Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Tumor Evolution in a Patient with Recurrent Endometrial Cancer and Synchronous Neuroendocrine Cancer and Response to Checkpoint Inhibitor Treatment

Both metachronous and synchronous tumors pose a diagnostic and clinical challenge, more so when one of the specimens demonstrates the rare neuroendocrine histology. We describe a patient with sarcoidosis who was treated for endometrial and ovarian neoplasm, recurred with two separate histologies (adenocarcinoma and high grade neuroendocrine), both associated with microsatellite instability (MSI)-high status. Targeted next-generation sequencing of tumor with synonymous somatic alterations pointed to a common ancestry of all three tumors and patient was successfully treated with a tailored immunotherapy regimen. Her sarcoidosis worsened only slightly, and immunotherapy did not need to be discontinued. This case highlights the importance of molecular testing for the optimal therapy of complex synchronous tumors and the need for communication between surgical and medical oncologists in patients with MSI-high cancer. KEY POINTS: The case of a patient with a recurrent gynecological cancer presenting as microsatellite instability (MSI)-high endometrial adenocarcinoma and MSI-high neuroendocrine tumor is reported. This case demonstrated a common genetic lineage with good response to checkpoint inhibition without clinical worsening of autoimmune disease. This article adds to the literature, suggesting tumor evolution with neuroendocrine differentiation in some cancers, and argues that a molecular-based approach to treatment might achieve better understanding and possibly superior treatment outcomes.

Erratum: Purpuric bullae on the lower extremities

In the article "Purpuric bullae on the lower extremities" from the June 2020 issue (Grandhi R, Shamloul N, Powell M. Cutis. 2020;105:282,286-287), the images were incorrect. The correct images appear below. The article has been corrected online at www.mdedge.com/dermatology. We apologize for the error.

Bevacizumab plus fosbretabulin in recurrent ovarian cancer: Overall survival and exploratory analyses of a randomized phase II NRG oncology/gynecologic oncology group study

OBJECTIVE

To explore the relationship between tumor size and response to combined anti-vascular targeted therapy using the anti-angiogenesis inhibitor, bevacizumab, and the tubulin-binding vascular disrupting agent, fosbretabulin.

METHODS

An exploratory, post-hoc analysis of the randomized phase II trial, Gynecologic Oncology Group-0186I, was performed. One hundred and seven patients with recurrent ovarian carcinoma, treated with up to 3 prior regimens, were randomized to bevacizumab 15 mg/kg body weight with or without intravenous fosbretabulin 60 mg/m² body surface area every 21 days until progression or unacceptable toxicity. The primary analysis favored the combination (HR 0.69; 95% CI, 0.47-1.00; p = .049) [Monk BJ, et al. J Clin Oncol 2016;34:2279-86]. The Cox proportional hazards model was used to estimate the treatment effect in various subpopulations.

RESULTS

With extended follow-up, the median PFS for bevacizumab plus fosbretabulin was 7.6  months as compared to 4.8  months with bevacizumab alone (HR 0.74; 90% CI, 0.54-1.02). Overall survival was similar in the experimental and control arms (25.2 vs 24.4 mos, respectively, HR 0.85; 90% CI, 0.59-1.22; p = .461). Eighty-one patients had measurable disease and median tumor size was 5.7  cm. In the ≤5.7  cm subgroup, the HR for progression or death was 0.77 (90% CI 0.45-1.31). Patients with tumors >5.7  cm (n = 40) had a HR for progression or death of 0.55; 90% CI, 0.32-0.96; p = .075).

CONCLUSIONS

Although no significant survival benefit was observed, the trend showing a reduced HR for progression or death with increasing tumor size when fosbretabulin is added to bevacizumab compared to bevacizumab alone warrants further study.

Abstract A13: Therapeutic AXL inhibition with AVB-S6-500 improves response to chemotherapy and induces a homologous recombination deficiency in ovarian cancer

Background: Over 80% of patients with advanced ovarian cancer will develop chemoresistance and die within 5 years. Biomarkers to predict chemoresponse and novel therapies to target chemoresistance would be practice changing. We aim to establish serum and tissue GAS6 as predictive biomarkers of chemoresponse and to determine if AXL inhibition through sequestration of its ligand, GAS6, with AVB-S6-500 (AVB) can improve chemoresponse. Further, we desired to understand the affect AVB has on DNA damage response (DDR).

Methods: AVB was supplied by Aravive Biologics. High-grade serous ovarian cancer (HGSOC) tumor samples were obtained pre- and post-neoadjuvant chemotherapy. AXL and GAS6 expression were evaluated by immunohistochemistry and serum concentration. In vitro viability and clonogenic assays were performed on chemoresistant tumor cells (OVCAR8, OVCAR5, COV62, and POV71-hTERT) treated with chemotherapy +/- AVB. Mouse models (OVCAR8, PDX, OVCAR5) were used to determine if the combination of chemotherapy + AVB reduced tumor burden. Immunofluorescent (IF) assays targeting γH2AX were used to evaluate DNA damage and additional assays targeting 53BP1, RAD51, BRCA1, and BRCA2 were used to evaluate DNA damage response in cells treated with AVB, carboplatin, and/or AVB+carboplatin. Flow cytometry was used to evaluate RPA binding and cell cycle.

