GOTIC-018: Phase I, open-label, multicenter study to assess the safety of pre- and co-administration of ONO-4538 (nivolumab) with concurrent chemoradiation (CCRT) in patients (pts) with locally advanced cervical carcinoma (LACvCa)

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Background: LACvCa has a poor prognosis. CCRT is the standard treatment for LACvCa, and the 5-year survival rate is estimated at around 60%. Nivolumab (Nivo), an anti-PD1 monoclonal antibody, showed clinical activity in recurrent or persistent CvCa pts. Nivo may enhance antitumor immune responses induced by CCRT. The safety and feasibility of Nivo plus CCRT for LACvCa pts has not yet been reported. We report data from a phase I trial evaluating safety and feasibility of pre- and co-administration of Nivo with CCRT in pts with LACvCa (GOTIC-018; JMA-IIA00425). Methods: The treatment plan in cohort A is co-administration of Nivo (240mg/body once every 2 weeks) with CCRT followed by maintenance therapy with Nivo. The treatment plan in cohort B is pre- (two doses of Nivo before CCRT) and then co-administration of Nivo with CCRT followed by Nivo maintenance. The CCRT regimen includes 4 or more cycles of cisplatin (40 mg/m2 weekly) and external beam radiotherapy (EBRT) followed by brachytherapy. The Nivo maintenance therapy was scheduled for 52 weeks after completion of CCRT. The primary objective is the rate of Grade≧3 adverse events (AEs) during the acute phase, which is defined as 90 days from the start date of EBRT. Secondary objectives include the incidence of dose limiting toxicity (DLT) and progression-free survival. Results: A total of 30 patients, 15 patients in each cohort, was enrolled in this study. This report is a safety evaluation in the acute phase of the study. There were 1 stage IVA, 11 stage IIIB, 16 stage II and 2 stage IB tumors based on FIGO 2009. 28 squamous cell and 2 adeno/adenosquamous carcinomas were included. No DLT was observed in the first 6 DLT-evaluable pts in each cohort. All 30 patients completed planned EBRT and brachytherapy. 2 and 0 patients required a break from EBRT in cohort A and B, respectively. The median cycles of cisplatin administration was 5 and 6 in cohort A and B, respectively. 2 and 0 patient required cisplatin dose reduction in cohort A and B, respectively. 1 patient required cisplatin discontinuation in each cohort. The median cycles of Nivo administration were 6 and 9 in cohort A and B, respectively. 1 patient required Nivo discontinuation due to AEs in each cohort. All patients experienced Grade≧3 AEs. Most common Grade≧3 AEs were neutropenia (60.0 and 26.7% in cohort A and B, respectively), anemia (13.3 and 16.7%) and diarrhea (13.3 and 26.7%). In cohort B, no patients required delay in starting CCRT due to the AEs related to pre-administration of Nivo, and no patients had disease progression before starting CCRT. Conclusions: No DLT was reported during the acute phase in both cohort A and B, and no new safety signals were observed. Addition of pre-and co- administration of Nivo appears safe and feasible in patients with LACvCa treated with CCRT. Clinical trial information: JMA-IIA00425.

Clinical significance of metabolism-related genes and FAK activity in ovarian high-grade serous carcinoma

BACKGROUND

Administration of poly (ADP-ribose) polymerase (PARP) inhibitors after achieving a response to platinum-containing drugs significantly prolonged relapse-free survival compared to placebo administration. PARP inhibitors have been used in clinical practice. However, patients with platinum-resistant relapsed ovarian cancer still have a poor prognosis and there is an unmet need. The purpose of this study was to examine the clinical significance of metabolic genes and focal adhesion kinase (FAK) activity in advanced ovarian high-grade serous carcinoma (HGSC).

