Practice patterns and survival in FIGO 2009 stage 3B endometrial cancer

OBJECTIVE

To describe the practice patterns and outcomes of patients with stage 3B endometrial cancer.

METHODS

We queried the National Cancer Database for all surgically staged, stage 3 patients between 2012 and 2016. Patients who received any pre-operative therapy were excluded. Demographics, tumor factors, and adjuvant therapy for the stage 3 substages were compared. Logistic regression was used to identify factors associated with adjuvant therapy. Kaplan Meier curves were generated and compared using the log-rank test. Multivariable Cox Proportional Hazards Model was used to adjust for prognostic factors. Findings with p < 0.05 were considered significant.

RESULTS

Of 7363 patients with stage 3 disease, 478 (6%) had stage 3B; 1732 (23%) had stage 3A, 3457 (48%) had stage 3C1, and 1696 (23%) had stage 3C2 disease. Post-surgical treatment consisted of: combined chemotherapy (CT) and radiation (RT) (49%), CT alone (28%), RT alone (9%), 14% received no postoperative therapy. Among all stage 3 substages, patients with stage 3B disease were the least likely to receive any CT, and the most likely to receive RT alone. After adjusting for known prognostic factors, patients with stage 3A (Hazard ratio (HR) of death = 0.64) and 3C1 (HR of death = 0.79) disease had significantly worse overall survival compared to stage 3B; survival was not demonstrably different from patients with stage 3C2 disease. Patients with stage 3B disease who received CT + RT had the best overall survival.

CONCLUSION

Survival of patients with stage 3B disease is similar to that of patients with para-aortic node metastases and is inferior to all others with stage 3 endometrial cancer. Less frequent CT and a higher rate of post-operative RT alone, describes a distinct practice from that seen in other stage 3 patients.

Trends and geographic variation in women's representation as principal investigators (PI) in phase 3 gynecologic oncology clinical trials

OBJECTIVE

To investigate the representation of women as principal investigators (PI) in phase 3, gynecologic oncology clinical trials.

METHODS

ClinicalTrials.gov was queried for all phase 3 clinical trials with start dates between January 1, 2010 and December 31, 2020 using the search terms: "ovarian cancer", "endometrial cancer", and "cervical cancer". Trial characteristics were abstracted from the website. Gender of the PI was assessed by name, image on institutional website or by querying the trial coordinator. Trials were considered to have women's representation if women were the sole PI or among multiple co-PIs. Chi-square tests and relative risks were used to compare proportions across groups. Linear regression was used to assess trends over time.

RESULTS

200 unique clinical trials were included in this analysis, of which women were represented as PI in 76 (38%). Women were more likely to be a PI of trials funded by multiple sites than a single entity (RR = 1.80, 95% confidence interval (CI) 1.25, 2.61, p = 0.01), registered outside of Asia than those in Asia (RR = 1.78, 95% CI 1.11, 2.88, p = 0.02), and trials with multiple co-PIs than with one PI (RR = 1.78 (95% CI 1.18, 2.67), p = 0.01). Overall, women's representation as a PI increased by 3% annually (by year of registration, R² = 0.61, p = 0.01). This increase was most evident in trials registered in multiple continents and Europe (both 4% annually).

CONCLUSIONS

Women's representation as PIs in clinical trials has increased in the last decade. Trials funded by multiple sources outside of Asia have the highest proportion of PIs who are women. These trends may represent ongoing leadership and mentorship opportunities for women gynecologic oncologists.

Assessment of malnutrition by unintentional weight loss and its implications on oncologic outcomes in patient with locally advanced cervical cancer receiving primary chemoradiation

OBJECTIVES

To determine the prevalence, risk factors for, and clinical implications of unintentional weight loss on oncologic outcomes in locally advanced cervical cancer (LACC) treated with concurrent chemotherapy and contemporary radiation techniques.

METHODS

This a single-institution, retrospective cohort study of patients with LACC who received definitive chemoradiation (CRT) from 2010 to 2015. Clinicopathologic factors were abstracted by chart review and characterized using descriptive statistics. Factors associated with severe weight loss (≥10% from baseline) were determined by Chi-square test. Time-to-event analysis was performed using the Kaplan Meier method and regression was performed using the Cox Proportional hazards model.

RESULTS

One hundred and eight patients comprised the cohort. The majority of patients were White, obese, and had squamous histology. Almost 80% of patients experienced at least some weight loss, with 14% of patients experiencing severe weight loss. Patients with FIGO 2009 stage 3 or 4 disease had a 3.4-fold increased risk of severe weight loss compared to those with earlier stage disease. Patients who had severe weight loss had a higher risk for death (HR = 2.37, 95% confidence interval [CI] 1.77, 7.37, p = 0.036) and a trend toward high risk for recurrence (HR = 1.43, 95% CI 0.46, 3.32, p = 0.107) compared to patients without severe weight loss.

