2008) 373–386
demographics, procedural information, and postoperative course were obtained from patient hospital and office records. SAS 9.1 was utilized to generate frequencies and linear regression models. Results. There were 639 patients involved with no exclusions. The most common procedures performed, in order of frequency, included: hysterectomy with bilateral/unilateral salpingooophorectomy (261); hysterectomy with bilateral salphingooophorectomy and lymph node dissection (201); unilateral or bilateral salphingo-oophorectomy (70); and radical and modified radical hysterectomy (28). The mean operative time for all procedures was 127 min (SD = 82.1) and estimated blood loss was 67.3 cm3 (SD = 87.1). The mean age of patients was 55 years of age, mean body mass index was 29.9 (SD 8.0), node count 12.0 (SD 11.73) and hospital stay was 1.33 days (SD 0.92). The total number of intra-operative complications was 18 (2.8%) with the most common including vascular (0.63%), bladder (0.63%) and bowel (0.63%). Postoperative complications occurred in 21 (3.3%) patients, with the most common including vaginal cuff dehiscence (0.78%), DVT/PE (0.63%) and genitourinary infections (0.63%). The conversion to laparotomy rate was 3.8% with the most common reasons being uterine size (1.1%), adhesions (0.94%) and need for staging (0.94%). Of the 639 procedures, 495 involved a form of hysterectomy. The operative times (min) by procedure type were as follows: hysterectomy with bilateral/unilateral salpingo-oophorectomy 113 (SD = 70), hysterectomy with bilateral salphingo-oophorectomy and lymphadenectomy 155 (SD = 70), radical hysterectomy with lymphadenectomy 217 (SD = 128), modified radical hysterectomy with lymphadenectomy 180 (SD = 0.0), and simple hysterectomy (N = 5). Mean operative time for each procedure (min) in order:),), and Estimated blood loss (EBL) decreased for one physician, while operative time decreased for three of the physicians. Conclusions. The da Vinci Robotic Surgical System provides gynecologic oncologists with a minimally invasive option for performing multiple surgical procedures while minimizing operative time and blood loss. Operative time seems to improve with each sequential case; however, EBL decreases rapidly with the first several cases but is less easily improved after this milestone.
(PR) expression is common in uterine sarcomas and that hormonal therapy would be an effective treatment option. Methods. Under an IRB-approved protocol we retrospectively reviewed 46 charts of patients with uterine sarcomas. Information on patient demographics, surgico-pathologic features and outcomes were abstracted. We reviewed the treatment and recurrence patterns with specific focus on hormonal treatment of both primary and recurrent disease. Results. 8 patients with ESS were treated with hormone therapy of which 7 were low grade ESS and ER/PR positive. 4 of these patients had adjuvant hormone therapy: 2 received aromatase inhibitors (AI) and remain without disease for 16– 40 months and 1 received Megace and remains without disease for 149 months. 2 patients with recurrent ESS have had sustained clinical responses on AI: one CR for 54 months and 1 PR for 60 months. 8 pts with ER positive leiomyosarcoma (LMS) have been treated with hormone therapy. 3 of these patients received AI as adjuvant treatment and remain without evidence of disease for 18 to 68 months. 5 patients with recurrent LMS received salvage hormone therapy of whom 4 had stable disease sustained for 12–60 months: 3 treated with AI and 1 treated with Tamoxifen. 3 pts with mixed mesodermal mullerian tumors (MMMT) whose ER/PR status was not tested were treated with hormones as salvage therapy for recurrent disease. 2 of these patients had stable disease for 4 months with Megace and Tamoxifen. 1 patient with ER positive adenosarcoma (AS) treated with adjuvant Tamoxifen remains without evidence of disease at 23 months. There were no reported grade 3 or 4 toxicities with any hormonal therapy. Conclusions. The majority of patients, 26/29 (90%), with uterine sarcomas whose receptor status was tested were ER/PR positive. Thus, routine staining for ER/PR status is advised. We report durable responses to AI in 2 patients with recurrent ESS and disease stabilization with Tamoxifen and Megace in the majority of treated patients. Given the minimal toxicity and ease of administration associated with these medications, hormonal therapy should be considered as salvage therapy for recurrent uterine sarcomas. Future investigation of hormonal therapy as adjuvant treatment is warranted.
