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Kim S, Han DJ, Lee SY, Moon Y, Kang SJ, Kim TM. A Subset of Microsatellite Unstable Cancer Genomes Prone to Short Insertions over Deletions Is Associated with Elevated Anticancer Immunity. Genes (Basel) 2024; 15:770. [PMID: 38927706 PMCID: PMC11202581 DOI: 10.3390/genes15060770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Deficiencies in DNA mismatch repair (MMRd) leave characteristic footprints of microsatellite instability (MSI) in cancer genomes. We used data from the Cancer Genome Atlas and International Cancer Genome Consortium to conduct a comprehensive analysis of MSI-associated cancers, focusing on indel mutational signatures. We classified MSI-high genomes into two subtypes based on their indel profiles: deletion-dominant (MMRd-del) and insertion-dominant (MMRd-ins). Compared with MMRd-del genomes, MMRd-ins genomes exhibit distinct mutational and transcriptomic features, including a higher prevalence of T>C substitutions and related mutation signatures. Short insertions and deletions in MMRd-ins and MMRd-del genomes target different sets of genes, resulting in distinct indel profiles between the two subtypes. In addition, indels in the MMRd-ins genomes are enriched with subclonal alterations that provide clues about a distinct evolutionary relationship between the MMRd-ins and MMRd-del genomes. Notably, the transcriptome analysis indicated that MMRd-ins cancers upregulate immune-related genes, show a high level of immune cell infiltration, and display an elevated neoantigen burden. The genomic and transcriptomic distinctions between the two types of MMRd genomes highlight the heterogeneity of genetic mechanisms and resulting genomic footprints and transcriptomic changes in cancers, which has potential clinical implications.
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Affiliation(s)
- Sunmin Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Dong-Jin Han
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Seo-Young Lee
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Youngbeen Moon
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Su Jung Kang
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Tae-Min Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.)
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedicine & Health Sciences, Graduate School, The Catholic University of Korea, Seoul 06591, Republic of Korea
- CMC Institute for Basic Medical Science, The Catholic Medical Center, The Catholic University of Korea, Seoul 06591, Republic of Korea
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2
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Wan X, Huang J, Huang L, Wang Y, Fu Y, Jin X, Huang Z, Xiong J. Effectiveness and safety of PD-1/PD-L1 inhibitors monotherapy in patients with endometrial cancer. Discov Oncol 2024; 15:168. [PMID: 38750182 PMCID: PMC11096149 DOI: 10.1007/s12672-024-01033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/11/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Studies evaluating the effectiveness of immune checkpoint inhibitors (ICI) for endometrial cancer (EC) are limited. This study aimed to assess the efficacy of PD-1/PD-L1 inhibitors as monotherapy for EC by conducting a meta-analysis. The predictive significance of MMR status, a biomarker for ICI response, also required further investigation. METHODS A systematic literature search was conducted in English databases until September 2023. The analysis included objective response rate (ORR), disease control rate (DCR), adverse events (AEs), and odds ratios (OR), along with their corresponding 95% confidence intervals (CI). RESULTS There were twelve trials totaling 685 individuals. PD-1/PD-L1 inhibitor monotherapy resulted in an ORR for 34% (95% CI = 24-44%) of the pooled EC patients. Subgroup analysis revealed a significantly higher ORR in dMMR EC (45%) compared to pMMR EC (8%), with an OR of 6.36 (95% CI = 3.64-11.13). The overall DCR was 42%, with dMMR EC at 51% and pMMR EC at 30% (OR = 2.61, 95% CI = 1.69-4.05). Grade three or higher adverse events (AEs) occurred in 15% of cases (95% CI = 9-24%) of the pooled incidence of AEs, which was 68% (95% CI = 65-72%). CONCLUSIONS This meta-analysis provides significant evidence for the effectiveness of PD-1/PD-L1 inhibitors as monotherapy for EC. Notably, dMMR EC patients demonstrated superior treatment efficacy with PD-1/PD-L1 inhibitor immunotherapy. Further research is required to explore subclassifications of EC based on dMMR molecular subtypes, enabling improved treatment strategies and outcomes for EC patients.
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Affiliation(s)
- Xiaoyan Wan
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Jiezheng Huang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Liu Huang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Yibin Wang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Yiyuan Fu
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Xiaolong Jin
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Zheng Huang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China.
| | - Jian Xiong
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China.
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3
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Dasgupta S, Gayen S, Chakraborty T, Afrose N, Pal R, Mahata S, Nasare V, Roy S. Potential role of immune cell therapy in gynecological cancer and future promises: a comprehensive review. Med Oncol 2024; 41:98. [PMID: 38536512 DOI: 10.1007/s12032-024-02337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/20/2024] [Indexed: 05/31/2024]
Abstract
Gynecological malignancies are most leading causes of death among women worldwide. The high prevalence of gynecologic malignancies remains significant, necessitating to turn the novel treatment approach like immunotherapy, wherein cancer cells are killed by the invasion of immune system. In recent year, immunotherapy has mostly an advanced treatment approach to repressing the tumor cells survival, proliferation, and invasion via the activation of immune systems. Moreover, various types of immune cells including T-cells, B-cells, and dendritic cells are associated with the immunotherapeutic strategy in cancer treatment. Although the significant role of T-cells against cancer is well established, while B-cells and dendritic cells also play an important role against different gynecological cancer by regulating the immune system. This review focuses on that arena and highlight the role of immune cells in the treatment of gynaecological cancer. Various immune cell-based anticancer therapies such as T-cell therapies, Adoptive Cellular transfer, B-cell therapies as well as approaches to Dendritic Cell therapies have been discussed in detail. Furthermore, the clinical settings and future avenues regarding immunotherapy on gynecological cancer have also been reviewed and illuminated in the recent study.
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Affiliation(s)
- Sandipan Dasgupta
- Department of Pharmaceutical Technology, Maulana Abul Kalam Azad University of Technology, Kolkata, West Bengal, India
| | - Sakuntala Gayen
- NSHM Knowledge Campus, Kolkata - Group of Institutions, 124, B. L. Saha Road, Tara Park, Behala, Kolkata, West Bengal, 700053, India
| | - Tania Chakraborty
- NSHM Knowledge Campus, Kolkata - Group of Institutions, 124, B. L. Saha Road, Tara Park, Behala, Kolkata, West Bengal, 700053, India
| | - Naureen Afrose
- Department of Pharmaceutical Technology, Jadavpur University, Kolkata, West Bengal, India
| | - Ranita Pal
- Department of Pathology and Cancer Screening, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Sutapa Mahata
- Department of Pathology and Cancer Screening, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Vilas Nasare
- Department of Pathology and Cancer Screening, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Souvik Roy
- NSHM Knowledge Campus, Kolkata - Group of Institutions, 124, B. L. Saha Road, Tara Park, Behala, Kolkata, West Bengal, 700053, India.
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Johnson RL, Ganesan S, Thangavelu A, Theophilou G, de Jong D, Hutson R, Nugent D, Broadhead T, Laios A, Cummings M, Orsi NM. Immune Checkpoint Inhibitors Targeting the PD-1/PD-L1 Pathway in Advanced, Recurrent Endometrial Cancer: A Scoping Review with SWOT Analysis. Cancers (Basel) 2023; 15:4632. [PMID: 37760602 PMCID: PMC10527181 DOI: 10.3390/cancers15184632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/06/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Results of recent clinical trials using the immune check point inhibitors (ICI) pembrolizumab or dostarlimab with/without lenvatinib has led to their approval for specific molecular subgroups of advanced recurrent endometrial cancer (EC). Herein, we summarise the clinical data leading to this first tissue-agnostic approval. As this novel therapy is not yet available in the United Kingdom standard care setting, we explore the strengths, weaknesses, opportunities, and threats (SWOT) of ICI treatment in EC. Major databases were searched focusing on clinical trials using programmed cell death protein 1 (PD-1) and its ligand (PD-L1) ICI which ultimately contributed to anti-PD-1 approval in EC. We performed a data quality assessment, reviewing survival and safety analysis. We included 15 studies involving 1609 EC patients: 458 with mismatch repair deficiency (MMRd)/microsatellite instability-high (MSI-H) status and 1084 with mismatch repair proficiency/microsatellite stable (MMRp/MSS) status. Pembrolizumab/dostarlimab have been approved for MMRd ECs, with the addition of lenvatinib for MMRp cases in the recurrent setting. Future efforts will focus on the pathological assessment of biomarkers to determine molecular phenotypes that correlate with response or resistance to ICI in order to identify patients most likely to benefit from this treatment.