CONCLUSION

Unintentional weight loss is a common symptom of patients with LACC receiving CRT that affects oncologic outcomes, yet it remains under-recognized. Increased awareness of weight loss and malnutrition may encourage interventions to improve this potentially modifiable risk factor for worse prognosis and quality of life.

HIPEC after neoadjuvant chemotherapy and interval debulking is associated with development of platinum-refractory or -resistant disease

OBJECTIVE

To describe our single-institution oncologic outcomes of patients who received neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

We compared clinicopathologic information and outcomes for all patients with advanced stage, high-grade serous ovarian cancer who received NACT and IDS with (N = 20) or without (N = 48) HIPEC at our institution from 2010 to 2019 RESULTS: Mean age (62 years with HIPEC and 60 years without HIPEC) and proportion of stage 4 disease (40% for both) did not differ between cohorts. HIPEC patients had higher rates of complete cytoreduction (95% vs 50%), longer mean duration of surgery (530 vs. 216 min), more grade 3 or 4 postoperative complications (65% vs. 4%), and longer mean length of hospital stay (8 vs. 5 days). HIPEC patients had significantly higher risk for platinum-refractory progression or platinum-resistance recurrence (50% vs 23%; RR = 2.18; 95% CI 1.11, 4.30, p = 0.024). Median progression free survival (11.5 vs. 12 months) and all-cause mortality (19.1 vs. 30.5 months) in the HIPEC and non-HIPEC cohorts, respectively, did not differ CONCLUSIONS: HIPEC was associated with increased risk for platinum refractory or resistant disease. Higher surgical complexity may contribute to higher complication rates without improving oncologic outcomes in our patients. Further investigations and long-term follow-up are needed to assess the utility of HIPEC in primary treatment of advanced stage ovarian cancer.

Abstract AP23: A PLATINUM–RESISTANT SUBTYPE OF HIGH–GRADE SEROUS OVARIAN CANCER IDENTIFIED BY A NETWORK OF SOMATIC MUTATIONS

PURPOSE: Like many solid tumors, high grade serous ovarian carcinoma (HGSOC) is a heterogeneous entity with a widely variable clinical course even among patients of the same stage and histological subtype. Although most patients will achieve remission with platinum-based chemotherapy, approximately 20% will display primary platinum resistance. If it were possible to platinum resistance from the molecular profile of a tumor, patients with platinum resistant tumor could be identified for alternative therapy, however, currently no such biomarker exists.

METHODS: We have recently developed an analysis method called Network-based Stratification (NBS), which combines genome-scale somatic mutation profiles with genetic interaction networks. Briefly, somatic mutations for each patient are mapped onto a network, and then the influence of each mutation is propagated over its network neighborhood to give each gene a propagated mutation score (PM score). Unsupervised clustering is then used to assign the propagated networks into subtypes.

RESULTS: Using NBS a high risk subtype consisting of approximately 20% of the patients was identified in both TCGA (n=330) and the ICGC (n=92) HGSOC cohorts. The median overall survival (OS) for the high risk (HR) subtype was a year less than standard risk (SR) subtype (36 vs. 48 mo, Log rank p = 1.6x 10-5) in TCGA cohort and similarly shorter (22 mo vs. not-yet-reached, p = 3.6x10-4), see figure 1. These survival differences were independent of age, tumor stage and residual tumor after surgical resection. The PM scores of the HR tumors from TCGA and ICGC cohorts we remarkably correlated (Pearson r2 = 0.94, p &lt; 0.001). In contrast, the correlation of PM scores from the full TCGA to ICGC cohorts was 0.58, and within the TCGA the correlation between HR and SR was only 0.18. The network of frequently mutated genes for the HR subtype was enriched for genes in the nucleoskeleton, caspase, and FGFR pathways.

We then built a classifier to identify molecularly matched cell line models for in vitro study. The three cell lines with mutation profiles match the HR subtype (Kuramochi,Ovkate, OAW28) were significantly more resistant to cisplatin relative to cell lines characteristic of SR tumors (COV318, TYK-NU, OVCAR4), (IC50 14.4 vs. 3.3 µM, p &lt; 0.0001). There was no significant difference in sensitivity to paclitaxel. Figure 1.Kaplan-Meier plots of Overall Survival, A TCGA, B ICGCFigure 1. Kaplan-Meier plots of Overall Survival, A TCGA, B ICGC

CONCLUSIONS: NBS can be used to identify a molecular distinct subtype of HGSOC characterized by poor patient survival and primary platinum resistance.

