Microbiological epidemiology and antibiotic susceptibility of infected meshes after prosthetic abdominal wall repair

INTRODUCTION

Infectious complications of parietal mesh after prosthetic abdominal wall repair are rare. Their management is complex. Furthermore, the emergence of bacterial resistance, the presence of a foreign material, the need to continue an extended antibiotic therapy, and the choice of an appropriate treatment are crucial. The objective of this study is to access the microbiological epidemiology of infected parietal meshes in order to optimize the empirical antibiotic therapy.

METHODS

Between January 2016 and December 2021, a monocentric and retrospective study was performed in patients hospitalized for infected parietal meshes at Avicenne hospital, in Paris area. Clinical and microbiological data such as antibiotic susceptibility were collected.

RESULTS

Twenty-six patients with infected parietal meshes have been hospitalized during this period. Meshes were in preaponevrotic positions (n=10; 38%), retromuscular (n=6; 23%) and intraperitoneal (n=10; 38%). Among the 22 (84.6%) documented cases of infections, 17 (77.3%) were polymicrobial. A total of 54 bacteria were isolated, 48 of which had an antibiogram available. The most frequently isolated bacteria were: Enterobacterales (n=19), Enterococcus spp. (n=11) and Staphylococcus aureus (n=6), whereas anaerobes were poorly isolated (n=3). Concerning these isolated bacteria, amoxicillin-clavulanic acid, metronidazole-associated cefotaxime, piperacillin-tazobactam and meropenem were susceptible in 45.5%, 68.2%, 63.6%, 77.2%, of cases, respectively.

CONCLUSION

This work highlights that infections of abdominal parietal meshes may be polymicrobial and the association amoxicillin-clavulanic acid cannot be used as a probabilist antibiotic therapy because of the high resistance rate in isolated bacteria. The association piperacillin-tazobactam appears to be a more adapted empirical treatment to preserve carbapenems, a broad-spectrum antibiotic class.

Pooled analysis of onapristone extended release (ONA ER) in metastatic cancer patients (pts): A review of liver safety

e14647

Background: ONA, a type I progesterone receptor (PR) antagonist, prevents PR activation by disrupting PR dimerization and DNA binding, and inhibits tumor progression. ONA (immediate release) has efficacy comparable to other endocrine therapies in pts with metastatic breast cancer (BC). The only notable toxicity was transient elevation in liver chemistries in some pts. In 2 clinical trials, ONA ER was given to 88 cancer pts who underwent frequent liver chemistry monitoring. Methods: We pooled and reviewed all liver safety data from 2 trials. A hepatologist (PBW) reviewed all pts with either a hepatobiliary SOC AE or who experienced an elevation > ULN of any liver-related laboratory test. Results: Of 88 pts who received ONA ER for a median 8 weeks (3-51), 59% were female, median age 68 (36-89), 99% Caucasian, 28% had liver metastases (mets), 48% bone mets and 17% also took abiraterone (ABI), which has liver toxicity. 54 pts (61%) experienced any ONA ER-related AE. More AEs were seen in ABI pts (67%), those with liver mets (72%) and BC (76%).. In terms of liver-related TEAEs, overall 10% of pts had ALT and 13% AST elevations, while 20% pts with liver mets had raised ALT/AST and 29% of BC pts. Overall 15% pts had G3 TEAEs, compared to 28% pts with liver mets, mostly due to increased GGT (24%), which has unclear clinical impact. There were no discontinuations for LFT elevations. A relationship between the liver events and ONA ER was judged to be unlikely in each subject, except one. This event was detected at day 29 of treatment and consisted of a marked rise in serum GGT and alkaline phosphatase with only a moderate rise in serum ALT (peak – 262). These abnormalities improved quickly after stopping ONA but recurred on reintroduction: these events are not serious by international criteria and the pt was able to continue ONA at a lower dose for 40 weeks without recurrence Conclusions: The safety experience for ONA ER has been reassuring but must continue to be characterized. For new ONA ER studies, weekly liver chemistry monitoring is planned for the first 4 weeks with Q2W monitoring thereafter. The occasional G3 elevations in serum AST, ALT or bilirubin will prompt interruption, but re-starting treatment at a lower dose should be possible for most pts. Clinical trial information: NCT02052128 and NCT02049190.

Phase I study of onapristone, a type I antiprogestin, in female patients with previously treated recurrent or metastatic progesterone receptor-expressing cancers

INTRODUCTION

Onapristone is a type I progesterone receptor (PR) antagonist, which prevents PR- mediated DNA transcription. Onapristone is active in multiple preclinical models and two prior studies demonstrated promising activity in patients with breast cancer. We conducted a study of extended release (ER) Onapristone to determine a recommended dose and explore the role of transcriptionally-activated PR (APR), detected as an aggregated subnuclear distribution pattern, as a predictive biomarker.

METHODS

An open-label, multicenter, randomized, parallel-group, phase 1 study (target n = 60; NCT02052128) included female patients ≥18 years with PRpos tumors. APR analysis was performed on archival tumor tissue. Patients were randomized to five cohorts of extended release (ER) onapristone tablets 10, 20, 30, 40 or 50 mg BID, or immediate release 100 mg QD until progressive disease or intolerability. Primary endpoint was to identify the recommended phase 2 dose. Secondary endpoints included safety, clinical benefit and pharmacokinetics.

RESULTS

The phase 1 dose escalation component of the study is complete (n = 52). Tumor diagnosis included: endometrial carcinoma 12; breast cancer 20; ovarian cancer 13; other 7. Median age was 64 (36-84). No dose limiting toxicity was observed with reported liver function test elevation related only to liver metastases. The RP2D was 50 mg ER BID. Median therapy duration was 8 weeks (range 2-44), and 9 patients had clinical benefit ≥24 weeks, including 2 patients with APRpos endometrial carcinoma.

CONCLUSION

Clinical benefit with excellent tolerance was seen in heavily pretreated patients with endometrial, ovarian and breast cancer. The data support the development of Onapristone in endometrial endometrioid cancer. Onapristone should also be evaluated in ovarian and breast cancers along with APR immunohistochemistry validation.