Results: Patients with high pretreatment tumor GAS6 expression (>85%, n=7) or serum GAS6 concentrations (>25ng/mL, n=13) were more likely to be resistant to neoadjuvant chemotherapy than those with low tumor GAS6 expression (<45%, n=4) (P=0.010) or low serum GAS6 concentrations (<15ng/mL, n=5) (P=0.002). Carboplatin plus AVB (2μM, 5μM) and paclitaxel plus AVB (1μM) resulted in decreased cell viability and clonogenic growth compared to chemotherapy alone (p<0.05) in all tumor cell lines. In vivo tumor mouse models treated with chemotherapy+AVB had significantly smaller subcutaneous and intraperitoneal (IP) tumors than those treated with chemotherapy alone (P<0.001). Increased DNA damage occurred in tumor cells treated with AVB than controls and in tumor cells treated with carboplatin+AVB than carboplatin alone (OVCAR8, COV362, CAOV3, OVCAR3-TPMES P<0.001). Cells treated with AVB either alone or in combination with carboplatin demonstrated decreased binding of protein involved in homologous recombination including RPA, RAD51, BRCA1, and BRCA2 (P<0.05). Conversely, these same cells demonstrated increased binding of the nonhomologous end joining protein 53BP1 (P<0.05). There were no differences in cell cycle among the treatment groups.

Conclusions: High GAS6 is associated with poor neoadjuvant chemoresponse in HGSOC patients. The combination of chemotherapy with AVB decreases tumor cell viability and tumor growth. AVB imparts a homologous recombination deficiency through downregulation of homology-directed DNA repair with an associated upregulation of nonhomologous end joining.

Citation Format: Mary Margaret Mullen, Elena Lomonosova, Hollie Noia, Daniel Wilke, Alyssa Oplt, Lei Guo, Lindsay Kuroki, Andrea Hagemann, Carolyn McCourt, Premal Thaker, David Mutch, Matthew Powell, Katherine Fuh. Therapeutic AXL inhibition with AVB-S6-500 improves response to chemotherapy and induces a homologous recombination deficiency in ovarian cancer [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr A13.

Effects of a mannan-rich yeast cell wall-derived preparation on cecal concentrations and tissue prevalence of Salmonella Enteritidis in layer chickens

Salmonella Enteritidis (SE) has been the most common Salmonella serotype associated with foodborne infections in the last several years. Dietary applications of yeast-based preparations in feed have shown to reduce Salmonella colonization in chickens augmenting SE control strategies. This study was conducted to evaluate the effects of a mannan-rich yeast cell wall-derived preparation (Actigen^®) administered in feed at a rate of 400 g/ton on SE colonization in the cecum and internal organs of commercial layer chickens. Sixteen week-old layer pullets were orally challenged with a selected nalidixic acid resistant SE strain at a dose of 1.7×10^9 colony forming units (CFU) per bird. SE colonization was assessed by evaluating isolation rates from ovary and pooled liver/spleen samples as well as enumeration of SE in cecal pouches one week post-challenge. Recovery rates of SE from the ovaries of directly challenged birds receiving Actigen^® were significantly lower (P <0.02) than those in directly challenged birds fed an unsupplemented control diet. Recovery rates of SE from pooled liver/spleen samples were not significantly different between Actigen^®-treated pullets and controls (P = 0.22). Using direct plate count methods, cecal SE concentrations were 1 log₁₀ lower (P <0.001) in challenged pullets in the Actigen^®-supplemented group than in the challenged controls. The SE concentration distributions in the ceca were similar in groups testing positive and groups testing negative for SE in the ovaries and liver/spleens tissues. As a result, SE concentrations in the ceca could not be directly related to the occurrence or prevalence of SE in these tissues. In conclusion, Actigen^® supplementation appears to decrease the prevalence of SE in ovarian tissue and concentrations of SE in cecal contents and may be useful as a tool for reducing the risk of eggshell contamination and transovarian transmission of SE in eggs.

A randomized, double-blind, placebo-controlled phase 1b/2 study of ralimetinib, a p38 MAPK inhibitor, plus gemcitabine and carboplatin versus gemcitabine and carboplatin for women with recurrent platinum-sensitive ovarian cancer

OBJECTIVE

This phase 1b/2 clinical trial (NCT01663857) evaluated the efficacy of ralimetinib in combination with gemcitabine (G) and carboplatin (C), followed by maintenance ralimetinib, for patients with recurrent platinum-sensitive epithelial ovarian cancer.

METHODS

Phase 1b was to determine the recommended phase 2 dose (RP2D) of ralimetinib administered Q12H on Days 1-10 (q21d) in combination with G (1000 mg/m², Days 3 and 10) and C (AUC 4, Day 3) for six cycles. In phase 2, patients were randomized double-blind 1:1 to ralimetinib (R)+GC or placebo (P)+GC, for six cycles, followed by ralimetinib 300 mg Q12H or placebo on Days 1-14, q28d.

RESULTS

118 patients received at least one dose of ralimetinib or placebo; eight in phase 1b and 110 in phase 2 (R+GC, N = 58; P+GC, N = 52). The RP2D for R+GC was 200 mg Q12H. The study met its primary objective of a statistically significant difference in PFS (median: R+GC, 10.3 mo vs. P+GC, 7.9 mo; hazard ratio [HR] = 0.773, P = 0.2464, against a two-sided false positive rate of 0.4). Secondary objectives were not statistically significant for median overall survival (R+GC, 29.2 mo vs. P+GC, 25.1 mo; HR = 0.827, P = 0.4686) or overall response rate (R+GC 46.6% vs. P+GC, 46.2%; P = 0.9667). The safety profile of R+GC therapy was mainly consistent with safety of the chemotherapy backbone alone. Grade 3/4 elevated alanine aminotransferase was more common in the ralimetinib arm.

CONCLUSIONS

Addition of ralimetinib to GC resulted in a modest improvement in PFS.

Factors influencing residents’ interest in gynecologic oncology fellowship

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OB/GYN residents at academic programs are more likely to express intent to pursue a fellowship in gynecologic oncology.

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Strong mentor-mentee relationships influence OB/GYN residents’ interest in gynecologic oncology fellowship.

•

The perception of burnout in gynecologic oncology fellows and faculty negatively impacts resident interest in the field.

Objectives

To identify the role of mentorship and other factors associated with obstetrics and gynecology (OB/GYN) resident interest in pursuing a fellowship in gynecologic oncology.