METHODS

The RNA sequencing (RNA-seq) data and clinical data of HGSC patients were obtained from the Genomic Data Commons (GDC) Data Portal and analysed ( https://portal.gdc.cancer.gov/ ). In addition, tumour tissue was sampled by laparotomy or screening laparoscopy prior to treatment initiation from patients diagnosed with stage IIIC ovarian cancer (International Federation of Gynecology and Obstetrics (FIGO) classification, 2014) at the Saitama Medical University International Medical Center, and among the patients diagnosed with HGSC, 16 cases of available cryopreserved specimens were included in this study. The present study was reviewed and approved by the Institutional Review Board of Saitama Medical University International Medical Center (Saitama, Japan). Among the 6307 variable genes detected in both The Cancer Genome Atlas-Ovarian (TCGA-OV) data and clinical specimen data, 35 genes related to metabolism and FAK activity were applied. RNA-seq data were analysed using the Subio Platform (Subio Inc, Japan). JMP 15 (SAS, USA) was used for statistical analysis and various types of machine learning. The Kaplan-Meier method was used for survival analysis, and the Wilcoxon test was used to analyse significant differences. P < 0.05 was considered significant.

RESULTS

In the TCGA-OV data, patients with stage IIIC with a residual tumour diameter of 1-10 mm were selected for K means clustering and classified into groups with significant prognostic correlations (p = 0.0444). These groups were significantly associated with platinum sensitivity/resistance in clinical cases (χ2 test, p = 0.0408) and showed significant relationships with progression-free survival (p = 0.0307).

CONCLUSION

In the TCGA-OV data, 2 groups classified by clustering focusing on metabolism-related genes and FAK activity were shown to be associated with platinum resistance and a poor prognosis.

A pilot study of mobile digital colposcopy in Japanese patients with cervical intraepithelial neoplasm

Digital colposcopy built around a smartphone is becoming common, and this has advantages for telemedicine and data sharing by taking advantage of smartphone characteristics. However, digital colposcopy itself is not allowed in clinical practice in Japan. The aim of the present study was to investigate the feasibility of mobile digital colposcopy incorporating a smartphone for management of cervical screening in Japanese patients. Patients who underwent colposcopy at Saitama Medical University International Medical Center between July 2019 and February 2020 were enrolled in the present study. The inclusion criteria were women aged 21-65 years old referred for colposcopy following the Japanese standard of care. Written informed consent was obtained from all patients. A total of 40 patients (52 tests) were included in the study. Following the standard of care, acetic acid was applied to the cervix, which was then visualized using a traditional colposcope, with biopsies collected as necessary. The cervix was then visualized and an imaged was captured using a mobile digital colposcope incorporating a smartphone (EVA System; Mobile ODT). All images were collected before biopsy. Images were stored on a secure cloud portal for subsequent evaluation by the provider who performed the conventional colposcopy, and the diagnoses were compared. The present study was approved by the Institutional Review Board of Saitama Medical University International Medical Center (Hidaka, Japan). The match rates for diagnoses were 75%. The match rates for the actual (from conventional colposcopy) and assumed (from digital colposcopy) biopsy sites were 61, 16 and 23%, based on definitions of the ‘same’, ‘almost the same’ and ‘different’, respectively. The present results indicated that ≥75% cases were equivalent in digital colposcopy and conventional colposcopy. This suggests that digital colposcopy may not be inferior to conventional colposcopy.

Pre-operative endovascular coil embolisation for chronic pulmonary aspergillosis

OBJECTIVE: To retrospectively evaluate the clinical outcomes of pre-operative endovascular coil embolisation (ECE) for chronic pulmonary aspergillosis (CPA).METHODS: We evaluated surgical patients with CPA between November 2016 and April 2020. Pre-operative ECE for CPA with severe adhesions was selectively performed to reduce intra-operative blood loss. ECE procedures, operative procedures, intra-operative blood loss and complications were evaluated.RESULTS: Twenty-eight patients (21 males and 7 females; median age: 55 years) were included in the study. Of the 28 patients, 8 (28.6%) underwent pre-operative ECE. Technical success rate in pre-operative ECE was 100%. The median time required for ECE procedures was 123 min. The median number of vessels embolised per procedure was 2.5. The median period between embolisation and surgery was 5 days. Major complications were observed in three patients (10.7%). There were no significant differences between patients with and without pre-operative ECE in operative time (284 vs. 365 min, respectively, P = 0.7602) and intra-operative blood loss (294 vs. 228 mL, respectively, P = 0.8987).CONCLUSIONS: Pre-operative ECE for CPA appears to be feasible and safe; however, its role in reducing intra-operative blood loss needs further investigation.

