Next generation sequencing reveals a high prevalence of pathogenic mutations in homologous recombination DNA damage repair genes among patients with uterine sarcoma

OBJECTIVE

Investigate the incidence of homologous recombination DNA damage response (HR-DDR) genomic alterations among patients with uterine sarcoma.

METHODS

The American Association for Cancer Research GENIE v13.0 database was accessed and patients with uterine leiomyosarcoma, adenosarcoma, undifferentiated uterine sarcoma, high-grade endometrial stromal sarcoma, low-grade endometrial stromal sarcoma, and endometrial stromal sarcoma not otherwise specified were identified. We determined the incidence of pathogenic alterations in the following genes involved in HR-DDR: ATM, ARID1A, ATRX, BAP1, BARD1, BLM, BRCA2, BRCA1, BRIP1, CHEK2, CHEK1, FANCA, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCL, MRE11, NBN, PALB2, RAD50, RAD51, RAD51B, RAD51C, RAD51D, WRN. Data from the OncoKB database, as provided by cBioPortal, was utilized to determine the presence of pathogenic genomic alterations.

RESULTS

A total of 509 patients contributing with 525 samples were identified. Median patient age at sample collection was 56 years while the majority were White (80.7%). The most common histologic subtype was leiomyosarcoma (63.8%) followed by adenosarcoma (12.3%). The overall incidence of HR-DDR genomic alterations was 28.2%. The most commonly altered genes were ATRX (18.2%), BRCA2 (4%), and RAD51B (2.6%). The highest incidence of HR-DDR genomic alterations was observed among patients with leiomyosarcoma (35.4%), adenosarcoma (27%) and undifferentiated uterine sarcoma (30%), while those with low-grade endometrial stromal sarcoma had the lowest (2.9%) incidence.

CONCLUSIONS

Approximately 1 in 3 patients with uterine sarcoma harbor a pathogenic alteration in HR-DDR genes. Incidence is high among patients with uterine leiomyosarcoma and adenosarcoma.

Abstract 5610: [18F]FluorThanatrace ([18F]FTT) PET Imaging of PARP-inhibitor drug-target engagement as a biomarker of response in ovarian cancer

Purpose: Poly(ADP-ribose) polymerase enzyme inhibitors (PARPi) have become the standard-of-care treatment for homologous recombination deficient (HRD) high-grade serous ovarian cancer (HGSOC). However, not all HRD tumors respond to PARPi and biomarkers to predict response are needed. [18F]FluorThanatrace (FTT) is a PARPi-analog PET radiotracer that non-invasively measures PARP-1 expression. Herein, we evaluate the ability of FTT uptake to serve as a biomarker to predict response to PARPi in patient-derived xenograft (PDX) models and patients with HGSOC.

Patients and Methods: In PDX models, FTT-PET was performed before and after PARPi (olaparib), ataxia-telangiectasia inhibitor (ATRi), or both. Changes in FTT were correlated with tumor size changes. Patients with HRD and HGSOC that were enrolled in CAPRI (PARPi+ATRi), LIGHT (PARPi only), or off-trial (PARPi only) were selected for this single-center, prospective, cohort, IRB-approved study. FTT-PET/CT imagining was obtained from the skull base to the proximal thighs on an Ingenuity TF scanner (Philips Healthcare) 60-90 minutes after intravenous infusion of 8-12 mCi FTT. Subjects were imaged with FTT-PET at baseline and after ~1 week of PARPi monotherapy treatment. Target lesions (primary tumor and/or metastases) were identified at the time of the baseline imaging on correlative anatomic imaging using RECIST 1.1 and maximum standardized uptake value (SUVmax) data, normalized by body weight, was collected. Changes in FTT-PET uptake were compared to changes in tumor size, CA-125, and progression free survival (PFS).

Results: A decrease in FTT tumor uptake after 1 week of PARPi treatment correlated with response to PARPi+ATRi treatment in PARPi-resistant PDX models (r=0.81-0.83, P=0.1-0.22). In HGSOC patients (n=13), percent differences in FTT-PET after ~7 days of PARPi compared to baseline correlated with the first RECIST response (r=0.60, P=0.034), best RECIST response (r=0.75, P=0.01), best CA-125 response (r=0.73, P=0.033), and PFS (r=0.67, P=0.027). All patients with >50% reduction in FTT uptake had >6-month PFS and >50% reduction in CA-125 (P=0.004 and P=0.016, respectively). Utilizing only baseline FTT uptake correlated to best RECIST response (r=-0.65, P=0.035) but did not predict response when corelated with other measures. Importantly, a decrease in FTT uptake does not appear to be associated with a reduction in tumor burden or apoptosis in response to drug cytotoxic activity at this early timepoint, indicating specificity for drug-target engagement.

Conclusions: The decline in FTT uptake shortly after PARPi initiation compared to baseline provides an in vivo measure of drug-target engagement and shows promise as an early biomarker to guide PARPi therapy. FTT-PET has both pre-clinical and clinical applications warranting further study, including guiding PARPi combination therapy.

Citation Format: Sarah B. Gitto, Austin R. Pantel, Mehran Makvandi, Hyoung Kim, Sergey Medvedev, Joanna K. Weeks, Drew A. Torigian, Chia-Ju Hsieh, Benjamin Ferman, Nawar A. Latif, Janos L. Tanyi, Lainie P. Martin, Shannon M. Lanzo, Fang Liu, Quy Cao, Gordon B. Mills, Robert K. Doot, David A. Mankoff, Robert H. Mach, Lilie L. Lin, Fiona Simpkins. [18F]FluorThanatrace ([18F]FTT) PET Imaging of PARP-inhibitor drug-target engagement as a biomarker of response in ovarian cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5610.

A retrospective case series of Mohs micrographic surgery and interdisciplinary management of female genital skin cancers: Local recurrence rates and patient-reported outcomes

BACKGROUND

Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRR) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers.

OBJECTIVE

To evaluate LRR, PROs, and interdisciplinary care after MMS for female genital skin cancers METHODS: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care.

RESULTS

Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n=26), basal cell cancer (n=12), and extramammary Paget's disease (n=11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60).

LIMITATIONS

Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data.

CONCLUSIONS

Incorporating MMS into interdisciplinary teams may help achieve low LRR and satisfactory function after genital skin cancer surgery.

Facility level variation in the utilization of neoadjuvant chemotherapy is associated with higher surgical morbidity for patients with advanced stage epithelial ovarian carcinoma

OBJECTIVE

Investigate outcomes for advanced stage epithelial ovarian cancer (EOC) patients based on facility-level utilization of neoadjuvant chemotherapy (NACT).

METHODS

Stage III-IV EOC patients diagnosed between 2010 and 2016 were identified in the National Cancer Database. Percentage of patients managed with NACT was calculated for facilities, reporting ≥120 patients. Facilities with lowest and highest quartile of NACT rate comprised the low and high-utilizing groups. Clinico-pathological characteristics were collected, and appropriate statistical analysis performed.

RESULTS

High- and low-utilizing facilities managed on average 54.1% and 25.4% of patients with NACT respectively. Patients managed at high-utilizing facilities were significantly more likely to be >65 (p = 0.029), have stage IV disease (p < 0.001) and comorbidities (p < 0.001). Patients managed with primary debulking surgery (PDS) at low-utilizing facilities were significantly more likely to be >65, have stage IV disease, and have comorbidities (all, p < 0.001). Patients undergoing PDS at low-utilizing facilities were significantly less likely to achieve complete gross resection (p < 0.001), and were significantly more likely to experience 90-day mortality (p < 0.001), and unplanned 30-day readmission (p < 0.001). After controlling for age, comorbidities, race, insurance status, stage, grade and histology, high-utilizing facilities trended towards better overall survival (OS) (HR: 0.92, 95% CI: 0.85-0.99). Overall, patients undergoing PDS had better OS compared to those who had NACT (median 42 vs 27 months, p < 0.001).

CONCLUSIONS

Despite treating an EOC population with more advanced disease and comorbidities, high-utilizing facilities have lower surgical morbidity and mortality with no detrimental impact on long-term survival. Careful patient selection to minimize the morbidity and mortality associated with PDS is pivotal.

