Combination treatment with paclitaxel, carboplatin and cetuximab in maxillary sinus cancer: A case report

The standard treatment for maxillary sinus cancer is surgery; however, surgery for advanced cases often leads to significant aesthetic and functional disability. Combination treatment (induction chemotherapy) with paclitaxel, carboplatin and cetuximab (PCE) can be effective in head and neck cancer. The present study describes the case of a patient with advanced maxillary sinus cancer that was successfully treated using the PCE regimen. A 69-year-old man presented to the Department of Dentistry and Oral Surgery, Hokuto Hospital (Obihiro, Japan) with left buccal swelling and an irregular mass on the left maxillary gingiva. The lesion filled the ethmoid and maxillary sinus, and destroyed the pterygoid process. Numerous lymph node metastases were suspected in the bilateral cervical region. The patient was diagnosed with left maxillary sinus cancer T4aN2cM0 and treated with PCE. The size of the tumor was markedly reduced after the initial treatment. After six cycles of PCE, bioradiotherapy (BRT; 66 Gy/33 Fr) was performed for the remaining lesion, and a complete response was achieved. Ten months after BRT, the tumor recurred in the anterior wall of the left maxillary sinus, which was treated by partial maxillary resection and split-thickness skin grafting. No local or cervical recurrence was observed 2 years after the surgery. These findings suggested that PCE could be considered as the first step for the treatment of highly advanced malignant tumors in the head and neck.

A case of low-grade endometrial stromal sarcoma presented as an intramyometrial mass mimicking uterine leiomyoma on MRI

A low-grade endometrial stromal sarcoma (ESS) has a pattern of presenting as an intramyometrial mass and is often misdiagnosed as cellular leiomyoma or degenerative uterine leiomyoma. A low-grade ESS is a malignant tumour that requires total hysterectomy with bilateral salpingo-oophorectomy; while a leiomyoma is a benign tumour and could be acceptable for enucleation. As the treatment strategies differ between a low-grade ESS and leiomyoma, radiologists should be familiar with the characteristic MRI findings of a low-grade ESS. A 51-year-old woman with abnormal uterine bleeding had been observed for 2 years at a previous hospital for a uterine leiomyoma based on MRI findings. A contrast-enhanced MRI demonstrated an intramyometrial mass composed of three components with the hypointense rim on T2-weighted images (T2WI): the first component was a homogeneous solid structure with mild hyperintensity on T2WI with a low apparent diffusion coefficient value; the second component was cystic; the third component was a structure of low signal intensity on T2WI similar to the muscle. Although a degenerative uterine leiomyoma was a differential diagnosis, these MRI findings were suggestive of a low-grade ESS. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and partial omentectomy were performed. The pathological diagnosis was a low-grade ESS. In a low-grade ESS, there are three major patterns of MRI findings: one of these patterns is the less popular but clinically important intramyometrial mass pattern, which can be misdiagnosed as a leiomyoma, and this case conformed to this pattern.

Prevention of symptomatic pulmonary embolism for gynecologic malignancies with preoperative asymptomatic venous thromboembolism: GOTIC-VTE trial

OBJECTIVE

In Japan, perioperative prophylaxis of pulmonary embolism (PE) in gynecologic cancer patients with preoperative asymptomatic venous thromboembolism (VTE) has not been well established yet. The GOTIC-VTE trial was a prospective, multi-center, single-arm clinical trial to investigate the prevention of postoperative symptomatic PE onset by seamless anticoagulant therapy from the preoperative period to 4 weeks after surgery instead of using intermittent pneumatic compression.

METHODS

Anticoagulant therapy was started immediately after asymptomatic VTE diagnosis and stopped preoperatively according to the rules of each institution. Unfractionated heparin administration was resumed within 12 hours postoperatively, and this was followed by the switch to low-molecular-weight heparin and subsequently, edoxaban; this cycle was continued for 28 days. Primary outcome was the occurrence of symptomatic PE in 28 days postoperatively. Secondary outcomes were the incidence of VTE-related events in 28 days and 6 months postoperatively and protocol-related adverse events.

RESULTS

Between February 2018 and September 2020, 99 patients were enrolled; of these, 82 patients were assessed as the full analysis set, including 58 for ovarian cancer, fallopian tube, or peritoneal cancer; 21 for endometrial cancer; and 3 for cervical cancer. No symptomatic PE was observed within 28 days postoperatively; two patients had bleeding events (major bleeding and clinically relevant nonmajor bleeding) and three had grade 3 adverse events (increased alanine transaminase, aspartate aminotransferase, or gamma-glutamyl transferase).

CONCLUSION

The multifaceted perioperative management for gynecologic malignancies with asymptomatic VTE effectively prevented postoperative symptomatic PE.

TRIAL REGISTRATION

JRCT Identifier: jRCTs031180124.

Infantile outcome at 3 years of age among monochorionic twins with Type-II or -III selective fetal growth restriction with isolated oligohydramnios who underwent fetoscopic laser photocoagulation

OBJECTIVE

This study aimed to examine infantile outcomes at 3 years of age with selective fetal growth restriction (sFGR) Types II and III with isolated oligohydramnios who underwent fetoscopic laser photocoagulation (FLP).

METHODS

This multicenter prospective cohort study included monochorionic diamniotic twins who underwent FLP for sFGR between 16 and 25 weeks of gestation. The indication for performing FLP was in cases of sFGR Type II or III with oligohydramnios, where the maximal vertical pocket was ≤2 cm among twins with FGR. This was done in the absence of a typical twin-twin transfusion syndrome diagnosis. The primary outcome was the intact survival (IS) rate of infants at the corrected age of 40 weeks and 3 years. IS at the corrected age of 40 weeks was defined as survival without grade III or IV intraventricular hemorrhage or cystic periventricular leukomalacia, and IS at 3 years of age was defined as survival without neurodevelopmental morbidity, including cerebral palsy, neurodevelopmental impairment with a total developmental quotient of ≤70, bilateral deafness, or bilateral blindness.

RESULTS

Among 45 patients with sFGR, 30 (66.7%) were classified as having Type II and 15 (33.3%) as Type III sFGR. The prevalence of IS at the corrected age of 40 weeks was 51.1% (n=23) in FGR twins and 95.5% (n=42) in larger twins. The prevalence of IS at 3 years of age was 46.7% (n=21) in FGR twins and 86.4% (n=38) in larger twins. Among the 24 FGR twins who were not diagnosed with IS at 3 years of age, 91.7% (22 of 24 cases) suffered fetal or infantile demise other than miscarriage and neurodevelopmental impairment. All larger twins who were not diagnosed with IS at 3 years of age (n=6, 13.6%) had neurological morbidity, in addition to one case of miscarriage.

CONCLUSIONS

FGR twins and larger twins, when subjected to FLP due to sFGR coupled with umbilical artery Doppler abnormalities and isolated oligohydramnios, exhibit low rates of neurological morbidity and low mortality, respectively. Therefore, FLP for Type II or III sFGR with oligohydramnios may be a feasible and preferable management option. This article is protected by copyright. All rights reserved.

Gestational choriocarcinoma

Gestational choriocarcinoma accounts for 5% of gestational trophoblastic neoplasms. Approximately 50%, 25%, and 25% of gestational choriocarcinoma occur after molar pregnancies, term pregnancies, and other gestational events, respectively. The FIGO scoring system categorizes patients into low (score 0 to 6) and high risk (score 7 or more) choriocarcinoma. Single-agent and multi-agent chemotherapy are used in low- and high-risk patients, respectively. Chemotherapy for localized disease has a goal of eradication of disease without surgery and is associated with favorable prognosis and fertility preservation. Most patients with gestational choriocarcinoma are cured with chemotherapy; however, some (<5.0%) will die as a result of multi-drug resistance, underscoring the need for novel approaches in this group of patients. Although there are limited data due to its rarity, the treatment response with immunotherapy is high, ranging between 50-70%. Novel combinations of immune checkpoint inhibitors with targeted therapies (including VEGFR-2 inhibitors) are under evaluation. PD-L1 inhibitors are considered a potential important opportunity for chemo-resistant patients, and to replace or de-escalate chemotherapy to avoid or minimize chemotherapy toxicity. In this review, the Rare Tumor Working Group and the European Organization for Research and Treatment of Cancer evaluated the current landscape and further perspective in the management of patients diagnosed with gestational choriocarcinoma.

Lymphoscintigraphy with single-photon emission computerized tomography/computed tomography for evaluating lymphatic leakage following pelvic and para-aortic lymphadenectomy

Lymphatic ascites following pelvic and para-aortic lymphadenectomy is a well-known complication. Surgical treatment and interventional radiology are required in a few cases. To determine the appropriate treatment strategy, it is important to preoperatively detect the presence and location of lymphatic leakage. However, the methods have yet to be established. We report a case in which lymphoscintigraphy with single-photon emission computerized tomography/computed tomography (SPECT/CT) was performed to evaluate pelvic lymphorrhea that occurred following total hysterectomy with pelvic and para-aortic lymphadenectomy for stage IIIA uterine sarcoma. Lymphoscintigraphy with SPECT/CT showed leakage of radioisotopes into the pelvic space, and intranodal lymphangiography was performed based on these findings. Following the procedure, the pelvic lymphorrhea improved, and no radioisotope leakage was confirmed by re-evaluation with lymphoscintigraphy with SPECT/CT. Our case indicates that lymphoscintigraphy with SPECT/CT may be useful for detecting the precise site of lymphatic leakage before interventional radiology or surgery.

