- Email: [email protected]
Surviving vulvar cancer, does obesity matter?
Abstracts / Gynecologic Oncology 141 (2016) 2–208
OF
DP
Objectives: The aim was to investigate, in a prospective cohort of postmenopausal women, endometrial tissue expression of hormonal and insulin/insulin like growth factor (IGF) receptors in relation to cancer risk factors. Methods: This institutional review board–approved prospective study enrolled 50 postmenopausal women undergoing hysterectomy. Clinical data were obtained using a study questionnaire. Immunohistochemical (IHC) staining was done on formalin-fixed paraffin-embedded endometrial tissue sections using primary antibodies specific for estrogen receptor alpha (ERα), progesterone receptor (PR), type 1 IGF receptor (IGF1R), insulin receptor (IR), and phosphorylated IR/IGF1R (p-IR/ IGF1R). The study pathologist evaluated staining intensity and percentage of positive cells; receptor expression was categorized as positive or negative, as previously described. Statistical significance of receptor expression differences according to risk factor categories was evaluated with the Fisher exact test. P b .05 was considered significant; analyses were performed using R version 3.1.1. Results: Patients completing the study questionnaire and from whom sufficient endometrial tissue was obtained were eligible for analysis (n = 29). The mean age was 60.9 years. The mean body mass index was 29.3 kg/m2. The primary indications for hysterectomy were uterine prolapse or leiomyomata. Twenty-eight percent were diabetic. Diabetics were more likely to have positive endometrial glandular expression of p-IGF1R/IR (P = .02). Forty-eight percent reported NSAID use. Women reporting NSAID use were more likely to have positive PR expression in the endometrial stromal tissue (P = .01). Conclusions: This is the first study to evaluate the relationship of hormonal and insulin/IGF receptor expression in normal postmenopausal endometrium, in relation to cancer risk factors. Our finding of increased insulin/IGF receptor activation in diabetics suggests that detectable signaling alterations in the endometrium may precede neoplastic transformation in these at-risk women. NSAID usage has been linked to decreased endometrial cancer risk in epidemiologic studies. The increased PR expression observed in the endometrial stromal tissue of NSAID users may be associated with a novel mechanism of cancer protection. In summary, clinical cancer risk factors are associated with altered receptor expression in nonmalignant endometrium, and should be further investigated as biomarkers in cancer risk assessment and prevention studies.
Results: We identified 437 endometrial cancer survivors with data after 42 to 78 months of follow-up. At the time of diagnosis, 18% of patients were of normal weight based on BMI, 20% were overweight, and 62% were obese (BMI of ≥ 30). More than a quarter of patients (26%) were class III obese, with a BMI of 40 or greater. Overall mean BMI for this cohort was 34. Mean BMI was comparable for patients with type I and II disease, with BMIs of 35 and 31, respectively. Although 44% of all patients had an increase in BMI over time, there was no overall change in mean BMI from time of initial encounter to long-term follow-up (P = .53). An increase in BMI was significantly associated with presence of hypertension (P b .001) or diabetes (P b .001). A decrease in BMI was significantly associated with older age (P b .001) and performance of lymphadenectomy (P b .001). Histologic type and stage were not associated with change in BMI over time. Conclusions: In a large single institution cohort of endometrial cancer survivors, nearly half the patients gained weight over the follow-up period, whereas mean BMI from time of diagnosis to longterm follow-up was unchanged. Given the large percentage of patients with elevated BMI at diagnosis and the lack of useful disease-related characteristics to predict weight gain, this study confirms the need for weight loss intervention in the entire endometrial cancer survivor population. The presence of hypertension and diabetes was significantly associated with BMI increase over time, and may represent a group of patients to more aggressively target for weight loss intervention.
