Bio

Clinical Focus


  • Gynecologic Oncology

Boards, Advisory Committees, Professional Organizations


  • Board Member, Society for Gynecologic Oncology (2018 - 2019)
  • Member, International Society for the Study of Trophoblastic Disease (2017 - Present)
  • Member, American Society of Clinical Oncology (2014 - Present)
  • Member, Society of Gynecologic Oncology (2014 - Present)

Professional Education


  • Board Certified, American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2018)
  • Fellowship, Massachusetts General Hospital, Harvard University, Gynecologic Oncology (2017)
  • Residency, Brigham and Women's Hospital / Massachusetts General Hospital, Harvard University, Obstetrics and Gynecology (2014)
  • Medical School, Columbia University College of Physicians and Surgeons, M.D. (2010)

Research & Scholarship

Clinical Trials


  • Phase 2 Multicohort Study to Evaluate the Safety and Efficacy of Novel Treatment Combinations in Patients With Recurrent Ovarian Cancer Recruiting

    This study is a phase 2, multi-cohort study, which will assess the safety and efficacy of new treatment combinations in patients with recurrent ovarian cancer.

    View full details

Teaching

2018-19 Courses


Publications

All Publications


  • Sentinel lymph node biopsies in endometrial cancer - practice patterns among Gynecologic Oncologists in the United States. Journal of minimally invasive gynecology Renz, M., Diver, E., English, D., Kidd, E., Dorigo, O., Karam, A. 2019

    Abstract

    To evaluate practice patterns among gynecologic oncologists with regards to sentinel lymph node injection and biopsy in endometrial cancer.Observational study with no control group.Active members of the Society of Gynecologic Oncology.After IRB approval, we performed an online survey amongst active members of the Society of Gynecologic Oncology. Members were contacted via email and their answers anonymously captured. Study data were collected using REDCap.318 of 1216 listed members completed the online survey, The majority of respondents (82.7%) perform sentinel lymph node sampling for endometrial cancer staging. Most technical aspects of sentinel lymph node sampling were consistently applied by the vast majority of respondents, including the choice of indocyanine green (ICG) as lymphatic tracer (97.3%) and its injection into the cervix (100%). Other technical aspects of sentinel lymph node sampling, such as the depth of injection, varied amongst respondents. While 50.9% of the respondents perform an intraoperative assessment of the uterus by frozen section, only 17.9% assess sentinel lymph nodes by frozen section and/or touch prep. Some of the respondents' approaches are based on limited data, including (i) the use of sentinel lymph node injection and biopsy for high-risk histologies (performed by 69 - 75% of the respondents dependent upon the histology), (ii) omitting side-specific completion lymphadenectomy in the absence of sentinel node mapping (in up to 57.8%) or (iii) when lymph node metastases are present (in 39.9%).In summary, despite the growing use of sentinel lymph node injection and biopsy in endometrial cancer, practice patterns vary considerably among providers sampled by this survey. Some of the decisions are based on limited evidence and, in some instances, deviate from current published guidelines.

    View details for PubMedID 30980995

  • Timing of Referral to the New England Trophoblastic Disease Center Decentralized Treatment for Postmolar Gestational Trophoblastic Neoplasia is Associated with Increased Lines of Chemotherapy and Longer Time to Remission Diver, E. J., Horowitz, N. S., Elias, K. M., Goldstein, D. P., Berkowitz, R. S., Growdon, W. B. SCI PRINTERS & PUBL INC. 2018: 193–98
  • Assessment of treatment factors and clinical outcomes in cervical cancer in older women compared to women under 65 years old. Journal of geriatric oncology Diver, E. J., Hinchcliff, E. M., Gockley, A. A., Melamed, A., Contrino, L., Feldman, S., Growdon, W. B. 2018

    Abstract

    OBJECTIVE: This study aims to understand the treatment patterns and clinical outcomes of older women with cervical cancer compared to younger women.METHODS: Women undergoing care for cervical cancer between 2000 and 2013 at two academic institutions were identified. The cohort of older patients was defined as >65 years old at diagnosis. Patient charts were retrospectively reviewed, and clinical variables were extracted. Fisher's exact tests, logistic regression, and Kaplan-Meier analyses were performed.RESULTS: From 2000 to 2013 1119 women with cervical cancer were identified. Of these, 191 (17.0%) were >65 years old at the time of diagnosis. Older women were more likely to present with higher stage disease (p < 0.001). Controlling for stage, older women were less likely to undergo surgery during their treatment course (38% versus 70%, p < 0.001) and more likely to undergo radiation (77% versus 52%, p < 0.001), but no more likely to receive chemotherapy (p = 0.34). If they did undergo surgery, older women were less likely to have a pelvic lymph node dissection performed (41% versus 61%, p = 0.04), though the rate of positive pelvic lymph nodes was not different (p = 0.80). Overall survival was decreased in the older cohort (p < 0.001). A multivariate model identified age > 65 (HR 1.76, 95%CI 1.30-2.40), stage (HR 2.77, 95%CI 2.40-3.21), and ever undergoing surgery (HR 0.60, 95%CI 0.44-0.82) as independently associated with overall survival.CONCLUSIONS: Women over age 65 with cervical cancer are less likely to undergo surgical management and were observed to have a decreased overall survival, even when controlling for use of surgery and stage of disease.