Neoadjuvant chemotherapy (NACT) increases immune infiltration and programmed death-ligand 1 (PD-L1) expression in epithelial ovarian cancer (EOC)

Background

Lymphocytic infiltration at diagnosis is prognostic in EOC, however, the impact of NACT on tumour infiltrating lymphocytes (TILs) or PD-L1 expression remains poorly described.

Patients and methods

Patients with EOC and sequential samples (pre-NACT, post-NACT or relapse) were retrospectively identified. TILs were evaluated on whole sections; stromal TILs (sTILs) scored as percentage of stromal area with high sTILs defined as ≥50%; intra-epithelial TILs (ieTILs) scored semi-quantitatively (0-3) with high ieTILs ≥2. A smaller number were available for PD-L1 evaluation, cut-off for positivity was ≥5% staining.

Results

sTILs were detected in all tumours at diagnosis (range 2-90%, median 20%), with 22% (25/113) showing high sTILs. Among evaluable paired pre/post-NACT samples (N = 83), an overall increase in median sTILs from 20% to 30% was seen following NACT (P = 0.0005); individually the impact of NACT varied with sTILs increasing in 51% (42/83), decreasing in 25%, and stable in 24%. Post-NACT sTILs were predictive of platinum-free interval (PFI), patients with PFI ≥6 months had significantly higher post-NACT sTILs (sTILs 28% versus 18% for PFI <6 months, P = 0.026); pre-NACT sTILS were not predictive. At diagnosis, 23% showed high ieTILs, and following NACT 33% showed increasing ieTILs. Proportion of tumours with PD-L1-positive immune cells was 30% (15/50) pre-NACT and 53% (27/51) post-NACT (P = 0.026). Among paired tumours, 63% of PD-L1-negative tumours became positive after NACT, furthermore cisplatin induced PD-L1 expression in PD-L1-negative EOC cell lines. On multivariate analysis, high sTILs both pre- and post-NACT were independent prognostic factors for progression-free survival (PFS) (HR 0.49, P = 0.02 and HR 0.60, P = 0.05, respectively). No prognostic impact of ieTILs or PD-L1 expression was detected.

Conclusions

In EOC, sTILs levels are prognostic at diagnosis and remain prognostic after NACT. TILs and PD-L1 expression increase following NACT. Evaluation of immune parameters in the post-NACT tumour may help select patients for immunotherapy trials.

Abstract B02: DNA repair landscape in High Grade Ovarian Cancer (HGOC) and evolution with neo-adjuvant chemotherapy

Background: HGOC is frequently diagnosed at an advanced stage where NeoAdjuvant Chemotherapy (NACT) provides an essential component of the treatment strategy. HGOC are initially very chemosensitive, putatively due to DNA repair defects. While BRCA mutations explain impaired homologous recombination in 12% to 15% of HGOC, loss of other DNA repair proteins may also be relevant. Unfortunately despite initial response rates of 80%, most invariably relapse. Chemo-resistance mechanisms are poorly understood and previous studies have only focused on the characterization at diagnosis. However given their chemosensitivity, profiling the post-NACT tumor (cleared of sensitive cells and enriched for chemoresistant clones) may be more relevant to uncover mechanisms of platinum resistance. We aimed to evaluate the evaluate the expression of key DNA repair biomarkers in a large series of HGOC tumors obtained at baseline, Post-NACT and at relapse.

Methods: TMA was constructed using sequential FFPE tumor samples of high-grade ovarian cancer collected at diagnosis (pre-NACT) (N=143), post-NACT (N=139) and at relapse (N=36) in 170 patients, encompassing 115 patients with sequential tumor samples. Expression of 53BP1, PAR, PARP-1 and ATM were scored by immunohistochemistry using an H-score (0-300) with biomarker negative defined as H-score =&lt; 10. Markers were analysed with a Cox model to predict overall survival (OS) and progression free survival (PFS).

Results: At diagnosis, a significant proportion of tumors showed loss of DNA repair proteins: 61% were PAR-negative, and 24%, 15% and 3% negative for ATM, 53BP1 and PARP-1 respectively and a fifth of tumors showed concomitant loss in 2 or more DNA proteins. There was an overall decrease in DNA repair protein expression with NACT, which was significant for PAR (pre-NACT vs post-NACT H-score= 45 vs 19, p=0.0025, N=201) and PARP-1(H-score=208 vs 190; p=0.0149, N=205). In addition paired samples analysis of matched pre- and post-NACT samples showed complete loss of biomarker expression after treatment in a subset (24%, 16%, 6% and 3% for PAR, ATM, TP53BP1 and PARP-1). When comparing post-NACT to relapsed samples, PAR expression increased significantly (mean H-score=19 vs 54, p=0,025). The prognostic value of loss of each DNA repair at diagnosis and after NACT was evaluated. At diagnosis, 53BP1-negative tumors were associated with a significantly worst PFS (HR=3.484; p: 0.0025). Post-NACT, ATM-negative tumors had a significantly worst PFS (HR=1.690; p: 0.0374). As PAR, TP53BP1 and ATM were shown not to be correlated in individual tumors (Pearson correlation), the impact of combined biomarker loss on PFS was evaluated. At diagnosis, double TP53BP1/PAR-negative tumors predicted shorter PFS (PFS: median=17.65 vs 23.23 mths, p:0.0372, HR=0.2237, N=58), while post-NACT double ATM/PAR-negativity was significantly predictive of poor outcome in terms of PFS and OS (PFS: median=17.35 vs 23.77 mths, p:0.0198, HR=0.4759; OS: median=35 vs 50 mths, p:0.0120, HR=0.3602; N=80).

Conclusions: We present the first study of change in DNA repair protein expression with NACT. At diagnosis, HGOC is associated with loss of key DNA repair proteins in a significant proportion of patients and NACT can induce significant loss of DNA repair proteins. Combined loss of DNA repair proteins was significantly predictive of survival. Work in ongoing to extend this analysis to a greater panel of DNA repair biomarkers.

