Molecular landscape of ERBB2/HER2 gene amplification among patients with gynecologic malignancies; clinical implications and future directions

OBJECTIVE

Investigate the prevalence of ERBB2/HER2 gene amplification among patients with gynecologic malignancies.

METHODS

The American Association of Cancer Research (AACR) Genomics Evidence of Neoplasia Information Exchange (GENIE) (version 13.1) database was accessed and patients with endometrial, ovarian, and cervical cancer were identified. Patients with available data on the presence of copy-number gene alterations were selected for further analysis. Incidence of ERBB2 amplification following stratification by tumor site and histology was evaluated. Data from the OncoKB database, as provided by cBioPortal, was utilized to determine presence of pathogenic genomic alterations.

RESULTS

A total of 6961 patients who met the inclusion criteria were identified: 49.1% with ovarian cancer, 45.2% with endometrial cancer and 5.7% with cervical cancer respectively. Overall incidence of ERBB2 amplification was 3.8%. Highest incidence of ERBB2 amplification was observed among patients with mucinous ovarian (14.4%), uterine serous (13.2%), uterine clear cell (9.4%), and uterine carcinosarcoma (7.9%). ERBB2 amplification was rare among patients with TP53 wild-type endometrioid endometrial cancer (0.4%). High incidence of mutations in genes of the PI3K pathway was observed among patients with ERBB2 amplified tumors.

CONCLUSION

ERBB2 amplification is frequently encountered among patients with uterine serous carcinoma, and mucinous ovarian carcinoma. In addition, a high incidence was also observed among those with uterine clear cell carcinoma, and uterine carcinosarcoma. For patients with endometrioid endometrial carcinoma, incidence of ERBB2 amplification is low, especially in the absence of TP53 mutations.

Impact of adjuvant chemotherapy on the overall survival of patients with advanced-stage low-grade serous ovarian carcinoma following primary cytoreductive surgery

OBJECTIVE

To investigate the use and outcomes of adjuvant chemotherapy for patients with advanced-stage low-grade serous ovarian carcinoma following primary cytoreductive surgery.

METHODS

Patients diagnosed between 2010 and 2015 with International Federation of Gynecology and Obstetrics stage II-IV low-grade serous ovarian carcinoma who underwent primary debulking surgery with known residual disease status and had at least 1 month of follow-up were identified in the National Cancer Database. Adjuvant chemotherapy was defined as receipt of chemotherapy within 6 months of surgery. Overall survival was evaluated using the Kaplan-Meier method and compared with the log-rank test. A Cox model was constructed to control for a priori-selected confounders. A systematic review of the literature was also performed.

RESULTS

In total, 618 patients with stage II-IV low-grade serous ovarian carcinoma who underwent primary cytoreductive surgery were identified; 501 (81.1%) patients received adjuvant chemotherapy, while 117 (18.9%) patients did not. The median follow-up of the present cohort was 47.97 months. There was no difference in overall survival between patients who did and did not receive adjuvant chemotherapy (p=0.78; 4-year overall survival rates were 77.5% and 76.1%, respectively). After controlling for patient age, medical co-morbidities, disease stage, and residual disease status, administration of adjuvant chemotherapy was not associated with better overall survival (HR=0.87, 95% CI 0.55 to 1.38). Based on data from three retrospective studies, omission of adjuvant chemotherapy following cytoreductive surgery was not associated with worse progression-free survival benefit (HR=1.25, 95% CI 0.80 to 1.95) for patients with stage III-V low-grade serous ovarian carcinoma.

CONCLUSIONS

Adjuvant chemotherapy may not be associated with an overall survival benefit for patients with advanced-stage low-grade serous ovarian carcinoma following primary cytoreductive surgery.

Role of immunotherapy for lymph node positive vulvar melanoma: utilization and outcomes

OBJECTIVE

To investigate the utilization and outcomes of adjuvant immunotherapy for patients with vulvar melanoma and inguinal lymph node metastases.