[18F]FluorThanatrace ([18F]FTT) PET Imaging of PARP-inhibitor Drug-Target Engagement as a Biomarker of Response in Ovarian Cancer, a pilot study

Purpose: Poly(ADP-ribose) polymerase enzyme inhibitors (PARPi) have become the standard-of-care treatment for homologous recombination deficient (HRD) high-grade serous ovarian cancer (HGSOC). However, not all HRD tumors respond to PARPi. Biomarkers to predict response are needed. [18F]FluorThanatrace ([18F]FTT) is a PARPi-analog PET radiotracer that non-invasively measures PARP-1 expression. Herein, we evaluate [18F]FTT as a biomarker to predict response to PARPi in patient-derived xenograft (PDX) models and subjects with HRD HGSOC. Methods: In PDX models, [18F]FTT-PET was performed before and after PARPi (olaparib), ataxia-telangiectasia inhibitor (ATRi), or both (PARPi-ATRi). Changes in [18F]FTT were correlated with tumor volume changes. Subjects were imaged with [18F]FTT-PET at baseline and after ~1 week of PARPi. Changes in [18F]FTT-PET uptake were compared to changes in tumor size (RECIST1.1), CA-125, and progression-free survival (PFS). Results: A decrease in [18F]FTT tumor uptake after PARPi correlated with response to PARPi, or PARPi-ATRi treatment in PARPi-resistant PDX models (r=0.77-0.81). In subjects (n=11), percent difference in [18F]FTT-PET after ~7 days of PARPi compared to baseline correlated with best RECIST response (P=0.01), best CA-125 response (P=0.033), and PFS (P=0.027). All subjects with &gt;50% reduction in [18F]FTT uptake had &gt;6-month PFS and &gt;50% reduction in CA-125. Utilizing only baseline [18F]FTT uptake did not predict such responses. Conclusions: The decline in [18F]FTT uptake shortly after PARPi initiation provides a measure of drug-target engagement and shows promise as a biomarker to guide PARPi therapies in this pilot study. These results support additional pre-clinical mechanistic and clinical studies in subjects receiving PARPi +/- combination therapy.

Addition of External Beam Radiation Therapy to Adjuvant Chemotherapy for Patients With Stage IIIC Uterine Endometrioid Carcinoma: Utilization and Outcomes

OBJECTIVES

Evaluate whether the addition of external beam radiation (EBRT) to adjuvant chemotherapy with or without vaginal brachytherapy is associated with better survival for patients with stage IIIC endometrioid endometrial carcinoma.

MATERIALS AND METHODS

Patients diagnosed between 2010 and 2015 with apparent early-stage endometrioid adenocarcinoma, without a history of another tumor, who underwent hysterectomy with lymphadenectomy and had positive lymph nodes were identified in the National Cancer Database. Those who received adjuvant chemotherapy (defined as receipt of treatment within 6 mo from surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared between patients who did and did not receive EBRT within 6 months from surgery with the log-rank test. A Cox model was also constructed to control for confounders.

RESULTS

A total of 3116 patients were identified; 1458 (46.8%) received chemotherapy without and 1658 (53.2%) with EBRT. Pathologic characteristics (tumor grade, size, endocervical, and lymph-vascular invasion) were comparable between the two groups. Patients who received external beam radiation had better survival compared with those who did not, P =0.001; 5-year overall survival rates were 83.1% and 77.9%, respectively. After controlling for patient age, race, presence of comorbidities, insurance status, tumor size, grade and endocervical invasion, and the presence of lymph-vascular invasion, the addition of EBRT was associated with a survival benefit (HR: 0.75, 95% CI: 0.62, 0.91).

CONCLUSIONS

For patients with endometrioid adenocarcinoma metastatic to the lymph nodes, addition of external beam radiation to adjuvant chemotherapy may be associated with a survival benefit.

Safety of ovarian preservation for premenopausal patients with FIGO stage I grade 2 and 3 endometrioid endometrial adenocarcinoma

OBJECTIVE

To investigate the utilization and outcomes of ovarian preservation for premenopausal patients with International Federation of Gynecology and Obstetrics (FIGO) stage I grade 2 and 3 endometrioid endometrial carcinoma undergoing hysterectomy.

METHODS

The National Cancer Database was accessed; patients aged ≤45 years diagnosed between January 2004 and December 2015 with FIGO stage I grade 2 or 3 endometrioid endometrial carcinoma, who underwent hysterectomy with or without bilateral salpingo-oophorectomy and had at least 1 month of follow-up, were identified. Overall survival was assessed following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected variables.

RESULTS

A total of 2941 patients who met the inclusion criteria were identified; 200 (6.8%) patients did not undergo bilateral salpingo-oophorectomy. Rate of ovarian preservation was comparable between patients with grade 2 (n=163, 6.6%) and grade 3 (n=37, 7.7%) tumors (p=0.38). Patients who did not undergo bilateral salpingo-oophorectomy were younger (median 39 vs 41 years, p<0.001) and less likely to undergo surgical lymph node assessment (52% vs 76.2%, p<0.001). There was no difference in overall survival between patients who did and did not undergo bilateral salpingo-oophorectomy (p=0.94); 5 year overall survival rates were 96.6% and 97%, respectively. After controlling for confounders, including tumor grade, ovarian preservation was not associated with worse overall survival (HR 0.92, 95% CI 0.47 to 1.84).

CONCLUSIONS

For patients with grade 2 and 3 FIGO stage I endometrioid carcinoma undergoing hysterectomy, ovarian preservation is rarely performed while no clear detrimental effect on overall survival was found.

Oncologic outcomes of surgical para-aortic lymph node staging in patients with advanced cervical carcinoma undergoing chemoradiation

OBJECTIVES

We aimed to evaluate the utilization and impact of surgical para-aortic lymph node staging on the survival of patients with locally advanced stage cervical carcinoma receiving definitive chemoradiation.

METHODS

We identified patients in the National Cancer Database diagnosed between January 2010 and December 2015 with locally advanced (FIGO 2009 stage IB2-IVA) cervical carcinoma who did not undergo hysterectomy, received primary chemoradiation and had at least 1 month of follow-up. Two groups of patients were formed based on the assessment method of para-aortic lymph node status - radiologic assessment only versus surgical lymphadenectomy. Overall survival was compared with the log-rank test after Kaplan-Meier curves were generated. A Cox model was constructed to control for a priori selected confounders.

RESULTS

We identified a total of 3540 patients who met the inclusion criteria. Para-aortic staging was performed in 333 (9.4%) patients. These patients were younger (median age 46 vs 52 years, p<0.001), less likely to have co-morbidities (8.7% vs 15.6%, p<0.001), more likely to have private insurance (48.9% vs 37.8%, p<0.001) and receive brachytherapy (76.9% vs 70.9%, p=0.022). The rate of para-aortic lymphadenectomy was comparable between patients with stage IB2-II and III-IVA disease (9.4% for both groups, p=0.98). Patients who underwent para-aortic lymphadenectomy were also more likely to have lymph nodes categorized as positive compared with those who had imaging only (27.3% vs 13.2%, p<0.001). There was no difference in overall survival between patients who underwent radiologic only or surgical para-aortic lymph node assessment (p=0.80 from log-rank test); 4 year overall survival rates were 62.9% and 63%. After controlling for confounders, performance of para-aortic lymphadenectomy was not associated with a survival benefit (HR 1.07, 95% CIs: 0.88 to 1.31).

CONCLUSIONS

In a large cohort of patients with locally advanced stage cervical carcinoma, para-aortic lymphadenectomy was rarely performed and not associated with a survival benefit.

Adjuvant chemotherapy for stage I high-intermediate risk endometrial carcinoma with lymph-vascular invasion

OBJECTIVE

The goal of this study was to evaluate if addition of adjuvant chemotherapy to radiation therapy improves overall survival in patients with high-intermediate risk stage I endometrial carcinoma with lymphovascular invasion.

METHODS

Patients diagnosed between January 2010 and December 2015 with FIGO (International Federation of Gynecology and Obstetrics) stage I endometrioid endometrial carcinoma with lymphovascular invasion who underwent hysterectomy with lymphadenectomy and met the GOG-99 criteria for high-intermediate risk were identified in the National Cancer Database. Patients who received adjuvant radiotherapy with or without adjuvant chemotherapy (administered within 6 months of surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared with the log-rank test following stratification by type of radiation treatment. A Cox model was constructed to control for a priori selected confounders.

RESULTS

A total of 2881 patients who met the inclusion criteria were identified; 2417 (83.9%) patients received radiation therapy alone while 464 (16.1%) received chemoradiation. Rate of adjuvant chemotherapy administration was comparable between patients who received vaginal brachytherapy alone (16.2%), and external beam radiation therapy (with or without vaginal brachytherapy) (15.8%), p=0.78. Rate of chemoradiation was higher for patients with grade 3 (28.8%) tumors compared with those with grade 2 (9.9%) and grade 1 (8.3%) tumors, p<0.001. After controlling for confounders for patients receiving external beam radiation, addition of chemotherapy was not associated with improved overall survival (HR 0.90, 95% CI 0.56 to 1.46). For patients receiving vaginal brachytherapy addition of chemotherapy was associated with better overall survival (HR 0.644, 95% CI 0.45 to 0.92). Benefit was limited to patients with grade 3 tumors, p=0.026; 4-year overall survival rate was 81.1% versus 74.9%.

