[Fertility-preserving treatment outcomes in endometrial cancer and atypical hyperplasia patients with different molecular profiles]

Objective: To investigate the impact of molecular classification and key oncogenes on the oncologic outcomes in patients with endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) receiving fertility-preserving treatment. Methods: Patients with EC and AEH undergoing progestin-based fertility-preserving treatment and receiving molecular classification as well as key oncogenes test at Obstetrics and Gynecology Hospital, Fudan University from January 2021 to March 2023 were reviewed. Hysteroscopic lesion resection and endometrial biopsy were performed before initiating hormone therapy and every 3 months during the treatment to evaluate the efficacy. The risk factors which had impact on the treatment outcomes in EC and AEH patients were further analyzed. Results: Of the 171 patients analyzed, the median age was 32 years, including 86 patients with EC and 85 patients with AEH. The distribution of molecular classification was as follows: 157 cases (91.8%) were classified as having no specific molecular profile (NSMP); 9 cases (5.3%), mismatch repair deficient (MMR-d); 3 cases (1.8%), POLE-mutated; 2 cases (1.2%), p53 abnormal. No difference was found in the cumulative 40-week complete response (CR) rate between the patients having NSMP or MMR-d (61.6% vs 60.0%; P=0.593), while the patients having MMR-d had increased risk than those having NSMP to have recurrence after CR (50.0% vs 14.4%; P=0.005). Multi-variant analysis showed PTEN gene multi-loci mutation (HR=0.413, 95%CI: 0.259-0.658; P<0.001) and PIK3CA gene mutation (HR=0.499, 95%CI: 0.310-0.804; P=0.004) were associated with a lower cumulative 40-week CR rate, and progestin-insensitivity (HR=3.825, 95%CI: 1.570-9.317; P=0.003) and MMR-d (HR=9.014, 95%CI: 1.734-46.873; P=0.009) were independent risk factors of recurrence in EC and AEH patients. Conclusions: No difference in cumulative 40-week CR rate is found in the patients having NSMP or MMR-d who received progestin-based fertility-preserving treatment, where the use of hysteroscopy during the treatment might be the reason, while those having MMR-d have a higher risk of recurrence after CR. Oncogene mutation of PTEN or PIK3CA gene might be associated with a lower response to progestin treatment. The molecular profiles help predict the fertility-preserving treatment outcomes in EC and AEH patients.

[Comparison of the effects and safety of dydrogesterone and medroxyprogesterone acetate on endometrial hyperplasia without atypia: a randomized controlled non-inferior phase Ⅲ clinical study]

