Major clinical research advances in gynecologic cancer in 2023: a tumultuous year for endometrial cancer

In the 2023 series, we summarized the major clinical research advances in gynecologic oncology based on communications at the conference of Asian Society of Gynecologic Oncology Review Course. The review consisted of 1) Endometrial cancer: immune checkpoint inhibitor, antibody drug conjugates (ADCs), selective inhibitor of nuclear export, CDK4/6 inhibitors WEE1 inhibitor, poly (ADP-ribose) polymerase (PARP) inhibitors. 2) Cervical cancer: surgery in low-risk early-stage cervical cancer, therapy for locally advanced stage and advanced, metastatic, or recurrent setting; and 3) Ovarian cancer: immunotherapy, triplet therapies using immune checkpoint inhibitors along with antiangiogenic agents and PARP inhibitors, and ADCs. In 2023, the field of endometrial cancer treatment witnessed a landmark year, marked by several practice-changing outcomes with immune checkpoint inhibitors and the reliable efficacy of PARP inhibitors and ADCs.

Clinical implications of histologic subtypes on survival outcomes in primary mucinous ovarian carcinoma

OBJECTIVE

In 2014, the World Health Organization introduced a new histologic classification by dividing primary mucinous ovarian carcinoma (PMOC) into two: expansile (ES) or infiltrative subtypes (IS). This study investigated the clinical implications of these histological subtypes on survival outcomes.

METHODS

Data from 131 patients with PMOC who underwent primary surgery between 2003 and 2021 were analyzed. The patients baseline characteristics, surgical and pathological information were collected. Survival outcomes were calculated, while factors affecting them were also investigated.

RESULTS

During 55.9 months of median follow-up, 27 (20.6%) patients experienced recurrence and 20 (15.3%) died. Among 131 patients, 113 patients were classified into 87 (77%) ES and 26 (23%) IS after a slide review. Advanced stage, lymph node involvement, and residual tumors after surgery were more common in the IS, showing poorer prognosis. In multivariate analyses, advanced stage and residual tumors after surgery were associated with worse survival, while the IS showed no statistical significance. In subgroup analysis for stage I disease, survival did not vary between subtypes. Nevertheless, patients in the IS group who underwent fertility-sparing surgeries demonstrated a 5-year progression-free survival (PFS) rate of 83.3%, significantly lower than patients without fertility preservation, irrespective of histologic subtypes (5-year PFS rate: 97.9%; P = 0.002 for the ES, 5-year PFS rate: 100%; P = 0.001 for the IS).

CONCLUSIONS

The IS of PMOC had poorer survival outcomes and a higher proportion of advanced-stage tumors. Although its independent prognostic significance remains uncertain, adjuvant chemotherapy should be considered for patients with fertility preservation in the IS group.

Tissue Expression and Prognostic Role of CXCL12 and CXCR4 in High-grade Serous Ovarian Carcinoma

BACKGROUND/AIM

The complex of C-X-C motif chemokine receptor 4 (CXCR4) and its ligand, C-X-C motif chemokine ligand 12 (CXCL12), plays an essential role in cancer cell proliferation, invasion, and metastasis. These are emerging therapeutic targets, and recent studies have reported that inhibition of CXCL12-CXCR4 signaling pathway enhances the effects of immune checkpoint inhibitors. Thus, we aimed to investigate tissue expression of CXCL12 and CXCR4 in high-grade serous ovarian carcinoma (HGSOC) and to determine their potential as prognostic markers.

PATIENTS AND METHODS

We used chemotherapy-naïve, formalin-fixed paraffin-embedded primary ovarian cancer tissues obtained from patients with advanced-stage HGSOC at the time of primary cytoreductive surgery. After histological reassessment, we constructed a tissue microarray and performed immunohistochemical staining for CXCL12 and CXCR4. Thereafter, clinicopathological characteristics and survival outcomes were compared between the high- and low-expression groups.