Methods

A survey link was emailed to U.S. OB/GYN residency program coordinators to disperse to current residents. The 80-item survey asked about plans to pursue fellowship and influencing factors. Participants were stratified based on decision to pursue a fellowship in gynecologic oncology. Student’s t-test and Mann-Whitney tests were applied.

Results

Among 236 surveyed residents, 32 (13.6%) were planning to pursue a fellowship in gynecologic oncology. There were no demographic differences favoring the choice of gynecologic oncology; however, trainees at academic programs were more likely to aspire to the subspecialty (p = 0.01). Residents interested in gynecologic oncology had marginally more mentors than others (p = 0.06), were more likely to have a gynecologic oncology mentor (p < 0.01), and were more likely to have cited mentorship as a reason for their career aspirations (p = 0.01). These residents were also less likely to report obvious burnout among faculty and fellows in their department (p < 0.01 and p = 0.01, respectively).

Conclusions

Strong mentor relationships and the display of job satisfaction and work-life balance influence OB/GYN residents’ interest in gynecologic oncology fellowships. Programs should consider formal mentorship programs for residents, with priority on matching by subspecialty. The value of fellow and faculty efforts in mentorship should be recognized, and appropriate time should be protected for these relationships, along with efforts to support fellows and faculty at risk for burnout.

Incidence and mortality trends and geographic patterns of follicular lymphoma in Canada

Background

Follicular lymphoma (fl) is the most common indolent lymphoma and the 2nd most common non-Hodgkin lymphoma, accounting for 10%-20% of all lymphomas in the Western world. Epidemiologic and geographic trends of fl in Canada have not been investigated. Our study's objective was to analyze incidence and mortality rates and the geographic distribution of fl patients in Canada for 1992-2010.

Methods

Demographic and geographic patient data for fl cases were obtained using the Canadian Cancer Registry, the Registre québécois du cancer, and the Canadian Vital Statistics database. Incidence and mortality rates and 95% confidence intervals were calculated per year and per geographic area. Rates were plotted using linear regression models to assess trends over time. Overall data were mapped using Microsoft Excel mapping software (Redmond, WA, U.S.A.) to identify case clusters across Canada.

Results

Approximately 22,625 patients were diagnosed with fl during 1992-2010. The age-standardized incidence rate of this malignancy in Canada was 38.3 cases per million individuals per year. Geographic analysis demonstrated that a number of Maritime provinces and Manitoba had the highest incidence rates, and that the provinces of Nova Scotia and Quebec had the highest mortality rates in the nation. Regional data demonstrated clustering of fl within cities or regions with high herbicide use, primary mining, and a strong manufacturing presence.

Conclusions

Our study provides a comprehensive overview of the fl burden and its geographic distribution in Canada. Regional clustering of this disease in concentrated industrial zones strongly suggests that multiple environmental factors might play a crucial role in the development of this lymphoma.

Parallel replica dynamics simulations of reactions in shock compressed liquid benzene

The study of the long-term evolution of slow chemical reactions is challenging because quantum-based reactive molecular dynamics simulation times are typically limited to hundreds of picoseconds. Here, the extended Lagrangian Born-Oppenheimer molecular dynamics formalism is used in conjunction with parallel replica dynamics to obtain an accurate tool to describe the long-term chemical dynamics of shock-compressed benzene. Langevin dynamics has been employed at different temperatures to calculate the first reaction times in liquid benzene at pressures and temperatures consistent with its unreacted Hugoniot. Our coupled engine runs for times on the order of nanoseconds (one to two orders of magnitude longer than traditional techniques) and is capable of detecting reactions that are characterized by rates significantly slower than we could study before. At lower pressures and temperatures, we mainly observe Diels-Alder metastable reactions, whereas at higher pressures and temperatures we observe stable polymerization reactions.

Direct observation of electrons in microwave vacuum components

Apparatus which is used to directly observe electrons in microwave vacuum components was designed and implemented into a WR-284 like waveguide operated at 2.85 GHz with up to approx. 1 MW power. To generate desired electric field levels for driving secondary emission, the waveguide structure is manipulated by reducing the test section height to 6 mm from the standard WR-284 rectangular waveguide height of 34 mm. Both test and standard sections were operated in the dominant TE₁₀ mode. A 1 mm aperture was cut into the broadside wall of the waveguide section enabling a portion of electrons in the waveguide to enter a properly biased electron multiplier tube mounted atop of the test section. Waveforms are presented showing the direct measurement of electrons, providing a local detection method with nanosecond temporal resolution. Future work will incorporate the test setup for multipactor studies.

Detection of distant metastatic disease by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) at initial staging of cervical carcinoma

OBJECTIVE

The detection of distant metastatic disease in cervical cancer patients at diagnosis is critical in accurate prognostication and directing treatment strategies. This study describes the frequency and sites of distant metastatic disease at diagnosis in patients with cervical cancer as detected by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET).

METHODS

Patients with newly diagnosed cervical cancer underwent pre-treatment whole-body FDG-PET starting in 1997 at an academic institution. Patients with evidence of distant FDG-avid disease, defined as disease outside of typical sites of lymphatic spread, were included for analyses. Patients were not surgically staged, but biopsy to confirm metastatic disease was attempted at the discretion of the treating physicians. Overall survival was calculated using Kaplan-Meier analysis.

RESULTS

From 1997 to 2017, 72 (6.2%) of 1158 consecutively evaluated cervical cancer patients exhibited FDG-avid distant disease at diagnosis; 27 (38%) of these had biopsy confirmation of distant disease. Only 35 (49%) of FDG-detected metastases were clinically apparent. The sites of distant disease were lung (35%), multiple sites (25%), omentum (16.5%), bone (16.5%), and liver (7%). There were 12 (17%) patients with distant disease who did not display FDG-avid lymph nodes. Median overall survival among patients with distant FDG-avid disease was 7.0 months (95% CI 4.3 to 9.7). Patients with multiple sites of distant disease demonstrated the worst overall survival.