Clinical characteristics and prognostic factors of endometrial stromal sarcoma and undifferentiated uterine sarcoma confirmed by central pathologic review: A multi-institutional retrospective study from the Japanese Clinical Oncology Group

OBJECTIVES

Low-grade and high-grade endometrial stromal sarcomas (LGESS and HGESS) and undifferentiated uterine sarcomas (UUS) are rare tumors whose pathological classification and staging system have changed recently. These tumors are reported to contain fusion genes. We aimed to clarify the genetic background, clinical features, prognostic factors, and optimal therapy of these tumors using a new classification and staging system.

METHODS

We analyzed the clinical features and prognostic information of 72 patients with LGESS, 25 with HGESS, and 16 with UUS using central pathological review. Estrogen and progesterone receptors (PgRs) were examined by immunohistochemistry. JAZF1-SUZ12 and YWHAE-NUTM2A/B gene fusions were tested using real-time polymerase chain reaction.

RESULTS

The 5-year overall survival (OS) rates of LGESS, HGESS, and UUS were 94%, 53%, and 25%, respectively. In LGESS, stage IV, incomplete surgery, and absence of PgR were associated with poor OS. The presence of JAZF1-SUZ12 fusion gene was not associated with OS. In HGESS, the relationship between stage and prognosis was unclear. None of the 3 patients with YWHAE-NUTM2A/B fusion gene died during follow-up. Adjuvant chemotherapy was associated with a favorable OS. Incomplete resection of UUS was associated with poor OS; however, residual tumors frequently occurred. Although most patients underwent adjuvant chemotherapy, their prognosis was extremely poor even in stage I disease.

CONCLUSIONS

Prognosis of LGESS is generally good; however, stage IV, incomplete surgery, and PgR-negative tumors are associated with poor prognosis. Adjuvant chemotherapy may be useful for HGESS. Prognosis of UUS is extremely poor, even with adjuvant chemotherapy.

Real-world clinical practice of pulmonary arterial hypertension in Japan: Insights from a large administrative database

Pulmonary arterial hypertension (PAH) is a fatal disease that often occurs at an early age. In recent years, aggressive treatment with multiple drugs from the early-stage diagnosis is expected to improve the prognosis. Indeed, a high rate of initial combination therapy and excellent treatment outcomes have been reported from specialized centers for PAH in Japan. However, information on PAH epidemiology, including non-PAH specialized centers in Japan, is unclear. To address the above, we conducted a retrospective observational cohort study from April 2008 to September 2020 using real-world evidence from a large-scale administrative database (Medical Data Vision) to examine baseline characteristics, comorbidities, and treatment profiles of Japanese patients with PAH. Five hundred and eighteen patients with PAH (treatment-naive PAH, age 67.2 ± 15.9) were identified through our comprehensive approach which combined PAH disease codes, medications, and diagnostic procedures. Moreover, we showed that a larger proportion of patients received monotherapy in their initial treatment (66%) compared to those receiving combination therapy (34%). During the 1-year follow-up after PAH diagnosis, 13% of patients increased their PAH medications while other patients either decreased their PAH medications (6%) or discontinued PAH treatment (27%). The 3- and 5-year event-free survival rates of all-cause death were 72% and 64%, respectively. This is the first large-scale administrative database study that provides insights into real-world PAH management in Japan. This study highlighted a different PAH clinical landscape which included a larger portion of the elderly population, higher initial monotherapy treatment, and lower survival rates than previous studies.

Clinical significance of retained products of conception in placenta previa: a retrospective analysis

BACKGROUND

Retained products of conception (RPOC) often cause severe postpartum hemorrhage (PPH) but the clinical significance of RPOC in placenta previa is unclear. This study aimed to investigate the clinical significance of RPOC in women with placenta previa. The primary outcome was to evaluate risk factors of RPOC and the secondary outcome was to consider risk factors of severe PPH.

METHODS

Singleton pregnant women with placenta previa who underwent cesarean section (CS) and placenta removal during the operation at the National Defense Medical College Hospital between January 2004 and December 2021 were identified. A retrospective analysis was performed to examine the frequency and risk factors of RPOC and the association of RPOC with severe PPH in pregnant women with placenta previa.

RESULTS

This study included 335 pregnant women. Among these, 24 (7.2%) pregnant women developed RPOC. Pregnant women with prior CS (Odds Ratio (OR) 5.98; 95% Confidence Interval (CI) 2.35-15.20, p < 0.01), major previa (OR 3.15; 95% CI 1.19-8.32, p < 0.01), and placenta accreta spectrum (PAS) (OR 92.7; 95% CI 18.39-467.22, p < 0.01) were more frequent in the RPOC group. Multivariate analysis revealed that prior CS (OR 10.70; 95% CI 3.47-33.00, p < 0.01,) and PAS (OR 140.32; 95% CI 23.84-825.79, p < 0.01) were risk factors for RPOC. In pregnant women who have placenta previa with RPOC or without RPOC, the ratio of severe PPH were 58.3% and 4.5%, respectively (p < 0.01). Furthermore, the occurrence of prior CS (OR 9.23; 95% CI 4.02-21.20, p < 0.01), major previa (OR 11.35; 95% CI 3.35-38.38, p < 0.01), placenta at the anterior wall (OR 3.44; 95% CI 1.40-8.44, p = 0.01), PAS (OR 16.47; 95% CI 4.66-58.26, p < 0.01), and RPOC (OR 29.70; 95% CI 11.23-78.55, p < 0.01) was more in pregnant women with severe PPH. In the multivariate analysis for severe PPH, prior CS (OR 4.71; 95% CI 1.29-17.13, p = 0.02), major previa (OR 7.50; 95% CI 1.98-28.43, p < 0.01), and RPOC (OR 13.26; 95% CI 3.61-48.63, p < 0.01) were identified as risk factors.

CONCLUSIONS

Prior CS and PAS were identified as risk factors for RPOC in placenta previa and RPOC is closely associated with severe PPH. Therefore, a new strategy for RPOC in placenta previa is needed.

Genetic analysis for mucinous ovarian carcinoma with infiltrative and expansile invasion and mucinous borderline tumor: a retrospective analysis

BACKGROUND

Mucinous carcinoma (MC) is a histological subtype of ovarian cancer that has a worse prognosis at advanced stages than the most prevalent histological subtype, high-grade serous carcinomas. Invasive patterns have been recognized as prognostic factors for MCs. MCs with infiltrative invasion were more aggressive than those with expansile invasion. MC with an expansile pattern exhibited behavior similar to mucinous borderline tumors (MBT). However, genomic analysis of invasive patterns is insufficient. This study aimed to compare genetic information between groups with MC and infiltrative invasion (Group A) and those with MC with expansile invasion or MBT (Group B).

METHODS

Ten cases each of MC with infiltrative invasion, MC with expansile invasion, and MBT between 2005 and 2020 were identified. Deoxyribonucleic acid (DNA) extraction from formalin-fixed paraffin-embedded tissues was performed, and cases with DNA fragmentation or the possibility of DNA fragmentation were excluded. Mutant base candidates and tumor mutation burden (TMB) values (mutations/megabase) were calculated.

RESULTS

After assessing the quality of purified DNA, seven cases of MC with infiltrative invasion, five cases of MC with expansile invasion, and three cases of MBT were included. More patients in group A experienced recurrence or progression (p < 0.01) and died of disease (p = 0.03). Moreover, the TMB value was statistically higher in group A than in group B (p = 0.049). There were no statistical differences in the incidence of the mutations of KRAS, TP53, and CREBBP. KRAS, TP53, and CREBBP mutations were discovered in 8/15 (53.3%), 6/15 (40.0%), and 5/15 (33.3%) cases, respectively.

CONCLUSIONS

Genetic analysis revealed that Group A had higher TMB than Group B. Therefore, this result might be useful for future treatment.

JGOG2046: a feasibility study of neoadjuvant chemotherapy followed by debulking surgery for clinically diagnosed FIGO stage IVb endometrial cancer

BACKGROUND

We evaluated the feasibility of neoadjuvant chemotherapy, followed by debulking surgery, for clinically diagnosed FIGO stage IVb endometrial cancer (protocol number: JGOG2046).

METHODS

The experimental treatment consisted of 3 cycles of paclitaxel (180 mg/m2) plus carboplatin (AUC5) followed by debulking surgery, including total abdominal hysterectomy, bilateral salpingo-oophorectomy, and 3 cycles of adjuvant chemotherapy. Patients were considered as eligible if they were pathologically diagnosed as primary endometrial cancer, and had both endometrial tumor and distant metastasis confirmed by imaging examinations. The primary endpoint was the incidence of patients who completed debulking surgery after the neoadjuvant chemotherapy.