Pre-operative evaluation of circulating KL-6 levels as a biomarker for epithelial ovarian carcinoma and its correlation with tumor MUC1 expression

Krebs von den Lungen-6 (KL-6), a mucinous sialylated sugar chain on human mucin-1 glycoprotein (MUC1), is a diagnostic marker for interstitial lung diseases. Furthermore, elevated serum KL-6 levels have been observed in certain malignant tumor types of epithelial origin. The expression of MUC1 has been observed in patients with epithelial ovarian cancer (EOC) and is considered a potential therapeutic target. In the present study, KL-6 serum levels were investigated in patients clinically suspected of having malignant ovarian tumors. A total of 219 patients were enrolled in the study, which analyzed their serum KL-6 levels in addition to tumor expression of MUC1 using immunohistochemistry. High serum KL-6 levels were predominantly observed in patients with EOC, and did not occur in patients with benign or borderline tumors. The level of serum KL-6 was highly correlated with tumor stage, grade and histological type, and demonstrated superior sensitivity for the detection of ovarian cancer compared with that of serum cancer antigen 125. High serum KL-6 was significantly associated with shorter progression-free survival. In addition, tumor MUC1 expression status was significantly correlated with serum KL-6 levels. These data suggest that serum KL-6 may be a useful, non-invasive biomarker surrogate for tumor MUC1 expression in future clinical trials of MUC1-targeted therapy.

[Combination Therapy of Pregabalin with Tramadol for Treatment of Peripheral Neuropathy in Patients with Gynecological Cancer Receiving Taxane Containing Chemotherapy]

Taxane-based regimens are often used in gynecologic cancer chemotherapy. Chemotherapy-induced peripheral neuropathy( CIPN)is one of the typical side effects caused by taxanes. Grade 2 or higher CIPN is observed in 5% to 30% of ovarian cancer patients who are treated with paclitaxel, which is recognized as one of the unmanageable side effects leading to treatment interruption. We retrospectively investigated the significance of combination therapy of pregabalin with tramadol for CIPN in patients with gynecological cancer. In the current study, 19 patients(19/22; 86%)were administered pregabalin with tramadol orally for at least 1week, and we observed improvement of the CIPN in 15 patients(15/19; 79%).We suggest that the combination therapy of pregabalin with tramadol has a positive impact on the CIPN in patients under a taxane-based chemotherapy.

Focal Fatty Masses of the Pancreas

Five patients with solitary fatty mass of the pancreas examined with CT and ultrasound (US) were evaluated. The areas of fat replacement were located in the pancreatic neck, body or tail. The size ranged from 4 to 30 mm in the longest diameter. The shape varied from roundish, to ovoid to semicircular, and the contour was universally well defined. The internal structure was homogeneous in 3 patients, but in one case there were thin septa and, in another, a slightly hyperdense part in the peripheral portion. All the masses except the smallest one were in part contact with pancreatic fat. CT showed fat with the same density as the peripancreatic fat and low HU units. The mass was hypoechoic in 2 cases and hyperechoic in one. The masses in the tail of the pancreas were not detected by US.

Serum folate receptor alpha as a biomarker for ovarian cancer: Implications for diagnosis, prognosis and predicting its local tumor expression

