Adherence to risk-reducing salpingo-oophorectomy guidelines among gynecologic oncologists compared to general gynecologists

BACKGROUND

Risk-reducing bilateral salpingo-oophorectomy reduces mortality from high-grade serous carcinoma in patients with hereditary breast and ovarian cancer associated gene mutations. Ideal surgical management includes 5 steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists. In addition, it is recommended that pathologic examination include serial sectioning of specimens. In practice, risk-reducing salpingo-oophorectomy is performed by both gynecologic oncologists and general gynecologists. To ensure optimal detection of occult malignancy, standardized adherence to outlined guidelines is necessary.

OBJECTIVE

This study aimed to evaluate the adherence to optimal surgical and pathologic examination guidelines and to compare the rate of occult malignancy at the time of surgery between 2 provider types.

STUDY DESIGN

Institutional review board exemption was obtained. A retrospective review of patients undergoing risk-reducing bilateral salpingo-oophorectomy without hysterectomy from October 1, 2015, to December 31, 2020, at 3 sites within a healthcare system was conducted. The inclusion criteria included age ≥18 years and a documented indication for surgery being a mutation in BRCA1 or BRCA2 or a strong family history of breast and/or ovarian cancer. Compliance with 5 surgical steps and pathologic specimen preparation was based on medical record documentation. Multivariable logistic regression was used to determine differences in adherence between provider groups and surgical and pathologic examination guidelines. A P value of <.025 was considered statistically significant for the 2 primary outcomes after Bonferroni correction was applied to adjust for multiple comparisons.

RESULTS

A total of 185 patients were included. Among the 96 cases performed by gynecologic oncologists, 69 (72%) performed all 5 steps of surgery, 22 (23%) performed 4 steps, 5 (5%) performed 3 steps, and none performed 1 or 2 steps. Among the 89 cases performed by general gynecologists, 4 (5%) performed all 5 steps, 33 (37%) performed 4 steps, 38 (43%) performed 3 steps, 13 (15%) performed 2 steps, and 1 (1%) performed 1 step. Gynecologic oncologists were more likely to document adherence to all 5 recommended surgical steps in their surgical dictation (odds ratio, 54.3; 95% confidence interval, 18.1-162.7; P<.0001). Among the 96 cases documented by gynecologic oncologists, 41 (43%) had serial sectioning of all specimens performed, compared with 23 of 89 cases (26%) performed by general gynecologists. No difference in adherence to pathologic guidelines was identified between the 2 provider groups (P=.0489; note: P value of >.025). Overall, 5 patients (2.70%) had occult malignancy diagnosed at the time of risk-reducing surgery, with all surgeries performed by general gynecologists.

CONCLUSION

Our results demonstrated greater compliance with surgical guidelines for risk-reducing bilateral salpingo-oophorectomy in gynecologic oncologists than in general gynecologists. No considerable difference was determined between the 2 provider types in adherence to pathologic guidelines. Our findings demonstrated a need for institution-wide protocol education and implementation of standardized nomenclature to ensure provider adherence to evidence-based guidelines.

Abstract 2398: Precision molecular biomarkers for the surveillance of gynecologic malignancies: Rapid and efficient pipeline for the design and highly sensitive detection of circulating tumor DNA

Gynecologic malignancies affect over 94,000 women in the U.S. and will result in close to 29,000 deaths this year alone. Currently available biomarkers are inadequate for the early detection of disease recurrence. The development of more sensitive and accurate biomarkers represents a critical and immediate necessity towards improving both patient outcome and quality of life. The measurement of circulating tumor DNA (ctDNA), the so-called “liquid biopsy,” represents a powerful emerging technology capable of providing accurate assessment of both tumor behavior and disease burden, and has great potential for revolutionizing our standard approach to tumor surveillance. The ability to translate the various ctDNA detection technologies from the laboratory to the clinic and begin defining clinical utility will in part be determined by the time and cost efficiencies of the pipelines and inherent detection sensitivities.

We have developed a precision-medicine based approach that couples targeted tumor-specific mutation identification for each patient to droplet digital PCR-based (ddPCR) ctDNA detection. Using two rapid-turnaround sequencing panels (targeted full-gene PacBio single-molecule real time (SMRT) long-read sequencing coupled with the Ion AmpliSeq™Cancer Hotspot Panel v2) in lieu of more expensive and time-consuming approaches like whole-exome or whole-genome sequencing, we comprehensively identified tumor mutations for each of our ovarian and endometrial cancer patients by sequencing normal and tumor DNA from each patient. Analysis of an initial cohort of ovarian and endometrial cancer patients resulted in mutation identification frequencies comparable to previously reported data with mutations in TP53, PTEN, and PIK3CA being most frequently represented. Candidate mutations for ctDNA detection were identified for greater than 80% of subjects using this approach. By targeting specific genes, we raise the likelihood that identified tumor mutations are drivers essential to the disease, rather than passenger mutations that may be selected out during disease progression. ctDNA biomarkers specific to each patient's tumor mutations were generated and tested using ddPCR, allowing for detection down to 0.05% mutant allele fraction. ctDNA levels were assessed longitudinally from prospectively collected serums during multiple time points throughout each patient's clinical course and compared to clinical findings and current gold-standard serum and radiologic tests. ctDNA was successfully detected in all subjects; and to our knowledge for the first time in endometrial cancer.