RESULTS

While 51 patients were enrolled from 23 hospitals, the final study cohort consisted of 49 patients with a mean age of 59.0 years. Although the response ratio of the neoadjuvant chemotherapy was 65.3% (95% CI 50.4-78.3%), 67.3% (95% confidence interval (CI) 52.5-80.1%) underwent debulking surgery after the neoadjuvant chemotherapy and 59.2% (95% CI 45.2-71.8%) completed the protocol treatment including 3 courses of adjuvant chemotherapy. The median disease-free survival time was 9.1 months (95% CI 6.5-11.9), while the median overall survival time was 23.2 months (95% CI 11.9-27.8). A patient with sigmoid colon cancer and another with cervical cancer were included in this study.

CONCLUSIONS

Neoadjuvant chemotherapy followed by debulking surgery was a feasible and acceptable treatment for metastatic endometrial cancer. (225 words).

Endometrial carcinosarcoma

Endometrial carcinosarcoma is a rare and aggressive high-grade endometrial carcinoma with secondary sarcomatous trans-differentiation (conversion theory). The clinical presentation and diagnostic work-up roughly align with those of the more common endometrioid counterpart, although endometrial carcinosarcoma is more frequently diagnosed at an advanced stage. Endometrial carcinosarcoma is not a single entity but encompasses different histological subtypes, depending on the type of carcinomatous and sarcomatous elements. The majority of endometrial carcinosarcomas are characterized by p53 abnormalities. The proportion of POLE and microsatellite instablity-high (MSI-H) is directly related to the epithelial component, being approximately 25% and 3% in endometrioid and non-endometrioid components.The management of non-metastatic disease is based on a multimodal approach with optimal surgery followed by (concomitant or sequential) chemotherapy and radiotherapy, even for early stages. Palliative chemotherapy is recommended in the metastatic or recurrent setting, with carboplatin/paclitaxel doublet being the first-line regimen. Although the introduction of immunotherapy plus/minus a tyrosine kinase inhibitor shifted the paradigm of treatment of patients with recurrent endometrial cancer, patients with endometrial carcinosarcoma were excluded from most studies evaluating single-agent immunotherapy or the combination. However, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) approved the use of pembrolizumab and lenvatinib in endometrial cancer (all histotypes) after progression on chemotherapy and single-agent immunotherapy in MSI-H cancers. In the era of precision medicine, emerging knowledge on molecular endometrial carcinosarcoma is opening new promising therapeutic options for more personalized treatment. The present review outlines state-of-the-art knowledge and future directions for patients with endometrial carcinosarcoma.

Combination of fluorescence visualization and iodine solution-guided surgery for local control of early tongue cancer

The control of enclosed oral epithelial dysplasia is important for the control of oral cancer. Fluorescence visualization and iodine solution are able to detect oral epithelial dysplasia and surrounding oral cancer. The purpose of this study was to clarify the effectiveness of combining fluorescence visualization and iodine solution-guided surgery for early tongue cancer. Participants comprised 264 patients with primary early tongue cancer who underwent surgery. The surgical margin was set at 10 mm outside the clinical tumour, and 5 mm outside the area of fluorescence visualization loss, and 5mm outside the iodine unstained area. The 5-year disease-free survival rate was 87.1% vs 76.1% (P = 0.016) and the 5-year local control rate was 98.6% vs 93.0% (P = 0.008) for combination-guided surgery when compared to conventional surgery. Positive margin rates were 0% for cancer, and 6.5% and 0% for low- and high-grade dysplasia, respectively, with combination-guided surgery (P = 0.257). Multivariate analysis revealed that combination-guided surgery (odds ratio 0.140, 95% confidence interval 0.045-0.437; P < 0.001) and intraoperative frozen section examination (odds ratio 0.302; 95% confidence interval 0.115-0.791; P = 0.015) were significantly associated with local control. The combination of fluorescence visualization and iodine solution are effective in selecting surgical margins for early tongue cancer.

Robust osteogenic efficacy of 2α-heteroarylalkyl vitamin D analogue AH-1 in VDR (R270L) hereditary vitamin D-dependent rickets model rats

Active vitamin D form 1α,25-dihydroxtvitamin D₃ (1,25(OH)₂D₃) plays pivotal roles in calcium homeostasis and osteogenesis via its transcription regulation effect via binding to vitamin D receptor (VDR). Mutated VDR often causes hereditary vitamin D-dependent rickets (VDDR) type II, and patients with VDDR-II are hardly responsive to physiological doses of 1,25(OH)D₃. Current therapeutic approaches, including high doses of oral calcium and supraphysiologic doses of 1,25(OH)₂D_3, have limited success and fail to improve the quality of life of affected patients. Thus, various vitamin D analogues have been developed as therapeutic options. In our previous study, we generated genetically modified rats with mutated Vdr(R270L), an ortholog of human VDR(R274L) isolated from the patients with VDDR-II. The significant reduced affinity toward 1,25(OH)₂D₃ of rat Vdr(R270L) enabled us to evaluate biological activities of exogenous VDR ligand without 1α-hydroxy group such as 25(OH)D₃. In this study, 2α-[2-(tetrazol-2-yl)ethyl]-1α,25(OH)₂D₃ (AH-1) exerted much higher affinity for Vdr(R270L) in in vitro ligand binding assay than both 25(OH)D₃ and 1,25(OH)₂D₃. A robust osteogenic activity of AH-1 was observed in Vdr(R270L) rats. Only a 40-fold lower dose of AH-1 than that of 25(OH)D₃ was effective in ameliorating rickets symptoms in Vdr(R270L) rats. Therefore, AH-1 may be promising for the therapy of VDDR-II with VDR(R274L).

Changes in the Characteristics and Initial Treatments of Pulmonary Hypertension Between 2008 and 2020 in Japan

Background

Pulmonary arterial hypertension (PAH) is a rare, progressive disease. The treatment landscape for PAH in Japan has evolved considerably in recent years, but there is limited knowledge of the changes in treatment practices or patient characteristics.

Objectives

The aim of this study was to evaluate the changes in characteristics and initial treatments for PAH in Japan over time.

Methods

This study used data from the Japan Pulmonary Hypertension Registry (JAPHR) to compare patient characteristics and treatment practices between 2008-2015 (n = 316) and 2016-2020 (n = 315).

Results

The mean ± standard deviation age at diagnosis increased from 47.9 ± 16.7 years in 2008-2015 to 52.7 ± 16.9 years in 2016-2020. The mean pulmonary arterial pressure decreased from 45.4 ± 15.0 to 38.6 ± 13.1 mm Hg. Idiopathic/hereditary PAH was the most common etiology in both periods (50.0% and 51.1%, respectively). The proportion of patients prescribed oral/inhaled combination therapies increased from 47.8% to 57.5%. Oral/inhaled combination therapies were frequently prescribed to patients with congenital heart disease-related PAH (81.8%). There was no significant trend in prescribing practices based on French low-risk criteria: among patients with 0, 1, 2, 3, or 4 criteria, 53.8%, 68.8%, 52.8%, 66.7%, and 39.4% were prescribed oral/inhaled combination therapies, and 0%, 16.7%, 27.0%, 17.3%, and 15.2% were prescribed oral/inhaled monotherapies. Macitentan, tadalafil, selexipag, and epoprostenol were the most frequently prescribed drugs.

Conclusions

The severity of PAH decreased over time in Japan. Oral/inhaled combination therapies were generally preferred. Physicians generally prescribed therapies after considering the patients’ hemodynamics and clinical severity. (Japan Pulmonary Hypertension Registry [JAPHR]; UMIN000026680)

Rapidly Growing Superficial Angiomyxoma in Mandibular Gingiva: A Case Report and Literature Review

Superficial angiomyxoma (SA) is a benign tumor characterized by extensive myxoid stroma, numerous small blood vessels, sparse spindle-shaped fibroblastic cells, and inflammatory cell infiltrate. Oral cavity SA is extremely rare and typically presents as a painless, slow growth. We experienced SA in the mandibular gingiva that is rapidly growing. The patient was a 15-year-old female whose chief complaint was a painless mass in the lingual gingiva of the mandible that increased in size over 1 month. An excisional biopsy was performed under local anesthesia. According to histopathological examination, the mass was diagnosed as SA. The patient experienced recurrence twice because of positive margins. The second recurrent lesion, including periosteum, was resected, and no recurrence has been observed for 1 year. The cause of rapid growth was attributed to edematous changes due to tongue habit or traumatic stimuli. As this case exhibited repeated local recurrence, careful follow-up is required.

Intraepithelial lymphocytes are indicators of better prognosis in surgically resected endometrioid-type endometrial carcinomas at early and advanced stages

Background

Tumor-infiltrating lymphocytes (TILs) and tumor-associated macrophages (TAMs) may be useful prognostic indicators in endometrial cancer. However, standardized assessment methods and the prognostic roles of these cells in different stage groups are unclear.

Methods

Formalin-fixed paraffin-embedded tissue samples of 107 endometrioid-type endometrial carcinomas (EECs) comprising 60 stage IB and 47 stage IIIC or IVB cases were evaluated. CD3⁺ TILs, CD8⁺ TILs, CD68⁺ TAMs, and CD163⁺ TAMs were detected by immunohistochemistry, and their densities were evaluated by semiquantitative and quantitative methods. TILs within tumor epithelial cell nests (E-TILs) and those within the stroma at the invasive front (S-TILs) were evaluated separately for CD3⁺ and CD8⁺ cells. The “TIL score” was defined as the sum of semiquantitative scores of CD3⁺ E-TILs, CD3⁺ S-TILs, CD8⁺ E-TILs, and CD8⁺ S-TILs. For TAMs, the area of CD68⁺ and CD163⁺ cells in the invasive margin were semiquantitatively and quantitatively evaluated. Clinicopathological and prognostic implications of TILs and TAMs in stage IB and IIIC/IVB EECs were examined by Cox univariate and multivariate analyses.