RO
Medicine, London, United Kingdom, bAlbert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, USA
173
doi:10.1016/j.ygyno.2016.04.450
RR
EC
TE
419 – Poster Surviving vulvar cancer, does obesity matter? A. Schwartza, L.B. Huffmanb, C. Ashleyb, S. Sahab, S.L. Roseb, D.M. Kushnerb, E.M. Hartenbachb, L.W. Riceb, L.M. Barroilhetb, A.N. AlNiaimib. aUniversity of Wisconsin, Madison, WI, USA, bUniversity of Wisconsin School of Medicine and Public Health, Madison, WI, USA
doi:10.1016/j.ygyno.2016.04.449
UN
CO
418 – Poster Highlighting the need for intervention: Long-term evaluation of change in BMI in endometrial cancer survivors J.A. Dottinoa, C. Acharyab, A.A. Secorda, L.J. Havrileskya. aDuke University Medical Center, Durham, NC, USA, bDuke University, Durham, NC, USA Objectives: To evaluate change in body mass index (BMI) over time in long-term endometrial cancer survivors in the absence of a formal weight loss intervention program and to describe the relationship between BMI change and patient characteristics. Methods: A retrospective cohort analysis was conducted of endometrial cancer patients in our institutional database who underwent surgery as the primary treatment for endometrial cancer from 2000 to 2009 with approximate 5-year follow-up. Weight and BMI values at the time of surgery were compared to values 5 years later. Patients who underwent weight loss surgery were excluded. Longitudinal analysis was performed using generalized estimating equations (GEE) to model BMI over time as a function of clinicopathological variables.
Objectives: To determine the relationship between obesity and progression-free survival (PFS) and overall survival (OS) in vulvar cancer patients. Methods: A single-institution retrospective chart review was conducted of patients with vulvar cancer treated from 2000 to 2014. Demographic, clinical, pathologic, recurrence, and survival data were collected. Patients were identified as obese based on body mass index (BMI) of 30 or higher. Univariate and multivariable Cox proportional hazards models were used to determine the association of age at diagnosis, obesity, smoking, diabetes mellitus (DM), hypertension (HTN), stage, grade, and tumor size with PFS and OS. Results: A total of 240 patients with vulvar cancer were identified in our institution’s tumor registry from 2000 to 2014, of whom 169 had data available for analysis. Significantly more obese patients had a history of DM and HTN compared with nonobese patients, but no differences in age, smoking status, stage, grade, and tumor size were noted between the 2 groups. The mean number of lymph nodes removed per inguinofemoral lymphadenectomy was not significantly different between the 2 groups (obese vs nonobese: right—7.22 [standard deviation, SD, 3.92] vs 8.16 (SD 9.19), P = .194; left—7.6 (SD 3.53) vs 8.22 (SD 3.76), P = .367). Median time to recurrence was 5.4 years (95% CI 4–10.2 years) and median time to death was 11.2 years (95% CI 8.3–NR) for the entire cohort. Age, DM, and stage were significantly associated with PFS on univariate and multivariable analyses. Obesity, smoking, HTN, grade, and tumor size were not associated. OS was significantly associated with age, DM, stage, grade, and tumor size on univariate analysis, but only age remained significantly associated with OS on multivariable analysis.
174
Abstracts / Gynecologic Oncology 141 (2016) 2–208
Conclusions: Obesity was not associated with PFS and OS in vulvar cancer patients. However, DM, a common comorbidity of obesity, was significantly associated with worse PFS.
OF
Table 1 Clinical and pathologic characteristics of obese v. non-obese patients with vulvar cancer.
hypertension (P = .13), preoperative blood transfusion (P = .90), or American Society of Anesthesiology class (P = .10). There was a trend toward higher risk of VTE among patients with disseminated cancer compared with those with early cancers (P = .05). No difference was found in the risk of VTE based on operative time (P = .96). No difference was noted in the risk of VTE among those who underwent lymphadenectomy compared with those who did not (P = .35). Using multivariable logistic regression analysis, after adjusting for age (P = .12), BMI (P = .90), operative time (P = .71), and lymphadenectomy status (P = .30), none of these variables was significantly associated with risk of VTE. In multivariable analysis, after adjusting for other confounders, VTE within 30 days was a significant predictor of higher 30-day morality (OR 24.7, 95% 1.0– 345.2, P = .022). Conclusions: The VTE rate is low after major laparoscopic surgery for gynecologic cancers but is associated with increased 30-day mortality. Higher rate was noted in those with disseminated cancer who might benefit from VTE prophylaxis.
