Maximizing ovarian function and fertility following chemotherapy in premenopausal patients: Is there a role for ovarian suppression?

As more premenopausal patients undergo fertility preserving cancer treatments, there is an increased need for fertility counseling and ovarian sparing strategies. Many patients receive gonadotoxic chemotherapeutic agents which can put them at risk of primary ovarian insufficiency or profoundly diminished ovarian reserve. Traditionally, estradiol and follicle stimulating hormone (FSH) values have been used to evaluate ovarian function but more recently, reproductive endocrinologists have been proponents of anti-mullerian hormone (AMH) as a validated measure of ovarian potential. While the gold standard for fertility preservation remains oocyte cryopreservation, data suggest there may be additional interventions that can mitigate the gonadotoxic effects of chemotherapeutic agents. The main objectives of this focused review were to quantify the risk of primary ovarian failure associated with the most common chemotherapies used in treatment of gynecologic cancers and to evaluate and recommend potential interventions to mitigate toxic effects on ovarian function. Chemotherapeutic agents can cause direct loss of oocytes and primordial follicles as well as stromal and vascular atrophy and the extent is dependent upon mechanism of action and age of the patient. The risk of ovarian failure is the highest with alkylating agents (42.2 %), anthracyclines (<10-34 % in patients under 40 years versus 98 % in patients aged 40-49), taxanes (57.1 %) and platinum agents (50 %). Multiple trials demonstrate that gonadotropin releasing hormone (GnRH) agonists, when administered concurrently with chemotherapy, may have protective effects, with more patients experiencing resumption of a regular menstruation pattern and recovering ovarian function more quickly post-treatment. Premenopausal patients receiving chemotherapy for the treatment of gynecologic cancers should receive adequate counseling on the potential adverse effects on their fertility. Although oocyte cryopreservation remains the gold standard for fertility preservation, there is some evidence to suggest that GNRH agonists could help maintain and preserve ovarian function and should be considered.

Condyloma lata mimicking vulvar carcinoma in an immunocompromised patient: A case report

Background

Syphilis is a sexually transmitted infection with increasing incidence in the United States. Presentations of syphilis vary widely and can be easily mistaken for other diagnoses, including cancer, especially in atypical cases.

Case description

At her delivery after no prenatal care, a 35-year-old woman was found to have exophytic vulvar and perianal lesions, inguinal lymphadenopathy, and a new diagnosis of HIV, with a strong clinical concern for vulvar and/or anal carcinoma. She was subsequently diagnosed with presumed late latent syphilis and began weekly intramuscular penicillin G benzathine treatment. CT imaging demonstrated a perineal plaque-like area with bilateral inguinal, external iliac and retroperitoneal lymphadenopathy. She was seen in gynecologic oncology clinic one week after her initial presentation with notable improvement in the vulvar lesions, raising suspicion for condyloma lata rather than invasive or preinvasive disease on the vulva, however concern remained for dysplasia in the perianal lesion. Another week later, she underwent an exam under anesthesia with vulvar and perianal biopsies revealing chronic inflammation and granulomatous change without evidence of malignancy or dysplasia. At the four week post operative visit, there was almost complete resolution of the lesions.

Conclusion

Syphilis should be considered in the differential diagnosis of atypical vulvar lesions.

Optimizing post-operative opiate prescribing following gynecologic surgery

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Procedure based opiate prescribing often does not reflect patient opiate utilization resulting in overprescribing.

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Using patient opiate utilization to determine the discharge opiate prescription lowers the quantity of opiate prescribed.

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Patient-based opiate prescription recommendations can be successfully implemented into discharge order sets.

Background

Post-operative opiate prescribing has traditionally been stratified by procedure type with little regard for patient opiate utilization. We sought to evaluate peri-operative factors associated with patient opiate utilization post-operatively to develop, implement, and assess a discharge prescribing intervention.

Study design

This was a quality improvement study of opiate prescribing practices for patients undergoing gynecologic surgery on an enhanced recovery pathway (ERAS) pre- and post-discharge prescription intervention. In the pre-intervention cohort (12/2018 to 05/2019), peri-operative factors (demographic, procedure, and pain scores) associated with post-operative patient opiate usage and quantity of opiate prescribed were identified. A discharge planning intervention based solely on opiate usage was implemented. The pre- and post-intervention cohort (07/2020 to 09/2020) were compared to assess changes in post-operative opiate prescribing and refill requests.

Results

There were 220 patients in the pre-intervention cohort and 120 patients post-intervention. Post-operative opiate usage in the pre-intervention cohort was correlated only with pain score and age (p < 0.001, p = 0.04). Quantity of opiate prescribed was correlated only with procedure type and not reflective of patient opiate usage. Using this information, a discharge planning intervention for opiate prescription informed by opiate usage in the twenty-four hours prior to discharge was added to the discharge order set. Post-intervention, adherence to recommended prescription was 40.8%. Opiate prescriptions decreased from a mean 27.3 tablets to 14.8 tablets (p < 0.001).

Conclusions

A tailored, patient specific approach to post-operative opiate prescribing can significantly decrease the quantity of opiates prescribed.

Effect of risk-reducing salpingo-oophorectomy on sex steroid hormone serum levels among postmenopausal women: an NRG Oncology/Gynecologic Oncology Group study

BACKGROUND

Risk-reducing salpingo-oophorectomy is an effective ovarian cancer risk reduction strategy. However, bilateral oophorectomy has also been associated with increased long-term nonneoplastic sequelae, effects suggested to be mediated through reductions in systemic sex steroid hormone levels. Currently, it is unclear whether the postmenopausal ovary contributes to the systemic hormonal milieu or whether postmenopausal ovarian volume or other factors, such as body mass index and age, affect systemic hormone levels.

OBJECTIVE

We examined the impact of oophorectomy on sex steroid hormone levels in postmenopausal women. Furthermore, we explored how well ovarian volume measured by transvaginal ultrasound correlated with direct ovarian measures obtained during surgical pathology evaluation and investigated the association between hormone levels and ovarian volumes.

STUDY DESIGN

Postmenopausal women who underwent risk-reducing salpingo-oophorectomy (180 cases) or ovarian cancer screening (38 controls) enrolled in an international, prospective study of risk-reducing salpingo-oophorectomy and risk of ovarian cancer algorithm-based screening among women at increased risk of ovarian cancer (Gynecologic Oncology Group-0199) were included in this analysis. Controls were frequency matched to the cases on age at menopause, age at study entry, and time interval between blood draws. Ovarian volume was calculated using measurements obtained from transvaginal ultrasound in both cases and controls and measurements recorded in surgical pathology reports from cases. Serum hormone levels of testosterone, androstenedione, androstenediol, dihydrotestosterone, androsterone, dehydroepiandrosterone, estrone, estradiol, and sex hormone-binding globulin were measured at baseline and follow-up. Spearman correlation coefficients were used to compare ovarian volumes as measured on transvaginal ultrasound and pathology examinations. Correlations between ovarian volumes by transvaginal ultrasound and measured hormone levels were examined using linear regression models. All models were adjusted for age. Paired t tests were performed to evaluate individual differences in hormone levels before and after risk-reducing salpingo-oophorectomy.