CONCLUSIONS

Distant metastatic disease detected by FDG-PET is found in 6.2% of patients with cervical cancer at the time of initial diagnosis and the most common site of disease is the lung. Further prospective investigation is warranted to delineate best treatment practices for cervical cancer patients presenting with distant metastases.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Abstract 4034: Inhibition of AXL improves response to platinum and taxane in chemotherapy-resistant uterine and ovarian cancers

AXL expression has been associated with decreased survival in uterine serous cancer (USC) and high-grade ovarian serous cancer (HGSOC). We determined whether therapeutic inhibition of AXL with BGB324, which is in Phase I/II clinical trials for solid tumors, would improve chemotherapy response in chemotherapy resistant uterine and ovarian cancers.

Taxane and platinum resistant ovarian and uterine cancer cell lines were used for in vitro cell viability (XTT) assays. Selective small molecule inhibition of AXL was achieved using BGB324. Western blotting was used to detect protein expression and activation. Tritium-labeled paclitaxel was utilized to measure chemotherapy accumulation in cancer cells. In vivo subcutaneous models were performed with the USC cell line ARK1 and patient-derived HGSOC xenografts (PDX). Statistical significance (p&lt;0.05) and IC50 determination was assessed using Prism7.

Upon AXL inhibition by BGB324, the HGSOC cell lines OVCAR5, OVCAR3TP, and OVCAR3TPMes demonstrated a dose-dependent sensitization to paclitaxel and carboplatin chemotherapy. BGB324 treatment of OVCAR3TPMes cells improved response to carboplatin from untreated (IC50 of 73uM) to IC50 of 66uM, 51uM and 31uM at 0.25uM, 0.5uM, and 1uM, respectively (p&lt;0.01). Similarly, paclitaxel response improved from untreated (IC50 of 15.4nM) to IC50 of 13.0nM, 11.3nM and 9.8nM at 0.25uM, 0.5uM, and 1uM, respectively (p&lt;0.05).

To assess the dynamics of this chemoresponse, ARK1 USC cells were pre-treated with 0.5uM BGB324 and 1.0uM BGB324 and demonstrated a 31% and 43% increase in intracellular 3H-paclitaxel accumulation, respectively, when compared to cells without AXL inhibition (p&lt;0.05). RT-PCR was utilized to detect changes in multidrug resistance protein transcripts; mRNA levels of P-Glycoprotein (PGP) had a 6.3-fold reduction in OVCAR3TPMES cells treated with 1uM BGB324 (p&lt;0.05). This suggests that inhibition of AXL contributes to chemoresistance by increasing exposure of paclitaxel in tumor cells. The combination of paclitaxel and BGB324 therapy decreased USC tumor volume by 51-67% when compared to treatment with paclitaxel, BGB324, or vehicle control alone (p&lt;0.05). In PDX models, BGB324 therapy improved tumor response with combined carboplatin and paclitaxel therapy when compared to chemotherapy alone, inhibitor alone, or vehicle control (77%, 87%, and 88% decrease in tumor volume at day 11, respectively, p&lt;0.0001).

AXL expression contributes to platinum and taxane chemoresistance, and therapeutic inhibition of AXL with BGB324 restores chemosensitivity in ovarian and uterine cancer cell lines and patient derived xenograft models. Based on this data, chemoresistant tumors with AXL expression could be considered for treatment with BGB324 to restore chemosensitivity to carboplatin and paclitaxel.

Citation Format: Jeanne Quinn, Marguerite Palisoul, Lei Guo, Andrea Hagemann, Matthew Powell, David Mutch, Carolyn McCourt, Premal Thaker, Katherine Fuh. Inhibition of AXL improves response to platinum and taxane in chemotherapy-resistant uterine and ovarian cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4034.

Impact of molecular profiling on overall survival of patients with advanced ovarian cancer

OBJECTIVE

Patients with recurrent epithelial ovarian cancer (EOC) have limited treatment options. Studies have reported that biomarker profiling may help predict patient response to available treatments. This study sought to determine the value of biomarker profiling in recurrent EOC.

RESULTS

Patients in the Matched cohort had a median OS of 36 months compared to 27 months for patients in the Unmatched cohort (HR 0.62, 95% CI 0.41-0.96; p < 0.03). Individual biomarkers were analyzed, with TUBB3, and PGP prognostic for survival. Biomarker analysis also identified a molecular subtype (positive for at least two of the following markers: ERCC1, RRM1, TUBB3, PGP) with particularly poor overall survival.

METHODS

224 patients from a commercial registry (NCT02678754) with stage IIIC/IV EOC at diagnosis, or restaged to IIIC/IV EOC at the time of molecular profiling, were retrospectively divided into two cohorts based on whether or not the drugs they received matched their profile recommendations. The Matched cohort received no drugs predicted to be lack-of-benefit while the Unmatched cohort received at least one drug predicted to be lack-of-benefit. Profile biomarker/drug associations were based on multiple test platforms including immunohistochemistry, fluorescent in situ hybridization and DNA sequencing.

CONCLUSIONS

This report demonstrates the ability of multi-platform molecular profiling to identify EOC patients at risk of inferior survival. It also suggests a potential beneficial role of avoidance of lack-of-benefit therapies which, when administered, resulted in decreased survival relative to patients who received only therapies predicted to be of benefit.

"Safe Foods" or "Fear Foods": the implications of food avoidance in college students from low- and middle-income countries

PURPOSE

The primary objective of this study was to explore if self-reported food avoidance (fats, carbohydrates and protein) exists among college students in low- and middle-income countries (LMICs) and its relationship with body mass index (BMI), dieting, mood/anxiety symptoms, physical activities and general health knowledge.

