OBJECTIVE:The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. METHODS:Patients with SLNs-isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan-Meier methods. RESULTS:494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs-isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1-3.0) and 2.6 years (IQR 0.6-4.2) in the SLN-isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN-isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. CONCLUSIONS:Patients with SLNs-isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs-isolated tumor cells was not associated with worse overall survival.

OBJECTIVES:The incidence of venous thromboembolism (VTE) following radical surgery for vulvar carcinoma remains poorly characterized, and recommendations for postoperative chemoprophylaxis are varied. Our objective was to assess the incidence of postoperative VTE in patients undergoing surgery for vulvar carcinoma and to determine if VTE incidence differs by radical vulvectomy with or without lymph node assessment. METHODS:The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients with a diagnosis of vulvar cancer undergoing radical vulvectomy with or without lymph node assessment from 2012 to 2020. Clinical characteristics and 30-day incidence of VTE as well as other postoperative outcomes were abstracted. Variables were compared using Chi-square test and Fischer's exact test, as well as Kruskal-Wallis and Wilcoxon rank sum tests where appropriate. RESULTS:A total of 1672 patients underwent radical vulvectomy for vulvar carcinoma. 11 patients (0.7%) experienced postoperative VTE within 30 days of surgery. The incidence of VTE was similar when radical vulvectomy was performed alone or with lymph node dissection by any method (p = 0.116). Longer operative times (p = 0.033) and greater postoperative length of stay (p = 0.001) were associated with increased risk of postoperative VTE. CONCLUSIONS:The incidence of postoperative VTE is low in patients undergoing radical vulvar surgery in this national cohort. Inguinofemoral lymph node dissection by any method does not appear to be a risk factor for VTE when compared to radical vulvectomy alone. Further research is needed to determine if extended VTE prophylaxis is beneficial in this population.

Background: Distress among gynecologic oncology patients correlates with poor clinical outcomes and decreased quality of life. The purpose of this study was to determine risk factors for elevated NCCN Distress Thermometer (DT) results among postoperative gynecologic oncology patients. Patients and Methods: We performed a retrospective chart review of all postoperative visits over a 5-year period. NCCN DT results were analyzed as both discretized values (DT <= 3 = low distress; DT 4-8 = moderate distress; DT >= 9 = high distress) and continuous variables. Patients with a DT score >= 4 were referred to social work. Univariate and multivariate regression analyses were performed to compare NCCN DT results with clinical and sociodemographic variables. Statistical significance was P<.05. Results: In total, 1,795 NCCN DT results were included, with uterine (37.72%) being the most common disease site. Benign pathology was known prior to completion of the NCCN DT in 13.15% of patients. Most patients (71.75%) endorsed low levels of distress. Moderate/High levels of distress were reported by 28.25% of patients. Increasing levels of distress were significantly associated with younger age (P=.006), history of depression (P <=.001), status as a current smoker (P=.028), and history of asthma (P=.041). Knowledge of benign pathology was associated with low levels of distress (P=.002). Procedure type and disease site were not associated with distress. Conclusions: More than one-fourth of postoperative patients in a gynecologic oncology practice reported moderate or high distress. Distress was highest among those with malignancy regardless of disease site or surgical intervention. Benign pathology correlated with decreased distress. Identified associations with distress provide opportunities for prevention, early intervention, and tailored counseling.

Objectives The current recommendation for hysterectomy specimens performed for cervical cancer following conization is that the entire cervix be submitted for histologic examination. Given the high cost of medical procedures and concerns regarding difficulties with laboratory staffing, we sought to evaluate the potential for selective histologic examination in this setting.Methods Post-conization hysterectomy cases were reviewed for the presence of residual disease in relation to the findings of the prior conization, with consideration of margin status. Residual disease was then assessed for clinical significance. The number of submitted blocks was recorded and the associated costs were estimated.Results Among 32 cases with invasive carcinoma, only cases with margins positive for invasive carcinoma on the conization specimen had residual invasion in the hysterectomy (n = 7), and there were no upgrades due to subtle microscopic disease; 1 case had a change in pathologic stage from pT1b1 to pT2b due to parametrial involvement in the setting of a grossly apparent lesion. Among 20 cases performed following a diagnosis of dysplasia, none were upgraded to invasive carcinoma. Based on protocol-based submission of the entire cervix, 16 blocks of cervix were submitted on average (range, 4-41).Conclusions We estimate that representative sections from each cervical quadrant would save approximately 2 work hours for laboratory staff per case and up to 6 hours for larger cases, reducing costs for the laboratory accordingly. Selective cervical sampling in the setting of negative margins on conization provides an opportunity for improved resource utilization without compromising patient care; as this is a small study, confirmation of these findings in a larger number of cases may be warranted. Additional studies are necessary to determine what other contexts in surgical pathology could benefit from a similar reductive approach.