METHODS

The National Cancer Database was accessed and patients with vulvar melanoma diagnosed between 2004 and 2015 who did not have distant metastases, underwent inguinal lymphadenectomy, had positive lymph nodes, and at least 1 month of follow-up were identified. Administration of immunotherapy was evaluated and clinicopathological characteristics were compared. Median overall survival was compared with the log-rank test. Stratified analysis based on clinical status of lymph nodes was performed. A Cox model was constructed to evaluate survival after controlling for confounders.

RESULTS

A total of 300 patients were identified; the rate of immunotherapy use was 25% (75 patients). Patients who received immunotherapy were younger (median 58 vs 70 years, p<0.001); however, the two groups were comparable in terms of clinical lymph node status, rate of positive tumor margins, presence of tumor ulceration, tumor size, Breslow thickness, and performance of comprehensive lymphadenectomy. There was no overall survival difference between patients who did (median 31.08 months) and did not (median 22.77 months) receive immunotherapy (p=0.18). Following stratification by clinical lymph node status, immunotherapy did not improve overall survival of patients with clinically negative (median 35.35 vs 33.22, p=0.75) or positive lymph nodes (median 23.33 vs 16.99, p=0.64). After controlling for confounders, administration of immunotherapy was not associated with better overall survival (HR 0.81, 95% CI 0.57 to 1.14).

CONCLUSIONS

In this study approximately one in four patients received adjuvant immunotherapy. Immunotherapy was not associated with improved overall survival.

Combination ATR (ceralasertib) and PARP (olaparib) Inhibitor (CAPRI) Trial in Acquired PARP Inhibitor-Resistant Homologous Recombination-Deficient Ovarian Cancer

PURPOSE

Addition of ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) to PARP inhibitors (PARPi) overcomes PARPi resistance in high-grade serous ovarian cancer (HGSOC) cell and mouse models. We present the results of an investigator-initiated study of combination PARPi (olaparib) and ATRi (ceralasertib) in patients with acquired PARPi-resistant HGSOC.

PATIENTS AND METHODS

Eligible patients had recurrent, platinum-sensitive BRCA1/2 mutated or homologous recombination (HR)-deficient (HRD) HGSOC and clinically benefited from PARPi (response by imaging/CA-125 or duration of maintenance therapy; > 12 months first-line or > 6 months ≥ second-line) before progression. No intervening chemotherapy was permitted. Patients received olaparib 300 mg twice daily and ceralasertib 160 mg daily on days 1 to 7 of a 28-day cycle. Primary objectives were safety and objective response rate (ORR).

RESULTS

Thirteen patients enrolled were evaluable for safety and 12 for efficacy; 62% (n = 8) had germline BRCA1/2 mutations, 23% (n = 3) somatic BRCA1/2 mutations, and 15% (n = 2) tumors with positive HRD assay. Prior PARPi indication was treatment for recurrence (54%, n = 7), second-line maintenance (38%, n = 5) and first-line treatment with carboplatin/paclitaxel (8%, n = 1). There were 6 partial responses yielding an ORR of 50% (95% confidence interval, 0.15-0.72). Median treatment duration was 8 cycles (range 4-23+). Grade (G) 3/4 toxicities were 38% (n = 5); 15% (n = 2) G3 anemia, 23% (n = 3) G3 thrombocytopenia, 8% (n = 1) G4 neutropenia. Four patients required dose reductions. No patient discontinued treatment due to toxicity.

CONCLUSIONS

Combination olaparib and ceralasertib is tolerable and shows activity in HR-deficient platinum-sensitive recurrent HGSOC that benefited and then progressed with PARPi as the penultimate regimen. These data suggest that ceralasertib resensitizes PARPi-resistant HGSOCs to olaparib, warranting further investigation.

Awareness and Interest in Uterus Transplantation over Time: Analysis of Those Seeking Surgical Correction for Uterine-Factor Infertility in the US

This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.

Structural, molecular and functional characterization of the aorta in HCM

Introduction

Changes in the Extracellular Matrix (ECM) in Hypertrophic Cardiomyopathy (HCM) is thought to involve the myocardium as well as extracardiac tissues. The extent and significance of extra-myocardial changes has not been adequately studied.

Purpose

To describe the structural, molecular, and functional changes in the aorta of HOCM patients.