METHODS

This study is a subset (N = 6096) of a larger 26 LMICs cross-sectional survey, which consisted of 21,007 college students. We ascertained socio-demographic information, food avoidance, physical activities, dieting behaviours, depressive and PTSD symptoms, and recorded anthropometric measurements. Chi-square analyses assessed the relationship between predictor variables and food categories eliminated from participants' diet. Multiple logistic regression assessed if food avoidance predicts outcome variables such as binge drinking, high physical activity, being underweight, exhibiting significant depressive and PTSD symptoms.

RESULTS

Food avoidance exists in as many as one-third of college students in low- and middle-income countries, with this being more likely in persons who are trying to lose weight whether by dieting or otherwise. Food avoidance was associated with higher BMI, depressive symptoms, and high intensity exercises, as well as the level of health knowledge influencing the types of food avoided. A significant difference was noted between lower middle-income and upper middle-income countries with respect to the foods they avoided.

CONCLUSION

Despite being knowledgeable about health-related behaviours, we found that college students in our sample were not that different from those in developed countries and may be influenced by a similar advice given by non-experts about macronutrients. These results hold implications for intervention programmes and policy makers.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional survey.

Abstract AP18: FUNCTIONAL GENOMIC SCREEN FOR ATTACHMENT AND INVASION IN METASTATIC OVARIAN CANCER

PURPOSE: To perform a biologically relevant functional genomic screen for genes involved in attachment and early invasion incorporating tumor microenvironment cells cultured from human omentum.

METHODS: Primary fibroblasts cultured from the human omentum were plated as one component to recapitulate the tumor microenvironment. An arrayed small interfering RNA (siRNA) panel targeting 719 genes encoding kinases was used. Each well contained 2 oligos per gene. Three ovarian cancer cells with known metastatic capabilities (OVCAR8, ES2, and A2780) were selected and stably labeled with GFP. Following exposure to siRNA, ovarian cancer cells are overlaid upon a mixed submesothelial matrix (NOFs, collagen I, and fibronectin). After 72 hours of attachment/early invasion, a wash step was performed, and the functional readout of the intensity of fluorescence was performed. Cell death due to the siRNA was evaluated by staining with resazurin. Data was analyzed by expressing the effect of increased or decreased attachment using the median average deviation (MAD).

RESULTS: MAD values were generated for each gene. A baseline MAD value of 0 was used and positive MAD values denoted genes that influenced an increase in adhesion when knocked down whereas negative values represented genes that had decreased adhesion when knocked down. Negative controls for adhesion/early invasion were used and found to have a MAD value of 0.52 for mock transfection reagent control and 2.45 for siNEG control. Positive controls for adhesion/early invasion had a MAD value of -6.13 for siB1- integrin and -8.91 for a known inhibitor of attachment – canthardin. The transfection efficiency control, siDEATH, had a MAD value of -8.8. Of the 719 genes encoding kinases, we found 17 genes with MAD values above +3 and 19 genes with MAD values below -3. Of these hits, JAK1 and Wee1 were identified. JAK1 has been found to contribute to ovarian cancer invasion, migration, and metastasis in preclinical models. Wee1 is involved in cell cycle progression, and a Wee1 inhibitor is currently in a Phase II trial in relapsed ovarian cancer. Both targets confirm that biologically-relevant genes can be identified through this screen by incorporating stromal cells cultured from human omentum. Additionally, across 3 cell lines, we identified kinases that overlapped in at least 2 cell lines with a MAD lower range of -1.85. There were 94 kinases identified: 9 with a role in adhesion, 7 in immune response, 17 in proliferation, 6 in apoptosis, 16 in metabolism, 33 in cell cycle, 2 in migration, 3 in ribosomal, 1 in autophagy, and 23 genes with overlapping functions.

CONCLUSIONS: By incorporating the tumor microenvironment into a functional genomic screen, biologically relevant genes for ovarian cancer cell attachment and early invasion can be identified and will be validated as potential novel therapeutic targets.

Citation Format: Katherine Fuh, Anne Gibson, Daniel Wilke, Maxene Ilagan, Andrea Hagemann, Carolyn McCourt, Premal Thaker, David Mutch, Matthew Powell, and Gregory Longmore. FUNCTIONAL GENOMIC SCREEN FOR ATTACHMENT AND INVASION IN METASTATIC OVARIAN CANCER [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr AP18.

FGFR2 mutations are associated with poor outcomes in endometrioid endometrial cancer: An NRG Oncology/Gynecologic Oncology Group study

PURPOSE

Activating FGFR2 mutations have been identified in ~10% of endometrioid endometrial cancers (ECs). We have previously reported that mutations in FGFR2 are associated with shorter disease free survival (DFS) in stage I/II EC patients. Here we sought to validate the prognostic importance of FGFR2 mutations in a large, multi-institutional patient cohort.

METHODS

Tumors were collected as part of the GOG 210 clinical trial "Molecular Staging of Endometrial Cancer" where samples underwent rigorous pathological review and had more than three years of detailed clinical follow-up. DNA was extracted and four exons encompassing the FGFR2 mutation hotspots were amplified and sequenced.

RESULTS

Mutations were identified in 144 of the 973 endometrioid ECs, of which 125 were classified as known activating mutations and were included in the statistical analyses. Consistent with FGFR2 having an association with more aggressive disease, FGFR2 mutations were more common in patients initially diagnosed with stage III/IV EC (29/170;17%) versus stage I/II EC (96/803; 12%; p=0.07, Chi-square test). Additionally, incidence of progression (progressed, recurred or died from disease) was significantly more prevalent (32/125, 26%) among patients with FGFR2 mutation versus wild type (120/848, 14%; p<0.001, Chi-square test). Using Cox regression analysis adjusting for known prognostic factors, patients with FGFR2 mutation had significantly (p<0.025) shorter progression-free survival (PFS; HR 1.903; 95% CI 1.177-3.076) and endometrial cancer specific survival (ECS; HR 2.013; 95% CI 1.096-3.696).