CONCLUSIONS

In patients with high-intermediate risk FIGO stage I endometrioid endometrial carcinoma and lymphovascular invasion, addition of chemotherapy to radiation therapy was associated with a survival benefit for patients with grade 3 tumors receiving vaginal brachytherapy.

Early mortality in epithelial ovarian cancer

e17585

Background: Investigate the prevalence and characteristics of patients with epithelial ovarian carcinoma (EOC) who experience early mortality defined as death within 90 days of diagnosis. Methods: The National Cancer Database was accessed, and patients diagnosed with a pathologically confirmed EOC between 2004-2015 were identified. Patients who died within 90 days from diagnosis were identified. Clinico-pathological characteristics were compared with the chi-square and Mann Whitney U test. Results: A total of 150064 patients diagnosed with EOC were identified; 13561 (9%) patients died within 90 days from diagnosis with a decreasing incidence per year of diagnosis (from 9.8% in 2004 to 8% in 2015). These patients were older (median 76 vs 61 years, p < 0.001), more likely to be Black (11.4% vs 7.1%, p < 0.001), have government-issued insurance (75.6% vs 45.4%, p < 0.001), median income < 48000$ (45.1% vs 37.9%, p < 0.001), comorbidities (35% vs 19.1%, p < 0.001), reside closer to treatment facility (median 8 vs 12.3 miles, p < 0.001) and present to non-academic facilities (68.5% vs 58.1%, p < 0.001). Incidence of early mortality was 3.6% for patients aged < 65 years, 11.2% for those 65-79 years and 28.6% among those > = 80 years. For patients who experienced early mortality, 6067 (44.7%) did not receive any treatment, 2969 (21.9%) received chemotherapy only, 3345 (24.7%) underwent surgery only and 1180 (8.7%) received both. The rate of patients who did not receive any treatment was higher for patients aged > = 80 years (25.6%) compared to those aged 65-79 (6.9%) and < 65 years (2.5%), p < 0.001. For patients who underwent surgery, median inpatient stay was 9 days while unplanned readmission rate within 30-days from discharge was 10.8%. After controlling for insurance, type of treatment facility, comorbidities, income, race, and stage, octogenarians had higher odds of early mortality (OR 6.02, 95% CI: 5.65, 6.41) compared to those aged < 65 years. Higher odds of early mortality were also observed among octogenarians who received chemotherapy (OR 4.28, 95% CI: 3.84, 4.77) or surgery (OR 5.72, 95% CI: 5.15, 6.35) compared to those < 65 years, after controlling for the aforementioned confounders. Conclusions: Approximately 1 in 10 patients diagnosed with ovarian cancer will expire within 90 days from diagnosis. These patients are older and more likely to have medical comorbidities. More than 1 in 4 octogenarians with ovarian cancer will die within 90 days of diagnosis. Some of these patients may not be candidates for active treatment; however, interventions that facilitate timely presentation, target frailty, and allow medical optimization are greatly warranted.

Fertility-sparing surgery for patients with stage IC2 or IC3 epithelial ovarian carcinoma: any evidence of safety?

OBJECTIVE

Investigate the overall survival of patients with stage IC2/IC3 epithelial ovarian carcinoma undergoing fertility-sparing surgery.

METHODS

Patients aged <45 years diagnosed between January 2004 and December 2015 with epithelial ovarian carcinoma, who underwent surgical staging and had tumor involving the ovarian surface (IC2), malignant ascites or positive cytology (IC3), were identified in the National Cancer Database. The fertility-sparing surgery group included patients who had preservation of the uterus and the contralateral ovary while the radical surgery group included patients who had hysterectomy with bilateral salpingo-oophorectomy. Overall survival was evaluated following generation of Kaplan-Meier curves while a Cox model was constructed to control for tumor grade and performance of lymphadenectomy. A systematic review of the literature was performed and cumulative relapse rate among patients with IC2/IC3 disease who underwent fertility-sparing surgery was calculated.

RESULTS

A total of 235 cases were identified; 105 (44.7%) patients underwent fertility-sparing surgery. There was no difference in overall survival between the fertility-sparing and radical surgery groups (p=0.37; 5- year overall survival rates 90.2% and 85%, respectively). After controlling for tumor grade and performance of lymphadenectomy, fertility-sparing surgery was not associated with worse overall survival (HR 1.22, 95% CI 0.56, 2.62). A systematic review identified 151 patients with stage IC2/IC3 disease who underwent fertility-sparing surgery. Cumulative relapse rate was 19.3% (n=29) while 12 (6.7%) deaths were reported. Median time to recurrence was 19 (range 1-128.5) months. Tumor recurrence involved the ovary exclusively in 42% (11/26) of patients, while 15% (4/26) had a lymph node, 35% (9/26) a pelvic/abdominal, and 8% (2/26) a distant tumor relapse.

CONCLUSIONS

In a large cohort of patients with stage IC2/IC3 epithelial ovarian carcinoma, fertility-sparing surgery was not associated with worse overall survival. However, based on a literature review, relapse rate is approximately 20%.

Ascites volume at the time of primary debulking and overall survival of patients with advanced epithelial ovarian cancer

OBJECTIVES

To investigate the impact of malignant ascites volume on the outcomes of patients with advanced epithelial ovarian carcinoma who undergo primary debulking surgery.

METHODS

Patients diagnosed with stage III-IV epithelial ovarian carcinoma and bulky intra-abdominal (TIIIC) disease between 2010 and 2015, who underwent primary debulking surgery followed by multi-agent chemotherapy and known status of residual disease, were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was categorized as absent, low (<980 mL), and high (>980 mL) volume. Median overall survival was determined from Kaplan-Meier curves and compared with the log rank test. A multivariate Cox model was constructed to control for confounders.

RESULTS

2493 patients were identified; 31.9% (n=795) had no ascites, 40.2% (n=1001) had low, and 28% (n=697) had high volume malignant ascites. Rate of complete gross resection was higher for patients with no ascites (65.9%) compared with those with low (35.6%) and high (23%) volume ascites (p<0.001). After controlling for stage, histology, grade, age, and comorbidities, compared with those with no ascites, patients with low (odds ratio (OR) 3.49, 95% confidence intervals (CI) 2.89 to 4.26) and high (OR 6.40, 95% CI 5.07 to 8.06) volume ascites were more likely to have gross residual disease. For patients who achieved complete gross resection after controlling for confounders compared with patients with no ascites, those with low (hazard ratio (HR) 1.37, 95% CI 1.09 to 1.72) and high volume ascites (HR 1.94, 95% CI 1.47 to 2.55) had worse overall survival. Similarly, patients with low volume ascites had better survival compared with those with high volume ascites (HR 0.71 95% CI 0.54 to 0.93).

CONCLUSIONS

The presence and volume of malignant ascites at the time of primary debulking surgery was associated with the likelihood of achieving a complete gross resection and worse overall survival.

Outcomes of comprehensive lymphadenectomy for patients with advanced stage ovarian carcinoma and rare histologic sub-types

OBJECTIVE

To investigate the prognostic significance of comprehensive lymphadenectomy at the time of primary debulking surgery for patients with rare histologic sub-types of epithelial ovarian carcinoma and clinically advanced stage disease who underwent complete gross resection.

METHODS

The National Cancer Database was accessed and patients diagnosed between January 2010 and December 2015 with stage III-IV clear cell, endometrioid, mucinous, and low-grade serous carcinoma who underwent primary debulking surgery and achieved complete gross resection were identified. Patients who did not undergo lymphadenectomy and those who underwent comprehensive lymphadenectomy (defined as at least 20 lymph nodes removed) were selected for further analysis. Overall survival was compared with the log-rank test and a Cox model was constructed to control for confounders.

RESULTS

A total of 381 patients were identified; 133 (34.9%) patients underwent comprehensive lymphadenectomy while 248 (65.1%) patients did not. There were no differences between the two groups in terms of patient race, age, presence of co-morbidities, type of treatment facility, disease stage, histology, and extent of intra-abdominal disease (p>0.05). There was no difference in overall survival between patients who did and did not undergo comprehensive lymphadenectomy (p=0.42); median overall survival was 51.48 and 47.38 months, respectively. After controlling for patient age, race, insurance status, presence of co-morbidities, intra-abdominal tumor spread, stage and histology, performance of systematic lymphadenectomy was not associated with better survival (HR 0.96, 95% CI 0.69 to 1.35).

CONCLUSION

Comprehensive lymphadenectomy is not associated with a survival benefit for patients with rare histologic sub-types of epithelial ovarian carcinoma and advanced stage disease who underwent primary debulking surgery and complete gross resection.