Methods

The structural and molecular changes in the aortic wall were studied in a cohort of 102 consecutive patients with hypertrophic obstructive cardiomyopathy undergoing myectomy. The biopsies were examined histologically, immunohistochemically and by Electron microscopy. The findings were compared to 10 normal controls obtained from the homograft bank of the Harefield hospital, following IRB guidelines. Changes in expression were quantified using morphometry and western blotting. For aortic stiffness, pulse wave velocity [PWV] was measured using Cardiac Magnetic Resonance (CMR), in the 102 HCM patients as well as age-matched 166 normal controls.

Results

Specimens from HCM aortas showed a misalignment in collagen and elastin fibres. There was a significant reduction in smooth muscle cells [SMCs] markers; integrin beta1 and smooth muscle actin, and an increase in an apoptosis marker, Caspase3. In addition, there was a significant decrease in the number of lamellae and an increase in the interlamellar distance in HCM aortas. FBLNs 1, 2 and 5 showed a reduction in expression in tunica intima and tunica media of HCM biopsies. PWV was significantly higher in HCM patients compared to healthy controls with the highest levels in patients with LV fibrosis.

Conclusion

This study illustrates the link between functional abnormalities in the aorta of HCM patients with structural and molecular changes. These findings can have a potential value in risk stratification and identify new therapeutic targets in HCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): STDF-EgyptMagdi Yacoub Foundation

The First 5 Years of Uterus Transplant in the US

Importance

Uterus transplant is a viable surgical treatment for women affected by absolute uterine-factor infertility, which affects 1 in 500 women.

Objective

To review transplant and birth outcomes of uterus transplant recipients in the US since the first case in 2016.

Design, Setting, and Participants

In this cohort study, 5 years of uterus transplant outcome data were collected from the 3 centers performing uterus transplants in the US: Baylor University Medical Center, Dallas, Texas; Cleveland Clinic, Cleveland, Ohio; and University of Pennsylvania, Philadelphia. A total of 33 women with absolute uterine-factor infertility who underwent uterus transplant between February 2016 and September 2021 were included.

Main Outcomes and Measures

Graft survival, live birth, and neonatal outcome.

Results

Of the 33 included uterus transplant recipients, 2 (6%) were Asian, 1 (3%) was Black, 1 (3%) was South Asian, and 29 (88%) were White; the mean (SD) age was 31 (4.7) years; and the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 24 (3.6). Most uterus transplant recipients (31 of 33 [94%]) had a congenitally absent uterus (Mayer-Rokitansky-Küster-Hauser syndrome), and 21 of 33 (64%) received organs from living donors. Mean (range) follow-up was 36 (1-67) months. There was no donor or recipient mortality. One-year graft survival was 74% (23 of 31 recipients). Through October 2021, 19 of 33 recipients (58%) had delivered 21 live-born children. Among recipients with a viable graft at 1 year, the proportion with a live-born child was 83% (19 of 23). The median (range) gestational age at birth of neonates was 36 weeks 6 days (30 weeks, 1 day to 38 weeks), and the median (range) birth weight was 2860 (1310-3940) g (median [range], 58th [6th-98th] percentile). No congenital malformations were detected.

Conclusions and Relevance

Uterus transplant is a surgical therapy that enables women with uterine-factor infertility to successfully gestate and deliver children. Aggregate data from US centers demonstrate safety for the recipient, living donor, and child. These data may be used to counsel women with uterine-factor infertility on treatment options.

Interdisciplinary Management of Extramammary Paget's Disease using Mohs Micrographic Surgery with Frozen Section Cytokeratin-7 Immunostains

OBJECTIVES

To describe local recurrence rates and patient reported outcomes when Mohs micrographic surgery with cytokeratin-7 immunostains (MMS-CK7) is included in the interdisciplinary management of extramammary Paget's Disease (EMPD).

METHODS

A retrospective study was conducted of EMPD treated with MMS-CK7 as part of an interdisciplinary team at an academic medical center between 2009 and 2016. Local recurrence rates and patient-reported outcomes were determined by record review and patient surveys.