RESULTS

Ovarian volumes measured by transvaginal ultrasound were only moderately correlated with those reported on pathology reports (Spearman rho [ρ]=0.42). The median time interval between risk-reducing salpingo-oophorectomy and follow-up for the cases was 13.3 months (range, 6.0-19.3), and the median time interval between baseline and follow-up for the controls was 12.7 months (range, 8.7-13.4). Sex steroid levels decreased with age but were not correlated with transvaginal ultrasound ovarian volume, body mass index, or time since menopause. Estradiol levels were significantly lower after risk-reducing salpingo-oophorectomy (percentage change, -61.9 post-risk-reducing salpingo-oophorectomy vs +15.2 in controls; P=.02), but no significant differences were seen for the other hormones.

CONCLUSION

Ovarian volumes measured by transvaginal ultrasound were moderately correlated with volumes directly measured on pathology specimens and were not correlated with sex steroid hormone levels in postmenopausal women. Estradiol was the only hormone that declined significantly after risk-reducing salpingo-oophorectomy. Thus, it remains unclear whether the limited post-risk-reducing salpingo-oophorectomy changes in sex steroid hormones among postmenopausal women impact long-term adverse outcomes.

Beneficial effects of exercise on chemotherapy-induced peripheral neuropathy and sleep disturbance: A review of literature and proposed mechanisms

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Exercise counters chemotherapy-induced peripheral neuropathy and sleep disturbances.

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Exercise reduces inflammation, promotes neuroplasticity, modulates pain signaling.

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Exercise improves sleep disturbances by entraining circadian rhythmicity.

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Oncologists should learn how to prescribe exercise regimens for their patients.

The goal of this narrative review is to evaluate the literature regarding exercise training as a therapy to prevent or mitigate deleterious side effects of chemotherapy, specifically peripheral neuropathy and sleep disturbances and to make concrete recommendations for implementation for the practicing oncologist. A literature search was conducted for studies that included an exercise intervention to be implemented for patients undergoing or previously treated with chemotherapy along with an analysis of its effect on either chemotherapy-induced peripheral neuropathy (CIPN) or chemotherapy-induced sleep disturbances. Studies were subsequently analyzed and summarized in order to determine the overall promise of exercise as a therapy in this setting. Five studies met inclusion criteria to be assessed with regard to the effect of exercise on CIPN and eight were included for sleep disturbances. Exercise was found to be a significantly beneficial therapy in preventing, mitigating, or improving the symptoms of CIPN and sleep disturbances in cancer patients in the majority of studies evaluated. Exercise is an effective intervention and should be specifically prescribed concurrently with chemotherapy to maximize potential of avoiding these debilitating side effects, which significantly and negatively impact quality of life in cancer survivors.

MLH1/PMS2-deficient Endometrial Carcinomas in a Universally Screened Population: MLH1 Hypermethylation and Germline Mutation Status

MLH1/PMS2 loss due to epigenetic hypermethylation of the MLH1 promoter is the most common cause of mismatch repair deficiency in endometrial carcinoma, and typically provides reassurance against an associated germline mutation. To further characterize the genetic features of MLH1/PMS2-deficient endometrial cancers, the departmental database was searched for cases with dual MLH1/PMS2 loss and retained MSH2/6 expression which underwent MLH1 hypermethylation testing. Genetic testing results were obtained when available. One hundred seventeen endometrial cancers met inclusion criteria: 100 (85%) were MLH1-hypermethylated, 3 (3%) were low-level/borderline, 7 (6%) were nonmethylated, and 7 (6%) were insufficient for testing. Sixteen cases (12 MLH1-hypermethylated, 3 nonmethylated, and 1 insufficient for testing) underwent germline testing, 6 of which (37.5%) demonstrated germline variants of unknown significance (VUS) (MSH6, PMS2, POLD1, BRIP1, RAD51D, CHEK2) but no known deleterious mutations. Notably, however, the patients harboring the MSH6 and PMS2 germline VUS had clinical features concerning for Lynch syndrome. One nonmethylated, germline-normal case underwent somatic tumor testing, and demonstrated a somatic MLH1 mutation. In summary, MLH1-hypermethylation accounts for the vast majority of MLH1/PMS2-deficient cancers in a universally screened population, although MLH1 somatic and germline mutations can occur. Occasionally, patients with MLH1-hypermethlated tumors also bear germline VUS in other mismatch repair genes as well as genes implicated in other hereditary cancer syndromes, but their clinical relevance is unclear. Family and personal cancer histories must always be evaluated to determine the need for germline testing in women with loss of MLH1/PMS2, even in the setting of hypermethylation.

Characteristics of Immune Memory and Effector Activity to Cancer-Expressed MHC Class I Phosphopeptides Differ in Healthy Donors and Ovarian Cancer Patients

Elevated immunity to cancer-expressed antigens can be detected in people with no history of cancer and may contribute to cancer prevention. We have previously reported that MHC-restricted phosphopeptides are cancer-expressed antigens and targets of immune recognition. However, the extent to which this immunity reflects prior or ongoing phosphopeptide exposures was not investigated. In this study, we found that preexisting immune memory to cancer-expressed phosphopeptides was evident in most healthy donors, but the breadth among donors was highly variable. Although three phosphopeptides were recognized by most donors, suggesting exposures to common microbial/infectious agents, most of the 205 tested phosphopeptides were not recognized by peripheral blood mononuclear cells (PBMC) from any donor and the remainder were recognized by only 1 to 3 donors. In longitudinal analyses of 2 donors, effector immune response profiles suggested active reexposures to a subset of phosphopeptides. These findings suggest that the immunogens generating most phosphopeptide-specific immune memory are rare infectious agents or incipient cancer cells with distinct phosphoproteome dysregulations, and that repetitive immunogenic exposures occur in individual donors. Phosphopeptide-specific immunity in PBMCs and tumor-infiltrating lymphocytes from ovarian cancer patients was limited, regardless of whether the phosphopeptide was expressed on the tumor. However, 4 of 10 patients responded to 1 to 2 immunodominant phosphopeptides, and 1 showed an elevated effector response to a tumor-expressed phosphopeptide. As the tumors from these patients displayed many phosphopeptides, these data are consistent with lack of prior exposure or impaired ability to respond to some phosphopeptides and suggest that enhancing phosphopeptide-specific T-cell responses could be a useful approach to improve tumor immunotherapy.

Patient-reported outcome changes at the end of life in recurrent platinum-resistant ovarian cancer: An NRG oncology/GOG study

OBJECTIVES

In a prospective study of platinum-resistant ovarian cancer patients, we examined whether the Disease-related Symptoms-Physical (DRS--P) scale of the NCCN/FACT-Ovarian Cancer Symptom Index-18 (NFOSI-18) is responsive to clinical change in patients estimated by their provider to survive at least six months.

METHODS

The NFOSI-18, and other FACT measures, was collected at study entry and 3 and 6 months post-enrollment. Measures were compared for those who died or dropped off study prior to 3 months or prior to 6 months (assumed as health deterioration over time), or those who stayed on study through 6 months (presumed as stable disease over time). Statistical analyses included a fitted linear mixed model for estimating the group differences over time, Cox regression to assess the probability of survival with patient-reported outcomes, and effect size.

