Robert L Giuntoli

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (84)339.46 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: The aim of this study was to screen for depression and anxiety and to assess well-being among women diagnosed with gynecologic malignancies, identify factors associated with elevated depressive or anxiety symptoms, and further characterize the needs of those with elevated anxiety or depressive symptoms. Methods/materials: Women presenting for gynecologic cancer at an academic center during the course of 10 months were offered screening for depressive and anxiety symptoms. Patients were screened with the Primary Care Evaluation of Mental Disorders' Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7. The Functional Assessment of Cancer Therapy-General assessed well-being. Demographics, psychiatric history, and components about the cancer and treatment were collected. Those who screened positive with scores of 10 or higher on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 were offered a meeting with the study psychiatrist for further evaluation both with the Structured Clinical Interview for Diagnosis as well as with an interview to discuss their experiences and to assess their desired needs. Results: When family and social well-being was added to the logistic regression model, higher family and social well-being was the strongest factor associated with lower amounts of anxiety (odds ratio, 0.10; P = 0.001 for a cutoff of 10; odds ratio, 0.21; P = 0.012 for a cutoff of 8). Less than 30% who screened positive met with the study psychiatrist and were not receiving optimal treatment. Conclusions: Given that low family and social well-being and elevated anxiety symptoms were so highly correlated, those with anxiety symptoms would most benefit from social interventions. However, this study also found that patients with elevated depressive or anxiety symptoms were difficult to engage with a psychiatric provider. We need partnership between psychiatry and gynecology oncology to identify those with elevated depressive and anxiety symptoms and develop better ways to provide psychosocial supports.
    International Journal of Gynecological Cancer 11/2014; 24(9):1700-8. DOI:10.1097/IGC.0000000000000285 · 1.96 Impact Factor
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    ABSTRACT: Objectives: The aim of this study was to determine if a gynecologic cancer patient's comfort level discussing end-of-life care issues with her caregivers is related to her death anxiety level. Materials/methods: Gynecologic oncology clinic patients were asked to rate their degree of agreeability with 4 statements regarding comfort level discussing end-of-life care issues. Participants also completed the Hoge's Intrinsic Religiosity Scale and Templer's Death Anxiety Scale. Results: Four hundred one surveys were distributed. One hundred twenty-nine patients participated, with a response rate of 32.2%. The median age of the sample was 55 years. Most patients were white (72.9%), married (58.9%), and Christian (85.3%). Most patients had ovarian cancer (40.4%). Of the 74 patients who knew their cancer stage, 59% had been diagnosed with advanced (stage III-IV) disease. Thirty-three percent were currently in remission, and 17% had recurrent disease. Of all patients surveyed, 32.6% were currently receiving treatment. Chemotherapy was the most common treatment (62% of those being treated). Higher level of comfort discussing end-of-life care topics such as do-not-resuscitate orders with family members was significantly associated with decreased death anxiety (P = 0.008 and P = 0.001). There was no significant association between comfort level when patients discussed do-not-resuscitate orders with physicians and patients' death anxiety (P = 0.14). After controlling for age, race, marital status, education level, current treatment status, and religiosity, linear regression analysis demonstrated that the relationship between a patient's increased comfort level when discussing end-of-life care topics with family members and decreased death anxiety remained statistically significant (P = 0.005 and P = 0.001). Conclusions: Conversations regarding goals of treatment are an important component of caring for cancer patients. Death anxiety may contribute to decreased communication between patients and their family members regarding the patient's end-of-life care wishes. Obtaining a better understanding of the role death anxiety plays in end-of-life care discussions may help patients receive the end-of-life care they desire.
