OBJECTIVE: To describe the sensitivity, specificity, and positive and negative predictive values of the COST (Comprehensive Score for Financial Toxicity) survey for predicting whether patients would report altering spending habits, borrowing money, not filling prescriptions, or experiencing an inability to afford groceries secondary to cancer care costs in a population of patients with gynecologic cancer. METHODS: This was a single-institution, cross-sectional study of patients with gynecologic cancer within 5 years of initial diagnosis or disease recurrence. Patients completed a one-time COST survey and were screened for altering spending habits, borrowing money, not filling prescriptions, or experiencing food insecurity. RESULTS: A total of 323 patients consented and completed the survey; their mean age was 63 years, and 36.5% self-identified as Black. The mean COST score was 22. The COST score had an area under the curve value of 0.92 for predicting whether a patient would report altering spending habits, borrowing money, not filling prescriptions, or experiencing food insecurity. The cutoff COST score to maximize sensitivity and specificity was 26. At this cutoff, the score was 83.1% sensitive and 88.2% specific and had a positive predictive value of 92.9% and a negative predictive value of 73.7% for identifying those who would screen positive for reporting altering spending habits, borrowing money, delaying buying medications, or experiencing food insecurity. CONCLUSION: Our data indicate that the COST score, a measure of financial toxicity, is associated with social determinants of health in patients with gynecologic cancer. The COST score may help to predict additional needs outside of financial assistance.

Serous endometrial intraepithelial carcinoma (SEIC) is an aggressive precursor and a similar biology to uterine serous carcinoma (USC). Patients diagnosed with SEIC should undergo surgical staging that includes total hysterectomy with bilateral salpingo-oophorectomy, lymph node sampling, and omentectomy. With trends in lymph node evaluation shifting towards sentinel lymph node sampling, we recommend bilateral sentinel lymph node sampling as a reasonable alternative to full pelvic and para-aortic lymphadenectomy. There is limited data to support the use of adjuvant chemotherapy, however, it is apparent that those with extrauterine disease have a higher likelihood of recurrence and decreased overall survival. Those with stage IVB SEIC have similar rates of survival to those with stage IVB USC and may be a population that could benefit from newer regimens for advanced stage endometrial cancer including immunotherapy and maintenance therapy. Unfortunately, strong data to support this will continue to be a challenge given the rare incidence of isolated SEIC without concurrent USC. The utility of adjuvant radiotherapy remains unclear and given its noninvasive nature and propensity for distant recurrence, may be of little utility. Regardless of the adjuvant therapies selected, routine surveillance like that of USC should be followed as recurrences are often noted greater than one year after initial surgery. Unlike other precursor lesions, SEIC behaves similarly to invasive carcinoma and ultimately should be treated as such for optimal disease control and outcomes.

OBJECTIVES:To determine if nutritional status effects response to immunotherapy in women with gynecologic malignancies. METHODS:A retrospective chart review was conducted on gynecologic cancer patients who received immunotherapy at a single institution between 2015 and 2022. Immunotherapy included checkpoint inhibitors and tumor vaccines. The prognostic nutritional index (PNI) was calculated from serum albumin levels and total lymphocyte count. PNI values were determined at the beginning of treatment for each patient and assessed for their association with immunotherapy response. Disease control response (DCR) as an outcome of immunotherapy was defined as complete response, partial response, or stable disease. RESULTS:One hundred and ninety-eight patients received immunotherapy (IT) between 2015 and 2022. The gynecological cancers treated were uterine (38%), cervix (32%), ovarian (25%), and vulvar or vaginal (4%) cancers. The mean PNI for responders was higher than the non-responder group (p < 0.05). The AUC value for PNI as a predictor of response was 49. A PNI value of 49 was 43% sensitive and 85% specific for predicting a DCR. In Cox proportional hazards analysis, after adjusting for ECOG score and the number of prior chemotherapy lines, severe malnutrition was associated with progression-free survival (PFS) (HR = 1.85, p = 0.08) and overall survival (OS) (HR = 3.82, p < 0.001). Patients with PNI < 49 were at a higher risk of IT failure (HR = 2.24, p = 0.0001) and subsequent death (HR = 2.84, p = 9 × 10-5). CONCLUSIONS:PNI can be a prognostic marker to predict response rates of patients with gynecologic cancers treated with immunotherapy. Additional studies needed to understand the mechanistic role of malnutrition in immunotherapy response.