Results

By Cox univariate analyses, semiquantitatively low CD3⁺ E-TILs, low CD8⁺ E-TILs, and low “TIL score” were significantly correlated with worse prognosis in stage IB patients (P = 0.011, 0.040, and 0.039, respectively). Likewise, low CD3⁺ E-TILs and low CD8⁺ E-TILs, by both semiquantitative (P = 0.011 and 0.0051) and quantitative evaluations (P < 0.0001, and P = 0.0015) and low “TIL score” (P = 0.020) were significantly correlated with worse prognosis in stage IIIC/IVB patients. By Cox multivariate analyses, semiquantitatively low CD3⁺ E-TILs and low CD8⁺ E-TILs, low “TIL score”, and quantitatively low CD3⁺ E-TILs and low CD8⁺ E-TILs were independent worse prognostic factors in stage IIIC/IVB (P = 0.0011, 0.0053, 0.012, < 0.0001, and < 0.0001, respectively). CD68⁺ or CD163⁺ TAMs were not correlated with prognosis in any patients.

Conclusions

Both semiquantitatively and quantitatively low E-TILs, are correlated with worse prognosis in both early and advanced stage patients with EECs. In particular, CD3⁺ E-TILs and CD8⁺ E-TILs are potentially useful prognostic markers in patients with EEC regardless of the stage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09363-0.

Technical methods employed for the On-Site Inspection

In the paper, the technical methods to be used for the on-site inspection (OSI) are reviewed. The main purpose of the OSI is to find evidences of a nuclear explosion conducted anyplace in the world, however, the technical methods described in the paper might be employed for a suspected underground explosion. Various technical methods are described but they can be classified into two categories, namely, technical methods, 1) to identify fission products, and 2) to identify underground evidences. Fission products can be identified by conventional gamma spectrum analysis, however, for the OSI, radioactive Xe and Ar are important nuclides since they are supposed to leak to the ground surface even when the explosion is conducted in deep underground. The seismic and various other technical methods, which might be commonly used by mining industry, can identify the underground evidences, such as a cavity. However, these technical methods might be necessary to be verified to confirm the applicability and effectiveness to OSI objectives.

Potential efficacy of weekly low-dose administration of bevacizumab as a combination therapy for platinum-resistant ovarian carcinoma: a retrospective analysis

Background

Bevacizumab (Bev) plays the central role of the adjuvant therapy for patients with ovarian carcinoma. The aim of our study was to examine whether differences in the administration of Bev influence the prognosis of patients.

Methods

Patients with ovarian carcinoma who received treatment at two hospitals between 1999 and 2020 were identified. Patients treated with weekly low-dose administration of Bev (100 mg Bev on days 1 and 8 and 200 mg Bev on day 15, monthly) at one hospital (group A) and those with monthly high-dose administration of Bev (15 mg/kg of Bev on day 1, monthly) at another hospital (group B) were retrospectively compared.

Results

Among the total patients, 44 were assigned to group A and 33 were assigned to group B. More patients in group A had advanced disease (p = 0.03) and a lower dose of Bev at the first time during the first cycle administration (p < 0.01) than in group B. Progression-free survival (PFS) was better in group A than in group B (p < 0.01). Multivariate analysis revealed that group A was a better prognostic factor for PFS (hazard ratio 0.53, p = 0.03). Stable duration was longer in group A than in group B (p < 0.01). The incidences of adverse effects, including hematological toxicities such as neutropenia (p = 0.01) and nonhematological toxicities such as hypertension (p < 0.01), intestinal obstruction (p < 0.01), and thromboembolic events (p < 0.01), were lower in group A than in group B.

Conclusions

Weekly low-dose administration of Bev might improve prognosis and decrease the frequency of adverse effects associated with this drug although the prospective study was needed to get corroboration.

Clinical significance of CD8-positive lymphocytes on tumor cell clusters of ascites cell block in ovarian high-grade serous carcinoma

Background

The clinical significance of CD8‐positive (CD8⁺) lymphocytes on tumor cell clusters of ascites cell blocks in patients with ovarian high‐grade serous carcinoma (HGSC) was investigated.

Methods

Among HGSC patients who underwent surgery from January 2014 to December 2019, 38 patients with ascites cell block were selected. Using these cell blocks and primary ovarian tumor tissue, the presence of CD8⁺ lymphocytes and the expression of PD‐L1 were examined immunohistochemically. Tumor cell clusters were defined as cell clumps consisting of more than 10 malignant cells in cell block. Cases with at least one CD8⁺ lymphocyte in tumor cell cluster were defined as positive CD8⁺ lymphocytes (Group A); others were defined as negative CD8⁺ lymphocytes (Group B). The tumor tissue CD8⁺ lymphocytes were counted mechanically. Clinicopathological features were retrospectively compared between the two groups.

Results

In total, 38 cases were identified: 25 (65.8%) in Group A and 13 (34.2%) in Group B. More cases in Group A were positive for CD4 (p < 0.01), PD‐L1 (p = 0.02), FoxP3 (p = 0.02) and had a higher number of CD8⁺ lymphocytes in the tissue (p = 0.03). Patients in Group A had better progression‐free survival (p < 0.01) and overall survival (p = 0.04). In multivariate analysis, Group A was an independent prognostic factor for both progression‐free survival (hazard ratio, 0.24; p < 0.01) and overall survival (hazard ratio, 0.21; p = 0.03).

Conclusion

The presence of CD8⁺ lymphocytes in tumor cell clusters of ascites was associated with the status of immune reaction in the tissue and prognosis in patients with HGSC and might be useful information of the immune‐associated therapy.

Comparison of clinical behavior between mucinous ovarian carcinoma with infiltrative and expansile invasion and high-grade serous ovarian carcinoma: a retrospective analysis

Background

The aim of this study was to evaluate the clinicopathological factors and prognosis of mucinous carcinoma (MC) with infiltrative invasion, MC with expansile invasion, and high-grade serous carcinoma (HGSC).

Methods

Cases of MC and HGSC between 1984 and 2019 were identified. The clinicopathological factors and prognosis of MC with infiltrative invasion or expansile invasion and HGSC were retrospectively compared. Although our present study included cases in our previous studies, we extended observational period when analysis was performed. Accordingly, our study added increased cases and survival analysis was newly conducted.

Results

After pathological review, 27 cases of MC with infiltrative invasion, 25 cases of MC with expansile invasion, and 219 cases of HGSC were included. MC had a better prognosis in terms of progression-free survival (PFS, p < 0.01) and overall survival (OS, p < 0.01) than HGSC for all International Federation of Gynecology and Obstetrics (FIGO) stages; however, multivariate analysis did not show statistical differences in PFS and OS. There were no statistically significant differences in PFS and OS for all FIGO stages between MC with infiltrative invasion and HGSC. However, in cases with FIGO stages II to IV, MC with infiltrative invasion had worse PFS (p < 0.01) and OS (p < 0.01) than HGSC. In univariate analysis, MC with infiltrative invasion was a worse prognostic factor for PFS (hazard ratio [HR] 2.83, p < 0.01) and OS (HR 3.83, p < 0.01) than HGSC. Compared with HGSC, MC with expansile invasion had better PFS (p < 0.01) and OS (p < 0.01). Multivariate analysis demonstrated that MC with expansile invasion was a better prognostic factor for PFS (HR 0.17, p < 0.01) and OS (HR 0.18, p = 0.03) than HGSC.

Conclusions

Compared to the prognosis of HGSC, that of MC was different according to the invasive pattern and FIGO stage. Therefore, future study may be needed to consider this association.

Resuscitative efficacy of hemoglobin vesicles for severe postpartum hemorrhage in pregnant rabbits

We aimed to investigate the resuscitative efficacy of hemoglobin vesicles (HbVs) as a red blood cell (RBC) substitute for the initial treatment of severe postpartum hemorrhage (PPH). Twenty-five pregnant rabbits underwent cesarean section; uncontrolled hemorrhage was induced by transecting the right uterine artery to establish a severe PPH model. During the first 30 min, all rabbits were administered 6% hydroxyethyl starch (HES) of an equivalent volume to the hemorrhage every 5 min. Thereafter, they received any of the following three isovolemic fluids for resuscitation every 5 min: RBCs with platelet-poor plasma (RBC/PPP) (n = 8), 6% HES (n = 7), or HbVs with 25% human serum albumin (n = 10). After surgical hemostasis at 60 min, survival was monitored until 12 h. No rabbits receiving only HES infusion survived beyond 6 h, whereas all rabbits receiving RBC/PPP transfusion survived. The rabbits receiving HbV infusion showed significantly higher mean arterial pressure and hemoglobin levels than the HES-receiving rabbits, and 8 of 10 rabbits survived for 6 h. The HbV group showed significantly higher survival than the HES group but worse survival than the RBC/PPP group. In conclusion, HbV infusion for severe PPH effectively prevents lethal hemorrhagic shock in a pregnant rabbit model.