    International Journal of Gynecological Cancer 09/2014; 24(8). DOI:10.1097/IGC.0000000000000250 · 1.96 Impact Factor
  • Gynecologic Oncology 06/2014; 133:142. DOI:10.1016/j.ygyno.2014.03.371 · 3.77 Impact Factor
  • Gynecologic Oncology 06/2014; 133:75. DOI:10.1016/j.ygyno.2014.03.202 · 3.77 Impact Factor
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    ABSTRACT: Objective: The study objective was to compare the ability to detect sentinel lymph nodes (SLNs) in women with endometrial cancer (EC) or complex atypical hyperplasia (CAH) using fluorometric imaging with indocyanine green (ICG) versus colorimetric imaging with isosulfan blue (ISB). Methods: Women underwent SLN mapping, with either ISB or ICG, during robotic-assisted total laparoscopic hysterectomy (RA-TLH) from September 2012 to March 2014. SLNs were submitted for permanent pathologic analysis. Completion lymphadenectomy and ultrastaging were performed according to institutional protocols. Results: RA-TLH and SLN mapping was performed in 71 women; 64 had EC (64) and 7 had CAH. Age, body mass index (BMI), stage and tumor characteristics were similar in the ICG versus the ISB cohorts. Overall, SLNs were identified bilaterally (62.0%), unilaterally (21.1%), or neither (16.9%), and in 103 of 142 hemi-pelvises (72.5%). The mean number of SLNs retrieved per hemipelvis was 2.23(SD 1.7). SLNs were identified in the hypogastric (76.8%), external iliac (14.2%), common iliac (4.5%) and paraaortic (4.5%) regions. ICG mapped bilaterally in 78.9% of women compared with 42.4% of those injected with ISB (p=0.02). Five women (7%) had positive lymph nodes, all identified by the SLN protocol (false negative rate: 0%). On multivariate analysis, BMI was negatively correlated with bilateral mapping success (p=0.02). When stratified by dye type, the association with BMI was only significant for ISB (p=0.03). Conclusions: Fluorescence imaging with ICG may be superior to colorimetric imaging with ISB in women undergoing SLN mapping for endometrial cancer. SLN mapping success is negatively associated with increasing patient BMI only when ISB is used.
    Gynecologic Oncology 05/2014; 134(2). DOI:10.1016/j.ygyno.2014.05.022 · 3.77 Impact Factor
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    ABSTRACT: The development of noninvasive methods to detect and monitor tumors continues to be a major challenge in oncology. We used digital polymerase chain reaction-based technologies to evaluate the ability of circulating tumor DNA (ctDNA) to detect tumors in 640 patients with various cancer types. We found that ctDNA was detectable in >75% of patients with advanced pancreatic, ovarian, colorectal, bladder, gastroesophageal, breast, melanoma, hepatocellular, and head and neck cancers, but in less than 50% of primary brain, renal, prostate, or thyroid cancers. In patients with localized tumors, ctDNA was detected in 73, 57, 48, and 50% of patients with colorectal cancer, gastroesophageal cancer, pancreatic cancer, and breast adenocarcinoma, respectively. ctDNA was often present in patients without detectable circulating tumor cells, suggesting that these two biomarkers are distinct entities. In a separate panel of 206 patients with metastatic colorectal cancers, we showed that the sensitivity of ctDNA for detection of clinically relevant KRAS gene mutations was 87.2% and its specificity was 99.2%. Finally, we assessed whether ctDNA could provide clues into the mechanisms underlying resistance to epidermal growth factor receptor blockade in 24 patients who objectively responded to therapy but subsequently relapsed. Twenty-three (96%) of these patients developed one or more mutations in genes involved in the mitogen-activated protein kinase pathway. Together, these data suggest that ctDNA is a broadly applicable, sensitive, and specific biomarker that can be used for a variety of clinical and research purposes in patients with multiple different types of cancer.