Folate receptor alpha (FRA) is a GPI-anchored glycoprotein and encoded by the FOLR1 gene. High expression of FRA is observed in specific malignant tumors of epithelial origin, including ovarian cancer, but exhibits very limited normal tissue expression, making it as an attractive target for the ovarian cancer therapy. FRA is known to shed from the cell surface into the circulation which allows for its measurement in the serum of patients. Recently, methods to detect the soluble form of FRA have been developed and serum FRA (sFRA) is considered a highly promising biomarker for ovarian cancer. We prospectively investigated the levels of sFRA in patients clinically suspected of having malignant ovarian tumors. A total of 231 patients were enrolled in this study and analyzed for sFRA as well as tumor expression of FRA by immunohistochemistry. High sFRA was predominantly observed in epithelial ovarian cancer patients, but not in patients with benign or borderline gynecological disease or metastatic ovarian tumors from advanced colorectal cancers. Levels of sFRA were highly correlated to clinical stage, tumor grade and histological type and demonstrated superior accuracy for the detection of ovarian cancer than did serum CA125. High sFRA was significantly associated with shorter progression-free survival in both early and advanced ovarian cancer patients. Finally, tumor FRA expression status was strongly correlated with sFRA levels. Taken together, these data suggest that sFRA might be a useful noninvasive serum biomarkers for future clinical trials assessing FRA-targeted therapy.

Serum folate receptor alpha as a biomarker for ovarian cancer: Implications for diagnosis, prognosis and predicting its local tumor expression

Folate receptor alpha (FRA) is a GPI-anchored glycoprotein and encoded by the FOLR1 gene. High expression of FRA is observed in specific malignant tumors of epithelial origin, including ovarian cancer, but exhibits very limited normal tissue expression, making it as an attractive target for the ovarian cancer therapy. FRA is known to shed from the cell surface into the circulation which allows for its measurement in the serum of patients. Recently, methods to detect the soluble form of FRA have been developed and serum FRA (sFRA) is considered a highly promising biomarker for ovarian cancer. We prospectively investigated the levels of sFRA in patients clinically suspected of having malignant ovarian tumors. A total of 231 patients were enrolled in this study and analyzed for sFRA as well as tumor expression of FRA by immunohistochemistry. High sFRA was predominantly observed in epithelial ovarian cancer patients, but not in patients with benign or borderline gynecological disease or metastatic ovarian tumors from advanced colorectal cancers. Levels of sFRA were highly correlated to clinical stage, tumor grade and histological type and demonstrated superior accuracy for the detection of ovarian cancer than did serum CA125. High sFRA was significantly associated with shorter progression-free survival in both early and advanced ovarian cancer patients. Finally, tumor FRA expression status was strongly correlated with sFRA levels. Taken together, these data suggest that sFRA might be a useful noninvasive serum biomarkers for future clinical trials assessing FRA-targeted therapy.

Synchronous mucinous metaplasia and neoplasia of the female genital tract with external urethral meatus neoplasm: A case report

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We present a case of multiple mucinous metaplasia and neoplasia of cervix, endometrium, fallopian tube, ovary, and mesenterium with external urethral meatus neoplasm.

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Immunohistochemistry showed almost same pattern in each neoplasms.

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PCR-direct sequencing showed no existence of both KRAS and GNAS mutations.

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This report suggests a possibility of synchronous mucinous metaplasia and neoplasia “beyond” female genital tract.

Mesonephric adenocarcinoma with a sarcomatous component, a notable subtype of cervical carcinosarcoma: a case report and review of the literature

Abstract

Carcinosarcoma of the uterine cervix is less common than its counterpart in the uterine corpus. On the other hand, mesonephric adenocarcinoma is also a rare neoplasm in the uterine cervix, and it has been reported that mesonephric adenocarcinomas are often accompanied by sarcomatous components. We present a case of mesonephric adenocarcinoma with a sarcomatous component which arose in a 63-year-old postmenopausal woman. The hysterectomy specimen grossly showed an exophytic mass measuring 1.8 cm in the uterine cervix. Histologically, diffuse mesonephric hyperplasia and adenocarcinoma with malignant spindle cell proliferation was recognized, and therefore the tumor was diagnosed as “mesonephric adenocarcinoma with a sarcomatous component.” The review of the literature of cervical carcinosarcoma and cervical mesonephric adenocarcinoma revealed that 16% of cervical carcinosarcoma is of mesonephric duct origin, and that mesonephric adenocarcinoma seems to be more likely to have sarcomatous change. We think the presence of a sarcomatous component in the cervical biopsy specimen could be helpful in the diagnosis of mesonephric duct origin.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1243996503911062

