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Risk of uterine malignancy (UM) increases proportionally with increasing body mass index (BMI)
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
women with CR after childbearing due to a high rate of late recurrence. Fig. 1. Cumulative incidence funtions representing the probability of a complete response over time.
e69
and 23% vs. 4%, respectively; P ≤ 0.008) but similar rates of relapse in the pelvis and other distant sites compared to those with negative cytology. Conclusions: Positive peritoneal cytology is highly predictive of poor outcome in stage III endometrial cancer, independent of other adverse features, and is associated with distinct patterns of relapse. Therefore, the status of peritoneal cytology not only provides important prognostic information, but also may have treatment implications. Table. Hazard Ratios (HR) for Specific Factors in Stage III Endometrial Cancer.
doi:10.1016/j.ygyno.2013.04.225
doi:10.1016/j.ygyno.2013.04.224
166 The significance of positive peritoneal cytology in stage III endometrial cancer S. Milgrom, M. Kollmeier, N. Abu-Rustum, V. Makker, G. Gardner, R. Barakat, K. Alektiar. Memorial Sloan-Kettering Cancer Center, New York, NY. Objective: According to the revised FIGO staging system for endometrial cancer, positive cytology is reported without affecting the stage. This change may lead to a decline in obtaining peritoneal cytology. While such a decline may have little impact in early-stage disease, the implications for stage III patients are unclear. The aim of this study was to determine the prognostic significance of positive peritoneal cytology in patients with FIGO (2009) stage III endometrial cancer. Methods: Patients were identified who had stage III endometrial cancer and were treated at a tertiary cancer center between 04/1995 and 12/2009. All patients had peritoneal cytology. Those with positive cytology as their only extrauterine disease extension were excluded. Results: Of the 196 patients in this cohort, 114 (58%) were ≥60 years old, 94 (48%) had deep myometrial invasion, 139 (71%) had lymphovascular invasion, and 49 (25%) had cervical stromal invasion. Aggressive histology (serous, clear cell, undifferentiated, or grade 3 endometrioid) was present in 90 patients (46%), adnexal involvement in 73 (37%), and nodal involvement in 154 (79%). Pelvic lymph node dissection was performed in 174 cases (89%). Positive peritoneal cytology was present in 45 patients (23%) and was significantly (P ≤ 0.03) associated with cervical stromal invasion, adnexal involvement, and aggressive histology. Regarding adjuvant therapy, positive cytology patients were more likely to receive chemotherapy (80% vs. 68%, P = 0.1) but less likely radiation (60% vs. 74%, P = .0.08). With a median follow-up of 47 months, the 5-year risk of relapse was 58% for positive cytology vs 31% for negative (P b 0.001). The corresponding rates for death from endometrial cancer were 66% vs. 28% (P b 0.001). Positive cytology retained its independence on multivariate analysis (Table). Patients with positive cytology had significantly higher rates of recurrence in the para-aortic nodes and peritoneum (30% vs. 9%
167 Risk of uterine malignancy (UM) increases proportionally with increasing body mass index (BMI) K. Ward, N. Shah, M. Davis, C. Saenz, M. McHale, S. Plaxe. UCSD- The Moores Cancer Center, La Jolla, CA. Objective: To quantify the relationship of UM with BMI. Methods: University HealthSystems Consortium (UHC) maintains an administrative database with information contributed by 116 academic medical centers and 276 affiliate hospitals, representing more than 90% of United States nonprofit academic medical centers. The UHC database was queried to identify all women undergoing hysterectomy (all ICD-9 68x.x) with a recorded BMI in the overweight and obese categories (BMI 25 to 39.9; ICD-9 v652139). The admission for total hysterectomy was chosen to avoid biasing the sample with multiple admissions for the same patient. Least squares regression was applied to evaluate the association between increasing BMI and the proportion of women with a diagnosis of UM (all ICD-9 182.x and 179). Multivariate binary logistic regression was then performed to adjust for other known risk factors for endometrial cancer (EC) in addition to BMI, including age, race (white, black, or other), and presence of any of 23 other comorbidities. Results: Six thousand, nine hundred five (4.6%) of women having hysterectomy had recorded BMI within the study range. One thousand, eight hundred ninety- one (27.4%) of these had UM. In the overweight and obese cohorts separately, and when combined into a single-study population, least squares fit of the probability of UM vs. BMI demonstrated a linear relationship (Figure). For the entire population, the line was described by the equation: y = 0.015x - 0.23, R2 = 0.92 where risk of EC is the ordinate and BMI is the abscissa. After adjusting for other risk factors, we found that each 1-unit increase in BMI was independently associated with an 11% increase in the proportion of patients diagnosed with uterine malignancy (odd ratio 1.11, 95% CI 1.09-1.13, P b 0.001.) Increasing age and white race were also independently associated with uterine cancer. The presence of other comorbidities was not found to be independently related to the risk of UM. Conclusions: In a population of women undergoing hysterectomy, risk of UM increased linearly with increasing BMI. Since the majority of United States women have a BMI between 25 and 40, these results can be regarded as applicable to the general population’s risk. Our
e70
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
findings further support the importance of weight management as a component of general health maintenance and cancer risk reduction.