Citation Format: Aurelie Auguste, Soizick Mesnage, Audrey Le Formal, Elena Cojocaru, Francoise Drusch, Julien Adam, Sebastien Gouy, Enrica Bentivegna, Catherine Lhomme, Patricia Pautier, Catherine Genestie, Alexandra Leary. DNA repair landscape in High Grade Ovarian Cancer (HGOC) and evolution with neo-adjuvant chemotherapy [abstract]. In: Proceedings of the AACR Special Conference on DNA Repair: Tumor Development and Therapeutic Response; 2016 Nov 2-5; Montreal, QC, Canada. Philadelphia (PA): AACR; Mol Cancer Res 2017;15(4_Suppl):Abstract nr B02.

Pattern of tumor-infiltrating lymphocytes (TILs) and PD-L1 expression in primary and metastatic epithelial ovarian cancer (EOC)

64

Background: Tumour immune response plays a critical role in progression and prognosis of EOC, however patterns of TILs and PD-L1 expression in primary and metastatic disease remain poorly described. Methods: Patients treated with neoadjuvant chemotherapy (NACT) for advanced EOC, between 2002-2014, and available sequential tumours (pre-NACT, post-NACT, or relapse) were retrospectively identified. Stromal TILs (sTILs) were evaluated according to the International TILs Working Group 2014 (Salgado 2015) on whole sections, and scored as a percentage of stromal area. Immune cell PD-L1 expression was evaluated by immunohistochemistry (E1L3N clone, Cell Signaling) in a smaller number of tumours. Cutoffs for analysis were: high sTILs ≥50%, PD-L1 positivity ≥5% membranous staining. Results: Among a total of 236 tumour samples from 150 patients (110 pre-NACT, 111 post-NACT, and 15 relapse tumours) median sTILs levels was significantly higher in metastatic tumours ( n=151) compared with primary tumours ( n=85) (median 30, IQR 10-50 vs. 15, IQR 5-30, p=0.0004). Among diagnostic samples, median sTILs level was 20 (IQR 10-45, n=85) in metastatic tumours compared with 10 (IQR 5-20, n =25) in primary tumours ( p=0064). Similarly in post-NACT samples, median sTILs level was 40 (IQR 15-60, n=51) in metastatic tumours compared with 20 (IQR 6.25-30, n=60) in primary tumours ( p=0026). Among relapse samples median sTILs level was 30 (IQR 10-50, n=15). Among all available samples ( n=97) PD-L1 positivity was detected in 33% (9/30) of primary and 50% (34/68) of metastatic tumours (Fisher’s exact test OR 2.3, 95%CI 0.94-5.4, p =0.08). Conclusions: In patients with EOC there is increased lymphocytic infiltration in both synchronous metastatic disease at diagnosis, and metachronous metastatic disease at relapse, compared with the primary tumour. This suggests increased immunogenicity as disease progresses. Furthermore, there is a trend towards upregulation of the PD-L1 immune checkpoint with disease progression.

Abstract A1-27: Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) beyond SMARCA4 mutations: A comprehensive genomic analysis

Background: Small cell ovarian carcinoma of the hypercalcemic type (SCCOHT) is an extremely rare and aggressive tumor that affects mainly young women (median age = 24 years). Prognosis is poor as most patients die within 2 years of diagnosis. Until recently, the literature describing the genomic profile of SCCOHT was scarce. In the last few months, four groups have now confirmed that SMARCA4 mutations are a frequent event in SCCOHT.

Methods: We performed an integrated genomic analysis using WES, RNA-seq and CGH approaches to identify other recurrent genomic alteration and potential therapeutic targets. Candidate SNVs identified by WES were validated by Sanger and RNA-Seq. 8 frozen tumors were available, including 6 with matching normal control DNA. In addition 33 tumor samples were available as FFPE.

Results: Despite their high grade and aggressive clinical course, SCCOHT tumors display genomic stability, low mutation load (0.53mut.Mb) and few SCNAs. However when present, genomic alterations were recurrent. Integrated WES and CGH analysis revealed a frequent and unusual 19p CN LOH (in 5 of 6 tumors). Although overall mutation rate was low, the mutations that did occur were novel and recurrent in 50%-80% of SCCOHT. In addition to SMARCA4 mutation (M+), we validated 10 novel recurrent M+ (including ABCA7, ANKRD24, CACTIN, EMR1, FBN3, FUT5, GRIN3B, KANK3, KRI1 and PLK5) in 50%-80% of tumors at high allelic frequencies (mean=0.87). Similarly, when present, amplifications were recurrent, common to a third of tumors: such as the mitochondrial redox enzymes (SHMT2, NDUFA4L2) or the transmembrane transporter LRP1 were amplified (Log2&gt;2.3). No common fusion transcripts were identified.

Since SCCOHT often display initial chemosensitivity, but rapid progressions, we investigated the differential genomic profiles of treatment naive versus chemotherapy treated tumors to uncover candidate resistance genes. The only alteration significantly enriched in post treatment tumors were M+ in the putative efflux pump, ABCA7. These M+ could not be identified even at low allele fractions in treatment naive tumors, but were identified in all 3 treated tumors with a mean allelic frequency of 0.83.