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Affiliation(s)
- Racheal Louise Johnson
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Subhasheenee Ganesan
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Amudha Thangavelu
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Georgios Theophilou
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Diederick de Jong
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Richard Hutson
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - David Nugent
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Timothy Broadhead
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Alexandros Laios
- Department of Gynaecological Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Michele Cummings
- Leeds Institute of Medical Research, St James’s University Hospital, The University of Leeds, Leeds LS9 7TF, UK
| | - Nicolas Michel Orsi
- Leeds Institute of Medical Research, St James’s University Hospital, The University of Leeds, Leeds LS9 7TF, UK
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Kok PS, Antill YC, Scott CL, Lee CK. The impact of single agent PD-1 or PD-L1 inhibition on advanced endometrial cancers: meta-analysis. ESMO Open 2022; 7:100635. [PMID: 36410086 PMCID: PMC9808459 DOI: 10.1016/j.esmoop.2022.100635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) therapy is an emerging option for advanced endometrial cancer (EC). Mismatch repair (MMR) status is widely regarded as a biomarker predictive of response to ICIs. The predictive value of MMR based on small, single-arm trials, however, is conflicting. In this meta-analysis, we aimed to assess the activity of single-agent ICI in advanced EC, and compared the magnitude of treatment benefit in MMR deficient (dMMR) and MMR proficient (pMMR) EC. METHODS We carried out an electronic search to identify prospective trials of single-agent ICI in advanced EC. Data on objective response rate (ORR) and progression-free survival (PFS) were extracted and pooled. ORR was estimated using the inverse variance method and subgroup difference by MMR status was examined. PFS difference according to MMR status was summarized using the Kaplan-Meier approach. RESULTS From eight trials with 492 women, the pooled ORR was 19% [95% confidence interval (CI) 16% to 22%]. ORR was significantly greater in dMMR (n = 281) than pMMR EC (n = 211) (dMMR: 46%, pMMR: 8%; risk ratio 5.74, 95% CI 3.58-9.21; interaction P < 0.001). Complete response was 11% and 0.05% and median PFS was 8.3 and 2.1 months in dMMR and pMMR EC, respectively (hazard ratio PFS 0.58, 95% CI 0.38-0.89; P = 0.01). The 12-month PFS rates were 42.0% and 20.7%, respectively. CONCLUSION Single-agent ICI is associated with a 5.74 times greater objective response and 42% reduction in risk of disease progression or death in dMMR compared with pMMR EC. MMR status should be determined prospectively and be used as a stratification factor in future trials of advanced EC. Further translational analysis is urgently required to identify the cause of dMMR and allow subclassification of EC into different dMMR molecular subtypes.
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Affiliation(s)
- P-S Kok
- Australia New Zealand Gynaecological Oncology Group, Sydney, Australia; National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia; Prince of Wales Hospital, Randwick, Australia.
| | - Y C Antill
- Australia New Zealand Gynaecological Oncology Group, Sydney, Australia; Faculty of Medicine, Dentistry and Health Sciences, Monash University, Melbourne, Australia
| | - C L Scott
- Australia New Zealand Gynaecological Oncology Group, Sydney, Australia; Walter and Eliza Hall Institute of Medical Research, Parkville, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia; Sir Peter MacCallum Cancer Centre Department of Oncology, University of Melbourne, Parkville, Australia
| | - C K Lee
- Australia New Zealand Gynaecological Oncology Group, Sydney, Australia; Cancer Care Centre, St George Hospital, Sydney, Australia
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Maiorano BA, Maiorano MFP, Cormio G, Maglione A, Lorusso D, Maiello E. How Immunotherapy Modified the Therapeutic Scenario of Endometrial Cancer: A Systematic Review. Front Oncol 2022; 12:844801. [PMID: 35494078 PMCID: PMC9047829 DOI: 10.3389/fonc.2022.844801] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/21/2022] [Indexed: 12/20/2022] Open
Abstract
Background Endometrial cancer (EC) represents the sixth most common female tumor. In the advanced setting, the prognosis is dismal with limited treatment options. Platinum-based chemotherapy represents the actual standard of care in first-line chemotherapy, but no standard second-line chemotherapy is approved, with less than 1/4 of patients responding to second-line chemotherapy. In the last 10 years, immune checkpoint inhibitors (ICIs) have changed the treatment landscape of many solid tumors. Methods The review was conducted according to the PRISMA guidelines. We searched EMBASE, MEDLINE, Cochrane Database, and conference abstracts from international societies, up to November 2021. Clinical trials employing ICIs in advanced EC, written in English, were included. Reviews, letters, and commentaries were excluded. The overall response rate (ORR), progression-free survival (PFS), overall survival (OS), and safety (number and grade of treatment-related adverse events [TRAEs]) were evaluated. Results 15 studies, for a total of 1,627 patients, were included: 14 non-randomized phase I/II trials and 1 randomized phase III trial. Anti-PD1 (pembrolizumab, nivolumab, dostarlimab) and anti-PD-L1 agents (avelumab, atezolizumab, durvalumab) were administered as single agents; pembrolizumab and nivolumab were combined with the tyrosine-kinase inhibitors (TKI) lenvatinib and cabozantinib, respectively; and durvalumab was associated with anti-CTLA4 tremelimumab. 4 studies selected only MSI patients. Single agents determined an ORR from 26.7% to 58% among MSI patients, from 3% to 26.7% among MSS patients. DCR ranged from 53.5% to 88.9% in MSI, 31.4% to 35.2% in MSS patients. The combination of TKI and ICIs determined 32% to 63.6% of ORR in all-comers, 32%–36.2% in MSS patients. 54.2% to 76% of patients developed TRAEs. The combination of ICIs and TKI achieved a higher toxicity rate than single agents (≥G3 TRAEs 88.9%). Conclusion ICIs represent an effective option for pretreated advanced EC patients with a tolerable profile. Given the encouraging results in MSI patients, every woman diagnosed with EC should be investigated for MS status. In MSS women, the combination of ICIs and TKI is more effective than monotherapy, notwithstanding safety concerns. PD-L1 cannot predict ICI response, whereas other biomarkers such as MSI and tumor mutational burden seem more accurate. Ongoing randomized trials will further clarify the role of these therapeutic options. Systematic Review Registration PROSPERO, CRD42021293538.
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Affiliation(s)
- Brigida Anna Maiorano
- Oncology Department, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, Rome, Italy
- *Correspondence: Brigida Anna Maiorano,
| | - Mauro Francesco Pio Maiorano
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Gennaro Cormio
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Annamaria Maglione
- Obstetrics and Gynecology Department, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Domenica Lorusso
- Department of Women and Child Health, Division of Gynaecologic Oncology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Scientific Directorate, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Evaristo Maiello
- Oncology Department, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
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The Use of Targeted Agents in the Treatment of Gynecologic Cancers. Curr Treat Options Oncol 2022; 23:15-28. [PMID: 35167006 DOI: 10.1007/s11864-021-00918-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT Patients with advanced and recurrent ovarian, uterine, and cervical cancers have limited efficacious treatment options and poor outcomes. The development of agents that target DNA repair mechanisms, angiogenesis, immune checkpoints, and hormone receptor expression provides additional options for these patients. Many available targeted therapies have limited efficacy as single agents, so clinical trials investigating combination therapies as well as continued identification and validation of predictive biomarkers are critical. Many novel small molecule therapies, antibody drug conjugates, and therapeutic vaccines are also in development. This review will focus on recent evidence supporting the use of clinically available targeted therapies for gynecologic cancer.
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Aravantinou-Fatorou A, Andrikopoulou A, Liontos M, Fiste O, Georgakopoulou VE, Dimopoulos MA, Gavriatopoulou M, Zagouri F. Pembrolizumab in endometrial cancer: Where we stand now. Oncol Lett 2021; 22:821. [PMID: 34691248 PMCID: PMC8527559 DOI: 10.3892/ol.2021.13082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 07/02/2021] [Indexed: 12/18/2022] Open
Abstract
Recently, immunotherapy has shown promising results in solid tumors. To the best of our knowledge, this is the first systematic review of published literature synthesizing all the available data and evaluating both the efficacy and safety of pembrolizumab in endometrial cancer. The present study was performed in accordance with the PRISMA guidelines. Eligible articles were identified by searching the MEDLINE and ClinicalTrials.gov databases, using a predefined combination of the terms 'endometrial cancer' and 'pembrolizumab'. Overall, nine articles incorporating data from 712 patients were eligible. Pembrolizumab was demonstrated to be an effective and safe therapeutic option for the management of advanced/metastatic endometrial cancer. Results of ongoing trials evaluating either pembrolizumab alone or in combination with other antineoplastic regimens are expected to confirm its efficacy in this setting of patients. Pembrolizumab appears to be both durable and robust in endometrial cancer. However, there is an emerging need for novel predictive biomarkers to guide clinical practice.