RESULTS

A total of 97 patients with FIGO stage IIIC-IV HGSOC were included: 15 (15.5%), 66 (68.0%), and 13 (13.4%) patients showed high expression of CXCL12, CXCR4, and both, respectively. The expression level of each protein was not associated with germline BRCA1/2 mutational status, FIGO stage, or residual tumor after primary cytoreductive surgery. In multivariate analysis adjusted for confounders, high CXCL12 expression was identified as an independent poor prognostic biomarker for progression-free survival (adjusted hazards ratio, 1.990; 95% confidence interval=1.090-3.633; p=0.025). However, CXCR4 expression was not associated with patient survival outcomes.

CONCLUSION

The CXCL12 expression level may represent a prognostic biomarker for HGSOC. Proteins related to the CXCL12/CXCR4 complex may serve as therapeutic targets in HGSOC treatment.

Corrigendum: Introducing a healthcare-assistive robot in primary care: a preliminary questionnaire survey

[This corrects the article DOI: 10.3389/frobt.2023.1123153.].

Introducing a healthcare-assistive robot in primary care: a preliminary questionnaire survey

A Healthcare-assistive Infection-control RObot (HIRO) is a healthcare-assistive robot that is deployed in an outpatient primary care clinic to sanitise the premises, monitor people in its proximity for their temperature and donning of masks, and usher them to service points. This study aimed to determine the acceptability, perceptions of safety, and concerns among the patients, visitors, and polyclinic healthcare workers (HCWs) regarding the HIRO. A cross-sectional questionnaire survey was conducted from March to April 2022 when the HIRO was at Tampines Polyclinic in eastern Singapore. A total of 170 multidisciplinary HCWs serve approximately 1,000 patients and visitors daily at this polyclinic. The sample size of 385 was computed using a proportion of 0.5, 5% precision, and 95% confidence interval. Research assistants administered an e-survey to gather demographic data and feedback from 300 patients/visitors and 85 HCWs on their perceptions of the HIRO using Likert scales. The participants watched a video on the HIRO's functionalities and were given the opportunity to directly interact with it. Descriptive statistics was performed and figures were presented in frequencies and percentages. The majority of the participants viewed the HIRO's functionalities favourably: sanitising (96.7%/91.2%); checking proper mask donning (97%/89.4%); temperature monitoring (97%/91.7%); ushering (91.7%/81.1%); perceived user friendliness (93%/88.3%), and improvement in the clinic experience (96%/94.2%). A minority of the participants perceived harm from the HIRO's liquid disinfectant (29.6%/31.5%) and that its voice-annotated instructions may be upsetting (14%/24.8%). Most of the participants accepted the HIRO's deployment at the polyclinic and perceived it to be safe. The HIRO used ultraviolet irradiation for sanitisation during after-clinic hours instead of disinfectants due to the perceived harm.

Reversible sulfur dioxide capture by amino acids containing a single amino group at low sulfur dioxide concentrations

SO₂, an air pollutant, is harmful to human health and causes air pollution; therefore, numerous studies have focused on the development of SO₂ control technologies. Although limestone- and ammonia-based absorbents have been widely used in wet desulfurization, they are difficult to regenerate and do not enable the recycling of SO₂, which is a useful resource. Recently, amino acids have attracted attention as reversible SO₂ absorbents because they are eco-friendly and have excellent reactivity with SO₂, as well as high regeneration performance. Glycine, L-alanine, β-alanine, 4-aminobutyric acid, 5-aminovaleric acid, and 6-aminohexanoic acid were analyzed to investigate the relationship between SO₂ absorption and the amino acid molecular structure using the simulated actual flue gas (200 ppmv SO₂ + 13% CO₂ in N₂ balance). The SO₂ absorption of amino acids (with the molecular structure of glycine and alkyl chains of various lengths) improved as the alkyl chain length increased, possibly owing to a decrease in the inductive effect in the molecular structure of the amino acid. Furthermore, ¹³C-nuclear magnetic resonance spectroscopy was conducted to analyze the SO₂ absorption reaction mechanism (including the possible generation of irreversible species), and experiments involving a number of consecutive absorption-desorption cycles were used to confirm the reusability of the amino acids. The tested amino acids exhibited higher cyclic capacities compared to those of deep eutectic solvents and ionic liquids reported in the literature, thereby exhibiting excellent potential as SO₂ absorbents. Thus, this study can guide the future design and development of eco-friendly SO₂ absorbents.