doi:10.1016/j.ygyno.2008.07.073
doi:10.1016/j.ygyno.2008.07.074
11 Hormonal therapies demonstrate high response rates in treatment of recurrent uterine sarcomas Y.J. Ioffe, A.J. Li, C. Walsh, B.Y. Karlan, R. Leuchter, I. Cass Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
12 Frozen section is inaccurate at predicting need for staging in endometrial cancer A. Papadia a, G. Azioni b, K. Nishida a, S. Seitz c, S. Bucholz c, B. Brusacà b, E. Fulcheri b, N. Ragni b, E. Jimenez a, J.A. Lucci III a a University of Miami Miller School of Medicine, USA b University of Genova, Italy c University of Regensburg, Germany
Objectives. Uterine sarcomas are a heterogeneous group of tumors with a highly variable clinical course. While hormonal approaches have been reported to be effective in the treatment of low-grade endometrial stromal sarcomas (ESS), their utility in treating other higher grade uterine sarcomas remains unknown. We hypothesized that estrogen and progesterone receptor (ER)/
Objective. To evaluate accuracy of intraoperative frozen section (FS) at identifying risk for lymph node involvement when compared with final pathology.
and the formation of the activating synapse displaces MUC 16 from the area of cell to cell contact. It was observed that MUC16 is virtually absent from the interface between the NK cell and the tumor cell when treated with KS-IL2. Conclusions. MUC16/CA125 protects tumor cells from the cells of the innate immune system by providing a steric barrier to immune cell synapse formation. The high affinity of the antibody–antigen interaction coupled with the high affinity Fc– Fc receptor interaction and the activating effects of Immunocytokine KS-IL2 can overcome this barrier making ovarian cancer cells sensitive to NK cell lysis. doi:10.1016/j.ygyno.2008.07.068
9 Effect of robotic surgery on a Gynecologic Oncology Fellowship Training Program A.V. Hoekstra, A. Jairam-Thodla, E. Berry, J.R. Lurain, B.M. Buttin, D.K. Singh, J.C. Schink, M.P. Lowe Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Northwestern University, Chicago, IL, USA Objective. Robotic surgery is increasingly being incorporated into the practice of gynecologic oncology and into some institutions with fellowship programs. The purpose of this study was to analyze the feasibility and evaluate the impact of a new robotic surgery program on the surgical practice management of endometrioid adenocarcinoma of the uterus in a fellowship training program. Methods. In July of 2007, a robotic surgery program was introduced into a fellowship training program. A prospective database of all patients undergoing surgical staging of endometrial cancer at Northwestern University between July and December of 2007 was analyzed. Demographic data and perioperative outcomes were compared between cases performed via laparotomy (LAP), laparoscopy (LSC) and robotassistance (ROB). Variables analyzed included age, body mass index (BMI), stage, grade, operative time, estimated blood loss (EBL), length of hospital stay, and total lymph node count. Proportion of staging surgeries performed with minimally invasive surgery, number of days this cohort of patients spent inpatient, and number of staging surgeries in which the fellow was either first-assist (LAP/LSC) or performed as console operator (ROB) were also evaluated. Results. Thirty-eight patients were identified who underwent surgical staging procedures for endometrioid adenocarcinoma of the uterus, including hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and peritoneal washings at our institution during a six-month period. There were 18 patients in the LAP group, 6 in the LSC group, and 14 in the ROB group. Median age (57 vs. 59 vs. 61; p = 0.74) and BMI (35 vs. 29 vs. 29; p = 0.15) did not differ between the LAP, LSC and ROB groups, respectively. Total lymph node counts (20 vs. 20 vs.