Development of In Vitro and In Vivo Evaluation Systems for Vitamin D Derivatives and Their Application to Drug Discovery

We have developed an in vitro system to easily examine the affinity for vitamin D receptor (VDR) and CYP24A1-mediated metabolism as two methods of assessing vitamin D derivatives. Vitamin D derivatives with high VDR affinity and resistance to CYP24A1-mediated metabolism could be good therapeutic agents. This system can effectively select vitamin D derivatives with these useful properties. We have also developed an in vivo system including a Cyp27b1-gene-deficient rat (a type I rickets model), a Vdr-gene-deficient rat (a type II rickets model), and a rat with a mutant Vdr (R270L) (another type II rickets model) using a genome editing method. For Cyp27b1-gene-deficient and Vdr mutant (R270L) rats, amelioration of rickets symptoms can be used as an index of the efficacy of vitamin D derivatives. Vdr-gene-deficient rats can be used to assess the activities of vitamin D derivatives specialized for actions not mediated by VDR. One of our original vitamin D derivatives, which displays high affinity VDR binding and resistance to CYP24A1-dependent metabolism, has shown good therapeutic effects in Vdr (R270L) rats, although further analysis is needed.

Functional expression of equilibrative and concentrative nucleoside transporters in alveolar epithelial cells

Equilibrative nucleoside transporters (ENTs) and concentrative nucleoside transporters (CNTs) mediate the cellular uptake of nucleosides and nucleobases across the plasma membrane and play important roles in the salvage pathways of nucleotide synthesis. However, information about nucleoside transport systems in the lung alveolar epithelial cells is limited. Therefore, in the present study, we examined the function and expression of nucleoside transporters using primary cultured alveolar type II cells and transdifferentiated type I-like cells. The uptake of uridine, a substrate for ENTs and CNTs, in type II and type I-like cells was time, temperature, and concentration dependent, and was inhibited by other nucleoside transporter substrates such as adenosine. Uridine uptake in both cells was insensitive to nanomolar concentrations of NBMPR, a potent ENT1 inhibitor, while it was inhibited by higher concentrations of NBMPR, suggesting that ENT2, but not ENT1, is involved in uridine uptake in these cells. Additionally, uridine uptake was higher in the presence of Na⁺ than in the absence of Na + and was partially inhibited by a CNT inhibitor phloridzin in these cells, suggesting that CNT is also involved in uridine uptake. In both cells, the mRNA expression of ENT1, ENT2, CNT2, and CNT3 was observed. Finally, the activity of uridine uptake was considerably higher in type II cells than in type I-like cells. In addition, the mRNA expression of ENT2, CNT2, and CNT3, but not ENT1, was lower in type I-like cells than in type II cells. These findings would help understand the functional roles of equilibrative and concentrative nucleoside transporters in alveolar epithelial cells.

Prognostic similarity between ovarian mucinous carcinoma with expansile invasion and ovarian mucinous borderline tumor: A retrospective analysis

There is a similarity of histological features and survival between ovarian mucinous carcinoma (MC) with expansile invasion and ovarian mucinous borderline tumor (MBT). The aim of this study was to compare the clinical outcomes of MC with expansile invasion with those of MBT based on the 2020 World Health Organization (WHO) criteria.A pathological review was performed on patients with MC, ovarian MBT, and seromucinous borderline tumors that underwent surgery at our hospital between 1984 and 2019. Clinicopathological features were compared retrospectively between MC with expansile invasion and MBT.Among 83 cases of MC, 85 cases of MBT, and 12 cases of seromucinous borderline tumor, 25 MC cases with expansile invasion and 98 MBT cases were included through review. MC cases with expansile invasion were diagnosed with advanced International Federation of Gynecology and Obstetrics (FIGO) stages more frequently (P = .02) than that of MBT cases. In addition, patients with MC with expansile invasion received adjuvant chemotherapy more often (P < .01) than that of patients with MBT. There were no statistically significant differences in recurrence rate (P = .10) between MC with expansile invasion and MBT. Progression-free survival (PFS) was worse in MC cases with expansile invasion than that in MBT cases (P = .01). However, a multivariate analysis for PFS showed that histological subtype, FIGO stage, and adjuvant chemotherapy were not an independent prognostic factor.The prognostic outcome of MC with expansile invasion might mimic those of MBT. These results showed ovarian borderline tumor treatment could be applied to MC treatment.

MicroRNA-21 expression in cancer cells is an independent biomarker of progression-free survival of endometrioid endometrial carcinoma

Endometrial carcinoma is one of the most common gynecological cancers. MicroRNA-21 (miR-21) is the most consistently overexpressed miRNA in almost all human cancer types, and it might be a useful clinical biomarker and therapeutic target. However, its precise localization and significance in endometrial carcinoma have not been clarified. This study aimed to examine miR-21 expression in endometrial carcinoma and reveal its clinicopathological importance. We investigated miR-21 expression by in situ hybridization (ISH) using locked nucleic acid (LNA)-modified probes in 230 endometrial carcinoma patients. We evaluated miR-21 expression in cancer cells and stroma separately. High miR-21 expression in cancer cells was significantly associated with higher histological grade and lymph node metastasis. In Kaplan-Meier analysis, high miR-21 expression in cancer cells was significantly associated with poor progression-free survival. In particular, in endometrioid carcinoma, high miR-21 expression in cancer cells was an independent prognostic factor associated with poor progression-free survival, as well as older age and higher International Federation of Gynecology and Obstetrics (FIGO) stage.

Psoas muscle index at the fifth lumbar vertebra as a predictor of survival in epithelial ovarian cancers

Almost a quarter of a century has passed since the term sarcopenia was defined. Sarcopenia is recognized as a poor prognostic factor in a variety of cancer types. In ovarian cancer, it remains controversial whether sarcopenia affects prognosis and how it should be evaluated. The present study aimed to evaluate the association between the volume of the psoas major muscle and survival in patients with epithelial ovarian cancer. Medical charts of patients with epithelial ovarian cancer who received first-line chemotherapy with paclitaxel and carboplatin at the National Defense Medical College Hospital (Tokorozawa, Japan) between April 2010 and January 2015 were retrospectively reviewed. The bilateral psoas major muscle areas at the fifth lumbar vertebra were measured using computed tomography images. The Institutional Review Board at National Defense Medical College Hospital (Tokorozawa, Japan) approved the study protocol. A total of 72 patients with epithelial ovarian cancer who received combination therapy with paclitaxel and carboplatin were identified and enrolled. The median psoas muscle index (PMI; psoas muscle major cross-sectional area divided by height squared) was 5.4 cm²/m² (range, 3.3-10.0). Patients with higher PMI had significantly improved overall survival (OS) compared with those with lower PMI [log-rank test P=0.014; hazard ratio (HR), 2.61; 95% confidence interval (CI), 1.21-6.06]. Multivariate analysis for OS revealed that lower PMI was an independent unfavorable prognostic factor (HR, 3.87; 95% CI, 1.37-12.1; P=0.0098). The volume of psoas major muscle mass could be a potential biomarker for prognosis in patients with epithelial ovarian cancer.

Grade 1 Endometrioid Carcinoma With an Area of Serous Carcinoma Less than 5% Is More Aggressive than Stage IA Pure-type Grade 1 Endometrioid Carcinoma

BACKGROUND/AIM

In 2020, the percentages were removed from the World Health Organization's criteria for mixed carcinoma. The aim was to examine the clinical significance of an area of serous carcinoma (SC) <5%.

PATIENTS AND METHODS

Our study included 236 patients with the 2009 International Federation of Obstetrics and Gynecology (FIGO) stage IA grade 1 endometrioid carcinoma (EG1) from multiple hospitals. EG1 patients with an area of SC <5% and those with pure-type EG1 were retrospectively compared.

RESULTS

In the multivariate analysis for recurrence, an area of SC <5% was an independent risk factor [hazard ratio (HR)=101.51, p<0.01]. In the multivariate analysis for progression-free survival, an area of SC <5% was identified as a negative prognostic factor (HR=62.43, p<0.01).

CONCLUSION

EG1 with an area of SC <5% may be more aggressive than pure-type EG1 at FIGO stage IA.

Significance of mesothelin and CA125 expression in endometrial carcinoma: a retrospective analysis

Background

This study aimed to investigate the association between clinicopathologic factors, mesothelin, and cancer antigen (CA) 125 in endometrial carcinoma.

Methods

Between 1989 and 2017, patients with endometrial carcinoma who underwent total hysterectomy and bilateral salpingo-oophorectomy at our hospital were identified. The association between either or both immunochemical expression of mesothelin and CA125 and clinicopathological features were retrospectively examined.

Results

Among 485 patients, 171 were positive for mesothelin, 368 were positive for CA125, and 167 were positive for mesothelin and CA125. The expression of mesothelin and CA125 was positively correlated (p < 0.01). More patients with mesothelin expression showed myometrial invasion of more than 50% (p = 0.028) and positive lymphovascular invasion (p = 0.027). Similarly, more patients with co-expression of mesothelin and CA125 had myometrial invasion of more than 50% (p = 0.016) and positive lymphovascular invasion (p = 0.02). Patients with mesothelin expression and co-expression of mesothelin and CA125 demonstrated worse progression-free survival (PFS) and overall survival (OS). In the multivariate analysis, mesothelin expression and co-expression were poor prognostic factors for PFS (mesothelin expression: hazard ratio [HR] = 2.14, p < 0.01; co-expression: HR = 2.19, p < 0.01) and OS (mesothelin expression: HR = 2.18, p < 0.01; co-expression: HR = 2.22, p < 0.01).