Consumer Experience of Mistreatment and Fraud in Financial Services: Implications from an Integrative Consumer Vulnerability Framework

This study utilizes the National Financial Well-Being Survey (NFWS) from the Consumer Financial Protection Bureau (CFPB) to investigate the profiles of American consumers who experience mistreatment or a type of fraud in financial services (compromised accounts). An integrative consumer vulnerability framework was used as the theoretical framework to examine how disadvantaged consumer characteristics and vulnerable consumer characteristics are associated with mistreatment and compromised accounts. Consumers in vulnerable states, due to low financial capability, cognitive decline, material hardships, financial shocks, and more exposure to various financial services, were more likely to report experiencing mistreatment and having their financial accounts compromised. Consumers from higher socio-economic status were more likely to have been victims of mistreatment and compromised accounts in financial services. These findings offer implications for consumer financial education and protection.

Effect of BRCA1/2 Mutational Status on Survival Outcomes According to Secondary Cytoreductive Surgery and Maintenance Therapy in Platinum-Sensitive Relapsed Ovarian Cancer: A Real-World Evidence Study

PURPOSE

This study aimed to investigate the impact of BRCA1/2 mutational status on survival outcomes in patients with platinum-sensitive relapsed (PSR) epithelial ovarian cancer (EOC).

MATERIALS AND METHODS

We retrospectively identified patients who received secondary treatment for PSR EOC at our institution between January 2007 and June 2021 and who underwent BRCA1/2 gene testing by either germline or somatic methods. The association between BRCA1/2 mutational status and survival outcomes was evaluated. Both secondary cytoreductive surgery (CRS) and maintenance therapy were stratified considering real-world clinical practice.

RESULTS

Of 262 patients, 91 (34.7%) and 171 (65.3%) were assigned to BRCA1/2 mutation and wild-type groups, respectively. The two groups had similar proportions of patients undergoing secondary CRS (26.4% vs. 32.7%, p=0.286) and maintenance therapy (54.9% vs. 46.2%, p=0.178). Overall, no differences in progression-free survival (PFS; median, 19.7 vs. 15.1 months, p=0.120) and overall survival (OS; p=0.400) were observed between the two groups. In multivariate analyses, BRCA1/2 mutational status was not associated with PFS (adjusted hazard ratio, 0.816; 95% confidence interval, 0.596 to 1.119; p=0.207). BRCA1/2 mutational status did not affect PFS among patients who underwent secondary CRS (n=80) and among those who did not (n=182) (p=0.074 and p=0.222, respectively). PFS did not differ in the BRCA1/2 mutational status among the patients who received bevacizumab maintenance (n=90, p=0.992).

CONCLUSION

In this real-world evidence study, BRCA1/2 mutational status itself was not associated with PFS and OS in PSR EOC, which was consistent with whether secondary CRS or not and with bevacizumab maintenance.

Ventricular arrhythmias and sudden cardiac death caused by mitral valve prolapse: should we operate and when?

Background

Several autopsy and observational studies have investigated the link between mitral valve prolapse (MVP) and sudden cardiac death (SCD) due to the well accepted yet rare occurrence of complex ventricular arrhythmia (VA) in this cohort. Few studies however have investigated whether arrhythmia burden and more importantly SCD are reduced following surgical correction of MVP.

Purpose

To investigate the impact of mitral valve surgery (MVS) (replacement or repair) on VA and SCD in patients with MVP.

Methods

A systematic review of the current literature was conducted using an electronic search of the PubMed database in October 2021. Studies were included if subjects had undergone mitral valve (MV) repair or replacement with documented rates of arrythmias/SCD pre- and post-intervention. Small patient numbers in individual reports precluded formal meta-analysis and results were reported on a per study basis.

Results

19 identified studies (10 cohort studies, nine case studies) comprised 1322 patients with a pooled mean age of 63.4 years and 38.9% were female. 748 of the 1322 patients underwent MVS: 263 MV repair, 18 MV replacement (one with leaflet and papillary muscle excision), two MV repair with Maze procedure, 177 percutaneous transcatheter MV repair, 45 annuloplasty with or without valve repair, and in 243 cases the surgical method was not specified.