    View details for DOI 10.1016/j.jgo.2018.02.004

    View details for PubMedID 29503115

  • Patterns of palliative care referral in ovarian cancer: A single institution 5 year retrospective analysis GYNECOLOGIC ONCOLOGY Nitecki, R., Diver, E. J., Kamdar, M. M., Boruta, D. M., del Carmen, M. C., Clark, R. M., Goodman, A., Schorge, J. O., Growdon, W. B. 2018; 148 (3): 521–26

    Abstract

    The American Society of Clinical Oncology recommends that patients with advanced cancer receive dedicated palliative care services early in their disease course. This investigation serves to understand how palliative care services are utilized for ovarian cancer patients in a tertiary referral center.We conducted a retrospective review of women treated for ovarian cancer at our institution from 2010 through 2015. Clinical variables included presence and timing of palliative care referral. Data were correlated utilizing univariable and multivariable parametric and non-parametric testing, and survivals were analyzed using the Kaplan-Meier method and cox-proportional hazard models.We identified 391 women treated for ovarian cancer, of whom 68% were diagnosed with stage III or IV disease. Palliative care referral was utilized in 28% in the outpatient (42%) and inpatient (58%) settings. Earlier use of referral was observed in those who never underwent surgical cytoreduction or had interval cytoreductive surgery (p < 0.001). Palliative care referral was independently associated with advanced stage (OR 1.7, p = 0.02), recurrence (OR 2.0, p = 0.002) and hospice referral (OR 6.0, p < 0.001). In 38% of women referral occurred within 30 days of death, and 17% within one week of death. Outpatient initial consultation was associated with an unadjusted 1 year overall survival benefit (p < 0.01) compared to inpatient consultation.The outcomes in this study suggest a late use of palliative care that is reactionary to patient needs and not a routine component of ovarian cancer care as national guidelines recommend.

    View details for PubMedID 29395315

  • Minimally Invasive Staging Surgery in Women with Early-Stage Endometrial Cancer: Analysis of the National Cancer Data Base ANNALS OF SURGICAL ONCOLOGY Bregar, A. J., Melamed, A., Diver, E., Clemmer, J. T., Uppal, S., Schorge, J. O., Rice, L. W., del Carmen, M. G., Rauh-Hain, J. A. 2017; 24 (6): 1677-1687

    Abstract

    The aim of this study was to determine factors associated with the adoption of minimally invasive surgery (MIS) compared with laparotomy in the treatment of endometrial cancer and to compare surgical outcomes and survival between these two surgical modalities.We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with presumed early-stage endometrial cancer between 2010 and 2012. We also identified factors associated with the performance of MIS and utilized propensity score matching to create a matched cohort of women who underwent minimally invasive staging surgery or laparotomy for surgical staging.Overall, 20,346 women were eligible for inclusion in the study; 12,604 (61.9%) had MIS, while 7742 (38.1%) had a laparotomy. African American race (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.49-0.60], Hispanic ethnicity (OR 0.70, 95% CI 0.61-0.80), Charlson score >2 (OR 0.79, 95% CI 0.69-0.91), high-grade histology (OR 0.63, 95% CI 0.59-0.68), presumed clinical stage II disease (OR 0.53, 95% CI 0.46-0.60), and surgery at a community cancer program (OR 0.46, 95% CI 0.39-0.55) or in the Midwest region (OR 0.70, 95% CI 0.64-0.76) were associated with a decreased likelihood of having MIS, while private insurance (OR 1.69, 95% CI 1.45-1.97) and highest quartile median household income (OR 1.13, 95% CI 1.03-1.24) were associated with an increased likelihood of having MIS. After propensity score matching, there was no association between minimally invasive staging surgery and 3-year overall survival (hazard ratio 1.03, 95% CI 0.92-1.16).There are notable racial, ethnic, socioeconomic, and geographic variations in the utilization of MIS for endometrial cancer staging in the US. After controlling for the aforementioned factors, MIS had a similar 3-year survival compared with laparotomy in women undergoing staging surgery for endometrial cancer.