OBJECTIVES:Radical hysterectomy is the standard of care for management of early-stage cervical cancer and is associated with postoperative urinary retention. No clear consensus exists regarding optimal voiding trial methodology for mitigating postoperative urinary retention. Our objective was to evaluate the association between type of postoperative voiding trial and risk of urinary retention after radical hysterectomy for cervical cancer. METHODS:We conducted a retrospective analysis of patients undergoing radical hysterectomy for apparent early-stage cervical cancer (FIGO 2018 Stage IA2-IB2) between January 2014 and February 2023. We compared incidence of urinary retention and perioperative outcomes based on method of postoperative voiding trial (timed, autofill, or backfill). Multivariate logistic regression was used to determine association of type of void trial with absence of urinary retention within 30 days postoperatively. RESULTS:Of the 115 patients identified, 48 (41.8%) patients completed a timed void trial, 40 (34.7%) an autofill void trial, and 27 (23.5%) a backfill void trial. 44.3% of patients developed postoperative urinary retention with no differences based on void trial (p = 0.17). Urinary retention was more likely to resolve by 7 (p = 0.012) and 30 days (p = 0.01) for patients undergoing backfill voiding trials, compared to other trials. In multivariate models, backfill void trial was associated with absence of 30-day urinary retention, compared to other trials (aOR 15.1; 95% C.I. 1.5-154.9). CONCLUSIONS:Rates of urinary retention following radical hysterectomy do not differ based on postoperative void trial methodology. A backfill void trial following radical hysterectomy may lead to increased rates of resolution of postoperative urinary retention.

Leiomyosarcomas (LMS) of the uterus are rare, aggressive malignancies with high rates of recurrence. Both uterine leiomyoma and LMS share common presenting symptoms; because of this, the diagnosis of uterine LMS is commonly made upon pathology evaluation after myomectomy or hysterectomy for suspected benign disease. Uterine LMS commonly expresses estrogen (ER) and progesterone (PR) receptors. However, the role of oophorectomy in premenopausal women with uterine LMS remains controversial. Based on the current literature, there appears to be no added benefit of removing bilateral ovaries following the diagnosis of early stage uterine LMS in premenopausal women. In addition, there remains minimal data demonstrating any increased risk of recurrence or tumor growth following ovarian preservation in this patient population. If the ovaries are preserved, close long-term follow-up is important.

National guidelines, including those from the Society of Gynecologic Oncology, recommend the use of thromboprophylaxis in high-risk gynecologic cancer patients undergoing systemic cytotoxic chemotherapy. The purpose of this quality improvement project was to determine the feasibility of utilizing direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) prevention in high-risk gynecologic cancer patients undergoing primary chemotherapy.

