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Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer
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Abstracts / Gynecologic Oncology 145 (2017) 2–220
complications). Only 1 patient in the Db group required intensive care unit admission. For the groups combined, high-level compliance was observed for the following ERAS protocol elements: avoidance of bowel preparation (96.2%), avoidance of preoperative sedative medication (100%), thrombosis prophylaxis (80.8%), aggressive postoperative nausea/vomiting prophylaxis (95.7%), and avoidance of resection site drainage (96.2%). Poor compliance was observed for early termination of urinary drainage (57.7%), mobilization on day of surgery (61.5%), early termination of intravenous fluids (11.5%), and introduction of solid food on day of surgery (25%). Conclusion: Despite formal implementation of an enhanced recovery protocol, audit of compliance with protocol elements showed widespread differences in uptake. This study emphasizes the importance of continued audit and feedback allowing the clinical team to iterate toward improved protocol compliance that theoretically should translate into improved patient outcomes. doi:10.1016/j.ygyno.2017.03.436
409 - Poster Session Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer R.A. Cowan, J.H. Tseng, V. Murthy, R. Srivastava, K. Long Roche, O. Zivanovic, G.J. Gardner, D.S. Chi, Y. Sonoda. Memorial Sloan Kettering Cancer Center, New York, NY, USA Objective: Surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) in the setting of primary treatment for advanced ovarian cancer has not been widely studied. The objective of this study was to report a cohort of patients who underwent CPLN resection at a single institution. Method: With institutional review board approval, all patients with stage IIIB-IV ovarian cancer who underwent primary cytoreductive surgery for high-grade epithelial ovarian cancer from January 2001 to December 2013 were identified. Patients who underwent CPLN resection composed the study cohort. Clinical and pathological data were collected. Appropriate statistical tests were performed. Results: There were 54 patients who underwent CPLN resection. Enlarged CPLNs were documented on the preoperative radiologic imaging in all cases. The median diameter of the enlarged CPLN was 1.3 cm (range 0.6–2.9). The median age was 59 years (range 41–74). Forty-eight patients (88.9%) underwent transdiaphragmatic resection either by gynecologic oncologist or a consulting physician, while 6 (11.1%) underwent a VATS procedure by a thoracic surgeon. A median of 3 nodes (range 1–23) was resected. A median of 2 nodes (range 0–22) was positive for metastatic disease. Of 54 patients, 51 (94.4%) had nodes positive for metastatic disease. Fifty-one patients (94.4%) had a chest tube placed at time of procedure and median time to removal was 4 days (range 2–12). Peritoneal carcinomatosis was present in 44 patients (81.4%). Twenty-three (43%) patients experienced a general postoperative complication; however, only 4 (7%) were directly related to the thoracic procedure. Median time to adjuvant chemotherapy was 40 days (range 19–205). All patients were optimally cytoreduced, and 30 (55.6%) had no visible residual disease. Median progression-free survival was 17.2 months (95% CI 12.6–21.8). Median overall survival was 70.1 months (95% CI 51.2–89.0). Conclusion: Enlarged CPLN can be identified on preoperative imaging and may be indicative of metastases. CPLN metastases can be resected to document extra-abdominal disease and to obtain an optimal cytoreduction. In the proper setting, CPLN resection can be performed safely and does not delay chemotherapy. doi:10.1016/j.ygyno.2017.03.437
410 - Poster Session Impact of consistent intraoperative assessment on predicting tumor size, myometrial invasion, and cervical involvement: Results from an observational cohort B.Q. Smith, J.D. Boone, E.D. Thomas, T.B. Turner, G. McGwin, A.M. Stisher, C.A. Leath III, W.K. Huh. University of Alabama at Birmingham, Birmingham, AL, USA Objective: The initial treatment for endometrial cancer (EC) involves surgical resection as well as a staging procedure. Attempts have been made to determine which patients are at an increased risk of lymph node metastasis in an effort to avoid lymphadenectomy and its associated morbidity. No study to date has evaluated a surgeon’s use of the Mayo Criteria intraoperatively to determine the need for lymphadenectomy. The goal of this study is to assess the reliability of intraoperative uterine assessment compared to final pathologic evaluation in patients with EC and whether assessment improves with experience. Method: Following institutional review board approval, a prospective study of women surgically managed with biopsy proven complex atypical hyperplasia (CAH) or EC between March 2015 and September 2016 was performed. 