Alyssa Larish

Impact of hysteroscopy on course of disease in high-risk endometrial carcinoma

Previous studies have investigated the impact of preoperative hysteroscopy on the staging and survival of predominantly grade 1 endometrial cancers. We sought to evaluate the effect of hysteroscopy on the peritoneal spread of tumor cells and disease course in a large series of patients with high-risk endometrial cancer. Patients who underwent hysterectomy for grade 3 endometrial carcinoma on final surgical pathology at the Mayo Clinic in Rochester, MN between January 2009 to June 2016 were included, noting hysteroscopy within 6 months from surgery. Intra-peritoneal disease was defined as any positive cytology OR adnexal invasion OR stage IV. The presence of intra-peritoneal disease OR peritoneal recurrence within 2 years from surgery was defined as peritoneal dissemination. Cox proportional hazards models were fit to evaluate associations between hysteroscopy exposure and progression within 5 years following surgery. Among 831 patients, 133 underwent hysteroscopy. There was no difference in age, body mass index, ASA ≥3, or serous histology between patients who did or did not undergo hysteroscopy. Advanced stage disease (III/IV) was less common among patients who underwent hysteroscopy (30.1% vs 43.8%, P=0.003). No difference was observed between those with vs without hysteroscopy in the rate of positive cytology (22.0% vs 29.7%, P=0.09), stage IV (16.5% vs 21.9%, P=0.16), intra-peritoneal disease (28.6% vs 36.1%, P=0.09), or peritoneal dissemination (30.8% vs 39.3%, P=0.06). On stratifying by stage, hysteroscopy did not increase the risk of progression (HR 1.06, 95% CI 0.59 to 1.92 for stage I/II; HR 0.96, 95% CI 0.62 to 1.48 for stage III/IV). In this retrospective study of grade 3 endometrial cancer, we did not observe any significant association between pre-operative hysteroscopy and the incidence of positive cytology, peritoneal disease, peritoneal dissemination, or cancer progression.

Recurrence patterns in patients with abnormal cardiophrenic lymph nodes at ovarian cancer diagnosis

Metastases in cardiophrenic lymph nodes noted at diagnosis of epithelial ovarian cancer confer a poor prognosis. It is unclear if cardiophrenic nodal metastases portend an atypical pattern of recurrence. We report on patients with radiographically involved cardiophrenic lymph nodes who underwent optimal primary debulking surgery to describe patterns of recurrence and response to chemotherapy. Patients undergoing primary debulking surgery for stage IIIC/IV epithelial ovarian carcinoma with residual disease ≤1.0 cm at our institution from 2003 to 2011 with a pre-operative computed tomography (CT) scan were identified. Scans were reviewed by blinded radiologists, who identified abnormal cardiophrenic lymph nodes via a qualitative assessment scale based on size, heterogeneity, and architecture. Of the 250 patients identified, a recurrence site was documented in 22/27 (81.5%) with abnormal pre-operative cardiophrenic lymph nodes (defined by an elevated Qualitative Assessment Scale (QAS) score of ≥4), and in 128/223 (57.4%) without abnormal pre-operative cardiophrenic lymph nodes. Median short axis and long axis lymph node diameters for these patients was 9 (range 6-15) mm and 15 (range 11-22) mm, respectively. Cardiophrenic lymph nodes were resected in one patient. Patients with abnormal cardiophrenic nodes are more likely to have synchronous recurrence in thorax/pelvis and abdomen (50.0% (11/22) vs 25.0% (32/128), p=0.02) and less likely to have isolated recurrence in pelvis or abdomen (40.9% (9/22) vs 68.0% (87/128)). All patients who had a CT scan after six cycles of chemotherapy had improvement (defined as reduction of QAS score) in cardiophrenic lymphadenopathy. Despite cardiophrenic adenopathy demonstrating a complete radiographic response to chemotherapy, their presence pre-operatively is associated with an increased risk of recurrence in the thorax. Knowledge of this propensity to recur in the thorax is important to ensure all extra-abdominal recurrence sites are diagnosed and managed appropriately.