Disorders of sexual development (DSDs) represent a spectrum of conditions characterized by atypical gonadal and/or genital development. The incidence is 1 in 5,000 live births. Patients with DSD may be at increased risk for developing gonadal and reproductive tract tumors. This report summarizes the current knowledge on the risks of gonadal tumors in patients with DSD. Specifically, we focus on ovotesticular DSD (OT-DSD), which accounts for 5% of DSD cases and is defined by the presence of both ovarian and testicular tissues in the same individual. We present a rare case of a phenotypically male XY patient with OT-DSD who was diagnosed with aggressive peritoneal cancer at the age of 71.

Background: A pure ovarian dysgerminoma in a postmenopausal female is a rare phenomenon. Case: A 65-year-old female presented with a large pelvic mass. Following surgical debulking, the patient was diagnosed with FIGO Stage IIB ovarian dysgerminoma. She was treated with three cycles of etoposide and cisplatin and has been disease-free for 12 months. Conclusion: Dysgerminomas in postmenopausal females are uncommon. Gynecologic oncologists should be familiar with the pathological diagnosis and treatment recommendations to achieve optimal outcomes.

Background: Use of immune checkpoint inhibitors in treatment of gynecologic malignancies is increasing. Rare, but potentially fatal, immune-related neurologic adverse events may occur as a result of treatment. Case: A 72 year old female with recurrent metastatic uterine adenocarcinoma received pembrolizumab and lenvatinib combination therapy. Following her second dose of pembrolizumab, the patient developed multiple neurologic symptoms. She was ultimately diagnosed with Guillain-Barre Syndrome based on neurologic evaluation with imaging, serum studies, and cerebrospinal fluid analysis. The patient was successfully treated with high-dose intravenous corticosteroids and intravenous immunoglobulin. Conclusion: Neurologic complications related to immune checkpoint inhibitor therapy are rare. It is imperative for gynecologic oncologists to be familiar with potentially fatal hazards of therapy to allow for rapid diagnosis and treatment.

Objective: The purpose of this study was to evaluate the response to therapy in patients with platinum-resistant ovarian cancer and the effectiveness of subsequent lines of therapy.

STUDY OBJECTIVE:To compare intraoperative and perioperative narcotic use, recovery room time, and total hospital stay for patients treated with robotic vs laparoscopic surgery for endometrial cancer.DESIGN:Retrospective cohort.SETTING:Teaching hospital.PATIENTS:All patients having minimally invasive surgery in the division of gynecologic oncology during a 20-month period.INTERVENTION:Laparoscopic cases were compared with robot-assisted cases with respect to perioperative outcome.MEASUREMENT AND MAIN RESULTS:Hospital billing records were used to identify all patients with endometrial cancer treated from January 1, 2018 through July 31, 2019 undergoing either laparoscopic or robotic surgery. Data were collected including total narcotic use converted to intravenous morphine milligram equivalent (MME), total amount of time in recovery, and length of hospital stay. A total of 139 laparoscopic and 101 robotic surgeries were eligible for analysis. There was no difference between the groups with respect to blood loss, alcohol use, or smoking. Patients undergoing laparoscopy had a significantly lower body mass index compared with patients undergoing robotic surgery (32.9 vs 38.0 kg/m2; p <.001). Univariate analysis showed no difference between the 2 groups with respect to narcotic use in surgery (21.7 vs 21.1 MME; p = .64), recovery (4.3 vs 4.5 MME; p = .70), or total dose (26.0 vs 25.6 MME; p = .78). However, patients who underwent a robotic approach had a longer recovery room time (128 minutes vs 163 minutes; p <.001 and a longer surgical time (288 minutes vs 204 minutes; p = .001). Patients in the robotic group were also more likely to undergo full lymphadenectomy than patients in the laparoscopy group (38.0% vs 20.8% p <.001). In a multivariate analysis, the only significant factors for predicting total narcotic dose were age, use of a preoperative enhanced recovery after surgery program, and surgical time. Patients who had laparoscopy were more likely to achieve same-day discharge (39.3% vs 17.8%; p <.001), but in the multivariate analysis, the type of surgery did not predict same-day discharge.CONCLUSION:There was no difference in narcotic use in the perioperative period with robotic surgery compared with laparoscopy. Recovery time was longer for robotic surgery, but this was not significant in multivariate analysis. Same-day discharges were less frequent with robotics, which may be more related to the physician's choice rather than the procedure.

