Comprehensive characterization of genomic features and clinical outcomes following targeted therapy and secondary cytoreductive surgery in OCCC: a single center experience

OBJECTIVE

Ovarian clear cell carcinoma (OCCC) is associated with chemoresistance. Limited data exists regarding the efficacy of targeted therapies such as immune checkpoint inhibitors (ICI) and bevacizumab, and the role of secondary cytoreductive surgery (SCS).

METHODS

We retrospectively analyzed genomic features and treatment outcomes of 172 OCCC patients treated at our institution from January 2000 to May 2022. Next-generation sequencing (NGS) was performed where sufficient archival tissue was available.

RESULTS

64.0% of patients were diagnosed at an early stage, and 36.0% at an advanced stage. Patients with advanced/relapsed OCCC who received platinum-based chemotherapy plus bevacizumab followed by maintenance bevacizumab had a median first-line progression-free survival (PFS) of 12.2 months, compared with 9.3 months for chemotherapy alone (hazard ratio=0.69; 95% confidence interval [CI]=0.33, 1.45). In 27 patients who received an ICI, the overall response rate was 18.5% and median duration of response was 7.4 months (95% CI=6.5, 8.3). In 17 carefully selected patients with fewer than 3 sites of relapse, median PFS was 35 months (95% CI=0, 73.5) and median overall survival was 96.8 months (95% CI=44.6, 149.0) after SCS. NGS on 58 tumors revealed common mutations in ARID1A (48.3%), PIK3CA (46.6%), and KRAS (20.7%). Pathogenic alterations in PIK3CA, FGFR2, and NBN were associated with worse survival outcomes. Median tumor mutational burden was 3.78 (range, 0-16). All 26 patients with available loss of heterozygosity (LOH) scores had LOH <16%.

CONCLUSION

Our study demonstrates encouraging outcomes with bevacizumab and ICI, and SCS in select relapsed OCCC patients. Prospective trials are warranted.

Does initial routine use of a compression garment reduce the risk of lower limb lymphedema after gynecological cancer treatment? A randomized pilot study in an Asian institution and review of the literature

This is a randomized pilot study evaluating the effectiveness of customized compression garments (CG) in reducing the risk of lower limb lymphedema (LLL) in gynecological cancer patients. Patients who completed pelvic node dissection or radiation were routinely educated on reducing the risk of LLL by good skin care and manual lymphatic massage. After baseline lower limb volume perometry and clinical assessment, they were randomized to customized compression garment (CG) for 6 weeks (26 patients) or observation (30 patients). Both groups were followed up for 2 years and the primary outcome was the development of LLL. LLL incidence in the control group was 13.3% (4 of 30 patients) compared to 7.7% (2 of 26 patients) in the CG group. However the difference was not statistically significant (P=0.496). In the control group, 10.7% (3/28) who underwent node dissection developed LLL vs 7.7% (2/26) in the CG group. Among patients with node dissection plus radiation, LLL incidence was 14.3% (1/7) in the control group vs 12.5% (1/8) in the CG group. The mean onset of LLL was 12 months; compliance to CG wearing was high and QOL scores were similar in both groups. Customized low-compression CG worn for 6 weeks may have a possible benefit in reducing the risk of LLL when added to patient education on risk reduction although statistic significance was not achieved in this small pilot study. A larger multi-center study would be justified to expand these findings.

Monte Carlo study of PbSe quantum dots as the fluorescent material in luminescent solar concentrators

In this paper, Monte Carlo simulations were performed to determine the potential efficiencies of luminescent solar concentrator (LSC) systems using PbSe quantum dots (QDs) as the active fluorescent material. The simulation results suggest that PbSe QD LSCs display good absorption characteristics, but yield limited LSC power conversion efficiency due to self-absorption and down-conversion loss. It is proposed that the self-absorption loss can be reduced by utilizing Förster resonance energy transfer between two different sizes of PbSe QDs, yielding pronounced improvement in the optical efficiency of LSCs.

The association with age, human tissue kallikreins 6 and 10 and hemostatic markers for survival outcome from epithelial ovarian cancer

PURPOSE

To assess known cancer biomarkers CA-125, human tissue kallikreins KLK6 and KLK10, hemostatic markers and age with 5-year survival outcome from epithelial ovarian cancer.

METHODS

Forty-one benign cyst cohorts and 83 patients diagnosed with ovarian cancer were recruited. The following assays were performed: fibrinogen, vWF antigen, D: -dimer, ATIII activity, tPA, PAI-1, uPAR, KLK6, KLK10 and CA-125. Follow-up visits of cancer patients of more than 60 months were noted. Data between those who survived past 60 months and mortality from cancer were analyzed.