doi:10.1016/j.ygyno.2013.04.226
168 Surgical staging for uterine papillary serous carcinoma: Is omentectomy really necessary? R. Eitan1, A. Gershoni2, G. Sabah2, Y. Peled2, H. Levavi2. 1Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel, 2Tel-Aviv University, Tel-Aviv, Israel.
cancer. Recognizing those cases by frozen section can be challenging. Tumor diameter and preoperative CA-125 level were analyzed to predict tumor spread. We propose the correlation of those parameters with HR. Methods: All patients operated upon for endometrial cancer between September 2011 and August 2012 were included. Cases with definitive pathology consistent with grade 3 or nonendometrioid histology or myometrial invasion N50% were classified as HR. Cases that did not match 1 of those criteria were classified as low-risk (LR) endometrial cancer. Cases with simple polyps or hyperplasia lesions were considered benign lesions. Means of tumor diameter (cm) and preoperative CA-125 levels were compared between groups using Kruskall-Wallis test and Mann-Whitney test to determine differences between each group. P value of b0.05 was considered significant. Results: A total of 42 patients were included (19 HR, 16 LR, and 7 benign lesions). Means of tumor diameter in each group were, respectively, 5.00 cm (standard deviation [sd]: 2.56), 3.52 cm (sd: 1.87), and 2.21 cm (sd: 1.57) (P = 0.02). The differences were not significant between HR vs. LR groups (P = 0.09), and LR vs. benign lesion (P = 0.12), but it was significant considering HR vs. benign lesion (P = 0.01). Mean of CA-125 preoperative levels in each group was, respectively, 24.56 U/dL (sd: 12.51), 23.42 U/dL (sd: 23.66), and 14.38 U/dL (sd: 10.17) (P = 0.34). Conclusions: In this initial sample, tumor diameter and preoperative CA-125 value were not able to differentiate HR from LR group, and, therefore, were not considered adequate parameters to decide if the patient should undergo systematic lymphadenectomy.
doi:10.1016/j.ygyno.2013.04.228 Objective: Uterine papillary serous carcinomas (UPSC) are considered more aggressive histologic subtypes of epithelial adenocarcinomas, with a higher risk of extrauterine disease at presentation. Guidelines for surgical staging of UPSC include procedures performed for ovarian cancer such as omentectomy. We sought to describe our experience with aggressive surgical staging and assess the extent of omental involvement. Methods: Pathologic results of consecutive patients with a diagnosis of UPSC treated surgically at our institution between January 2005 and December 2011 were evaluated. Data regarding staging procedures and histology results were recorded. Results: Fifty-four patients were surgically staged during the study period. Median age was 76 years. Eighty percent had omentectomy performed and 85% a complete lymph node dissection. Washing for cytology was positive in 29% of patients. Positive lymph nodes were found in 20%. Omentum was involved in 6 patients (12%), but in all but 1 of these patients, involvement was macroscopic. Conclusions: UPSC is confirmed to be a more aggressive subtype, and extrauterine disease is often found during staging. Gross omental involvement is not uncommon and when found, the omentum should be removed as part of cytoreduction. The rate of microscopic omental involvement is very low, and resection of a normal-looking omentum as part of the staging procedure is probably unnecessary. doi:10.1016/j.ygyno.2013.04.227
169 Tumor diameter and preoperative CA-125 level evaluation for high-risk endometrial cancer patients C. Andrade, G. Carrara, M. Vieira, M. Cadamuro, M. Mengatto, J. Fregnani, A. Tsunoda. Barretos Cancer Hospital, Barretos, São Paulo, Brazil. Objective: The systematic lymphadenectomy is commonly performed to improve tailored adjuvant treatment for high-risk (HR) endometrial