RESULTS

Twenty tumors in 19 patients were treated using MMS-CK7. After MMS-CK7 defined clear microscopic margins, seventy-five percent (15/20) of tumors underwent excision or reconstruction by a surgical colleague. Internal malignancy screening was performed by multiple specialties in 17 patients, with one associated malignancy of prostate cancer detected. No local recurrence was detected with a mean follow-up of 75.2 months. Most patients were satisfied with appearance (18/19, 95%) and function (16/19, 84%) after surgery.

CONCLUSIONS

Interdisciplinary teams that include MMS-CK7 can treat EMPD with low local recurrence rates, high patient satisfaction, and thorough internal malignancy screening.

Simultaneous malignant hyperthermia reactions in two siblings during living donor liver transplantation

We report a case of simultaneous malignant hyperthermia reactions occurring in two siblings during living donor liver transplantation. This report highlights the conflicting goals in the clinical management of liver transplantation and malignant hyperthermia, including the use of total intravenous anaesthesia and dantrolene in the face of the potential for drug-induced hepatotoxicity in the remnant liver or transplanted liver graft, as well as cautious fluid management needed for liver transplantation balanced against the liberal fluid therapy required to prevent acute kidney injury associated with malignant hyperthermia. The logistical challenges of managing this emergency in two closely related patients are discussed, including rapid preparation of two vapour-free anaesthesia machines, the need for availability of additional dantrolene and the requirement for additional personnel. Prompt recognition, immediate removal of the triggering agents and conversion to total intravenous anaesthesia helped to curtail the malignant hyperthermic reactions in our patients, both of whom made a full recovery.

Patterns of adjuvant treatment and survival outcomes in stage I uterine carcinosarcoma

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5-year survival for stage I uterine carcinosarcoma without adjuvant therapy is 43%.

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Nationally 40% of stage I uterine carcinosarcoma do not receive adjuvant therapy.

•

Adjuvant chemotherapy alone improved OS and CSS in stage I uterine carcinosarcoma.

Objective

To determine patterns in type and sequence of adjuvant treatment and associated differences in overall survival among women with Stage I uterine carcinosarcoma (UCS).

Methods

Women with stage I UCS from 2000 to 2015 were identified through the National Cancer Institute’s Surveillance, Epidemiology and End Results database linked to Medicare-based claims follow-up data through 2016. Data including demographics, co-morbidities, surgical procedure, surgical pathology and type and sequence of adjuvant treatment were collected. The primary study outcome was overall survival (OS) by type and sequence of adjuvant therapy. Cancer specific survival was also analyzed.

Results

A total of 755 women with Stage I UCS were identified. Of these, 56.3% (n = 445) received adjuvant therapy, whereas 43.7% (n = 330) did not. In comparison to no adjuvant treatment, an overall survival benefit was noted with receipt of chemotherapy alone for women with Stage I disease (log rank p < 0.01). Pairwise comparisons did not show a benefit in OS of concurrent RT-chemo, sequential RT-chemo, or sequential chemo-RT, over chemotherapy alone (p > 0.05 for all). Likewise, radiation alone and no treatment were associated with worse OS compared to chemotherapy alone (p < 0.001 for both). Adjusted Cox regression models demonstrated an OS benefit only in the chemotherapy alone cohort for Stage I disease (HR 0.43 95% CI 0.32, 0.60, p < 0.0001), as well as for CSS (HR 0.41, 95 %CI 0.26, 0.62, p < 0.0001), compared to no treatment.

Conclusions

In comparison to no adjuvant therapy, an overall survival and cancer-specific survival benefit was noted with receipt of chemotherapy alone in Stage I UCS.

Disparities in Cancer-Specific and Overall Survival in Black Women with Endometrial Cancer: A Medicare-SEER Study

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This study uses a dataset made up of women with Medicare who underwent primary surgical staging for endometrial cancer.

•

Data analysis evaluated overall survival and cancer specific survival based upon race, stratified by stage and histology.

•

Black women diagnosed with stage I endometrial cancer have worse 5-year cancer specific survival than white women.

•

Disparities in cancer specific survival persists even when controlling for histology, demographics, and adjuvant therapy.

•

Future research and interventions should target surveillance, recurrence, and differences in tumor cell characteristics.