Of the 10 included cohort studies, seven of the eight which investigated rates of VA post MVS concluded there was a significant reduction, while one reported the predisposition to arrythmia persisted after relieving the abnormal mechanical effects of non-ischaemic MR (75% due to MVP). One study reported a reduction in SCD post MVS. Each of the nine included case studies showed a reduction in VA post MVS. One study showed mitral annular disjunction (MAD) was independently associated with a higher risk of arrhythmic events, this link persisting with time dependent MVS although reduced compared to medical management.

Conclusions

The underlying mechanisms for VA and SCD associated with MVP are not completely understood, and guidelines for the surgical correction of MVP based on arrhythmic and SCD risk are lacking. This systematic review illustrates a possible reduction in VA following MVS. Further identification of patients at risk of SCD, and potential use of risk stratification algorithms, would allow for consideration of earlier management and appropriate use of implantable cardioverter-defibrillators (ICD) placement / MVS with an expected survival benefit.

Funding Acknowledgement

Type of funding sources: None.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

INTRODUCTION

Even though the injection of diluted vasopressin into the uterus is expected to reduce intraoperative bleeding with decreased adverse effects during robot-assisted laparoscopic myomectomy (RALM), there is a lack of relevant trials to show its effect and safety. Thus, this study was designed to compare the effect and safety of vasopressin injection on bleedings based on dilution levels of vasopressin with constant volumes during RALM.

METHODS AND ANALYSIS

This is a randomised controlled pilot trial, where a total of 39 patients will be randomly divided into three experimental groups in a 1:1:1 ratio. All patients will be classified into the three groups based on the dilution level of vasopressin: group 1-a solution prepared by mixing 20 units of vasopressin with 100 mL of normal saline to make a total of 100 mL; group 2-a solution prepared by mixing 20 units of vasopressin with 200 mL of normal saline to make a total of 100 mL and group 3-a solution prepared by mixing 20 units of vasopressin with 400 mL of normal saline to make a total of 100 mL. During RALM, we will inject diluted vasopressin at different concentrations with a total of 100 mL. As the primary endpoint, estimated blood loss would be compared. As secondary endpoints, we will check the level of haemoglobin and haematocrit, operation time, amount of transfusion, and the period of hospitalisation. In addition, we will check other complications related to vasopressin injection.

ETHICS AND DISSEMINATION

This pilot study has been approved by the Institutional Review Board of the Seoul National University Hospital (No. H-2011-107-1174). All potential subjects will be provided written informed consent. The results of this study will be published in peer-reviewed journals and be presented at academic conferences.

TRIAL REGISTRATION NUMBERS

NCT04874246 and CKCT0006225.

Establishment of a piglet model for peritoneal metastasis of ovarian cancer

Background

A piglet model for peritoneal metastasis (PM) of ovarian cancer was developed. It will contribute to establishing innovative chemotherapeutical and surgical strategies without any limitation on rodent models.

Methods

A total of 12 four- to five-week-old piglets of 7 to 8 kg were used. Two phases of ovarian cancer cell injections were performed with laparoscopic surgery.

In phase I trial, 5.0 × 10⁶ SK-OV-3 cells in 0.1 ml suspension were inoculated into the omentum, peritoneum, and uterine horns of two piglets twice with a one-week interval. In the phase II trial, 5.0 × 10⁶ SNU-008 cells in 0.1 ml suspension were injected only into uterine horns within the same time frame because tumor implantation after inoculation of SK-OV-3 cells was not observed at the omentum or peritoneum in the phase I trial. Modified peritoneal cancer index (PCI) score was used to monitor tumorigenesis up to 4 weeks after inoculation. Tumor tissues disseminated in the peritoneum 4 weeks after injection were used for histological examination with hematoxylin and eosin (H&E) and paired-box gene 8 (PAX-8) staining.