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Affiliation(s)
- Aikaterini Aravantinou-Fatorou
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens 11527, Greece
| | - Angeliki Andrikopoulou
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Michael Liontos
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Oraianthi Fiste
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Vasiliki E. Georgakopoulou
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens 11527, Greece
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
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Ryan NAJ, Walker TDJ, Bolton J, ter Haar N, Van Wezel T, Glaire MA, Church DN, Evans DG, Bosse T, Crosbie EJ. Histological and Somatic Mutational Profiles of Mismatch Repair Deficient Endometrial Tumours of Different Aetiologies. Cancers (Basel) 2021; 13:4538. [PMID: 34572765 PMCID: PMC8469577 DOI: 10.3390/cancers13184538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Mismatch repair deficient (MMRd) tumours may arise from somatic events acquired during carcinogenesis or in the context of Lynch syndrome (LS), an inherited cancer predisposition condition caused by germline MMR pathogenic variants. Our aim was to explore whether sporadic and hereditary MMRd endometrial cancers (EC) display distinctive tumour biology. METHODS Clinically annotated LS-EC were collected. Histological slide review was performed centrally by two specialist gynaecological pathologists. Mutational analysis was by a bespoke 75- gene next-generation sequencing panel. Comparisons were made with sporadic MMRd EC. Multiple correspondence analysis was used to explore similarities and differences between the cohorts. RESULTS After exclusions, 135 LS-EC underwent independent histological review, and 64 underwent mutational analysis. Comparisons were made with 59 sporadic MMRd EC. Most tumours were of endometrioid histological subtype (92% LS-EC and 100% sporadic MMRd EC, respectively, p = NS). Sporadic MMRd tumours had significantly fewer tumour infiltrating lymphocytes (p ≤ 0.0001) and showed more squamous/mucinous differentiation than LS-EC (p = 0.04/p = 0.05). PTEN mutations were found in 88% sporadic MMRd and 61% LS-EC, respectively (p < 0.001). Sporadic MMRd tumours had significantly more mutations in PDGFRA, ALK, IDH1, CARD11, CIC, MED12, CCND1, PTPN11, RB1 and KRAS, while LS-EC showed more mutations affecting SMAD4 and ARAF. LS-EC showed a propensity for TGF-β signalling disruption. Cluster analysis found that wild type PTEN associates predominantly with LS-EC, whilst co-occurring mutations in PTEN, PIK3CA and KRAS predict sporadic MMRd EC. CONCLUSIONS Whilst MMRd EC of hereditary and sporadic aetiology may be difficult to distinguish by histology alone, differences in infiltrating immune cell counts and mutational profile may predict heterogenous responses to novel targeted therapies and warrant further study.
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Affiliation(s)
- Neil A. J. Ryan
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (N.A.J.R.); (T.D.J.W.)
- Division of Evolution and Genomic Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9WL, UK;
| | - Thomas D. J. Walker
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (N.A.J.R.); (T.D.J.W.)
| | - James Bolton
- Manchester Academic Health Science Centre, Department of Pathology, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK;
| | - Natalja ter Haar
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (N.t.H.); (T.V.W.); (T.B.)
| | - Tom Van Wezel
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (N.t.H.); (T.V.W.); (T.B.)
| | - Mark A. Glaire
- Tumour Genomics and Immunology Group, Wellcome Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford OX3 7DQ, UK; (M.A.G.); (D.N.C.)
| | - David N. Church
- Tumour Genomics and Immunology Group, Wellcome Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford OX3 7DQ, UK; (M.A.G.); (D.N.C.)
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7DQ, UK
| | - D. Gareth Evans
- Division of Evolution and Genomic Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9WL, UK;
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (N.t.H.); (T.V.W.); (T.B.)
| | - Emma J. Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (N.A.J.R.); (T.D.J.W.)
- Manchester Academic Health Science Centre, Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
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10
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Schepisi G, Casadei C, Toma I, Poti G, Iaia ML, Farolfi A, Conteduca V, Lolli C, Ravaglia G, Brighi N, Altavilla A, Martinelli G, De Giorgi U. Immunotherapy and Its Development for Gynecological (Ovarian, Endometrial and Cervical) Tumors: From Immune Checkpoint Inhibitors to Chimeric Antigen Receptor (CAR)-T Cell Therapy. Cancers (Basel) 2021; 13:840. [PMID: 33671294 PMCID: PMC7922040 DOI: 10.3390/cancers13040840] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 12/24/2022] Open
Abstract
Gynecological tumors are malignancies with both high morbidity and mortality. To date, only a few chemotherapeutic agents have shown efficacy against these cancer types (only ovarian cancer responds to several agents, especially platinum-based combinations). Within this context, the discovery of immune checkpoint inhibitors has led to numerous clinical studies being carried out that have also demonstrated their activity in these cancer types. More recently, following the development of chimeric antigen receptor (CAR)-T cell therapy in hematological malignancies, this strategy was also tested in solid tumors, including gynecological cancers. In this article, we focus on the molecular basis of gynecological tumors that makes them potential candidates for immunotherapy. We also provide an overview of the main immunotherapy studies divided by tumor type and report on CAR technology and the studies currently underway in the area of gynecological malignancies.
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Affiliation(s)
- Giuseppe Schepisi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Chiara Casadei
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Ilaria Toma
- Clinical Oncology, Arcispedale Sant’Anna University Hospital, 44124 Ferrara, Italy;
| | - Giulia Poti
- Istituto Dermopatico dell’Immacolata, IDI IRCCS, 00167 Rome, Italy;
| | - Maria Laura Iaia
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
- Medical Oncology Unit 1, University of Genoa, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy
| | - Alberto Farolfi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Vincenza Conteduca
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Cristian Lolli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Giorgia Ravaglia
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy;
| | - Nicole Brighi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Amelia Altavilla
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Giovanni Martinelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
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11
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Taha T, Reiss A, Amit A, Perets R. Checkpoint Inhibitors in Gynecological Malignancies: Are we There Yet? BioDrugs 2020; 34:749-762. [PMID: 33141420 DOI: 10.1007/s40259-020-00450-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The emergence of immune checkpoint inhibitors (ICIs) has revolutionized the field of oncology. For many cancer types, treatment paradigms have changed, as immunotherapy is increasingly being integrated into frontline standard-of-care treatments and producing meaningful and prolonged responses. This has inspired an avalanche of clinical trials studying ICIs in all types of malignancies, including gynecological cancers. Ovarian and endometrial cancers are characterized by DNA damage repair defects, either via disruption of the homologous recombination DNA repair mechanism in the former or via defects in the mismatch repair (MMR) pathway in the latter, which lead to a high load of neoantigens in both. Cervical cancer is dependent on the expression of human papillomavirus (HPV) proteins, which induce an immune response. Regardless, clinical trials testing ICIs in gynecological malignancies have initially led to disappointing results. Despite durable responses in some patients, overall response rates have been dismal. Nevertheless, in recent years, with the development of better predictive tumor biomarkers, such as microsatellite instability for endometrial cancer and programmed death ligand 1 for cervical cancer, ICIs have found their way into routine treatments for patients with advanced-stage disease. ICI-based combinations, although adding toxicity, have further improved response rates, and new combinations are currently being tested in clinical trials, as are other immunotherapy modalities, such as adoptive cell transfer and HPV-based vaccines. This review summarizes current clinical evidence supporting the use of immunotherapy in gynecological malignancies and describes studies in progress, with a focus on ICIs and predictive response biomarkers.
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Affiliation(s)
- Tarek Taha
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Ari Reiss
- Division of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Amnon Amit
- Division of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Technion, Israel Institute of Technology, Haifa, Israel
| | - Ruth Perets
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel. .,Technion, Israel Institute of Technology, Haifa, Israel. .,Clinical Research Institute at Rambam, Rambam Health Care Campus, Haifa, Israel.