377
17; p = 0.81) also did not differ between the LAP, LSC and ROB groups. The ROB group had shorter median operating time (185 min for ROB vs. 202 min for LAP vs. 281 min for LSC; p = 0.0022), less EBL (50 mL for ROB vs. 400 mL for LAP vs. 125 for LSC; p b 0.0001), shorter median hospital stay than LAP (1 day vs. 4 days; p b 0.0001) and equal hospital stay to LSC (1 day). Minimally invasive surgical staging surgeries increased from b10% (laparoscopy) to 53% (laparoscopy and robotic) after the introduction of the robotic surgery program. Total number of inpatient days for this group of patients decreased from 204 to 96 during the six months before and after the robotic surgery program was established. The fellow-in-training was either firstassist or console operator for 73% of all of the endometrial staging surgeries in the first 3 months after robotic surgery was introduced, increasing to 100% in the following 3-month block. The fellow role transitioned in the latter 3 months from bedside assistant to console operator, performing the hysterectomy and pelvic nodal dissections. Conclusions. The introduction of a robotic surgery program at a fellowship training program is feasible, offering broadened surgical training, improved perioperative patient outcomes, lower complication rates, and decreased hospital census. Robotic surgery dramatically altered our surgical practice management of endometrial cancer from use of laparotomy to a minimally invasive approach within 6 months. High levels of participation in robotic staging procedures as well as continued training in laparoscopic and open techniques for fellows are challenges to be considered by centers. doi:10.1016/j.ygyno.2008.07.071
10 Current utilization of robotic procedures by gynecologic oncologist: A multi-institutional retrospective review of outcomes M.L. Tyndall a, M.P. Lowe b, P.R. Johnson c , S.A. Kamelle c, W.B. Davenport a, J.J. Bringman a, D.H. Chamberlain d, T.D. Tillmanns a a UT HSC, Memphis, TN, USA b Northwestern University Feinberg School of Medicine, Chicago, IL, USA c Aurora Gynecologic Oncology, Milwaukee, WI, USA d UT HSC, Chattanooga, TN, USA Objective. Limited data exists regarding the effectiveness of the da Vinci Robotic Surgical System in the gynecologic oncology community. The primary objective was to report typical patterns of usage, operative details, and complications associated with the use of the da Vinci Robotic Surgical System in gynecologic oncology and to determine whether operative time and estimated blood loss decreased with successive surgeries per surgeon. Methods. This was a multi-institutional retrospective study regarding the utilization of the da Vinci Robotic Surgical System. Five gynecologic oncologists at four geographically separate locations compiled data from 4/2003 to 3/2008. Patient
378
ABSTRACTS / Gynecologic Oncology 111 (2008) 373–386
demographics, procedural information, and postoperative course were obtained from patient hospital and office records. SAS 9.1 was utilized to generate frequencies and linear regression models. Results. There were 639 patients involved with no exclusions. The most common procedures performed, in order of frequency, included: hysterectomy with bilateral/unilateral salpingooophorectomy (261); hysterectomy with bilateral salphingooophorectomy and lymph node dissection (201); unilateral or bilateral salphingo-oophorectomy (70); and radical and modified radical hysterectomy (28). The mean operative time for all procedures was 127 min (SD = 82.1) and estimated blood loss was 67.3 cm3 (SD = 87.1). The mean age of patients was 55 years of age, mean body mass index was 29.9 (SD 8.0), node count 12.0 (SD 11.73) and hospital stay was 1.33 days (SD 0.92). The total number of intra-operative complications was 18 (2.8%) with the most common including vascular (0.63%), bladder (0.63%) and bowel (0.63%). Postoperative complications occurred in 21 (3.3%) patients, with the most common including vaginal cuff dehiscence (0.78%), DVT/PE (0.63%) and genitourinary infections (0.63%). The conversion to laparotomy rate was 3.8% with the most common reasons being uterine size (1.1%), adhesions (0.94%) and need for staging (0.94%). Of the 639 procedures, 495 involved a form of hysterectomy. The operative times (min) by procedure type were as follows: hysterectomy with bilateral/unilateral salpingo-oophorectomy 113 (SD = 70), hysterectomy with bilateral salphingo-oophorectomy and lymphadenectomy 155 (SD = 70), radical hysterectomy with lymphadenectomy 217 (SD = 128), modified radical hysterectomy with lymphadenectomy 180 (SD = 0.0), and simple hysterectomy (N = 5). Mean operative time for each procedure (min) in order:),), and Estimated blood loss (EBL) decreased for one physician, while operative time decreased for three of the physicians. Conclusions. The da Vinci Robotic Surgical System provides gynecologic oncologists with a minimally invasive option for performing multiple surgical procedures while minimizing operative time and blood loss. Operative time seems to improve with each sequential case; however, EBL decreases rapidly with the first several cases but is less easily improved after this milestone.