Objectives

To examine overall survival (OS) and cancer-specific survival (CSS) for different racial groups of women with surgically staged endometrial cancer by histologic subtype.

Methods

This is a retrospective cohort study of women with stage I-III endometrioid, serous, clear cell, and carcinosarcoma who underwent hysterectomy as primary surgical staging in the 2000–2016 SEER-Medicare database. OS and CSS outcomes were stratified by race (defined as White, Black, Other), stage, and histology. Survival was assessed with descriptive analyses, log-rank tests and unadjusted and adjusted multivariable cox regression models.

Results

Of the 24,142 women identified, 85.5% were White, 8.5% Black, and 6% other races. Receipt of adjuvant therapy differed only for stage III endometrioid: Black women were less likely to receive adjuvant treatment after hysterectomy (61.2% vs. 70.1% White, p = 0.03). For stage I, Black women had worse CSS for all histologies other than clear cell in unadjusted and adjusted analyses. For stage II, Black women had worse CSS for endometrioid histology in unadjusted analyses and similar OS. For stage III, Black women with endometrioid carcinoma had worse CSS and OS in unadjusted analyses, but no significant difference in CSS in adjusted analyses. “Other” race showed improved OS for Stage I endometrioid adenocarcinoma without significant differences in outcomes when compared to White women.

Conclusion

Across histologies other than clear cell, Black women diagnosed with stage I endometrial cancer had consistently worse CSS, despite similar receipt of adjuvant therapy. Differences in CSS and OS at higher stages disappeared once accounting for treatment disparities.

Combination ATR and PARP Inhibitor (CAPRI): A phase 2 study of ceralasertib plus olaparib in patients with recurrent, platinum-resistant epithelial ovarian cancer

OBJECTIVE

Platinum-resistant, high-grade serous ovarian cancer (HGSOC) has limited treatment options. Preclinical data suggest that poly(ADP-ribose) polymerase inhibitors (PARPi) and ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) are synergistic. CAPRI (NCT03462342) is an investigator-initiated study of olaparib plus ceralasertib in recurrent HGSOC. Herein, we present results from the platinum-resistant cohort.

METHODS

A Simon 2-stage design was utilized. Platinum-resistant HGSOC patients received ceralasertib 160 mg orally daily, days 1-7 and olaparib 300 mg orally twice daily, days 1-28 of a 28-day cycle until toxicity or progression. Primary endpoints were toxicity and efficacy including objective response rate (ORR) by RECIST. Secondary endpoint was progression-free survival (PFS). The null hypothesis (≤5% ORR) would be rejected if there were ≥ 1 responses in 12 patients.

RESULTS

Fourteen PARPi-naïve patients were evaluable for toxicity; 12 were evaluable for response. Three had BRCA1 mutations (1 germline, 2 somatic). Adverse events possibly related to treatment were primarily grade (G) 1/2. G3 toxicities included nausea (14.3%), fatigue (7.1%), anorexia (7.1%), and anemia (7.1%). No objective responses occurred. Best response was stable disease in 9 patients and progressive disease in three. Five patients had a ≥ 20% to <30% reduction in disease burden, including 3 with BRCA1 mutations. Three of 11 patients (27%; 2 with BRCA1 mutations) evaluable by Gynecologic Cancer Intergroup criteria had >50% CA-125 decline, including 2 with CA-125 normalization. Median PFS was 4.2 months overall (90% CI:3.5-8.2) and 8.2 months (3.6 months-not determined) for patients with BRCA1 mutations.

CONCLUSIONS

Olaparib plus ceralasertib is well-tolerated. No objective responses occurred, though a signal of activity was seen particularly in disease associated with BRCA1. Further evaluation of this combination should include alternate dosing strategies in genomically-selected populations.

Impact of surgical approach on prevalence of positive peritoneal cytology and lymph-vascular invasion in patients with early-stage endometrial carcinoma: a National Cancer Database study

OBJECTIVE

To investigate the prevalence of positive peritoneal cytology and lymph-vascular invasion by surgical approach among patients with early stage endometrioid endometrial carcinoma undergoing hysterectomy.

