Objective In postoperative patients with a high risk of bleeding, sequential compression devices (SCD) and ambulation are effective methods to reduce venous thromboembolic (VTE) risks. High leg venous flow decreases VTE risk. We postulated that ankle flexion and extension (AFE) while in bed increased leg venous flow velocity as well. We wished to compare the effectiveness of SCD versus AFE in increasing leg venous velocity. Methods Thirty-two healthy volunteers were recruited into the study. Each subject had two legs that were randomized into SCD or AFE. After 15 minutes of rest, SCD or AFE was applied, followed by 15 minutes of rest, and then an alternate treatment was given to the second leg. The sequence of leg and methodology was then reversed so the second treatment was applied to the first leg, and the first treatment to the second leg, and measurements were obtained. All treatments were separated by a rest period of 15 minutes. The venous velocity on each leg was measured by Doppler ultrasound at the superficial femoral vein. Venous velocity was measured initially (first cycle peak venous velocity) and during subsequent cycles. The alternate treatments on both legs with both treatments allowed for analysis in a manner where each subject could act as its control. Results Relative to baseline bed rest, SCD increased peak venous flow velocity by 112%, while AFE increased peak venous flow velocity by 161%. AFE resulted in 43% higher venous velocity on average than did SCDs (p<0.05). Conclusions AFE leads to significantly higher venous flow in the femoral veins of healthy subjects.

Objective: To compare dosimetric data and complication rates in cervical cancer patients receiving HDR brachytherapy with either traditional packing or RadiaDyne® balloon packing.

Purpose: Identify the incidence and factors contributing to the termination of gynecologic patient-physician relationships.Methods: All patients terminated from the practice between January 2008 and December 2012 were identified. Charts were reviewed for demographic information, termination reason, and cancer diagnosis.Results: In the five year study period, 8851 new patients presented to the division of gynecologic oncology. Within this cohort, 123 patient-physician relationships were terminated. Among terminated patients, missed appointments (63.4%), noncompliance to treatment (23.6%), disruptive behavior (10.6%), and drug abuse behavior (2.4%) were the key reasons for termination. While no patients were terminated for financial reason, statistical differences were found for those with Medicaid insurance (OR = 5; 95% CI: 3.4-7.1). Terminated patients were more likely to be younger, African American/Black, and have a diagnosis of GTD or cancer, particularly cervical cancer, when compared against all retained patients.Conclusion: The prevalence of patient-physician relationship termination was low at 1.4% (123/8851). However, the finding that the 52% of terminated patients had a diagnosis of cancer is concerning; 73% of which had stage III or greater disease, or were unstaged. We hope that the identification and quantification of reasons for termination and those at risk for termination, as well as the introduction of patient-navigators, will lead to improved methods to ensure patient compliance and retention. (C) 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license

This selection from the NCCN Guidelines for Ovarian Cancer focuses on the less common ovarian histopathologies (LCOHs), because new algorithms were added for LCOHs and current algorithms were revised for the 2016 update. The new LCOHs algorithms include clear cell carcinomas, mucinous carcinomas, and grade 1 (low-grade) serous carcinomas/endometrioid epithelial carcinomas. The LCOHs also include carcinosarcomas (malignant mixed Müllerian tumors of the ovary), borderline epithelial tumors (also known as low malignant potential tumors), malignant sex cord-stromal tumors, and malignant germ cell tumors.