RESULTS

Only 24 patients lived past 60 months, and 31 died (advanced stage n = 27). Those living past 60 months were significantly older and associated with similar pre-operative levels seen in benign cyst cohorts especially for KLK6, fibrinogen, vWF, AT levels despite upregulation of D: -dimer, CA-125 and KLK10. Ovarian cancer cohorts living past 60 months were younger than those who died within 12 months (n = 12). Mortality within 12 months was associated with older age, upregulation of KLK6, fibrinogen, D: -dimer, vWF, tPA antigen and reduced ATIII levels. Similarly, mortality within 36 months of disease showed older age with upregulation of CA-125, KLK6 D: -dimer vWF antigen and tPA antigen levels. Late stage cancer (III/IV) showed upregulated CA-125, KLK6, KLK10, D: -dimer and reduced AT compared to early stage cancer (I/II). The 5-year survival rate for early cancer was 80%, advanced 22.9% and overall 5-year survival rate was 43.6%.

CONCLUSION

Older age together with the novel biomarkers studied and their association with adverse outcome from epithelial ovarian cancer was seen especially within 12 and 36 months of disease. Those who lived past 60 months of disease showed similar pre-operative levels seen in benign cyst cohorts despite elevated D: -dimer, CA125 and KLK 10. An enlarged study is needed to confirm these findings.

Combined adjuvant cisplatin and ifosfamide chemotherapy and radiotherapy for malignant mixed müllerian tumors of the uterus

The role of adjuvant therapy for malignant mixed müllerian tumors of the uterus has not been established. Our aim was to review our experience with sequential adjuvant therapy using cisplatin and ifosfamide chemotherapy and radiotherapy after surgical staging. A retrospective study of 43 patients from 1995 to 2004 was undertaken. Survival was calculated using the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazard regression model was used to assess the effect of treatment on survival after adjustment for age and stage. Twenty-eight patients received adjuvant chemotherapy and 28 patients had adjuvant radiotherapy. Twenty-one patients underwent sequential adjuvant chemotherapy and radiotherapy. Tumor recurrence occurred in 14 patients at a median duration of 10 months. The overall 2- and 5-year survival was 64% and 60%, respectively. The 2- and 5-year survival for stage I and II diseases was both 95%, while the 2-year survival for stage III and IV diseases was 25%. Patients who underwent sequential adjuvant therapy had an improved survival compared with patients who did not follow the protocol (P= 0.024). Our results with sequential adjuvant therapy are encouraging and justify future randomized trials.

Endometrioid adenocarcinoma of the uterus: surgico-pathological correlations and role of pelvic lymphadenectomy

INTRODUCTION

In 1988, FIGO added lymph node surgery to the staging system for endometrial cancer. This change remains controversial to date. From our study we aim to determine the significance of surgico-pathological parameters of endometrioid carcinoma for pelvic nodal metastases and survival, as well as to study the role of pelvic lymphadenectomy in the surgical treatment of this disease.

MATERIALS AND METHODS

A retrospective study was conducted in 198 women with endometrioid carcinoma who underwent full surgical staging including pelvic lymphadenectomy. The multiple variant regression analysis and the multi-variant logistic regression analysis were applied in the analysis of relationship.

RESULTS

A positive correlation between nodal metastases and grade, myometrial invasion, peritoneal cytology, adnexal involvement, lympho-vascular space involvement and tumour size was found. For survival, significant prognosticators were grade, myometrial invasion, peritoneal cytology, lympho-vascular space involvement, adnexal involvement, associated atypia and pelvic nodal metastases. Thirty-five per cent of the patients had high risk of recurrence based on uterine pathological factors but were node negative. They were spared external beam radiation and its associated morbidities, and were treated with adjuvant vault brachytherapy instead. Six per cent of the patients would have been understaged based on uterine factors alone if pelvic lymphadenectomy had not been done.

CONCLUSION

We infer that routine pelvic lymphadenectomy should be considered for all surgically fit patients with endometrioid carcinoma. The accurate staging will allow individualized adjuvant therapy and prevent understaging and overtreatment.

FIGO stage 1B2 cervical carcinoma--the KK Women's and Children's Hospital experience

INTRODUCTION

The objectives of this review were to document the surgico-pathological characteristics of surgically resected FIGO stage 1B2 cervical carcinoma and to review our overall experience with this disease.