Combination of PARP and ATR inhibitors (olaparib and ceralasertib) shows clinical activity in acquired PARP inhibitor-resistant recurrent ovarian cancer

5516

Background: Following multiple blockbuster studies demonstrating long-term progression free and overall survival benefits with poly(ADP-ribose)polymerase inhibitors (PARPi), they have become an integral component of high grade serous ovarian cancer (HGSOC) treatment. Unfortunately, tumors ultimately acquire resistance and thus therapies that overcome PARPi-resistance are urgently needed. Preclinical studies show the addition of ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) to PARPi overcome PARPi-resistance. We present results of an investigator-initiated study of the combination PARPi (olaparib) and ATRi (ceralasertib) in patients who were on a PARPi and experienced disease progression. Methods: We conducted a non-randomized trial (NCT03462342) in platinum sensitive HGSOC immediately following prior PARPi treatment of a 28 day cycle of olaparib 300mg orally twice daily and ceralasertib 160mg orally once daily on days 1-7. Eligibility required a germline or somatic BRCA1/2 mutation, other homologous recombination deficient (HRD) mutation, or positive HRD score (>42 on Myriad My Choice). Clinical benefit from prior PARPi was required ( > 12 months on treatment for 1st line maintenance, > 6 months for ≥2nd line maintenance, or treatment of recurrence with response by CA-125 or imaging). No intervening treatment between the PARPi and enrollment was permitted. The primary objectives were safety and objective response rate (ORR). Results: Thirteen patients (pt) of median age 60 years (range 43-78) were enrolled. 9 pt (69%) had germline BRCA mutations, 3 (23%) somatic BRCA mutations and 1 (8%) a positive HRD score. Median time on prior PARPi was 13 months (range 4-60). Prior PARPi indication was 1st line maintenance in 8% (n = 1), 2nd line maintenance in 38% (n = 5) and recurrence in 54% (n = 7). Nine pt (69%) had received olaparib prior to enrollment. The time from prior PARPi to cycle 1, day 1 was 34 days (range 22-311). The ORR was 46% (n = 6); all 6 demonstrating a PR. Pt received a median of 8 (range 3-23) cycles of olaparib and ceralasertib. 4 pt remain on study (4-14 months). 4 pt (31%) experienced grade 3 toxicity: 23% (n = 3) thrombocytopenia, 16% (n = 2) anemia, and 16% (n = 2) neutropenia. There were no grade 4/5 toxicities. There were 4 dose reductions (3 olaparib, 1 ceralasertib). No pt discontinued treatment due to toxicity. Conclusions: The combination of olaparib and ceralasertib is well tolerated and shows clinical activity in in a cohort of patients with recurrent HRD HGSOC who have progressed on prior PARPi thus warranting further investigation. This study is the first to suggest the potential of ATR inhibitors to overcome PARPi resistance in an HRD patient population. Molecular profiling studies are underway to identify potential biomarkers associated with response to guide future clinical trial design. Clinical trial information: NCT03462342.

Oncologic outcomes of minimally invasive versus open radical hysterectomy for early stage cervical carcinoma and tumor size <2 cm: a systematic review and meta-analysis

OBJECTIVE

To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size <2 cm who underwent open or minimally invasive radical hysterectomy.

METHODS

The Pubmed/Medline, Embase, and Web-of-Science databases were queried from inception to January 2021 (PROSPERO CRD 42020207971). Observational studies reporting progression-free survival and/or overall survival for patients who had open or minimally invasive radical hysterectomy for early-stage cervical carcinoma and tumor size <2 cm were selected. Level of statistical heterogeneity was evaluated with the I² statistic. A random-effects model was used to compare progression and overall survival between the two groups and HR with 95% confidence intervals were calculated with the Der Simonian and Laird approach. Risk of bias and quality of included studies was assessed with the Newcastle-Ottawa scale.

RESULTS

A total of 10 studies that met the inclusion criteria were included encompassing 4935 patients. Of these, 2394 (48.5%) patients had minimally invasive and 2541 (51.5%) patients had open radical hysterectomy; respectively. Patients who underwent minimally invasive hysterectomy had worse progression-free survival than those who had open surgery (HR 1.68, 95% CI 1.20, 2.36, I² 26%). Based on five studies, patients who had minimally invasive (n=1808) hysterectomy had a trend towards worse overall survival than those who had open surgery (n=1853) (HR 1.64, 95% CI 1.00 to 2.68, I² 15%).

CONCLUSION

Based on a systematic review of the literature and meta-analysis of studies that control for confounders, for patients with cervical cancer and tumor size <2 cm, minimally invasive radical hysterectomy was associated with worse progression-free survival than laparotomy.

Role of adjuvant radiation therapy after radical hysterectomy in patients with stage IB cervical carcinoma and intermediate risk factors

OBJECTIVE

To investigate the outcomes of observation-alone versus adjuvant radiotherapy for patients with lymph node negative FIGO 2018 stage IB cervical carcinoma following radical hysterectomy with negative prognostic factors.

METHODS

The National Cancer Database was accessed and patients with no history of another tumor, diagnosed with intermediate risk (defined as tumor size 2-4 cm with lymph-vascular invasion or tumor size >4 cm) pathological stage IB squamous, adenosquamous carcinoma or adenocarcinoma of the cervix between January 2010 and December 2015 who underwent radical hysterectomy with lymphadenectomy and had negative tumor margins were identified. Overall survival was assessed following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for a priori selected confounders known to be associated with overall survival.

RESULTS

A total of 765 patients were identified and adjuvant external beam radiotherapy was administered to 378 patients (49.4%). There was no difference in overall survival between patients who did and did not receive adjuvant radiotherapy, P=0.44: 4-year overall survival rates were 88.4% and 87.1% respectively. After controlling for patient age, histology, and surgical approach, the administration of adjuvant radiotherapy was not associated with better survival (HR 0.86, 95% CI 0.54 to 1.38). For patients who received adjuvant radiotherapy, there was no survival difference between those who did (n=219) and did not (n=159) receive concurrent chemotherapy, P=0.36: 4-year overall survival rates were 89.8% and 86.3%, respectively.

CONCLUSION

In a large cohort of patients with lymph node negative, margin negative, stage IB cervical carcinoma, with negative prognostic factors, the administration of adjuvant external beam radiation therapy was not associated with a survival benefit compared with observation alone.

Minimally invasive hysterectomy for stage IA cervical carcinoma: a survival analysis of the National Cancer Database

OBJECTIVE

To evaluate the outcomes of minimally invasive surgery for patients with stage IA cervical carcinoma undergoing hysterectomy.

METHODS

Patients with pathological stage IA (IA1, IA2, IA not otherwise specified) squamous, adenocarcinoma, adenosquamous carcinoma of the cervix, no history of another tumor, who underwent radical or simple hysterectomy with known mode of surgery, diagnosed between 2010 and 2015 with at least 1 month of follow-up, were drawn from the National Cancer Database. Comparisons of demographic and clinicopathologic characteristics were made with the χ² test. The impact of minimally invasive surgery (robotic-assisted or traditional laparoscopic) on overall survival was assessed with the log-rank test following generation of Kaplan-Meier curves. A Cox model was constructed to control for confounders.

RESULTS

A total of 1930 patients were identified; the majority (73.3%, 1414 patients) had stage IA1 disease, while 458 (23.7%) patients had stage IA2, and 58 (3%) patients had stage IA not otherwise specified. In the present cohort, 685 patients (35.5%) had open, 438 patients (22.7%) had laparoscopic, and 807 patients (41.8%) had robotic-assisted laparoscopic hysterectomy. Patients who had an open approach were more likely to undergo lymphadenectomy (58.1% vs 52.7%, p=0.021) and have radical hysterectomy (42% vs 32.4%, p<0.001). Patients who had minimally invasive surgery had a shorter hospital stay (median 1 vs 3 days, p<0.001). There was no difference in overall survival between patients who had open and minimally invasive hysterectomy (p=0.87); 4-year overall survival rates were 97.7% and 98.6%, respectively. There was no difference in overall survival between the open and minimally invasive surgery groups for patients who had simple (p=0.61; 4-year overall survival rates 97.6% and 98.7%, respectively) or radical hysterectomy (p=0.70; 4-year overall survival rates 97.8% and 98.4%, respectively). After controlling for patient age, tumor histology, and presence of lymphovascular invasion, minimally invasive hysterectomy was not associated with worse survival (HR 0.94, 95% CI 0.49 to 1.81). In a sensitivity analysis, based on 3048 patients with clinical stage IA after controlling for confounders, minimally invasive surgery was not associated with worse survival than laparotomy (HR 1.06, 95% CI 0.65 to 1.72).