    View details for DOI 10.1245/s10434-016-5752-8

    View details for Web of Science ID 000400615200032

    View details for PubMedID 28074326

  • Minimally Invasive Radical Hysterectomy for Cervical Cancer Is Associated With Reduced Morbidity and Similar Survival Outcomes Compared With Laparotomy JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY Diver, E., Hinchcliff, E., Gockley, A., Melamed, A., Contrino, L., Feldman, S., Growdon, W. 2017; 24 (3): 402-406

    Abstract

    To assess outcomes of women with cervical cancer undergoing upfront radical hysterectomy (RH) via a minimally invasive surgery (MIS) or a traditional laparotomy (XL) approach at 2 large US academic institutions to determine whether the mode of surgery affects patient outcomes.Retrospective cohort study (Canadian Task Force classification II-1).Two academic medical institutions in the United States.Women undergoing upfront RH for cervical cancer between 2000 and 2013.Minimally invasive techniques (laparoscopic and robotic) for RH compared with XL.A total of 383 women met the eligibility requirements. Of these, 101 underwent an MIS (i.e., traditional laparoscopy, laparoendoscopic single site, or robotic) approach, and 282 underwent an XL approach. Overall survival (median not reached; p = .29) was not different between the 2 groups. Recurrence was rare and equivalent in the 2 groups, affecting 5.0% of patients in the MIS group and 6.4% of those in the XL group (p = .86). Pelvic lymph nodes were dissected in 98% of patients in the MIS group and 97% of those in the XL group (p > .99) and were found to be positive in 10.9% and 8.5% of those patients, respectively (p = .55). The mean number of pelvic lymph nodes retrieved was higher in the MIS group (19.4 vs 16.0; p < .001). There was no between-group difference in the rate of postoperative chemotherapy (p = .32) or radiation therapy (p = .28). Surgical margins were positive in 5.0% of specimens in the MIS group and in 4.6% of specimens in the XL group (p = .54). Although there was no difference in the overall rate of complications (15.1% and 17.2%, respectively; p = .87), laparotomy was associated with a higher median estimated blood loss (EBL) (50 cm(3) vs 500 cm(3)) and a higher rate of perioperative blood transfusion (3.0% vs 26.2%; p < .001). Length of perioperative hospital stay was significantly shorter in the MIS group (1.9 days vs 4.9 days; p < .001).MIS RH does not compromise patient outcomes, including overall survival, rate of recurrence, and the frequency of pelvic lymph node dissection or positivity. Morbidity was decreased in the MIS group, including decreased EBL, fewer blood transfusions, and shorter hospital stay.

    View details for DOI 10.1016/j.jmig.2016.12.005

    View details for Web of Science ID 000396807700010

    View details for PubMedID 28011096

  • Associations between residual disease and survival in epithelial ovarian cancer by histologic type. Gynecologic oncology Melamed, A., Manning-Geist, B., Bregar, A. J., Diver, E. J., Goodman, A., Del Carmen, M. G., Schorge, J. O., Rauh-Hain, J. A. 2017

    Abstract

    Surgical cytoreduction has been postulated to affect survival by increasing the efficacy of chemotherapy in ovarian cancer. We hypothesized that women with high-grade serous ovarian cancer, which usually responds to chemotherapy, would derive greater benefit from complete cytoreduction than those with histologic subtypes that are less responsive to chemotherapy, such as mucinous and clear cell carcinoma.We conducted a retrospective cohort study of patients who underwent primary cytoreductive surgery and adjuvant chemotherapy for stage IIIC or IV epithelial ovarian cancer from 2011 to 2013 using data from the National Cancer Database. We constructed multivariable models to quantify the magnitude of associations between residual disease status (no residual disease, ≤1cm, or >1cm) and all-cause mortality by histologic type among women with clear cell, mucinous, and high-grade serous ovarian cancer. Because 26% of the sample had unknown residual disease status, we used multiple imputations in the primary analysis.We identified 6,013 women with stage IIIC and IV high-grade serous, 307 with clear cell, and 140 with mucinous histology. The association between residual disease status and mortality hazard did not differ significantly among histologic subtypes of ovarian cancer (p for interaction=0.32). In covariate adjusted models, compared to suboptimal cytoreduction, cytoreduction to no gross disease was associated with a hazard reduction of 42% in high-grade serous carcinoma (hazard ratio [HR]=0.58, 95% confidence interval [CI]=0.49-0.68), 61% in clear cell carcinoma (HR=0.39, 95% CI=0.22-0.69), and 54% in mucinous carcinoma (HR=0.46, 95% CI=0.22-0.99).We found no evidence that surgical cytoreduction was of greater prognostic importance in high-grade serous carcinomas than in histologies that are less responsive to chemotherapy.

    View details for DOI 10.1016/j.ygyno.2017.08.003

    View details for PubMedID 28822556

  • Patient, treatment and discharge factors associated with hospital readmission within 30 days after surgery for vulvar cancer GYNECOLOGIC ONCOLOGY Dorney, K. M., Growdon, W. B., Clemmer, J., Rauh-Hain, J. A., Hall, T. R., Diver, E., Boruta, D., del Carmen, M. G., Goodman, A., Schorge, J. O., Horowitz, N., Clark, R. M. 2017; 144 (1): 136-139