RESULTS

DRS-P scores of patients who completed only one assessment were significantly lower compared to patients who were able to complete two assessments [5.9 points lower (2.0-9.8); p < 0.01], or three assessments [8.1 points lower (4.8-11.5); p < 0.01]. Measures of abdominal discomfort, functional well-being, emotional well-being, and quality of life were also significant, but treatment side effects were not. Further, in every scale except for neurotoxicity, higher (better) baseline scores were associated with a decreased likelihood of death, after adjusting for age, performance and disease status.

CONCLUSION

The NFOSI-18 DRS-P scale is responsive to clinical change. It has potential as an indicator of changing health status with ovarian cancer disease progression, distinct from treatment side effects.

FLORA-5: Front-line chemoimmunotherapy (Paclitaxel-Carboplatin-Oregovomab [PCO] versus chemotherapy (Paclitaxel-Carboplatin-Placebo [PCP]) in patients with advanced epithelial ovarian cancer (EOC)—Phase III double-blind placebo controlled multinational study

TPS5606

Background: Oregovomab binds tumor-associated CA125 rendering the target antigen CA125 more immunogenic or “neoantigen-like” through altered and enhanced antigen processing and presentation to specific T cells. This phenomenon is hypothesized to bypass tumor-associated immune suppression when administered in combination with chemotherapy. In a randomized phase II study, immunization with oregovomab in a schedule-dependent combination with paclitaxel and carboplatin induced tumor immunity and demonstrated significant improvement in PFS (median (months) 41.8 PCO vs 12.3 PCP, HR 0.44 p = 0.0027, and OS median N.E. PCO vs 43.2 PCP HR O.34 (p = 0.0077)) in patients with previously untreated EOC. The FLORA-5, the definitive confirmatory global registration trial, is currently recruiting patients in the front-line setting. Methods: The study is a phase 3, multicenter, double-blind, placebo-controlled clinical trial. Optimally debulked patients with FIGO III/IV EOC and serum CA125 > 50 U/ml receiving adjuvant (Cohort 1) or neoadjuvant (Cohort 2) chemotherapy will be randomized post-surgery to paclitaxel and carboplatin with or without oregovomab. Patients with germline BRCA1/2 mutations will be excluded. Chemotherapy will be administered every 3 weeks in both cohorts. Oregovomab/placebo is administered simultaneously at cycles 1, 3, and 5 of chemotherapy with a single maintenance dose at 12 weeks following cycle 5 in Cohort 1. Neoadjuvant patients (Cohort 2) will be administered oregovomab/placebo post interval debulking surgery at cycles 4 and 6 with maintenance doses at 6- and 18-weeks following cycle 6. No other post front-line maintenance therapy is permitted. The primary objective is PFS determined by RECIST 1.1 criteria. Cohort 1 will recruit 372 patients with a 90% power to detect a difference with an alpha of 0.025 and a hazard ratio of 0.65 when 252 PFS events have been observed. Cohort 2 will be analyzed separately recruiting 232 patients with a 90% power to detect a difference with an alpha of 0.025 and a hazard ratio of 0.60 when 165 PFS events have been observed. An interim analysis for futility will be performed. Secondary objectives include OS, frequency and severity of adverse events, and quality of life. Exploratory objectives include iRECIST, TFST, TSST, PFS2, and evaluation of potential biomarkers. The study is actively enrolling in the US with 9 patients enrolled at time of submission. Centers in Europe, South America and Asia are expected to begin accruing shortly. Clinical trial information: NCT04498117.

Phase II study of atezolizumab in combination with bevacizumab in patients with advanced cervical cancer

Background

There are limited treatment options for patients with metastatic or recurrent cervical cancer. Platinum-based chemotherapy plus the anti-vascular endothelial growth factor antibody bevacizumab remains the mainstay of advanced treatment. Pembrolizumab is Food and Drug Agency approved for programmed death ligand 1 (PD-L1) positive cervical cancer with a modest response rate. This is the first study to report the efficacy and safety of the PD-L1 antibody atezolizumab in combination with bevacizumab in advanced cervical cancer.

Methods

We report the results from a phase II, open-label, multicenter study (NCT02921269). Patients with advanced cervical cancer were treated with bevacizumab 15 mg/kg intravenous every 3 weeks and atezolizumab 1200 mg intravenous every 3 weeks. The primary objective was to measure the objective response rate (ORR). Secondary endpoints included disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and safety.

Results

In the total evaluable population (n=10), zero patients achieved an objective response as assessed by Response Evaluation Criteria In Solid Tumors (RECIST) V.1.1, resulting in a confirmed ORR of 0%. Of note, there were two patients who achieved an unconfirmed PR. The DCR by RECIST V.1.1 was 60% (0% complete response, 0% partial response, 60% stable disease). Median PFS was 2.9 months (95% CI, 1.8 to 6) and median OS was 8.9 months (95% CI, 3.4 to 21.9). Safety results were generally consistent with the known safety profile of both drugs, notably with two high-grade neurologic events.

Conclusions

The combination of bevacizumab and atezolizumab did not meet the predefined efficacy endpoint, as addition of bevacizumab to PD-L1 blockade did not appear to enhance the ORR in cervical cancer.

Neoadjuvant chemotherapy with paclitaxel/carboplatin/bevacizumab in advanced vulvar cancer: Time to rethink standard of care?

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Current chemoradiation and surgical treatments for advanced vulvar cancer treatments are morbid.

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Neoadjuvant therapy with paclitaxel/carboplatin/bevacizumab can have impressive tumor regression with good quality of life.

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Further research on neoadjuvant treatment and targeted therapies are needed for advanced vulvar cancers.

Vulvar cancer remains a rare entity and treatment options for advanced disease are limited. This case report highlights the excellent response of two patients with FIGO Stage IV vulvar cancer treated with neoadjuvant paclitaxel/carboplatin/bevacizumab chemotherapy. While definitive conclusions are impossible, neoadjuvant chemotherapy may ultimately prove to be a better initial treatment option for locally advanced disease in terms of quality of life and response compared to the traditional chemoradiation regimens.

"Moving Away From Cancer" Prospective Exercise Trial for Female Rural Cancer Survivors: How Can We Step It Up?

PURPOSE

This prospective trial's objective was to determine feasibility and outcomes of an exercise-based intervention for rural overweight/obese female cancer survivors.

MATERIALS AND METHODS

Survivors of endometrial, breast, or ovarian cancer enrolled in a 6-month program of increased aerobic activity (30 minutes daily walking) and strength-training exercises using exercise bands (THERABAND; Akron, OH) with personalized telephone motivational coaching. Baseline demographics, anthropomorphic measurements, quality of life (QOL), fitness, and readiness to adopt exercise changes were assessed; daily steps, band use, and follow-up measurements were assessed at 3 and 6 months. Study completion was modeled using logistic regression.

RESULTS

The mean age of the 99 women was 59.9 years, the mean body mass index (BMI) was 35.9 kg/m², 88.9% were white, and 41.4% reported current exercise. Fifty-five women (55.6%) completed the 6-month program, and 36 (36.4%) completed exercise interventions. Using logistic regression to model study completion, only baseline QOL scores (physical component summary) and mental component summary) remained significant predictors. The mean weight change was a gain (0.88 kg). Higher MCS baseline scores and prior regular exercise predicted continued exercise and increased step counts, whereas higher BMI and baseline sleep predicted decreased QOL. Top walking barriers were feeling unwell and weather; barriers to strength exercises were band dislike and pain.

