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Perioperative thromboembolism prophylaxis: How much is enough?
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Abstracts / Gynecologic Oncology 133 (2014) 2–207
179 - Poster Session A Determinants of pelvic and para-aortic lymph node metastasis in endometrial cancer and its role in tailoring lymphadenectomy H. Fakhry1, I. Konishi2. 1South Egypt Cancer Institute, Assiut University, Assiut, Egypt, 2Kyoto University Graduate School of Medicine, Sakyo-ku, Japan. Objectives: Complete lymphadenectomy may be omitted in selected cases in which the risk of lymph node spread is low (low-risk cancer). In this study, we aimed to study the various clinicopathologic variables affecting lymph node metastasis, to evaluate the incidence and distribution of pelvic lymph nodes (PLN) and paraaortic lymph node (PALN) metastases in endometrial cancer, and to study intraoperative and postoperative complications of pelvic and para-aortic lymphadenectomy. Methods: Our study included 78 patients with endometrial cancer between June 2005 and May 2011. The surgical procedure involved peritoneal cytology, total or radical hysterectomy, and bilateral salpingooophorectomy with pelvic and para-aortic lymphadenectomy. Statistical analysis was performed using Fisher's exact probability test, and P b 0.05 was considered statistically significant. Results: Positive LN metastasis was diagnosed in 41% of patients: 23% with PLN and PALN metastasis, 10.3% with PLN metastasis only, and 7.7% with PALN metastasis only. The most commonly involved PLN groups were internal iliac and obturator LNs (67.9% and 61.5%). In the aortic area, the most commonly involved group (66.6%) was the preaortic LNs (supra- and inframesentric). PLN and PALN metastasis in stages III and IV was significantly higher than in stages I and II. Myometrial invasion, cervical invasion, adnexal metastasis, and lymphovascular invasion were significantly correlated with PLN metastasis, while myometrial invasion, adnexal metastasis, and lymphovascular invasion were significantly correlated with PALN metastasis. Postoperative complications were observed in 50 patients (64.1%). The most common complication was pelvic lymphocysts in 46.1%. Ileus and deep venous thrombosis were seen in 7.6%. None of the complications resulted in death. Conclusions: Our findings suggest that systemic lymphadenectomy can be omitted in endometrial carcinoma patients who have favorable clinicopathological determinants (stage I, endometroid type, myometrial invasion b50%, and absence of lymphovascular invasion) because of low risk for LN metastasis and to avoid perioperative complications. However, these results should be confirmed in prospective large-scale, randomized clinical trials. doi:10.1016/j.ygyno.2014.03.199
180 - Poster Session A Perioperative thromboembolism prophylaxis: How much is enough? E. Chalas, M. Quinones , V. Rojas, J.A. Villella, K.C. Chan, E.A. Jimenez, S. Islam. Winthrop University Hospital, Mineola, NY, USA. Objectives: Determine the incidence of venous thromboembolism (VTE) in a single institution and identify a subgroup of patients who may benefit from prolonged VTE prophylaxis after discharge. Methods: A retrospective review was carried out of perioperative care of women undergoing major surgery for gynecologic cancer and treated in accordance to a standardized perioperative thromboprophylaxis management between 2008 and 2010. Comprehensive data from the entire perioperative course were collected from hospital and outpatient records. Univariate, multivariate, and logistic regression analysis were used to identify risk factors associated with VTE. Costs of diagnostic tests and therapy were calculated applying published 2012 Medicare rates. Results: A total of 285 patients met inclusion criteria. VTE occurred in 6 patients (2.1%). The mean demographics were: age 61 years,
body mass index 31, 227 minutes of anesthesia, 169 minutes of surgery, 305 mL of estimated blood loss (EBL), and length of stay (LOS) of 2.78 days. Metastasis was present in 90 (32%) of patients. Significant variables by univariate analysis were presence of metastasis (P = 0.013), higher EBL (P = 0.004), and increased LOS (P = 0.008). Multilogistic regression linked prolonged LOS (P = 0.002) with the risk of VTE, which increased to 8.5% if LOS was N3 days. A published study of a similar hypothetical population estimated a 10% decrease in VTE incidence (1.9%) with prophylaxis extending to 30 days postsurgery. Applying this information to our population would decrease the rate of VTE from six to five patients. Total cost of prophylaxis and treatment of VTE in our population was $185,565. If extended prophylaxis had been used, the cost would have been $441,928. Thus, the cost of preventing one VTE and two diagnostic tests with this treatment approach would increase by $256,363. Conclusions: The incidence of VTE in our institution using our standardized perioperative protocol is low. Patients with metastatic disease and an LOS N3 days were at highest risk of developing a VTE. Continued prophylaxis after discharge should be considered for these patients. Extended prophylaxis for all women undergoing major surgery for cancer is not cost-effective. doi:10.1016/j.ygyno.2014.03.200
