Variability of treatment of locally advanced cervical cancer: How French multidisciplinary teams follow European guidelines?

INTRODUCTION

Cervical cancer is a global public health concern. Despite ESGO recommendations and FIGO classification changes, management of locally advanced cervical cancer (LACC) remains debated in France. Our study aimed to review LACC treatment practices and assess adherence to ESGO recommendations among different practitioners.

METHODS

From February 2021 to August 2022, we conducted a survey among gynecologic oncology surgeons, radiation oncologists, and medical oncologists practicing in France and managing LACC (FIGO stages IB3-IVA) according to the 2018 FIGO classification. We analyzed responses against the 2018 ESGO recommendations as a "gold standard."

RESULTS

Among 115 respondents (56% radiation oncologists, 30% surgeons, 13% medical oncologists), 48.6% of gynecologic surgeons didn't perform para-aortic lymphadenectomy (PAL) with significant radiologic pelvic involvement. PAL, when indicated by PET-CT, was more common in university hospitals (66.7% of surgeons). Surgeons in university hospitals also followed ESGO recommendations more closely. Overall, compliance with all ESGO recommendations was low: 5.7% of surgeons, 21.5% of radiation oncologists, and 60% of medical oncologists. Prophylactic para-aortic irradiation, per ESGO, was more frequent in comprehensive cancer centers (52% of radiation oncologists).

CONCLUSION

Adherence to ESGO recommendations for LACC treatment appears low in France, particularly in surgery, with limited PAL in cases of lymph node negativity on PET-CT. However, these recommendations are more often followed by surgeons in university hospitals and radiation oncologists in cancer centers. Adherence to these recommendations may impact patient survival and warrants evaluation of care quality, justifying the organization of LACC management in expert centers.

Comparative analysis of response to treatments and molecular features of tumor-derived organoids versus cell lines and PDX derived from the same ovarian clear cell carcinoma

BACKGROUND

In the era of personalized medicine, the establishment of preclinical models of cancer that faithfully recapitulate original tumors is essential to potentially guide clinical decisions.

METHODS

We established 7 models [4 cell lines, 2 Patient-Derived Tumor Organoids (PDTO) and 1 Patient-Derived Xenograft (PDX)], all derived from the same Ovarian Clear Cell Carcinoma (OCCC). To determine the relevance of each of these models, comprehensive characterization was performed based on morphological, histological, and transcriptomic analyses as well as on the evaluation of their response to the treatments received by the patient. These results were compared to the clinical data.

RESULTS

Only the PDX and PDTO models derived from the patient tumor were able to recapitulate the patient tumor heterogeneity. The patient was refractory to carboplatin, doxorubicin and gemcitabine, while tumor cell lines were sensitive to these treatments. In contrast, PDX and PDTO models displayed resistance to the 3 drugs. The transcriptomic analysis was consistent with these results since the models recapitulating faithfully the clinical response grouped together away from the other classical 2D cell culture models. We next investigated the potential of drugs that have not been used in the patient clinical management and we identified the HDAC inhibitor belinostat as a potential effective treatment based on PDTO response.

CONCLUSIONS

PDX and PDTO appear to be the most relevant models, but only PDTO seem to present all the necessary prerequisites for predictive purposes and could constitute relevant tools for therapeutic decision support in the context of these particularly aggressive cancers refractory to conventional treatments.

Pelvic insufficiency fractures after intensity modulated radiation therapy combined with chemotherapy for cervix carcinoma: Incidence and impact of bone mineral density

Background and Purpose

The aim of this study was to evaluate the incidence and predictive factors of Pelvic Insufficiency Fractures (PIFs) occurring after Intensity Modulated Radiation Therapy (IMRT) combined with chemotherapy for locally advanced cervical cancer (CC).

Material and methods

Medical records of patients receiving radio-chemotherapy with IMRT between 2010 and 2020 for advanced CC were reviewed. PIFs were detected during follow-up on pelvic Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). The cumulative incidence rate of PIFs and its confidence interval were calculated at 2 and 5 years of follow-up. Pre-therapeutic Bone Mineral Density (BMD) (g/cm³) was evaluated on CT simulation for sacrum and the fourth lumbar (L4) vertebrae. Sacrum dosimetric parameters (V30Gy, V40Gy, D50%, Dmean) were analyzed.