CONCLUSION

The most significant predictor of trial completion and improved exercise outcomes was a higher baseline mental QOL. Motivation, belief in the importance of exercise, and prescribed/monitored exercise regimens were not sufficient; supportive and cognitive behavioral therapy interventions for survivors are needed to sustain uptake.

Adjuvant treatment improves overall survival in women with high-intermediate risk early-stage endometrial cancer with lymphovascular space invasion

BACKGROUND

Adjuvant therapy in early-stage endometrial cancer has not shown a clear overall survival benefit, and hence, patient selection remains crucial.

OBJECTIVE

To determine whether women with high-intermediate risk, early-stage endometrial cancer with lymphovascular space invasion particularly benefit from adjuvant treatment in improving oncologic outcomes.

METHODS

A multi-center retrospective study was conducted in women with stage IA, IB, and II endometrial cancer with lymphovascular space invasion who met criteria for high-intermediate risk by Gynecologic Oncology Group (GOG) 99. Patients were stratified by the type of adjuvant treatment received. Clinical and pathologic features were abstracted. Progression-free and overall survival were evaluated using multivariable analysis.

RESULTS

405 patients were included with the median age of 67 years (range 27-92, IQR 59-73). 75.0% of the patients had full staging with lymphadenectomy, and 8.6% had sentinel lymph node biopsy (total 83.6%). After surgery, 24.9% of the patients underwent observation and 75.1% received adjuvant therapy, which included external beam radiation therapy (15.1%), vaginal brachytherapy (45.4%), and combined brachytherapy + chemotherapy (19.1%). Overall, adjuvant treatment resulted in improved oncologic outcomes for both 5-year progression-free survival (77.2% vs 69.6%, HR 0.55, p=0.01) and overall survival (81.5% vs 60.2%, HR 0.42, p<0.001). After adjusting for stage, grade 2/3, and age, improved progression-free survival and overall survival were observed for the following adjuvant subgroups compared with observation: external beam radiation (overall survival HR 0.47, p=0.047, progression-free survival not significant), vaginal brachytherapy (overall survival HR 0.35, p<0.001; progression-free survival HR 0.42, p=0.003), and brachytherapy + chemotherapy (overall survival HR 0.30 p=0.002; progression-free survival HR 0.35, p=0.006). Compared with vaginal brachytherapy alone, external beam radiation or the addition of chemotherapy did not further improve progression-free survival (p=0.80, p=0.65, respectively) or overall survival (p=0.47, p=0.74, respectively).

CONCLUSION

Adjuvant therapy improves both progression-free survival and overall survival in women with early-stage endometrial cancer meeting high-intermediate risk criteria with lymphovascular space invasion. External beam radiation or adding chemotherapy did not confer additional survival advantage compared with vaginal brachytherapy alone.

Evaluation of breast screening strategies in a high risk breast and ovarian cancer clinic

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BRCA mutation carriers are more likely to be diagnosed with breast cancer compared to high-risk non-BRCA carriers.

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MRI was able to effectively identify DCIS in the BRCA population.

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In BRCA mutation carriers younger than 40, there were no MRI occult cancers found.

Recent data suggest that BRCA mutation carriers younger than 40 may not benefit from mammography in addition to MRI. Our objective was to evaluate screening modalities utilized in a high-risk population. Clinicopathologic data were abstracted for patients followed in a high risk clinic from 2007 to 2017. Descriptive statistics were calculated and associations between categorical variables were evaluated using chi-square tests. 631 women comprised the study population; 496 patients had no known mutation (79%), 128 (20%) had a BRCA mutation, and 7 patients had other deleterious mutations. BRCA mutation carriers were more likely to have cancers diagnosed after mammogram callbacks (p = 0.0046) and biopsies (p = 0.0026) compared to non-BRCA mutation carriers. BRCA mutation carriers were also more likely to have cancers diagnosed after biopsies following screening MRI (p = 0.045). 13 BRCA patients were diagnosed with cancer (average age 51). Of the cancers diagnosed after abnormal MRI, 3 were DCIS; all 3 patients had a normal mammogram 4–6 months prior. In those found after abnormal mammogram (n = 6), follow up MRI was performed in 4 cases; all demonstrated the lesion. Three patients were diagnosed younger than 40, 1 on mammogram and 2 on MRI. The patient diagnosed on mammogram had no prior MRI and the lesion was seen on follow-up MRI. Interval screening MRI identified DCIS in BRCA patients with a previous normal mammogram and cancers diagnosed on mammogram were all identified on follow-up MRI. These findings support further evaluation of MRI alone until age 40 in BRCA mutation carriers.

Mechanisms to increase cascade testing in hereditary breast and ovarian cancer: Impact of introducing standardized communication aids into genetic counseling

AIM

Precancer identification of women with hereditary breast and ovarian cancer (HBOC) could prevent 20% of these ovarian cancers. The objective was to determine whether standardized Facing Our Risk of Cancer Empowered (FORCE) materials are acceptable, improve knowledge of HBOC and increase disclosure to family members.

METHODS

A prospective cohort of women with breast or ovarian cancer was identified prior to genetic testing. Subjects completed a baseline knowledge survey and were provided three communication aids. Knowledge, acceptability and communication to family members were reassessed at 6 months and compared to a retrospective cohort who had undergone genetic testing for breast or ovarian cancer prior to the intervention. The primary outcome was increase in HBOC knowledge, requiring 20 pre- and postknowledge scores to detect a 10% difference.

RESULTS

Forty women were enrolled. The median age at cancer diagnosis was 50 years and 55% had a family history of breast or ovarian cancer. Though subjects found the resources acceptable, knowledge scores did not improve after their use. Disclosure rates were of no different between cohorts (83% preintervention vs 77% postintervention, P = 0.26) though there was an increase in deleterious mutation carriers, 0% (0/6) preintervention vs 100% (22/22) postintervention. Rates of subsequent testing in relatives were low in both preintervention and postintervention cohorts (0% vs 4.5%).

CONCLUSION

Inclusion of standardized communication tools is acceptable to patients. Knowledge did not improve after their use. In deleterious mutation carriers, disclosure rates increased postintervention.

Optimal age for genetic cancer predisposition testing in hereditary SMARCA4 Ovarian Cancer Families: How young is too young?

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Small cell carcinoma of the ovary, hypercalcemic type is a deadly cancer.

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SMARCA4 deleterious variant causes hypercalcemic small cell carcinoma of the ovary.

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Deleterious variants of the SMARCA4 gene can be somatic or germline.

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Cascade genetic testing within at-risk families, need to be performed.

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Use a shared decision model to optimize genetic testing for patients and family.

Small cell carcinoma of the ovary, hypercalcemic type is a rare, aggressive, and typically fatal ovarian cancer that primarily affects young women less than 40 years of age. It is caused by a pathogenic variant in the SMARCA4 gene, with nearly half of patients found to have germline pathogenic variants and the remainder demonstrating somatic SMARCA4 pathogenic variants. This case report discusses an illustrative case and explores the existing data and potential recommendations to optimize timing of genetic testing in family members, given the presence of a familial germline pathogenic variant.