In terms of therapeutic implications, modulating mitochondrial metabolism or targeting the membrane transporter LRP1 or the ABCA7 efflux pump could provide therapeutic venues in the future. However the most promising approaches for now may be targeting cell cycle checkpoint regulators or chromatin remodelling. M+ in the tumor suppressor PLK5 were confirmed in 79% of a cohort of 33 SCCOHT and many were predicted as damaging. Inactivation of PLK5 is associated with a loss of G2/M checkpoint regulation and cell harbouring PLK5 mutations were sensitive to PLK1 inhibitors. More interestingly, SMARCA4-M+ SCCOHT demonstrated complete loss of SMARCA4 expression as well as loss of the only other SWI/SNF catalytic subunit SMARCA2 suggesting that double SMARCA4/SMARCA2 negative SCCOHTs are characterized by a catalytically inactive SWI/SNF complex. This hypothesis was supported by changes in RNA expression levels in the main transcriptional targets for SWI/SNF (RHOA, RB and the E2F family). Importantly, the double SMARCA2/4 negative BIN-67 SCCOHT cell line displaying both a SMARCA4 M+ and loss of SMARCA2 expression was exquisitely sensitive to HDAC and MT inhibitors, while cell lines with either a SMARCB1-M+ or SMARCA4-M+ with retained SMARCA2 expression were not. These data make double SMARCA2/4 negative by IHC a potential predictive biomarker for histone modifying inhibitors in SCCOHT or potentially in other double SMARCA2/4 negative malignancies.

Conclusions: We present the 1st integrated genomic analysis of SCCOHT. SCCOHT demonstrate a remarkably homogeneous genomic profile and potentially actionable alterations. In particular, dual null SMARCA2/SMARCA4 SCCOHTs could be selected for clinical trials with EZH2, HDAC or MT inhibitors.

Citation Format: Aurélie Auguste, Marc Deloger, Joanna Cyrta, Audrey Le Formal, Catherine Richon, Nathalie Droin, Beatrice Brunn, Olivier Caron, Mojgan Devouassoux, Catherine Lhomme, Patricia Pautier, Catherine Genestie, Alexandra Leary. Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) beyond SMARCA4 mutations: A comprehensive genomic analysis. [abstract]. In: Proceedings of the AACR Special Conference on Translation of the Cancer Genome; Feb 7-9, 2015; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2015;75(22 Suppl 1):Abstract nr A1-27.

Novel membrane-based targets - Therapeutic potential in gynecological cancers

Recent advances have been made in the molecular profiling of gynecological tumors. These discoveries have led to the development of targeted therapies that have the potential to disrupt molecular pathways involved in the oncogenesis or tumor progression. In this review, we highlight areas of recent progress in the field of membrane receptor inhibitors in gynecological malignancies and describe the biological rationale underlying the inhibition of these receptors. We will introduce drug immuno-conjugates, and give an update on the biological rationale and the clinical studies involving agents directed against EGFR, HER3, IGFR, MET, FGFR, NOTCH, and TRAIL. We also discuss the challenge facing these new therapies.

Kidney diseases associated with anti-vascular endothelial growth factor (VEGF): an 8-year observational study at a single center

Expanded clinical experience with patients taking antiangiogenic compounds has come with increasing recognition of the renal adverse effects. Because renal histology is rarely sought in those patients, the renal consequences are underestimated. Antiangiogenic-treated-cancer patients, who had a renal biopsy for renal adverse effects from 2006 to 2013, were included in the current study. Clinical features and renal histologic findings were reviewed. Our cohort was 100 patients (58 women) with biopsy-proven kidney disease using anti-vascular endothelial growth factor (VEGF) therapy with a mean age of 59.8 years (range, 20-85 yr). Patients were referred for proteinuria, hypertension, and/or renal insufficiency. Kidney biopsy was performed 6.87 ± 7.18 months after the beginning of treatment. Seventy-three patients experienced renal thrombotic microangiopathy (TMA) and 27 patients had variable glomerulopathies, mainly minimal change disease and/or collapsing-like focal segmental glomerulosclerosis (MCN/cFSGS). MCN/cFSGS-like lesions developed mainly with tyrosine-kinase inhibitors, whereas TMA complicated anti-VEGF ligand. Thirty-one percent of TMA patients had proteinuria up to 1 g/24 h. Half of TMA cases are exclusively renal localized. Pathologic TMA features are intraglomerular exclusively. MCN/cFSGS glomeruli displayed a high abundance of KI-67, but synaptopodin was not detected. Conversely, TMA glomeruli exhibited a normal abundance of synaptopodin-like control, whereas KI-67 was absent. Median follow-up was 12 months (range, 1-80 mo). Fifty-four patients died due to cancer progression. Hypertension and proteinuria resolved following drug discontinuation and antihypertensive agents. No patient developed severe renal failure requiring dialysis. Drug continuation or reintroduction resulted in a more severe recurrence of TMA in 3 out of 4 patients requiring maintenance of anti-VEGF agents despite renal TMA. In conclusion, TMA and MCN/cFSGS are the most frequent forms of renal involvement under anti-VEGF therapy. Careful risk-benefit assessment for individual patients should take into account risk factors related to the host and the tumor.

Lymphocele and ovarian cancer: risk factors and impact on survival

INTRODUCTION

We describe the incidence, impact on survival, and the risk factors for symptomatic lymphoceles in patients with ovarian cancer.

METHODS

This retrospective study includes patients with ovarian cancer who had complete cytoreductive surgery and para-aortic and pelvic lymphadenectomy performed in our institute from 2005 to 2011. Patients were classified into two groups: patients with symptomatic lymphoceles and a control group.

RESULTS

During the study period, 194 patients with epithelial ovarian cancer underwent cytoreductive surgery and a lymphadenectomy without macroscopic residual disease. Fifty-four patients had symptomatic lymphoceles (28%). In the multivariate analysis, only supraradical surgery was significantly and independently associated with the risk of symptomatic lymphoceles occurring postoperatively. Median follow-up was 24.8 months (range, 1-74 months). Survival rates were not significantly different between the symptomatic lymphocele group and the control group. Two-year disease-free survival rates were 54% for the lymphocele group and 48% for the control group. Two-year overall survival rates were 90% for the lymphocele group and 88% for the control group.

CONCLUSIONS

Symptomatic lymphoceles occur frequently after cytoreductive surgery in ovarian cancer. Supraradical surgery is an independent risk factor. The occurrence of symptomatic lymphoceles does not decrease survival. Nevertheless, further studies are needed to reduce the risk of lymphoceles in such patients.

