Robotic-assisted surgery in gynecologic oncology

The quest for improved patient outcomes has been a driving force for adoption of novel surgical innovations across surgical subspecialties. Gynecologic oncology is one such surgical discipline in which minimally invasive surgery has had a robust and evolving role in defining standards of care. Robotic-assisted surgery has developed during the past two decades as a more technologically advanced form of minimally invasive surgery in an effort to mitigate the limitations of conventional laparoscopy and improved patient outcomes. Robotically assisted technology offers potential advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve surgeon dexterity, and tremor canceling software that improves surgical precision. These technological advances may allow the gynecologic oncology surgeon to perform increasingly radical oncologic surgeries in complex patients. However, the platform is not without limitations, including high cost, lack of haptic feedback, and the requirement for additional training to achieve competence. This review describes the role of robotic-assisted surgery in the management of endometrial, cervical, and ovarian cancer, with an emphasis on comparison with laparotomy and conventional laparoscopy. The literature on novel robotic innovations, special patient populations, cost effectiveness, and fellowship training is also appraised critically in this regard. (C) 2014 by American Society for Reproductive Medicine

Updates in Sentinel Lymph Node Mapping in Gynecologic Cancer

Purpose of Review The aim of this study is to review the indications, techniques, and outcomes of sentinel lymph node (SLN) mapping in endometrial, cervical, and vulvar cancers. Recent Findings In endometrial cancer, the prospective FIRES trial showed that the negative predictive value of SLN mapping was 99.6%. Furthermore, multi-institutional retrospective studies comparing SLN mapping to traditional lymphadenectomy have found comparable survival between the two techniques, in both type 1 and type 2 endometrial cancer. In cervical cancer, randomized data from the SENTICOL-2 study has demonstrated significant reduction in postoperative complications without compromising survival with SLN mapping as compared to SLN mapping and pelvic lymphadenectomy. In vulvar cancer, the GROINS-V-II study protocol was amended to mandate inguinofemoral lymphadenectomy in all patients with SLN macrometastasis greater than 2 mm after unacceptably high rates of groin recurrences were observed on interim analysis. SLN mapping is now included in the treatment guidelines of the National Comprehensive Cancer Network guidelines for endometrial, cervical, and vulvar cancer as an acceptable lymphatic assessment technique in select patients. Summary SLN biopsy is a safe and effective alternative to systematic lymphadenectomy for women with early-stage endometrial, cervical, and vulvar cancer. Recent data has validated the excellent sensitivity and negative predictive value of this technique in carefully selected patients, without compromising survival. The use of an algorithm that mandates pathologic ultrastaging on all SLNs, and ipsilateral lymphadenectomy in cases of failed bilateral mapping improves sensitivity and negative predictive value. All suspicious lymph nodes should be resected regardless of the location of the SLN. In patients with vulvar cancer, SLN biopsy is an acceptable standard of care for patients with unifocal tumors, less than 4 cm in largest diameter, and clinically and radiographically negative groin nodes

Universal social needs assessment in gynecologic oncology: An important step toward more informed and targeted care in the public safety net

Background Social needs are actionable mediators of social determinants of health. Along with distress, they affect quality of life and survival in patients with cancer. The objectives of this study were to identify the most common social needs and distress in a largely immigrant gynecologic oncology patient population at a public safety‐net hospital and to evaluate for specific needs associated with distress and poor outcomes. Methods This was a prospective, survey‐based cohort study of patients who participated in a performance‐improvement initiative offering social needs assessment and distress screening. Patients provided sociodemographic information and completed validated surveys adapted from the Health Leads Social Needs Screening Toolkit, the National Comprehensive Cancer Network Distress Thermometer, and the Emotion Thermometers Tool. Associations between social needs, distress, and treatment outcomes were analyzed. Results In total, 135 women were included. Of these, 65.2% had at least 1 unmet social need, and 36.3% screened positive for distress. Help reading hospital materials (30.4%) was the most frequently reported need. Social isolation (odds ratio [OR], 3.65; 95% CI, 1.35‐9.9; P = .01) and lack of safety at home (OR, 4.90; 95% CI, 2.23‐10.62; P = .0001) were associated with distress. Perceived lack of finances for medical care (OR, 5.69; 95% CI, 1.12‐28.9; P = .036) and lack of transportation (OR, 20.5; 95% CI, 2.69‐156.7; P = .004) were associated with nonadherence‐related treatment interruption, whereas positive distress scores were associated with interruption because of comorbidities or treatment‐related toxicities (OR, 20.5; 95% CI, 1.5‐268.6; P = .02). Conclusions Systematically identifying social needs and developing interventions aimed at mitigating them may lead to more actionable health care disparities research and affect treatment outcomes. Lay Summary Social needs are individual‐level social conditions that drive health disparities. In this survey‐based study, the objective was to identify common social needs and how these relate to distress and poor health outcomes in a largely immigrant and underserved gynecologic oncology patient population. The authors found that greater than one‐third of patients screened positive for distress, nearly two‐thirds had at least 1 unmet social need, and these factors were associated with emergency room visits, hospital admissions, and treatment interruptions. These findings suggest that screening for universal social needs allows providers to identify unrecognized needs and implement interventions to mitigate distress and improve health outcomes. Health care disparities research must pivot from simply describing the poor outcomes associated with the social determinants of health to identifying and targeting actionable mediators of inequitable medical outcomes. This study provides evidence for the feasibility of universal social needs assessment in a low‐resource setting and offers examples of interventions with the potential for large downstream effects on treatment outcomes