Results

In the phase I trial, two piglets showed PM with modified PCI scores of 5 and 4 at 3 weeks after the first inoculation, which increased to 14 and 15 after 4 weeks, respectively. In the phase II trial, PM was detected in eight of ten piglets, which showed modified PCI scores of 6 to 12 at 4 weeks after the first inoculation. The overall incidence of PM from the total of 12 piglets after inoculation was 75%. Immunohistochemical H&E and PAX-8 staining confirmed metastatic tumors.

Conclusions

This study provides strong evidence that piglets can be employed as a model for PM by inoculating ovarian cancer cell lines from humans. Using two cell lines, the PM rate is 75%.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03533-1.

Clinical implications of neoadjuvant chemotherapy in advanced endometrial cancer: a multi-center retrospective cohort study

Background

The mainstay of endometrial cancer treatment is surgical resection of tumors and postoperative adjuvant treatment is recommended if necessary. However, there is no consensus on the management of unresectable metastatic endometrial cancer. This study aimed to assess the feasibility and effectiveness of neoadjuvant chemotherapy followed by interval debulking surgery (NAC-IDS) in unresectable, metastatic endometrial cancer.

Methods

From the endometrial cancer cohorts of four institutions in Korea, we identified patients with International Federation of Gynecology and Obstetrics stages IIIC–IVB endometrial cancer who received NAC-IDS between January 2008 and December 2020. Through a medical record review, we collected patients’ clinicopathological data. Progression-free survival (PFS), overall survival (OS), and the factors affecting survival outcomes were analyzed.

Results

Overall, 32 patients were included with endometrioid (n = 18), serous (n = 5), carcinosarcoma (n = 6), and other histological types (n = 3). Among them, 28 (87.5%) patients had stage IVB disease. The most common neoadjuvant chemotherapy (NAC) regimen was paclitaxel-carboplatin (n = 25, 78.1%), which was administered for a median of six cycles. While 26 (81.3%) patients showed an objective response, two (6.3%) progressed despite NAC. At the time of interval debulking surgery (IDS), 23 (71.9%) patients achieved complete cytoreduction. During 31.0 months of the median follow-up, there were 23 recurrences and 11 deaths, corresponding to a median PFS of 19.7 months and a 3-year OS rate of 69.7%. In multivariate analyses, non-endometrioid histology and residual tumor after IDS were identified as independent poor prognostic factors for PFS (adjusted hazard ratio [HR], 7.322; P < 0.001 and 5.934; P = 0.001, respectively). Multivariate analysis for OS could not be conducted because of the small number of events, although non-endometrioid histology was the only factor associated with worse OS in univariate analysis (adjusted HR, 4.523; P = 0.032).

Conclusions

NAC-IDS may be a treatment option for unresectable metastatic endometrial cancer. Tumor histology and the possibility of complete cytoreduction are the primary considerations for NAC-IDS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09746-3.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

Impact of no residual disease on postoperative computed tomography on survival in patients with optimally debulked advanced high-grade serous ovarian cancer during upfront surgery

OBJECTIVE

We sought to investigate the impact of size of residual tumors as determined by postoperative computed tomography (CT) on survival of patients with advanced, high-grade serous ovarian carcinoma (HGSC) who achieved residual disease less than 1 cm after primary debulking surgery (PDS).

METHODS

We collected data of patients with stage III HGSC who had residual tumor less than 1 cm after PDS between 2013 and 2018. Surgeon-assessed residual disease during surgery was defined as sR0 (no gross residual) or sR1 (gross residual <1 cm), and radiologist-assessed residual disease on postoperative CT was defined as rR0 (no evidence of disease) or rRany (existing residual disease). All patients were classified into the following groups: sR0/rR0, sR1/rR0, sR0/rRany, and sR1/rRany.

RESULTS

A total of 436 patients was placed into the sR0/rR0 (n = 187, 42.9%), sR1/rR0 (n = 59, 13.5%), sR0/rRany (n = 79, 18.1%), or sR1/rRany group (n = 111, 25.5%). Discrepancies between surgical and radiological assessments were recorded for 176 patients (40.4%) including 38 cases of sR1/rRany group with discordant residual tumor location indicated between two methods. During multivariate analysis, patients with ascites on preoperative CT, sR0/rRany group inclusion, and sR1/rRany group inclusion showed unfavorable progression-free and overall survival.