Objective: Ovarian cancer is difficult to diagnose early and many patients present with advanced disease. The presence of exfoliated ovarian cancer cells in the peritoneal cavity after debulking surgery is a poor prognostic indicator. Sterilization of the peritoneum during surgery may have clinical benefit in reducing tumor burden. Several studies have evaluated osmotic cytotoxicity in gastrointestinal and genitourinary cancers with varied results. We studied the cytotoxic effect of lavage fluids of differing osmolarities against multiple ovarian cancer cell lines (SKOV3, OV90, and OVCAR3) in vitro. Methods: Cells were treated for either 10 minutes or 30 minutes with water, or 5 mOsm, 10 mOsm, 50 mOsm, 100 mOsm, 200 mOsm, 280 mOsm NaCl (dilutions in water), and PBS. After 24 hours, surviving cells were enumerated in a Coulter Counter. Results: All 3 ovarian cancer cell lines were lysed progressively as lavage osmolarity was reduced (p<0.01). For the OVCAR3 ovarian cancer cells, lavage for 30 min resulted in greater cell cytotoxicity for lavage with the water, 5, 10, 50, and 200 mOsm saline when compared to lavage for 10 min. For the OV90 cancer cell line, lavage for 30 min resulted in greater cell cytotoxicity for the water, 5, and 10 mOsm saline lavages. In the SKOV3 ovarian cancer cell line, only lavage for the 30 min water had cytotoxicity. Conclusions: Since ovarian cancer uniquely resides in the peritoneal cavity, this anatomic feature allows concentrated washing to directly target these cancer cells residing in the peritoneal cavity. Hypo-osmolar treatment was found to be most effective in lysing ovarian cancer cell lines in vitro.

Objective The aim of this study was to assess the incidence of and risk factors for hypomagnesemia in patients undergoing gynecologic surgery by a gynecologic oncologist.Methods A retrospective chart review was performed on all patients undergoing surgery for gynecologic pathology from July 2011 to July 2015 by a single surgeon. Demographic data, surgical indication, surgery performed, preoperative laboratory values, postoperative laboratory values, and medical history were examined. Hypomagnesemia was defined as less than 1.8 mg/dL. Hypermagnesemia was defined as greater than 2.5 mg/dL.Results Six hundred sixty-nine patients were identified for analysis. One hundred ninety-seven patients had hypomagnesemia (29.4%). Four hundred sixty-six patients had normal magnesium levels (69.5%), and 6 patients had hypermagnesemia (1%). Among patients with benign disease, 24.9% had preoperative hypomagnesemia compared with 32.7% of patients with a gynecologic malignancy. African American race (P = 0.041), diabetes mellitus (P < 0.001), and malignancy (P = 0.029) were all associated with preoperative hypomagnesemia. Diabetes and major surgery were associated with postoperative hypomagnesemia (P = 0.012 and P = 0.048, respectively). Hypomagnesemia was associated with increased preoperative and postoperative pain (P = 0.049 and P < 0.001, respectively) as well as postoperative hypokalemia (P = 0.001). Age, body mass index, hypertension, cancer type, hematocrit, surgical indication, and length of hospital stay were not associated with hypomagnesemia.Conclusions Perioperative hypomagnesemia is prevalent in patients undergoing gynecologic surgery by a gynecologic oncology, especially in patients who have a gynecologic malignancy. We recommend routine preoperative and postoperative evaluation of serum magnesium in all patients undergoing gynecologic surgery by a gynecologic oncologist.

OBJECTIVE: To determine the bleeding risk in women undergoing minor gynecologic procedures while concurrently taking various anticoagulants. METHODS: Patient charts from January 2008 to August 2013 were reviewed to identify patients who underwent minor procedures while taking anticoagulants. Bleeding complications were graded as none, mild, moderate, or severe. No-bleeding diagnoses were defined as hemostatic biopsy sites. Mild bleeding was classified as occasional spotting requiring pressure for less than 5 minutes. Moderate bleeding required the use of suture for hemostasis. Severe bleeding complications required transfer to a tertiary care center or blood transfusion. RESULTS: We reviewed 7,453 medical records yielding 269 minor procedures during which patients were concurrently taking anticoagulants. The mean age was 65 years (range 30–96 years), with 148 African American and 121 Caucasian patients. Bleeding complications occurred in 14 patients: 13 mild and one moderate. Bleeding complications were not affected by age (P<.558) or race (P<.136) but were related to procedure type (P<.001). Specifically, the loop electrosurgical excision procedure was the only procedure to result in a statistically significant mild complication rate (P<.036). There was no association between type of anticoagulant used (P<.630) or medical diagnosis for anticoagulation (P<.759) and bleeding risk. CONCLUSION: Minor gynecologic surgical procedures can be undertaken safely in women who are concurrently taking antiplatelet or anticoagulant medications.