170 Prognostic value of positive cytology in endometrial cancer G. Baiocchi, M. Macedo, L. Badiglian-Filho, L. De Brot, C. Faloppa, E. Fukazawa, L. Kumagai, C. Osorio. AC Camargo Cancer Hospital, Sao Paulo, Brazil. Objective: In 2009, FIGO staging system for endometrial cancer was revised and the suggestion was made that positive cytology might be reported separately without changing the stage. The aim of our study was to analyze the impact of positive cytology on overall and disease-free survival and correlate them with clinicopathologic features. Methods: A retrospective analysis was performed in a series of 238 individuals who underwent surgical treatment for endometrioid endometrial cancer from March 1991 to July 2009. Patients with ovarian involvement, peritoneal disease, and distant metastasis were excluded. Results: Mean age was 64.3 years (range, 29-94 years). One hundred seventy-nine (75.2%) patients underwent complete staging that included lymphadenectomy with a median of 12 pelvic (range, 190) and 6 para-aortic (range, 1-38) nodes removed. Median followup was 64.4 months (range, 1.64-208.7 months). One hundred sixtyeight patients had peritoneal washings analyzed and in 13 (7.7%) the cytology was positive. Five patients with positive cytology (41.7%) recurred and all had distant metastasis. Positive cytology did not correlate with depth of invasion (N50%), lymph node metastasis, and lymphovascular invasion. Positive cytology had a negative impact on progression-free survival (P = 0.006) and overall survival (P b 0.001). Nevertheless, the presence of positive cytology also increased the risk of recurrence (HR 6.65; 95% CI 2.2-20.0; P = 0.001) and death (HR 5.99; 95% CI: 1.9-18.6; P = 0.002) in multivariate analysis when adjusted for lymph node metastasis, grade, and depth of invasion.
women with CR after childbearing due to a high rate of late recurrence. Fig. 1. Cumulative incidence funtions representing the probability of a complete response over time.
e69
and 23% vs. 4%, respectively; P ≤ 0.008) but similar rates of relapse in the pelvis and other distant sites compared to those with negative cytology. Conclusions: Positive peritoneal cytology is highly predictive of poor outcome in stage III endometrial cancer, independent of other adverse features, and is associated with distinct patterns of relapse. Therefore, the status of peritoneal cytology not only provides important prognostic information, but also may have treatment implications. Table. Hazard Ratios (HR) for Specific Factors in Stage III Endometrial Cancer.
doi:10.1016/j.ygyno.2013.04.225
doi:10.1016/j.ygyno.2013.04.224
166 The significance of positive peritoneal cytology in stage III endometrial cancer S. Milgrom, M. Kollmeier, N. Abu-Rustum, V. Makker, G. Gardner, R. Barakat, K. Alektiar. Memorial Sloan-Kettering Cancer Center, New York, NY. Objective: According to the revised FIGO staging system for endometrial cancer, positive cytology is reported without affecting the stage. This change may lead to a decline in obtaining peritoneal cytology. While such a decline may have little impact in early-stage disease, the implications for stage III patients are unclear. The aim of this study was to determine the prognostic significance of positive peritoneal cytology in patients with FIGO (2009) stage III endometrial cancer. Methods: Patients were identified who had stage III endometrial cancer and were treated at a tertiary cancer center between 04/1995 and 12/2009. All patients had peritoneal cytology. Those with positive cytology as their only extrauterine disease extension were excluded. Results: Of the 196 patients in this cohort, 114 (58%) were ≥60 years old, 94 (48%) had deep myometrial invasion, 139 (71%) had lymphovascular invasion, and 49 (25%) had cervical stromal invasion. Aggressive histology (serous, clear cell, undifferentiated, or grade 3 endometrioid) was present in 90 patients (46%), adnexal involvement in 73 (37%), and nodal involvement in 154 (79%). Pelvic lymph node dissection was performed in 174 cases (89%). Positive peritoneal cytology was present in 45 patients (23%) and was significantly (P ≤ 0.03) associated with cervical stromal invasion, adnexal involvement, and aggressive histology. Regarding adjuvant therapy, positive cytology patients were more likely to receive chemotherapy (80% vs. 68%, P = 0.1) but less likely radiation (60% vs. 74%, P = .0.08). With a median follow-up of 47 months, the 5-year risk of relapse was 58% for positive cytology vs 31% for negative (P b 0.001). The corresponding rates for death from endometrial cancer were 66% vs. 28% (P b 0.001). Positive cytology retained its independence on multivariate analysis (Table). Patients with positive cytology had significantly higher rates of recurrence in the para-aortic nodes and peritoneum (30% vs. 9%