Doxorubicin, cisplatin, and ifosfamide (API) as first-line therapy for relapsed or metastatic uterine leiomyosarcoma

10098

Background: Uterine leiomyosarcomas (ULMS) are rare gynecologic malignancies characterized by a poor prognosis due to a high rate of local and metastatic recurrences. Chemotherapy (CT) with doxorubicin or ifosfamide or both is associated with a 10 to 30% objective response rate (ORR) and a cisplatin-based multiCT approach achieved a good response rate (DECAV therapy: API + dacarbazine + vindesine, 54% ORR in uterine sarcomas), though toxic. We aimed to determine efficacy and toxicity of doxorubicin, cisplatin and ifosfamide (API) combination as first line treatment of metastatic or relapsed ULMS (MRULMS). Methods: This monocentric study included MRULMS pts with a physiological age < 65 y. CT consisted in doxorubicin 50 mg/m² d1, ifosfamide 3 g/m²/d d1d2 + mesna, cisplatin 75 mg/m² d3, + G-CSF; q 3 weeks. Results: Results in 38 pts with MRULMS were analyzed; median age was 51 (40-64), median cycles of CT was 5; 8 (21%) pts were treated for local relapse, 21 (55.3%) for metastatic disease and 9 (23.7%) for both. Metastatic sites were: lungs in 16 pts (42.1%), pelvis in 7 pts (18.4%), liver in 7 pts (18.4%), peritoneum in 6 pts (15.8%) and bone in 5 pts (13.2%); 14 pts (36.8%) had a multisite metastatic disease. Main grade 3-4 toxicities in 38 pts were neutropenia (74%), thrombopenia (60%), anemia (55%), fatigue (18%) and vomiting (13%). Febrile neutropenia was observed in 35% of pts and 1 patient died of septic shock after cycle 1. Thirty four pts were evaluable for response (4 pts had complete surgery at relapse) and 16 pts responded (4 CR + 12 PR) (ORR: 47%); 23.5% and 29.4% of the pts had respectively stable and progressive disease. For all pts (38) and evaluable pts (34), median PFS were 9.8 and 9.5 months and OS 27 and 25.3 months respectively. Conclusions: Despite toxicity observed, API is an effective treatment which compares favorably with other first line therapies for MRULMS pts.

Efficacy and safety of the APE (actinomycin D, cisplatin, etoposide) regimen for the management of high-risk gestational trophoblastic neoplasia

5028

Background: Patients (pts) with high risk gestational trophoblastic neoplasia (GTN) or who fail low risk single agent chemotherapy (CT) require multi agent CT to be cured. The most common regimen is etoposide (E), methotrexate and actinomycin D (A) alternating weekly with cyclophophamide and vincristine (EMA/CO). Cisplatin (P) is a very active drug but its role is controversial and usually restricted to second line. We report results of a platinum based therapy: APE. Methods: We evaluated the efficacy and safety on 103 pts treated at Institut Gustave Roussy (IGR) (n=80) or other French centers (n=23) between 1983 and 2010 with APE for high risk GTN (defined by IGR criteria [Azab, Cancer, 1988] and/or FIGO score >6). Pts with brain metastasis were excluded. Results: Efficacy was evaluated on 59 pts treated for high risk GTN in first line, and on 39 pts in >2nd line including 13 pts after multi agent CT. We excluded pts with placental site trophoblastic tumors (n=2), or with FIGO score <7 and without IGR criteria (n=3). Complete remission (CR) rate was 95%. Seven pts (7 %) relapsed and a second CR was obtained for all with surgery and/or CT. Only one patient died due to GTN, after successive CRs obtained with 3 regimens. Five year overall survival (median follow-up 6.6 years) was 98%. Toxicity was evaluated on 95 pts. No toxic death occurred. Given good efficacy and to avoid acute hematotoxicity and long-term G>1 neuro and ototoxicity APE regimen was modified as detailed in the Table (below). Long-term neuro (5 pts, G1), oto (2 pts, G1 and 2 pts, G2) and renal toxicities (1 pt, G1 ) were recorded. No long-term G2 toxicities were observed with APE3. One pt developed an AML 4 after 4cy APE and 6 cy EMA/CO. 37 pts of 40 who wished to be pregnant succeeded and all of them had at least one live birth. Conclusions: With a 98% long-term overall survival rate, an excellent reproductive outcome, and no detectable long-term toxicity, APE-3 should be regarded as an alternative standard option to EMA/CO for high-risk GTN. [Table: see text]

How to follow up advanced-stage borderline tumours? Mode of diagnosis of recurrence in a large series stage II-III serous borderline tumours of the ovary

BACKGROUND

The aim of this study was to describe how recurrences were diagnosed in the largest series of patients treated for an advanced-stage serous borderline ovarian tumour.

PATIENTS AND METHODS

From 1973 to 2006, 45 patients with a serous borderline tumour and peritoneal implants relapsed among 162 patients with a follow-up exceeding 1 year. Data concerning recurrences and the mode of diagnosis were reviewed.

RESULTS

The median follow-up interval was 8.2 years (range 19-286 months). The mode of diagnosis of recurrences was imaging (n = 19), clinical symptoms (n = 8), cancer antigen (CA) 125 elevation (n = 7), secondary surgery (n = 5) and unknown (n = 6). The median time to recurrence was 31 months (range 4-242 month). The type of recurrence was invasive low-grade serous carcinoma in 14 patients. Five patients died of recurrent tumour. Among the 39 patients with a known mode of diagnosis of recurrence, the most frequent diagnostic method for invasive recurrences was blood CA 125 elevation (6 of 13) and the majority of noninvasive recurrences were diagnosed by imaging (16 of 23).

CONCLUSIONS

This study demonstrates that ultrasound is the most relevant follow-up procedure in this context. Nevertheless, the blood CA 125 test is of particular interest for detecting invasive recurrent disease, which is the most crucial event.