RO
doi:10.1016/j.ygyno.2016.04.452
DP
421 – Poster Recurrent ovarian cancer: Can second clinical remission surpass the first? R.A. Cowana, A.G.Z. Erikssona, C.H. Kimb, Q. Zhoua, A. Iasonosa, W. Tewa, K. Long Rochea, Y. Sonodaa, D.S. Chia, G.J. Gardnera. aMemorial Sloan Kettering Cancer Center, New York, NY, USA, bThomas Jefferson University Hospital, Philadelphia, PA, USA
TE
Objectives: Most patients with ovarian cancer will have a recurrence, and the second remission is traditionally shorter than the first. Among patients who achieve second remission, we sought to evaluate those with a progression-free survival (PFS2) greater than their first remission (PFS1), and identify associated clinical factors. Methods: With institutional review board approval, all patients with recurrent platinum-sensitive epithelial ovarian cancer who underwent secondary cytoreductive surgery (SCS) from May 2001 to June 2014 were identified. Patient and tumor characteristics, operative findings, PFS, and overall survival (OS) were documented. The incidence of PFS2 N PFS1 was identified, and statistical analysis performed to identify associated clinical factors for this cohort. Results: Among 214 SCS cases, 52 (24%) had a second remission longer than the first remission. Of these 52 patients, 20 (38%) subsequently sustained disease progression, 10 of whom died of disease. The remaining 32 (62%) were without disease recurrence at a median follow-up of 62.8 months (range, 19.1–147.9). When comparing PFS2 N PFS1 patients with the PFS1 N PFS2 patients, age, performance status, stage, grade, histologic subtype, and number of sites of recurrent tumor were similar between the 2 groups. The outcome of primary debulking surgery (PDS) to residual disease of less than 0.5 cm was 78% for prolonged PFS2 patients compared with 69.4% for PFS1 N PFS2 patients (P = .034). Method of recurrent disease detection for prolonged PFS2 patients compared with PFS1 N PFS2 patients was CA-125 level (30.8% vs 49.4%, respectively), imaging (59.6% vs 35.8%), and physical examination/symptoms (9.2% vs 14.8%) (P = .012). Among patients in both groups, 86% achieved CGR at SCS. There was no difference in type of chemotherapy used for recurrence; however, more than 70% of all patients received a platinum doublet. Conclusions: Among patients who underwent SCS, 24% achieved a second remission greater than their first. Although many clinical and tumor characteristics are similar between the 2 groups, prolonged PFS2 patients had a higher rate of optimal PDS to less than 0.5 cm, and had tumor recurrence identified by serologic or radiographic
EC
doi:10.1016/j.ygyno.2016.04.451
RR
420 – Poster Risk of venous thromboembolism following major laparoscopic surgery for gynecologic malignancy L. Moulton, P.G. Rose, H. Mahdi. Cleveland Clinic, Cleveland, OH, USA
UN
CO
Objectives: To determine the incidence of venous thromboembolism (VTE) after laparoscopic surgery for uterine, cervical, and ovarian cancers from a national surgical registry. Methods: Patients who underwent at least 1 major laparoscopic surgery for uterine, ovarian, and cervical cancers were identified from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011. VTE was defined as deep venous thrombosis (DVT) requiring therapy and pulmonary embolism (PE) within 30 days of surgery. Statistical analysis for categorical and continuous covariates were assessed using the χ2 and Student t test, respectively, and regression models were used to identify risk factors for VTE. Results: Of the 2,219 patients included in the final analysis, 15 patients (0.7%) were diagnosed with VTE. Six patients (0.3%) were diagnosed before discharge, and 9 patients (0.4%) were diagnosed after discharge. The median time from surgery to diagnosis was 6 days (range, 0–28 days). For patients who had a diagnosis of VTE within 30 days, the 30-day mortality was significantly higher than in those who did not have VTE (7.0% vs 0.3%, P b .001). No difference was noted based on the site of cancer (P = .95). There was no difference in VTE rate when stratified by age (P = .10), body mass index (BMI; P = .68), diabetes (P = .22), smoking (P = .60), respiratory morbidities (P = .55), cardiac disease (P = .22),