Conclusions

Mesothelin expression and co-expression might be associated with tumor aggressiveness and poor prognosis in patients with endometrial carcinoma. Persons with mesothelin-expressing endometrial cancers present a particularly high medical unmet need.

Criteria for placenta accreta spectrum in the International Federation of Gynaecology and Obstetrics classification, and topographic invasion area are associated with massive hemorrhage in patients with placenta previa

INTRODUCTION

Placenta previa with placenta accreta spectrum (PAS) is a life-threatening disease that results in massive hemorrhage. The clinical and histologic criteria of PAS were adopted according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. We aimed to investigate whether FIGO criteria and topography were associated with maternal complications in patients with placenta previa.

MATERIAL AND METHODS

Patients with placenta previa who underwent cesarean section at our institution between January 2003 and December 2019 were identified. First, they were divided based on FIGO classification, as follows: Group A, with clinical criteria; Group B, with histologic criteria; and Group C: without clinical or histologic criteria. Next, cases with PAS were classified according to the topographic invasion area, as follows: type 1, upper posterior bladder; type 2, lower posterior bladder; type 3, parametrium; type 4, posterior lower uterine segment. Predictive factors for massive hemorrhage were retrospectively analyzed.

RESULTS

Among the 350 patients, 24 (6.9%) were classified as Group A, 16 (4.6%) as Group B and 310 (88.5%) as Group C. Regarding maternal history and hemostatic procedures, there were no significant factors other than hysterectomy (p < .01) in Groups A and B. The volume of blood loss in both Groups A and B was greater than in Group C (p < .01). The rates of uterine artery embolization and blood transfusion were higher in Groups A and B than in Group C (p < .01). In addition, there were no significant factors other than hysterectomy between Groups A and B. In the multivariate analysis for massive hemorrhage, Group A (odds ratio: 2.73, p = .04) and Group B (odds ratio: 12.69, p < .01) were identified as independent predictive factors. In addition, massive hemorrhage was closely related to the lower posterior bladder and parametrial invasion in both Groups A and B.

CONCLUSIONS

Both clinical and histologic criteria for PAS in the FIGO classification were associated with massive hemorrhage. Diagnosing clinical PAS using the FIGO classification, additional hemostatic procedures might be necessary according to the topographic invasion area.

Diagnostic efficacy of ascites cell block for ovarian clear cell carcinoma

BACKGROUND

Ascites cytology is important for determining the stage and treatment methods for ovarian clear cell carcinoma (CCC) as defined by the 2014 International Federation of Obstetrics and Gynecology classification.

METHODS

Patients with CCC who underwent surgery at our hospital between January 2012 and December 2019 and who received cytodiagnosis of their ascites using Papanicolaou (Pap) and May-Grünwald-Giemsa (MGG) staining, and cell block methods were identified. The cell block technique was performed using hematoxylin-eosin (H&E) staining and immunohistochemical staining for hepatocyte nuclear factor-1β (HNF-1β), estrogen receptor (ER), progesterone receptor (PR), and Wilms tumor-1 (WT-1). Cancer cells of CCC were defined as tumor cells that were positive for HNF-1β and negative for ER, PR, and WT-1. The diagnostic accuracy of ascites cytology using Pap and MGG staining and cell block methods was examined.

RESULTS

Based on cytological data, our study included 17 patients: seven (41.1%) with malignant (MAL) ascites, eight (47.1%) with negative for malignancy (NFM), and two (11.8%) with atypia of undetermined significance (AUS) because of a few atypical cells based on Pap and MGG staining. Malignant cells diagnosed by cell blocks were detected in 7/7 patients with MAL ascites based on PAP and MGG staining, 2/8 (25.0%) patients with NFM, and 1/2 (50%) patients with AUS.

CONCLUSION

These findings show that the cell block method combined with the immunohistochemical investigation may be useful for increasing the diagnostic accuracy of malignant cells in CCC.

Clear cell borderline tumor without fibromatous component: Pathological and literature review and report of two cases

The aim of the present study was to examine the clinical outcome of ovarian clear cell borderline tumor (CCBT) through pathological review for cases with clear cell carcinoma (CCC) and CCBT between 1984 and 2015 who received surgery at the National Defense Medical College Hospital using 2020 World Health Organization (WHO) criteria. In addition to the definition of CCBT in 2020 WHO criteria, clear cell with atypia of the glandular epithelium without fibromatous component was added to the diagnostic criteria of CCBT. Two cases with CCBT were identified through review in the current study. There were no cases that changed from the initial CCBT diagnosis that were included in the current study. Case 1 was a 43-year-old woman who received total hysterectomy, bilateral salpingo-oophorectomy and partial omentectomy. Pathologically, cysts were lined by cuboidal, hobnail and clear cells with eosinophilic cytoplasm and moderate nuclear atypia without the fibromatous component. These cells were adjacent to atypical endometriosis and non-atypical endometriosis, and the patient was diagnosed with CCBT. She exhibited no evidence of the disease for 37 months following surgery. Case 2 was a 42-year-old woman who received left salpingo-oophorectomy, partial omentectomy and pelvic lymphadenectomy. The tumor exhibited a cyst (80 mm) and nodular component. Pathologically, the tumor cells were lined by hobnail cells with mild atypia and eosinophilic cytoplasm without the fibromatous component. This patient was diagnosed with CCBT and exhibited no evidence of disease for 20 months following surgery. CCBT without fibromatous component is a rare and non-aggressive histological subtype. Additionally, regardless of fibromatous component, CCBT was able to be diagnosed.

Survival and biomarker analysis for ovarian mucinous carcinoma according to invasive patterns: retrospective analysis and review literature

BACKGROUND

In ovarian mucinous carcinoma, invasive pattern is the important factor but there were less reposts to investigate it. The aim of this study was to examine the association between prognosis and invasive patterns of ovarian mucinous carcinoma and to investigate the biomarkers of the diagnosis and prognosis immunochemically. Patients with ovarian mucinous carcinoma at our institution between 1984 and 2018 were identified. A pathological review was conducted using the 2020 World Health Organization criteria. The prognosis of infiltrative invasion and expansile invasion of ovarian mucinous carcinoma were retrospectively compared. In addition, immunohistochemical staining was conducted for all cases, and the immunohistochemical differences between the two invasive patterns were compared.

RESULTS

After the pathological review, 25 cases with infiltrative invasion and 24 cases with expansile invasion were included. Ovarian mucinous carcinoma with infiltrative invasion showed significantly worse progression-free survival (PFS, p < 0.01) and overall survival (OS, p < 0.01) than those with expansile invasion. Multivariate analysis demonstrated that the pattern of infiltrative invasion was a worse prognostic factor for PFS (hazard ratio 9.01, p < 0.01) and OS (hazard ratio 17.56, p < 0.01). Immunohistochemically, cytokeratin (CK) 5/6 (p = 0.01), cluster of differentiation (CD) 24 (p = 0.02), and epithelial growth factor receptor (EGFR) (p < 0.01) were statistically related to infiltrative invasion. The PFS (p = 0.04) and OS (p = 0.02) of cases with EGFR-positive OMC were worse than those with negative OMC.

CONCLUSIONS

Infiltrative invasion was observed to be a prognostic factor showing worse outcomes for ovarian mucinous carcinoma compared to expansile infiltration. CK5/6, CD24, and EGFR might be biomarkers of the diagnosis.

Ovarian Seromucinous Borderline Tumors Are Histologically Different from Mucinous Borderline Tumors

AIM

To examine the clinicopathological features of ovarian seromucinous borderline tumors (SMBTs) and compare them with those of mucinous borderline/atypical proliferative mucinous tumors (MB/APMTs).

PATIENTS AND METHODS

Patients with SMBT between 2014 and 2018 and those with MB/APMT between 1988 and 2018 who underwent surgery at our Institution were identified. Pathological review was conducted using the 2014 World Health Organization criteria. Clinical features were compared retrospectively between SMBT and MB/APMT.

RESULTS

In total, 11 (12.9%) patients with SMBT and 74 (87.1%) patients with MB/APMT were included in our study. The diagnosis of six patients with SMBT and 73 patients with MB/APMT was not revised on review. SMBT was diagnosed at a younger age (p=0.04), was of smaller size (p<0.01) and bilateral (p=0.03), coexisted with endometriosis (p<0.01), and more frequently recurred than MB/APMT (p=0.04).

CONCLUSION

SMBT might be more aggressive than MB/APMT.

A New Model to Improve the Prediction of Prognosis of Endometrial Carcinoma by Combining Traditional Classification With the Presence of Tumor-infiltrating Lymphocytes

BACKGROUND/AIM

We aimed to predict the prognosis of endometrial carcinoma by combining traditional histological classification with the status of tumor-infiltrating lymphocytes (TILs).