Citation Format: John Paul Shen, Ana Bojorquez-Gomez, Justin Huang, Matan Hofree, Kristin Klepper, Alex Beckett, Cheryl Saenz, Jason Kreisberg, Trey Ideker. A PLATINUM–RESISTANT SUBTYPE OF HIGH–GRADE SEROUS OVARIAN CANCER IDENTIFIED BY A NETWORK OF SOMATIC MUTATIONS [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr AP23.

Haploinsufficiency networks identify targetable patterns of allelic deficiency in low mutation ovarian cancer

Identification of specific oncogenic gene changes has enabled the modern generation of targeted cancer therapeutics. In high-grade serous ovarian cancer (OV), the bulk of genetic changes is not somatic point mutations, but rather somatic copy-number alterations (SCNAs). The impact of SCNAs on tumour biology remains poorly understood. Here we build haploinsufficiency network analyses to identify which SCNA patterns are most disruptive in OV. Of all KEGG pathways (N=187), autophagy is the most significantly disrupted by coincident gene deletions. Compared with 20 other cancer types, OV is most severely disrupted in autophagy and in compensatory proteostasis pathways. Network analysis prioritizes MAP1LC3B (LC3) and BECN1 as most impactful. Knockdown of LC3 and BECN1 expression confers sensitivity to cells undergoing autophagic stress independent of platinum resistance status. The results support the use of pathway network tools to evaluate how the copy-number landscape of a tumour may guide therapy.

Abstract AS02: Network-based stratification: combining genome-scale somatic mutation profiles with genetic interaction networks to identify clinically relevant subtypes in high grade serous ovarian carcinoma

Background: Like many solid tumors, high grade serous ovarian carcinoma (HGS-OvCa) is a heterogeneous entity with a widely variable clinical course even among patients of the same stage and histological subtype. We have recently developed a method called Network-based Stratification (NBS), which combines genome-scale somatic mutation profiles with genetic interaction networks and performs unsupervised clustering of patients into subtypes. Remarkably, patients in these subtypes display distinct biological and clinical characteristics.

Methods: Briefly, somatic mutations for each patient are represented as a profile of binary (1,0) states on genes, in which a ‘1’ indicates a mutated gene. For each patient we project mutation profiles onto a human gene interaction network, then apply network propagation to spread the influence of each subsampled mutation profile over its network neighborhood. These ‘network-smoothed’ profiles are then clustered into a predefined number of subtypes using the unsupervised technique of non-negative matrix factorization (NMF).

Results: Using the NBS technique four distinct subtypes were identified from the TCGA HGS-OvCa cohort of 330 exome sequenced and clinically-annotated tumors. The median overall survival (OS) in months for these four subtypes was 36, 48, 56, and not-yet-reached respectively, which was highly significant (Logrank p = 1.59 x 10-5). No significant differences between subtypes were found in age, tumor stage at presentation, or percentage of patients with an optimal surgical resection. Furthermore, the survival difference is significant when comparing a Cox proportional hazards model of NBS subtypes together with the above factors and mutation rate is compared to a model of these factors alone (Likelihood ratio test p = 3.3x10-4). Each subtype exhibits a distinct set frequently mutated pathways, with subtype 1 (which had the worst OS) enriched for mutation in the fibroblast growth factor receptor, caspase and nucleoskeleton pathways, subtype 2 enriched for ‘classic’ HGS-OvCa mutations including mutation in DNA damage response genes.

Recognizing that full exome sequencing is not yet standard of care, we have built a limited classifier that only requires as input the mutational status of 50 genes. This 50 gene classifier performed with 94% accuracy and 80% precision relative to full exome. Using this 50 gene classifier we have stratified an independent cohort of 93 Australian HGS-OvCa patients from the ICGC and found survival relationships similar to what was seen in the TCGA cohort (median OS of 22 months for subtype 1 vs. not-yet-reached for other subtypes, Logrank p = 3.6x10-4). The 50 gene NBS classifier was also applied to a panel of cell lines from The Genomics of Drug Sensitivity in Cancer Project. Cell lines classified as subtype 1 had significantly higher cisplatin IC50 relative to other subtypes, whereas there was no difference in docetaxel or paclitaxel IC50.

Citation Format: John Paul Shen, Matan Hofree, Ana Bojorquez-Gomez, Cheryl Saenz, Trey Ideker. Network-based stratification: combining genome-scale somatic mutation profiles with genetic interaction networks to identify clinically relevant subtypes in high grade serous ovarian carcinoma [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr AS02.

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox

OBJECTIVE

The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta.

STUDY DESIGN

This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011.

RESULTS

Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs.