Adjuvant therapy for early stage, endometrial cancer with lymphovascular space invasion: Is there a role for chemotherapy?

OBJECTIVES

Lymphovascular space invasion (LVSI) is an independent risk factor for recurrence and poor survival in early-stage endometrioid endometrial cancer (EEC), but optimal adjuvant treatment is unknown. We aimed to compare the survival of women with early-stage EEC with LVSI treated postoperatively with observation (OBS), radiation (RAD, external beam and/or vaginal brachytherapy), or chemotherapy (CHEMO)+/-RAD.

METHODS

This was a multi-institutional, retrospective cohort study of women with stage I or II EEC with LVSI who underwent hysterectomy+/-lymphadenectomy from 2005 to 2015 and received OBS, RAD, or CHEMO+/-RAD postoperatively. Progression-free survival and overall survival were evaluated using Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

In total, 478 women were included; median age was 64 years, median follow-up was 50.3 months. After surgery, 143 (30%) underwent OBS, 232 (48.5%) received RAD, and 103(21.5%) received CHEMO+/-RAD (95% of whom received RAD). Demographics were similar among groups, but those undergoing OBS had lower stage and grade. A total of 101 (21%) women recurred. Progression-free survival (PFS) was improved in both CHEMO+/-RAD (HR = 0.18, 95% CI: 0.09-0.39) and RAD (HR = 0.31, 95% CI: 0.18-0.54) groups compared to OBS, though neither adjuvant therapy was superior to the other. However, in grade 3 tumors, the CHEMO+/-RAD group had superior PFS compared to both RAD (HR 0.25; 95% CI: 0.12-0.52) and OBS cohorts (HR = 0.10, 95% CI: 0.03-0.32). Overall survival did not differ by treatment.

CONCLUSIONS

In early-stage EEC with LVSI, adjuvant therapy improved PFS compared to observation alone. In those with grade 3 EEC, adjuvant chemotherapy with or without radiation improved PFS compared to observation or radiation alone.

When to Worry about Cancer: Concurrent Carcinoma and Recurrence in Borderline Ovarian Tumors

OBJECTIVES

The objectives of this study were to identify and assess the factors associated with concurrent carcinoma and recurrence in women with epithelial borderline ovarian tumors.

METHODS

The cancer and pathology databases at a tertiary care academic cancer center were queried for all borderline ovarian tumors from 2005 to 2015. Cases with/without concurrent ovarian carcinoma and with/without recurrence were compared.

RESULTS

A total of 123 women with borderline tumors were identified (mean age 51.3 years). Concurrent carcinoma was present in 31 (25.2%). Women with concurrent carcinoma were significantly more likely to be peri- or postmenopausal, have an elevated CA-125, and have a nonserous histology. Seven (5.7%) women's cancer recurred at a mean of 23.5 months (mean follow-up 30.0 months). Women with recurrence were more likely to be nonwhite, have concurrent invasive carcinoma, and have had residual disease at the time of surgery.

CONCLUSIONS

Epithelial borderline ovarian tumors often co-exist with carcinoma and occur more frequently in postmenopausal women, in women with elevated CA-125, and in tumors with nonserous histology. The presence of any of these factors should alert clinicians to the potential need for comprehensive staging at the time of surgery. The recurrence of borderline tumors is associated with nonwhite race, concurrent carcinoma, and residual disease at initial surgery.

Genetic counseling referral for ovarian cancer patients: a call to action

The hereditary contribution to ovarian cancer has been increasingly recognized over the past decade, with a 2014 Society of Gynecologic Oncology (SGO) recommendation for all women with epithelial ovarian cancer to be considered for genetic testing. The objective of the study was to determine if disparities exist in genetic referrals and characterize referral patterns over time. A retrospective cohort study included all women diagnosed with invasive epithelial ovarian cancer at the University of Virginia from 2004 to 2015. Clinicopathologic data were abstracted from the electronic medical record and analyzed for association with genetic referral and testing. We identified 696 cases, with a median age of 62 years and a median follow up of 25.2 months (range 1-115). Thirty-four percent were referred for genetic counseling with an 80% genetic testing rate in those women. Referrals increased from a rate of 8% in 2004 to 68% in 2015. On multivariable analysis, papillary serous histology (OR 1.6, 95% CI 1.0-2.6), stage III disease (OR 3.4, 95% CI 1.6-7.5), ovarian cancer family history (OR 2.6, 95% CI 1.5-4.6), breast cancer family history (OR 1.7, 95% CI 1.1-2.5), and diagnosis after 2014 (OR 2.3, 95% CI 1.3-4.1) remained significantly associated with genetics referral. Older age and living > 100 miles away were associated with decreased referral (OR 0.97, 95% CI 0.95-0.99 per year and OR 0.49, 95% CI 0.28-0.86). As only 68% of women with epithelial ovarian cancer were referred in 2015 innovative strategies such as Medicare coverage for counseling are still needed to universalize testing.

Safety lead-in of the MEK inhibitor trametinib in combination with GSK2141795, an AKT inhibitor, in patients with recurrent endometrial cancer: An NRG Oncology/GOG study

OBJECTIVE

We sought to determine safety and efficacy of the AKT inhibitor, GSK2141795, combined with the MEK inhibitor, trametinib, in endometrial cancer.

METHODS

Patients with measurable recurrent endometrial cancer were eligible. One to two prior cytotoxic regimens were allowed; prior use of a MEK or PI3K pathway inhibitor was excluded. Initial trial design consisted of a KRAS mutation stratified randomized phase II with a safety lead-in evaluating the combination. For the safety lead in, the previously recommended phase 2 dose (RP2D; trametinib 1.5 mg, GSK2141795 50 mg) was chosen for Dose Level 1 (DL1).

RESULTS

Of 26 enrolled patients, 14 were treated on DL1 and 12 were treated on DL-1 (trametinib 1.5 mg, GSK2141795 25 mg). Most common histologies were endometrioid (58%) and serous (27%). Four of 25 (16%) patients were KRAS mutant. Dose limiting toxicities (DLTs) were assessed during cycle 1. DL1 had 8 DLTs (hypertension (n = 2), mucositis (2), rash (2), dehydration, stroke/acute kidney injury). DL1 was deemed non-tolerable so DL-1 was explored. DL-1 had no DLTs. Sixty-five percent of patients had ≥ grade 3 toxicity. There were no responses in DL1 (0%, 90%CI 0-15%) and 1 response in DL-1 (8.3%, 90%CI 0.4-33.9%). Proportion PFS at 6 months for DL1 is 14%, and 25% for DL-1.

CONCLUSION

The combination of trametinib and GSK2141795 had high levels of toxicity in endometrial cancer at the previously RP2D but was tolerable at a reduced dose. Due to insufficient preliminary efficacy at a tolerable dose, the Phase II study was not initiated.