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 coefficient (ICC). Results: A total of 240 patients with a preoperative diagnosis of CAH or EC were included, 61 (25.4%) with CAH and 179 (74.6%) with EC. Mean age was 62.65 ± 10.5 years, and mean BMI was 37.2 ± 10.7. The majority of women were Caucasian (67%). Two hundred five (85.4%) patients underwent a laparoscopic or robotic hysterectomy, and 35 (14.6%) underwent an exploratory laparotomy. Two hundred twenty two (92.5%) patients had EC, and 18 (7.5%) patients had CAH on final pathology. There was a fair correlation between intraoperative estimation of myometrial invasion (κ = 0.37). Moderate correlation exists between intraoperative estimation of lower uterine segment/ cervical involvement (κ = 0.61). There was a strong correlation between intraoperative tumor size assessment and final path (ICC = 0.75). Intraoperative correlation of tumor size was similar for the first half of the cohort (κ = 0.50) and the second half (κ = 0.46). Conclusion: Myometrial invasion is difficult to evaluate grossly and thus should not be relied upon. Cervical involvement and tumor size are more readily identified and can be utilized intraoperatively to aid in determining the need for a staging procedure. Intraoperative assessment does not appear to improve with experience. doi:10.1016/j.ygyno.2017.03.438
411 - Poster Session A comparison of robotic laparoendoscopic single site vs robotic multiport hysterectomy and sentinel lymph node mapping for low grade endometrial cancer: Surgical outcomes and cost analysis L.A. Moukarzela, A.N. Fadera, E.J. Tanner IIIb. aJohns Hopkins School of Medicine, Baltimore, MD, USA, bJohns Hopkins Hospital, Baltimore, MD, USA Objective: To compare operative times, surgical outcomes, and costs of robotic laparoendoscopic single-site (R-LESS) versus multiport robotic-assisted total laparoscopic hysterectomy (TLH) with sentinel lymph node (SLN) mapping for low-grade endometrial cancer.
Abstracts / Gynecologic Oncology 145 (2017) 2–220
complications). Only 1 patient in the Db group required intensive care unit admission. For the groups combined, high-level compliance was observed for the following ERAS protocol elements: avoidance of bowel preparation (96.2%), avoidance of preoperative sedative medication (100%), thrombosis prophylaxis (80.8%), aggressive postoperative nausea/vomiting prophylaxis (95.7%), and avoidance of resection site drainage (96.2%). Poor compliance was observed for early termination of urinary drainage (57.7%), mobilization on day of surgery (61.5%), early termination of intravenous fluids (11.5%), and introduction of solid food on day of surgery (25%). Conclusion: Despite formal implementation of an enhanced recovery protocol, audit of compliance with protocol elements showed widespread differences in uptake. This study emphasizes the importance of continued audit and feedback allowing the clinical team to iterate toward improved protocol compliance that theoretically should translate into improved patient outcomes. doi:10.1016/j.ygyno.2017.03.436
409 - Poster Session Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer R.A. Cowan, J.H. Tseng, V. Murthy, R. Srivastava, K. Long Roche, O. Zivanovic, G.J. Gardner, D.S. Chi, Y. Sonoda. Memorial Sloan Kettering Cancer Center, New York, NY, USA Objective: Surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) in the setting of primary treatment for advanced ovarian cancer has not been widely studied. The objective of this study was to report a cohort of patients who underwent CPLN resection at a single institution. Method: With institutional review board approval, all patients with stage IIIB-IV ovarian cancer who underwent primary cytoreductive surgery for high-grade epithelial ovarian cancer from January 2001 to December 2013 were identified. Patients who underwent CPLN resection composed the study cohort. Clinical and pathological data were collected. Appropriate statistical tests were performed. Results: There were 54 patients who underwent CPLN resection. Enlarged CPLNs were documented on the preoperative radiologic imaging in all cases. The median diameter of the enlarged