Major clinical research advances in gynecologic cancer in 2010

Major clinical research advances in gynecologic cancer in 2016: 10-year special edition

In 2016, 13 topics were selected as major research advances in gynecologic oncology. For ovarian cancer, study results supporting previous ones regarding surgical preventive strategies were reported. There were several targeted agents that showed comparable responses in phase III trials, including niraparib, cediranib, and nintedanib. On the contrary to our expectations, dose-dense weekly chemotherapy regimen failed to prove superior survival outcomes compared with conventional triweekly regimen. Single-agent non-platinum treatment to prolong platinum-free-interval in patients with recurrent, partially platinum-sensitive ovarian cancer did not improve and even worsened overall survival (OS). For cervical cancer, we reviewed robust evidences of larger-scaled population-based study and cost-effectiveness of nonavalent vaccine for expanding human papillomavirus (HPV) vaccine coverage. Standard of care treatment of locally advanced cervical cancer (LACC) was briefly reviewed. For uterine corpus cancer, new findings about appropriate surgical wait time from diagnosis to surgery were reported. Advantages of minimally invasive surgery over conventional laparotomy were reconfirmed. There were 5 new gene regions that increase the risk of developing endometrial cancer. Regarding radiation therapy, Post-Operative Radiation Therapy in Endometrial Cancer (PORTEC)-3 quality of life (QOL) data were released and higher local control rate of image-guided adaptive brachytherapy was reported in LACC. In addition, 4 general oncology topics followed: chemotherapy at the end-of-life, immunotherapy with reengineering T-cells, actualization of precision medicine, and artificial intelligence (AI) to make personalized cancer therapy real. For breast cancer, adaptively randomized trials, extending aromatase inhibitor therapy, and ribociclib and palbociclib were introduced.

Curcumin suppresses cisplatin resistance development partly via modulating extracellular vesicle-mediated transfer of MEG3 and miR-214 in ovarian cancer

PURPOSE

To investigate how curcumin alters the extracellular vesicles' (EVs) capability to ship drug resistance in ovarian cancer.

METHODS

The EVs from cisplatin-resistant A2780cp cells with curcumin treatment (EVs-CU) or without curcumin treatment (EVs-N) were collected for lncRNA profiling. Curcumin's effect on MEG3 promoter methylation and MEG3 expression were studied by MSP and qRT-PCR, respectively. The regulative effect of MEG3 on miR-214 expression and the functional role of EVs mediated transfer of miR-214 in cisplatin resistance were further investigated.

RESULTS

Curcumin weakened the EVs-N's capability to induce drug resistance and induced significant changes of lncRNAs in the EVs. MEG3 is one of the most upregulated lncRNAs. Curcumin led to demethylation in the promoter region of MEG3 and 5-AZA-dC treatment restored MEG3 expression in a dose dependent manner. There were at least two binding sites between MEG3 and miR-214. MEG3 restoration by curcumin significantly reduced miR-214 in cells and in EVs. Functionally, miR-214 inhibition weakened the EVs-N's capability to enhance chemoresistance, while miR-214 overexpression increased the capability of EVs-CU in inducing chemoresistance.

CONCLUSION

Curcumin can restore MEG3 levels via demethylation. MEG3 upregulation can decrease EVs mediated transfer of miR-214 in ovarian cancer cells, thereby reducing drug resistance.

Perioperative Outcomes of Radical Trachelectomy in Early-Stage Cervical Cancer: Vaginal Versus Laparoscopic Approaches

Objective

This study aimed to compare the laparoscopic-assisted radical vaginal trachelectomy (LARVT) and laparoscopic radical trachelectomy (LRT) surgical approaches and provide outcome data on patients who have undergone radical trachelectomy.

Methods

We identified patients who had undergone LARVT or LRT at Samsung Medical Center between January 2005 and March 2013.

Results

A total of 38 patients were identified, and 21 patients had undergone LARVT, whereas 17 patients had undergone LRT. The median age was 32 years for both groups. Most of the patients had a squamous cell carcinoma (68.4%) and International Federation of Gynecology and Obstetrics stage IB1 disease (76.3%). Twenty (52.6%) of 38 patients had tumor size greater than 2 cm. There were no significant differences between groups in the baseline characteristics except for the tumor size. Patients undergoing LRT had significantly larger tumor size than patients undergoing LARVT (median tumor size, 2.7 cm [range, 1.2–3.7] vs 2.1 cm [range, 0.4–3.0],P= 0.032). Perioperative outcomes were similar between groups except for the decline of hemoglobin after surgery. The median decline of hemoglobin indicating blood loss was significantly smaller in the LRT group than in the LARVT group (1.8 g/dL [range, 0.5–3.5] vs 2.6 g/dL [range, 0.7–6.2],P= 0.017). Intraoperative complications occurred in 2 patients (9.5%, 2/21) in LARVT group. Although 52.6% of tumors were larger than 2 cm, recurrence occurred only in 3 (7.9%) patients who underwent LARVT.

Conclusions

The study shows the feasibility of LRT, with the advantage of reduced blood loss. The LRT could be an alternative option for patients with large tumors. Further researches are needed to investigate the long-term outcomes.