OF
DP
Objectives: The aim was to investigate, in a prospective cohort of postmenopausal women, endometrial tissue expression of hormonal and insulin/insulin like growth factor (IGF) receptors in relation to cancer risk factors. Methods: This institutional review board–approved prospective study enrolled 50 postmenopausal women undergoing hysterectomy. Clinical data were obtained using a study questionnaire. Immunohistochemical (IHC) staining was done on formalin-fixed paraffin-embedded endometrial tissue sections using primary antibodies specific for estrogen receptor alpha (ERα), progesterone receptor (PR), type 1 IGF receptor (IGF1R), insulin receptor (IR), and phosphorylated IR/IGF1R (p-IR/ IGF1R). The study pathologist evaluated staining intensity and percentage of positive cells; receptor expression was categorized as positive or negative, as previously described. Statistical significance of receptor expression differences according to risk factor categories was evaluated with the Fisher exact test. P b .05 was considered significant; analyses were performed using R version 3.1.1. Results: Patients completing the study questionnaire and from whom sufficient endometrial tissue was obtained were eligible for analysis (n = 29). The mean age was 60.9 years. The mean body mass index was 29.3 kg/m2. The primary indications for hysterectomy were uterine prolapse or leiomyomata. Twenty-eight percent were diabetic. Diabetics were more likely to have positive endometrial glandular expression of p-IGF1R/IR (P = .02). Forty-eight percent reported NSAID use. Women reporting NSAID use were more likely to have positive PR expression in the endometrial stromal tissue (P = .01). Conclusions: This is the first study to evaluate the relationship of hormonal and insulin/IGF receptor expression in normal postmenopausal endometrium, in relation to cancer risk factors. Our finding of increased insulin/IGF receptor activation in diabetics suggests that detectable signaling alterations in the endometrium may precede neoplastic transformation in these at-risk women. NSAID usage has been linked to decreased endometrial cancer risk in epidemiologic studies. The increased PR expression observed in the endometrial stromal tissue of NSAID users may be associated with a novel mechanism of cancer protection. In summary, clinical cancer risk factors are associated with altered receptor expression in nonmalignant endometrium, and should be further investigated as biomarkers in cancer risk assessment and prevention studies.
Results: We identified 437 endometrial cancer survivors with data after 42 to 78 months of follow-up. At the time of diagnosis, 18% of patients were of normal weight based on BMI, 20% were overweight, and 62% were obese (BMI of ≥ 30). More than a quarter of patients (26%) were class III obese, with a BMI of 40 or greater. Overall mean BMI for this cohort was 34. Mean BMI was comparable for patients with type I and II disease, with BMIs of 35 and 31, respectively. Although 44% of all patients had an increase in BMI over time, there was no overall change in mean BMI from time of initial encounter to long-term follow-up (P = .53). An increase in BMI was significantly associated with presence of hypertension (P b .001) or diabetes (P b .001). A decrease in BMI was significantly associated with older age (P b .001) and performance of lymphadenectomy (P b .001). Histologic type and stage were not associated with change in BMI over time. Conclusions: In a large single institution cohort of endometrial cancer survivors, nearly half the patients gained weight over the follow-up period, whereas mean BMI from time of diagnosis to longterm follow-up was unchanged. Given the large percentage of patients with elevated BMI at diagnosis and the lack of useful disease-related characteristics to predict weight gain, this study confirms the need for weight loss intervention in the entire endometrial cancer survivor population. The presence of hypertension and diabetes was significantly associated with BMI increase over time, and may represent a group of patients to more aggressively target for weight loss intervention.