Direct oral anticoagulant use in gynecologic oncology: A Society of Gynecologic Oncology Clinical Practice Statement

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in women with gynecologic malignancies. This practice statement provides clinical data and overall quality of evidence regarding the use of direct oral anticoagulants (DOACs) in this patient population. Specifically, it reviews patient selection, safety measures, and nuances of perioperative use of these medications. The scope of this document is limited to DOAC use in gynecologic oncology rather than a broad discussion of VTE prophylaxis and management in general. The following recommendations and examination of extant data are based on DOAC trials conducted primarily in mixed populations with different cancer subtypes. Many of these trials include few, or no, women with gynecologic cancer. However, because there is very limited data in gynecologic cancer-specific populations, the results of these studies represent the best available evidence to support treatment recommendations in our patients. The members of the Society of Gynecologic Oncology (SGO) Clinical Practice Committee believe that the results of these studies may be extrapolated, with caution, to VTE treatment and prophylaxis for patients with gynecologic cancer. (C) 2020 Elsevier Inc. All rights reserved

Comparing Single-Site and Multiport Robotic Hysterectomy with Sentinel Lymph Node Mapping for Endometrial Cancer: Surgical Outcomes and Cost Analysis

To compare operative times, surgical outcomes, and costs of robotic laparoendoscopic single-site (R-LESS) vs multiport robotic (MPR) total laparoscopic hysterectomy (TLH) with sentinel lymph node (SLN) mapping for low-risk endometrial cancer. Retrospective cohort study (Canadian Task Force classification II-2). Academic university hospital. Patients with a biopsy-proven diagnosis of complex atypical hyperplasia (CAH) or low-grade (1 or 2) endometrial cancer with body mass index <30 kg/m2 and undergoing robotic TLH and SLN mapping between 2012 and 2016 were included. Surgical outcomes and cost data were collected retrospectively and analyzed based on the surgical approach with R-LESS vs MPR assistance. Twenty-seven patients who met the inclusion criteria were identified, including 14 patients who underwent R-LESS TLH with SLN mapping and 13 patients who underwent MPR TLH with SLN mapping. Median uterine weight was comparable in the 2 cohorts (111.3 g vs 83.8 g; p = .33). Operative and console times were equivalent with the R-LESS and MPR approaches (median, 175 minutes vs 184 minutes, p = .61 and 136 vs 140 minutes, p = .12, respectively). Median estimated blood loss was 50 mL in both cohorts. Successful bilateral SLN mapping occurred in 85.7% of the R-LESS procedures and 76.9% of MPR procedures. No intraoperative or 30-day complications were encountered, and all patients were discharged within 23 hours of surgery. MPR was associated with additional disposable instrument and drape costs of $460 to$660 compared with R-LESS, depending on the surgeon's instrument selection. Average total hospital charges were lower for R-LESS procedures ($13,410 vs$15,952; p < .05). In highly selected patients with CAH or low-grade endometrial cancer undergoing TLH and SLN mapping, R-LESS appears to result in equivalent perioperative outcomes as a MPR approach while offering a more cost-effective option. Further research is needed to determine the benefits of R-LESS procedures in the gynecologic oncology setting

Society of Gynecologic Oncology recommendations for fellowship education during the COVID-19 pandemic and beyond: Innovating programs to optimize trainee success