(PR) expression is common in uterine sarcomas and that hormonal therapy would be an effective treatment option. Methods. Under an IRB-approved protocol we retrospectively reviewed 46 charts of patients with uterine sarcomas. Information on patient demographics, surgico-pathologic features and outcomes were abstracted. We reviewed the treatment and recurrence patterns with specific focus on hormonal treatment of both primary and recurrent disease. Results. 8 patients with ESS were treated with hormone therapy of which 7 were low grade ESS and ER/PR positive. 4 of these patients had adjuvant hormone therapy: 2 received aromatase inhibitors (AI) and remain without disease for 16– 40 months and 1 received Megace and remains without disease for 149 months. 2 patients with recurrent ESS have had sustained clinical responses on AI: one CR for 54 months and 1 PR for 60 months. 8 pts with ER positive leiomyosarcoma (LMS) have been treated with hormone therapy. 3 of these patients received AI as adjuvant treatment and remain without evidence of disease for 18 to 68 months. 5 patients with recurrent LMS received salvage hormone therapy of whom 4 had stable disease sustained for 12–60 months: 3 treated with AI and 1 treated with Tamoxifen. 3 pts with mixed mesodermal mullerian tumors (MMMT) whose ER/PR status was not tested were treated with hormones as salvage therapy for recurrent disease. 2 of these patients had stable disease for 4 months with Megace and Tamoxifen. 1 patient with ER positive adenosarcoma (AS) treated with adjuvant Tamoxifen remains without evidence of disease at 23 months. There were no reported grade 3 or 4 toxicities with any hormonal therapy. Conclusions. The majority of patients, 26/29 (90%), with uterine sarcomas whose receptor status was tested were ER/PR positive. Thus, routine staining for ER/PR status is advised. We report durable responses to AI in 2 patients with recurrent ESS and disease stabilization with Tamoxifen and Megace in the majority of treated patients. Given the minimal toxicity and ease of administration associated with these medications, hormonal therapy should be considered as salvage therapy for recurrent uterine sarcomas. Future investigation of hormonal therapy as adjuvant treatment is warranted.
doi:10.1016/j.ygyno.2008.07.073
doi:10.1016/j.ygyno.2008.07.074
11 Hormonal therapies demonstrate high response rates in treatment of recurrent uterine sarcomas Y.J. Ioffe, A.J. Li, C. Walsh, B.Y. Karlan, R. Leuchter, I. Cass Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
12 Frozen section is inaccurate at predicting need for staging in endometrial cancer A. Papadia a, G. Azioni b, K. Nishida a, S. Seitz c, S. Bucholz c, B. Brusacà b, E. Fulcheri b, N. Ragni b, E. Jimenez a, J.A. Lucci III a a University of Miami Miller School of Medicine, USA b University of Genova, Italy c University of Regensburg, Germany
Objectives. Uterine sarcomas are a heterogeneous group of tumors with a highly variable clinical course. While hormonal approaches have been reported to be effective in the treatment of low-grade endometrial stromal sarcomas (ESS), their utility in treating other higher grade uterine sarcomas remains unknown. We hypothesized that estrogen and progesterone receptor (ER)/
Objective. To evaluate accuracy of intraoperative frozen section (FS) at identifying risk for lymph node involvement when compared with final pathology.