SMARCA4 loss irrelevant for ARID1A mutated ovarian clear cell carcinoma: A case report

Clear cell carcinomas are rare and relatively chemo-insensitive ovarian cancers with a characteristic molecular pathogenesis. Alterations in ARID1A, a component of the multiprotein chromatin remodeling complex SWI/SNF, are likely early events in the development of ovarian clear cancers arising from atypical endometriosis. Insight into additional driver events and particularly mutations in the same chromatin remodeling complex is limited. Isolated loss of SMARCA4, encoding the ATPase of the SWI/SNF complex, characterizes other aggressive gynecologic cancers including small cell carcinomas of the ovary hypercalcemic type (SCCOHT), undifferentiated endometrial carcinomas (UDEC), and uterine sarcomas (SDUS). The ovarian clear cell carcinoma of a 48-year-old showed in the initial surgical specimen a subclonal loss of SMARCA4 in addition to an ARID1A mutation, i.e., two alterations in the SWI/SNF heterochromatin remodeling complex. We anticipated that the SMARCA4 loss would worsen the disease course in analogy to SCCOHT, UDEC, and SDUS. However, the disease did not accelerate. Instead, the recurrent disease showed restored SMARCA4 expression while retaining the ARID1A mutation. Combinatorial redundancy, diversity and sequence in the SWI/SNF complex assembly as well as DNA- and tissue-specificity may explain the observed irrelevance of SMARCA4 loss in the presented ARID1A mutated ovarian clear cell carcinoma.

Aberrant nuclear β-catenin distribution does not prognosticate recurrences of endometrioid endometrial cancers - A retrospective single-institutional study

OBJECTIVE

Aberrant β-catenin distribution has been theorized as a predictive biomarker for recurrence in early stage, low grade endometrioid endometrial cancer.

METHODS

This retrospective single-institution cohort study reviewed 410 patients with endometrial cancer from May 2018 to May 2022. Only endometrioid histology was included. Demographic and clinicopathological data were collected from the medical records. Univariate and multivariate logistic regressions, and sensitivity analyses for early stage, low grade and no specific molecular profile (NSMP) tumors were performed.

RESULTS

297 patients were included for analysis. Most patients were over 60 years old, White, and with a BMI >30 and early stage low grade disease. Aberrant β-catenin distribution was found in 135 patients (45.5%) and wild type membranous β-catenin distribution in 162 (54.5%). While TP53 mutation correlated with endometrial cancer recurrence in this cohort (OR = 4.78), aberrant β-catenin distribution did not correlate in the overall population (OR = 0.75), the early stage low grade cancers (OR = 0.84), or the NSMP group (OR = 1.41) on univariate or multivariate analysis. No correlation between β-catenin distribution and local (OR = 0.61) or distant recurrences (OR = 0.90) was detected.

CONCLUSIONS

Aberrant β-catenin distribution did not significantly correlate with recurrence in endometrioid endometrial cancer, nor in the early stage, low grade and NSMP sub-cohorts.

Incisional infiltration versus transversus abdominis plane block of liposomal bupivacaine after midline vertical laparotomy for suspected gynecologic malignancy: a pilot study

Background

To evaluate whether incisional infiltration of liposomal bupivacaine would decrease opioid requirement and pain scores after midline vertical laparotomy for suspected or known gynecologic malignancy compared with transversus abdominis plane (TAP) block with liposomal bupivacaine.

Methods

A prospective, single blind randomized controlled trial compared incisional infiltration of liposomal bupivacaine plus 0.5% bupivacaine versus TAP block with liposomal bupivacaine plus 0.5% bupivacaine. In the incisional infiltration group, patients received 266 mg free base liposomal bupivacaine with 150 mg bupivacaine hydrochloride. In the TAP block group, 266 mg free base bupivacaine with 150 mg bupivacaine hydrochloride was administered bilaterally. The primary outcome was total opioid use during the first 48-hour postoperative period. Secondary outcomes included pain scores at rest and with exertion at 2, 6, 12, 24 and 48 h after surgery.