METHODS

The National Cancer Database was accessed and patients with FIGO stage I endometrioid endometrial carcinoma (with no history of another tumor diagnosed) who underwent simple hysterectomy (open or minimally invasive) between January 2010 and December 2015 and had available data on the presence of lymph-vascular invasion and/or status of peritoneal cytology were selected for further analysis. The impact of a surgical approach on the odds of lymph-vascular invasion and positive peritoneal cytology was calculated after controlling for tumor grade, size, and depth of myometrial invasion.

RESULTS

A total of 74 732 patients who met the inclusion criteria were identified. The rate of minimally invasive hysterectomy was 75.7%. Data on peritoneal cytology status and lymph-vascular invasion were available for 50 185 and 71 641 patients, respectively. A higher proportion of patients who had minimally invasive hysterectomy had positive peritoneal cytology (4.4% vs 2.3%, p<0.001), and presence of lymph-vascular invasion (10.4% vs 9.2%, p<0.001). After controlling for tumor size, tumor grade, and disease substage, the performance of minimally invasive surgery was associated with higher odds of positive peritoneal cytology (OR 2.08, 95% CI 1.83 to 2.37) and presence of lymph-vascular invasion (OR 1.33, 95% CI 1.25 to 1.41). After controlling for confounders there was no difference in survival between open and minimally invasive surgery groups (HR 0.93, 95% CI 0.85 to 1.004).

CONCLUSIONS

Minimally invasive surgery may be associated with a higher incidence of positive peritoneal cytology and lymph-vascular invasion among patients with early stage endometrioid endometrial cancer. There was no difference in overall survival between patients who had laparotomy or minimally invasive surgery.

Lymphadenectomy is associated with an increased risk of postoperative venous thromboembolism in early stage endometrial cancer

OBJECTIVES

In patients undergoing surgery for early stage endometrial cancer, we sought to evaluate the effect of lymphadenectomy (LND), as well as surgical route, on the risk of postoperative venous thromboembolism (VTE).

METHODS

The Surveillance, Epidemiology, and End Results cancer registries (2000-2013) linked to Medicare claims follow up from 1999 to 2014 was accessed to identify those with stage I-II endometrioid endometrial cancer who underwent hysterectomy. Performance of LND, 90-day incidence of postoperative VTE, open vs minimally invasive surgery (MIS), demographics, comorbidities, grade, and stage were collected. A washout period of 12 months with no prior VTE was required. t-test, Chi square test, univariate and multivariable Poisson regression with robust variance estimator were used.

RESULTS

A total of 15,101 patients had hysterectomy for early stage endometrial cancer. LND was performed in 9004 (60%) patients. VTE was found in 486 patients. There were 346 VTEs (3.8%) in the LND group vs 140 (2.3%) in those without LND (RR = 1.67, p < 0.0001). Adjusting for age, stage, grade, comorbidities and surgical approach, LND remained a significant risk for VTE (RR = 1.7, p < 0.001). In those who underwent MIS, LND was associated with a two-fold increase in the risk of VTE (p = 0.0008) (adjusted RR = 1.99, p = 0.0014) and had a statistically comparable rate of VTE when compared to the open surgical approach (p = 0.054).

CONCLUSIONS

LND is associated with an increased 90-day risk of postoperative VTE in patients undergoing surgery for early stage endometrial cancer. The need for extended postoperative VTE prophylaxis in patients undergoing LND via MIS needs further exploration.

Lymphadenectomy for early-stage mucinous ovarian carcinoma

OBJECTIVES

There is evidence to suggest that the rate of lymph node metastases in patients with ovarian mucinous tumors is rare. The objective of this study was to investigate the prevalence of regional lymph node metastases among patients with apparent stage IA and IC mucinous ovarian carcinoma.

METHODS

A retrospective cohort study was performed and included patients from the National Cancer Database with apparent stage IA and IC mucinous ovarian tumors who underwent surgery between January 1, 2004 and December 31, 2015. Data collected included demographics, surgical procedures, and pathologic characteristics. The primary outcome was the effect of tumor stage, grade, and size on the risk of lymph node metastases. Categorical and continuous variables were compared using the χ² and Mann-Whitney U tests, respectively.