167 Risk of uterine malignancy (UM) increases proportionally with increasing body mass index (BMI) K. Ward, N. Shah, M. Davis, C. Saenz, M. McHale, S. Plaxe. UCSD- The Moores Cancer Center, La Jolla, CA. Objective: To quantify the relationship of UM with BMI. Methods: University HealthSystems Consortium (UHC) maintains an administrative database with information contributed by 116 academic medical centers and 276 affiliate hospitals, representing more than 90% of United States nonprofit academic medical centers. The UHC database was queried to identify all women undergoing hysterectomy (all ICD-9 68x.x) with a recorded BMI in the overweight and obese categories (BMI 25 to 39.9; ICD-9 v652139). The admission for total hysterectomy was chosen to avoid biasing the sample with multiple admissions for the same patient. Least squares regression was applied to evaluate the association between increasing BMI and the proportion of women with a diagnosis of UM (all ICD-9 182.x and 179). Multivariate binary logistic regression was then performed to adjust for other known risk factors for endometrial cancer (EC) in addition to BMI, including age, race (white, black, or other), and presence of any of 23 other comorbidities. Results: Six thousand, nine hundred five (4.6%) of women having hysterectomy had recorded BMI within the study range. One thousand, eight hundred ninety- one (27.4%) of these had UM. In the overweight and obese cohorts separately, and when combined into a single-study population, least squares fit of the probability of UM vs. BMI demonstrated a linear relationship (Figure). For the entire population, the line was described by the equation: y = 0.015x - 0.23, R2 = 0.92 where risk of EC is the ordinate and BMI is the abscissa. After adjusting for other risk factors, we found that each 1-unit increase in BMI was independently associated with an 11% increase in the proportion of patients diagnosed with uterine malignancy (odd ratio 1.11, 95% CI 1.09-1.13, P b 0.001.) Increasing age and white race were also independently associated with uterine cancer. The presence of other comorbidities was not found to be independently related to the risk of UM. Conclusions: In a population of women undergoing hysterectomy, risk of UM increased linearly with increasing BMI. Since the majority of United States women have a BMI between 25 and 40, these results can be regarded as applicable to the general population’s risk. Our
e70
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
findings further support the importance of weight management as a component of general health maintenance and cancer risk reduction.
doi:10.1016/j.ygyno.2013.04.226
168 Surgical staging for uterine papillary serous carcinoma: Is omentectomy really necessary? R. Eitan1, A. Gershoni2, G. Sabah2, Y. Peled2, H. Levavi2. 1Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel, 2Tel-Aviv University, Tel-Aviv, Israel.
cancer. Recognizing those cases by frozen section can be challenging. Tumor diameter and preoperative CA-125 level were analyzed to predict tumor spread. We propose the correlation of those parameters with HR. Methods: All patients operated upon for endometrial cancer between September 2011 and August 2012 were included. Cases with definitive pathology consistent with grade 3 or nonendometrioid histology or myometrial invasion N50% were classified as HR. Cases that did not match 1 of those criteria were classified as low-risk (LR) endometrial cancer. Cases with simple polyps or hyperplasia lesions were considered benign lesions. Means of tumor diameter (cm) and preoperative CA-125 levels were compared between groups using Kruskall-Wallis test and Mann-Whitney test to determine differences between each group. P value of b0.05 was considered significant. Results: A total of 42 patients were included (19 HR, 16 LR, and 7 benign lesions). Means of tumor diameter in each group were, respectively, 5.00 cm (standard deviation [sd]: 2.56), 3.52 cm (sd: 1.87), and 2.21 cm (sd: 1.57) (P = 0.02). The differences were not significant between HR vs. LR groups (P = 0.09), and LR vs. benign lesion (P = 0.12), but it was significant considering HR vs. benign lesion (P = 0.01). Mean of CA-125 preoperative levels in each group was, respectively, 24.56 U/dL (sd: 12.51), 23.42 U/dL (sd: 23.66), and 14.38 U/dL (sd: 10.17) (P = 0.34). Conclusions: In this initial sample, tumor diameter and preoperative CA-125 value were not able to differentiate HR from LR group, and, therefore, were not considered adequate parameters to decide if the patient should undergo systematic lymphadenectomy.