In approximately ten months' time, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected over 34 million people and caused over one million deaths worldwide. The impact of this virus on our health, relationships, and careers is difficult to overstate. As the economic realities for academic medical centers come into focus, we must recommit to our core missions of patient care, education, and research. Fellowship education programs in gynecologic oncology have quickly adapted to the “new normal” of social distancing using video conferencing platforms to continue clinical and didactic teaching. United in a time of crisis, we have embraced systemic change by developing and delivering collaborative educational content, overcoming the limitations imposed by institutional silos. Additional innovations are needed in order to overcome the losses in program surgical volume and research opportunities. With the end of the viral pandemic nowhere in sight, program directors can rethink how education is best delivered and potentially overhaul aspects of fellowship curriculum and content. Similarly, restrictions on travel and the need for social distancing has transformed the 2020 fellowship interview season from an in-person to a virtual experience. During this time of unprecedented and rapid change, program directors should be particularly mindful of the needs and health of their trainees and consider tailoring their educational experiences accordingly. • The novel coronavirus pandemic has disrupted medical education at all levels. • Fellowship programs must adapt to the realities of social distancing, workforce redeployments, and laboratory closures. • The integration of teleconferencing into clinical practice and learning provides both challenges and growth opportunities. • Program directors should be aware of new stressors our fellows, particularly underrepresented minorities, are facing. • Programs should take advantage of the opportunity to rethink fellowship education and the needs of our recent graduates

Reducing overtreatment: A comparison of lymph node assessment strategies for endometrial cancer

To compare the utility of three lymph node (LN) assessment strategies to identify lymphatic metastases while minimizing complete lymphadenectomy rates in women with low-grade endometrial cancer (EC). Using our institutional standard protocol (SP), patients with complex atypical hyperplasia (CAH) or grade 1/2 EC underwent sentinel lymph node (SLN) mapping, hysterectomy, and intraoperative frozen section (FS). Lymphadenectomy was performed if high-risk uterine features were identified on FS. Utilizing SP data, two alternative strategies were applied: a Universal FS Strategy (UFS), omitting SLN mapping and performing lymphadenectomy based on FS results, and a SLN-Restrictive FS Strategy (SLN-RFS) in which FS and lymphadenectomy are performed only if bilateral SLN mapping fails. Of 114 patients managed on the SP, SLNs were identified in 86%, with lymphatic metastases detected in eight patients. Six patients recurred after a median follow up of 15months. Most (83%) developed in those who had a negative systematic lymphadenectomy (n=4; mean LNs: 18) or no lymphadenectomy indication. When applying the alternative lymphatic assessment strategies, the SLN-RFS approach would theoretically result in lower lymphadenectomy rates compared to both the SP and the alternative UFS strategies (9.2% versus 36.8% and 36.8%, respectively; p=0.004), without a reduction in detection of LN metastases (8/8 versus 8/8 and 5/8, respectively). In this modeling analysis, an operative strategy omitting universal frozen section and restricting its use to cases with failed SLN mapping may result in lower lymphadenectomy rates and reduce the risk of overtreatment without compromising oncologic outcome for patients with EC

Sentinel lymph node detection rates using indocyanine green in women with early-stage cervical cancer

Objective. Our study objective was to determine feasibility and mapping rates using indocyanine green (ICG) for sentinel lymph node (SLN) mapping in early-stage cervical cancer. Methods. We performed a retrospective review of all women who underwent SLN mapping with ICG during primary surgical management of early-stage cervical cancer by robotic-assisted radical hysterectomy (RA-RH) or fertility-sparing surgery. Patients were treated at two high-volume centers from 10/2012 to 02/2016. Completion pelvic lymphadenectomy was performed after SLN biopsy; additionally, removal of clinically enlarged/suspicious nodes was part of the SLN treatment algorithm. Results. Thirty women with a median age of 42.5 and BMI of 26.5 were included. Most (90%) had stage IB disease, and 67% had squamous histology. RA-RH was performed in 86.7% of cases. One patient underwent fertility sparing surgery. Median cervical tumor size was 2.0 cm. At least one SLN was detected in all cases (100%), with bilateral mapping achieved in 87%. SLN detection was not impacted by tumor size and was most commonly identified in the hypogastric (403%), obturator (26.0%), and external iliac (20.8%) regions. Five cases of lymphatic metastasis were identified (16.7%): three in clinically enlarged SLNs, one in a clinically enlarged non-SLN, and one case with cytokeratin positive cells in an SLN. All metastatic disease would have been detected even if full lymphadenectomy had been omitted from our treatment algorithm, Conclusions. SLN mapping with ICG is feasible and results in high detection rates in women with early-stage cervical cancer. Prospective studies are needed to determine if SLN mapping can replace lymphadenectomy in this setting. (C) 2016 Elsevier Inc. All rights reserved