RESULTS

A total of 4379 patients were identified: 3088 and 1213 with stage IA and IC disease, respectively, with an additional 78 patients who were stage I Not Otherwise Specified (NOS). Lymphadenectomy was performed in 70.6% of patients with stage IA and 70.3% of patients with stage IC cancers. Stratifying by grade, 68.4%, 71.3%, and 72.8% of patients with grades 1, 2, and 3 tumors underwent a lymphadenectomy, respectively. Furthermore, lymphadenectomy was performed in 64.9% of patients with tumors <10 cm and 72.4% with tumors >10 cm. Lymph node metastases were identified in 1.2% and 1.6% of patients with stage IA and IC disease, respectively (p=0.063). Additionally, metastases were present in 0.6% of patients with grade 1 tumors, 1.1% of patients with grade 2 tumors, and 5.3% of patients with grade 3 tumors (p<0.001). Lastly, 0.9% of patients with tumors <10 cm and 1.4% of patients with tumors >10 cm had lymph node metastases (p=0.19).

CONCLUSIONS

Among patients with mucinous ovarian carcinoma, lymph node metastases are rare. However, metastases are significantly more common in patients with higher grade tumors. These factors may be considered when making decisions regarding the need for lymphadenectomy in early-stage mucinous ovarian tumors.

Abstract A72: Combination ATR and PARP inhibitor (CAPRI) for recurrent, platinum-resistant ovarian cancer

Background: Platinum-resistant (PR) ovarian cancer (OC) is a lethal disease for which effective therapies are limited. Preclinical data suggest that inhibitors of poly(ADP-ribose) polymerase (PARP) and ataxia telangiectasia and Rad3-related kinase (ATR) have synergistic antitumor activity in these tumors. We hypothesize that targeting two unique DNA repair pathways with combination therapy may increase response rates, durability of response, and lower off-target toxicities compared to standard treatments. This clinical trial examines PARP and ATR inhibition (PARPi-ATRi) in patients (pts) with recurrent OC (NCT03462342). Data from the PR arm of this trial are presented.

Methods: Twelve patients were enrolled with PROC in the first stage of a Simon optimal two-stage design with alpha=0.10 and beta=0.10. Eligible pts had recurrent, PR high-grade serous OC, measurable disease, and no prior treatment with a targeted inhibitor of DNA repair. Pts may or may not have a somatic or germline mutation of BRCA1 or BRCA2. Pts received olaparib (O) 300mg orally twice daily on days 1-28 and AZD6738 (A) 160mg orally daily on days 1-7 of a 28-day cycle. Endpoints were safety (toxicity based on CTCAE v5.0), objective response rate (RECIST v1.1), and PFS (RECIST v1.1). If ≥1 patient of 12 treated has a partial or complete response, then 25 additional patients will be treated; if no responses are seen, the PR arm of this trial will be terminated.

Results: Nine patients have been treated and 8 pts have had on-study imaging thus far. Median (M) age is 63 years (53-73); M ECOG, 0 (0-1); M prior lines of chemotherapy, 2.5 (1-4); M prior therapies after acquiring platinum resistance, 0.5 (0-2). BRCA1/2m status (positive/negative/unknown) is: gBRCA1 (1/5/4); gBRCA2 (0/6/4); sBRCA1 (1/7/2); sBRCA2 (0/8/2). No complete or partial responses were seen. Six of 8 patients achieved SD with a mean duration on study of 6.7 cycles (range 4-10 cycles), including 1 pt with gBRCA1m. Three of these 6 pts demonstrated 20-27% tumor regression of target lesions. Two patients had disease progression. Toxicities occurring in ≥50% of pts that were at least possibly related to combination therapy were nausea (grade (G) 1/2: 6, G3: 1); anorexia (G1/2: 5, G3: 1); fatigue (G1/2: 4, G3: 1), anemia (G1/2: 4, G3: 1). No G4 toxicities were observed and no pts discontinued therapy due to toxicity.