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12
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Wang Q, Peng H, Qi X, Wu M, Zhao X. Targeted therapies in gynecological cancers: a comprehensive review of clinical evidence. Signal Transduct Target Ther 2020; 5:137. [PMID: 32728057 PMCID: PMC7391668 DOI: 10.1038/s41392-020-0199-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022] Open
Abstract
Advanced and recurrent gynecological cancers are associated with poor prognosis and lack of effective treatment. The developments of the molecular mechanisms on cancer progression provide insight into novel targeted therapies, which are emerging as groundbreaking and promising cancer treatment strategies. In gynecologic malignancies, potential therapeutic targeted agents include antiangiogenic agents, poly (ADP-ribose) polymerase (PARP) inhibitors, tumor-intrinsic signaling pathway inhibitors, selective estrogen receptor downregulators, and immune checkpoint inhibitors. In this article, we provide a comprehensive review of the clinical evidence of targeted agents in gynecological cancers and discuss the future implication.
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Affiliation(s)
- Qiao Wang
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China
| | - Hongling Peng
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China
| | - Xiaorong Qi
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China
| | - Min Wu
- Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, 58203, USA
| | - Xia Zhao
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China.
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13
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Lynam S, Lugade AA, Odunsi K. Immunotherapy for Gynecologic Cancer: Current Applications and Future Directions. Clin Obstet Gynecol 2020; 63:48-63. [PMID: 31833846 PMCID: PMC7298668 DOI: 10.1097/grf.0000000000000513] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The role of the immune system in the development of cancer has been a subject of ongoing clinical investigation in recent years. Emerging data demonstrate that tumorigenesis resulting in ovarian, uterine, and cervical cancers is a consequence of impaired host immune responses to cancerous cells. Leveraging the immune system through the use of immune checkpoint inhibitors, therapeutic vaccine therapy, and adoptive cell transfer presents a profound opportunity to revolutionize cancer treatment. This review will encompass the role of the immune system in development of gynecologic cancers and highlight recent data regarding immunotherapy applications in ovarian, uterine, and cervical cancers.
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Affiliation(s)
| | - Amit A Lugade
- Center for Immunotherapy Roswell Park Cancer Institute, Buffalo, New York
| | - Kunle Odunsi
- Department of Gynecologic Oncology
- Center for Immunotherapy Roswell Park Cancer Institute, Buffalo, New York
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14
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Expression of Immunomodulatory Molecules PD-1, PD-L1, and PD-L2, and their Relationship With Clinicopathologic Characteristics in Endometrial Cancer. Int J Gynecol Pathol 2020; 38:404-413. [PMID: 30134343 DOI: 10.1097/pgp.0000000000000543] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chemotherapeutic agents are not very effective in treating advanced endometrial cancers (ECs). Recent studies have demonstrated the immune evasion mechanism of tumors and possible remedies. Programmed cell death protein 1 (PD-1), programmed death ligand 1 (PD-L1), and programmed death ligand 2 (PD-L2) are immunomodulator molecules that have been the focus of research in lung cancer, melanoma, and renal cell cancer. However, there are few studies concerning EC. This retrospective study aimed to determine PD-1, PD-L1, and PD-L2 expression immunohistochemically in EC, and to study their correlation with clinicopathologic tumor characteristics. This study comprised 127 patients with EC. Anti PD-1, PD-L1, and PD-L2 antibodies were examined immunohistochemically on sections obtained from tissue microarray paraffin blocks. No staining with PD-1 in tumor cells was seen; however, we found positive staining in tumor cells at 36.2% with PD-L1 and 64.4% with PD-L2, and at 61.6% with PD-1, 36.2% with PD-L1, and 93.2% with PD-L2 in immune cells. When comparing staining and clinicopathologic findings, most of the PD-L1 negative tumors (both in tumor and immune cells) were FIGO Stage I, which was significantly higher than stage II-III-IV tumors (P<0.05). There was a statistically significant association between the FIGO grade and the PD-L1 score in immune cells (P=0.009), and between staining of PD-1, PD-L1, and PD-L2 and age (P=0.004, 0.013, and 0.043, respectively). Interaction between PD-1, PD-L1, and PD-L2 may be a potential target for immunotherapy in elderly and advanced stage EC patients.
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15
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Li K, Luo H, Huang L, Luo H, Zhu X. Microsatellite instability: a review of what the oncologist should know. Cancer Cell Int 2020; 20:16. [PMID: 31956294 PMCID: PMC6958913 DOI: 10.1186/s12935-019-1091-8] [Citation(s) in RCA: 247] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/28/2019] [Indexed: 02/06/2023] Open
Abstract
The patients with high microsatellite instability (MSI-H)/mismatch repair deficient (dMMR) tumors recently have been reported that can benefit from immunotherapy, and MSI can be used as a genetic instability of a tumor detection index. However, many studies have shown that there are many heterogeneous phenomena in patients with MSI tumors in terms of immunotherapy, prognosis and chemotherapy sensitivity. Here we mainly review the research results of MSI detection methods, the mechanisms of MSI occurrence and its relationship with related tumors, aiming to make a brief analysis of the current research status of MSI and provide comparable reference and guidance value for further research in this field.
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Affiliation(s)
- Kai Li
- 1Guangdong Key Laboratory for Research and Development of Natural Drugs, Guangdong Medical University, Zhanjiang, 524023 China.,2The Marine Biomedical Research Institute, Southern Marine Science and Engineering Guangdong Laboratory Zhanjiang, Guangdong Medical University, Zhanjiang, 524023 China.,3Cancer Center, The Affiliated Hospital, Guangdong Medical University, Zhanjiang, 524023 China
| | - Haiqing Luo
- 3Cancer Center, The Affiliated Hospital, Guangdong Medical University, Zhanjiang, 524023 China
| | - Lianfang Huang
- 1Guangdong Key Laboratory for Research and Development of Natural Drugs, Guangdong Medical University, Zhanjiang, 524023 China.,2The Marine Biomedical Research Institute, Southern Marine Science and Engineering Guangdong Laboratory Zhanjiang, Guangdong Medical University, Zhanjiang, 524023 China
| | - Hui Luo
- 2The Marine Biomedical Research Institute, Southern Marine Science and Engineering Guangdong Laboratory Zhanjiang, Guangdong Medical University, Zhanjiang, 524023 China
| | - Xiao Zhu
- 1Guangdong Key Laboratory for Research and Development of Natural Drugs, Guangdong Medical University, Zhanjiang, 524023 China.,2The Marine Biomedical Research Institute, Southern Marine Science and Engineering Guangdong Laboratory Zhanjiang, Guangdong Medical University, Zhanjiang, 524023 China
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16
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Ramchander NC, Ryan NAJ, Walker TDJ, Harries L, Bolton J, Bosse T, Evans DG, Crosbie EJ. Distinct Immunological Landscapes Characterize Inherited and Sporadic Mismatch Repair Deficient Endometrial Cancer. Front Immunol 2020; 10:3023. [PMID: 31998307 PMCID: PMC6970202 DOI: 10.3389/fimmu.2019.03023] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/10/2019] [Indexed: 01/08/2023] Open
Abstract
Around 30% of endometrial cancers (EC) are mismatch repair (MMR) deficient, mostly as a consequence of mutations acquired during tumorigenesis, but a significant minority is caused by Lynch syndrome (LS). This inherited cancer predisposition syndrome primes an anti-cancer immune response, even in healthy carriers. We sought to explore the intra-tumoral immunological differences between genetically confirmed LS-associated MMR-deficient (MMRd), sporadic MMR-deficient, and MMR-proficient (MMRp) EC. Endometrial tumors from women with known LS were identified (n = 25). Comparator tumors were recruited prospectively and underwent microsatellite instability (MSI) testing, immunohistochemistry (IHC) for MMR expression and MLH1 methylation testing. Those found to have MLH1 hypermethylation formed the sporadic MMR-deficient group (n = 33). Those found to be mismatch repair proficient and microsatellite stable formed the MMR-proficient group (n = 35). A fully automated monoplex IHC panel was performed on sequential formalin-fixed paraffin-embedded tumor sections to identify CD3+, CD8+, CD45RO+, FoxP3+, and PD-1+ immune cells, and PD-L1 expression by tumor/immune cells. Two independent observers quantified immune marker expression at the tumor center and invasive margin. Mean and overall compartmental T-cell counts generated standard (binary: Low/High) and higher resolution (quaternary: 0-25, 25-50, 50-75, 75-100%) immune scores, which were used as explanatory features in neural network, support vector machine, and discriminant predictive modeling. Overall T-cell counts were significantly different between the three cohorts: CD3+ (p = <0.0001), CD8+ (p = <0.0001), CD45RO+ (<0.0001), FoxP3+ (p = <0.0001), and PD1+ (p = <0.0001), with LS-associated MMR-deficient tumors having highest infiltrations. There were significant differences in CD8+ (p = 0.02), CD45RO+ (p = 0.007), and PD-1+ (p = 0.005) T-cell counts at the invasive margin between LS-associated and sporadic MMR-deficient tumors, but not between sporadic MMR-deficient and MMR-proficient tumors. Predictive modeling could accurately determine MMR status based on CD8+ T-cell counts within the tumor center alone. This study shows that LS-associated and sporadic MMR-deficient EC are distinct immunological entities, which has important implications for treatment and prognosis.