We demonstrate that our molecular approach allows for rapid, highly sensitive and accurate assessment of patient tumor status and, for some patients, is an improved and better predictor of outcome than current gold-standard surveillance strategies.

Citation Format: Elena B. Pereira, Olga Camacho-Vanegas, Sanya Anand, Chanpreet Singh, Andrew Uzilov, Robert Sebra, David Chappell, Peter Dottino, John A. Martignetti. Precision molecular biomarkers for the surveillance of gynecologic malignancies: Rapid and efficient pipeline for the design and highly sensitive detection of circulating tumor DNA. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2398. doi:10.1158/1538-7445.AM2015-2398

Kinetic studies of lipase from Candida rugosa: a comparative study between free and immobilized enzyme onto porous chitosan beads

The search for an inexpensive support has motivated our group to undertake this work dealing with the use of chitosan as matrix for immobilizing lipase. In addition to its low cost, chitosan has several advantages for use as a support, including its lack of toxicity and chemical reactivity, allowing easy fixation of enzymes. In this article, we describe the immobilization of Candida rugosa lipase onto porous chitosan beads for the enzymatic hydrolysis of olive oil. The binding of the lipase onto the support was performed by physical adsorption using hexane as the dispersion medium. A comparative study between free and immobilized lipase was conducted in terms of pH, temperature, and thermal stability. A slightly lower value for optimum pH (6.0) was found for the immobilized form in comparison with that attained for the soluble lipase (7.0). The optimum reaction temperature shifted from 37 degrees C for the free lipase to 50 degrees C for the chitosan lipase. The patterns of heat stability indicated that the immobilization process tends to stabilize the enzyme. The half-life of the soluble free lipase at 55 degrees C was equal to 0.71 h (Kd = 0.98 h(-1)), whereas for the immobilized lipase it was 1.10 h (Kd = 0.63 h(-1)). Kinetics was tested at 37 degrees C following the hydrolysis of olive oil and obeys the Michaelis-Menten type of rate equation. The Km was 0.15 mM and the Vmax was 51 micromol/(min x mg), which were lower than for free lipase, suggesting that the apparent affinity toward the substrate changes and that the activity of the immobilized lipase decreases during the course of immobilization.

Radon flux at King George Island, Antarctic Peninsula

Fluxes of 222Rn from the ice-free terrain to the atmosphere were measured directly, for the first time, at the Brazilian Antarctic Station Ferraz during the summer field campaign of 1998/99. Average value for the flux was 7.7 +/- 4.8 x 10(-2) atoms cm(-2) s(-1) and it ranged between 0.21 x 10(-2) atoms cm(-2) s(-1) and 28 x l0(-2) atoms cm(-2) s(-1). The average flux of 220Rn was estimated to be 23 atoms cm(-2) s(-1), using a combination of two techniques: nuclear track detection and alpha spectrometry of radon daughters. It was found that the production of radon by uranium (41.54 + /-7.17 Bq kg(-1)) and thorium (57.97 +/- 12.14 Bq kg(-1)) equivalent soil contents, and a diffusion coefficient derived from experimental data for the local terrain could account for this average flux. Nevertheless, the large surges of 222Rn in the atmosphere frequently observed for that area could not be explained by this flux only.

Radon dynamics and reduction in an underground mine in Brazil. Implications for workers' exposure

This work was aimed at studying the behaviour of 222Rn in an experimental underground copper mine in Brazil with a single entrance. The 222Rn concentrations, meaured by using a dynamic radon measuring technique. varied between 30.5 Bq.m(-3), during ventilated conditions applied to the mine galleries, and 19.4 x 10(3) Bq.(-3) for non-ventilated conditions and when operational mining activities were conducted inside. High radon concentration surges were observed after blasting and drilling activities. In the cases of inadequate ventilation, it was estimated that workers could be subjected to exposures as high as 10 microSv.h(-1), only due to 222Rn and its short-lived progeny. The results show the importance of real-time measurements to evaluate radon dynamics during mining operations.

[Nutrition for 0-1 year-old infants]

RESUMO Os autores fazem uma análise suscinta dos componentes alimentares e de suas funções principais no organismo humano. Mostram a seguir a importância da alimentação adequada no crescimento da criança, apontando os requisitos básicos e condições a serem considerados na boa alimentação: quantidade, horário e número de refeições, apresentação, dosagem, dieta equilibrada e condições ambientais. Enfatizam o valor do aleitamento materno. A higiene alimentar é tratada visando principalmene a criança no 1.° mês de vida, quando os erros alimentares podem prejudicar muito o processo de crescimento. Os problemas da alimentação do lactente são tratados especificamente incluindo sugestões e recomendações sobre a prática da amamentação.