Results

136 patients were included. The median follow-up was 4.4 years. Median dose of D50% and V40Gy sacrum were 35.2 Gy (20.6-46.4) and 32.2% (7.2-73.4) respectively. The 2-year and 5-year cumulative incidence rates were 15.7% (95% CI: 9.88-22.71) and 22% (95% CI: 14.58-30.45) respectively. Median time interval between RT completion and PIFs' detection was 11.5 months (IQR: 7.4-22.3). Univariate analysis showed that older age (p < 0.01), postmenopausal status at baseline (p < 0.01), and lower sacral and spinal BMD at baseline (respectively p < 0.001 and p < 0.01) were significantly associated to all sites of PIFs, and lower sacral BMD with sacral fractures (p < 0.001).

Conclusion

Post-IMRT PIFs were detected in 18.4% of patients with locally advanced CC. Individual predisposing factors as older age, postmenopausal status, decreased bone density on the CT simulation were mainly predictive.

[Treatments for rare ovarian tumors: What's new?]

Even if each rare ovarian tumor (ROT) has a low incidence, the sum of all these entities represents almost the half of all ovarian neoplasms. Thus, development of dedicated clinical trial emerged as a prerequisite to improve their managements. Owing to the spreading of dedicated institutional networks and (supra)national collaborations, the number of clinical trials has increased the past few years, with different types of trials; while some focused on specific molecular features, others assessed innovative molecules. Furthermore, relevant randomized clinical trials were designed as a mean to position new treatment options. Currently, innovative molecular-driven trials, based on master protocol trials are emerging and may shed light towards the improvement of personalized medicine regarding ROT.

Abstract 4705: Profiling of immune cell components and soluble factors in ovarian cancer ascites highlights impaired immune environment

Background: It’s now increasingly recognized that ovarian cancer (OC) ascites play a significant role in OC progression - behavior of tumor cells is influenced by the nature of their surrounding microenvironment. Thus, characterization of ascites composition is essential to understand how this milieu affects tumor progression and particularly the immunosuppressive pathways that would underlie immune response dysfunctions and, in turn, how biological ascites effects can be influenced by that composition.

Methods: Ascites samples were collected from advanced OC patients. Through respective multiplexed approaches of flow cytometry-based marker expression analysis and quantitation of mediators, immune context was profiled by investigating immune cell composition and levels of a plethora of soluble factors, including cytokines/chemokines, and metabolic pathways of some amino acids known to be involved in immunosuppression. Furthermore, ascites fluids were functionally screened for their biological effects on healthy monocytes, either undifferentiated or undergoing M1 polarization.

Results: Unlike healthy PBMCs, OC ascites were mostly “enriched” in regulatory/immunosuppressive immune cell subsets including T and myeloid populations. Also, T cells were shown to highly express immune checkpoints such as PD1 in T cells and TIGIT in Tregs. Intriguingly, a high CD4/CD8 ratio was seen. Also, CD163+ tumor-associated macrophages were shown to express CSF1R, CCR8 and CCR2, and to even display a mixed phenotype since also expressing Arg1, CD80, and iNOS. On acellular fractions, most ascites demonstrated elevated CCL18, IL6, LIF, VEGF, and CCL2 levels, and low IL2, IL4, and IL17 levels. Interestingly, unlike healthy plasmas, these ascites appeared to harbor a metabolically-immunosuppressive profile characterized by high glutaminolysis and tryptophan (Trp) degradation in kynurenine (Kyn). Functionally, we demonstrated that not only ascites basically polarized monocytes into M2 macrophages, but even antagonized with their M1 polarization to ultimately tilt to M2 status.

Conclusions: Taken together, our data show that ascites fluids most favorable to the M2 phenotype were associated with high LIF, VEGF, IL6, CCL2, and CCL18 levels, and with elevated Kyn to Trp ratios - Kyn levels being strongly higher than in healthy plasmas. Our results thus highlight a peculiar altered environment of OC ascites where a mixture of suppressive cells and signaling factors mediate extracellular cues leading to immune cell activity dysfunction. Altogether, these translational findings highlight OC ascites as a valuable tool to understand the mechanisms of suppression and develop predictive profiles, and to provide new insights for the identification of new targets and development of targeted-therapies.