Phase II Trial of Chemopreventive Effects of Levonorgestrel on Ovarian and Fallopian Tube Epithelium in Women at High Risk for Ovarian Cancer: An NRG Oncology Group/GOG Study

A large body of epidemiologic evidence has shown that use of progestin-containing preparations lowers ovarian cancer risk. The purpose of the current study was to gather further preclinical evidence supporting progestins as cancer chemopreventives by demonstrating progestin-activation of surrogate endpoint biomarkers pertinent to cancer prevention in the genital tract of women at increased risk of ovarian cancer. There were 64 women enrolled in a multi-institutional randomized trial who chose to undergo risk-reducing bilateral salpingo-oophorectomy (BSO) and to receive the progestin levonorgestrel or placebo for 4 to 6 weeks prior to undergoing BSO. The ovarian and fallopian tube epithelia (FTE) were compared immunohistochemically for effects of levonorgestrel on apoptosis (primary endpoint). Secondary endpoints included TGFβ isoform expression, proliferation, and karyometric features of nuclear abnormality. In both the ovary and fallopian tube, levonorgestrel did not confer significant changes in apoptosis or expression of the TGFβ1, 2, or 3 isoforms. In the ovarian epithelium, treatment with levonorgestrel significantly decreased the proliferation index. The mean ovarian Ki-67 value in the placebo arm was 2.027 per 100 cells versus 0.775 per 100 cells in the levonorgestrel arm (two-sided P value via Mann-Whitney U test = 0.0114). The karyometric signature of nuclei in both the ovarian and FTE deviated significantly from normal controls (women at average risk of ovarian cancer), but was significantly less abnormal in women treated with levonorgestrel. These karyometric data further support the idea that progestins may clear genetically abnormal cells and act as chemopreventive agents against ovarian and fallopian tube cancer.

Cases and evidence for panel testing in cancer genetics: Is site-specific testing dead?

Historically in cancer genetic counseling, when a pathogenic variant is found which explains the cancers in the family, at risk family members are offered site-specific testing to identify whether or not they have the previously identified pathogenic variant. Factors such as turnaround times, cost, and insurance coverage all made site-specific testing the most appropriate testing option; however, as turnaround times and costs have substantially dropped and the recognition of double heterozygous families and families with nontraditional presentations has increased, the utility of site-specific testing should be questioned. We present four cases where ordering site-specific testing would have missed a clinically relevant pathogenic variant which raises the question of whether or not site-specific testing should be regularly used in cancer genetic testing.

Evaluation of screening and risk-reducing surgery for women followed in a high-risk breast/ovarian cancer clinic: it is all about the tubes in BRCA mutation carriers

The objectives of this study were to determine both surgical and subsequent cancer outcomes for high-risk women from the University of Virginia's High-Risk Breast/Ovarian Cancer clinic undergoing ovarian cancer risk-reducing surgery. Retrospective review identified high risk women who had ovarian risk reducing surgery over the past decade and surgical outcomes, pathology, pre-operative screening results, and pre-/post-operative cancer diagnoses were evaluated. One hundred and eighty-three high-risk women had risk reducing surgery at a mean age of 50.1 years and with a mean BMI of 28.9 kg/m2 at the time of surgery. Most women (103; 56.3%) had a strong family history of cancer concerning for a hereditary syndrome without an identified mutation, 35.5% of women carried a known deleterious mutation and 7.7% of women had a personal history of breast or ovarian cancer. The most common procedure was a risk-reducing bilateral salpingo-oophorectomy with or without hysterectomy (RRBSO, 89.1%). All women underwent the Sectioning and Extensively Examining the Fimbriated End (SEE-FIM) pathology protocol which found two (1.1%) invasive ovarian cancers (one ovarian/tubal carcinosarcoma, one granulosa cell ovarian cancer), three (1.6%) serous tubal intraepithelial carcinomas (STIC), and one (1.1%) invasive fallopian tube cancer. Subsequent cancer diagnoses included one (0.5%) primary peritoneal cancer, four (2.2%) DCIS, and seven (3.8%) invasive breast cancers. Ultimately, among all high-risk women undergoing RR surgery, about 3.3% were diagnosed with a STIC or an ovarian cancer none of which were identified on screening. All STIC and tubal cancers were diagnosed in women with BRCA mutations (6.6% rate for this group).

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Ovarian risk reducing surgery improves outcomes.

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Women with BRCA 1 mutations have a higher risk of occult tubal pathology.

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Subsequent cancers, particularly breast cancer, occur in these women.

Intussusception as a rare cause of bowel obstruction in a woman with recurrent ovarian cancer

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A woman with recurrent ovarian cancer presented with rectal bleeding and cramping abdominal pain.

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CT showed ileocolic intussusception.

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In ovarian cancer, intussusception requires surgery whereas other bowel obstructions are initially treated conservatively.

Endometrial cancer in an increasingly obese population: Exploring alternative options when surgery may not cut it

OBJECTIVES

The study objectives were to describe outcomes of obese patients with early endometrial cancer following primary non-surgical treatment, assess predictors of response, and estimate the increased surgical risk for these women.

METHODS

Retrospective chart review identified women with early stage endometrial cancer at a single institution with BMI ≥ 30 kg/m2 who did not undergo surgery as primary treatment modality due to obesity and medical co-morbidities. Clinicopathologic factors were abstracted, characteristics of responders vs. non-responders compared and the National Surgical Quality Improvement Program (NSQIP) surgical risk calculator utilized to quantify surgical risks.

RESULTS

Fifty-one patients were identified, with a mean BMI of 49.0 kg/m2. The NSQIP calculator predicted a significantly higher complication rate for our cohort compared to the expected average risk for hysterectomy (18.8% vs 7.2%, p < .0001). The majority of patients were treated with radiation alone (49%), followed by hormone therapy (45.1%). Response rates were 38.1% for women treated with hormones and 63.6% in the radiation group (p = .063). No significant differences were identified between responders and non-responders with regard to NSQIP scores, BMI, co-morbidities or age. Among those with persistent or progressive disease, 87.5% responded to secondary treatment. Only one death was from cancer progression. Two individuals died following treatment complications (one surgical, one chemotherapy); the remaining twelve deaths were due to pre-existing co-morbidities.

CONCLUSIONS

Hormone and radiation therapy are both viable options for obese patients deemed to have too significant risk of surgical complications. Pursuing surgical intervention in this population may do more harm than good.

Vaginal sarcoidosis without other organ involvement in a patient with a history of endometrial cancer: A case report

•Patient with history of endometrial cancer presented with vaginal discharge.•Biopsy showed non-necrotizing granulomas, potentially sarcoidosis.•She responded to steroids with symptom resolution.

Analysis of the circular RNA transcriptome in endometrial cancer

Circular RNAs (circRNAs) are a naturally occurring family of non-coding RNA that may regulate gene expression in mammals. circRNAs are more stable than messenger RNAs due to their resistance to RNA exonuclease. A growing body of evidence has shown that the expression of circRNAs is regulated during development in a tissue-specific manner. CircRNAs have been implicated in a number of cancers; however, their role in endometrial cancer (EC) is completely unknown. Here, we report the circular transcriptome specific for EC as determined by RNA sequencing. We found that the overall abundance of circRNAs is lower in EC than in normal endometrium. Further, there are numerous ‘hotspot’ genes from which circRNAs are transcribed that may account for alterations in circRNA expression between the normal and malignant endometrium. Most importantly, we have also identified circRNAs that are differentially expressed between malignant and normal endometrial tissue. The functional significance of these circRNAs in cancer remains to be determined, but they may serve as potential biomarkers for the diagnosis of EC or monitoring of EC progression.