PATIENTS AND METHODS

All patients with endometrial carcinoma, treated at our hospital, were classified into four categories-Category I: Type I positive for TILs; category II: type I negative for TILs; category III: type II positive for TILs; and category IV: type II negative for TILs. Prognoses were compared across all the categories. Positivity for TILs was defined as a continuously formed thick zone of TILs at the invasive front.

RESULTS

Multivariate analyses of progression-free and overall survival indicated that category classification was an independent prognostic factor, with hazard ratios of 3.127, 3.483, and 8.459 for progression-free survival, and 3.444, 4.374, and 11.058 for OS for patients in categories II, III, and IV, respectively.

CONCLUSION

Combining traditional histological classification with TIL status might better predict prognosis of endometrial carcinoma.

Applicability of ultrasonography for detection of marginal sinus placenta previa

This study aimed to examine whether marginal sinus placenta previa, defined as when the marginal sinus just reaches the internal cervical os and placental parenchyma might be >2 cm from the internal cervical os, can be diagnosed using ultrasonography (US). We identified the placenta previa cases that underwent both US and magnetic resonance imaging (MRI) between April 2010 and December 2018 at our institution. The diagnostic discrepancies for marginal sinus placenta previa between US and MRI were examined retrospectively. Of the 183 cases of placenta previa, 28 (15.3%) cases were diagnosed as marginal sinus placenta previa using MRI. Among them, 18 cases (64.3%) could also be diagnosed using US. The sensitivity and specificity of the diagnosis of marginal sinus placenta previa using US were 64.3% and 92.9%, respectively. A change in US diagnosis occurred in 10 (35.7%) cases, all of which were diagnosed with low-lying placenta previa or marginal placenta previa and did not develop any serious miserable obstetrical outcomes. In conclusion, the diagnostic accuracy of US for detecting marginal sinus placenta previa was not significant. MRI examination may be required to accurately categorize the types of placenta previa.

Randomized phase III trial comparing pegylated liposomal doxorubicin (PLD) at 50 mg/m² versus 40 mg/m² in patients with platinum-refractory and -resistant ovarian carcinoma: the JGOG 3018 Trial

Objective

The standard dose for pegylated liposomal doxorubicin (PLD) is 50 mg/m² every 4 weeks. While 40 mg/m² has recently been used in clinical practice, evidence supporting this use remains lacking.

Methods

This phase III randomized, non-inferiority study compared progression-free survival (PFS) for patients with platinum-resistant ovarian carcinoma between an experimental arm (40 mg/m² PLD) and a standard arm (50 mg/m² PLD) until 10 courses, disease progression or unacceptable toxicity. Eligible patients had received ≤2 prior lines. Stratification was by performance status and PFS of prior chemotherapy (<3 months versus ≥3 months). The primary endpoint was PFS and secondary endpoints were overall survival (OS), toxicity profile, clinical response and tolerability. The total number of patients was 470.

Results

The trial was prematurely closed due to slow recruitment, with 272 patients randomized to the experimental arm (n=137) and standard arm (n=135). Final analysis was performed with 234 deaths and 269 events for PFS. In the experimental arm vs. standard arm, median PFS was 4.0 months vs. 4.0 months (hazard ratio [HR]=1.065; 95% confidence interval [CI]=0.830–1.366) and median OS was 14.0 months vs. 14.0 months (HR=1.078; 95% CI=0.831–1.397). Hematologic toxicity and oral cavity mucositis (≥grade 2) were more frequent in the standard arm than in the experimental arm, but no difference was seen in ≥grade 2 hand-foot skin reaction.

Conclusion

Non-inferiority of 2 PLD dosing schedule was not confirmed because the trial was closed prematurely. However, recommendation of dose reduction of PLD should be based both on efficacy and safety.

Trial Registration

UMIN Clinical Trials Registry Identifier: UMIN000003130

Placenta previa may acquire invasive nature by factors associated with epithelial-mesenchymal transition and matrix metalloproteinases

AIM

To investigate the differences in epithelial-mesenchymal transition (EMT)- and matrix metalloproteinases (MMP)-related factors among placenta previa with and without placenta accreta spectrum (PAS) (n = 69), and normal placenta (n = 51).

METHODS

The women diagnosed with placenta previa with or without PAS, and normal placentas, who delivered at our institution between 2006 and 2016, were enrolled. The difference of EMT-related factors' expression by immunochemical analysis in chorionic villi and decidual cells between the normal placenta and placenta previa with or without PAS were evaluated.

RESULTS

In chorionic villi of placenta previa with and without PAS, E-cadherin expression decreased, while that of ZEB1, SNAIL2 and MMP-9 increased than that in normal placenta. In decidual cells of placenta previa with and without PAS, expression of vimentin, ZEB1 and MMP-9 increased than that in normal placenta. In placenta previa with and without PAS, there was strong co-expression of ZEB1 and vimentin in chorionic villi, of ZEB1 and MMP-2 or MMP-9 in decidual cells, and of SNAIL2 and vimentin or MMP-9 in both chorionic villi and decidual cell. Vimentin expression in both chorionic villi and decidual cells was higher in placenta previa with PAS (n = 18) than in placenta previa without PAS (n = 51). MMP-2 expression in decidual cells was higher in placenta previa with PAS than in placenta previa without PAS.

CONCLUSION

This study revealed that EMT- and MMP-associated factors may be related to placenta previa with and without PAS. Furthermore, placenta previa without PAS may acquire invasive nature.

The use of magnetic resonance imaging to predict placenta previa with placenta accreta spectrum

INTRODUCTION

Massive hemorrhage due to placenta previa with placenta accreta spectrum is associated with high maternal mortality and morbidity. Therefore, accurate prediction of placenta previa with placenta accreta spectrum is essential; magnetic resonance imaging (MRI) is a useful tool for this purpose. This study investigated novel predictors of anterior and posterior placenta previa with placenta accreta spectrum using MRI.

MATERIAL AND METHODS

This was a retrospective study at a tertiary obstetrics hospital in Japan. The singleton patients with placenta previa who were scanned with MRI prenatally and had a cesarean section at our institution between 2007 and 2018 were included. The prediction of anterior and posterior placenta previa with placenta accreta spectrum was evaluated using four MRI findings: heterogeneous signals in the placenta, dark T2-weighted intraplacental bands, myometrial thinning or interruption, and focal uterine bulging. The prediction of posterior placenta previa with placenta accreta spectrum was performed using the quantification of cervical varicosities, which were defined as the ratio of the distance between the minimum distance from the most dorsal cervical varicosities (a) to the deciduous and amniotic placenta (b) on a sagittal image.

RESULTS

Among 202 patients, 14 (6.9%) patients were pathologically diagnosed as having placenta accreta spectrum. Further, 38 (18.8%) patients had anterior placenta previa and 164 (81.2%) patients had posterior placenta previa. When anterior placenta previa with placenta accreta spectrum was predicted using at least one of the four MRI findings, the sensitivity and specificity of the anterior placenta previa with placenta accreta spectrum were 87.5% and 86.7%, respectively. In contrast, the sensitivity and specificity of posterior placenta previa with placenta accreta spectrum were 42.9% and 96.2%, respectively. But when the A/B ratio was set at 0.20, the sensitivity and specificity of the prediction for posterior placenta previa with placenta accreta spectrum using cervical varicosities were 100.0% and 89.2%, respectively.

CONCLUSIONS

The findings of MRI to predict the anterior placenta previa with placenta accreta spectrum were different from posterior placenta previa. The cervical varicosities may be useful in predicting posterior placenta previa with placenta accreta spectrum.

Transport of ribavirin in human myelogenous leukemia cell line K562

The anticancer effect of ribavirin, a purine nucleoside analogue, has been studied using cultured cancer cells such as the human myelogenous leukemia cell line K562. In order to exert its pharmacological effect, ribavirin has to enter cancer cells. However, there is little information concerning the transport mechanism of ribavirin into K562 cells. In this study, therefore, we examined the uptake mechanism of ribavirin in K562 cells. The uptake of ribavirin in K562 cells was time- and temperature-dependent, and was saturable with a Km value of 1.5 mM. Ribavirin uptake was inhibited by nucleosides such as adenosine and uridine, and by inhibitors of equilibrative nucleoside transporter 1 (ENT1) such as S-(4-nitrobenzyl)-6-thioinosine and dipyridamole in a concentration-dependent manner. In addition, the expression of ENT1 mRNA in K562 cells was confirmed by real-time PCR. On the other hand, Na⁺-dependence of ribavirin uptake was not observed, suggesting the involvement of ENT1, but not Na⁺-dependent concentrative nucleoside transporters, in ribavirin uptake in K562 cells. Treatment of K562 cells with sodium butyrate induced erythroid differentiation, but ribavirin uptake activity and sensitivity of the uptake to various inhibitors were not different between native and differentiated K562 cells. These results suggest that ribavirin uptake into K562 cells is mainly mediated by ENT1, which may have a pivotal role in anticancer effect of ribavirin.