Results

Forty three patients were evaluated. After interim analysis, a three-fold higher sample size than originally calculated was required to detect a statistically significant difference. There was no clinical difference between the two arms in mean opioid requirement (morphine milligram equivalents) for the first 48 h after surgery (59.9 vs. 80.8, p = 0.13). There were no differences in pain scores at rest or with exertion between the two groups at pre-specified time intervals.

Conclusion

In this pilot study, incisional infiltration of liposomal bupivacaine and TAP block with liposomal bupivacaine demonstrated clinically similar opioid requirement after gynecologic laparotomy for suspected or known gynecologic cancer. Given the underpowered study, these findings cannot support the superiority of either modality after open gynecologic surgery.

Reactivated disseminated tuberculosis in pregnancy: Case report and review of the literature

This case report describes the evaluation and management of a 32-year-old woman who presented shortly after a fetal demise at 23 weeks of gestation with multiple symptoms, including bloody vaginal discharge. Although the initial diagnostic concern was for metastatic malignancy, the patient was ultimately determined to have disseminated tuberculosis. Genital tuberculosis is common worldwide, yet guidelines for evaluation are limited. This report highlights the relationship between pregnancy-reactivated tuberculosis, and guides clinicians on diagnostic and management considerations in the peripartum period.

Invasive Paget’s disease of the breast versus genitalia versus skin: What are the demographic and prognostic differences?

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Background: Invasive extramammary Paget’s disease is most commonly in the vulva but can also occur in other genitalia as well as primary skin locations (face, scalp, neck, trunk, extremities). We aim to determine the clinicopathologic and prognostic factors of invasive Paget’s disease of the breast, genitalia and skin. Methods: Data on patients with invasive Paget’s disease of the breast, genitalia and skin were collected between 2001 and 2015 from the National Cancer Data Base Participant Use File 2016. Univariate, multivariate analyses, and Kaplan-Meier survival analysis were performed by SAS. Results: 10, 122 female patients were eligible, of which 7, 051 had invasive disease (breast n = 5, 105, genitalia n = 1, 717, skin n = 229) and the remainder had in situ disease. Median age for invasive disease was 63 years for breast, 73 years for genitalia and 75 years for skin. Among Whites, the proportion of invasive Paget’s of breast, genitalia, and skin was 70.8%, 25.8%, 3.4%; Blacks 93.8% breast, 5.3% genitalia and 0.9% skin; Asian/Pacific Islanders 65.0% breast, 31.8% genitalia and 3.2% skin. Among treatment institutions, academic centers treated 30.2% of invasive breast, 48.9% genitalia and 51.5% skin. Surgery was performed in 89.4% of invasive breast compared to 21.1% genitalia and 46.7% skin. Radiotherapy was administered to 25.3% of invasive breast, 3.0% genitalia and 15.3% skin. Chemotherapy was given to 28.0% of breast, 1.9% genitalia and 5.7% skin. Early stage (I or II) disease was diagnosed in 70.8% of invasive breast, 63% genitalia and 30.6% skin. Five-year OS from any cause for patients with invasive Paget’s disease of breast, genitalia and skin was 81.9%, 83.8%, and 69.9%, respectively. In univariate analysis, older age (HR 3.75, 95% CI 3.27-4.31, p < 0.001), Black race (HR 1.21, 95% CI 1.00-1.46, p = 0.046), history of other cancer (HR 1.53, 95%CI 1.36-1.71, p < 0.001), higher comorbidity score (HR 2.12, 95%CI 1.88-2.39, p < 0.001), higher stage (HR 4.25, 95%CI 3.73-4.85, p < 0.001), and no surgical treatment (HR 3.47, 95% CI 2.87-4.19, p < 0.001) were associated with worse survival. In multivariate analysis, invasive Paget’s of the skin was associated with the worst survival (HR 1.56, 95% CI 1.19-2.05, p = 0.001). For all three types of invasive Paget’s disease, better prognosis was associated with Asian/Pacific Islander race (HR 0.49, 95% CI 0.31-0.80, p = 0.004), income ≥ $63, 000 (HR 0.83, 0.70-0.98, p = 0.028) and treatment at an academic/research center (HR 0.78, 0.62-0.99, p = 0.037). Conclusions: Invasive Paget’s disease of the breast is 3-fold more common than genitalia with younger age at diagnosis. Most are diagnosed at early stages with good prognosis. Blacks have a higher proportion of invasive Paget’s disease of the breast than other races. Invasive Paget’s disease of primary skin had the poorest prognosis.