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer. (c) RSNA, 2023

Introduction/Background The clinical impact of isolated tumor cells (ITC) (≤0.2 mm) in sentinel lymph nodes (SLN) of endometrial cancer (EC) is unclear. This study compared the recurrence-free survival (RFS) of intermediate-risk EC patients who underwent SLN biopsy and were node-negative vs. those who had ITC. Methodology Patients with SLN-ITC, between 2012 and 2019, were identified from 21 centers worldwide, while SLN-node-negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018 and served as comparing group. Only patients with uterine-confined EC and intermediate-risk factors [grade 1 or 2 endometrioid and myometrial invasion (MI) ≥50%; grade 3 endometrioid and MI <50%; non-endometrioid without MI] were included. Adjuvant therapy (ATx) included vaginal brachytherapy (VB), external beam radiation and/or chemotherapy (EBRT±CHT). The primary outcome was non-vaginal recurrence (hematogenous, peritoneal or lymphatic). Results Of 200 patients included, 74 had ITC and 126 were node-negative. Sixteen patients had a non-vaginal recurrence and the median follow-up for patients without recurrence was 2.9 (IQR, 1.8–3.8) and 2.8 (0.8–4.4) years for the two groups, respectively. Among the 162 patients with ATx (VB only=112; EBRT±CHT=50), there was no significant difference in non-vaginal RFS between ITC vs. node-negative patients [p=0.34; 4-year RFS 84.1% (95% CI, 72.1–98.1%) vs. 91.5% (95% CI, 84.1–99.4%) for 61 ITC vs. 101 node-negative]. However, we observed worse non-vaginal RFS in the subgroup of 32 patients with concurrent ITC and LVSI (p=0.006, figure 1). In particular, the 4-year RFS was 64.6% (95% CI, 43.2–96.8%) in this subgroup compared to 93.3% (95% CI, 81.5–100%) and 91.7% (95% CI, 83.9–100%) for the node-negative patients with and without LVSI, respectively. There were no recurrences among 29 patients with ITC and no LVSI. Conclusion Our results on intermediate-risk EC, who received ATx, suggest that the simultaneous presence of ITC and LVSI is associated with a poorer prognosis. Further studies are warranted.

Introduction/Background The prognostic value of isolated tumor cells (ITC) (≤0.2 mm) in sentinel lymph nodes (SLN) of patients with endometrial cancer (EC) is still unclear. This study compared the recurrence-free survival (RFS) of low-risk EC patients who received no adjuvant therapy, who underwent a SLN biopsy and were node-negative vs. those who had ITC. Methodology Patients with SLN-ITC, between 2012 and 2019, were identified from 21 centers worldwide, while SLN-node-negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018 and served as a comparing group. Only patients with stage IA endometrioid histology, and low-risk profile (grade 1 or 2 endometroid and myometrial infiltration <50%) who did not receive adjuvant therapy were included. The primary outcome was non-vaginal recurrence (peritoneal, hematogenous, and lymphatic). Results A total of 494 patients (42 ITC and 452 node-negative) were included. There were 15 recurrences and the overall median follow-up for patients without recurrence was 2.2 (IQR 1.1–3.0) years for the ITC group and 2.6 (IQR 0.6–4.2) years for the node-negative group. The presence of SLN-ITC (HR, 5.66; 95% CI, 1.76–18.23), LVSI (HR, 10.66 95% CI, 2.27–50.04) and grade 2 (HR, 3.16; 95% CI, 1.14–8.75) were significant risk factors for non-vaginal recurrence at univariate analysis. Non-vaginal RFS was significantly poorer for the ITC group (vs. node-negative) [p=0.001, figure 1, 4-year RFS: 88.2% (95% CI, 77.8–100) vs 96.9% (95% CI, 94.5–99.3)]. Furthermore, among those without LVSI (N=480), the presence of SLN-ITC (adjusted HR, 4.47; 95% CI, 1.21–16.60) was significantly associated with non-vaginal recurrence after adjusting for grade. Conclusion Patients with SLN-ITC and a low-risk profile who received no adjuvant therapy had a worse prognosis than node-negative patients with similar risk factors after considering grade and LVSI. Longer follow-up is needed to confirm this finding.

Preoperative bowel preparation has been part of the surgical dogma for patients undergoing planned colorectal, gynecologic, or other pelvic surgery for decades. With the introduction of enhanced recovery after surgery (ERAS), many dogmatic approaches to perioperative care were replaced by evidence-based approaches which may ultimately favorably impact the outcomes intended to be reduced by preoperative bowel preparations. There remains a greater volume of data in support of oral antibiotic preparation with mechanical bowel preparation when a preoperative bowel preparation is utilized. Mechanical bowel preparation alone carries no benefit, may be harmful in the perioperative setting, and should be avoided. Emerging research suggests that oral antibiotic preparation alone may be beneficial, and the ERAS perioperative landscape has introduced a new era that favorably impacts bowel-related outcomes even in the setting of no bowel preparation. As such, the role of preoperative bowel preparation warrants revisiting as perioperative care evolves.