Objective: The purpose of this study was to review the impact of an enhanced recovery after surgery (ERAS) protocol on recovery after minimally invasive surgery performed by gynecologic oncologists related to intraoperative narcotics, narcotics in phase I recovery, time in phase I recovery, and total hospital time.

Objective: Neuroendocrine tumors (NETs) of the gynecologic tract have historically represented rare, aggressive tumors with a poor prognosis, high rates of recurrence despite multimodal treatment, and limited therapeutic options. The objective of this study was to identify potential therapeutic targets for gynecologic NETs through molecular profiling of a large cohort of patients.

Objective To perform comprehensive genomic profiling on a large cohort of patients with uterine carcinosarcomas to identify potential therapeutic targets. Methods Molecular profiling was conducted on 168 retrospectively de-identified patients with uterine carcinosarcomas using the Caris Life Sciences platform. Specimens were evaluated for aberrations in protein expression by immunohistochemistry, DNA sequence mutation using a 592-gene next generation sequencing panel, copy number amplification using next generation sequencing or in situ hybridization, and fusion events using NextGen RNA sequencing. Tumor mutational load and microsatellite instability were also evaluated. Results We identified 168 patients with uterine carcinosarcoma; median age of the cohort was 67 years. The most common mutations were observed in the following genes: TP53 (86%), PIK3CA (34%), FBXW7 (23%), PTEN (18%), KRAS (16%), PPP2R1A (10%). Tumor mutational load was low to moderate in most cases (50% and 45%, respectively). HER2/neu (ERBB2) was amplified in 9% of tumors. Immunohistochemistry protein expression was elevated in TOP2A (95%), TS (80%), PTEN (76%), and TUBB3 (66%). Mismatch repair deficiency was rare (4%). Conclusions Multiple somatic mutations and copy number alterations in genes that are therapeutic targets were identified in half of cases. Uterine carcinosarcomas represent an aggressive histology with limited treatment options and poor outcomes, and clinical trials are needed to validate new therapeutic targets.

Objectives The aim of this study was to demonstrate the utility of a comprehensive program involving management-based evidence, telemedicine, and patient navigation to provide genetic counseling services for patients with ovarian and breast cancer across a geographically large health care system. Methods We identified all patients with newly diagnosed ovarian and breast cancer in our health care system from January 2013 to December 2015 through the cancer registry. Referral characteristics and testing outcomes were recorded for each year and compared using the χ2 or Fisher exact test. Results Because the implementation of this program, the number of new ovarian cancer cases remained constant (109–112 cases/year) but patients referred for genetic counseling increased annually from 37% to 43% to 96% (P < 0.05). The percentage of ovarian cancer patients who underwent genetic testing increased annually from 24% to 27% to 53% (P < 0.05). The number of new breast cancer patients was constant (1543–1638 cases/year). The percentage of patients with triple negative breast cancer referred for genetic counseling rose from 69% in 2013 to 91% in 2015; the percentage of patients who underwent testing increased annually from 59% to 86% (P < 0.05). Of women with breast cancer diagnosed at less than 45 years of age, 78% to 85% were referred for genetic counseling across this period; the percentage of patients who underwent testing increased annually from 66% to 82% (P < 0.05). Patient navigation was initiated and was available to all patients in the system during this period. Telemedicine consults were performed in 118 breast/ovarian patients (6%) during this period. Conclusions A comprehensive program may improve access to effective genetic counseling services in patients with ovarian and breast cancer despite geographic barriers.