doi:10.1016/j.ygyno.2013.04.228 Objective: Uterine papillary serous carcinomas (UPSC) are considered more aggressive histologic subtypes of epithelial adenocarcinomas, with a higher risk of extrauterine disease at presentation. Guidelines for surgical staging of UPSC include procedures performed for ovarian cancer such as omentectomy. We sought to describe our experience with aggressive surgical staging and assess the extent of omental involvement. Methods: Pathologic results of consecutive patients with a diagnosis of UPSC treated surgically at our institution between January 2005 and December 2011 were evaluated. Data regarding staging procedures and histology results were recorded. Results: Fifty-four patients were surgically staged during the study period. Median age was 76 years. Eighty percent had omentectomy performed and 85% a complete lymph node dissection. Washing for cytology was positive in 29% of patients. Positive lymph nodes were found in 20%. Omentum was involved in 6 patients (12%), but in all but 1 of these patients, involvement was macroscopic. Conclusions: UPSC is confirmed to be a more aggressive subtype, and extrauterine disease is often found during staging. Gross omental involvement is not uncommon and when found, the omentum should be removed as part of cytoreduction. The rate of microscopic omental involvement is very low, and resection of a normal-looking omentum as part of the staging procedure is probably unnecessary. doi:10.1016/j.ygyno.2013.04.227
169 Tumor diameter and preoperative CA-125 level evaluation for high-risk endometrial cancer patients C. Andrade, G. Carrara, M. Vieira, M. Cadamuro, M. Mengatto, J. Fregnani, A. Tsunoda. Barretos Cancer Hospital, Barretos, São Paulo, Brazil. Objective: The systematic lymphadenectomy is commonly performed to improve tailored adjuvant treatment for high-risk (HR) endometrial
170 Prognostic value of positive cytology in endometrial cancer G. Baiocchi, M. Macedo, L. Badiglian-Filho, L. De Brot, C. Faloppa, E. Fukazawa, L. Kumagai, C. Osorio. AC Camargo Cancer Hospital, Sao Paulo, Brazil. Objective: In 2009, FIGO staging system for endometrial cancer was revised and the suggestion was made that positive cytology might be reported separately without changing the stage. The aim of our study was to analyze the impact of positive cytology on overall and disease-free survival and correlate them with clinicopathologic features. Methods: A retrospective analysis was performed in a series of 238 individuals who underwent surgical treatment for endometrioid endometrial cancer from March 1991 to July 2009. Patients with ovarian involvement, peritoneal disease, and distant metastasis were excluded. Results: Mean age was 64.3 years (range, 29-94 years). One hundred seventy-nine (75.2%) patients underwent complete staging that included lymphadenectomy with a median of 12 pelvic (range, 190) and 6 para-aortic (range, 1-38) nodes removed. Median followup was 64.4 months (range, 1.64-208.7 months). One hundred sixtyeight patients had peritoneal washings analyzed and in 13 (7.7%) the cytology was positive. Five patients with positive cytology (41.7%) recurred and all had distant metastasis. Positive cytology did not correlate with depth of invasion (N50%), lymph node metastasis, and lymphovascular invasion. Positive cytology had a negative impact on progression-free survival (P = 0.006) and overall survival (P b 0.001). Nevertheless, the presence of positive cytology also increased the risk of recurrence (HR 6.65; 95% CI 2.2-20.0; P = 0.001) and death (HR 5.99; 95% CI: 1.9-18.6; P = 0.002) in multivariate analysis when adjusted for lymph node metastasis, grade, and depth of invasion.