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Affiliation(s)
- Neal C Ramchander
- University of Manchester Medical School, Manchester, United Kingdom.,Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Neil A J Ryan
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Division of Evolution and Genomic Medicine, Faculty of Biology, Medicine and Health, St. Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Thomas D J Walker
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Lauren Harries
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - James Bolton
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
| | - D G Evans
- Division of Evolution and Genomic Medicine, Faculty of Biology, Medicine and Health, St. Mary's Hospital, University of Manchester, Manchester, United Kingdom.,Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Department of Obstetrics and Gynaecology, Manchester Academic Health Science Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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17
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How J, Patel A, Jazaeri A. Immuno-oncology for Gynecologic Malignancies. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1244:149-182. [PMID: 32301014 DOI: 10.1007/978-3-030-41008-7_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with advanced and/or recurrent gynecologic cancers derive limited benefit from currently available cytotoxic and targeted therapies. Successes of immunotherapy in other difficult-to-treat malignancies such as metastatic melanoma and advanced lung cancer have led to intense interest in clinical testing of these treatments in patients with gynecologic cancers. Currently, in the realm of gynecologic oncology, the FDA-approved use of immune checkpoint inhibitors is limited to microsatellite instable cancers and PD-L1-positive cervical cancer. However, there has been an exponential growth of clinical trials testing immunotherapy approaches, both alone and in combination with chemotherapy and/or targeted agents, in patients with gynecologic cancers. This chapter reviews some of the major reported and ongoing immunotherapy clinical trials in patients with endometrial, cervical, and epithelial ovarian cancer.
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Affiliation(s)
- Jeffrey How
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ami Patel
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amir Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Crusz SM, Miller RE. Targeted therapies in gynaecological cancers. Histopathology 2019; 76:157-170. [DOI: 10.1111/his.14009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/15/2019] [Accepted: 09/30/2019] [Indexed: 01/01/2023]
Affiliation(s)
| | - Rowan E Miller
- Department of Medical Oncology St Bartholomew’s Hospital London UK
- Department of Medical Oncology University College London Hospital London UK
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19
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Evrard C, Tachon G, Randrian V, Karayan-Tapon L, Tougeron D. Microsatellite Instability: Diagnosis, Heterogeneity, Discordance, and Clinical Impact in Colorectal Cancer. Cancers (Basel) 2019; 11:E1567. [PMID: 31618962 PMCID: PMC6826728 DOI: 10.3390/cancers11101567] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/17/2022] Open
Abstract
Tumor DNA mismatch repair (MMR) deficiency testing is important to the identification of Lynch syndrome and decision making regarding adjuvant chemotherapy in stage II colorectal cancer (CRC) and has become an indispensable test in metastatic tumors due to the high efficacy of immune checkpoint inhibitor (ICI) in deficient MMR (dMMR) tumors. CRCs greatly benefit from this testing as approximately 15% of them are dMMR but only 3% to 5% are at a metastatic stage. MMR status can be determined by two different methods, microsatellite instability (MSI) testing on tumor DNA, and immunohistochemistry of the MMR proteins on tumor tissue. Recent studies have reported a rate of 3% to 10% of discordance between these two tests. Moreover, some reports suggest possible intra- and inter-tumoral heterogeneity of MMR and MSI status. These issues are important to know and to clarify in order to define therapeutic strategy in CRC. This review aims to detail the standard techniques used for the determination of MMR and MSI status, along with their advantages and limits. We review the discordances that may arise between these two tests, tumor heterogeneity of MMR and MSI status, and possible explanations. We also discuss the strategies designed to distinguish sporadic versus germline dMMR/MSI CRC. Finally, we present new and accurate methods aimed at determining MMR/MSI status.
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Affiliation(s)
- Camille Evrard
- Department of Medical Oncology, Poitiers University Hospital, 86021 Poitiers, France.
| | - Gaëlle Tachon
- Department of Cancer biology, Poitiers University Hospital, 86021 Poitiers, France.
- Faculty of medicine, University of Poitiers, 86000 Poitiers, France.
- Laboratory of Experimental and Clinical Neuroscience, Institut national de la santé et de la recherche médicale (INSERM) 1084, F-86073 Poitiers, France.
| | - Violaine Randrian
- Faculty of medicine, University of Poitiers, 86000 Poitiers, France.
- Department of Gastroenterology, Poitiers University Hospital, 86021 Poitiers, France.
| | - Lucie Karayan-Tapon
- Department of Cancer biology, Poitiers University Hospital, 86021 Poitiers, France.
- Faculty of medicine, University of Poitiers, 86000 Poitiers, France.
- Laboratory of Experimental and Clinical Neuroscience, Institut national de la santé et de la recherche médicale (INSERM) 1084, F-86073 Poitiers, France.
| | - David Tougeron
- Department of Medical Oncology, Poitiers University Hospital, 86021 Poitiers, France.
- Faculty of medicine, University of Poitiers, 86000 Poitiers, France.
- Department of Gastroenterology, Poitiers University Hospital, 86021 Poitiers, France.
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20
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Current Possibilities of Gynecologic Cancer Treatment with the Use of Immune Checkpoint Inhibitors. Int J Mol Sci 2019; 20:ijms20194705. [PMID: 31547532 PMCID: PMC6801535 DOI: 10.3390/ijms20194705] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/17/2022] Open
Abstract
Despite the ongoing progress in cancer research, the global cancer burden has increased to 18.1 million new cases and 9.6 million deaths in 2018. Gynecological cancers, such as ovarian, endometrial, and cervical cancers, considerably contribute to global cancer burden, leading to $5,862.6, $2,945.7, and $1,543.9 million of annual costs of cancer care, respectively. Thus, the development of effective therapies against gynecological cancers is still a largely unmet medical need. One of the novel therapeutic approaches is to induce anti-cancer immunity by the inhibition of the immune checkpoint pathways using monoclonal antibodies. The molecular targets for monoclonal antibodies are cytotoxic T lymphocyte-associated protein-4 (CTLA-4), programmed cell death protein-1 (PD-1), and programmed death-ligand 1 (PD-L1). The rationale for the use of immune checkpoint inhibitors in patients with gynecological cancers was based on the immunohistological studies showing high expression levels of PD-1 and PD-L1 in those cancers. Currently available immune checkpoint inhibitors include nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, and ipilimumab. The efficacy and safety of these inhibitors, used as monotherapy and with combination with chemotherapy, is being currently evaluated in several clinical studies. As the results are promising, more clinical trials are being planned, which may lead to the development of efficient therapies for gynecological cancer patients.
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21
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Ono R, Nakayama K, Nakamura K, Yamashita H, Ishibashi T, Ishikawa M, Minamoto T, Razia S, Ishikawa N, Otsuki Y, Nakayama S, Onuma H, Kurioka H, Kyo S. Dedifferentiated Endometrial Carcinoma Could be A Target for Immune Checkpoint Inhibitors (Anti PD-1/PD-L1 Antibodies). Int J Mol Sci 2019; 20:ijms20153744. [PMID: 31370215 PMCID: PMC6696376 DOI: 10.3390/ijms20153744] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/11/2019] [Accepted: 07/29/2019] [Indexed: 01/05/2023] Open
Abstract
Dedifferentiated endometrial carcinoma (DDEC) is defined as an undifferentiated carcinoma admixed with differentiated endometrioid carcinoma (Grade 1 or 2). It has poor prognosis compared with Grade 3 endometrioid adenocarcinoma and is often associated with the loss of mismatch repair (MMR) proteins, which is seen in microsatellite instability (MSI)-type endometrial cancer. Recent studies have shown that the effectiveness of immune checkpoint inhibitor therapy is related to MMR deficiency; therefore, we analyzed the immunophenotype (MMR deficient and expression of PD-L1) of 17 DDEC cases. In the undifferentiated component, nine cases (53%) were deficient in MMR proteins and nine cases (53%) expressed PD-L1. PD-L1 expression was significantly associated with MMR deficiency (p = 0.026). In addition, the presence of tumor-infiltrating lymphocytes (CD8+) was significantly associated with MMR deficiency (p = 0.026). In contrast, none of the cases showed PD-L1 expression in the well-differentiated component. Our results show that DDEC could be a target for immune checkpoint inhibitors (anti PD-L1/PD-1 antibodies), especially in the undifferentiated component. As a treatment strategy for DDEC, conventional paclitaxel plus carboplatin and cisplatin plus doxorubicin therapies are effective for those with the well-differentiated component. However, by using immune checkpoint inhibitors in combination with other conventional treatments, it may be possible to control the undifferentiated component and improve prognosis.