181 — Poster Session A Malignant endometrial polyps in uterine serous carcinoma: Does size matter? C. Ouyang1, M. Frimer1, Y. Wang1, L.Y. Hou2, D.Y.S. Kuo1, G.L. Goldberg1, J.Y. Hou1. 1Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA, 2New England Baptist Hospital, Boston, MA, USA. Objectives: Uterine papillary serous carcinoma (UPSC) can present with extrapelvic metastasis in the setting of limited intrauterine disease. We sought to evaluate clinical and pathologic parameters, such as polyp size, and their impact on outcome in stage IA USC patients with cancer limited to a polyp vs those in whom disease involved the endometrium. Methods: From 2002 to 2013, relevant clinical and pathologic information were retrospectively extracted in 129 patients with pure UPSC, with the disease limited to a polyp and/or endometrium without extrauterine spread. Separately, data were collected for patients with UPSC limited to a polyp in the endometrium and with extrapelvic spread (stage IVB). Logistic regression was used to compute the odds ratio (OR) in continuous and categorical variables via SAS v9.1. Results: Twenty-seven patients had stage IA USC without any myometrial invasion (Table 1). Fourteen patients (52%) had tumor confined to a polyp (polyp group [PG]), with three patients having focal polyp stromal involvement. Thirteen patients had tumor limited to the endometrium (endometrial group [EG]) with (n = 5) or without (n = 8) polyp involvement. The median follow-up period was 31.6 months (range, 1–163 months). No patients had evidence of lymphovascular involvement (LVI). Patients in the PG had significantly less expression of the progesterone receptor (PR) than those in the EG. Significantly fewer patients received adjuvant treatment in the EG (6/13 [42.8%]). Recurrence was rare, with one patient in the PG recurring distally in her lungs after receiving external beam radiation therapy at 29 months after diagnosis and none in the EG. Comparing our cohort to a group of stage IVB patients with polyp-only disease in the uterus, the polyp diameter was significantly larger in those with abdominal metastasis (P = 0.009). Logistic regression analysis showed that with every 1 cm increase in malignant polyp size, the odds of having disease limited to the endometrium decreased by almost twofold (OR 0.502, 95% CI 0.285–0.883, P = 0.017). Polyps that
Abstracts / Gynecologic Oncology 133 (2014) 2–207
179 - Poster Session A Determinants of pelvic and para-aortic lymph node metastasis in endometrial cancer and its role in tailoring lymphadenectomy H. Fakhry1, I. Konishi2. 1South Egypt Cancer Institute, Assiut University, Assiut, Egypt, 2Kyoto University Graduate School of Medicine, Sakyo-ku, Japan. Objectives: Complete lymphadenectomy may be omitted in selected cases in which the risk of lymph node spread is low (low-risk cancer). In this study, we aimed to study the various clinicopathologic variables affecting lymph node metastasis, to evaluate the incidence and distribution of pelvic lymph nodes (PLN) and paraaortic lymph node (PALN) metastases in endometrial cancer, and to study intraoperative and postoperative complications of pelvic and para-aortic lymphadenectomy. Methods: Our study included 78 patients with endometrial cancer between June 2005 and May 2011. The surgical procedure involved peritoneal cytology, total or radical hysterectomy, and bilateral salpingooophorectomy with pelvic and para-aortic lymphadenectomy. Statistical analysis was performed using Fisher's exact probability test, and P b 0.05 was considered statistically significant. Results: Positive LN metastasis was diagnosed in 41% of patients: 23% with PLN and PALN metastasis, 10.3% with PLN metastasis only, and 7.7% with PALN metastasis only. The most commonly involved PLN groups were internal iliac and obturator LNs (67.9% and 61.5%). In the aortic area, the most commonly involved group (66.6%) was the preaortic LNs (supra- and inframesentric). PLN and PALN metastasis in stages III and IV was significantly higher than in stages I and II. Myometrial invasion, cervical invasion, adnexal metastasis, and lymphovascular invasion were significantly correlated with PLN metastasis, while myometrial invasion, adnexal metastasis, and lymphovascular invasion were significantly correlated with PALN metastasis. Postoperative complications were observed in 50 patients (64.1%). The most common complication was pelvic lymphocysts in 46.1%. Ileus and deep venous thrombosis were seen in 7.6%. None of the complications resulted in death. Conclusions: Our findings suggest that systemic lymphadenectomy can be omitted in endometrial carcinoma patients who have favorable clinicopathological determinants (stage I, endometroid type, myometrial invasion b50%, and absence of lymphovascular invasion) because of low risk for LN metastasis and to avoid perioperative complications. However, these results should be confirmed in prospective large-scale, randomized clinical trials. doi:10.1016/j.ygyno.2014.03.199