Objectives: The rate of venous thromboembolism (VTE) in gynecologic cancer patients undergoing cancer-directed therapy is not well described. The objective of this study was to evaluate the incidence and risk factors for VTE among patients with newly diagnosed and recurrent gynecologic cancer who receive systemic chemotherapy. Methods: This is a single institution longitudinal retrospective cohort study. The primary endpoint of this study was to determine the cumulative incidence of VTE from the time of cancer diagnosis to receipt of outpatient chemotherapy between January 1, 2020, and January 1, 2021. Secondary outcomes included identifying risk factors associated with VTE. Clinical and demographic data were collected, and descriptive statistics were performed. Pearson Chi-square or Fisher’s exact tests were used for categorical variables. Student’s t-tests or the Wilcoxon Rank-Sum tests were used for continuous variables. All statistical tests considered were two-sided, and a p-value of <0.05 was considered significant. Data analyses were performed in R (V 4.0.5 or later). Results: Of the 215 ambulatory gynecologic cancer patients who underwent chemotherapy, 45 (21%) experienced venous thromboembolism at some point during their cancer course. Our cohort included 117 (54%) ovarian, 66 (31%) uterine, 24 (11%) cervical, and eight (4%) vulvovaginal cancers. The timeline for VTE diagnoses was as follows: nine (20%) were diagnosed at the time of cancer diagnosis, 21 (46.7%) while actively getting chemotherapy, seven (15.6%) in the postoperative period, and eight (17.8%) during surveillance. The incidence of VTE during chemotherapy was 9.6% in patients with a new diagnosis and 12.5% in those with recurrence. Prechemotherapy anemia with hemoglobin <10g/dL (p=0.01), thrombocytosis with platelet ≥350,000/μL (p=0.01), albumin level (p=0.042), and more than three prior chemotherapy lines (p=0.003) were significantly associated with risk of embolism. There was a significant association of Khorana score with VTE risk (p=0.039), with higher scores in the VTE group (median: 2) than in the group without VTE (median: 1). Conclusions: In our cohort of gynecologic cancer patients, we found a high overall incidence of VTE, particularly during receipt of chemotherapy. This was true for patients with newly diagnosed and recurrent cancer. As recently recommended by the Society of Gynecologic Oncology, the use of pharmacologic thromboprophylaxis in highrisk cancer patients undergoing chemotherapy should be strongly considered. Objectives: The rate of venous thromboembolism (VTE) in gynecologic cancer patients undergoing cancer-directed therapy is not well described. The objective of this study was to evaluate the incidence and risk factors for VTE among patients with newly diagnosed and recurrent gynecologic cancer who receive systemic chemotherapy. Methods: This is a single institution longitudinal retrospective cohort study. The primary endpoint of this study was to determine the cumulative incidence of VTE from the time of cancer diagnosis to receipt of outpatient chemotherapy between January 1, 2020, and January 1, 2021. Secondary outcomes included identifying risk factors associated with VTE. Clinical and demographic data were collected, and descriptive statistics were performed. Pearson Chi-square or Fisher’s exact tests were used for categorical variables. Student’s t-tests or the Wilcoxon Rank-Sum tests were used for continuous variables. All statistical tests considered were two-sided, and a p-value of <0.05 was considered significant. Data analyses were performed in R (V 4.0.5 or later). Results: Of the 215 ambulatory gynecologic cancer patients who underwent chemotherapy, 45 (21%) experienced venous thromboembolism at some point during their cancer course. Our cohort included 117 (54%) ovarian, 66 (31%) uterine, 24 (11%) cervical, and eight (4%) vulvovaginal cancers. The timeline for VTE diagnoses was as follows: nine (20%) were diagnosed at the time of cancer diagnosis, 21 (46.7%) while actively getting chemotherapy, seven (15.6%) in the postoperative period, and eight (17.8%) during surveillance. The incidence of VTE during chemotherapy was 9.6% in patients with a new diagnosis and 12.5% in those with recurrence. Prechemotherapy anemia with hemoglobin <10g/dL (p=0.01), thrombocytosis with platelet ≥350,000/μL (p=0.01), albumin level (p=0.042), and more than three prior chemotherapy lines (p=0.003) were significantly associated with risk of embolism. There was a significant association of Khorana score with VTE risk (p=0.039), with higher scores in the VTE group (median: 2) than in the group without VTE (median: 1). Conclusions: In our cohort of gynecologic cancer patients, we found a high overall incidence of VTE, particularly during receipt of chemotherapy. This was true for patients with newly diagnosed and recurrent cancer. As recently recommended by the Society of Gynecologic Oncology, the use of pharmacologic thromboprophylaxis in highrisk cancer patients undergoing chemotherapy should be strongly considered.