    Abstract

    The majority of hospital readmissions are unexpected and considered adverse events. The goal of this study was to examine the factors associated with unplanned readmission after surgery for vulvar cancer.Patient demographic, treatment, and discharge factors were collected on 363 patients with squamous cell carcinoma in situ or invasive cancer who underwent vulvectomy at our institution between January 2001 and June 2014. Clinical variables were correlated using χ(2) test and Student's t-test as appropriate for univariate analysis. Multivariate analysis was then performed.Of 363 eligible patients, 35.6% had in situ disease and 64.5% had invasive disease. Radical vulvectomy was performed in 39.1% and 23.4% underwent lymph node assessment. Seventeen patients (4.7%) were readmitted within 30days, with length of stay ranging 2 to 37days and 35% of these patients required a re-operation. On univariate analyses comorbidities, radical vulvectomy, nodal assessment, initial length of stay, and discharge to a post acute care facility (PACF) were associated with hospital readmission. On multivariate analysis, only discharge to a PACF was significantly associated with readmission (OR 6.30, CI 1.12-35.53, P=0.04). Of those who were readmitted within 30days, 29.4% had been at a PACF whereas only 6.6% of the no readmission group had been discharged to PACF (P=0.003).Readmission affected 4.7% of our population, and was associated with lengthy hospitalization and reoperation. After controlling for patient comorbidities and surgical radicality, multivariate analysis suggested that discharge to a PACF was significantly associated with risk of readmission.

    View details for DOI 10.1016/j.ygyno.2016.11.009

    View details for Web of Science ID 000392367000025

    View details for PubMedID 27836203

  • Timing of Referral to the New England Trophoblastic Disease Center Does Referral with Molar Pregnancy Versus Postmolar Gestational Trophoblastic Neoplasia Affect Outcomes? JOURNAL OF REPRODUCTIVE MEDICINE Diver, E. J., Horowitz, N. S., Goldstein, D. P., Bernstein, M., Berkowitz, R. S., Growdon, W. B. 2016; 61 (5-6): 187-191

    Abstract

    To assess if referral of patients with molar pregnancy who then developed postmolar gestational trophoblastic neoplasia (PMGTN) is associated with different outcomes when compared to referral of patients already with a diagnosis of PMGTN.The records of the New England Trophoblastic Disease Center (NETDC) were queried for all patients with molar pregnancy or PMGTN from 1993-2013. Retrospective chart review was performed to extract relevant clinical and demographic data. Parametric and nonparametric tests were utilized to compare variables.From 1993-2013, 429 women with molar disease were evaluated at the NETDC. Of those, 68% were referred with molar pregnancy and 32% were referred with PMGTN. Comparing women with PMGTN who were referred with a molar pregnancy versus referred with PMGTN, the women were of equivalent stage and World Health Organization (WHO) score. Additionally, referral with molar pregnancy or PMGTN did not associate with time to persistence, time to remission, or number of lines of chemotherapy administered.In this trophoblastic disease specialty center in the United States, referral at the time of PMGTN as opposed to at diagnosis of molar pregnancy did not appear to affect the stage or WHO score at diagnosis, the need for multiple chemotherapy lines, or time to remission.

    View details for Web of Science ID 000376228500003

    View details for PubMedID 27424356

  • Racial disparities in survival in malignant germ cell tumors of the ovary GYNECOLOGIC ONCOLOGY Hinchcliff, E., Rauh-Hain, J. A., Clemmer, J. T., Diver, E., Hall, T., Stall, J., Growdon, W., Clark, R., Schorge, J. 2016; 140 (3): 463-469

    Abstract

    To investigate racial disparities with respect to adjuvant treatment and survival in patients presenting with malignant ovarian germ cell tumors (OGCT).The National Cancer Database (NCDB) was used to identify women diagnosed with OGCT. Demographic data were abstracted, including stratification by race and histology. Standard univariate and multivariate analyses using logistic regression were performed to describe predictors of adjuvant treatment. Kaplan-Meier and Cox proportional hazards survival methods were used to evaluate racial differences in survival between African American (AA) and white (W) women.The study population included 2196 patients, with 1654 (75.3%) W and 328 (14.9%) AA women. Histologic distribution varied significantly by race (p<0.0001), but neither age nor stage at presentation showed racial differences (p=0.086 and p=0.209, respectively). AA received more chemotherapy than W (W: 54.6%, AA: 65.5%, p=0.008), but in multivariate analysis there was no statistically significant difference in any adjuvant treatment modality. Despite similar treatment, and independent of histology, survival varied significantly by race with 91% (CI 0.89-0.93) five year survival in W patients compared to 84% five year survival in AA (CI 0.8-0.89) (p=0.02). These disparities were most pronounced in advanced stage disease, with 5 year survival of 84% (CI 0.79-0.89) in W compared to 61% (CI 0.48-0.78) for AA in stage III (p=0.0002), and 54% (CI 0.42-0.68) compared to 14% (CI 0.03-0.71) for stage IV (p=0.05).AA with OGCT have significantly worse 5 year survival when compared to W patients despite similar rates and modalities of adjuvant treatment.