Co-Expression of Mesothelin and CA125 Is Associated with the Poor Prognosis of Endometrial Serous Carcinoma and Mixed Carcinomas Including Serous Carcinoma

The aim of this study was to investigate the association between the clinicopathologic factors and either expression or co-expression of mesothelin and cancer antigen (CA) 125 in endometrial serous carcinoma and mixed carcinomas including serous carcinoma. Between 1990 and 2017, patients with endometrial serous carcinoma and mixed carcinoma including serous carcinoma treated by total hysterectomy and bilateral salpingo-oophorectomy at our hospital were identified. The association between either expression or co-expression of mesothelin and CA125 was evaluated by immunochemical analysis and the clinico-pathological features were retrospectively examined. Among the 40 patients included, 19, 31, and 18 patients exhibited single positive mesothelin, single positive CA125, and positive co-expression, respectively. The expression of mesothelin and CA125 was observed to be positively associated (p = 0.021). There was no significant association of age and FIGO stage with individual mesothelin or CA125 expression or their co-expression. Overall survival (OS), but not progression-free survivals (PFS), of only mesothelin-positive patients was worse (p = 0.024). Hence, OS and PFS of patients with positive co-expression were worse (PFS: p = 0.043, OS: p = 0.012). In multivariate analysis, single mesothelin expression and single CA125 expression did not lead to worse prognosis. However, positive co-expression was the worst prognostic factor for OS (hazard ratio: 3.32, p = 0.039). Co-expression of mesothelin and CA125 may accurately predict OS in endometrial serous carcinoma and mixed carcinomas including serous carcinoma. Further studies should examine this relationship.

Rapid decrease in serum VEGF-A levels may be a worse prognostic biomarker for patients with platinum-resistant recurrent ovarian cancer treated with bevacizumab and gemcitabine

PURPOSE

The aim of this study was to investigate the association between changes in the levels of vascular endothelial growth factors (VEGFs) after treatment with bevacizumab and gemcitabine (Bev-Gem) and the clinical outcome.

METHODS

Platinum-resistant ovarian cancer patients treated with Bev-Gem therapy at our hospital between 2014 and 2018 were identified. Serum VEGF levels at the first and second treatment cycle were measured by ELISA. All patients were categorized into two groups-patients with > 50% decrease in serum VEGF-A levels (Group A) and patients with < 50% decrease serum VEGF-A levels (Group B). The association between clinical outcome and serum VEGF levels was investigated between the two groups.

RESULTS

Among 18 patients, 10 were in Group A and 8 in Group B. Group A exhibited a lower response rate (0% vs.75% p < 0.01) and clinical benefit rate (60% vs.100% p = 0.02) than Group B. The median serum VEGF-A level of Group A before the first cycle of Bev-Gem therapy was higher than that in Group B (61.2 vs. 3.7 pg/mL, p < 0.01). Group A exhibited worse PFS (7 vs., 10 months, p < 0.01) and OS (17 vs. 26 months, p = 0.04) than Group B. There were more patients with > 10% increase in serum VEGF-B levels in Group A than in Group B (p < 0.01).

CONCLUSION

The rapid decrease in VEGF-A levels and the resultant increase in serum VEGF-B levels might be associated with an unfavorable clinical outcome. Large-scale studies are needed to further examine these results.

Comparison of survival between primary debulking surgery and neoadjuvant chemotherapy for stage III/IV ovarian, tubal and peritoneal cancers in phase III randomised trial

BACKGROUND

Regarding the comparison between primary debulking surgery (PDS) and neoadjuvant chemotherapy (NACT) for stage III/IV ovarian, tubal and peritoneal cancers, EORTC55971 and CHORUS studies demonstrated noninferiority of NACT. Previously, we reported reduced invasiveness of NACT in JCOG0602. This is a final analysis including the primary endpoint of overall survival (OS).

METHODS

Patients were randomised to PDS (PDS followed by 8x paclitaxel and carboplatin, i.e. TC regimen) or NACT (4x TC, interval debulking surgery [IDS], 4x TC). The primary endpoint was OS. The noninferiority hazard ratio (HR) margin for NACT compared with PDS was 1·161. The planned sample size was 300.

FINDINGS

Between 2006 and 2011, 301 patients were randomised, 149 to PDS and 152 to NACT. The median OS was 49·0 and 44·3 months in the PDS and NACT. HR for NACT was 1·052 [90·8% confidence interval (CI) 0·835-1·326], and one-sided noninferiority p-value was 0·24. Median progression-free survival was 15·1 and 16·4 months in the PDS and NACT (HR: 0·96 [95%CI 0·75-1·23]). In the PDS arm, 147/149 underwent PDS and 49/147 underwent IDS. In the NACT arm 130/152 underwent IDS. Complete resection was achieved in 12% (17/147) of PDS and 31% (45/147) of PDS ± IDS in the PDS arm and in 64% (83/130) of IDS in the NACT arm. Optimal surgery (residual tumour <1 cm) was achieved in 37% (55/147), 63% (92/147), and 82% (107/130 respectively. In the NACT, PS 2/3, serum albumin ≤2·5, CA125 > 2000 an institution with low study activity was advantageous, whereas clear/mucinous histology was disadvantageous for OS.

INTERPRETATION

The noninferiority of NACT was not confirmed. NACT may not always be a substitute for PDS. However, as our study had smaller numbers, the noninferiority of the previous studies cannot be denied.

FUNDING

Ministry of Health, Labour and Welfare, Japan and the National Cancer Center, Japan.

CLINICAL TRIAL INFORMATION

UMIN000000523.

A multi-center retrospective study of neuroendocrine tumors of the uterine cervix: Prognosis according to the new 2018 staging system, comparing outcomes for different chemotherapeutic regimens and histopathological subtypes

OBJECTIVE

To analyze the clinical behavior of neuroendocrine tumors (NETs) of the uterine cervix, we conducted a multicenter, retrospective study of 193 patients.

METHODS

We evaluated the prognosis of NETs according to the new International Federation of Gynecology and Obstetrics (FIGO) staging system, compared the clinical response to different chemotherapy regimens, and compared different histological subtypes of NETS.

RESULTS

Diagnoses of the subjects were atypical carcinoid tumor (ACT, n = 37), small cell neuroendocrine carcinoma (SCNEC, n = 126), large cell neuroendocrine carcinoma (LCNEC, n = 22), and NET, not elsewhere classified (n = 8), according to central pathological review. According to FIGO 2018, 69, 17, 74, and 33 patients were at stage I, II, III, or IV, respectively. Five-year survival was 64.5%, 50.1%, 30.2%, and 3.4% for patients at stage I, II, III and IV. About 40% of patients with stage IIIC1 survived >5 years. On multivariate analyses, locally-advanced disease, para-aortic node metastasis, distant metastasis, and <4 cycles of chemotherapy were associated with poor survival. Histological subtype and pelvic node metastasis had no prognostic significance. Response rates to etoposide-platinum (EP) or irinotecan-platinum (CPT-P) regimens were 43.8% (28/64), but only 12.9% to a taxane-platinum (TC) regimen (4/31). The response rate for ACT was 8.7% (2/23), significantly less than the 36.6% for high-grade neuroendocrine carcinomas (HGNEC: both SCNEC and LCNEC, 41/111).

CONCLUSIONS

Locally-advanced, extra-pelvic disease and insufficient chemotherapy were independent prognostic factors for cervical NET. HGNEC showed good responses to EP or CPT-P but not TC. Chemotherapy was less effective for ACT, which had a prognosis identical to HGNEC.

P2651Seasonal variations in the pathogenesis of acute coronary syndromes

Background

Seasonal variations in acute coronary syndrome (ACS) has been known with the winter being the peak in incidence and mortality. However, underlying pathophysiology for this variation has not been studied.

Purpose

We sought to compare pathobiology of the culprit lesions assessed by optical coherence tomography (OCT) among the four seasons.

Methods

Patients with ACS who underwent OCT were recruited from 6 countries in the Northern Hemisphere. The prevalence of 3 most common pathologies, plaque rupture, plaque erosion and calcified plaque, and other features of coronary plaques were compared among the four seasons.

Results

In 1113 patients with ACS, 284 (25%) patients were admitted in spring, 243 (22%) patients in summer, 290 (26%) patients in autumn and 296 (27%) patients in winter. The proportion of underlying 3 pathologies was significantly different in each season (prevalence of plaque rupture, plaque erosion, calcified plaque was 50%, 39%, and 11%, respectively in the spring; 44%, 43%, and 13% in the summer; autumn: 49%, 39%, and 12% in the autumn; 57%, 30%, and 13% in the winter; P=0.039). The proportion of plaque rupture was higher in winter but lower in summer, and that of plaque erosion was higher in summer, but lower in winter. Maximum and minimum temperatures on the day of OCT procedure were significantly lower in the plaque rupture group than in the plaque erosion group (P=0.02 and P=0.012, respectively). In the rupture group, the prevalence of hypertension was significantly higher in winter, but in the erosion group, it was not different among the four seasons.

Figure 1. The proportion of culprit lesion characteristics were significantly different among the 4 season groups. (P=0.039) The proportion of plaque rupture was significantly higher in winter but lower in summer. In contrast, the proportion of plaque erosion was higher in summer, but lower in winter.

Conclusions

Seasonal variation of the underlying mechanisms of ACS reflects different pathobiology. The proportion of plaque rupture is highest in winter and the proportion of plaque erosion is highest in summer. A different approach may be needed for the prevention and treatment of ACS depending on the season of its occurrence.