CONCLUSION

Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Incompatibilities of lansoprazole injection with other drugs during simulated y-site coadministration

The physical compatibility of lansoprazole injection with selected other drugs during simulated Y-site coadministration was evaluated by means of visual observation, turbidity measurement, and particle content assessment. Five-milliliter samples of lansoprazole 0.55 mg/mL in 0.9% sodium chloride injection were conbined with 5 mL of 112 other drugs including antineoplastics, analgesics, antiinfectives, and supportive-care drugs undiluted or diluted in 0.9% sodium chloride injection or 5 % dextrose injection for amphotericin B. Visual examinations were performed with the unaided eye in fluorescent light and by means of a Tyndall beam (a high-intesity, monodirectional light beam) to enhance the visualization of small particles and low-level trubidity. The turbidity of each sample was measured as well. Particle sizing and counting were performed on selected samples. Evaluation of the samples was performed initially and at 1 and 4 hours after preparation. Of the drugs tested, 92 were incompatible with lansoprazole 0.55 mg/mL in 0.9% sodium chloride injection during the 4-hour observation period. Gross precipitation or color changes visible in normal diffuse room light with the unaided eye occurred with 45 drugs. Phenomena not visible with the unaided eye, such as microprecipitation and /or increases in measured turbidity, occurred with 47 drugs. Only 20 drugs were found to be compatible for at least 4 hours. The measured turbidity of the lansoprazole control solutions and the compatible test samples, remained essentially unchanged throughout the study. In addition, the compatible samples exhibited no color change or substantial change in particle size and content throughout the observation period. In conbination with lansoprazole, only 20 drugs were considered to be physically compatible. Ninety-two drugs exhibited frank precipitation, microparticulate formation, color changes, or unacceptable increases of measured turbidity within 4 hours and should not be simultaneously coadministered with lansoprazole.

Octreotide therapy of large-volume refractory AIDS-associated diarrhea: a randomized controlled trial

OBJECTIVE

To compare the effect of octreotide (a long-acting somatostatin analog) to that of antidiarrheal therapy plus placebo on large-volume refractory AIDS-associated diarrhea.

DESIGN

A randomized controlled trial.

SETTING

Referral-based clinic and hospital in a tertiary care center.

PATIENTS

Twenty male patients with AIDS and refractory diarrhea, with stool volume > 1000 ml/day who failed to improve after initial supportive management. All patients finished the study.

INTERVENTIONS

Patients were randomly given either octreotide in doses of 100, 200 and 300 micrograms subcutaneously every 8 h, or high doses of loperamide and diphenoxylate orally plus placebo subcutaneously for 10 days.

MAIN OUTCOME MEASURES

Bowel movements and stool volume were registered before and every day after treatment by the patients themselves and the nursing personnel.

RESULTS

Patients from both groups were similar for age, time of AIDS diagnosis, duration of diarrhea and etiology. Baseline mean bowel movements per day (9.4 +/- 2.8 in the octreotide group versus 10 +/- 3.1 in controls) and baseline mean stool volume (2753 +/- 840 versus 2630 +/- 630 ml/day, respectively) were similar in both groups before therapy (P < 0.05). Mean bowel movements per day after 10 days of therapy was 2.1 +/- 1.6 in the octreotide group versus 7 +/- 3 in controls (P < 0.05). Mean stool volume after 10 days of therapy was 485 +/- 480 in the octreotide group versus 1080 +/- 420 ml/day in controls (P < 0.05). Complete response (stool volume < 250 ml/day) was observed in two patients from the octreotide group and none from controls; partial response (decrease > 50% in stool volume) in four and two; and no response (decrease < 50% or no change) in four and eight (P < 0.05), respectively. Side-effects occurred in eight out of 10 octreotide patients and three out of 10 controls (P < 0.05), but none were significant to result in discontinuation of medication.

CONCLUSION

Octreotide proved to be superior to conventional therapy in this short-term treatment of large-volume refractory AIDS-associated diarrhea.

Macronodular lesions associated with Staphylococcus aureus bacteremia. A condition that resembles a 'lymphocutaneous' syndrome

A 54-year-old man, diagnosed as having Wegener's granulomatosis and treated with a regimen of cyclophosphamide and prednisone and hemodialysis, was found to have Staphylococcus aureus in blood, urine, and pus that were removed from the infected area. He had unusual macronodular lesions of the skin that resembled the lymphocutaneous syndrome. These lesions resolved with antibiotic therapy. To our knowledge, this condition has not been described previously.

Interaction between acetohydroxamic acid and 12 antibiotics against 14 gram-negative pathogenic bacteria

Acetohydroxamic acid (AHA) is a potent inhibitor of urease which prevents alkalinization of urine and stone formation in rats in the presence of infection caused by urease-producing bacteria. Because an antibacterial effect of AHA, and synergy between kanamycin and AHA have also been described, we studied the interaction between AHA and 12 antibiotics against 14 gram-negative bacteria. Synergy, sometimes to a striking degree, was found in 17% of interactions; however, antagonism was detected in 5%. Infecting organisms would need to be studied individually before the antibacterial effect of AHA and an antibiotic could be predicted.