Objective. To assess oncologic outcomes in endometrial cancer patients with low-volume metastasis (LVM) in the sentinel lymph nodes (SLNs). Methods. Patients with endometrial cancer and SLN-LVM (<2 mm) from December 3, 2009, to December 31, 2018, were retrospectively identified from 22 centers worldwide. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV, adnexal involvement, or unknown adjuvant therapy (ATx) were excluded. Results. Of 247 patients included, 132 had isolated tumor cell (ITC) and 115 had micrometastasis (MM). Overall 4-year recurrence-free survival (RFS) was 77.6% (95% CI, 70.2%-85.9%); median follow-up for patients without recurrence was 29.6 (interquartile range, 19.2-41.5) months. At multivariate analysis, Non-endometrioid (NE) (HR, 5.00; 95% CI, 2.50-9.99; P < .001), lymphovascular space invasion (LVSI) (HR, 3.26; 95% CI, 1.45-7.31; P = .004), and uterine serosal invasion (USI) (HR, 3.70; 95% CI, 1.44-9.54; P = .007) were independent predictors of recurrence. Among 47 endometrioid ITC patients without ATx, 4-year RFS was 82.6% (95% CI, 70.1%-97.2). Considering 18 ITC patients with endometrioid grade 1 disease, without LVSI, USI, or ATx, only 1 had recurrence (median follow-up, 24.8 months). Conclusions. In patients with SLN-LVM, NE, LVSI, and USI were independent risk factors for recurrence. Patients with any risk factor had poor prognosis, even when receiving ATx. Patients with ITC and grade 1 endometrioid disease (no LVSI/USI) had favorable prognosis, even without ATx. Further analysis (with more patients and longer follow-up) is needed to assess whether ATx can be withheld in this low-risk subgroup. (c) 2021 Elsevier Inc. All rights reserved.

Objectives: Minimally invasive surgery (MIS) is increasingly utilized for gynecologic cancers. While incidence of venous thromboembolism (VTE) after MIS is low, some guidelines recommend extended chemoprophylaxis for these patients undergoing MIS. Our objectives were to determine incidence of postoperative VTE in patients undergoing MIS, evaluate differences in the incidence by MIS modality and assess the need for extended chemoprophylaxis. Methods: We conducted a retrospective cohort study including all patients undergoing MIS (robot-assisted, multi-port laparoscopy, single-port laparoscopy) for gynecologic cancers between January 2014 and December 2018 at our institution. Demographic and perioperative variables were collected. Patients <18 years, with benign pathology, or on preoperative anticoagulation were excluded. Chi-square, Fisher's exact test, and one-way ANOVA were performed to determine risk factors related to VTE occurrence. Results: We identified 806 patients who underwent MIS with median age 61. Most had Stage I disease (81.5%) and uterine cancer (81.5%). Five VTE events occurred within 90 days following surgery (0.6%). Incidence of 90 day VTE did not differ between MIS modalities (p = 0.6). Patients with longer OR times (p = 0.004) were more likely to experience VTE. Age, smoking status, BMI, type of cancer and stage were not significant risk factors for VTE. Conclusions: The incidence of postoperative VTE in patients with gynecologic cancers undergoing MIS is low and does not appear to differ by MIS modality. Given the very low incidence of postoperative VTE, extended chemoprophylaxis is unlikely to benefit patients with gynecologic malignancies undergoing MIS procedures. (C) 2021 Elsevier Inc. All rights reserved.

Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging. Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms. An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific. : This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging. • This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.

Objective: Perioperative blood transfusion is associated with poor ovarian cancer outcomes and higher complication rates. Our aim was to reduce perioperative red blood cell transfusion by 30% among open cancer cases through implementation of a standardized bundle of interventions.

OBJECTIVE: To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. METHODS: This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. RESULTS: In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P <.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P =.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P =.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P =.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. CONCLUSION: Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.