Long-term efficacy of megestrol acetate and tamoxifen in a recurrent adult granulosa cell tumor of the ovary

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Recurrent, non-resectable ovarian granulosa cell tumor has no standard treatment.

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Estrogen/progesterone receptor signaling regulates granulosa cell tumor growth.

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Granulosa cell tumor responds well to alternating megestrol and tamoxifen therapy.

Radical Trachelectomy for the Treatment of Early-Stage Cervical Cancer: A Systematic Review

OBJECTIVE

To assess surgical, oncologic, and pregnancy outcomes in patients undergoing radical vaginal, abdominal, or laparoscopic trachelectomy for the treatment of early-stage cervical cancer, using a methodic review of published literature.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library sources, including ClinicalTrials.gov, were searched from 1990-2019 with terms "cervical cancer" and "(vaginal, abdominal, open, minimally invasive, or laparoscopic) radical trachelectomy." Grey literature and unpublished data were omitted.

METHODS OF STUDY SELECTION

After removal of duplicates from a combined EndNote library of results, 490 articles were reviewed using Covidence software. Two reviewers screened titles and abstracts, and then screened full texts. Selection criteria included articles that reported radical trachelectomy with lymph node assessment as primary therapy for cervical carcinoma, with stated follow-up intervals and recurrences.

TABULATION, INTEGRATION, AND RESULTS

Variables of interest were manually extracted into an electronic database. A total 47 articles that reported on 2,566 women met inclusion criteria. Most tumors were of squamous histology (68.5%), stage IB1 (74.8%), 2 cm or less (69.2%), and without lymphovascular invasion (68.8%). Of planned trachelectomies, 9% were converted intraoperatively to hysterectomy. Separated by route of trachelectomy, 58.1%, 37.2%, and 4.7% were performed using radical vaginal, abdominal, and laparoscopic approaches, respectively. With median follow-up of 48 months (range 2-202 months) across studies, median recurrence rate was 3.3% (range 0-25%); median time to recurrence was 26 months (range 8-44 months). Median 5-year recurrence-free and overall survival were 94.6% (range 88-97.3%) and 97.4% (range 95-99%), respectively. The posttrachelectomy pregnancy rate was 23.9%, with a live-birth rate of 75.1%.

CONCLUSION

Radical trachelectomy for fertility-preserving treatment of cervical cancer is widely reported in the literature, though publications are mainly limited to case reports and case series. Reported follow-up periods infrequently meet standard oncologic parameters but show encouraging recurrence-free and overall survival rates and pregnancy outcomes. Higher-level evidence needed for meta-analysis is lacking.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019132443.

Clinical Utility of Preoperative Assessment in Ovarian Cancer Cytoreduction

Ovarian cancer is the deadliest gynecologic cancer, in part due to late presentation. Many women have vague early symptoms and present with disseminated disease. Cytoreductive surgery can be extensive, involving multiple organ systems. Novel therapies and recent clinical trials have provided evidence that, compared to primary cytoreduction, neoadjuvant chemotherapy has equivalent survival outcomes with less morbidity. There is increasing need for validated tools and mechanisms for clinicians to determine the optimal management of ovarian cancer patients.

Removal of 132-pound ovarian mucinous cystadenoma: A case report

Ovarian masses larger than 100 pounds are rarely encountered in developed countries given advancements in early diagnosis and treatment. Their successful resections pose unique surgical and anesthetic challenges. An otherwise healthy 38-year-old para 1 woman developed a 50 × 60 cm pelvic mass. An exploratory laparotomy, left salpingo-oophorectomy and anterior abdominal wall reconstruction were performed. A total of 60 L of cystic fluid were drained. Close monitoring of hemodynamics and massive volume resuscitation required intensive care. Inpatient physical rehabilitation reinstated independent mobility. Final pathology revealed benign ovarian mucinous cystadenoma. A multidisciplinary approach in the preoperative, intraoperative and postoperative stages of management optimizes patient outcomes.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.