[Thoracoscopic repair of peritoneopleual communication with a giant diaphragmatic bullae in a patient with liver cirrhosis; report of a case]

Hepatic hydrothorax is defined as pleural effusion in patients with a cirrhotic liver. The pleural effusion occurs due to ascites flowing to the pleural cavity through a diaphragmatic communication. Recent literature has described the usefulness of a thoracoscopic repair and has shown that it can control pleural effusion very efficaciously. The patient was a 65-year-old woman who complained of dyspnea and was admitted to our hospital. A chest X-ray revealed marked right pleural effusion. We injected indigo carmine intraperitoneally and observed indigo carmine-colored pleural effusion; thus peritoneopleural communication was validated. After the failure of thoracic drainage and pleurodesis with minocycline hydrochloride, thoracoscopic surgery was performed 5 weeks after hospitalization. Obvious bulla formation was observed on the diaphragm, which was immediately resected with linear staplers. The postoperative course was excellent without any recurrence of pleural effusion.

Confocal laser scanning microscopic analysis of early plaque formed on resin composite and human enamel

The purpose of this study was to analyse quantitatively the early bacterial plaque formed on resin composite and human enamel in vivo, using a confocal laser scanning microscope. Test pieces of resin composite and human enamel were retained at the buccal surfaces of the upper first molars of three volunteers for 4, 8 and 24 h to allow plaque formation. Then, the specimens were immersed in propidium iodide in phosphate-buffered saline to stain adherent bacteria and observed with a confocal laser scanning microscope. The ratios of the area occupied by microorganisms to the whole area of the optical field were calculated using a photo-image analysis system. The thickness of the plaque was also measured. Quantitative analysis revealed that the resin composite showed significantly higher bacterial adherence than human enamel throughout the test period. A difference was noticed in the morphology of the bacteria between the two groups. Our findings suggest that resin composite shows higher bacteria adherence during early plaque formation compared with human enamel. In addition, the present findings may suggest a presence of the difference in bacterial composition of plaque in both specimens.

[A clinicopathological study of pulmonary cryptococcosis--chest CT and pathologic correlation]

We reviewed the clinicopathological features in 12 patients (7 males and 5 females; mean age 54 yr) with pulmonary cryptococcosis. Eleven of the patients were asymptomatic and the disease was detected by chest radiograph abnormalities. The underlying systemic disease had been diagnosed as diabetes mellitus in two. Chest CT scans showed a solitary nodule in 9 of the 12 patients, multiple nodules in 2, and infiltration in 1. The nodular diameter was less than 2 cm in 10 of the 12. All nodules were located in the subpleural region. On the chest CT, cavitary nodules, scattered nodules, or both, and spiculated nodules were difficult to distinguish from pulmonary tuberculosis and primary lung cancer, respectively. According to McDonnell's pathological classification of pulmonary cryptococcosis, the resected 8 lungs revealed peripheral pulmonary granuloma in 5 and granulomatous pneumonia in 3. It is important to perform a pathological examination for the diagnosis of pulmonary cryptococcosis to avoid misdiagnosis as lung cancer or pulmonary tuberculosis.

Duodenal somatostatinoma: a case report and review of 31 cases with special reference to the relationship between tumor size and metastasis

Somatostatinomas are rare functioning neoplasms usually arising in the pancreas and duodenum. We report a case of somatostatinoma in a 42-year-old male with neither neurofibromatosis nor somatostatinoma syndrome. A large tumor in the descending duodenum had given rise to multiple lymph node metastases. An additional 31 duodenal somatostatinoma cases were also reviewed. Most originated in the descending part of the duodenum, with the ampulla and peri-ampullary area as the most common sites (60%). Frequent manifestations were abdominal pain (25%), jaundice (25%), or cholelithiasis (19%), the latter two reflecting obstruction of the bile duct by tumors. Only two cases showed a possible somatostatinoma syndrome (6%). The tumors with metastases, lymph nodes (10) and liver (2), were significantly larger than average than those without (2.91 +/- 1.49 cm vs 1.36 +/- 0.71 cm, P < 0.05). With a cut-off point of 2.0 cm, diagnostic accuracy for metastasis was 77.78% with 87.50% specificity and 63.64% sensitivity. The smallest tumor with metastases was 0.8 cm and the largest without metastases was 3.0 cm. These results indicate that duodenal somatostatinomas are malignant by nature and the risk of metastasis significantly increases with tumors larger than 2.0 cm.