    Science translational medicine 02/2014; 6(224):224ra24. DOI:10.1126/scitranslmed.3007094 · 15.84 Impact Factor
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    ABSTRACT: WHIM syndrome is a rare immunodeficiency disorder caused by gain-of-function mutations in the G protein-coupled chemokine receptor CXCR4. The CXCR4 antagonist plerixafor, which is FDA-approved for stem cell mobilization in cancer and administered for that indication at 0.24 mg/kg, has been shown in short-term (1-2 week) Phase 1 dose escalation studies to correct neutropenia and other cytopenias in WHIM syndrome; however, long-term safety and long-term hematologic and clinical efficacy data are lacking. Here we report results from the first long-term clinical trial of plerixafor in any disease, in which three adults with WHIM syndrome self-injected 0.01-0.02 mg/kg (4-8% of the FDA-approved dose) subcutaneously twice daily for 6 months. Circulating leukocytes were durably increased throughout the trial in all patients, and this was associated with fewer infections and improvement in warts in combination with imiquimod; however immunoglobulin levels and specific vaccine responses were not fully restored. No drug-associated side effects were observed. These results provide preliminary evidence for the safety and clinical efficacy of long-term, low-dose plerixafor in WHIM syndrome, and support its continued study as mechanism-based therapy in this disease. The identifier for this study is NCT00967785.
    Blood 02/2014; 123(15). DOI:10.1182/blood-2013-09-527226 · 10.45 Impact Factor
  • Gynecologic Oncology 10/2013; 131(1):283. DOI:10.1016/j.ygyno.2013.04.041 · 3.77 Impact Factor
  • C.L. Kushnir · N. Zhao · K. Frick · R.L. Giuntoli
    Gynecologic Oncology 10/2013; 131(1):260. DOI:10.1016/j.ygyno.2013.07.034 · 3.77 Impact Factor
  • C. Kushnir · K. Kensler · K. Frick · R. Giuntoli
    Gynecologic Oncology 10/2013; 131(1):263. DOI:10.1016/j.ygyno.2013.07.044 · 3.77 Impact Factor
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    ABSTRACT: To examine whether adjuvant therapy after primary surgery for treatment of early-stage uterine leiomyosarcoma (LMS) improves recurrence and survival rates. A multisite, retrospective study of women diagnosed with Stage I-II high grade LMS from 1990-2010 was performed. All patients (pts) underwent primary surgery followed by observation (OBS), radiotherapy (RT), or chemotherapy (CT) postoperatively. One hundred eight patients were identified with long-term follow-up; 94 pts (87.0%) had stage I and 14 (13.0%) had stage II disease. The mean patient age was 55.4years and mean BMI was 28.0. Thirty-four (31.5%) patients underwent OBS, 35 (32.4%) received RT, and 39 (36.1%) received chemotherapy. After a median follow up of 41.8months, a recurrence was diagnosed in 70.8%. Recurrence was evident in 25/34 (73.5%) OBS, 23/35 (65.7%) RT, and 28/39 (71.8%) of CT cohorts and was not different based on treatment (p=0.413). However, extra-pelvic recurrences were significantly higher in the RT (95.2%) than in the OBS (60%) or CT (64.3%) cohorts (p=0.012). Additionally, recurrences were more likely to be successfully treated or palliated in those who initially received CT (p=0.031). On multivariate analysis, stage (p<0.001) and chemotherapy (p=0.045) were associated with overall survival. Women with early-stage, high grade uterine LMS experience high recurrence rates and poor survival outcomes, irrespective of adjuvant therapy. These rates are higher than previously reported in the literature. Although women treated with CT had similar recurrence rates as those treated with OBS or RT, treatment with adjuvant chemotherapy may decrease the risk of extra-pelvic recurrence and improve survival.