MATERIALS AND METHODS

This is a retrospective review of 35 patients diagnosed and treated from September 1990 to November 2001.

RESULTS

The median age was 42 years and the mean tumour diameter was 5.1 cm. Majority were squamous cell carcinomas (65.7%), 28.6% were adenocarcinomas and 5.7% were adeno-squamous carcinomas. The primary treatment comprised radical surgery in 77.1%, radiotherapy in 20% and neoadjuvant chemotherapy followed by radical surgery and adjuvant radiotherapy in 2.9%. Significant surgico-pathological features noted were deep stromal invasion (66.7%), lympho-vascular space invasion (55.6%), parametrial involvement (22.2%), positive margins (3.7%) and pelvic node metastases (33.3%). Postoperative radiation was given to 92.6% of the patients who underwent primary surgery, of whom 29% received concurrent chemotherapy. Radiation toxicity was mild with no grade 3 or 4 toxicity documented. For the patients who had surgery, the recurRence rate was 14.8% (11.1% pelvic and 3.7% distant) and the survival rate was 88.9%. For those who had primary radiation, the rate of persistent disease was 28.6%, the distant recurrence rate was 28.6% and the survival rate was 57.1%.

CONCLUSION

FIGO stage 1B2 cervical carcinomas are associated with significant rates of adverse surgico-pathological features. The ideal primary treatment is yet to be established and should be determined by prospective randomised trials.

Pt L-edge XANES as a probe of Pt clusters

The sensitivity of Pt L-edge XANES to local geometric and electronic structure in various Pt(n) clusters is investigated using the ab initio self-consistent FEFF8 code. Calculations based on FEFF8 are found to be in good agreement with experiment. For pure Pt clusters the XANES can distinguish between 2- and 3-dimensional clusters. Self-consistency is important in determining the variation of XANES with cluster size. The effect of a support is also studied. In Pt-Cl(x) clusters the presence of a Cl-Pt bond leads to a "hybridization peak," i.e., a peak in the Cl d-density of states (d-DOS) mixed with Pt d-states. For Pt-H clusters hydrogen addition is well correlated with the growth of a broad shoulder on the white line. This change is attributed largely to AXAFS, i.e., to a corresponding change in the atomic background absorption.

Conservative surgery to preserve ovarian function in patients with malignant ovarian germ cell tumors. A review of 74 cases

BACKGROUND

Effective combination chemotherapy has improved the previously dismal prognosis for malignant ovarian germ cell tumors (MOGCT) dramatically. In young patients, conservative surgery with adjuvant chemotherapy has made the preservation of fertility possible, even in patients with advanced disease. The increase in cure rates has shifted the focus of recent studies to the long term menstrual, reproductive, and gynecologic outcomes in these patients.

METHODS

The current study is a retrospective review of 74 patients with MOGCT treated by conservative surgery, retaining the uterus and contralateral ovary to preserve ovarian function, with or without chemotherapy.

RESULTS

The mean age of the patients was 20.9 years (range, 10-35 years). The histologic subtypes included 31 dysgerminomas (41.9%), 16 immature teratomas (21.6%), 13 endodermal sinus tumors (17.6%), 11 mixed germ cell tumors (14.9%), and 3 embryonal cell tumors (4.1%). There were 56 International Federation of Gynecology and Obstetrics (FIGO) Stage I tumors (75.7%), 3 Stage II tumors, (4.1%), 11 Stage III tumors (14.9%), and 4 Stage IV tumors (5.4%). Adjuvant chemotherapy was administered in 47 patients (63.5%). The overall mean follow-up period was 52.1 months. There were 7 recurrences (9.5%) and 2 deaths (2.7%). Survival for patients with Stage I disease was 98.2% and that for patients with advanced disease stages was 94.4%. During chemotherapy 61.7% of patients developed amenorrhea but 91.5% of these women resumed normal menstrual function on completion of chemotherapy. Fourteen healthy live births were recorded in the chemotherapy group and there were no documented birth defects. There was 1 case of infertility (1.4%).

CONCLUSIONS

The surgical approach in young patients with MOGCT confined to a single ovary should aim to preserve fertility. Advanced disease is not usually accompanied by contralateral ovarian disease and should not necessarily contraindicate conservative surgery. The majority of these patients who have received combination chemotherapy resume normal ovarian function and can expect a normal fertility rate and healthy offspring.