    View details for DOI 10.1016/j.ygyno.2016.01.006

    View details for Web of Science ID 000371372700016

    View details for PubMedID 26773470

  • Changing Trends in Lymphadenectomy for Endometrioid Adenocarcinoma of the Endometrium. Obstetrics and gynecology Melamed, A., Rauh-Hain, J. A., Clemmer, J. T., Diver, E. J., Hall, T. R., Clark, R. M., Uppal, S., Goodman, A., Boruta, D. M. 2015; 126 (4): 815-822

    Abstract

    To describe trends in the use of lymphadenectomy for endometrioid adenocarcinoma of the endometrium between 1998 and 2012.A time-trend analysis was conducted using a population-based cancer registry covering 28% of the population of the United States. To quantify differences over the study period time, the frequency of lymphadenectomy and nodal metastasis among women who underwent surgical treatment of endometrioid endometrial adenocarcinoma was compared among consecutive 3- to 4-year periods. Biannual frequency of lymphadenectomy was modeled with Joinpoint regression to identify when potential changes in trends occurred and calculate annual percentage change.A total of 74,365 women who underwent surgery between 1998 and 2012 were analyzed. Frequency of lymphadenectomy increased by 4.2% annually (95% confidence interval [CI] 3.7-4.6) from 1998 to 2007, after which the frequency declined by 1.6% per year (95% CI 0.9-2.2). Between 1998-2000 and 2007-2009, the frequency of lymphadenectomy rose from 48.7% to 65.5% (risk difference 16.8%, 95% CI 15.4-18.1), the proportion of women found to have nodal metastasis increased by 1.1% (95% CI 0.4-1.7), and the frequency of negative lymphadenectomy increased by 15.7% (95% CI 14.3-17.1). The decline in frequency of lymphadenectomy after 2007 was associated a 3.1% (95% CI 2.1-4.1) decline in the rate of negative lymphadenectomy, but no change in the proportion of women found to have nodal metastasis (P=.17).The frequency of lymphadenectomy in the surgical treatment of endometrioid endometrial cancer increased by 4.2% annually from 1998 to 2007 and decreased by 1.6% annually from 2007 to 2012.II.

    View details for DOI 10.1097/AOG.0000000000001063

    View details for PubMedID 26348192

  • Patterns of care, associations and outcomes of chemotherapy for uterine serous carcinoma: Analysis of the National Cancer Database GYNECOLOGIC ONCOLOGY Rauh-Hain, J. A., Diver, E., Meyer, L. A., Clemmer, J., Lu, K. H., del Carmen, M. G., Schorge, J. O. 2015; 139 (1): 77-83

    Abstract

    Evaluate rates of chemotherapy and radiotherapy delivery in the treatment of uterine serous carcinoma, and compare clinical outcomes of treated and untreated patients.The National Cancer Database was queried to identify patients diagnosed with uterine serous carcinoma between 2003 and 2011. The impact of chemotherapy on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model.A total of 13,752 patients met the study eligibility criteria. Stage I, II, III, and IV disease accounted for 4355 (31.7%), 1023 (7.4%), 3484 (25.3%), and 2451 (17.8%) of the study population, respectively. 2439 (17.7%) women had unknown stage. Chemotherapy was administered in 4290 (35.4%) patients, radiotherapy to 1673 (12.2%), adjuvant chemo-radiation to 2915 (21.2%), and 4874 (35.4%) of women did not receive adjuvant therapy during the study period. Utilization of chemotherapy became more frequent over time. Over the entire study period, after adjusting for age, period of diagnosis, race, facility location, facility type, insurance provider, socioeconomic status, comorbidity index, lymph node dissection, treatment modality, and stage, there was an association between treatment modality and survival, with the lowest hazard ratio in patients that received chemo-radiation. After adjusting for the same factors in women with stages I and II, chemo-radiation was associated with improved survival compared to patients that received no treatment. Radiotherapy or chemotherapy alone was not associated with improved survival.Utilization of chemotherapy is increased in this population over the study period from 2003-2012 and more importantly that survival, particularly in advanced stage patients, is improving.

    View details for DOI 10.1016/j.ygyno.2015.08.016

    View details for PubMedID 26325526

  • Trends in the Treatment of Uterine Leiomyosarcoma in the Medicare Population INTERNATIONAL JOURNAL OF GYNECOLOGICAL CANCER Foley, O. W., Rauh-Hain, J. A., Clemmer, J., Clark, R. M., Hall, T., Diver, E. J., Schorge, J. O., del Carmen, M. G. 2015; 25 (3): 453-458