    Gynecologic Oncology 09/2013; 131(3). DOI:10.1016/j.ygyno.2013.08.037 · 3.77 Impact Factor
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    ABSTRACT: To evaluate the influence of distance on access to high-volume surgical treatment for patients with uterine cancer in Maryland. The Maryland Health Services Cost Review Commission database was retrospectively searched to identify primary uterine cancer surgical cases from 1994 to 2010. Race, type of insurance, year of surgery, community setting, and both surgeon and hospital volume were collected. Geographical coordinates of hospital and patient's zip code were used to calculate primary independent outcomes of distance traveled and distance from nearest high-volume hospital (HVH). Logistic regression was used to calculate odds ratios and confidence intervals. From 1994 to 2010, 8529 women underwent primary surgical management of uterine cancer in Maryland. Multivariable analysis demonstrated white race, rural residence, surgery by a high-volume surgeon and surgery from 2003 to 2010 to be associated with both travel 50 miles or more to the treating hospital and residence 50 miles or more from the nearest HVH (all P < 0.05). Patients who travel 50 miles or more to the treating hospital are more likely to have surgery at a HVH (odds ratio, 6.03; 95% confidence interval, 4.67-7.79) In contrast, patients, who reside ≥50 miles from a HVH, are less likely to have their surgery at an HVH. (odds ratio, 0.37; 95% confidence interval, 0.32-0.42). In Maryland, 50 miles or more from residence to the nearest HVH is a barrier to high-volume care. However, patients who travel 50 miles or more seem to do so to receive care by a high-volume surgeon at an HVH. In Maryland, Nonwhites are more likely to live closer to an HVH and more likely to use these services.
    International Journal of Gynecological Cancer 07/2013; 23(7). DOI:10.1097/IGC.0b013e31829ea002 · 1.95 Impact Factor
  • A. Brown · M. Shen · R. Giuntoli · T. Diaz-Montes
    Gynecologic Oncology 07/2013; 130(1):e138. DOI:10.1016/j.ygyno.2013.04.394 · 3.77 Impact Factor
  • Gynecologic Oncology 07/2013; 130(1):e84. DOI:10.1016/j.ygyno.2013.04.258 · 3.77 Impact Factor
  • Gynecologic Oncology 07/2013; 130(1):e145-e146. DOI:10.1016/j.ygyno.2013.04.412 · 3.77 Impact Factor
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    ABSTRACT: Objectives: Uterine leiomyosarcoma (LMS) was traditionally staged by modified 1988 International Federation of Gynecology and Obstetrics (FIGO) staging criteria for endometrial adenocarcinoma. Contemporary methods of staging include the 2009 FIGO system for uterine LMS and the 2010 American Joint Committee on Cancer (AJCC) soft tissue sarcoma system. The aim of this study was to compare the accuracy of these 3 staging systems and a novel system in predicting disease-specific survival for patients with uterine LMS. Methods: Patients, evaluated at our institution with uterine LMS from 1976 to 2009, were identified. Stage was assigned retrospectively based on operative and pathology reports. Staging systems performance was compared using confidence indices. Results: We identified 244 patients with uterine LMS with sufficient information to be staged by all 3 systems. For each staging method, lower stage was associated with significantly improved disease-specific survival, P < 0.001. Patients with 2010 AJCC stage IA disease (low-grade, ≤5 cm) experienced no disease-specific deaths. We created a novel staging system, which used size and grade to stratify patients with disease confined to the uterus and/or cervix and combined the remaining patients with extrauterine disease as stage IV. Based on confidence index, the 2010 AJCC system and our novel system provided more accurate prognostic information than either of the 2 FIGO systems. Conclusions: Uterine LMS remains a clinically aggressive malignancy. Size and grade provided accurate prognostic information for patients with disease confined to the uterus and/or cervix. Patients with small, low-grade uterine LMS do not benefit from adjuvant therapy.