CPLN was 1.3 cm (range 0.6–2.9). The median age was 59 years (range 41–74). Forty-eight patients (88.9%) underwent transdiaphragmatic resection either by gynecologic oncologist or a consulting physician, while 6 (11.1%) underwent a VATS procedure by a thoracic surgeon. A median of 3 nodes (range 1–23) was resected. A median of 2 nodes (range 0–22) was positive for metastatic disease. Of 54 patients, 51 (94.4%) had nodes positive for metastatic disease. Fifty-one patients (94.4%) had a chest tube placed at time of procedure and median time to removal was 4 days (range 2–12). Peritoneal carcinomatosis was present in 44 patients (81.4%). Twenty-three (43%) patients experienced a general postoperative complication; however, only 4 (7%) were directly related to the thoracic procedure. Median time to adjuvant chemotherapy was 40 days (range 19–205). All patients were optimally cytoreduced, and 30 (55.6%) had no visible residual disease. Median progression-free survival was 17.2 months (95% CI 12.6–21.8). Median overall survival was 70.1 months (95% CI 51.2–89.0). Conclusion: Enlarged CPLN can be identified on preoperative imaging and may be indicative of metastases. CPLN metastases can be resected to document extra-abdominal disease and to obtain an optimal cytoreduction. In the proper setting, CPLN resection can be performed safely and does not delay chemotherapy. doi:10.1016/j.ygyno.2017.03.437
410 - Poster Session Impact of consistent intraoperative assessment on predicting tumor size, myometrial invasion, and cervical involvement: Results from an observational cohort B.Q. Smith, J.D. Boone, E.D. Thomas, T.B. Turner, G. McGwin, A.M. Stisher, C.A. Leath III, W.K. Huh. University of Alabama at Birmingham, Birmingham, AL, USA Objective: The initial treatment for endometrial cancer (EC) involves surgical resection as well as a staging procedure. Attempts have been made to determine which patients are at an increased risk of lymph node metastasis in an effort to avoid lymphadenectomy and its associated morbidity. No study to date has evaluated a surgeon’s use of the Mayo Criteria intraoperatively to determine the need for lymphadenectomy. The goal of this study is to assess the reliability of intraoperative uterine assessment compared to final pathologic evaluation in patients with EC and whether assessment improves with experience. Method: Following institutional review board approval, a prospective study of women surgically managed with biopsy proven complex atypical hyperplasia (CAH) or EC between March 2015 and September 2016 was performed. 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 coefficient (ICC). Results: A total of 240 patients with a preoperative diagnosis of CAH or EC were included, 61 (25.4%) with CAH and 179 (74.6%) with EC. Mean age was 62.65 ± 10.5 years, and mean BMI was 37.2 ± 10.7. The majority of women were Caucasian (67%). Two hundred five (85.4%) patients underwent a laparoscopic or robotic hysterectomy, and 35 (14.6%) underwent an exploratory laparotomy. Two hundred twenty two (92.5%) patients had EC, and 18 (7.5%) patients had CAH on final pathology. There was a fair correlation between intraoperative estimation of myometrial invasion (κ = 0.37). Moderate correlation exists between intraoperative estimation of lower uterine segment/ cervical involvement (κ = 0.61). There was a strong correlation between intraoperative tumor size assessment and final path (ICC = 0.75). Intraoperative correlation of tumor size was similar for the first half of the cohort (κ = 0.50) and the second half (κ = 0.46). Conclusion: Myometrial invasion is difficult to evaluate grossly and thus should not be relied upon. Cervical involvement and tumor size are more readily identified and can be utilized intraoperatively to aid in determining the need for a staging procedure. Intraoperative assessment does not appear to improve with experience. doi:10.1016/j.ygyno.2017.03.438
411 - Poster Session A comparison of robotic laparoendoscopic single site vs robotic multiport hysterectomy and sentinel lymph node mapping for low grade endometrial cancer: Surgical outcomes and cost analysis L.A. Moukarzela, A.N. Fadera, E.J. Tanner IIIb. aJohns Hopkins School of Medicine, Baltimore, MD, USA, bJohns Hopkins Hospital, Baltimore, MD, USA Objective: To compare operative times, surgical outcomes, and costs of robotic laparoendoscopic single-site (R-LESS) versus multiport robotic-assisted total laparoscopic hysterectomy (TLH) with sentinel lymph node (SLN) mapping for low-grade endometrial cancer.