Current and future role of genetic screening in gynecologic malignancies

The world of hereditary cancers has seen exponential growth in recent years. While hereditary breast and ovarian cancer and Lynch syndrome account for the majority of mutations encountered by gynecologists, newly identified deleterious genetic mutations continue to be unearthed with their associated risks of malignancies. However, these advances in genetic cancer predispositions then force practitioners and their patients to confront the uncertainties of these less commonly identified mutations and the fact that there is limited evidence to guide them in expected cancer risk and appropriate risk-reduction strategies. Given the speed of information, it is imperative to involve cancer genetics experts when counseling these patients. In addition, coordination of screening and care in conjunction with specialty high-risk clinics, if available, allows for patients to have centralized management for multiple cancer risks under the guidance of physicians with experience counseling these patients. The objective of this review is to present the current literature regarding genetic mutations associated with gynecologic malignancies as well to propose screening and risk-reduction options for these high-risk patients.

The impact of physician burnout on clinical and academic productivity of gynecologic oncologists: A decision analysis

OBJECTIVE

Physician burnout is associated with mental illness, alcohol abuse, and job dissatisfaction. Our objective was to estimate the impact of burnout on productivity of gynecologic oncologists during the first half of their career.

METHODS

A decision model evaluated the impact of burnout on total relative value (RVU) production during the first 15years of practice for gynecologic oncologists entering the workforce from 2011 to 2015. The SGO practice survey provided physician demographics and mean annual RVUs. Published data were used to estimate probability of burnout for male and female gynecologic oncologists, and the impact of depression, alcohol abuse, and early retirement. Academic productivity was defined as annual PubMed publications since finishing fellowship.

RESULTS

Without burnout, RVU production for the cohort of 250 gynecologic oncologists was 26.2 million (M) RVUs over 15years. With burnout, RVU production decreased by 1.6 M (5.9% decrease). Disproportionate rates of burnout among females resulted in 1.1 M lost RVUs for females vs. 488 K for males. Academic production without burnout was estimated at 9277 publications for the cohort. Burnout resulted in 1383 estimated fewer publications over 15years (14.9%).

CONCLUSIONS

The impact of burnout on clinical and academic productivity is substantial across all specialties. As health care systems struggle with human resource shortages, this study highlights the need for effective burnout prevention and wellness programs for gynecologic oncologists. Unless significant resources are designated to wellness programs, burnout will increasingly affect the care of our patients and the advancement of our field.

Hormonal Contraceptives for Endometrial Cancer Prevention in Obese and High-Risk Women in Virginia

OBJECTIVES

Endometrial cancer remains the fourth most common malignancy among US women, and hormonal contraceptives drastically reduce this risk. The study objectives were to assess the prescribing patterns, counseling practices, and knowledge of family physicians and obstetrician/gynecologists (OB/GYNs) regarding hormonal contraceptives, obesity, and cancer prevention.

METHODS

A 25-question survey was mailed to 4600 OB/GYNs and family practitioners licensed in Virginia to assess self-reported hormonal contraceptive prescription practices, patient evaluation and counseling, and gynecologic oncology knowledge. χ² and t tests were used to assess for differences across groups. P < 0.05 was deemed significant.

RESULTS

In total, 392 (9%) surveys were returned, with 256 (6%) being complete for analysis. The mean physician age was 53.6 years, 50.2% were men, and 92.6% of physicians prescribed hormonal contraception. Most physicians recognized decreased endometrial cancer risk associated with oral contraceptive pills (73.0%) and increased risk with obesity (95.3%), but only 36.7% consistently counseled patients on obesity-associated cancer risk. Compared with family physicians, OB/GYNs were more likely to cite endometrial cancer prevention as an indication for hormonal contraceptives (53.3% vs 10.9%, P < 0.0001); more often counseled patients on obesity-related cancer risk (P = 0.003); and were more likely to correctly identify Lynch syndrome (69.4% vs 22.5%, P < 0.0001), diabetes mellitus (85.2% vs 38.8%, P < 0.0001), and hypertension (41.7% vs 10.1%, P < 0.0001) as risk factors for endometrial cancer. Endometrial or ovarian cancer prevention factored into <2% of total hormonal contraception prescriptions; however, OB/GYN physicians were more likely to prescribe for those indications than family physicians (P = 0.005 and P < 0.001, respectively).

CONCLUSIONS

Family physicians and OB/GYNs could improve their knowledge of endometrial cancer risk factors and the use of hormonal contraception for chemoprevention. This represents a significant opportunity for both specialties to optimize primary endometrial cancer prevention in their increasingly obese and at-risk female patients.

The emerging role of long non-coding RNAs in endometrial cancer

The human genome is pervasively transcribed and approximately 98% of the genome is non-coding. Long non-coding RNAs (lncRNAs) are a heterogeneous group of RNA transcripts that are >200 nucleotides in length with minimal to no protein-coding potential. Similar to proteins, lncRNAs have important biological functions in both normal cells and disease states including many types of cancer. This review summarizes recent advances in our understanding of lncRNAs in cancer biology and highlights the potential for lncRNA as diagnostic biomarkers and therapeutics. Herein we focus on the poorly understood role of lncRNAs in endometrial cancer, the most common gynecologic malignancy in the developed world.

Body mass index and mortality in endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

To evaluate the association between body mass index (BMI) and mortality in women with endometrial cancer.

METHODS

A systematic review was performed utilizing a Medline search with Mesh keywords 'endometrial neoplasms' and ('body mass index' or 'obesity') and ('survival analysis' or 'mortality' or 'survivor' or 'survival') for studies published prior to June 2013. Inclusion criteria included studies that assessed associations between BMI and survival in endometrial cancer patients. Two investigators independently reviewed the title and abstract and full-text of articles for inclusion or exclusion decision; discordant decisions were adjudicated by a third reviewer. A random-effects model was constructed that was comparable to the standard random-effects models used in the meta-analysis of odds ratios. The model was fitted using SAS PROC NLMIXED.

RESULTS

1451 studies were identified and reviewed in duplicate, 18 met inclusion criteria. A random-effects meta-analysis demonstrated significantly higher odds of mortality with increasing BMI in endometrial cancer patients. Specifically the odds ratios were 1.01, 1.17, 1.26, and 1.66 for BMI categories of 25-29.9, 30-34.9, 35-39.9, and 40+, respectively. The odds ratio for all-cause mortality in endometrial cancer patients with a BMI≥40 compared to those with a BMI<25 was 1.66 (CI: 1.10-2.51, p=0.02). A single dose-response model indicated that a 10% increase in BMI resulted in a 9.2% increase in the odds of all-cause mortality (p=0.007).

CONCLUSION

Increased BMI is significantly associated with increased all-cause mortality in women with endometrial cancer, with the highest risk for those with a BMI≥40.