RO
Medicine, London, United Kingdom, bAlbert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, USA
173
doi:10.1016/j.ygyno.2016.04.450
RR
EC
TE
419 – Poster Surviving vulvar cancer, does obesity matter? A. Schwartza, L.B. Huffmanb, C. Ashleyb, S. Sahab, S.L. Roseb, D.M. Kushnerb, E.M. Hartenbachb, L.W. Riceb, L.M. Barroilhetb, A.N. AlNiaimib. aUniversity of Wisconsin, Madison, WI, USA, bUniversity of Wisconsin School of Medicine and Public Health, Madison, WI, USA
doi:10.1016/j.ygyno.2016.04.449
UN
CO
418 – Poster Highlighting the need for intervention: Long-term evaluation of change in BMI in endometrial cancer survivors J.A. Dottinoa, C. Acharyab, A.A. Secorda, L.J. Havrileskya. aDuke University Medical Center, Durham, NC, USA, bDuke University, Durham, NC, USA Objectives: To evaluate change in body mass index (BMI) over time in long-term endometrial cancer survivors in the absence of a formal weight loss intervention program and to describe the relationship between BMI change and patient characteristics. Methods: A retrospective cohort analysis was conducted of endometrial cancer patients in our institutional database who underwent surgery as the primary treatment for endometrial cancer from 2000 to 2009 with approximate 5-year follow-up. Weight and BMI values at the time of surgery were compared to values 5 years later. Patients who underwent weight loss surgery were excluded. Longitudinal analysis was performed using generalized estimating equations (GEE) to model BMI over time as a function of clinicopathological variables.
Objectives: To determine the relationship between obesity and progression-free survival (PFS) and overall survival (OS) in vulvar cancer patients. Methods: A single-institution retrospective chart review was conducted of patients with vulvar cancer treated from 2000 to 2014. Demographic, clinical, pathologic, recurrence, and survival data were collected. Patients were identified as obese based on body mass index (BMI) of 30 or higher. Univariate and multivariable Cox proportional hazards models were used to determine the association of age at diagnosis, obesity, smoking, diabetes mellitus (DM), hypertension (HTN), stage, grade, and tumor size with PFS and OS. Results: A total of 240 patients with vulvar cancer were identified in our institution’s tumor registry from 2000 to 2014, of whom 169 had data available for analysis. Significantly more obese patients had a history of DM and HTN compared with nonobese patients, but no differences in age, smoking status, stage, grade, and tumor size were noted between the 2 groups. The mean number of lymph nodes removed per inguinofemoral lymphadenectomy was not significantly different between the 2 groups (obese vs nonobese: right—7.22 [standard deviation, SD, 3.92] vs 8.16 (SD 9.19), P = .194; left—7.6 (SD 3.53) vs 8.22 (SD 3.76), P = .367). Median time to recurrence was 5.4 years (95% CI 4–10.2 years) and median time to death was 11.2 years (95% CI 8.3–NR) for the entire cohort. Age, DM, and stage were significantly associated with PFS on univariate and multivariable analyses. Obesity, smoking, HTN, grade, and tumor size were not associated. OS was significantly associated with age, DM, stage, grade, and tumor size on univariate analysis, but only age remained significantly associated with OS on multivariable analysis.
174
Abstracts / Gynecologic Oncology 141 (2016) 2–208
Conclusions: Obesity was not associated with PFS and OS in vulvar cancer patients. However, DM, a common comorbidity of obesity, was significantly associated with worse PFS.
OF
Table 1 Clinical and pathologic characteristics of obese v. non-obese patients with vulvar cancer.
hypertension (P = .13), preoperative blood transfusion (P = .90), or American Society of Anesthesiology class (P = .10). There was a trend toward higher risk of VTE among patients with disseminated cancer compared with those with early cancers (P = .05). No difference was found in the risk of VTE based on operative time (P = .96). No difference was noted in the risk of VTE among those who underwent lymphadenectomy compared with those who did not (P = .35). Using multivariable logistic regression analysis, after adjusting for age (P = .12), BMI (P = .90), operative time (P = .71), and lymphadenectomy status (P = .30), none of these variables was significantly associated with risk of VTE. In multivariable analysis, after adjusting for other confounders, VTE within 30 days was a significant predictor of higher 30-day morality (OR 24.7, 95% 1.0– 345.2, P = .022). Conclusions: The VTE rate is low after major laparoscopic surgery for gynecologic cancers but is associated with increased 30-day mortality. Higher rate was noted in those with disseminated cancer who might benefit from VTE prophylaxis.