Citation Format: Assia Chaibi, Coriolan Lebreton, Dominique Bodet, Jean-Philippe Guegan, Guillaume Babin, Antoine Italiano, Alban Bessede, Imane Nafia. Profiling of immune cell components and soluble factors in ovarian cancer ascites highlights impaired immune environment. [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 4705.

Biomarkers Associated with Lymph Nodal Metastasis in Endometrioid Endometrial Carcinoma

Simple Summary

In endometrial cancer, lymph node invasion assessed through surgical lymphadenectomy or sentinel lymph node biopsy is a determinant factor for the prognosis and planification of adjuvant treatment. Those surgical procedures are associated with short- and long-term complications. Recent advances in molecular characterization of endometrial cancer have provided important insights into the biological nature of tumors but have not improved the pre-operative prediction of LND. This study is a description of the transcriptomic landscape associated with lymph node metastases in endometroid endometrial carcinomas. A 54-genes expression signature was generated at analysis of the primary tumor. Differential gene expression was found between patients with and without lymph node metastasis, with an 87% accuracy. Our findings provide a basis for the development of a gene expression-based signature that can be used to pre-operatively select patients for whom surgical assessment of lymph node status is of little value, and, consequently, an unfavorable risk–benefit balance.

Abstract

Introduction. Lymph node metastasis is determinant in the prognosis and treatment of endometrioid endometrial cancer (EEC) but the risk–benefit balance of surgical lymph node staging remains controversial. Objective. Describe the pathways associated with lymph node metastases in EEC detected by whole RNA sequencing. Methods. RNA-sequencing was performed on a retrospective series of 30 non-metastatic EEC. N+ and N− patients were matched for tumoral size, tumoral grade and myometrial invasion. Results. Twenty-eight EECs were analyzable (16 N+ and 12 N−). Bioinformatics Unsupervised analysis revealed three patterns of expression, enriched in N+, mix of N+/N− and enriched in N−, respectively. The cluster with only N+ patient overexpressed extra cellular matrix, epithelial to mesenchymal and smooth muscle contraction pathways with respect to the N− profile. Differential expression analysis between N+ and N− was used to generate a 54-genes signature with an 87% accuracy. Conclusion. RNA-expression analysis provides a basis to develop a gene expression-based signature that could pre-operatively predict lymph node invasion.

The Anterior GRadient (AGR) family proteins in epithelial ovarian cancer

Epithelial ovarian cancer (EOC) is the most common gynecologic disorder. Even with the recent progresses made towards the use of new therapeutics, it still represents the most lethal gynecologic malignancy in women from developed countries.

The discovery of the anterior gradient proteins AGR2 and AGR3, which are highly related members belonging to the protein disulfide isomerase (PDI) family, attracted researchers’ attention due to their putative involvement in adenocarcinoma development. This review compiles the current knowledge on the role of the AGR family and the expression of its members in EOC and discusses the potential clinical relevance of AGR2 and AGR3 for EOC diagnosis, prognosis, and therapeutics.

A better understanding of the role of the AGR family may thus provide new handling avenues for EOC patients.

E-consult: To better inform patient

e17049

Background: All surgeons have a personalized way of consulting, some deliver information exclusively orally, others through free-form diagrams or anatomical charts. Most patients go home with these patterns that are more or less readable with all the uncertainty of what they really understood or assimilated. Methods: To meet the expectations of patients, we made a computer application to help the surgeon during the consultation.During the consultation, gynecologist surgeons from Center F BACLESSE explained, with the help of the e-consult application, the pathology, surgical intervention, postoperative consequences and potential drug treatments to a cohort of 61 patients admitted for consultation. At the end of the consultation, all the patients received a PDF sheet or an email containing the diagrams constructed in collaboration with the surgeon. Using a questionnaire, we evaluated the satisfaction of the patients. Results: The computer tool was popular with the majority of patients. Regarding the information on the surgical procedure, 86% of the patients judged them as very good, 80% judged the information on adjuvant treatment (radiotherapy, chemotherapy, hormone therapy) as very good and 89% were very satisfied with the information given by the doctor. For the computer tool, 81% of patients found the illustrations very clear, 79% found that the application is a very good help to understanding and 89% found that the interaction with the doctor is sufficient. During the consultation, 100% of the patients were able to ask the desired questions, and 97% think that this computer tool completes the information. For the submitted document, 100% of the patients found it very clear and 100% found that it meets the expectations of the patients. Discussion: E-consult is a unique app created to improve the quality of information delivered to patients during the consultation. The doctor can prove that the information was delivered to the patient, through the development of a PDF during the consultation. A video demonstration is available with the following link: Play the video . Conclusions: e-health is becoming more and more important in medicine. Patients are becoming more connected. E-consult improves the quality of the information received in a simple and personalized way, it is the first application, available at will, designed to improve the understanding of patients. This application integrates with each step in the patient care path.