CONCLUSIONS

In a large cohort of patients with stage IA cervical carcinoma, performance of minimally invasive hysterectomy was not associated with a detrimental effect on overall survival.

The impact of sentinel lymph node sampling versus traditional lymphadenectomy on the survival of patients with stage IIIC endometrial cancer

OBJECTIVE

To investigate the survival of patients with lymph node positive endometrial carcinoma by type of surgical lymph node assessment.

METHODS

Patients diagnosed between January 2012 and December 2015 with endometrial carcinoma and uterine confined disease and nodal metastases on final pathology who underwent minimally invasive hysterectomy were identified in the National Cancer Database. Patients who had sentinel lymph node biopsy alone or underwent systematic lymphadenectomy were selected. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log rank test. A Cox model was constructed to evaluate survival after controlling for confounders.

RESULTS

A total of 1432 patients were identified: 1323 (92.4%) and 109 (7.6%) underwent systematic lymphadenectomy and sentinel lymph node biopsy only, respectively. The rate of adjuvant treatment was comparable between patients who had sentinel lymph node biopsy alone and systematic lymphadenectomy (83.5% vs 86.6%, p=0.39). However, patients who had sentinel lymph node biopsy were less likely to receive chemotherapy alone (13.6% vs 36.6%, p<0.001) and more likely to receive radiation therapy alone (19.8% vs 5.4%, p<0.001) compared with patients who had systematic lymphadenectomy. There was no difference in overall survival between patients who had sentinel lymph node biopsy alone and systematic lymphadenectomy (p=0.27 from log rank test), and 3 year overall survival rates were 82.2% and 79.4%, respectively (p>0.05). After controlling for confounders, there was no difference in survival between the systematic lymphadenectomy and sentinel lymph node biopsy alone groups (hazard ratio 0.82, 95% confidence interval 0.46 to 1.45).

CONCLUSIONS

Performance of sentinel lymph node biopsy alone was not associated with an adverse impact on survival in patients with lymph node positive endometrial cancer.

Oncologic outcomes of uterine preservation for pre-menopausal patients with stage II epithelial ovarian carcinoma

OBJECTIVE

Fertility-sparing surgery is rarely offered for patients with stage II epithelial ovarian carcinoma. The aim of the present study was to evaluate the overall survival of pre-menopausal patients with stage II epithelial ovarian carcinoma who did not undergo hysterectomy.

METHODS

The National Cancer Database was accessed, and patients aged ≤40 years without a history of another tumor diagnosed between 2004 and 2015 with a pathological stage II epithelial ovarian carcinoma, who underwent lymphadenectomy and received multi-agent chemotherapy, were identified. Overall survival was compared with the log-rank test after generation of Kaplan-Meier curves. A Cox model was constructed to control for tumor histology.

RESULTS

A total of 185 patients met the inclusion criteria. The rate of uterine preservation was 24.3% (45 patients). Patients who did not undergo hysterectomy were younger (median 32 vs 37 years, p<0.001) and less likely to have high-grade tumors compared with those who underwent hysterectomy. The two groups were comparable in terms of presence of co-morbidities and performance of adequate lymphadenectomy (p>0.05). Median follow-up of the present cohort was 62.3 months (95% CI 53.6 to 71.0) and a total of 22 deaths occurred. There was no difference in overall survival between patients who did and did not undergo hysterectomy (p=0.50; 5-year overall survival rates 87.5% and 91.4%, respectively). After controlling for tumor histology, grade and substage, omission of hysterectomy was not associated with worse survival (HR 0.69, 95% CI 0.22 to 2.12).

CONCLUSIONS

Uterine preservation was not associated with worse survival in this cohort of pre-menopausal patients with stage II epithelial ovarian carcinoma.

Is there a benefit of performing an omentectomy for clinical stage I high-grade endometrial carcinoma?

OBJECTIVES

Routine omentectomy is generally not performed in patients with endometrial cancer unless there is evidence of gross omental metastases. The aim of the current study was to evaluate the role of omentectomy in the staging of clinical stage I high-grade endometrial carcinoma and its impact on overall survival.

METHODS

Patients in the National Cancer Database who presented between 2010 and 2015 with clinical stage I serous, clear cell, carcinosarcoma, or grade 3 endometrioid carcinoma and underwent hysterectomy with lymphadenectomy were selected. Patients who did and did not receive an omentectomy were identified and clinico-pathological characteristics were compared. Overall survival was evaluated for patients diagnosed between 2010 and 2014 who had at least one month of follow-up following generation of Kaplan-Meier curves and comparison with the log-rank test. A Cox model was constructed to control for confounders.

RESULTS

A total of 9097 patients were identified, and 36.3% underwent an omentectomy. Patients who underwent omentectomy were more likely to be managed in academic institutions (50% vs. 44%, p < 0.001). They were also more likely to have an open surgery (48.2% vs. 27.2%, p < 0.001) and receive adjuvant chemotherapy (54.7% vs. 38.2%, p < 0.001). There was no difference in overall survival between patients who did and did not undergo omentectomy, p = 0.61; the 3-year OS rates were 82.3% and 82.2%, respectively. After controlling for confounders, the performance of an omentectomy was not associated with better survival (hazard ratio [HR]: 0.94, 95% confidence intervals [CI]: 0.84, 1.05).

CONCLUSIONS

Routine omentectomy may not be associated with a survival benefit for patients with clinical stage I high-grade endometrial carcinoma.

A Retrospective Study of Rapid Symptom Response in Bleeding Gynecologic Malignancies With Short Course Palliative Radiation Therapy: Less is More

CONTEXT

Advanced gynecologic malignancies can cause significant vaginal bleeding. Radiotherapy (RT) is often used to palliate symptoms, but limited data exist concerning the optimal dose and expected time to bleeding hemostasis in this population.

OBJECTIVES

1) To investigate the overall hemostasis response and kinetics of hemostasis in women with gynecologic malignancies receiving palliative RT. 2) To compare the efficacy of short-course RT (SCRT, less than or equal to five fractions, >3.5 Gy per fraction) vs. conventionally fractionated long-course regimens (greater than five fractions).

METHODS

We identified women receiving palliative RT for bleeding gynecologic malignancies. Initial and maximal hemostasis responses (IHR and MHR) were recorded and categorized as progressive bleeding (PD), stable disease (SD), partial response (PR), or complete response (CR). Clinical variables were correlated with response or toxicity using binary logistic regression statistical methods.

RESULTS

Thirty-three women (median age 63) were identified between 2010 and 2019. Median follow-up and survival after RT were 131 days. About 54.5% (18 of 33) received SCRT. Median time to IHR was five days (two-and-a-half days with SCRT) and 78.8% (26 of 33) responded during treatment. Median time to MHR was 13 days. About 100% achieved PR or CR at MHR. Rates of CR were similar between SCRT (83%) and conventionally fractionated schedules (87%). Average durability of hemostatic control was 5.4 months. Overall rate of rebleeding and Grade 3+ toxicity was 9.1% (3 of 33 each).

CONCLUSION

Women receiving SCRT for bleeding gynecologic malignancies achieved rapid symptom control (often during treatment) with minimal rebleeding. In a population whose median survival is four months, SCRT effectively addresses symptomatic disease while minimizing patient burden and toxicity.

Impact of Medicaid expansion on women with gynecologic cancer: a difference-in-difference analysis

BACKGROUND

Women with gynecologic cancer face socioeconomic disparities in care that affect survival outcomes. The Affordable Care Act offered states the option to expand Medicaid enrollment eligibility criteria as a means of improving timely and affordable access to care for the most vulnerable. The variable uptake of expansion by states created a natural experiment, allowing for quasi-experimental methods that offer more unbiased estimates of treatment effects from retrospective data than the traditional regression adjustment.

OBJECTIVE

To use a quasi-experimental, difference-in-difference framework to create unbiased estimates of impact of Medicaid expansion on women with gynecologic cancer.

STUDY DESIGN

We performed a quasi-experimental retrospective cohort study from the National Cancer Database files for women with invasive cancers of the uterus, ovary and fallopian tube, cervix, vagina, and vulva diagnosed from 2008 to 2016. Using a marker for state Medicaid expansion status, we created difference-in-difference models to assess the impact of Medicaid expansion on the outcomes of access to and timeliness of care. We excluded women aged <40 years owing to the suppression of the state Medicaid expansions status in the data and women aged ≥65 years owing to the universal Medicare coverage availability. Our primary outcome was the rate of uninsurance at diagnosis. Secondary outcomes included Medicaid coverage, early-stage diagnosis, treatment at an academic facility, and any treatment or surgery within 30 days of diagnosis. Models were run within multiple subgroups and on a propensity-matched cohort to assess the robustness of the treatment estimates. The assumption of parallel trends was assessed with event study time plots.