CONCLUSIONS

The incorporation of surgical and radiological evaluations for determining the size of residual tumors was more accurate than surgical evaluation only for predicting survival among patients with advanced ovarian cancer who underwent PDS to residual disease less than 1 cm.

Uptake Rate of Risk-Reducing Salpingo-Oophorectomy and Surgical Outcomes of Female Germline BRCA1/2 Mutation Carriers: A Retrospective Cohort Study

PURPOSE

This study investigated the uptake rate of risk-reducing salpingo-oophorectomy (RRSO) and surgical outcomes of germline BRCA1/2 mutation carriers at Seoul National University Hospital (SNUH).

MATERIALS AND METHODS

We examined the records of 824 women who underwent germline BRCA1/2 gene testing at SNUH between 2005 and 2020. Among them, we identified women with a pathogenic mutation on either the BRCA1 or the BRCA2 gene, and excluded ovarian cancer patients. Characteristics of participants who underwent RRSO (RRSO group) were compared to those who did not (non-RRSO group). Surgical outcomes and pathologic results were investigated in the RRSO group.

RESULTS

There were 117 BRCA1/2 mutation carriers included in the analysis. The uptake rate of RRSO was 70.1% (82/117). Older age (mean: 48.8 years vs. 42.1 years; p=0.002) and higher employment rate (65.9% vs. 14.3%; p<0.001) were observed in the RRSO group compared to the non-RRSO group. However, no differences in other factors, such as personal and family history of breast cancer, were observed between the two groups. In the RRSO group, the median time interval between the genetic test and RRSO was 10.0 months, and there were three (3.7%) incidental cases of high-grade serous carcinoma. However, one patient in the non-RRSO group developed primary peritoneal cancer after 103.8 months of surveillance.

CONCLUSION

The uptake rate of RRSO in BRCA1/2 mutation carriers was about 70%. Considering incidental cancer cases in women without abnormal findings on preoperative evaluation, BRCA1/2-mutated women might refrain from the delayed implementation of RRSO after the genetic test.

SERPINB11 Expression Is Associated With Prognosis of High-grade Serous and Clear Cell Carcinoma of the Ovary

BACKGROUND/AIM

To evaluate the role of serine protease inhibitor B11 (SERPINB11) expression as a prognostic biomarker in high-grade serous carcinoma (HGSC) and clear cell carcinoma of the ovary (CCC).

MATERIALS AND METHODS

We obtained tumor tissues from patients with HGSC (n=145) and CCC (n=59). We evaluated immunohistochemically the expression of SERPINB11 and investigated whether SERPINB11 expression affects platinum-resistance and the prognosis of HGSC and CCC.

RESULTS

High expression of SERPINB11 was more common in CCC than in HGSC (57.6% vs. 28.3%; p<0.01), and SEPRINB11 expression did not correlate with platinum-resistance of HGSC and CCC. High expression of SERPINB11 was associated with worse progression-free survival and overall survival with marginal significance in HGSC; no relation between SERPINB11 expression and the prognosis of CCC was found.

CONCLUSION

SERPINB11 expression maybe a prognostic biomarker for HGSC.

Preservation of the ovarian reserve and hemostasis during laparoscopic ovarian cystectomy by a hemostatic agent versus suturing for patients with ovarian endometriosis: study protocol for randomized controlled, non-inferiority trial (PRAHA-2 trial)

Background

Endometriosis (EMS) can be implanted everywhere, especially in pelvic organs. EMS can be asymptomatic, but it can result in pelvic pain and infertility by inducing local inflammation and pelvic adhesion. The prevalence of EMS is about 10% in reproductive-age women and higher in women with pelvic pain or infertility. For young patients with ovarian EMS, laparoscopic ovarian cystectomy is effective in relieving pelvic pain and preventing local recurrence. However, there is a concern that the ovarian reserve would decrease after the operation because of the removal of a part of the normal ovarian tissue and thermal damage during hemostasis, which depends on the types of hemostasis such as bipolar electrocoagulation, suturing, and the use of a hemostatic agent. In this study, we aim to evaluate the protective effect for the ovarian reserve and hemostasis between a hemostatic agent and suturing during laparoscopic ovarian cystectomy for patients with ovarian EMS.