CONCLUSION

In summary, our findings suggest that clinical trials testing the efficacy of FGFR inhibitors in the adjuvant setting to prevent recurrence and death are warranted.

Abstract P5-09-09: Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings

Many studies have reported lower breast cancer risk in women who develop hypertension in pregnancy with a meta-analysis reporting hazard ratios of 0.86 for preeclampsia and 0.83 for gestational hypertension. Our prior work in the Marin Women's Study (MWS) demonstrated both a lower breast density and a lower risk of breast cancer in women with pregnancy-induced hypertension (PIH) if they possess the TT genotype of IGF1R SNP rs2016347.

Breast cancer in MWS women with PIH by IGF1R genotypers2016347 genotype# with genotype# breast cancer cases% breast cancer casesGG9188.79%GT195147.18%TT8800.00%Fisher's exact = 0.008

The current study was designed to validate and expand upon these findings in the larger California Teachers Study (CTS) which consists of &gt;130,000 female educators. From original participants a case-control study was established in 2012 consisting of all non-Hispanic white women with DNA samples that became cases since entry into the study (N = 2030) and controls without invasive or in situ breast cancer (N = 1552). The current study nests within this case control study. All participants with a self-reported history of preeclampsia were selected (81 cases/56 controls). IGF1R SNP rs2016347 was assessed by Taqman assay.

Results: Women with the TT genotype had an odds ratio (OR) of 0.38 when compared to the GG genotype after adjusting for potential confounders. Stratification by HR+/HR- cases and by age of first birth (AFB) resulted in statistically significant adjusted OR's of 0.26 for HR+ positive cases and 0.15 for women with AFB &lt;30. Both showed significant trend effect for number of T alleles as shown below:

Preeclampsia and breast cancer in CTSrs2016347 genotypeAll cases (N=137)HR+ cases (N=118)AFB &lt;30 (N=106)TT vs GG0.38 (0.13, 1.14)0.26 (0.07, 0.89)*0.15 (0.04, 0.56)*GT vs GG0.53 (0.19, 1.46)0.57 (0.19, 1.74)0.34 (0.12, 1.12)Trend analysisp = 0.09p = 0.03*p = 0.005** p &lt; .05

Overall in the CTS, the adjusted hazard ratio for women with vs without preeclampsia was 0.94 (0.81, 1.08).

Conclusions: These results suggest significant breast cancer protection in women with preeclampsia that possess the TT genotype, specifically in those women with AFB &lt;30, and for the development of HR+ breast cancer. The overall OR for all women with the TT genotype was low at 0.38 but did not reach statistical significance. This analysis in a second cohort again demonstrates a lower risk of breast cancer in women with a hypertensive disorder of pregnancy possessing the same IGF1R variant.

Recent studies have associated the rs2016347 T allele with lower normal tissue expression of IGF1R mRNA, better survival in HR+ breast cancer, and improved pathological response to neoadjuvant chemotherapy. The protective T allele creates a new microRNA (miR-432) binding site within the IGF1R 3'UTR, offering a potential functional explanation for reduced mammary gland expression of this cancer-associated growth factor. This may interact with alterations of growth and metabolic factors characteristic of preeclampsia to imprint the immature gland with a lasting protective effect from later life breast tumorigenesis. If mechanistically substantiated, these findings could lead to a novel breast cancer prevention strategy.

Citation Format: Powell M, Von Behren J, Neuhausen S, Reynolds P, Benz C. Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-09-09.

Association between ratio indexes of body composition phenotypes and metabolic risk in Italian adults

The ratio between fat mass (FM) and fat-free mass (FFM) has been used to discriminate individual differences in body composition and improve prediction of metabolic risk. Here, we evaluated whether the use of a visceral adipose tissue-to-fat-free mass index (VAT:FFMI) ratio was a better predictor of metabolic risk than a fat mass index to fat-free mass index (FMI:FFMI) ratio. This is a cross-sectional study including 3441 adult participants (age range 18-81; men/women: 977/2464). FM and FFM were measured by bioelectrical impedance analysis and VAT by ultrasonography. A continuous metabolic risk Z score and harmonised international criteria were used to define cumulative metabolic risk and metabolic syndrome (MetS), respectively. Multivariate logistic and linear regression models were used to test associations between body composition indexes and metabolic risk. In unadjusted models, VAT:FFMI was a better predictor of MetS (OR 8.03, 95%CI 6.69-9.65) compared to FMI:FFMI (OR 2.91, 95%CI 2.45-3.46). However, the strength of association of VAT:FFMI and FMI:FFMI became comparable when models were adjusted for age, gender, clinical and sociodemographic factors (OR 4.06, 95%CI 3.31-4.97; OR 4.25, 95%CI 3.42-5.27, respectively). A similar pattern was observed for the association of the two indexes with the metabolic risk Z score (VAT:FFMI: unadjusted b = 0.69 ± 0.03, adjusted b = 0.36 ± 0.03; FMI:FFMI: unadjusted b = 0.28 ± 0.028, adjusted b = 0.38 ± 0.02). Our results suggest that there is no real advantage in using either VAT:FFMI or FMI:FFMI ratios as a predictor of metabolic risk in adults. However, these results warrant confirmation in longitudinal studies.

Territorial Justice and Thatcherism

Changes in the level of territorial justice in the construction of new dwellings during the 1980s are examined. It has been widely argued that spatial equity has declined since the 1970s, particularly in the context of the ‘north–south divide’. Thus, it may be expected that territorial justice—spatial equity at the local authority level—also declined during the Thatcher years. The general arguments and evidence on spatial equity are critically reviewed, and then the relationship between housing needs and housing provision is analysed empirically. The results indicate that there was less territorial justice in private provision, and there were conflicting trends in public provision: Territorial justice declined in the local authority sector, but increased in the housing association sector. However, in total, Thatcherism was associated with less territorial justice.