    International Journal of Gynecological Cancer 05/2013; 23(5). DOI:10.1097/IGC.0b013e3182916a1e · 1.95 Impact Factor
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    ABSTRACT: Our objectives were to compare the utility of learning a suturing task on the virtual reality da Vinci Skills Simulator versus the da Vinci Surgical System dry laboratory platform and to assess user satisfaction among novice robotic surgeons. Medical trainees were enrolled prospectively; one group trained on the virtual reality simulator, and the other group trained on the da Vinci dry laboratory platform. Trainees received pretesting and post-testing on the dry laboratory platform. Participants then completed an anonymous online user experience and satisfaction survey. We enrolled 20 participants. Mean pretest completion times did not significantly differ between the 2 groups. Training with either platform was associated with a similar decrease in mean time to completion (simulator platform group, 64.9 seconds [P = .04]; dry laboratory platform group, 63.9 seconds [P < .01]). Most participants (58%) preferred the virtual reality platform. The majority found the training "definitely useful" in improving robotic surgical skills (mean, 4.6) and would attend future training sessions (mean, 4.5). Training on the virtual reality robotic simulator or the dry laboratory robotic surgery platform resulted in significant improvements in time to completion and economy of motion for novice robotic surgeons. Although there was a perception that both simulators improved performance, there was a preference for the virtual reality simulator. Benefits unique to the simulator platform include autonomy of use, computerized performance feedback, and ease of setup. These features may facilitate more efficient and sophisticated simulation training above that of the conventional dry laboratory platform, without loss of efficacy.
    JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 04/2013; 17(2):219-26. DOI:10.4293/108680813X13654754535872 · 0.91 Impact Factor
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    ABSTRACT: Papanicolaou (Pap) smears have revolutionized the management of patients with cervical cancers by permitting the detection of early, surgically curable tumors and their precursors. In recent years, the traditional Pap smear has been replaced by a liquid-based method, which allows not only cytologic evaluation but also collection of DNA for detection of human papillomavirus, the causative agent of cervical cancer. We reasoned that this routinely collected DNA could be exploited to detect somatic mutations present in rare tumor cells that accumulate in the cervix once shed from endometrial or ovarian cancers. A panel of genes that are commonly mutated in endometrial and ovarian cancers was assembled with new whole-exome sequencing data from 22 endometrial cancers and previously published data on other tumor types. We used this panel to search for mutations in 24 endometrial and 22 ovarian cancers and identified mutations in all 46 samples. With a sensitive massively parallel sequencing method, we were able to identify the same mutations in the DNA from liquid Pap smear specimens in 100% of endometrial cancers (24 of 24) and in 41% of ovarian cancers (9 of 22). Prompted by these findings, we developed a sequence-based method to query mutations in 12 genes in a single liquid Pap smear specimen without previous knowledge of the tumor's genotype. When applied to 14 samples selected from the positive cases described above, the expected tumor-specific mutations were identified. These results demonstrate that DNA from most endometrial and a fraction of ovarian cancers can be detected in a standard liquid-based Pap smear specimen obtained during routine pelvic examination. Although improvements need to be made before applying this test in a routine clinical manner, it represents a promising step toward a broadly applicable screening methodology for the early detection of gynecologic malignancies.
    Science translational medicine 01/2013; 5(167):167ra4. DOI:10.1126/scitranslmed.3004952 · 15.84 Impact Factor
  • A.I. Tergas · A. Yemelyanova · R.L. Giuntoli
    International Journal of Gynecology & Obstetrics 10/2012; 119:S655. DOI:10.1016/S0020-7292(12)61578-1 · 1.54 Impact Factor

Publication Stats

2k Citations
339.46 Total Impact Points


  • 2007–2014
    • Johns Hopkins University
      • Department of Gynecology & Obstetrics
      Baltimore, Maryland, United States
  • 2005–2014
    • Johns Hopkins Medicine
      • Department of Gynecology & Obstetrics
      Baltimore, Maryland, United States
  • 2013
    • University of Louisville
      • Division of Gynecology Oncology
      Louisville, Kentucky, United States
  • 2003
    • Thomas Jefferson University
      Philadelphia, Pennsylvania, United States
  • 2002
    • Mayo Clinic - Rochester
      • Department of Obstetrics & Gynecology
      Rochester, Minnesota, United States