Ovarian cancer screening practices of obstetricians and gynecologists in puerto rico

Background. Ovarian cancer is the most fatal malignancy of the female genital tract and is associated with high mortality. The American Congress of Obstetricians and Gynecologists (ACOG) and the United States Preventive Services Task Force (USPSTF) recommend against screening for ovarian cancer in asymptomatic, average-risk women. Objective. To assess the ovarian cancer screening practices in asymptomatic, average-risk women among obstetricians and gynecologists (Ob/Gyn) in Puerto Rico. Methodology. From 2011 to 2012, self-administered anonymous questionnaires were mailed to all licensed obstetricians and gynecologists in PR. Results. Response rate was 25%. Overall, 53.9% were screening for the disease. Reported screening methods were CA-125 and transvaginal ultrasound (TVUS), 39.2%, TVUS only, 30.4%, and CA-125 only, 9.8%. In the logistic regression model, the odds that a given health practitioner routinely screened for ovarian cancer in the asymptomatic, average-risk population increased by 8% with every unit increase in his or her years in practice. Conclusion. The majority of the practicing Ob/Gyn in PR who participated are not following the guidelines established by the ACOG and the USPSTF for ovarian cancer screening.

RNA interference targeting CD147 inhibits the invasion of human cervical squamous carcinoma cells by downregulating MMP-9

Cervical squamous carcinoma is a highly invasive tumour that has a great capacity to metastasise. Extracellular matrix metalloproteinase inducer (EMMPRIN or CD147), a member of the immunoglobulin superfamily, is a widely distributed cell surface glycoprotein. It is highly expressed on malignant tumour cell surfaces, including human cervical squamous carcinoma. It also plays a critical role in the invasive and metastatic activity of malignant cells by stimulating the expression of matrix metalloproteinases (MMPs). The anti-invasive effect of small interfering RNA (siRNA) against CD147 on human cervical squamous carcinoma cells and its possible pathways has been investigated. The downregulation of CD147 by transfection with siRNA resulted in MMP-9 expression and decreased activity in the cervical squamous carcinoma cell line SiHa. In vitro analysis showed that the invasive capacity of SiHa cells decreased. Thus CD147 inhibition and subsequent MMP-9 deletion may have anti-tumour effects by inhibiting the invasiveness of human cervical squamous carcinoma cells.

Molecular bases of endometrial cancer: new roles for new actors in the diagnosis and the therapy of the disease

Endometrial carcinoma (EC) is the most commonly diagnosed gynecologic malignancy in the western world. The majority of these cancers are curable, but a subset about 15-20% of endometrial tumors exhibits an aggressive phenotype. Based on clinic-pathological and molecular characteristics, EC has been classified into two groups: Type I estrogen-dependent adenocarcinomas, which have a good prognosis and an endometrioid histology, and Type II or non-estrogen-dependent EC associated with poor prognosis and non-endometrioid histology. EC develops as a result of a stepwise accumulation of alterations that seem to be specific of each histological type. However, more knowledge is needed to better understand the differences in the biology and the clinical outcome of EC. We would like to highlight the need to explore new potential biomarkers of EC as a tool for the detection and monitoring of aggressive endometrial tumors that, at the same time, will allow us to develop novel and more selective molecular targeted therapies against EC.

Paradoxical expression of AHCYL1 affecting ovarian carcinogenesis between chickens and women

We investigated S-adenosylhomocysteine hydrolase-like protein 1 (AHCYL1) gene expression in human epithelial ovarian cancer (EOC) using the chicken, which is the most relevant animal model. Ovarian cancer was detected in 10 of 136 laying hens (7.4%). Results of the present study indicated that AHCYL1 mRNA and protein are most abundant in the glandular epithelium of adenocarcinoma of cancerous, but not normal, ovaries of hens. In addition, bisulfite sequencing to examine methylation patterns in the promoter region of the AHCYL1 gene revealed that 30-38% of the three CpG sites were demethylated in ovarian cancer cells as compared with normal ovarian cells. Furthermore, in human ovarian cancer cells such as OVCAR-3, AHCYL1 protein was predominantly in the nucleus and had a similar expression pattern to that in chicken ovarian cancer cells. Thereafter, we examined the prognostic value of AHCYL1 expression in patients with EOC using multivariate linear logistic regression and Cox's proportional hazard analyses. In 109 human patients with EOC, 14 (12.8%), 41 (37.6%) and 54 (49.6%) patients showed weak, moderate and strong expression of AHCYL1 protein, respectively. However, intermediate or high expression of AHCYL1 protein was a favorable factor for overall responses (adjusted odds ratio, 7.23; 95% confidence interval [CI], 1.36-38.39), and for progression-free survival (adjusted hazard ratio, 0.20; 95% CI, 0.07-0.55). From these results, we conclude that AHCYL1 expression is associated with ovarian carcinogenesis as an oncogene in chickens, whereas it plays the role of tumor suppressor in human EOC, suggesting a paradoxical function of AHCYL1 in ovarian carcinogenesis.