Abstract LB-060: A novel target for genetic silencing of AXL mediates taxane resistance, invasion, and migration in uterine cancer

Objectives: We investigated the role of AXL expression in chemotherapy response in uterine papillary serous cancer, and sought to reverse chemoresistance through inactivation of AXL. Methods: In vitro cell viability (XTT) assays were performed to confirm response to chemotherapy in AN3CA (taxane sensitive) and ARK1 (taxane resistant) uterine cell lines. AXL knockdown by siRNA was performed with either a traditional transfection reagent (DharmaFECT) or with a novel serum-stable, cell-penetrating, endosomolytic amphipathic peptide delivery system (p5RHH). Following knockdown of AXL using siRNA and p5RHH, chemotherapy response was assessed by XTT assay and invasion and migration assays were performed. Cell viability assays were analyzed using multiple t-tests. P &lt; 0.05 was considered statistically significant. Results: Expression of AXL was found to be associated with a worse prognosis in uterine cancer. Chemoresistance was validated with XTT assays for AN3CA and ARK1. Western blotting confirmed over-expression of AXL in the chemoresistant cell line, and lack of AXL expression in its chemosensitive counterparts. Reversal of paclitaxel resistance was achieved in ARK1 cells genetically by silencing AXL with shRNA. The novel delivery system, p5RHH, combined to siAXL, was shown to inactivate AXL in ARK1 cells at the RNA and protein level to a similar extent as traditional transfection technique (8.4-fold vs 8.7-fold decrease for RNA, respectively; 67% vs 83% knockdown at 48h and 84% vs 97% knockdown at 96 hours for protein, respectively). Reversal of paclitaxel resistance was achieved in ARK1 cells therapeutically and genetically using the p5RHH-siAXL complex. With AXL silencing using the p5RHH-siAXL complex, tumor cell invasion was inhibited by greater than 40%, and tumor cell migration was inhibited by greater than 60%. Conclusions: AXL expression is associated with chemoresistance in a uterine papillary serous cancer cells. Genetic inactivation of AXL in a taxane-resistant uterine cancer cells reverses chemoresistance. A novel siRNA nano-particle delivery system was successfully utilized to mimic genetic inactivation resulting in improved chemotherapy response and decreased invasion and migration.

Citation Format: Marguerite Palisoul, Mai Nguyen, Hua Pan, Anne Lohrey, Samuel Wickline, Matthew Powell, David Mutch, Katherine Fuh. A novel target for genetic silencing of AXL mediates taxane resistance, invasion, and migration in uterine cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-060.

Abstract 2350: Vaccination enhances anti-tumor immunity in ovarian cancer following repolarization of the tumor microenvironment with CCR2 blockade

Introduction: Ovarian cancer (OC) expresses the tumor associated antigen mesothelin and contains a relative abundance of T-cells. However, ovarian cancer is also infiltrated by immunosuppressive tumor associated macrophages (TAM) that dominate the tumor microenvironment (TME). The CCL2/CCR2 chemokine axis is co-opted by various human malignancies to facilitate the recruitment of bone marrow (BM) derived inflammatory monocytes (IM) to the TME where they become immunosuppressive TAMs. Herein, we explore the rationale for combination of a CCR2 inhibitor (CCR2i) with a mesothelin peptide vaccine.

Methods: Monocyte counts were obtained from preoperative CBCs under IRB approval. Mice were vaccinated with a dual eight-mer peptide (50 nM/vaccination) on days 0 and 7 with an irradiated peptide pulsed dendritic cell boost on day 14. Mice were challenged with 4 million syngeneic OC cells (ID8) on day 15. CCR2 inhibitor (Tocris) and CCR2 KO mice were used.

Results: Preoperative monocyte counts of human ovarian cancer patients were stratified into low (&gt;1 SD below mean), mid (within 1 SD of mean), and high (&gt;1 SD above the mean) groups. Patients with a high monocyte count (n = 15) had a significantly decreased median survival of 1.2 years compared to 4.8 years in the low monocyte group (n = 15). The mid group (n = 69) had a median survival of 3.5 years (p 0.001). The hazard ratio between the low and high groups was 0.24 (0.05-0.39). Flow cytometry of peripheral blood from these patients demonstrated that the majority of these monocytes were CCR2+ inflammatory monocytes. Human OC overexpresses CCL2 compared to normal ovarian tissue and analysis of the TME from resected human OC patients revealed an abundance of CCR2+ TAM, which greatly outnumbered tumor infiltrating lymphocytes (TIL). In a murine ID8 tumor model, which recapitulates features of human OC, CCR2i prevented IM egress from the bone marrow with a resultant decrease in TAM at the primary tumor site. Furthermore, there was an increase in TIL infiltrate following CCR2 blockade. Addition of vaccine to CCR2i caused an improvement of effector to suppressor ratio and prolonged survival compared to vaccine (p = 0.02) or CCR2i alone (p = 0.02) and control (p&lt;0.0001).

Conclusion: Thus far vaccination has not provided durable patient responses in OC. Therapies targeting the immunosuppressive TME are an attractive treatment modality to enhance vaccination and facilitate anti-tumor immunity in OC.

Citation Format: Darren Cullinan, Pratibha Binder, Timothy Nywening, Ivy Wilkinson-Ryan, Brian Belt, Peter Goedegebuure, David Linehan, Matthew Powell, William Hawkins. Vaccination enhances anti-tumor immunity in ovarian cancer following repolarization of the tumor microenvironment with CCR2 blockade. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2350.