[Effects of radiotherapy (external and/or internal) and chemotherapy on female fertility]

The impact of chemotherapy on a woman's fertility depends on her age and the types and doses of the drugs used. Alkylating agents have the biggest negative impact on ovarian function. A trial is currently examining the use of a GnRH agonist to protect ovarian function. The impact of external radiation therapy and brachytherapy on the ovaries depends on three factors: the patient's age, the dose delivered to the ovaries, and concurrent use of chemotherapy. Ovarian transposition is a simple surgical procedure that can be used in selected cases to reduce the risk of early menopause. Both external and internal radiation has an impact on the uterus, notably by altering its vascularization and by reducing its growth when treatment is delivered during childhood.

Postoperative morbidity after completion surgery in patients undergoing chemoradiotherapy for locally advanced cervical carcinoma

5595

Background: The aim of this study was to evaluate the morbidity rate in patients undergoing completion surgery after homogeneous chemoradiation therapy (CRT) for locally advanced stage cervical cancer. Methods: Patients fulfilling following inclusion criteria were studied: 1. Stage IB2-IVA cervical carcinoma; 2. Tumor confined radiologically initially to the pelvic cavity; 3. Pelvic external radiation therapy with delivery of 45 Gy in pelvic cavity with concomitant chemotherapy (cisplatin 40 mg/m2/week) followed by utero-vaginal brachytherapy; 4. Completion surgery after the end of radiation therapy including at least a hysterectomy. Modalities of this completion surgery depended on the presence, location and size of residual disease. Results: One-hundred and fifty patients treated between 1998 and 2007 fulfilled inclusion criteria. Modalities of hysterectomy performed were: extrafascial hysterectomy in 106 (71%) patients and radical hysterectomy in 44 (29%). Para-aortic lymphadenectomy was performed in 131 (87%) patients and pelvic lymphadenectomy in 34 (23%) patients. Thirty-four (23%) patients had macroscopic (> 1 cm) residual disease on pathologic examination. Twenty-five (23%) patients had post-operative complications (in whom 17 severe morbidity requiring surgical or radiological treatment). Presence of residual disease was the only factor associated with overall morbidity rate in univariate and multivariate analysis. The use of radical hysterectomy and pelvic lymphadenectomy increased significantly the rate of severe morbidity (particularly bowel and urinary tract morbidity). Conclusions: In the present study involving a large number of patients undergoing completion surgery after homogeneous CRT in locally advanced cervical carcinoma the morbidity rate is important. Radical hysterectomy and pelvic lymphadenectomy increase the rate of severe morbidity. The interest on the survival of this completion surgery should be evaluated in prospective trial.

No significant financial relationships to disclose.

Prognostic factors of patients with advanced stage serous borderline tumors of the ovary

5573

Background: The aim of this study was to determine prognostic factors in a large series of patients with stage II or III serous low malignant potential ovarian tumor (LMPOT) and peritoneal implants. Methods: A retrospective review of patients with a serous LMPOT and peritoneal implants treated or referred in our institution. The slides of ovarian tumors and peritoneal implants were reviewed by the same pathologist. Prognostic factors were studied. Results: From 1969 to 2006, 168 patients were reviewed, 21 of whom had invasive implants. Tumors exhibited a micropapillary pattern in 56 patients. Adjuvant treatment had been administered to 61 patients. The median duration of follow-up was 57 (range, 1–437) months. Forty-four patients had relapsed and 10 patients had died. 5-year overall survival of patients was 98%. Among patients with noninvasive and invasive implants, 8% and 10%, respectively, relapsed at 5 years in the form of invasive disease (p = 0.08). Prognostic factors for recurrence in the univariate analysis were: a laparoscopic approach, conservative treatment and positive second-look surgery. In the multivariate analysis the use of conservative treatment was the only prognostic factors for recurrence. Conclusions: The prognosis of serous LMPOT with peritoneal implants remains good. The strongest prognostic factor in patients with an advanced-stage borderline tumor is the use of conservative surgery. In this series, a micropapillary pattern and implant subtypes (invasive vs. noninvasive) were not prognostic factors.

No significant financial relationships to disclose.

Successful treatment for advanced small cell carcinoma of the ovary

Small cell carcinoma of the ovary is a rare and aggressive malignant tumour with a poor prognosis. The authors describe two females, 12 and 13 years old, who presented with advanced stage disease. They were treated with surgical resection, multiagent chemotherapy and high-dose chemotherapy followed by autologous bone marrow transplantation. They remain free of disease more than 9.5 and 14 years since the diagnosis.

Concomitant weekly carboplatin (CB) and paclitaxel (P) with pelvic radiotherapy (RT) for the treatment of advanced cervical cancer (ACC): A FNCLCC gynecologic group phase I trial

5542

Background: Standard primary treatment for locally ACC is RT with concomitant chemotherapy (CT). CB and P are radiosensitizers with in vitro synergistic action. Methods: Patients (pts) with FIGO stage IIB-IVA negative paraaortic lymph nodes cervical cancer were treated with 6 weekly cycles of CT during pelvic RT (45 Gy) and brachytherapy (BT) according to Table 1 . Each dose escalation step followed a 30-day period of observation on cohorts of 3 to 6 pts depending on dose limiting toxicity (DLT): toxic death; garde (G) 4 neutropenia > 1 week; G 4 toxicity (other hematologic or non-hematologic); any toxicity requiring = 1 week delay in RT, or > 2 dose reductions of CT, or G 3/4 hematologic toxicity > 3 weeks after treatment’s end; unendurable G 3 non hematologic toxicity. Results: 23 pts were included by 5 centers in 5 dose levels (L). Stage distribution: IIB (10), III (11), IVA (2); 20 epidermoid and 3 adenocarcinoma; ECOG: 0 (16), 1 (7). 22 pts received the 6 planned cycles. Median dose of irradiation was 45 Gy (43.2–50) with no toxicity related interruption. 17 pts underwent BT, 2 had hysterectomy and 1 received complementary external irradiation 12 Gy. CT dose reduction was necessary in 4 pts (cycle 5 or 6) and cycles postponed for 10 pts (cycle. 5 or 6). One pt experienced paclitaxel allergy at L1. G 3 anemia and/or neutropenia were reported in 11 pts and G 4 neutropenia = 1 week in 2 pts. Radiodermatitis occurred in 5 pts, asthenia in 3 and nausea in 1. One DLT was observed: unendurable G 3 asthenia + G 3 neutropenia and leucopenia at L3. Clinical and radiological complete response was obtained in 13 pts, 5 PRs and 2 SDs in 20 evaluable pts. Conclusions: Acceptable toxicity and optimal irradiation were possible at L4 in 7 pts. These doses are recommended for future phase II studies of concomitant CT/RT in ACC.