[Mediastinal lymph node metastasis from esophageal carcinoma: CT assessment with pathologic correlation]

Computed tomographic (CT) scans were performed in 179 patients with esophageal carcinoma to evaluate mediastinal lymph node metastasis. Histopathologic findings were compared with CT findings in a total of 7,218 resected lymph nodes. First, the criterion for lymph node metastasis on CT scans was 10 mm or more in long transverse diameter. The overall sensitivity and positive predictive value (PPV) were 19% (60 of 317 nodes) and 33% (60 of 180 nodes), respectively. Analysis of each of the eight subgroups of mediastinal nodes revealed that the PPV was more than 70% in node Nos. 105, 108, 110, and 112. In other subgroups, however, the PPV was less than 60%. Sensitivity was less than 50% in all eight subgroups. Second, the criterion for metastasis was 10 mm or more in short transverse diameter. The overall sensitivity and PPV were 8% (26 of 317 nodes) and 63% (26 of 41 nodes), respectively. Analysis of subgroups showed that the PPV in No. 106 nodes increased to 92%. In No. 106 nodes, use of a 5 mm criterion in long transverse diameter increased sensitivity to only 55%. Of the 317 histopathologically proven metastatic lymph nodes, 90 nodes (28%) were 10 mm or more in size, 112 (35%) were 5-10 mm, and 115 (36%) were less than 5 mm. Of the 6,901 non-metastatic lymph nodes, 473 nodes (7%) were 10 mm or more in size. Small (less than 5 mm in size) metastatic nodes were present in all eight subgroups. Among No. 107 and 109 nodes, large (10 mm or more in size) nonmetastatic nodes were prominent, resulting in low sensitivity and PPV. We conclude that CT does not provide an accurate assessment of metastatic versus non-metastatic mediastinal lymph nodes in patients with esophageal carcinoma.

Focal fatty masses of the pancreas

Five patients with solitary fatty mass of the pancreas examined with CT and ultrasound (US) were evaluated. The areas of fat replacement were located in the pancreatic neck, body or tail. The size ranged from 4 to 30 mm in the longest diameter. The shape varied from roundish, to ovoid to semicircular, and the contour was universally well defined. The internal structure was homogeneous in 3 patients, but in one case there were thin septa and, in another, a slightly hyperdense part in the peripheral portion. All the masses except the smallest one were in part contact with pancreatic fat. CT showed fat with the same density as the peripancreatic fat and low HU units. The mass was hypoechoic in 2 cases and hyperechoic in one. The masses in the tail of the pancreas were not detected by US.

Systemic arterial supply to normal basal segments of left lower lobe: CT findings

OBJECTIVE

The purpose of this study was to evaluate the usefulness of CT in making a diagnosis of systemic arterial supply to normal basal segments of the left lower lobe.

MATERIALS AND METHODS

We retrospectively reviewed chest radiography (three cases), CT (three cases), and angiography (two cases).

RESULTS

An anomalous systemic artery arising from the descending aorta was shown as a retrocardiac density on posteroanterior radiography and as a nodular density behind the heart on lateral radiography. Contrast enhanced CT revealed the vascular nature of the density adjacent to the descending aorta. Dynamic CT in one patient demonstrated that the nodular density was composed of an anomalous systemic artery and a prominent inferior pulmonary vein. High-resolution CT showed the interlobar artery distal to the origin of the superior segmental artery to be absent. The bronchial system of the left basal segments was normal as was the pulmonary parenchyma on CT.

CONCLUSION

Characteristic CT findings consist of absence of the interlobar artery distal to the origin of the superior segmental artery and origination of an anomalous artery from the descending aorta that gives off branches to normal left basal segments. With a constellation of these CT findings, angiography would be obviated for definite diagnosis of this anomaly.