Intensity modulated radiation therapy for recurrent ovarian cancer refractory to chemotherapy

OBJECTIVE

To evaluate local control, survival outcomes, and toxicity after intensity modulated radiotherapy (IMRT) for recurrent chemorefractory ovarian cancer.

METHODS

Between 2006 and 2014, 33 patients were treated with IMRT for recurrent ovarian cancer. Patients received a median of 3 chemotherapy regimens prior to IMRT (range, 1-12) with 11 (33%) undergoing concurrent therapy. Local control (LC), recurrence free survival (RFS), and overall survival (OS) were calculated via Kaplan-Meier method. Toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Impact of patient characteristics on outcomes was evaluated via Cox's proportional hazard model.

RESULTS

Median follow up was 23.7 months. Forty-nine sites were treated to a median dose of 5040cGy (range, 4500-7000). Nine (18%) of the 49 sites had in-field failures. Two year actuarial LC, RFS, and OS were 82%, 11%, and 63%, respectively. Seventeen patients had both a pre and post-treatment FDG-PET/CT; 6 (35%) had a complete metabolic response while 11 (65%) had a partial metabolic response. Acute ≥ grade 3 gastrointestinal (GI) toxicities occurred in 2 (6%) patients, late ≥ grade 3 GI toxicities occurred in 12 (36%), acute ≥ grade 3 hematological toxicities occurred in 5 (15%) and late ≥ grade 3 hematological toxicities occurred in 14 (42%).

CONCLUSIONS

IMRT for recurrent chemorefractory ovarian cancer is associated with excellent local control and limited radiation related toxicity. Future studies will be required to determine which subpopulation will benefit most from IMRT and whether alternative techniques such as stereotactic body radiotherapy may be feasible.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Clinical Outcomes among Women with Mucinous Adenocarcinoma of the Ovary

BACKGROUND/AIMS

Patterns of metastasis and clinical behavior of mucinous ovarian cancers are poorly understood because of their rarity.

METHODS

A retrospective review of records of women identified with pure mucinous invasive ovarian/tubal/peritoneal cancer during 1992-2012 at one institution. Survival differences were compared using Kaplan-Meier methods with log-rank tests.

RESULTS

Among 42 women with mucinous adenocarcinomas, the median age was 55 (range 33-83 years). Most cancers were well differentiated (n = 26, 68%) and in stage I/II (n = 31, 74%). One of 27 women with sampled nodes had nodal metastasis; one additional woman had recurrence in a pelvic node. Most had no visible residual tumor after initial surgery, but of 10 women with stage III/IV cancer and documented residual, 8 had >2 cm residual. Except for 1 woman alive with disease at last follow-up, all who had a recurrence died of the disease. Five-year survival was 83% for stage I/II cases but 29% among stage III/IV cases. Stage was a strong predictor of survival (hazard ratio of death among women with stage III/IV cancer 7.73, 95% CI 2.33-25.66, p < 0.001 vs. women with stage I/II cancer).

CONCLUSION

Mucinous ovarian cancers have a distinct biology, such that lymphadenectomy for staging is unnecessary and metastatic cancers have poor prognosis.

Prediction model for regional or distant recurrence in endometrial cancer based on classical pathological and immunological parameters

Background:

Adjuvant therapy increases disease-free survival in endometrial cancer (EC), but has no impact on overall survival and negatively influences the quality of life. We investigated the discriminatory power of classical and immunological predictors of recurrence in a cohort of EC patients and confirmed the findings in an independent validation cohort.

Methods:

We reanalysed the data from 355 EC patients and tested our findings in an independent validation cohort of 72 patients with EC. Predictors were selected and Harrell's C-index for concordance was used to determine discriminatory power for disease-free survival in the total group and stratified for histological subtype.

Results:

Predictors for recurrence were FIGO stage, lymphovascular space invasion and numbers of cytotoxic and memory T-cells. For high risk cancer, cytotoxic or memory T-cells predicted recurrence as well as a combination of FIGO stage and lymphovascular space invasion (C-index 0.67 and 0.71 vs 0.70). Recurrence was best predicted when FIGO stage, lymphovascular space invasion and numbers of cytotoxic cells were used in combination (C-index 0.82). Findings were confirmed in the validation cohort.

Conclusions:

In high-risk EC, clinicopathological or immunological variables can predict regional or distant recurrence with equal accuracy, but the use of these variables in combination is more powerful.

Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology

Residency training in obstetrics and gynecology is being challenged by increasingly stringent regulations and decreased operative experience. We sought to determine the perception of preparedness of incoming gynecologic oncology fellows for advanced surgical training in gynecologic oncology. An online survey was sent to gynecologic oncologists involved in fellowship training in the United States. They were asked to evaluate their most recent incoming clinical fellows in the domains of professionalism, level of independence/graduated responsibility, psychomotor ability, clinical evaluation and management, and academia and scholarship using a standard Likert-style scale. The response rate among attending physicians was 40% (n = 105/260) and 61% (n = 28/46) for program directors. Of those who participated, 49% reported that their incoming fellows could not independently perform a hysterectomy, 59% reported that they could not independently perform 30 min of a major procedure, 40% reported that they could not control bleeding, 40% reported that they could not recognize anatomy and tissue planes, and 58% reported that they could not dissect tissue planes. Fellows lacked an understanding of pathophysiology, treatment recommendations, and the ability to identify and treat critically ill patients. In the academic domain, respondents agreed that fellows were deficient in the areas of protocol design (54%), statistical analysis (54%), and manuscript writing (65%). These results suggest that general Ob/Gyn residency is ineffective in preparing fellows for advanced training in gynecologic oncology and should prompt a revision of the goals and objectives of resident education to correct these deficiencies.

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Ob/Gyn residency programs are facing an increasing number of challenges and restrictions.

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Recent incoming fellows may be underprepared for training in gynecologic oncology.

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Potential avenues to improve Ob/Gyn residency training are presented.