OBJECTIVE:To evaluate the acetowhite changes of the vulva as a predictor for high grade vulvar intraepithelial neoplasia.METHODS:We performed retrospective analysis from 344 patients referred to our gynecology oncology clinic for genital dysplasia. All patients underwent vulvar colposcopy. Vulvar biopsies were performed for acetowhite changes and visible vulvar lesions such as ulceration, hyperpigmentation, and thickening of the vulvar tissue. High grade vulvar dysplasia was defined as vulvar intraepithelial neoplasia 2 or worse. Results of the vulvar pathology were collected and sensitivity, specificity, negative and positive predictive values.RESULTS:Of the 344 women who underwent vulvoscopy 241 patients had acetowhite lesions, of whom 89 had true high grade dysplasia. Using colposcopic acetowhite changes as a marker for high grade vulvar dysplasia, the test's sensitivity was 97 %, specificity was 40 %, negative predictive value was 98 %, and the positive predictive value was 37 %.CONCLUSION:Acetowhitening of the vulva has high sensitivity but low specificity as a predictor of high grade vulvar intraepithelial neoplasia. The absence of acetowhite lesion can reassure that high grade vulvar lesion is absent.

OBJECTIVE:To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy. STUDY DESIGN:The study design was a comparison of a prospective cohort with a retrospective historical control. We enrolled endometrial cancer patients undergoing open abdominal hysterectomy with lymphadenectomy by the same surgeon. Control patients from 2008 to 2010 who received morphine PCA alone were compared with a similar demographic group of patients from 2011 to 2013 who received MMPC. MMPC consisted of gabapentin (900mg PO) and acetaminophen (1g IV) administered 45-60min preoperatively. The surgical site was injected with bupivacaine with 0.5% epinephrine prior to incision. The postoperative pain control regimen consisted of gabapentin (300mg PO every 6h), acetaminophen (1g IV every 8h for 24h postoperatively), ketorolac (15mg IV every 6h for 48h postoperatively), morphine PCA (2mg IV every 10min, no basal rate) and oxycodone/acetaminophen (10/325mg PO every 6h as needed). RESULTS:Length of hospital stay (LOH) of the study cohort (N=105 with MMPC) was compared with the historical with postoperative morphine alone (N=113 without MMPC). There were no differences in demographic, uterine cancer stage, or comorbidities between the two arms. The LOH was 1.6 days for patients receiving MMPC and 3.3 days for patients who received morphine alone (P<0.001). CONCLUSION:Multimodal pain control is associated with significantly reduced hospital stay after open abdominal hysterectomy.

Objectives: To investigate the relationship between imaging and the multivariate index assay (MIA) OVA1 in predicting the likelihood of ovarian malignancy before surgery.

OBJECTIVE: The purpose of this study was to investigate the relationship between imaging and the multivariate index assay (MIA) in the prediction of the likelihood of ovarian malignancy before surgery.STUDY DESIGN: Subjects were recruited in 2 related prospective, multiinstitutional trials that involved 44 sites across the United States. Women had ovarian imaging, biomarker analysis, and surgery for an adnexal mass. Ovarian tumors were classified as high risk for solid or papillary morphologic condition on imaging study. Biomarker and imaging results were correlated with surgical findings.RESULTS: Of the 1110 women who were enrolled with an adnexal mass on imaging, 1024 cases were evaluable. There were 255 malignant and 769 benign tumors. High-risk findings were present in 46% of 1232 imaging tests and 61% of 1024 MIA tests. The risk of malignancy increased with rising MIA scores; similarly, the likelihood of malignancy was higher for high-risk, compared with low-risk, imaging. Sensitivity and specificity for the prediction of malignancy were 98% (95% CI, 92-99) and 31% (95% CI, 27-34) for ultrasound or MIA; 68% (95% CI, 58-77) and 75% (95% CI, 72-78) for ultrasound and MIA, respectively. For computed tomography scan or MIA, sensitivity was 97% (95% CI, 92-99) and specificity was 22% (95% CI, 16-28); the sensitivity and specificity for computed tomography scan and MIA were 71% (95% CI, 62-79) and 70% (95% CI, 63-76). Only 1.6% of ovarian tumors were malignant when both tests indicated low risk. A logistic regression model to predict risk of malignancy is presented.CONCLUSION: An understanding of how pelvic imaging influences the MIA score can help clinicians better interpret the malignant risk of an ovarian tumor.