Methods

This study is a randomized controlled, non-inferiority trial, where a total of 90 patients with ovarian EMS will be randomly assigned to the experimental (hemostatic agent) and control (suturing) groups. In the control group, a barbed suture will be applied for hemostasis, whereas a hemostatic agent will be applied in the experimental group. If two methods are insufficient, bipolar electrocoagulation will be applied for complete hemostasis. As the primary endpoint, the reduction rate of serum anti- Müllerian hormone (AMH) levels reflecting the ovarian reserve will be compared between the two groups 12 weeks after surgery. As secondary endpoints, we will compare the reduction rate of AMH level 48 weeks after surgery, the time required to complete hemostasis, the success rate of hemostasis within 10 min, and adverse events associated with operation.

Discussion

We expect that the protective effect for the ovarian reserve and hemostasis may be comparable between the two methods, suggesting that a hemostatic agent may be preferred considering that it is easy to use during laparoscopic ovarian cystectomy.

Trial registration

ClinicalTrials.govNCT04643106. Registered on 22 November 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05431-1.

Development of rotational intraperitoneal pressurized aerosol chemotherapy to enhance drug delivery into the peritoneum

This study aims to evaluate the drug distribution, tissue concentrations, penetration depth, pharmacokinetic properties, and toxicities after rotational intraperitoneal pressurized aerosol chemotherapy (RIPAC) in pigs. Because relevant medical devices have not been introduced, we developed our prototype of pressurized intraperitoneal aerosol chemotherapy (PIPAC) and RIPAC by adding a conical pendulum motion device for rotating the nozzle. RIPAC and PIPAC were conducted using 150 ml of 1% methylene blue to evaluate the drug distribution and 3.5 mg of doxorubicin in 50 ml of 0.9% NaCl to evaluate the tissue concentrations and penetration depth, pharmacokinetic properties, and toxicities. All agents were sprayed as aerosols via the nozzle, DreamPen^® (Dalim Biotech, Gangwon, South Korea), with a velocity of 5 km/h at a flow rate of 30 ml/min under a pressure of 7 bars, and capnoperitoneum of 12 mmHg was maintained for 30 min. As a result, RIPAC showed a wider distribution and stronger intensity than PIPAC. Compared with PIPAC, RIPAC demonstrated high values of the tissue concentration in the central, right upper, epigastrium, left upper, left lower, right lower, and right flank regions (median, 375.5-2124.9 vs. 161.7-1240 ng/ml; p ≤ .05), and higher values of the depth of concentrated diffusion and depth of maximal diffusion (median, 232.5-392.7 vs. 116.9-240.1 μm; 291.2-551.2 vs. 250.5-362.4 μm; p ≤ .05) in all regions except for bowels. In RIPAC, the pharmacokinetic properties reflected hemodynamic changes during capnoperitoneum, and there were no related toxicities. Conclusively, RIPAC may have the potential to enhance drug delivery into the peritoneum compared to PIPAC.

Sudden cardiac death related to physical exercise and sports in the young: a nationwide cohort study of Australia

Funding Acknowledgements

Type of funding sources: None.

Background

Sudden cardiac death (SCD) during physical exercise is uncommon but devastating.

Purpose

We aimed to determine risk factors, causes and circumstances of sports and exercise-related SCD in the young in Australia.

Methods

We retrospectively reviewed the National Coronial Information System (NCIS) registry for deaths in Australia relating to cardiovascular disease (CVD) in cases aged 10 to 35 years between 2000-2016. Included cases had been undertaking sports or physical exercise at time of event. We collected baseline demographics and circumstances of death including location, type of physical exercise, whether the event was witnessed, and engagement of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use prior to ambulance arrival.