[Table: see text]

No significant financial relationships to disclose.

Phase II study of bleomycin, vindesine, mitomycin C and cisplatin (BEMP) in recurrent or disseminated squamous cell carcinoma of the uterine cervix

OBJECTIVE

We carried out a phase II trial with BEMP [bleomycin, vindesine (Eldisine(R)), mitomycin C and cisplatin] in patients with recurrent and/or metastatic squamous cell carcinoma of the uterine cervix with the specific aim to assess whether BEMP was of particular interest when certain disease sites were involved.

PATIENTS AND METHODS

Eligible patients received four cycles of E 3 mg/m(2), day 1 + 8; P 50 mg/m(2), day 1; B 15 mg/day (continuous infusion), day 2-4 and M 8 mg/m(2), day 5 (on alternate cycles), every 3 weeks during an induction phase. Thereafter, those without progression continued with MEP every 4 weeks in a maintenance phase. MEP consisted of E 3 mg/m(2), day 1 + 8, M 6 mg/m(2) (on alternate cycles) and P 50 mg/m(2), both on day 1. All drugs were given i.v. Both response evaluation and toxicity grading were assessed according to World Health Organization criteria.

RESULTS

Of the 161 eligible patients, 143 were assessable for survival, 148 for toxicity and 131 for response. Overall response rate was 45% [complete (CR) 14.5%, partial response (PR) 30.5%]. Most responsive disease sites were lung, lymph nodes and skin metastases (>60% response, CR rate >25%). Median duration of response was 7.6 months. Survival was significantly better in patients with only distant metastases: 12.9 months versus 8.6 months in those with other disease sites involved (P = 0.002). In a multivariate analysis, patients with a good performance status yielded a better prognosis (P = 0.0017), as did the patients with only metastatic disease compared with those who had pelvic disease also or solely (P = 0.045). There were two toxic deaths and 21% of patients stopped treatment because of excessive toxicity.

CONCLUSIONS

Patients with a good performance status and only distant metastases seem optimal candidates to receive the BEMP regimen. This benefit should be balanced against the expected serious toxic effects.

Immunopharmacology of cancer vaccines: Restoration of NKG2D levels and functions in metastatic melanoma treated with exosomes

2554

Background: The C-type lectin-like stimulatory immune receptor Natural Killer group 2 receptor (NKG2D) is expressed by NK and CD8+ T cells. NKG2D engagement is a natural mediator of immunosurveillance which can be compromised by locally sustained ligand expression. In cancer patients with NKG2D ligand- expressing tumors, NK and CD8+ T cells often express low levels of NKG2D and are functionally compromised. Dentritic cell-derived-exosomes (Dex) are nanomeric vesicles harboring functional MHC/peptide complexes capable of promoting T cell immune responses and tumor rejection in mice. Two Dex Phase I trials highlighted the and the safety of exosome administration. The observation of clinical regressions in the absence of detectable T cell responses prompted the search for alternate effector mechanisms. We study NKG2D expression and NK cells function in peripheral lymphocytes before and after Dex therapy. Methods: Exosomes were purified from day 7 autologous monocyte derived-DC cultures. Fifteen patients were enrolled and received exosome vaccinations. NK cells functions prior or following exosome vaccines were tested in standard Na251CrO4 chromium release assays. NKG2D and NKG2D ligand expression were studied using flow cytometry and/or western blot experiments. Results: In sharp contrast with DC, Dex bear functional NKG2D ligands leading to a selective downregulation of NKG2D activating receptors on autologous NK cells in vitro. Long term administration of Dex could enhance NKG2D expression levels on NK and CD8+ T cells in 50% of patients, restoring killing of NKG2D ligand expressing K562 and autologous tumour. In contrast to NKG2D ligands shed by tumors mediating immunosuppressive activity, exosomal NKG2D ligands promote NKG2D-dependent effector functions in vivo, that might account for the non MHC restricted-antitumor effects observed in the trial. Conclusions: NK cell activation represent a new pharmacodynamic for Dex leading to tumor recognition and regression in vivo. The Phase II trial using Dex shall include the monitoring of NKG2D ligands on Dex preparation and follow up NKG2D levels, functions and polymorphism in patients.

No significant financial relationships to disclose.

A phase II study of oral gimatecan (ST1481) in women with progressing or recurring advanced epithelial ovarian, fallopian tube and peritoneal cancers

5088

Background: Gimatecan, a new camptothecin derivative, is a potent topoisomerase I inhibitor, active by oral route. Methods: A multicenter two stage Simon design phase II study was performed to evaluate the single agent antitumor activity of gimatecan. Secondary objectives were safety, time to event/time related parameters, and translational medicine evaluations. Women with advanced epithelial ovarian, fallopian tube or peritoneal cancer who had progressed or recurred after prior treatment with platinum and taxanes, had a progression-free interval from last platinum-based therapy < 12 months, had measurable disease by RECIST or assessable by CA 125 (GCIG criteria) and a ECOG performance status ≤ 1 were eligible. Gimatecan 0.8 mg/m2 was administrated orally for five consecutive days every four weeks. Radiological response was assessed every two cycles. Results: From June to December 2005, 70 women [median age 61 years (range 37–79)] were treated in 10 European sites. Number of prior chemotherapy regimens was: 1 in 20, 2 in 35, 3 in 15 patients, respectively. Progression-free interval from last platinum-based therapy was 0–6 months in 51 patients and 6–12 months in 19 patients. The study is still ongoing, and to date 40 consecutive patients are assessable. Preliminary response analysis indicated a 23.5% response rate based on CA 125 (8/34) and a 10% response rate based on RECIST (3/29). Main toxicity was hematological, namely thrombocytopenia and neutropenia. Conclusions: Preliminary results suggest that oral gimatecan administered as single agent is active, with bone marrow suppression resulting at present as the main toxicity in these patients previously treated with platinum and taxanes. However, many patients are still on treatment and data need to mature to have a broader picture of activity and safety.