RESULTS

Our sample included 335,063 women. Among this cohort, 121,449 were from nonexpansion states and 213,614 were from expansion states, with 79,886 posttreatment cases diagnosed after the expansion took full effect in expansion states. The groups had minor differences in demographics, and we found occasional preperiod event study coefficients diverging from the mean, but the outcome trends were generally similar between the expansion and nonexpansion states in the preperiod, satisfying the necessary assumption for the difference-in-difference analysis. In a basic difference-in-difference model, the Medicaid expansion in January 2014 was associated with significant increases in insurance at diagnosis, treatment at an academic facility, and treatment within 30 days of diagnosis (P<.001 for all). In an adjusted model including all states and accounting for variable expansion implementation time, there was a significant treatment effect of Medicaid expansion on the reduction in uninsurance at diagnosis (-2.00%; 95% confidence interval, -2.3 to -1.7; P<.001), increases in early-stage diagnosis (0.80%; 95% confidence interval, 0.2-1.4; P=.02), treatment at an academic facility (0.83%; 95% confidence interval, 0.1-1.5; P=.02), treatment within 30 days (1.62%; 95% confidence interval, 1.0-2.3; P<.001), and surgery within 30 days (1.54%; 95% confidence interval, 0.8-2.3; P<.001). In particular, large gains were estimated for women living in low-income zip codes, Hispanic women, and women with cervical cancer. Estimates from the subgroup and propensity-matched cohorts were generally consistent for all outcomes besides early-stage diagnosis and treatment within 30 days.

CONCLUSION

Medicaid expansion was significantly associated with gains in the access and timeliness of treatment for nonelderly women with gynecologic cancer. The implementation of Medicaid expansion could greatly benefit women in nonexpansion states. Gynecologists and gynecologic oncologists should advocate for Medicaid expansion as a means of improving outcomes and reducing socioeconomic and racial disparities.

Palliative Radiation Therapy for Metastatic, Persistent, or Recurrent Epithelial Ovarian Cancer: Efficacy in the Era of Modern Technology and Targeted Agents

PURPOSE

Metastatic, persistent, or recurrent epithelial ovarian cancer (MPR-EOC) remains a significant threat to patient mortality despite advances in novel targeted agents. Radiation therapy (RT) is often used as a palliative option. We report outcomes of a large series of MPR-EOC patients treated with modern palliative RT (PRT) in an era of novel systemic therapies.

METHODS AND MATERIALS

A retrospective review was conducted of women treated with PRT for MPR-EOC between 2007 and 2019 at an academic institution. Clinical response rates were recorded at <1 month, 1 to 3 months, and >3 months. Radiographic responses were categorized by RECIST 1.1 criteria. Overall response rate (ORR) was the sum of complete and partial response. Linear regression analyses of baseline characteristics were conducted for statistical testing.

RESULTS

Eighty-six patients with PMR-OC received 120 courses of palliative RT. Median follow-up was 8.6 months. Median age was 61 (range, 22-82). Thirty-six percent of women received central nervous system (CNS)-directed RT. In addition, 43% received targeted therapies before RT. Clinical ORR within 1 month and at last follow-up for non-CNS lesions was 79% and 61% (69% and 88% for CNS lesions, respectively). High-grade serous lesions were more likely to have clinical response (P = .04). Biologically effective doses (BED) >39 Gy were associated with improved clinical response in CNS lesions (P = .049). Bony sites were associated with worse clinical (P = .004) response in non-CNS lesions compared with soft tissue or nodal sites. Acute or late grade 3+ toxicities with bevacizumab were low (8.7%/4.3%).

CONCLUSIONS

PRT offers excellent rates of response for symptomatic patients with MPR-EOC within 1 month of treatment, with durable responses beyond 3 months. High-grade serous lesions were associated with improved response in all patients. Higher BED and soft tissue or nodal sites were associated with improved response in CNS and non-CNS patients, respectively. Acute or late toxicities with bevacizumab and PRT were low. Prospective investigation is warranted to determine the optimal PRT regimen.

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer

OBJECTIVE

A retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomy METHODS: Patients diagnosed between January 2012 and December 2015 with vulvar squamous cell carcinoma of less than 4 cm in size, with invasion of at least 1 mm, who underwent sentinel lymph node biopsy, lymphadenectomy, or both were identified from the National Cancer Database. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test for patients who had at least 1 month of follow-up. A Cox model was constructed to control for confounders.

RESULTS

A total of 1583 patients were identified; 304 patients (19.2%) underwent sentinel lymph node biopsy alone. Sentinel lymph node biopsy utilization increased 13.9% between 2012 and 2015. Patients who underwent sentinel node biopsy alone were less likely to have comorbidities compared with those undergoing lymphadenectomy only or sentinel node biopsy with lymphadenectomy (25.3% vs 32.9% vs 31.9%, p=0.042), had smaller tumors (median 1.6 vs 2.0 vs 2.0 cm, p<0.001), and were less likely to have positive lymph nodes (11% vs 19.6% vs 28.1%, p<0.001). There was no difference in 3 year overall survival between the three groups (86.3% vs 82.1% vs 77.9%, p=0.26). After controlling for age, race, insurance, comorbidities, lymph node metastases, and tumor size, sentinel lymph node biopsy alone was not associated with worse overall survival compared with lymphadenectomy (HR 0.86, 95% CI 0.57 to 1.32). The sentinel node only group had shorter inpatient stays compared with lymphadenectomy only (median 1 vs 2 days, p<0.001) and a lower rate of unplanned readmission (1.7% vs 5.0%, p=0.010).

CONCLUSIONS

The utilization of sentinel lymph node biopsy is increasing in the management of vulvar cancer and is associated with superior perioperative outcomes without impacting overall survival.

Emergency department utilization by patients with gynecologic cancer in the United States

INTRODUCTION

Payment reform will give oncologists increasing responsibility for how patients with cancer meet unexpected care needs.

OBJECTIVE

To differentiate how patients with gynecologic cancers use emergency care, and to assess the characteristics associated with potentially avoidable treat-and-release visits.

METHODS

We performed a retrospective cohort study using the Nationwide Emergency Department Sample, a stratified sample of visits in United States hospital-based emergency departments, from 2010 to 2014. Visits by patients with a diagnosis of gynecologic cancer were selected. Sample weights were applied to calculate national estimates of care patterns and trends. Associations with treat-and-release disposition were assessed with weighted logistic regression.

RESULTS

In the study period, patients with gynecologic cancer made an estimated 370 104 annual emergency department visits (95% CI 351 997 to 388 211). A total of 50.2% of patients were treated and released, 48% were admitted, 1.6% were transferred, and 0.1% died. These visits corresponded to over US$1.27 billion in annual charges, with an average charge of US$3428 per visit (95% CI 3348 to 3509). Driven by growing treat-and-release utilization, annual visits increased, while admission rates fell over time. Patients with cervical cancer represented the plurality (36%) of visits; they were relatively younger, of lower socioeconomic status, and had fewer co-morbidities. Models for treat-and-release disposition did not vary significantly across different cancer populations. In the all-cancer model, increased odds of treat-and-release disposition was associated with cervical cancer diagnosis, younger age, lesser Elixhauser co-morbidity, Medicare coverage (OR=1.19; p<0.001), Medicaid coverage (OR=1.25; p<0.001), uninsured status (OR=1.70; p<0.001), and weekend visits. Visits in the northeast, at urban hospitals, and in winter months showed decreased odds of treat-and-release disposition.

DISCUSSION

Patients with gynecologic cancers have been using the emergency department at increasing rates, primarily driven by treat-and-release visits that did not result in admission or death. Patients with cervical cancer have higher rates of treat-and-release utilization and may over-use emergency department care.

Adjuvant treatment for patients with FIGO stage I uterine serous carcinoma confined to the endometrium

Objectives

The role of adjuvant treatment for early-stage uterine serous carcinoma is not defined. The goal of this study was to investigate the impact of adjuvant treatment on survival of patients with tumors confined to the endometrium.

Methods

Patients diagnosed with stage I uterine serous carcinoma with no myometrial invasion between January 2004 and December 2015 who underwent hysterectomy with at least 10 lymph nodes removed were identified from the National Cancer Database. Adjuvant treatment patterns defined as receipt of chemotherapy and/or radiotherapy within 6 months from surgery were investigated and overall survival was evaluated using Kaplan–Meier curves, and compared with the log-rank test for patients with at least one month of follow-up. A Cox analysis was performed to control for confounders.