We wish to develop a CT scan-based scoring system which estimates the probability of adnexal mass malignancy.

the intent of our study to assess the effectiveness of uterine massage as a therapeutic measure in addition to therapeutic oxytocic (uterine massage plus therapeutic oxytocic compared with therapeutic oxytocic alone) for excessive bleeding control. Although a 20% frequency of use of therapeutic oxytocics seemed to be a little high in our study, recent large studies have demonstrated even higher frequencies of therapeutic oxytocic administration (20–40%). This wide range across studies indicates that the use of therapeutic oxytocics might be a center-dependent or even physician-dependent decision. Therefore, the threshold to prescribe therapeutic oxytocics is really hard to define, making it difficult to conduct our study as Dr. Fröhlich suggests. Even so, the conclusion in our study that routine abdominal uterine massage may not be a necessary strategy in addition to oxytocin for the prevention of postpartum hemorrhage still makes sense. Although we agree with Dr. Fröhlich that further study is needed on uterine massage as a therapeutic measure for excessive bleeding control after delivery, we cannot agree that uterine massage would be as effective as a tension suture during cesarean delivery. Our experience in dealing with atonic uterine bleeding insensitive to oxytocics tells us that simply massaging the uterus transabdominally is far from satisfactory, and a continuous bimanual compression would be a better choice.

Effective postoperative pain management provides improved patient comfort and satisfaction, earlier mobilization, fewer pulmonary and cardiac complications, reduced risk of deep vein thrombosis, faster recovery, and reduced cost of care. Although many therapeutic modalities are available for pain management, the optimal combination in managing postoperative pain in total abdominal hysterectomy is controversial.The objective of this study was to review the literature to formulate optimal, evidence-based preoperative, intraoperative, and postoperative pain management for women undergoing total abdominal hysterectomy.Using the OVID platform, we searched in MEDLINE and PubMed using MeSH terms postoperative pain and total abdominal hysterectomy for published articles from 1960 to the present; we found 545 studies. We screened and included only randomized clinical trials, publications in English, human studies, and abdominal hysterectomy for noncancerous indications. We excluded 456 studies that reported on animal studies; laparoscopic, vaginal, supracervical, or robotic hysterectomy; pharmacokinetic studies; primary outcome other than pain management; and chronic pain management. Studies with inadequate power, poor methodology, or inconclusive results were further excluded from this review. Thus, 89 studies constituted the cohort for our article.Pain control remains complex given variables such as age, anxiety, and extent of surgery. In general, regimens should be tailored to the needs of the individual patient, taking into account medical, psychological, and physical condition. A multimodality approach is better than conventional, single-agent narcotic in achieving optimal pain management.After reading this article, the reader should be able to understand various modalities that can be considered for preoperative, intraoperative, and postoperative pain management in total abdominal hysterectomy.

Objective. We wished to investigate the prevalence of missing lymph nodes (MLN), factors contributing to MLN, and the effect of MLN on progression free survival (PFS).Methods. Patients with uterine cancer undergoing abdominal hysterectomy and lymphadenectomy were recruited. All surgeries adhered to the Gynecologic Oncology Group protocol in collecting all the lymph node tissues in paraaortic, common iliac, obturator fossa, and external and internal iliac bilaterally. Data regarding race, age, body mass index (BMI), lymph node counts, staging, location of missing lymph nodes, length of surgery, and estimated blood loss were collected and analyzed in reference to missing lymph nodes. The definition of missing lymph node was an incomplete nodal specimen obtained without actual lymph node tissue.Results. Between April 2003 and January 2010, 235 consecutive patients were enrolled prospectively; 108 patients had missing lymph nodes post-operatively (46%), and 127 patients had complete lymph nodes. We found no correlation between MLN relative to race (P = 0.97), age (P = 0.25), BMI (P = 0.09), estimated blood loss (P = 0.38), American Society of Anaesthesiologist physical status classification system (P = 0.18), surgery time (P = 0.22), hospital stay (P = 0.05), nodes without cancer (P = 0.12), nodes with cancer (P = 0.99), stage (P = 0.90), grade (P = 0.17), or PFS (P = 0.29).Conclusion. In our study, although prevalence of missing lymph nodes seems relatively high, none of the perioperative variables studied appeared to contribute to missing lymph nodes. Finally, missing lymph nodes did not affect progression free survival. (C) 2013 Elsevier Inc. All rights reserved.