Metabolic vulnerabilities in endometrial cancer

Women with metabolic disorders, including obesity and diabetes, have an increased risk of developing endometrial cancer. However, the metabolism of endometrial tumors themselves has been largely understudied. Comparing human endometrial tumors and cells with their nonmalignant counterparts, we found that upregulation of the glucose transporter GLUT6 was more closely associated with the cancer phenotype than other hallmark cancer genes, including hexokinase 2 and pyruvate kinase M2. Importantly, suppression of GLUT6 expression inhibited glycolysis and survival of endometrial cancer cells. Glycolysis and lipogenesis were also highly coupled with the cancer phenotype in patient samples and cells. To test whether targeting endometrial cancer metabolism could be exploited as a therapeutic strategy, we screened a panel of compounds known to target diverse metabolic pathways in endometrial cells. We identified that the glycolytic inhibitor, 3-bromopyruvate, is a powerful antagonist of lipogenesis through pyruvylation of CoA. We also provide evidence that 3-bromopyruvate promotes cell death via a necrotic mechanism that does not involve reactive oxygen species and that 3-bromopyruvate impaired the growth of endometrial cancer xenografts.

Overcoming platinum resistance in preclinical models of ovarian cancer using the neddylation inhibitor MLN4924

The nearly ubiquitous development of chemoresistant disease remains a major obstacle against improving outcomes for patients with ovarian cancer. In this investigation, we evaluated the preclinical activity of MLN4924, an investigational inhibitor of the NEDD8-activating enzyme, in ovarian cancer cells. Efficacy of MLN4924 both alone and in combination with platinum was assessed. Overall, single-agent MLN4924 exhibited moderate activity in ovarian cancer cell lines. However, the combination of MLN4924 with cisplatin or carboplatin produced synergistic effects in SKOV3 and ES2 cells, as well as in primary ovarian cancer cell lines established from high-grade serous, clear cell, and serous borderline ovarian tumors. The efficacy of cisplatin plus MLN4924 was also evident in several in vitro models of platinum-resistant ovarian cancer. Mechanistically, the combination of cisplatin and MLN4924 was not associated with DNA re-replication, altered platinum-DNA adduct formation, abrogation of FANCD2 monoubiquitination, or CHK1 phosphorylation. An siRNA screen was used to investigate the contribution of each member of the cullin RING ligase (CRL) family of E3 ubiquitin ligases, the best-characterized downstream mediators of MLN4924's biologic effects. Cisplatin-induced cytotoxicity was augmented by depletion of CUL3, and antagonized by siCUL1 in both ES2 and SKOV3 ovarian cancer cells. This investigation identifies inhibition of neddylation as a novel mechanism for overcoming platinum resistance in vitro, and provides a strong rationale for clinical investigations of platinum and MLN4924 combinations in ovarian cancer.

A phase II evaluation of motesanib (AMG 706) in the treatment of persistent or recurrent ovarian, fallopian tube and primary peritoneal carcinomas: a Gynecologic Oncology Group study

OBJECTIVES

Vascular endothelial growth factors (VEGF) and their receptors have a critical role in stimulating the growth of ovarian cancer cells. Motesanib is a small molecule inhibitor of multiple receptor tyrosine kinases including VEGF receptors 1-3, as well as c-KIT and platelet-derived growth factor which are related to the VEGF family.

PATIENTS AND METHODS

Twenty-two eligible patients with recurrent ovarian, fallopian tube or primary peritoneal carcinoma were treated with an oral daily dose of 125 mg of motesanib. Peripheral blood was analyzed for circulating tumor cells (CTC) and circulating endothelial cells/circulating endothelial progenitors (CEC/CEP), VEGF levels and cell-free circulating DNA (cfDNA).

RESULTS

The study was abruptly halted after four patients developed posterior reversible encephalopathy syndrome. One patient had a partial response and seven patients had stable disease at the time they were removed from study treatment. Twelve of the 22 patients (50%) had indeterminate responses at trial closure. Early closure without clinical efficacy data precludes meaningful correlative studies.

CONCLUSIONS

The serious central nervous system toxicity observed in patients with recurrent ovarian cancer precluded full examination of this agent in this population. There were no clear cut explanations for the high incidence of this known class effect in the study population compared with patients with other cancers.

Frailty: an outcome predictor for elderly gynecologic oncology patients

OBJECTIVES

The objective of this pilot study was to determine if frailty predicts surgical complications among elderly women undergoing gynecologic oncology procedures.

METHODS

A cohort of gynecologic oncology patients age ≥ 65, undergoing surgery between March and December 2011 was identified. Frailty was evaluated using a validated assessment tool. The primary outcome measure was 30 day postoperative complication rate.

RESULTS

Forty women were approached for study entry and 37 (92%) enrolled. The mean age was 73 years (range 65-95). The majority of women had a malignancy and underwent a major abdominal surgical procedure. Twenty-one women (57%) were not frail, 10 (27%) were intermediately frail and 6 (16%) were frail. There was no difference in age or prevalence of medical comorbidities between groups. Frail women had a significantly higher BMI compared to intermediately frail and not frail women, (36.0, 31.5 and 26.1 kg/m(2), p=0.02). The rate of 30-day surgical complications increased with frailty score and was 24%, versus 67% for women who were not frail as compared to the frail (p=0.04).

CONCLUSIONS

Pre-operative frailty assessment is well accepted by gynecologic oncology patients and feasible in a clinic setting. Frail women had a higher BMI, indicating that low body weight is not a marker for frailty, and had a significantly higher rate of 30-day postoperative complications in this pilot study. Initial findings support the concept of measuring frailty as a possible predictor for postoperative morbidity that will allow for improved patient counseling and decision making.

Coexisting atypical polypoid adenomyoma and endometrioid endometrial carcinoma in a young woman with Cowden Syndrome: Case report and implications for screening and prevention

► Cowden Syndrome is a rare hereditary cancer syndrome, which confers an increased risk of breast, thyroid, endometrial and colon cancer. ► Atypical polypoid adenomyoma does not generally represent a premalignant lesion, but must be carefully screened for foci of malignancy. ► Cancer screening must be intensified for patients who meet the diagnostic criteria for Cowden Syndrome.

Risk for residual adenocarcinoma in situ or cervical adenocarcinoma in women undergoing loop electrosurgical excision procedure/conization for adenocarcinoma in situ

OBJECTIVE

To evaluate the risk for residual adenocarcinoma in situ (AIS) or cervical adenocarcinoma in women undergoing loop electrosurgical excision procedure (LEEP)/conization as the initial management for AIS.

STUDY DESIGN

A retrospective chart study was conducted from 1990 to 2005. Patients with AIS were identified from a pathology database.

RESULTS

Forty-three patients were identified with AIS of the cervix who were initially treated with LEEP/conization. Twelve cases of invasive adenocarcinoma (28%) were identified on LEEP/conization. Margin status was available for 41 patients. Twenty (49%) patients had a positive margin, and 21 (51%) patients had a negative margin. Nineteen women with positive margins underwent definitive surgical therapy; 68% had residual AIS. Eleven women with negative margins underwent hysterectomy; 45% had residual AIS. Women with positive and negative margins were compared and found to differ significantly in regard to diagnosis of adenocarcinoma on LEEP/conization.

CONCLUSION

Women status post-LEEP/conization for AIS have a high risk of residual AIS, even with negative conization margins. If definitive hysterectomy is deferred, close follow-up is mandatory.