The inhibitory upstream open reading frame from mammalian S-adenosylmethionine decarboxylase mRNA has a strict sequence specificity in critical positions

The upstream open reading frame (uORF) in the 5' leader of the mammalian mRNA encoding S-adenosylmethionine decarboxylase (AdoMetDC) serves as a negative regulatory element by suppressing translation of the associated downstream cistron. Certain changes in the amino acid sequence of the hexapeptide (sequence MAGDIS) encoded by the uORF destroy suppressive activity, implying specific interaction with a cellular target. In this paper, we examine the extent of alterations that can be tolerated in this uORF. The mammalian AdoMetDC uORF inhibits downstream translation when placed into the 5' leader of a yeast mRNA with characteristics resembling those in mammalian cells, suggesting that the encoded peptide has a similar target across species. Using yeast for the initial screen, we tested the specificity of the critical three codons at the 3' end of the uORF by saturation mutagenesis. Altered uORFs selected from the primary yeast screen were then retested in mammalian cells. The requirements at codons 4 and 5 were quite stringent; only aspartic acid at codon 4 yielded a fully suppressive peptide, and only valine could substitute productively for isoleucine at codon 5. The specificity at codon 6 was much looser, with many substitutions retaining suppressive activity in both yeast and mammalian cells.

Eclampsia--are we doing enough?

OBJECTIVES

This paper reviews the cases of eclampsia managed at the Kandang Kerbau Hospital with respect to incidence, management, maternal and perinatal outcome.

METHOD

A retrospective analysis of eclampsia occurring over a 4-year period from January 1990 to December 1993.

RESULTS

There were 27 cases of eclampsia among 59,599 deliveries during the study period, giving an overall incidence of 45.3 per 100,000 deliveries. Sixteen patients were nulliparous and the mean age was 29 years. Two-thirds of the cohort were booked patients and more than half of the cohort (55.6%) had their first seizure despite being in hospital. The majority (86.2%) of all seizures recorded occurred in the antepartum and intrapartum period. Eleven of the patients (40.7%) were asymptomatic prior to the first fit while headache was the commonest symptom of impending eclampsia in the remainder. Fifteen patients (55.6%) had significant proteinuria and this was associated with significant neonatal morbidity. The mean gestational age was 35.9 weeks and the mean birth weight was 2,328g. Major areas of substandard management included failure to administer anticonvulsant prophylaxis and antihypertensive agents when indicated, failure to assess for proteinuria, and failure to closely monitor the hypertensive and proteinuric patient. Seven patients developed convulsions despite anticonvulsant prophylaxis. Twenty-four patients were delivered by Caesarean section. There were 26 live born infants (singletons) and one abortus. There was no perinatal mortality. Neonatal morbidity was frequent and attributable to prematurity (51.9%) and birth asphyxia (29.6%). The majority of infants were well neurologically on long term follow-up. There was no maternal mortality but significant morbidity was present in 8 patients (29.6%). High uric acid levels were associated with intrauterine death, prematurity and intrauterine growth retardation. Seven patients remained hypertensive on follow-up. Residual neurological deficits persisted in 3 patients.

CONCLUSIONS

The incidence of eclampsia at Kandang Kerbau Hospital shows an unsteady decline over the past 4 years. It carries significant foetal mortality (3.7%) as well as neonatal (74.1%) and maternal (29.6%) morbidity. The observation that neither the occurrence of antenatal office visits nor hospitalisation prevents eclampsia, and that substandard management was identified in most of the cases (77.8%) shows that there is no room for complacency and that more needs to be done. Improvement in patient assessment, institution of appropriate preventive therapy, a high index of suspicion even in apparently low-risk patients coupled with a disease notification system and regular audit may be the key strategies to reduce the incidence of this dreaded obstetric complication.

The role of urodynamics in evaluating incontinent females

A total of 84 patients had urodynamic evaluations. Twenty-two patients complained of stress incontinence, 41 patients complained of stress incontinence with other urinary symptoms and 21 complained of other urinary symptoms but not stress incontinence. Of those complaining of stress incontinence alone, 4 (18.2%) had detrussor instability, 11 (50%) had genuine stress incontinence and 7 (31%) had neither condition. Of those complaining of stress incontinence with other symptoms, 16 (39%) had detrussor instability, 19 (46.3%) had stress incontinence and 6 (14.6%) had neither condition. Of those complaining of other urinary symptoms except stress incontinence, 5 (23.8%) had detrussor instability, 3 (14.3%) had stress incontinence and 13 (61.9%) had neither condition. Urinary symptoms were found to have little correlation with the final diagnosis except for enuresis which was associated with detrussor instability.