Results

A total of 1709 patients were identified; 833 (48.7%) did not receive adjuvant treatment, 348 (20.4%) received both chemotherapy and radiotherapy, 353 (20.7%) received chemotherapy only, and 175 (10.2%) received radiotherapy only. Five-year overall survival rates for patients who did not receive adjuvant treatment (n=736) was 81.9%, compared with 91.3% for those who had chemoradiation (n=293), 85.1% for those who received radiotherapy only (n=143), and 91.0% for those who received chemotherapy only (n=298) (p<0.001). After controlling for age, insurance status, type of treatment facility, tumor size, co-morbidities, and history of another tumor, patients who received adjuvant chemotherapy (HR 0.64, 95% CI 0.42, 0.96), or chemoradiation (HR 0.55, 95% CI 0.35, 0.88) had better survival compared with those who did not receive any adjuvant treatment, while there was no benefit from radiotherapy alone (HR 0.85, 95% CI 0.53, 1.37). There was no survival difference between chemoradiation and chemotherapy only (HR 1.15, 95% CI 0.65, 2.01).

Conclusion

Adjuvant chemotherapy (with or without radiotherapy) is associated with a survival benefit for uterine serous carcinoma confined to the endometrium.

Performance of lymphadenectomy for apparent early stage malignant ovarian germ cell tumors in the era of platinum-based chemotherapy

OBJECTIVES

To investigate the patterns of use and impact of lymphadenectomy (LND) on overall survival (OS) of patients with apparent early stage malignant ovarian germ cell tumors (MOGCTs).

METHODS

Patients with apparent stage I MOGCT diagnosed between 2004 and 2015 were drawn from the National Cancer Database. The performance of LND was assessed from the pathology report. OS was evaluated using Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for confounders.

RESULTS

A total of 2774 patients were identified; 1426 (51.4%) underwent LND. The median number of lymph nodes (LN) removed was 9 (range 1-81); 48.3% of patients had at least 10 lymph nodes removed. The rate of regional lymph node metastasis was 10.3% (147 patients). There was no difference in OS, between patients who did (n = 1287) and did not (n = 1210) undergo LND, p = 0.81; 5-yr OS rates were 96.5% and 97.6% respectively. After controlling for patient age, insurance status, histology, presence of medical comorbidities, and receipt of chemotherapy, the performance of LND was not associated with better survival (HR: 1.33, 95% CI: 0.82, 2.14).

CONCLUSIONS

While LN metastasis is common in apparent early stage MOGCTs, the performance of LND was not associated with a survival benefit.

Advanced stage primary mucinous ovarian carcinoma. Where do we stand ?

OBJECTIVE

To evaluate factors associated with survival of patients with advanced stage mucinous ovarian carcinoma (MOC) using a large multi-institutional database.

METHODS

Patients diagnosed between 2004 and 2014 with advanced stage (III-IV) MOC were identified within the National Cancer Database. Those without a personal history of another primary tumor who received cancer-directed surgery with a curative intent were selected for further analysis. Overall survival (OS) was evaluated with Kaplan-Meier curves, and compared with the log-rank test. Multivariate Cox analysis was performed to identify independent predictors of survival.

RESULTS

A total of 1509 patients with a median age of 59 years (IQR 20) met the inclusion criteria: stage III (n = 1045, 69.3%) and stage IV disease (n = 464, 30.7%). Patients who received chemotherapy (n = 1065, 70.6%) had better OS compared to those who did not (n = 385, 25.5%), (median OS 15.44 vs 5.06 months, p < 0.001). The type of reporting facility (p = 0.65) and the year of diagnosis (p = 0.27) were not associated with OS. Presence of residual disease was strongly associated with OS (p < 0.001). After controlling for confounders, the administration of chemotherapy (HR 0.63, 95% CI 0.55, 0.72) was associated with better survival.

CONCLUSION

Advanced stage MOC has an extremely poor prognosis. Patients who received chemotherapy had a small improvement in survival. Every effort to achieve complete gross resection should be performed. Given no improvement in survival outcomes over time, there is an eminent need for novel treatment options.

Surgical and oncologic outcomes of minimally invasive surgery for stage I high-grade endometrial cancer

OBJECTIVE

To evaluate the prevalence and outcomes of minimally invasive surgery for stage I high grade endometrial cancer. We hypothesized that route of surgery is not associated with survival.

MATERIALS

Patients diagnosed between 2010 and 2014, with stage I grade 3 endometrioid, serous, clear cell and carcinosarcoma endometrial carcinoma, who underwent hysterectomy with lymphadenectomy were drawn from the National Cancer Database. Patients converted to open surgery were excluded. Overall survival was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.

RESULTS

A total of 12852 patients were identified. The rate of minimally invasive surgery was 62.2%. An increase in the use between 2010 and 2014 was noted (p < 0.001). Open surgery was associated with longer hospital stay (median 3 vs 1 day, p < 0.001), higher 30-day unplanned re-admission rate (4.5% vs 2.4%, p < 0.001) and 30-day mortality (0.6% vs 0.3%, p = 0.008). There was no difference in overall survival between patients who had open or minimally invasive surgery, p = 0.22; 3-yr overall survival rates were 83.7% and 84.4% respectively. After controlling for patient age, tumor histology, substage, type of insurance, type of reporting facility, receipt of radiation therapy and chemotherapy, extent of lymphadenectomy, the presence of comorbidities and personal history of another tumor, minimally invasive surgery was not associated with a worse survival (hazard ratio: 1.06, 95% confidence interval: 0.97, 1.15).

CONCLUSIONS

Minimally invasive surgery for patients with stage I high grade endometrial cancer, was associated with superior short-term outcomes with no difference in overall survival noted.

Trends in the surgical management of malignant ovarian germcell tumors

OBJECTIVE

To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests.

RESULTS

A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p > 0.05).

CONCLUSIONS

Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.

Adjuvant chemotherapy for early stage endometrioid ovarian carcinoma: An analysis of the National Cancer Data Base

INTRODUCTION

The benefit of adjuvant chemotherapy for Stage IC grade 1 and stage IA/IB grade 2 endometrioid ovarian adenocarcinoma (EOOC) remains unclear as the NCCN guidelines recommend either observation only or adjuvant chemotherapy. Therefore, we sought to determine whether patients with stage I EOOC had improved overall survival (OS) following receipt of adjuvant chemotherapy.

METHODS

Patients with pathological stage I ovarian endometrioid adenocarcinoma diagnosed between 2004 and 2014 were identified from the National Cancer Database. Demographics, pathologic factors including tumor grade, and treatment information including receipt of adjuvant chemotherapy were collected. The impact of chemotherapy on OS was evaluated with Kaplan-Meier curves, and compared with log-rank tests. Multivariate Cox analysis was performed to control for confounders.

RESULTS

A total of 4538 patients were identified and the median age was 55 years The rate of adjuvant chemotherapy use was 50.9%. Higher rates were noted among patients with stage IC and grade 3 tumors. Following stratification by tumor grade, substage and extent of lymphadenectomy, adjuvant chemotherapy was associated with a survival benefit for patients with grade 2 tumors who did not undergo (stage IA/IB: 95.7% vs 83%, p = 0.038; stage IC: 84.5% vs 84.8%, p = 0.39) or had limited lymphadenectomy (stage IA/IB: 96% vs 89.5%, p = 0.03; stage IC: 97.2% vs 83.9%, p = 0.001). A survival difference was also seen for patients with grade 3 tumors who did not undergo lymphadenectomy but did not reach statistical significance.

CONCLUSION

Adjuvant chemotherapy was associated with an overall survival benefit for patients with inadequately-staged, grade 2 stage I ovarian endometrioid adenocarcinoma. A possible benefit for inadequately-staged patients with grade 3 tumors cannot be excluded.

Increased Risk of Breast and Uterine Cancer Among Women With Ovarian Granulosa Cell Tumors

BACKGROUND/AIM

We evaluated the incidence of uterine and breast cancer among women diagnosed with granulosa cell tumors (GCTs) of the ovary.

PATIENTS AND METHODS

The US Surveillance, Epidemiology, and End Results (SEER) database was accessed and patients diagnosed with a GCT and had a known follow-up between 1973-2014 were identified. Personal tumor history was extracted and patients with a previous or subsequent malignant breast or uterine tumor were identified. The expected incidence of breast and uterine cancer was calculated based on the U.S age-specific rate of breast and uterine cancer per 100,000 women. Standardized incidence ratio (SIR) with 95% confidence intervals (95% CI) were calculated for each tumor.

RESULTS

A total of 1908 cases of GCT were identified. Seventy- nine (4.14%) and 53 (2.78%) patients were diagnosed with a malignant breast and uterine malignancy. The cumulative expected number of malignant breast and uterine tumors was 27 (1.41%) and 6 (0.31%), respectively. The calculated SIR for breast and uterine malignancies was 2.96 (95%CI=2.34, 3.68) and 8.83 (95%CI=6.61, 11.56), respectively.