Results

Over a 17-year period, 1,925 SCD cases were identified of which 110 cases (6%) related to sports/physical exercise were included in final analysis. Median age was 27 years (interquartile range [IQR] 21-32 years) with most being male (92%). Median BMI was 27 kg/m2 (IQR, 23-30) with 13 cases (12%) occurring in active athletes. Most common causes were coronary artery disease (CAD; 37%) and sudden arrhythmic death syndrome (SADS; 20%). Australian Rules Football (24%), running/jogging (14%) and soccer (14%) were the most frequently practiced at time of event. Prior symptoms were present in 39% (chest pain 37%, presyncope/syncope 26%). Most were witnessed (87%) with bystander CPR in 70%. AED use prior to ambulance arrival was 8%.

Conclusions

This study demonstrates the high occurrence of CAD and SADS in exercise-related SCD in the young. Although events were commonly witnessed, an AED was seldom used prior to ambulance arrival highlighting an important opportunity to improve outcomes in the post-arrest chain of survival.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

P5350Atrial fibrillation prediction using P wave signal-averaged ECG in patients with embolic stroke of undetermined source

Background

Approximately 10–25% of ischemic strokes are of unknown origin. Determining their potential association with subclinical atrial fibrillation (SCAF) is important for proper secondary prevention. We investigated whether SCAF can be predicted by assessing the atrial substrate with signal-averaged electrocardiography (SAECG).

Methods

Between April 2015 and February 2018, we recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation (AF) patients as control. All participants underwent P wave SAECG at baseline and ESUS patients were followed up with ECG and Holter ECG, at baseline, 3, 6, and 12 months after discharge, and every 12 months thereafter.

Results

In the ESUS group (69 males, 68.4±12.1 years), 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between both groups in terms of P wave duration [PWD] (ESUS vs. AF, P=0.321). PWD demonstrated a significant predictive efficacy for SCAF detection during follow-up (C-index of standard PWD=0.657, 95% confidence interval (CI) 0.552–0.761, P=0.008).

Stroke recurrence occurred in 22 patients (17.6%) and was significantly associated with PWD but not SCAF (odds ratio 2.756, 95% CI 1.061–7.161, P=0.037).

Conclusion

PWD, an ECG biomarker associated with atrial substrate directly contributes to AF and ESUS, is useful for predicting SCAF. The potential for using this simple ECG biomarker for screening for SCAF amongst ESUS patients merits further exploration.

P3466Cardiac output in end-stage liver disease increases with the severity of liver dysfunction

Background

End-stage liver disease is associated with significant systemic and haemodynamic alterations that affect cardiac function. Cirrhotic cardiomyopathy remains an ill-defined entity among cardiologists. Understanding the complex interplay between liver dysfunction and cardiac function can lead to a better understanding of the compensatory mechanisms of the heart in liver failure.

Purpose

To investigate whether severity of liver disease affects baseline cardiac output in a large contemporary cohort of patients undergoing liver transplant work-up.

Methods

Consecutive patients that underwent pre-liver transplant (LT) workup between 2010–2017 were included. All patients underwent a resting echocardiogram. Cardiac output (CO) was prospectively recorded at baseline by pulsed-wave Doppler examination of the left ventricular outflow tract from the apical window and systemic vascular resistance (SVR) was calculated as 80 x (mean arterial pressure (MAP)/CO). Severity of liver disease was characterized by the model of end-stage liver disease (MELD) and Child-Pugh scores.

Results

560 patients were included (mean age 57.5±7.7, 74.8% male). Mean MELD score was 19±7 and Child-Pugh Score was 9±3. There was an inverse linear relationship between the severity of liver disease by the MELD score and baseline SVR (rho 0.40, P<0.001). As SVR reduced, there was also a significant rise in baseline CO with a strong inverse correlation between the two variables (rho 0.86, p<0.001). There was a significant linear correlation between the severity of liver disease and baseline CO with both the scores (MELD Score rho 0.42, p<0.001; Child Pugh rho 0.44, p<0.001) (Figure).

Baseline CO in LT Patients by Severity

Conclusions

Baseline CO increased with the severity of liver dysfunction due to a reduced afterload. A higher resting CO may lead to patients encroaching on their cardiac reserve at rest. This provides a pathophysiological insight suggesting a limited role for beta-blockers, particularly in patients with advanced liver cirrhosis.