Journal of Surgical Research

Lessons in Cultural Adaptations: Translation of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Cervical Cancer Module From English to Chichewa in Malawi

To complete a culturally appropriate translation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Cervical Cancer module (QLQ-CX24) from English to Chichewa (one of the official languages of Malawi) in preparation for postsurgical outcomes research in rural Malawian cervical cancer patients. Following the EORTC translation procedure manual, two distinct forward translations from English were reconciled into a preliminary Chichewa translation, followed by two distinct back-translations to English. The English back-translation was reconciled and the translation report sent for discussion and proofreading by EORTC; this was followed by pilot testing. All translators were physicians fluent in English and Chichewa. Of 24 questions in QLQ-CX24, three had prior translations available; all three required revision to clarify tense or wording. Three discussion exchanges with EORTC refined the translation and ensured faithfulness to the original English meaning; proofreaders contributed minor changes. Pilot testing was completed on 10 female patients (three with cervical cancer, four suspicious cervical lesions, and three screening only). Three patients were illiterate. During pilot testing, translation of question 46 (Q46) was misunderstood as referring to vaginal discharge instead of feeling "feminine". The remaining questions were understood, with minor feedback for six questions. Final revision of Q46 yielded a phrase describing "feminine" as "appearance or activities as a woman". Concepts comparable to "feminine" were absent in the Chichewa language/regional Malawian culture. The final revision of Q46 was pilot-tested on five patients (three illiterate) and found acceptable. Translation of the QLQ-CX24 module was completed successfully and revealed absence of the modern concept of femininity in Chichewa language and regional Malawian culture. Care should be taken when creating and translating healthcare-related documents for surgical research to ensure broad applicability across cultures.

Response Regarding: Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy. A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion. Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P 5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy. In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Use of Ovarian Tumor Markers in Prediction of Malignancy Risk in Pediatric and Adolescent Patients

Pediatric and adolescent patients with ovarian masses undergo radiographic and serologic workup to determine malignancy risk before surgery. Commonly examined tumor markers for detecting malignancy among these patients are α-fetoprotein, β-human chorionic gonadotropin (β-HCG), cancer antigen-125, inhibin A, and lactate dehydrogenase. This study investigated the diagnostic performance of these tumor markers, individually and in combination, to assess malignancy risk in pediatric and adolescent patients with ovarian masses. This was a planned secondary analysis of a multi-institutional interventional study investigating a consensus-based, preoperative risk stratification algorithm in patients aged 6-21 y, undergoing surgery for an ovarian mass between August 2018 and February 2021 at 11 children's hospitals. All included patients underwent preoperative assessment with ≥ 1 tumor marker(s). Individual and all combinations of tumor marker performance were analyzed. A priori clinical consensus was that the optimal combination of tumor markers should minimize the misclassification of patients with malignancy (maximize negative predictive value). Tumor markers were assessed in 309 out of the 519 patients, and malignancy was found in 25 patients. β-HCG was present among all the best-performing combinations. The most accurate combination was β-HCG/inhibin A/lactate dehydrogenase (accuracy = 0.951). Three combinations did not misclassify any malignant lesions as likely benign (100% negative predictive value), and the most accurate of these three combinations was α-fetoprotein/β-HCG/cancer antigen-125/inhibin A (accuracy = 0.862). Tumor markers can support preoperative risk stratification for malignancy to determine which patients may benefit from ovary-sparing surgery and minimize those undergoing an unindicated oophorectomy or oophorectomy for benign disease.

Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer

We examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. Patients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. Among 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). Although extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.

Feasibility of Robotic Surgical Approach in Peritoneal Carcinomatosis

Clinical Outcomes in Patients With Krukenberg Tumors From Colorectal Cancer

Ovarian metastases from gastrointestinal cancers such as colorectal cancer, also known as Krukenberg tumors (KTs), present unique challenges in management due to diagnostic uncertainty, decreased responsiveness to systemic therapies compared to other sites of metastasis, and associated debilitating symptomatology. Thus, we sought to characterize our institutional outcomes in metastatic colorectal cancer (mCRC) patients with KTs. A retrospective single-institution study was performed identifying adult, female patients from 2012 to 2021 with a diagnosis of mCRC. Patient demographics and clinicopathologic characteristics were collected and analyzed. Descriptive statistics, univariate and multivariable analyses, and Kaplan-Meier survival analyses were performed. Of 235 mCRC patients, 45 (19.1%) had KTs, 41 (91.1%) of whom had KTs in conjunction with other metastatic sites. Other initial sites of metastasis included the liver (n = 93, 39.6%), lung (n = 28, 11.9%), and peritoneum (n = 18, 7.7%). In the KT cohort, the median age was 48 y, 53.3% were non-Hispanic White, 100% had microsatellite stable tumors, 33.3% had Kristen Rat Sarcoma Virus (KRAS) mutations, and 6.7% had V-raf Murine Sarcoma Viral Oncogene Homolog B (BRAF) mutations. Fifty five point six percent of KT patients underwent cytoreductive surgery (CRS), 24.4% underwent palliative debulking, and 20% underwent no surgical intervention. Reasons for not undergoing CRS were disease-related (n = 14, 70%), due to poor performance status (n = 1, 5%), or both (n = 5, 25%). Five-year overall survival was 48.2% in KT patients who underwent CRS. Poor tumor grade was an independent predictor of mortality (hazard ratio 10.69, 95% confidence interval 1.20-95.47, P = 0.03). Almost 90% of our patient cohort with KTs from mCRC experience additional sites of metastasis. Around half of KT patients who underwent CRS were alive at 5 y.

Letter Regarding: Complications and Survivorship Trends after Primary Debulking Surgery for Ovarian Cancer