Study Objective: To compare outcomes of advanced ovarian cancer patients who had minimally invasive surgery (MIS) with outcomes of advanced ovarian cancer patients who had laparotomy for interval cytoreduction after neoadjuvant chemotherapy (NACT). Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: One large teaching hospital with a tertiary referral function for gynecologic oncology and MIS. Patients: All consecutive patients with stages III to IV epithelial ovarian, tubal, or peritoneal cancer who underwent MIS or laparotomy for interval cytoreduction after at least 1 NACT cycle from 2006 to 2017 at 1 institution. Interventions: Patients underwent either MIS or laparotomy for interval cytoreduction after at least 1 cycle of NACT. Measurements and Main Results: Medical records were reviewed and data abstracted and analyzed. Survival was estimated by the Kaplan-Meier method, and outcomes were compared with Fisher's exact test, Student's t test, Wilcoxon rank sum test, and the log-rank test. In total, 157 assessable patients underwent interval cytoreductive surgery through MIS (n = 53) or laparotomy (n = 104). MIS was completed without conversion in 44 of 53 patients (83%), of whom 20 required a hand port and/or mini-laparotomy. R-zero and optimal resections were achieved in 60.4% and 96.3% of MIS patients respectively, compared with 42.3% and 82.7% of laparotomy patients (p = .02). MIS patients had lower estimated blood loss (EBL; 156 vs 278 mL, p < .001), fewer intraoperative transfusions (2% vs 17%, p = .006), and shorter hospital stay (3.0 vs 5.7 days, p < .001). Operative time was longer (171 vs 150 minutes, p = .007), but complications, intensive care unit stay, readmission, median progression-free survival (27 vs 29 months, p = .45), and median overall survival (37 vs 35 months, p = .74) were similar. Conclusion: MIS is feasible and effective for interval cytoreduction after NACT in advanced ovarian cancer patients. MIS is associated with less EBL, lower transfusion rate, and shorter length of hospital stay with no difference in patient outcomes. (C) 2018 AAGL. All rights reserved.

OBJECTIVES:To compare the outcomes after intraperitoneal (IP) chemotherapy in patients with and without pathogenic BRCA mutations. METHODS:Patients with high grade ovarian cancer who were treated with adjuvant IP chemotherapy in the initial setting between 2005 and 2016 were identified. Outcomes were compared between patients with pathogenic mutations in BRCA (BRCA+) and those who tested negative or were unknown (BRCA-). RESULTS:A total of 100 eligible patients were identified. The median follow-up was 47.0 months (range, 6.6-144.1 months). Of these 100 patients, 77 patients underwent BRCA testing; 25 patients (32%) were BRCA+ (23 germline, 2 somatic). No differences were noted between groups with respect to number of IP cycles, stage, or residual disease after surgery. The median progression-free survival (PFS) was longer in the BRCA+ group; median PFS was not reached in the BRCA+ group compared to 17.3 months in the BRCA- group (HR = 0.38; 95% CI 0.20-0.73, P = 0.003). Median overall survival (OS) was longer in the BRCA+ group at 110.4 months versus 67.1 months (HR = 0.28, 95% CI 0.11-0.73, P = 0.009). CONCLUSIONS:Pathogenic BRCA mutations are more common than expected in optimally resected ovarian cancer patients selected for IP therapy. IP therapy was associated with a dramatic improvement in PFS and OS in BRCA+ patients compared with BRCA- patients. This improvement is greater than has been reported for BRCA+ patients with IV chemotherapy. The magnitude of this benefit suggests that patients with pathogenic mutations in BRCA may benefit from IP therapy.

Objectives: Endometrial carcinoma is the most common gynecologic malignancy in the United States. Lynch syndrome accounts for 3%–5% of patients with endometrial cancer. Universal screening of endometrial cancer specimens with immunohistochemistry staining (IHCS) can be performed to determine loss of expression of mismatch repair (MMR) proteins. The purpose of this study was to assess compliance with the recommendation for genetic testing among endometrial cancer patients with IHCS screening as high risk for Lynch syndrome.

Objective: To demonstrate the utility of a comprehensive program involving telemedicine and patient navigation in providing genetic counseling services for patients with ovarian and breast cancer across a geographically large health care system.