[Table: see text]

Malignant Adnexal Masses in Pregnancy

Ovarian tumors during pregnancy are very rare; however, a cancer diagnosis causes distress to the couple. Reassurance is paramount, and the first consideration should be given to the safety of the mother. If both mother and fetus can be preserved, treatment to minimize the risks to both should be planned accordingly. It is imperative to care for the patient with a multidisciplinary team that includes a high-risk obstetrician, a gynecologic oncologist, and a medical oncologist specialized in gynecologic cancers.

Cutaneous side-effects of kinase inhibitors and blocking antibodies

Although kinase inhibitors raise hope for people with cancer, patients and their clinicians are commonly confronted with the cutaneous side-effects that are associated with the use of these drugs. This review is the result of collaborations between dermatologists, medical oncologists, and pathologists, and discusses the cutaneous side-effects seen after treatment with the inhibitors of epidermal-growth-factor receptor (EGFR), imatinib, sorafenib, and sunitinib. Some of the side-effects caused by these agents are very distressing, partly because they are chronic owing to the long duration of treatment. Therefore, patients need early and appropriate dermatological management. Moreover, several studies have reported a link between the antitumour efficacy of EGFR inhibitors and cutaneous side-effects. Elucidation of this connection could lead to the identification of crucial predictive factors for tumour response.

SOR guidelines for concomitant chemoradiotherapy for patients with uterine cervical cancers: evidence update bulletin 2004

BACKGROUND

In 1993 the French National Federation of Cancer Centres (FNCLCC) initiated the Standards, Options and Recommendations (SOR) project. This is a collaboration between the FNCLCC, the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics, and some specialists learned societies. The main objective is to develop clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

MATERIALS AND METHODS

The SORs are developed using a methodology based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

RESULTS

In 1999, the initial SORs for the management of women with cervical cancer were published. At that time the use of chemoradiotherapy was considered as an option. Since this original publication, five randomised trials comparing chemoradiotherapy with radiotherapy have been published, as well as a systematic review and two other clinical practice guidelines. In the light of this additional evidence, it was decided to update the guidelines on chemoradiotherapy in women with cervical cancer.

CONCLUSION

After selection, critical analysis and integration of new evidence, chemoradiotherapy has become a standard for women with cervical cancer.

Survival in cervix cancer patients treated with radiotherapy followed by radical surgery

AIM

To determine the incidence and predictive value of residual disease in the hysterectomy specimens of cervical cancer patients treated with primary radiotherapy, with or without chemotherapy, followed by surgery and to determine whether pathologically confirmed residual disease is a surrogate marker of outcome.

METHODS

The medical records of patients treated for stage IB/II carcinoma of the cervix in a single institution between 1985 and 2000 were retrospectively analysed into two different groups, depending on whether they had received radiotherapy or concurrent chemo-radiotherapy. Six to 8 weeks after irradiation, all patients underwent radical or extrafascial hysterectomy and pelvic and para-aortic lymphadenectomy.

RESULTS

A total of 403 patients were included in the study (360 in the radiotherapy only group and 43 in the chemo-radiotherapy group). One hundred and seventy-eight patients had residual disease on hysterectomy specimens in the radiotherapy group. Considering only the stages IB2 and II, 126 (52%) and 16 (37%) patients had residual disease on hysterectomy specimens in the radiotherapy group and in the chemo-radiotherapy group, respectively (P=0.08). Residual disease was associated with pelvic and para-aortic nodal metastases. The 5-year local control and overall survival rates were 88 and 86%, respectively, in the patients with complete pathologic response and 73 and 62%, respectively, in the patients with residual disease (P<0.001). In multivariate analysis, FIGO stage, residual disease, and pathologic nodal involvement were independent predictive factors of both local recurrence and overall survival.

CONCLUSION

Pathologically confirmed residual disease on hysterectomy specimen is an independent and strong predictive factor of both local recurrence and overall survival.

Results of Hysterectomy in Patients With Bulky Residual Disease at the End of Chemoradiotherapy for Stage IB2/II Cervical Carcinoma

BACKGROUND

We assessed the clinical outcome after hysterectomy in patients with bulky residual disease after chemoradiotherapy for stage IB2/II cervical carcinoma.

METHODS

Subjects were 10 patients who had bulky (>2 cm) residual disease in the cervix after external radiotherapy (45 Gy) combined with concomitant chemotherapy (cisplatin 40 mg/m2/week) and uterovaginal brachytherapy (15 Gy).

RESULTS

Extrafascial hysterectomy was performed in three patients, type II radical hysterectomy was performed in six patients, and pelvic exenteration was performed in one patient. Pelvic lymphadenectomy was performed in eight patients, and para-aortic lymphadenectomy was performed in eight. Five patients had nodal involvement (pelvic nodes in four and para-aortic nodes in four), and six had lymphovascular space involvement. Surgical margins were free in nine patients. Seven patients developed grade 2 (n = 3) and/or grade 3 (n = 4) complications. The median duration of follow-up after surgery was 22 months (range, 1-37 months). With follow-up available in nine patients, seven relapsed, and only two remained disease free.

CONCLUSIONS

This series confirms the high rate of nodal spread in patients with bulky residual cervical disease after chemoradiotherapy. Furthermore, patients who underwent hysterectomy had a high complication rate. Only two patients are alive and disease free. The results of surgery are disappointing; surgery does not seem to improve the survival of these patients.