RO
doi:10.1016/j.ygyno.2016.04.452
DP
421 – Poster Recurrent ovarian cancer: Can second clinical remission surpass the first? R.A. Cowana, A.G.Z. Erikssona, C.H. Kimb, Q. Zhoua, A. Iasonosa, W. Tewa, K. Long Rochea, Y. Sonodaa, D.S. Chia, G.J. Gardnera. aMemorial Sloan Kettering Cancer Center, New York, NY, USA, bThomas Jefferson University Hospital, Philadelphia, PA, USA
TE
Objectives: Most patients with ovarian cancer will have a recurrence, and the second remission is traditionally shorter than the first. Among patients who achieve second remission, we sought to evaluate those with a progression-free survival (PFS2) greater than their first remission (PFS1), and identify associated clinical factors. Methods: With institutional review board approval, all patients with recurrent platinum-sensitive epithelial ovarian cancer who underwent secondary cytoreductive surgery (SCS) from May 2001 to June 2014 were identified. Patient and tumor characteristics, operative findings, PFS, and overall survival (OS) were documented. The incidence of PFS2 N PFS1 was identified, and statistical analysis performed to identify associated clinical factors for this cohort. Results: Among 214 SCS cases, 52 (24%) had a second remission longer than the first remission. Of these 52 patients, 20 (38%) subsequently sustained disease progression, 10 of whom died of disease. The remaining 32 (62%) were without disease recurrence at a median follow-up of 62.8 months (range, 19.1–147.9). When comparing PFS2 N PFS1 patients with the PFS1 N PFS2 patients, age, performance status, stage, grade, histologic subtype, and number of sites of recurrent tumor were similar between the 2 groups. The outcome of primary debulking surgery (PDS) to residual disease of less than 0.5 cm was 78% for prolonged PFS2 patients compared with 69.4% for PFS1 N PFS2 patients (P = .034). Method of recurrent disease detection for prolonged PFS2 patients compared with PFS1 N PFS2 patients was CA-125 level (30.8% vs 49.4%, respectively), imaging (59.6% vs 35.8%), and physical examination/symptoms (9.2% vs 14.8%) (P = .012). Among patients in both groups, 86% achieved CGR at SCS. There was no difference in type of chemotherapy used for recurrence; however, more than 70% of all patients received a platinum doublet. Conclusions: Among patients who underwent SCS, 24% achieved a second remission greater than their first. Although many clinical and tumor characteristics are similar between the 2 groups, prolonged PFS2 patients had a higher rate of optimal PDS to less than 0.5 cm, and had tumor recurrence identified by serologic or radiographic
EC
doi:10.1016/j.ygyno.2016.04.451
RR
420 – Poster Risk of venous thromboembolism following major laparoscopic surgery for gynecologic malignancy L. Moulton, P.G. Rose, H. Mahdi. Cleveland Clinic, Cleveland, OH, USA
UN
CO
Objectives: To determine the incidence of venous thromboembolism (VTE) after laparoscopic surgery for uterine, cervical, and ovarian cancers from a national surgical registry. Methods: Patients who underwent at least 1 major laparoscopic surgery for uterine, ovarian, and cervical cancers were identified from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011. VTE was defined as deep venous thrombosis (DVT) requiring therapy and pulmonary embolism (PE) within 30 days of surgery. Statistical analysis for categorical and continuous covariates were assessed using the χ2 and Student t test, respectively, and regression models were used to identify risk factors for VTE. Results: Of the 2,219 patients included in the final analysis, 15 patients (0.7%) were diagnosed with VTE. Six patients (0.3%) were diagnosed before discharge, and 9 patients (0.4%) were diagnosed after discharge. The median time from surgery to diagnosis was 6 days (range, 0–28 days). For patients who had a diagnosis of VTE within 30 days, the 30-day mortality was significantly higher than in those who did not have VTE (7.0% vs 0.3%, P b .001). No difference was noted based on the site of cancer (P = .95). There was no difference in VTE rate when stratified by age (P = .10), body mass index (BMI; P = .68), diabetes (P = .22), smoking (P = .60), respiratory morbidities (P = .55), cardiac disease (P = .22),