These NCCN Guidelines Insights focus on the major updates to the 2013 NCCN Guidelines for Ovarian Cancer. Four updates were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials. The topics include 1) intraperitoneal chemotherapy, 2) CA-125 monitoring for ovarian cancer recurrence, 3) surveillance recommendations for less common ovarian histopathologies, and 4) recent changes in therapy for recurrent epithelial ovarian cancer. These NCCN Guidelines Insights also discuss why some recommendations were not made.

e20673 Background: Hypomagnesemia is a common problem, occurring in nearly 12% of hospitalized patients. Due to the link of hypomagnesemia with surgery and the potential antinociceptive effects of Mg multiple trials have been conducted. Unfortunately, the role of IV and epidural Mg supplementation in pain management perioperatively remains controversial. An unanswered question from the literature to date is whether low serum Mg concentrations correlate with pain intensity. This review of patients undergoing gynecological surgeries examines whether pre-operative serum Mg level can affect pain scores and opioid use postoperatively. Methods: This was a retrospective study of the electronic medical record at Methodist University Hospital from October 1st, 2011 to July 31st, 2012. Included for analysis are all cases that underwent a gynecologic surgery and were performed under one attending surgeon. Each patient included in the study had perioperative serum Mg levels, resting and moving pain intensity scores, and amount of opioids used. Patients were excluded for any of the following criteria: missing data, discharge in less than 24 hours, robotic surgery, and use of ketamine in anesthesia. Statistical analysis included descriptive statistics, Spearman’s rank correlation coefficient, and logistic regression. Results: The analysis included 121 patients; 54% were Caucasian, the mean age was 51.7 years and 89% of surgeries were for oncologic indications. Pre-operative serum Mg level was not significantly associated with resting or moving pain intensity scores on post operative day (POD) 1 (p=0.66; p=0.68) or POD 2 (p=0.58, p=0.83). Pre-operative Mg level was not significantly associated with opioid use on POD 1 or 2. Two variables had a possible correlation with opioid usage, on average older patients used a lower level of opioid on average and patients with higher BMI used a higher level of opioids. Conclusions: Preoperative magnesium level has no correlation with pain scores or opioid use. While repletion maybe warranted and magnesium supplementation has minimal toxicity and cost, effect on post-operative pain is uncertain. Larger randomized trials may be warranted.

These NCCN Guidelines Insights focus on the major updates to the 2013 NCCN Guidelines for Ovarian Cancer. Four updates were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials. The topics include 1) intraperitoneal chemotherapy, 2) CA-125 monitoring for ovarian cancer recurrence, 3) surveillance recommendations for less common ovarian histopathologies, and 4) recent changes in therapy for recurrent epithelial ovarian cancer. These NCCN Guidelines Insights also discuss why some recommendations were not made.

► The youngest case of endometrial carcinoma in the English literature ► Endometrial cancer is diagnosed in approximately 13-19% of women with Cowden Syndrome. ► Screening guidelines should follow that of Lynch Syndrome.

These NCCN Guidelines Insights focus on the major updates for the 2012 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer by describing how and why the new recommendations were made. The 6 update topics were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials, and include: 1) screening, 2) diagnostic tests for assessing pelvic masses, 3) primary treatment using neoadjuvant chemotherapy, 4) primary adjuvant treatment using bevacizumab in combination with chemotherapy, 5) therapy for recurrent disease, and 6) management of drug/hypersensitivity reactions. These NCCN Guidelines Insights also discuss why some recommendations were not made (eg, panel members did not feel the new data warranted changing the guideline). See "Updates" in the NCCN Guidelines for Ovarian Cancer for a complete list of all the recent revisions. (JNCCN 2012;10:1339-1349)