Objective: To compare the effects and safety of dydrogesterone (DG) and medroxyprogesterone acetate (MPA) on the treatment in patients with endometrial hyperplasia without atypia (EH). Methods: This was a single-center, open-label, prospective non-inferior randomized controlled phase Ⅲ trial. From February 2019 to November 2021, patients with EH admitted to the Obstetrics and Gynecology Hospital of Fudan University were recruited. Enrolled patients were stratified according to the pathological types of simple hyperplasia (SH) or complex hyperplasia (CH), and were randomised to receive MPA or DG. Untill May 14, 2022, the median follow-up time after complete response (CR) was 9.3 months (1.1-17.2 months). The primary endpoint was the 6-month CR rate (6m-CR rate). The secondary endpoints included the 3-month CR rate (3m-CR rate), adverse events rate, recurrence rate, and pregnancy rate in one year after CR. Results: (1) A total of 292 patients with EH were enrolled in the study with the median age of 39 years (31-45 years). A total of 135 SH patients were randomly assigned to MPA group (n=67) and DG group (n=68), and 157 CH patients were randomly assigned to MPA group (n=79) and DG group (n=78). (2) Among 292 patients, 205 patients enrolled into the primary endpoint analysis, including 92 SH patients and 113 CH patients, with 100 patients in MPA group and 105 in DG group, respectively. The 6m-CR rate of MPA group and DG group were 90.0% (90/100) and 88.6% (93/105) respectively, and there were no statistical significance (χ²=0.11, P=0.741), with the rate difference (RD) was -1.4% (95%CI:-9.9%-7.0%). Stratified by the pathology types, the 6m-CR rate of SH patients was 93.5% (86/92), and MPA group and DG group were respectively 91.1% (41/45) and 95.7% (45/47); and the 6m-CR rate of CH patients was 85.8% (97/113), and MPA group and DG group were 89.1% (49/55) and 82.8% (48/58) respectively. The 6m-CR rates of the two treatments had no statistical significance either (all P>0.05). A total of 194 EH patients enrolled into the secondary endpoint analysis, including 88 SH patients and 106 CH patients, and 96 patients in MPA group and 98 in DG group, respectively. The 3m-CR rate of SH patients were 87.5% (77/88), while the 3m-CR rates of MPA group and DG group were 90.7% (39/43) and 84.4% (38/45), respectively; the 3m-CR rate of CH patients was 66.0% (70/106), and MPA group and DG group had the same 3m-CR rate of 66.0% (35/53). No statistical significance was found between the two treatments both in SH and CH patients (all P>0.05). (3) The incidence of adverse events between MPA group and DG group had no statistical significance (P>0.05). (4) A total of 93 SH patients achieved CR, and the cumulative recurrence rate in one year after CR were 5.9% and 0 in MPA group and DG group, respectively. While 112 CH patients achieved CR, and the cumulative recurrence rate in one year after CR were 8.8% and 6.5% in MPA group and DG group, respectively. There were no statistical significance between two treatment groups (all P>0.05). Among the 93 SH patients, 10 patients had family planning but no pregnancy happened during the follow-up period. Among the 112 CH patients, 21 were actively preparing for pregnancy, and the pregnancy rate and live-birth rate in one year after CR in MPA group were 7/9 and 2/7, while in DG group were respectively 4/12 and 2/4, and there were no statistical significance in pregnancy rate and live-birth rate between the two treatment groups (all P>0.05). Conclusions: Compared with MPA, DG is of good efficacy and safety in treating EH. DG is a favorable alternative treatment for EH patients.

Abstract POSTER-TECH-1107: Primary platinum sensitivity in ovarian cancer and serum antibodies recognizing hypoxia-inducible factor 1-alpha and p53

Objective: Overexpression of hypoxia inducible factor 1-alpha (HIF-1α), a protein associated with apoptosis resistance, angiogenesis and metastasis, correlates with aberrant p53 protein accumulation in ovarian cancer. Humoral immunity to tumor-associated antigens in ovarian cancer has been associated with prognosis. We hypothesize that serum IgG antibodies recognizing HIF-1α and p53 in ovarian cancer patients could predict primary platinum response in ovarian cancer.

Methods: Serum samples collected from ovarian cancer patients (n = 171) at the time of their initial surgery were analyzed by enzyme-linked immunosorbent assay for IgG antibodies to human recombinant HIF-1α and p53 proteins. The positive cut-off for each IgG antibody was derived at a serum level yielding highest hazard ratio of overall survival. Age, stage, grade, histology, neo-adjuvant therapy, surgical outcome, primary platinum response, and overall survival (OS) were correlated with serum IgG antibody levels.

Results: Ovarian cancer patients were mostly stage III/IV (94%) with serous histology (85%), and the majority were optimally debulked (74%). Primary platinum sensitive patients (n = 116) had significantly higher IgG antibody levels than primary platinum resistant patients (n = 55) (median 0.83 µg/mL vs. 0.0 µg/mL, p = 0.001 for HIF-1α and median 6.37 µg/mL vs. 2.69 µg/mL, p =0.001 for p53). Humoral immune competence among cancer patients was not significantly different between primary platinum sensitive and resistant groups. Multivariate analysis of overall survival associated age and advanced stage with adverse survival, while elevated levels of serum HIF-1α IgG(≥ 0.32 µg/mL, HR = 0.57, p = 0.012) and p53 IgG (≥ 2.8 µg/mL, HR = 0.58, p = 0.024) were favorable prognostic factors. Multivariate logistic regression revealed HIF-1α and p53 -specific IgG antibody levels to be independent predictors of primary platinum sensitivity (OR=3.28, 95% CI 1.55 – 6.94, p = 0.002 for HIF-1α and OR = 4.61, 95% CI 2.11 – 10.1, p &lt; 0.001 for p53). A model predicting sensitivity to adjuvant platinum-based treatment that includes only 2 factors, HIF-1α and p53 IgG antibody levels, yields an AUC = 0.710 and bests one containing 6 clinical variables (age, stage, histology, grade, surgical outcome, neoadjuvant treatment) which reaches AUC = 0.688. Our selected model of 4 factors: HIF-1α and p53 IgG antibody levels, stage, and neoadjuvant treatment, achieves comparable discrimination (AUC = 0.797) with a comprehensive model of 2 serum biomarkers and 6 clinical factors (AUC = 0.802).