Phase II Study of Consolidation Chemotherapy after Adjuvant or Primary Concurrent Chemoradiation Using Paclitaxel and Carboplatin to Treat High-Risk Early-Stage or Locally Advanced Cervical Cancer

Purpose

This study investigated the efficacy and toxicity associated with consolidation chemotherapy using paclitaxel and carboplatin after concurrent chemoradiation (CCR) in cervical cancer patients.

Materials and Methods

From a total of 37 patients, 19 with International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IIA cervical cancer (group 1) underwent surgery followed by consolidation chemotherapy after CCR, and 18 with stage IIB-IVA disease (group 2) received consolidation chemotherapy after primary CCR. Three cycles of chemotherapy using paclitaxel (135 mg/m²) and carboplatin (AUC 5.0) were administered every 3 weeks for CCR therapy, and three cycles of consolidation chemotherapy using paclitaxel (175 mg/m²) and carboplatin (AUC 5.0) were used every 3 weeks after CCR.

Results

The complete and partial response rates were 77.8% and 22.2% in group 2. Moreover, the 3-year progression-free and overall survival rates were 62.7% and 90.9% in group 1, and 51.9% and 60% in group 2, respectively. The most common grade 3 or 4 hematologic toxicities observed were leukopenia (group 1, 10.5%; group 2, 13.0%) and neutropenia (group 1, 7.0%; group 2, 14.8%), and grade 3 or 4 diarrhea (group 1, 1.8%) and febrile illness (group 2, 1.9%) were the most frequently observed non-hematologic toxicities. When we compared these results with previous reports, consolidation chemotherapy after CCR using paclitaxel and carboplatin revealed a relatively lower complete response rate (77.8% vs. 87-100%, respectively) and shorter progression-free survival (51.9-62.7% vs. 81-86%, respectively) and overall survival (60-90.9% vs. 81-95%, respectively) in spite of similar toxicity findings.

Conclusion

Due to low efficacy results, consolidation chemotherapy using paclitaxel and carboplatin after CCR is not a feasible treatment regimen for high-risk early-stage or locally advanced cervical cancer.

Major clinical research advances in gynecologic cancer in 2011

The annual review of 2011 comprised 11 themes of major research achievements in gynecologic oncology including breast cancer. A potential paradigm shift in the management of ovarian cancer was reviewed through comprehensive genomic analyses and a tumor-specific new intraoperative fluorescence imaging technique using folate receptor-α targeted agent, which is expected to improve intraoperative staging and more radical cytoreduction. In addition, updates of bevacizumab and poly (ADP-ribose) polymerase inhibitors, risk-reducing salpingo-oophorectomy, and risk evaluation of pelvic mass were discussed. Regarding cervical cancer, this review covered new findings on human papillomavirus vaccines and human papillomavirus tests as well as the current status of clinical trials on locally advanced cervical cancer. The promising role of sentinel lymph node biopsy in the management of early stage endometrial cancer was followed by two notable clinical researches on: exemestane, an aromatase inhibitor, for the prevention of breast cancer and eribulin, a non-taxane microtubule dynamics inhibitor for the treatment of metastatic breast cancer. Lastly, in premenopausal women with breast cancer, the effect of gonadotropin-releasing hormone analogue on the occurrence of chemotherapy-induced early menopause was discussed.

[Advanced endometrial carcinoma: primary debulking surgery or neoadjuvant chemotherapy?]

Endometrial cancers with peritoneal spread are stage IVB of FIGO classification. Their pattern is similar to that of ovarian cancer. Optimal debulking surgery and chemotherapy are predictor of better overall and disease free survival. Despite the poor outcome, there is a need for new treatment options. Recommended management for this group of patients should consist of surgical cytoreduction followed by chemotherapy. There may be a role for neoadjuvant chemotherapy followed by interval surgery in selected subgroups of patients.

Treatment of Borrmann Type IV Gastric Cancer with a Neoadjuvant Chemotherapy Combination of Docetaxel, Cisplatin and 5-Fluorouracil/Leucovorin

This study evaluated the efficacy and safety of docetaxel, cisplatin and 5-fluorouracil/leucovorin as neoadjuvant chemotherapy before surgery (NCT group; n = 29) compared with postoperative chemotherapy alone (non-NCT group; n = 26) in the treatment of Borrmann type IV gastric carcinoma. Primary tumour response rate, surgical parameters, incised-edge residue rate, lymphatic metastasis status and side-effects were evaluated. The overall response rate was 58.6% in the NCT group, which included three (10.3%) patients in complete remission and 14 (48.3%) patients in partial remission. The postoperative pathological complete response rate was 6.9% (two patients) in the NCT group. NCT was associated with a significant increase in the radical resection rate and a significant decrease in the rate of incised-edge residues, compared with postoperative chemotherapy alone. Side-effects due to NCT were minimal and resolved with appropriate treatment. There were no chemotherapy-related deaths in either group. In conclusion, docetaxel, cisplatin and 5-fluorouracil/leucovorin was an effective and well-tolerated NCT regimen for Borrmann type IV gastric cancer.