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Affiliation(s)
- Ruriko Ono
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Kentaro Nakayama
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan.
| | - Kohei Nakamura
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Hitomi Yamashita
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Tomoka Ishibashi
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Masako Ishikawa
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Toshiko Minamoto
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Sultana Razia
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University School of Medicine, 6938501 Izumo, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, 4308558 Hamamatsu, Japan
| | - Satoru Nakayama
- Department of Obstetrics and Gynecology, Seirei Hamamatsu General Hospital, 4308558 Hamamatsu, Japan
| | - Hideyuki Onuma
- Department of Pathology, Shimane Prefectural Central Hospital, 6938555 Izumo, Japan
| | - Hiroko Kurioka
- Department of Obstetrics and Gynecology, Shimane Prefectural Central Hospital, 6938555 Izumo, Japan
| | - Satoru Kyo
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, 6938501 Izumo, Japan
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22
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TIM-3 in endometrial carcinomas: an immunotherapeutic target expressed by mismatch repair-deficient and intact cancers. Mod Pathol 2019; 32:1168-1179. [PMID: 30926882 DOI: 10.1038/s41379-019-0251-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 12/22/2022]
Abstract
The checkpoint molecule TIM-3 is a target for emerging immunotherapies and has been identified on a variety of malignancies. Mismatch repair-deficient endometrial carcinomas have demonstrated durable responses to other checkpoint inhibitors due to high neoantigen loads and robust tumor-associated immune responses. However, little is known about TIM-3 expression in this tumor type. Tumor-associated immune and tumoral expression of TIM-3 were evaluated by immunohistochemistry on 75 endometrial carcinomas [25 MLH1 promoter hypermethylated (MLH1-hypermethylated), 25 non-hypermethylated mismatch repair-deficient, and 25 mismatch repair-intact]. All cases showed at least focal immune staining, but moderate and robust immune cell expression were more often observed in mismatch repair-deficient vs intact cases [66 vs 12%, P = 0.00002]. While the majority (77%) of endometrial cancers showed ≥1% tumoral TIM-3 expression, the MLH1-hypermethylated subset was more likely to demonstrate >5% tumoral staining when compared to both mismatch repair-intact and non-methylated mismatch repair-deficient cancers [64 vs. 28% and 32%, respectively; P = 0.02 and P = 0.05]. Within the non-methylated mismatch repair-deficient subset, high-level expression was most often associated with MSH6 loss. Across mismatch repair subgroups, tumoral TIM-3 expression was more common among intermediate and high-grade vs. low-grade tumors using both the 1% (P = 0.02) and 5% expression cut-offs (P = 0.02). In conclusion, tumoral TIM-3 expression is common in both mismatch repair-intact and deficient endometrial cancers, with particularly high levels of expression identified in the setting of MLH1-hypermethylation, MSH6 loss, and intermediate to high histologic grade. Although focal immune cell expression was seen in all tumors, robust expression was significantly more common in the context of mismatch repair deficiency. These data support a potential role for checkpoint inhibitors targeting TIM-3 in a subset of endometrial cancers, including some mismatch repair-intact tumors which are not currently considered immunotherapy candidates.
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23
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Salmaninejad A, Valilou SF, Shabgah AG, Aslani S, Alimardani M, Pasdar A, Sahebkar A. PD-1/PD-L1 pathway: Basic biology and role in cancer immunotherapy. J Cell Physiol 2019; 234:16824-16837. [PMID: 30784085 DOI: 10.1002/jcp.28358] [Citation(s) in RCA: 246] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
Over the course of past few years, cancer immunotherapy has been accompanied with promising results. However, preliminary investigations with respect to immunotherapy concentrated mostly on targeting the immune checkpoints, nowadays, emerge as the most efficient strategy to raise beneficial antitumor immune responses. Programmed cell death protein 1 (PD-1) plays an important role in subsiding immune responses and promoting self-tolerance through suppressing the activity of T cells and promoting differentiation of regulatory T cells. PD-1 is considered as an immune checkpoint and protects against autoimmune responses through both induction of apoptosis in antigen-specific T cells and inhibiting apoptosis in regulatory T cells. Several clinical trials exerting PD-1 monoclonal antibodies as well as other immune-checkpoint blockades have had prosperous outcomes and opened new horizons in tumor immunotherapy. Nonetheless, a bulk of patients have failed to respond to these newly emerging immune-based approach and the survival rate was not satisfying. Additional strategies, especially combination therapies, has been initiated and been further promising. Attempts to identify novel and well-suited predictive biomarkers are also sensed. In this review, the promotion of cancer immunotherapy targeting PD-1 immunoinhibitory pathway is discussed.
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Affiliation(s)
- Arash Salmaninejad
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student Research Committee, Department of Medical Genetics, Medical Genetics Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Farajzadeh Valilou
- Medical Genetics Network (MeGeNe), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | | | - Saeed Aslani
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Malihe Alimardani
- Student Research Committee, Department of Medical Genetics, Medical Genetics Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Pasdar
- Student Research Committee, Department of Medical Genetics, Medical Genetics Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Division of Applied Medicine, Medical School, University of Aberdeen, Aberdeen, UK
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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24
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Eskander RN. Mismatch repair in endometrioid endometrial cancer: Increasing our therapeutic proficiency by capitalizing on molecular deficiency. Cancer 2019; 125:337-339. [PMID: 30561783 DOI: 10.1002/cncr.31902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Ramez N Eskander
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, University of California-San Diego Moores Cancer Center, La Jolla, California
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25
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Levinson K, Dorigo O, Rubin K, Moore K. Immunotherapy in Gynecologic Cancers: What We Know Now and Where We Are Headed. Am Soc Clin Oncol Educ Book 2019; 39:e126-e140. [PMID: 31099679 DOI: 10.1200/edbk_237967] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Immunotherapy, mainly in the form of immune checkpoint inhibitors (ICIs), has been transformative in both solid tumor and hematologic malignancies. Patients with previously terminal illnesses have experienced profound responses of great durability with these agents, fueling excitement among patients and providers regarding their use. Unfortunately, the gains seen in some solid tumors have not been replicated in a large percentage of patients with gynecologic cancer. This review focuses on the clinical benefits seen to date, toxicities and management when using ICIs, ways to improve prediction of who should receive immunotherapy, and a discussion of next-generation immunotherapy with cellular therapeutics and how these might relate to gynecologic cancers.
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Affiliation(s)
- Kimberly Levinson
- 1 The Kelly Gynecologic Oncology Service, Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | - Kathleen Moore
- 4 Stephenson Cancer Center at the University of Oklahoma Health Sciences Center, Oklahoma City, OK
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26
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Backes FJ, Haag J, Cosgrove CM, Suarez A, Cohn DE, Goodfellow PJ. Mismatch repair deficiency identifies patients with high‐intermediate–risk (HIR) endometrioid endometrial cancer at the highest risk of recurrence: A prognostic biomarker. Cancer 2018; 125:398-405. [DOI: 10.1002/cncr.31901] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/01/2018] [Accepted: 07/13/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Floor J. Backes
- Division of Gynecologic Oncology Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Jennifer Haag
- Division of Gynecologic Oncology Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Casey M. Cosgrove
- Division of Gynecologic Oncology Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Adrian Suarez
- Division of Pathology Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - David E. Cohn
- Division of Gynecologic Oncology Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Paul J. Goodfellow
- Division of Gynecologic Oncology Ohio State University Comprehensive Cancer Center Columbus Ohio
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27
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Eskander RN. The Epigenetic Landscape in the Treatment of Gynecologic Malignancies. Am Soc Clin Oncol Educ Book 2018; 38:480-487. [PMID: 30231335 DOI: 10.1200/edbk_200203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The care of patients with advanced-stage or recurrent endometrial, ovarian, and cervical cancer remains clinically challenging. Despite the identification of novel therapeutics and advancements in supportive care, survival outcomes have been relatively unchanged over the past decade. In addition to established genomic alterations and the contributions of the tumor microenvironment to cancer progression, epigenetic mechanisms have emerged as important contributors to gynecologic cancer progression. DNA methylation, histone modification, and noncoding RNA expression may be important contributors to disease initiation and progression and may represent novel therapeutic targets. This article reviews the epigenetic landscape of endometrial, ovarian, and cervical cancer, describing the state of the science and discussing potential clinical applications. To date, the role of epigenetic drugs in the treatment of gynecologic cancers remains unclear, although continued progress may inform future treatment modalities.