Conclusion: Viable strategies for the primary treatment of ovarian cancer have expanded beyond intravenous carboplatin and paclitaxel every 3 weeks after primary cytoreductive surgery to include alternate dosing, neoadjuvant chemotherapy, intraperitoneal administration, and the addition of novel biologic agents such as bevacizumab, yet there are no biomarkers to guide which patients derive the most benefit from these treatments, despite significant differences in their toxicities, cost, and associated quality of life. The ability of serum antibodies recognizing tumor associated antigens at time of diagnosis to identify patients most likely to achieve a durable response to platinum based chemotherapy may allow the selection of primary treatment to be optimized and improve response rates.

Citation Format: M. D. Dao, K. J. Ovenell, K. J. Agnew, E. M. Swisher, B. A. Goff, M. L. Disis, J. B. Liao. Primary platinum sensitivity in ovarian cancer and serum antibodies recognizing hypoxia-inducible factor 1-alpha and p53 [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 POSTER-TECH-1107.

Estrogen receptor expression in an endometrial stromal sarcoma after tamoxifen therapy

INTRODUCTION

Several cases of low-grade endometrial stromal sarcomas in women with breast cancer have been reported to be associated with tamoxifen therapy. Estrogen receptor expression has been used to characterize the partial estrogenic action of tamoxifen on the endometrium and has been found in tamoxifen-associated endometrial pathologies.

CASE

A low-grade endometrial stromal sarcoma in a woman with a history of breast cancer treated with adjuvant tamoxifen is presented. Steroid receptor studies performed on the tumor were negative for estrogen and positive for progesterone.

CONCLUSION

The absence of estrogen receptor expression suggests that endometrial stromal sarcomas are not necessarily caused by the estrogenic properties of tamoxifen.

Identification of prognostic factors in advanced epithelial ovarian carcinoma

OBJECTIVE

The Gynecologic Oncology Group (GOG) has demonstrated that age, tumor grade, and size and number of residual lesions after primary cytoreductive surgery are significant prognostic factors in advanced ovarian carcinoma. Recent studies have reported numerous other clinical features as having prognostic value. We sought to identify the independent prognostic factors for survival in a cohort of patients with advanced ovarian cancer.

METHODS

We performed a retrospective chart review of all patients with stage III and IV ovarian carcinoma who received their primary treatment at our institution between 1987 and 1994.

RESULTS

A total of 295 patients were identified, 282 of whom were evaluable. Of these 282 patients, 214 (76%) have died of disease or other causes. The median follow-up is 32 months (range: 1-139). Eighteen factors were evaluated for prognostic significance. Significant factors in univariate analysis included patient age, gravidity (0 vs > 0), parity (0 vs > 0), preoperative albumin level, preoperative total protein level, ascites (presence vs absence), disease stage (IIIA/IIIB vs IIIC vs IV), number of residual lesions (< or =20 vs >20), and diameter of largest residual tumor nodule (< or = 1 cm vs 1-2 cm vs > 2 cm). However, on multivariate analysis, only patient age (P < 0.001), ascites (P = 0.001), and size of residual disease (P = 0.005) retained prognostic significance. Substage of disease was of borderline significance (P = 0.086).

CONCLUSION

Although numerous clinical variables have recently been reported to have prognostic value in advanced ovarian carcinoma, only patient age, presence or absence of ascites, and diameter of the largest residual tumor nodule proved to be of statistical significance in our analysis.