    Abstract

    Uterine leiomyosarcoma (LMS) is a relatively rare malignancy that is associated with a poor prognosis. The rarity of LMS has led to a lack of consensus regarding appropriate treatment. The goal of this study was to identify the role that chemotherapy and radiotherapy have played in the treatment of uterine LMS in the United States as well as the effectiveness of adjuvant treatment.We used the SEER (Surveillance, Epidemiology, and End Results)-Medicare database to gather information on uterine LMS patients older than the age of 66 years diagnosed between 1992 and 2009. Basic demographic and clinical characteristics were collected. A logistic regression model analysis was performed to determine predictors of treatment. Cox proportional hazards models were used to identify clinical parameters and treatment strategies associated with survival differences.Our final study group included 230 patients. We found that the rate of use of chemotherapy and radiotherapy in the treatment of patients with uterine LMS increased over the period investigated. However, we identified no significant survival advantage associated with either mode of therapy. The strongest predictor of survival was stage at diagnosis. The logistic regression model analysis revealed that age at diagnosis, treatment year, stage, and underlying health status were all independent predictors of chemotherapy. Age at diagnosis was also a predictor of radiation therapy.The increasing rates of chemotherapy and radiotherapy use in this population seem to be unfounded given the lack of survival benefit. Further investigation into alternative treatment regimens is merited. The prognostic significance of stage at diagnosis indicates the importance of improving early detection of uterine LMS.

    View details for DOI 10.1097/IGC.0000000000000372

    View details for Web of Science ID 000350123800016

    View details for PubMedID 25628107

  • Palliative Gastrostomy in the Setting of Voluminous Ascites JOURNAL OF PALLIATIVE MEDICINE O'Connor, O. J., Diver, E., McDermott, S., Covarrubias, D. A., Shelly, M. J., Growdon, W., Hahn, P. F., Mueller, P. R. 2014; 17 (7): 811-821

    Abstract

    We report the indications, methods, and complications of percutaneous gastrostomy/gastrojejunostomy (G/GJ) in patients with voluminous ascites.Following institutional review board approval, 69 patients (14 male, 55 female, mean age 58±12 years, range 32-89 years) who underwent percutaneous G/GJ with paracentesis were identified from a prospectively acquired database. Electronic medical record data extracted included diagnosis, method of G/GJ insertion, clinical course, and complications, which were graded by The Society of Interventional Radiology (SIR) criteria. Statistics were performed using Graphpad Instat.Sixty-six G and three GJ catheters were placed in 62 patients with malignant and 7 patients with benign disease; 47 procedures were conducted using fluoroscopy and 22 using computed tomography (CT; 10 patients had failed fluoroscopy). Sixty-six patients had 1980±1371 mL (range, 20-5000 mL) ascites drained (more in males, p=0.01) 0.8±1.6 days (range, 0-5 days) prior to placement. Forty-one patients had significantly less ascites (1895±1426 mL; range, 100-5400 mL) drained after G/GJ (p>0.0.5). Mean survival after insertion was 43±57 days (range, 1-252 days) among 38 patients for whom data were available. Fifty-six patients had a mean postprocedure hospital stay of 8.6±8.4 days (range, 0-45 days); 3 were outpatients and 10 patients died in the hospital. Successful gastropexy was confirmed on subsequent cross-sectional imaging in 22 of 25 patients. There were 25 tube maintenance issues that included catheter displacement and leakage, one patient experienced hemorrhage, and there were two deaths. All except one patient had satisfactory gastrostomy function.Effective G/GJ placement is possible in most patients with voluminous ascites provided ascites is drained and gastrocutaneous fistula formation occurs. Caution is advised; placement is generally for fragile terminal patients, and fluoroscopy or CT guidance is required.

    View details for DOI 10.1089/jpm.2013.0397

    View details for Web of Science ID 000338946400013

    View details for PubMedID 24886044

  • Subsequent Pregnancy Outcomes After Complete and Partial Molar Pregnancy, Recurrent Molar Pregnancy, and Gestational Trophoblastic Neoplasia An Update from the New England Trophoblastic Disease Center JOURNAL OF REPRODUCTIVE MEDICINE Vargas, R., Barroilhet, L. M., Esselen, K., Diver, E., Bernstein, M., Goldstein, D. P., Berkowitz, R. S. 2014; 59 (5-6): 188-194

    Abstract

    To review and update the subsequent reproductive outcomes in patients with complete, partial, and recurrent hydatidiform moles, as well as gestational trophoblastic neoplasia (GTN) at the New England Trophoblastic Disease Center.Patients with complete and partial hydatidiform mole, recurrent hydatidiform mole, and GTN were identified from the Donald P. Goldstein, M.D., Trophoblastic Tumor Registry. Questionnaires regarding subsequent pregnancies were mailed to patients with current mailing addresses available. Additional patient data was obtained from electronic medical records.A total of 2,432 subsequent pregnancies have been reported since 1965. Of those, 1,388 pregnancies were after complete mole, 357 after partial mole, and 667 after GTN. The subsequent reproductive outcomes in patients with complete and partial molar pregnancies and persistent GTN remain similar to those in the general population. However, approximately 1.7% of patients with a prior molar pregnancy had a molar pregnancy in a later gestation. Furthermore, after successful chemotherapy for GTN the incidence of stillbirth was slightly increased to 1.3% in later pregnancies.Patients with molar pregnancies and GTN should expect similar reproductive outcomes as compared to the general population. However, patients receiving chemotherapy for GTN have a slightly increased risk stillbirth in subsequent pregnancies.