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Affiliation(s)
- Ramez N Eskander
- From the Division of Gynecologic Oncology, Department of Reproductive Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA
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28
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The Increase of Circulating PD-1- and PD-L1-Expressing Lymphocytes in Endometriosis: Correlation with Clinical and Laboratory Parameters. Mediators Inflamm 2018; 2018:7041342. [PMID: 30595667 PMCID: PMC6286737 DOI: 10.1155/2018/7041342] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/27/2018] [Indexed: 12/14/2022] Open
Abstract
The cause of endometriosis remains unknown. However, studies investigating the link between this condition and the immune system revealed several immunological abnormalities focused on cell-mediated immunity. As a major immune checkpoint, programmed cell death protein 1 (PD-1) displays an important inhibitory function in the maintenance of peripheral tolerance. The expression of PD-1 and its ligand (PD-L1) may contribute to continuous T cell activation and development of inflammation and injury of the tissue. To our knowledge, this is the first study evaluating frequencies of PD-1-positive T CD3+ cells (CD4+ and CD8+) and B cells (CD19+) in patients with endometriosis. Peripheral blood (PB) samples from 25 female patients and 20 healthy age and sex-matched subjects serving as controls were used in the study. Using flow cytometric analysis, we assessed the differences in the frequencies of PD-1-positive T and B lymphocytes in the study group and healthy individuals. Alteration of the PD-1/PD-L1 axis may contribute to the pathogenesis of endometriosis, as patients with advanced disease are characterized by higher frequencies of PD-1-positive T and B cells. Expression of PD-1 and PD-L1 on T and B cells could represent the hallmark of immune system reaction to chronic antigenic exposition in patients with endometriosis.
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29
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Kim J, Kong JK, Yang W, Cho H, Chay DB, Lee BH, Cho SJ, Hong S, Kim JH. DNA Mismatch Repair Protein Immunohistochemistry and MLH1 Promotor Methylation Testing for Practical Molecular Classification and the Prediction of Prognosis in Endometrial Cancer. Cancers (Basel) 2018; 10:E279. [PMID: 30134578 PMCID: PMC6162750 DOI: 10.3390/cancers10090279] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/13/2018] [Accepted: 08/18/2018] [Indexed: 11/20/2022] Open
Abstract
The incidence of endometrial cancer is rapidly increasing worldwide, and its molecular classification has gained importance for new therapeutic approaches. This study sought to examine the clinicopathologic features and immune markers associated with the DNA mismatch repair (MMR) status and MLH1 promoter methylation status of endometrial cancer patients. A total of 173 patients with primary endometrial cancer who had received a hysterectomy were evaluated for four MMR proteins (MLH1, MSH2, MSH6, and PMS2), immune markers (CD8, programmed cell death protein 1 (PD-1), and programmed death-ligand 1 (PD-L1)) and p53 by immunohistochemistry (IHC), followed by an MLH1 methylation test. Patients were classified into MMR deficiency or proficiency, sporadic cancer, or probable Lynch syndrome (PLS), and the clinicopathologic features (including the expression of peritumoral immune markers) and prognosis of each group were compared. Patients with MMR deficiency or PLS showed an increase in immune markers compared those with MMR proficiency or sporadic cancer, respectively, and PLS demonstrated higher immune marker expression than MLH1 promoter methylation. Regarding prognosis, patients with MMR deficiency showed significant adverse overall survival (OS) when in stages I and II. Practical molecular classifications based on p53 staining results, in addition to MMR or PLS status, revealed an increased predictive ability for OS compared with the European Society of Medical Oncologists (ESMO) risk groups. The results of this study suggest that PLS may be a better candidate for an immune checkpoint inhibitor than MMR deficiency. The practical molecular classification contributes not only to the screening of Lynch syndrome, but also assists in predicting the prognosis in endometrial cancer.
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Affiliation(s)
- Jisup Kim
- Department of Pathology, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Jin Kyoung Kong
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Wookyeom Yang
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Hanbyoul Cho
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Doo Byung Chay
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Bang Hyun Lee
- Department of Obstetrics and Gynecology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Korea.
| | - Seong Jin Cho
- Department of Pathology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Korea.
| | - Soonwon Hong
- Department of Pathology, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
| | - Jae-Hoon Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 06273, Korea.
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30
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Gong J, Le TQ, Massarelli E, Hendifar AE, Tuli R. Radiation therapy and PD-1/PD-L1 blockade: the clinical development of an evolving anticancer combination. J Immunother Cancer 2018; 6:46. [PMID: 29866197 PMCID: PMC5987486 DOI: 10.1186/s40425-018-0361-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 05/16/2018] [Indexed: 02/06/2023] Open
Abstract
Several inhibitors of programmed cell death-1 (PD-1) and programmed death ligand-1 (PD-L1) have been approved as a form of immunotherapy for multiple cancers. Ionizing radiation therapy (RT) has been shown to enhance the priming and effector phases of the antitumor T-cell response rendering it an attractive therapy to combine with PD-1/PD-L1 inhibitors. Preclinical data support the rational combination of the 2 modalities and has paved way for the clinical development of the combination across a spectrum of cancers. In this review, we highlight the preclinical and clinical development of combined RT and PD-1/PD-L1 blockade to date. In addition to a comprehensive evaluation of available safety and efficacy data, we discuss important points of consideration in clinical trial design for this promising combination.
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Affiliation(s)
- Jun Gong
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Thang Q Le
- Division of Angiography and Interventional Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erminia Massarelli
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrew E Hendifar
- Division of Medical Oncology, Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard Tuli
- Departments of Radiation Oncology and Biomedical Sciences, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, AC 1023, Los Angeles, CA, 90048, USA.
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31
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Di Tucci C, Schiavi MC, Faiano P, D'Oria O, Prata G, Sciuga V, Giannini A, Palaia I, Muzii L, Benedetti Panici P. Therapeutic vaccines and immune checkpoints inhibition options for gynecological cancers. Crit Rev Oncol Hematol 2018; 128:30-42. [PMID: 29958629 DOI: 10.1016/j.critrevonc.2018.05.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/21/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022] Open
Abstract
Treatments for gynecological cancer include surgery, chemotherapy, and radiation. However, overall survival is not improved, and novel approaches are needed. Immunotherapy has been proven efficacious in various types of cancers and multiple approaches have been recently developed. Since numerous gynecological cancers are associated to human papilloma virus (HPV) infections, therapeutic vaccines, targeting HPV epitopes, have been developed. The advancing understanding of the immune system, regulatory pathways and tumor microenvironment have produced a major interest in immune checkpoint blockade, Indeed, immune checkpoint molecules are important clinical targets in a wide variety of tumors, including gynecological. In this review, we will describe the immunotherapeutic targets and modalities available and review the most recent immunotherapeutic clinical trials in the context of gynecological cancers. The synergic results obtained from the combination of HPV therapeutic vaccines with radiotherapy, chemotherapy, or immune checkpoint inhibitors, may underlie the potential for a novel therapeutic scenario for these tumors.
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Affiliation(s)
- Chiara Di Tucci
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Michele Carlo Schiavi
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Pierangelo Faiano
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Ottavia D'Oria
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Giovanni Prata
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Valentina Sciuga
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy.
| | - Andrea Giannini
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy
| | - Innocenza Palaia
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy
| | - Ludovico Muzii
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Gynecological and Obstetric Sciences, and Urological Sciences, University of Rome "Sapienza", Umberto I Hospital, Rome, Italy
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Gong J, Chehrazi-Raffle A, Reddi S, Salgia R. Development of PD-1 and PD-L1 inhibitors as a form of cancer immunotherapy: a comprehensive review of registration trials and future considerations. J Immunother Cancer 2018; 6:8. [PMID: 29357948 PMCID: PMC5778665 DOI: 10.1186/s40425-018-0316-z] [Citation(s) in RCA: 853] [Impact Index Per Article: 142.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/09/2018] [Indexed: 12/13/2022] Open
Abstract
Early preclinical evidence provided the rationale for programmed cell death 1 (PD-1) and programmed death ligand 1 (PD-L1) blockade as a potential form of cancer immunotherapy given that activation of the PD-1/PD-L1 axis putatively served as a mechanism for tumor evasion of host tumor antigen-specific T-cell immunity. Early-phase studies investigating several humanized monoclonal IgG4 antibodies targeting PD-1 and PD-L1 in advanced solid tumors paved way for the development of the first PD-1 inhibitors, nivolumab and pembrolizumab, approved by the Food and Drug Administration (FDA) in 2014. The number of FDA-approved agents of this class is rapidly enlarging with indications for treatment spanning across a spectrum of malignancies. The purpose of this review is to highlight the clinical development of PD-1 and PD-L1 inhibitors in cancer therapy to date. In particular, we focus on detailing the registration trials that have led to FDA-approved indications of anti-PD-1 and anti-PD-L1 therapies in cancer. As the number of PD-1/PD-L1 inhibitors continues to grow, predictive biomarkers, mechanisms of resistance, hyperprogressors, treatment duration and treatment beyond progression, immune-related toxicities, and clinical trial design are key concepts in need of further consideration to optimize the anticancer potential of this class of immunotherapy.