[Sentinel node and breast cancer: A state-of-the-art in 2019]

Since 1994 and Giuliano's description of sentinel lymph node technique, this procedure has considerably improved and is nowadays, one of the essential pillars in the management of breast cancer. Neoadjuvant chemotherapy (NAC) is effective on regional control, especially on axillary lymph node. Various learned societies recommend that the initial proved GS can be realized before (CNGOF 2010, Saint-Paul de Vence 2013, ESMO 2015, St-Gallen 2015, NCCN 2016) or after (ASCO 2014, ESMO 2015, Saint-Gallen 2015) CNA when the patient is considered like N0. In patients with initial lymph node involvement, GS searching it is not yet recommended. SLN detection before NAC remains an important prognostic factor especially in N+ patients before surgery. The purpose of this article was a reviewing of medical literature regarding possible indications for SLN detection and axillary dissection in patients with NAC according to sentinel lymph node status. The secondary objective was to put forward different perspectives and studies dealing with this subject. The complete pathological response appears to be an important selection criterion for proposing SLN to these patients and avoiding a "useless" AD. It is important to include patients in the trials to make recommendations progress on SLN after NAC and avoid a rate of uninjured AD.

Primary debulking surgery of the upper abdomen and the diaphragm, with a plasma device surgery system, for advanced ovarian cancer

OBJECTIVE

Electrically neutral argon plasma (PlasmaJet™) technology is a surgical option that helps to get an aggressive cytoreduction in selected patients with ovarian cancer because it can be directly applied by the surgeon to treat the tissue surface [1,2]. Upper abdominal surgical procedures are an important part of the surgery in these patients [3], there is a 22% complications rate when they are performed [4]. We present a surgical approach to ovarian cancer debulking using PlasmaJet™.

METHODS

Case history and operative technique: 51 women supported for ovarian cancer Stage IIIC-IV were operated with systematic use of the PlasmaJet device at the Regional Institute Bergonié Cancer Center of Bordeaux, France between June 2012 and June 2014. 41.2% (n=21) patients underwent a Primary Debulking Surgery (PDS) and 58.8% (n=30) underwent an Interval Debulking Surgery. 78.4% (n=40) of the 51 patients studied had a complete cytoreduction. We present the case of a woman diagnosed with a mucinous ovarian carcinoma FIGO stage IVA, who underwent a PDS. Complete cytoreduction to no macroscopic disease was achieved, this included diaphragmatic and abdominal peritoneal stripping.

RESULTS

No post-operative complications were found in this case. 15.7% (n=8) of patients undergoing diaphragmatic stripping with the PlasmaJet required a pleural drain. It is a safe structured procedure, which could be performed to achieve optimal surgical results for patients with ovarian cancer.

CONCLUSIONS

PlasmaJet™ helps the surgeon to perform a peritoneal stripping of the upper abdominal areas and appears to enable the surgeon to remove more disease without increased morbidity, pushing the cytoreduction/morbidity tradeoff.

[A critical assessment of morcellation in case of uterine malignancies and its impact on gynecologic surgery: From "precautionary principle" to "realism"]

Minimally invasive surgery has demonstrated benefits that include improved pain control, decreased infection risk, and faster surgical recovery and return to work. Morcellation is an integral part of making laparoscopic surgery possible for the removal of large uterine leiomyomata, and the development of power morcellation has increased efficiency during these procedures. Morcellation may expose patients to increased morbidity in certain circumstances. This is particularly true in cases of unrecognized malignancy, where intra-abdominal dissemination of cancer may worsen the prognosis (overall survival and disease free survival). A critical review of published data supports that tissue morcellation can be performed safely in screened and selected patients.