    View details for Web of Science ID 000336419500003

    View details for PubMedID 24937955

  • Carcinosarcoma of the ovary compared to papillary serous ovarian carcinoma: A SEER analysis GYNECOLOGIC ONCOLOGY Rauh-Hain, J. A., Diver, E. J., Clemmer, J. T., Bradford, L. S., Clark, R. M., Growdon, W. B., Goodman, A. K., Boruta, D. M., Schorge, J. O., del Carmen, M. G. 2013; 131 (1): 46-51

    Abstract

    The aims of this study are to determine if outcomes of patients with ovarian carcinosarcoma (OCS) differ from women with high grade papillary serous ovarian carcinoma when compared by stage as well as to identify any associated clinico-pathologic factors.The Surveillance, Epidemiology, and End Results (SEER) Program data for all 18 registries from 1998 to 2009 was reviewed to identify women with OCS and high grade papillary serous carcinoma of the ovary. Demographic and clinical data were compared, and the impact of tumor histology on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazard model.The final study group consisted of 14,753 women. 1334 (9.04%) had OCS and 13,419 (90.96%) had high grade papillary serous carcinoma of the ovary. Overall, women with OCS had a worse five-year, disease specific survival rate, 28.2% vs. 38.4% (P<0.001). This difference persisted for each FIGO disease stages I-IV, with five year survival consistently worse for women with OCS compared with papillary serous carcinoma. Over the entire study period, after adjusting for histology, age, period of diagnosis, SEER registry, marital status, stage, surgery, radiotherapy, lymph node dissection, and history of secondary malignancy after the diagnosis of ovarian cancer, carcinosarcoma histology was associated with decreased cancer-specific survival.OCS is associated with a poor prognosis compared to high grade papillary serous carcinoma of the ovary. This difference was noted across all FIGO stages.

    View details for DOI 10.1016/j.ygyno.2013.07.097

    View details for Web of Science ID 000325842500011

    View details for PubMedID 23906658

  • Changes in clinical presentation of postterm choriocarcinoma at the New England Trophoblastic Disease Center in recent years GYNECOLOGIC ONCOLOGY Diver, E., May, T., Vargas, R., Bernstein, M., Goldstein, D., Berkowitz, R. 2013; 130 (3): 483-486

    Abstract

    To review the last 15 year experience of choriocarcinoma following a term gestation at the New England Trophoblastic Disease Center (NETDC) and compare these results to earlier data to determine any changes in the clinical presentation and outcome of this disease.Women with postterm choriocarcinoma from 1996 through 2011 followed by the NETDC were identified by diagnosis codes. Twenty charts were identified and reviewed. These data were then compared to published results from the NETDC of 44 women from 1964 to 1996.Time from antecedent pregnancy to diagnosis of choriocarcinoma was significantly longer in the current series, 46.1 vs. 19.7 weeks (p = 0.03). Despite this change, patient outcomes remained comparable, with similar overall mortality rates (13% vs. 10%, p = NS). However, patient presentation was notably different. In the early series, five (11%) infants suffered hydrops or stillbirth, while in the recent series there were no adverse infant outcomes (p = 0.08). Six women in the current series presented in the absence of symptoms suspicious for choriocarcinoma (either by an incidental positive pregnancy test without other symptoms or by placental pathology), compared to one woman in the prior series (30% vs. 2%, p = 0.001).In recent years postterm choriocarcinoma is being diagnosed or referred later after the antecedent pregnancy at our regional referral center. Recent patients more commonly have no other symptoms than a question of pregnancy and are less likely diagnosed due to the presence of fetal hydrops or stillbirth. Despite later diagnoses, survival with postterm choriocarcinoma continues to be high.

    View details for DOI 10.1016/j.ygyno.2013.06.014

    View details for Web of Science ID 000323687900017

    View details for PubMedID 23777658

  • Uterine Leiomyosarcoma An Updated Series INTERNATIONAL JOURNAL OF GYNECOLOGICAL CANCER Rauh-Hain, J. A., Oduyebo, T., Diver, E. J., Guseh, S. H., George, S., Muto, M. G., del Carmen, M. G. 2013; 23 (6): 1036-1043