CONCLUSION

An increased incidence of breast and uterine malignancies among patients diagnosed with GCTs was observed.

Prognostic significance of elevated pre-treatment serum CA-125 levels in patients with stage I ovarian sex cord-stromal tumors

OBJECTIVE

To investigate the prognostic significance of elevated pre-operative serum CA-125 values for patients with early stage ovarian sex cord - stromal tumors (SCSTs).

METHODS

Patients diagnosed between 2004 and 2015 with a SCST were drawn from the U.S National Cancer Database. Those with stage I disease, and normal or elevated CA-125 values were selected for further analysis. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 with Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for known confounders.

RESULTS

A total of 1156 patients met the inclusion criteria; 486 (42%) had elevated pre-treatment CA-125 values. Patients with elevated pre-treatment CA-125 (n = 417) had worse OS compared to those with normal values (n = 588), p < 0.001 from log-rank test; 5-yr OS rates were 86.8% and 94.8% respectively. After controlling for patient age (<50 vs > = 50 yrs), the presence of medical co-morbidities, tumor histology (granulosa vs non-granulosa), size (<10 vs > = 10 cm vs unknown) and the performance of lymphadenectomy, elevated pre-treatment CA-125 levels were associated with a worse survival (HR: 1.80, 95% CI: 1.15, 2.82, p = 0.01).

CONCLUSIONS

In a large cohort of patients with early stage SCSTs elevated preoperative CA-125 levels were associated with worse survival.

Treat-and-Release Emergency Department Utilization by Patients With Gynecologic Cancers

PURPOSE:

Seventeen percent of patients with cancer visit the emergency department (ED) annually, often with nonemergent complaints. We sought to describe the burden of treat-and-release ED utilization by patients with gynecologic cancers and to identify opportunities for improved triage.

MATERIALS AND METHODS:

Patients with gynecologic cancer diagnoses who were treated and released were identified within the Nationwide Emergency Department Sample, a stratified sample of US hospital-based ED visits, from 2009 to 2013. Sample weights were applied to generate national estimates. Associations with visit charges were assessed with weighted multivariable linear regression.

RESULTS:

Between 2009 and 2013, there were an estimated 174,092 annual treat-and-release ED visits by patients with gynecologic cancer (95% CI, 163,480 to 184,703 visits), which corresponded to $736 million in annual charges with an average visit charge of $4,232 (95% CI, $4,099 to $4,366). Annual visits and total charges increased significantly over the 5 years under study. Visits were more frequent for patients with cervical cancer (44.1%) versus ovarian (27.8%) and uterine (24.6%) cancer. These patients were younger and more likely to be from low socioeconomic status areas. The most common primary diagnoses were similar across cancers, including abdominal pain (10.5%), chest pain (6.1%), and urinary tract infection (5.2%). The most frequent diagnostics were culture/smear, computed tomography scan, and x-ray, and the most frequent therapeutic procedures included wound care, transfusion, and paracentesis.

CONCLUSION:

Patients with gynecologic cancers, and cervical cancer in particular, are frequently seen in the ED with issues that could be less expensively managed in an outpatient clinic or urgent care setting. Visit frequency, but not per-visit cost, is increasing over time.

Role of adjuvant chemotherapy in the management of stage IC ovarian granulosa cell tumors

Objective

The aim of the present study was to investigate the patterns of use and prognostic significance of adjuvant chemotherapy (CT) for patients with stage IC ovarian granulosa cell tumors (GCTs).

Methods

We identified patients with stage IC GCTs diagnosed between 2004 and 2015 in the National Cancer Data Base (NCDB). Logistic regression was performed to identify variables independently associated with chemotherapy administration. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for known confounders.

Results

A total of 492 patients with stage IC GCTs were identified, of which 166 (33.7%) received CT. Tumor size > = 10 cm (OR: 1.85, 95% CI: 1.21, 2.82) was independently associated with the administration of CT. There was no difference in OS between patients who did (n = 145) and did not (n = 282) receive CT, p = 0.52; 5-yr OS rates were 93.7% and 91.6% respectively. After controlling for patient age (<50 vs ≥50 years), tumor size and performance of lymphadenectomy (LND), the administration of CT was not associated with a survival benefit (HR: 1.07, 95% CI: 0.52, 2.21).

Conclusions

Approximately one in three patients with stage IC GCTs received CT in the NCDB, however CT was not associated with a survival benefit.

Isolated distant lymph node metastases in ovarian cancer. Should a new substage be created?

Objective

To evaluate the prognostic significance of isolated distant lymph node metastases in comparison to other metastatic sites and stage IIIC disease.

Methods

The National Cancer Data Base was accessed and patients diagnosed between 2004 and 2014 with stage IV or IIIC epithelial ovarian cancer who met criteria for pathological staging were identified. Overall survival (OS) was calculated with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.

Results

A total of 33,561 patients met the inclusion criteria; 582 (1.7%) had stage IV only due to distant lymph node metastases (stage IV-LN), 8130 (24.2%) had stage IV with other sites of distant metastases (stage IV-other) and 24,849 (75.4%) had stage IIIC disease. The median OS for patients with stage IV-LN was 42.41 months (95% CI: 37.59, 47.23) compared to 30.23 months (95% CI: 29.30, 31.16) for those with stage IV-other (p < .001) and 45.57 (95% CI: 44.86, 46.28) for those with stage IIIC disease (p = .54). On multivariate analysis, patients with stage IV-other had a worse survival (HR: 1.41, 95% CI: 1.27, 1.57) compared to those with stage IV-LN. There was no statistically significant difference in survival between patients with stage IV-LN and stage IIIC disease (HR: 1.00, CI: 0.90, 1.11, p = .99).

Conclusions

Isolated distant LN metastases is associated with better survival compared to stage IV disease due to other metastatic sites and comparable to patients with stage IIIC disease.

•

Stage IV due to isolated distant lymph node metastasis is rare.

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These patients had better survival compared to those with stage IV disease due to other metastases.

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Their survival was comparable to patients with stage IIIC disease.

Adjuvant therapy in early-stage endometrial cancer: a systematic review of the evidence, guidelines, and clinical practice in the U.S

Endometrial cancer is the most common gynecologic malignancy in the U.S., with an increasing incidence likely secondary to the obesity epidemic. Surgery is usually the primary treatment for early stage endometrial cancer, followed by adjuvant therapy in selected cases. This includes radiation therapy [RT] with or without chemotherapy, based on stratification of patients into categories dependent on their future recurrence risk. Several prospective trials (PORTEC-1, GOG#99, and PORTEC-2) have shown that the use of adjuvant RT in the intermediate risk (IR) and the high-intermediate risk (HIR) groups decreases locoregional recurrence (LRR) but has no effect on overall survival. The ad hoc analyses from these studies have shown that an even larger LRR risk reduction was seen within the HIR group compared with the IR group. Vaginal brachytherapy is as good as external beam radiotherapy in controlling vaginal relapse where the majority of recurrence occur, and with less toxicity. In the high-risk group, multimodality therapy (chemotherapy and RT) may play a significant role. Although adjuvant RT has been evaluated in many cost-effectiveness studies, high-quality data in this area are still lacking. The uptake of the above prospective trial results in the U.S. has not been promising. Factors that are driving current practices and defining quality-of-care measures for patients with early-stage disease are what future studies need to address.

Liposome as an adjuvant for the production of estradiol antibodies

Mice immunized with liposome associated estradiol-bovine serum albumin conjugate (E2-BSA) showed a significantly higher estradiol-specific immune response than did mice injected with the free conjugate. The conjugation of estradiol with BSA is imperative, since injection of liposomes with estradiol in the lipid bilayer was found to be ineffective in inducing an immune response. Entrapment of E2-BSA in neutral and positively charged liposomes was found to be a potent mode of immunostimulation, even better than emulsification in complete Freund's adjuvant (CFA). Covalent liposome surface association of E2-BSA induced a good immunopotentiation. However, the response was lower than that observed with the entrapped conjugate. The affinity and the specificity of antisera, raised in different ways, were determined.

The effect of surface-coupled antigen of liposomes in immunopotentiation

The effect of surface coupled antigens of liposomes on the immunological response has been investigated. Lysozyme was covalently coupled to neutral and positively charged liposomes using glutaraldehyde. Subcutaneous administration of these preparations stimulated a significant antibody response higher than that elicited by the antigen entrapped in neutral liposomes. Immunization by liposomal antigens together with complete Freund's adjuvant resulted in strong immune responses, highest with the antigen coupled to neutral and positively charged liposomes followed by the antigen entrapped in neutral liposomes. Primary and secondary immunization with lysozyme, both entrapped and coupled to liposomes, evoked an IgG response.