Conclusions: Combination O and A is tolerable with mostly low-grade toxicity similar to that of olaparib single-agent. 75% of response-evaluable pts had stable disease, half of whom had substantial tumor regression. Duration of disease stability was clinically meaningful in this PR, largely g/sBRCA1/2 wild-type OC population. Biopsy samples will be evaluated by genomics and proteomics. Updated response data will be presented.

Citation Format: Payal D. Shah, Haley Zarrin, Stephanie Wethington, Nawar Latif, Lainie Martin, Diego Rodriguez, Katie Elkins, Robert Giuntoli, Robert Burger, Janos Tanyi, Mark Morgan, Susan M. Domchek, Stephanie Gailliard, Deborah K. Armstrong, Fiona Simpkins. Combination ATR and PARP inhibitor (CAPRI) for recurrent, platinum-resistant ovarian cancer [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr A72.

Assessment of poor functional status and post-acute care needs following primary ovarian cancer debulking surgery

INTRODUCTION

Poor baseline functional status is associated with adverse surgical outcomes. Additionally, decline in the postoperative setting may result in the delay of additional treatments, impacting overall survival. This study assesses the incidence and risk factors for functional decline following primary ovarian cancer debulking surgery in previously independent women using discharge location as a surrogate.

METHODS

All patients with a postoperative diagnosis of ovarian cancer who underwent surgical debulking and had documentation of discharge location were identified using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database. Patients were excluded if their baseline functional status was dependent or partially dependent, or if they died before discharge. Discharge destination was dichotomized as home versus non-home. Descriptive data included demographics, comorbidities, and perioperative outcomes. Multivariable logistic regression was used to evaluate the association of clinical and surgical factors on discharge destination.

RESULTS

1786 patients met the criteria for analysis; 120 (6.7%) patients were discharged to non-home. Differences between home and non-home discharges included age (53.2% vs 83.3% ≥60), body mass index (26.5 vs 27.8 median), comorbidities (45.2% vs 64.2% with ≥1), and complications (8.6% vs 30.0% with ≥1, all p<0.05). In multivariable logistic regression analyses, only increasing age and complications were independently associated with discharge to non-home. Those age ≥70 had 9.0 times the risk (95% CI 3.5 to 23.4; p<0.001) as age <50. The presence of one or more postoperative complications carried 4.5 times (95% CI 2.9 to 7.0; p<0.001) the risk of those without complications. 30 day mortality was also increased in patients discharged to non-home.

DISCUSSION

6.7% of previously independent ovarian cancer patients were discharged to non-home following surgery. Major risk factors for non-home include older age, comorbidities, and postoperative complications. Efforts to optimize baseline functional status and minimize surgical complications may improve discharge rates to non-home and postoperative functional status.

Low rate of intraperitoneal port placement in ovarian cancer patients, a population-based assessment

INTRODUCTION

The National Comprehensive Cancer Network (NCCN) guidelines recommend intraperitoneal chemotherapy in optimally debulked stage III ovarian cancer patients. The objective of this investigation was to determine the rate of intraperitoneal port placement in patients undergoing surgery for ovarian cancer in a national database maintained by the American College of Surgeons.

METHOD

We identified ovarian cancer patients in the National Surgical Quality Improvement Program database from 2006 to 2012. Demographics, comorbidities, operative outcomes, and postoperative complications were abstracted. Descriptive analyses were conducted using Wilcoxon rank-sum and Chi square tests, and multivariate regression models were used to analyze pre-operative and post-operative variables associated with intraperitoneal port placement.

RESULTS

We identified 2659 ovarian cancer patients who underwent primary surgical management. Of these patients, only 128 (4.8%) had an intraperitoneal port placed at the time of surgery. In multivariable analyses, intraperitoneal ports were associated with body mass index ≤25, disseminated cancer, later portion of the study period (2009-2012), and operative time >200 min. Intraperitoneal port placement was not associated with any difference in surgical site infection, wound disruption, major postoperative complication, readmission within 30 days, or death within 30 days.

DISCUSSION

Recent investigation of practice at NCCN institutions between 2003 and 2012 found only 35% of eligible ovarian cancer patients received intraperitoneal chemotherapy. Using intraperitoneal port placement as a surrogate for intraperitoneal chemotherapy administration, our investigation suggests an even lower rate (4.8%) nationally.