    Abstract

    The aim of this study was to analyze and compare the clinicopathologic characteristics, treatment, and survival in patients with uterine leiomyosarcoma (ULMS) during the last 10 years in 3 referral academic centers.All patients with ULMS who underwent treatment at the participating institutions between January 1, 2000, and December 31, 2010, were identified from the tumor registry database. In each case, the diagnosis was confirmed by a dedicated gynecologic pathologist following postsurgery pathology review. The Kaplan-Meier method was used to generate overall survival (OS) data. Factors predictive of outcome were compared using the log-rank test and Cox regression analysis.Analysis of 167 women with ULMS with adequate follow-up was performed. One hundred twenty-eight patients (77%) were initially managed at the participating institutions, and 39 (23%) were referred after initial management at a different institution. Ninety-two (55%) had stage I disease, 7 (4%) had stage II, 18 (11%) stage III, and 50 (30%) had stage IV disease. The median OS for women with stage I was 75 months, for stage II 66 months, stage III 34 months, and stage IV 20 months (P < 0.001). For patients with early stage (I and II), race, lower grade, smaller tumor size (<11 cm), low number of mitosis (<25/10 high-power field [HPF]), lymphovascular space invasion, and presence of necrosis were identified as variables with prognostic influence on survival in the univariate analysis. A Cox proportional hazards model identified size 11 cm or greater (hazard ratio, 5.9; P < 0.001) and mitotic count of 25/10 HPF or greater (hazard ratio, 2.3; P = 0.05) as independent predictors of OS. For patients with late stage (stage III and IV), race, stage III versus IV, lower grade, smaller tumor size (<11 cm), and low number of mitosis (<25/10 HPF) were all associated with significantly improved OS. A Cox proportional hazards model identified mitotic count of 25/10 HPF or greater (P = 0.01) as independent predictor of OS.In early stage, size of the tumor and number of mitosis were associated to survival. In contrast to late stage, only mitotic count was associated to survival.

    View details for DOI 10.1097/IGC.0b013e31829590dc

    View details for Web of Science ID 000330373600012

    View details for PubMedID 23714705

  • Modest benefit of total parenteral nutrition and chemotherapy after venting gastrostomy tube placement GYNECOLOGIC ONCOLOGY Diver, E., O'Connor, O., Garrett, L., Boruta, D., Goodman, A., Del Carmen, M., Schorge, J., Mueller, P., Growdon, W. 2013; 129 (2): 332-335

    Abstract

    The aim of the study is to review a single institution's experience with gastrostomy tubes (GTs) performed for malignant bowel obstruction from gynecologic cancers.Women with gynecologic cancers who underwent venting GT placement from 2000 to 2008 were identified and clinical data were extracted. Logistic regression and spearman correlational coefficients were used to determine relationships between variables. Survival analysis was performed using the Kaplan-Meier method and a Cox proportional hazard model.We identified 115 women who underwent GT placement, the majority of whom were diagnosed with ovarian cancer (84%). Median time from cancer diagnosis to GT placement was 2.2 years. Median survival following GT placement was 5.6 weeks. A majority (56%) developed GT complications requiring GT revision. While burden of disease as assessed on CT scan by the validated peritoneal cancer index (PCI) was not associated with survival, low CA-125 within one week of GT placement was associated with improved survival (p<0.01). TPN was administered in 36% of women, was associated with concurrent chemotherapy (p<0.001) and a 5 week survival benefit (p<0.01). Chemotherapy after GT was administered in 40% of women and was associated with a 10 week survival benefit (p<0.001). Age-adjusted multivariate analysis identified chemotherapy as the only independent variable associated with survival.Women with malignant bowel obstructions from gynecologic cancers requiring palliative GT placement had a guarded prognosis measured in weeks. Gastrostomy tubes near the end of life had a high rate of complications requiring medical intervention. Chemotherapy after GT was associated with TPN administration, and both were associated with a modest extension in survival.

    View details for DOI 10.1016/j.ygyno.2013.02.002

    View details for Web of Science ID 000318058600011

    View details for PubMedID 23402902

  • Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstetrics and gynecology St Clair, C. M., Shah, M., Diver, E. J., Lewin, S. N., Burke, W. M., Sun, X., Herzog, T. J., Wright, J. D. 2010; 116 (3): 694-700

    Abstract

    To examine adherence to evidence-based recommendations for preoperative testing and health care costs associated with excessive testing.An institutional review of women who underwent gynecologic surgery between 2005 and 2007 was performed. Data on the type of surgery, age, comorbidities, and perioperative testing was extracted. We noted the preoperative performance of chest X-ray, electrocardiogram, metabolic panel, complete blood count, coagulation studies, liver function tests, and urinalysis. Each test was classified as being guideline-based (appropriate) or non-guideline-based (inappropriate) as described by the National Institute of Clinical Excellence perioperative guidelines.A total of 1,402 patients were identified. Ninety-five percent of patients underwent all of the guideline-recommended preoperative testing. Ninety percent of women underwent at least one nonindicated preoperative test. None of the 749 urinalyses, 407 liver function tests, or 1,046 coagulation studies performed was appropriate. Ninety-nine percent of the 427 chest X-rays ordered were inappropriate. Only 17% of metabolic panels, 36% of electrocardiograms, and 29% of complete blood counts were in accordance with evidence-based guidelines. Inappropriate perioperative tests led to a direct cost of more than $418,000. Of the inappropriate tests ordered, abnormalities were noted frequently but rarely changed management.Adherence to evidence-based recommendations for preoperative testing is poor. Inappropriate preoperative tests represent a major health care expenditure.III.

    View details for DOI 10.1097/AOG.0b013e3181ec448d

    View details for PubMedID 20733454