180 - Poster Session A Perioperative thromboembolism prophylaxis: How much is enough? E. Chalas, M. Quinones , V. Rojas, J.A. Villella, K.C. Chan, E.A. Jimenez, S. Islam. Winthrop University Hospital, Mineola, NY, USA. Objectives: Determine the incidence of venous thromboembolism (VTE) in a single institution and identify a subgroup of patients who may benefit from prolonged VTE prophylaxis after discharge. Methods: A retrospective review was carried out of perioperative care of women undergoing major surgery for gynecologic cancer and treated in accordance to a standardized perioperative thromboprophylaxis management between 2008 and 2010. Comprehensive data from the entire perioperative course were collected from hospital and outpatient records. Univariate, multivariate, and logistic regression analysis were used to identify risk factors associated with VTE. Costs of diagnostic tests and therapy were calculated applying published 2012 Medicare rates. Results: A total of 285 patients met inclusion criteria. VTE occurred in 6 patients (2.1%). The mean demographics were: age 61 years,
body mass index 31, 227 minutes of anesthesia, 169 minutes of surgery, 305 mL of estimated blood loss (EBL), and length of stay (LOS) of 2.78 days. Metastasis was present in 90 (32%) of patients. Significant variables by univariate analysis were presence of metastasis (P = 0.013), higher EBL (P = 0.004), and increased LOS (P = 0.008). Multilogistic regression linked prolonged LOS (P = 0.002) with the risk of VTE, which increased to 8.5% if LOS was N3 days. A published study of a similar hypothetical population estimated a 10% decrease in VTE incidence (1.9%) with prophylaxis extending to 30 days postsurgery. Applying this information to our population would decrease the rate of VTE from six to five patients. Total cost of prophylaxis and treatment of VTE in our population was $185,565. If extended prophylaxis had been used, the cost would have been $441,928. Thus, the cost of preventing one VTE and two diagnostic tests with this treatment approach would increase by $256,363. Conclusions: The incidence of VTE in our institution using our standardized perioperative protocol is low. Patients with metastatic disease and an LOS N3 days were at highest risk of developing a VTE. Continued prophylaxis after discharge should be considered for these patients. Extended prophylaxis for all women undergoing major surgery for cancer is not cost-effective. doi:10.1016/j.ygyno.2014.03.200
181 — Poster Session A Malignant endometrial polyps in uterine serous carcinoma: Does size matter? C. Ouyang1, M. Frimer1, Y. Wang1, L.Y. Hou2, D.Y.S. Kuo1, G.L. Goldberg1, J.Y. Hou1. 1Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA, 2New England Baptist Hospital, Boston, MA, USA. Objectives: Uterine papillary serous carcinoma (UPSC) can present with extrapelvic metastasis in the setting of limited intrauterine disease. We sought to evaluate clinical and pathologic parameters, such as polyp size, and their impact on outcome in stage IA USC patients with cancer limited to a polyp vs those in whom disease involved the endometrium. Methods: From 2002 to 2013, relevant clinical and pathologic information were retrospectively extracted in 129 patients with pure UPSC, with the disease limited to a polyp and/or endometrium without extrauterine spread. Separately, data were collected for patients with UPSC limited to a polyp in the endometrium and with extrapelvic spread (stage IVB). Logistic regression was used to compute the odds ratio (OR) in continuous and categorical variables via SAS v9.1. Results: Twenty-seven patients had stage IA USC without any myometrial invasion (Table 1). Fourteen patients (52%) had tumor confined to a polyp (polyp group [PG]), with three patients having focal polyp stromal involvement. Thirteen patients had tumor limited to the endometrium (endometrial group [EG]) with (n = 5) or without (n = 8) polyp involvement. The median follow-up period was 31.6 months (range, 1–163 months). No patients had evidence of lymphovascular involvement (LVI). Patients in the PG had significantly less expression of the progesterone receptor (PR) than those in the EG. Significantly fewer patients received adjuvant treatment in the EG (6/13 [42.8%]). Recurrence was rare, with one patient in the PG recurring distally in her lungs after receiving external beam radiation therapy at 29 months after diagnosis and none in the EG. Comparing our cohort to a group of stage IVB patients with polyp-only disease in the uterus, the polyp diameter was significantly larger in those with abdominal metastasis (P = 0.009). Logistic regression analysis showed that with every 1 cm increase in malignant polyp size, the odds of having disease limited to the endometrium decreased by almost twofold (OR 0.502, 95% CI 0.285–0.883, P = 0.017). Polyps that