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Affiliation(s)
- Jun Gong
- Department of Medical Oncology, City of Hope National Medical Center, 1500 E Duarte St, Duarte, CA 91010 USA
| | - Alexander Chehrazi-Raffle
- Department of Internal Medicine, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509 USA
| | - Srikanth Reddi
- Department of Internal Medicine, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509 USA
| | - Ravi Salgia
- Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Building 51, Room 101, 1500 E Duarte St, Duarte, CA 91010 USA
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Mismatch repair status and PD-L1 expression in clear cell carcinomas of the ovary and endometrium. Mod Pathol 2017; 30:1622-1632. [PMID: 28752845 DOI: 10.1038/modpathol.2017.67] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/02/2017] [Accepted: 05/06/2017] [Indexed: 12/17/2022]
Abstract
Clear cell carcinoma represents a distinct histologic type of müllerian carcinoma that is resistant to conventional chemotherapy. Expression of programmed cell death ligand (PD-L1) has been associated with immune evasion in numerous tumor types and may be used to identify patients who will benefit from targeted immunotherapy, particularly in the setting of mismatch repair defects. We evaluated PD-L1 expression in 23 ovarian clear cell carcinomas and 21 endometrial clear cell carcinomas, and correlated expression with mismatch repair status. Tumor PD-L1 staining was seen in 43% of ovarian tumors and 76% of endometrial tumors, including 71% of cases (67% of ovarian and 75% of endometrial) with mismatch repair defects. Extensive tumoral staining (>50%) was seen in only one case (an endometrial case with MSH6 loss). However, tumoral PD-L1 expression remained common in mismatch repair-intact tumors and mismatch repair status was not significantly correlated with PD-L1 expression. The increased incidence of PD-L1 positivity in tumor cells (P=0.04) in endometrial vs ovarian clear cell carcinomas suggests differences in the tumor microenvironment of these histologically and molecularly similar tumors that may inform treatment options. These results suggest that clear cell histology may be a useful susceptibility marker for immunotherapy targeting the PD-1/PD-L1 axis irrespective of mismatch repair status, particularly in endometrial carcinomas.
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35
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Heong V, Ngoi N, Tan DSP. Update on immune checkpoint inhibitors in gynecological cancers. J Gynecol Oncol 2017; 28:e20. [PMID: 28028993 PMCID: PMC5323287 DOI: 10.3802/jgo.2017.28.e20] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/04/2016] [Accepted: 11/28/2016] [Indexed: 12/21/2022] Open
Abstract
In recent years, progress in our understanding of immune-modulatory signaling pathways in immune cells and the tumor microenvironment (TME) has led to rejuvenated interest in cancer immunotherapy. In particular, immunotherapy targeting the immune checkpoint receptors such as cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), programmed cell-death 1 (PD-1), and programmed cell-death ligand 1 (PD-L1) have demonstrated clinical activity in a wide variety of tumors, including gynecological cancers. This review will focus on the emerging clinical data on the therapeutic role of immune checkpoint inhibitors, and potential strategies to enhance the efficacy of this class of compounds, in the context of gynecological cancers. It is anticipated that future biomarker-directed clinical trials will provide further insights into the mechanisms underlying response and resistance to immunotherapy, and help guide our approach to designing therapeutic combinations that have the potential to enhance the benefit of immunotherapy in patients with gynecologic cancers.
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Affiliation(s)
- Valerie Heong
- Department of Hematology-Oncology, National University Hospital, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Natalie Ngoi
- Department of Hematology-Oncology, National University Hospital, Singapore, Singapore
| | - David Shao Peng Tan
- Department of Hematology-Oncology, National University Hospital, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.
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Frey MK, Pothuri B. Homologous recombination deficiency (HRD) testing in ovarian cancer clinical practice: a review of the literature. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:4. [PMID: 28250960 PMCID: PMC5322589 DOI: 10.1186/s40661-017-0039-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/07/2017] [Indexed: 01/07/2023]
Abstract
Until recently our knowledge of a genetic contribution to ovarian cancer focused almost exclusively on mutations in the BRCA1/2 genes. However, through germline and tumor sequencing an understanding of the larger phenomenon of homologous recombination deficiency (HRD) has emerged. HRD impairs normal DNA damage repair which results in loss or duplication of chromosomal regions, termed genomic loss of heterozygosity (LOH). The list of inherited mutations associated with ovarian cancer continues to grow with the literature currently suggesting that up to one in four cases will have germline mutations, the majority of which result in HRD. Furthermore, an additional 5-7% of ovarian cancer cases will have somatic HRD. In the near future, patients with germline or somatic HRD will likely be candidates for a growing list of targeted therapies in addition to poly (ADP-ribose) polymerase (PARP) inhibitors, and, as a result, establishing an infrastructure for widespread HRD testing is imperative. The objective of this review article is to focus on the current germline and somatic contributors to ovarian cancer and the state of both germline and somatic HRD testing. For now, germline and somatic tumor testing provide important and non-overlapping clinical information. We will explore a proposed testing strategy using somatic tumor testing as an initial triage whereby those patients found with somatic testing to have HRD gene mutations are referred to genetics to determine if the mutation is germline. This strategy allows for rapid access to genomic information that can guide targeted treatment decisions and reduce the burden on genetic counselors, an often limited resource, who will only see patients with a positive somatic triage test.
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Affiliation(s)
- Melissa K Frey
- Division of Gynecologic Oncology, Weill Cornell Medicine, 525 East 68th Street, Suite J-130, New York, NY 10065 USA
| | - Bhavana Pothuri
- Division of Gynecologic Oncology, New York University Langone Medical Center, 240 E. 38th St, 19th floor, New York, NY 10016 USA
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Howitt BE, Strickland KC, Sholl LM, Rodig S, Ritterhouse LL, Chowdhury D, D'Andrea AD, Matulonis UA, Konstantinopoulos PA. Clear cell ovarian cancers with microsatellite instability: A unique subset of ovarian cancers with increased tumor-infiltrating lymphocytes and PD-1/PD-L1 expression. Oncoimmunology 2017; 6:e1277308. [PMID: 28344892 DOI: 10.1080/2162402x.2016.1277308] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022] Open
Abstract
Clear cell ovarian carcinoma (CCOC) represents a distinct histologic subtype of ovarian cancer associated with significantly worse prognosis across all stages and no effective therapeutic options. Here, we report a rare but clinically important cohort of CCOCs with microsatellite instability (MSI) (MSI-CCOCs), which are highly immunogenic and may thus be very responsive to immune checkpoint blockade. CCOCs with MSI exhibit a significantly higher number of CD8+ TILs, higher CD8+/CD4+ ratio, and higher PD-1+ TILs compared with microsatellite stable (MSS) CCOCs and compared with high grade serous ovarian cancers, which are the most common histologic subtype of ovarian cancer. Of note, PD-L1 expression in tumor cells or immune cells was noted in all cases of CCOCs with MSI. These observations open an alternative therapeutic avenue for a fraction of patients with CCOC and argue for the routine testing of CCOCs for MSI, a test that is not currently routinely performed.
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Affiliation(s)
- Brooke E Howitt
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Kyle C Strickland
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Scott Rodig
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Lauren L Ritterhouse
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Dipanjan Chowdhury
- Division of Genomic Stability and DNA Repair, Dana Farber Cancer Institute, Harvard Medical School , Boston, MA, USA
| | - Alan D D'Andrea
- Division of Genomic Stability and DNA Repair, Dana Farber Cancer Institute, Harvard Medical School , Boston, MA, USA
| | - Ursula A Matulonis
- Medical Gynecologic Oncology Program, Dana Farber Cancer Institute, Harvard Medical School , Boston, MA, USA
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