Mutational landscape of ovarian cancers (OC) identified by prospective clinical sequencing in a nationwide cancer network

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Background: Tumor genomic profiling is a critical component of precision oncology allowing the detection of genomic alterations (GA) that have the potential to be targeted therapeutically. We present an analysis of comprehensive genomic profiling (CGP) of a large series of OC assayed in a nationwide cancer network. Methods: 449 Pts with advanced OC underwent CGP with hybrid capture of up to 406 cancer-related genes on tumor tissue or for 62 genes on circulating tumor DNA ordered during clinical care for treatment decision-making between 01-2013 to 05-2018. Clinically relevant (CR) GA were defined as associated with targeted therapies or mechanism-driven clinical trials. Treatment histories for the 449 patients were obtained with IRB-approved retrospective review. Results: Median age was 56 years (range, 23-83), 71% were Caucasian. GA were identified in 94% (420/449) of OC, of which 283 (63%) had a clinically relevant genomic alteration (CRGA). 24.0% in HRD ( BRCA1/2, ATM, PALB2, BRIP1). CRGA in other potentially targetable pathways were identified: 48.0% MEK pathway ( KRAS, NRAS, HRAS, BRAF, RAF1, GNAS, NF1, NF2) CRGA, 33.5% PI3K/AKT/mTOR pathway ( PIK3CA, AKT1/2/3, PIK3R1, PTEN, MTOR, STK11, FBXW7), and 10.6% in ERBB ( ERBB2, ERBB3, ERBB4, EGFR). All OC tested were microsatellite stable and only one patient had a tumor mutational burden > 20 muts/Mb. 21% (59/283) of OC patients were ordered a genomically-matched treatment, 58% (37/64) were agents that were FDA approved in a different tumor type, and 17% (11/64) through referral to a matched mechanism driven clinical trial. With access to the clinical trial TAPUR, the frequency of matched treatment through clinical trials increased over time from 2013 to 2018. For the off label non-study population the median PFS was 19 weeks, and the median OS was 34 weeks. Conclusions: In a large series of OC assayed with CGP, 21% of pts received matched treatment, which was predominantly targeted therapy. The comprehensive sensitive and unbiased nature of CGP, coupled with a multidisciplinary molecular tumor board and staff dedicated to genomic interpretation, assisted in achieving a high frequency of patients’ participation in clinical trials and gene-directed treatment.

15years of progress in gestational trophoblastic disease: Scoring, standardization, and salvage

Significant improvements in treatment and the understanding of gestational trophoblastic neoplasia have occurred in the last 15years. These diseases are almost always curable, and refractory patients have more options for salvage therapy. Recent improvements in the understanding of epidemiology, diagnosis, and cell biology have resulted in changes in staging, advances in treatment options, and opportunities for fertility preservation.

Bringing PROMIS to practice: brief and precise symptom screening in ambulatory cancer care

BACKGROUND

Supportive oncology practice can be enhanced by the integration of a brief and validated electronic patient-reported outcome assessment into the electronic health record (EHR) and clinical workflow.

METHODS

Six hundred thirty-six women receiving gynecologic oncology outpatient care received instructions to complete clinical assessments through Epic MyChart, an EHR patient communication portal. Patient Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) were administered to assess fatigue, pain interference, physical function, depression, and anxiety. Checklists identified psychosocial concerns, informational and nutritional needs, and risk factors for inadequate nutrition. Assessment results, including PROMIS T scores with documented severity thresholds, were immediately populated in the EHR. Clinicians were notified of clinically elevated symptoms through EHR messages. EHR integration was designed to provide automated triage to social work providers for psychosocial concerns, to health educators for information, and to dietitians for nutrition-related concerns.

RESULTS

Four thousand forty-two MyChart messages sent, and 3203 (79%) were reviewed by patients. The assessment was started by 1493 patients (37%), and once they started, 93% (1386 patients) completed the assessment. According to first assessments only, 49.8% of the patients who reviewed the MyChart message completed the assessment. Mean PROMIS CAT T scores indicated a lower level of physical function and elevated anxiety in comparison with the general population. Fatigue, pain, and depression scores were comparable to those of the general population. Impaired physical functioning was the most common basis for clinical alerts and occurred in 4% of the patients.

CONCLUSIONS

PROMIS CATs were used to measure common cancer symptoms in routine oncology outpatient care. Immediate EHR integration facilitated the use of symptom reporting as the basis for referral to psychosocial and supportive care.

Improving diversity in cancer research trials: the story of the Cancer Disparities Research Network

The participation of racial and ethnic minorities and underserved populations in clinical trials is a critical link between scientific innovation and improvements in health care delivery and health outcomes. However, these population groups continue to be underrepresented in research. We describe the development of the Cancer Disparities Research Network (CDRN) to improve minority and underserved populations' participation in biobanking research. Between February and October 2011, we conducted a regional assessment to identify challenges and opportunities for cancer trials and biobanking research across the CDRN. Representatives from ten CDRN biorepository facilities completed an online survey assessing their facilities' minority biospecimen collection, biobanking practices, and education/outreach initiatives. Representatives of eight facilities also participated in stakeholder interviews. The majority (70%) of facilities reported that specimens were available for research, although only one tenth of these specimens were from non-White patients. Most facilities collected a patient's age, gender, race, medical history, and ethnicity with samples; however, less than half also collected family health history, education level, household income, or primary language spoken. In addition, few institutions collected Asian or Hispanic subgroup information. Only a few reported biospecimen collection outreach programs specifically targeting minority and underserved populations. Biospecimen directors and administrators indicated that funding, biospecimen sharing procedures, and standardization barriers limited their facilities from collaborating in biospecimen collection programs, despite their great interest. These findings suggest that the CDRN can provide opportunities for collaboration, resource sharing, and fostering of research ideas to address cancer disparities in biospecimen research.

Efficacy and safety of bevacizumab in recurrent sex cord-stromal ovarian tumors: results of a phase 2 trial of the Gynecologic Oncology Group

BACKGROUND

The Gynecologic Oncology Group conducted this phase 2 trial to estimate the antitumor activity of bevacizumab and to determine the nature and degree of toxicity in patients with recurrent sex cord-stromal tumors of the ovary.

METHODS

A prospective, multi-institutional cooperative group trial was performed in women with recurrent, measurable ovarian stromal tumors. Patients were allowed to have unlimited prior therapy, excluding bevacizumab. Bevacizumab 15 mg/kg was administered intravenously on day 1 of every 21-day cycle until patients developed disease progression or adverse effects that prohibited further treatment. The primary endpoint was the response rate (RR). Inhibin A and B levels were measured before each cycle, and the values were examined in relation to response and progression.

RESULTS

Thirty-six patients were enrolled, and all were eligible and evaluable. Patients received a median of 9 cycles of treatment (range, 2-37 cycles). Six patients (16.7%) had partial responses (90% confidence interval, 7.5%-30.3%), 28 patients (77.8%) had stable disease, and 2 patients (5.6%) had progressive disease. This met the criterion for declaring the regimen active. The median progression-free survival was 9.3 months, and the median overall survival was not reached in during reporting period. Two grade 4 toxicities occurred, including hypertension and proteinuria; and the most common grade 3 toxicities were hypertension (n = 5) and pain (n = 5). Inhibin A and B values were lower in patients who responded to treatment.

CONCLUSIONS

Bevacizumab has activity in the treatment of recurrent sex cord-stromal tumors of the ovary, and its toxicity is acceptable. Further investigation is warranted.

Ovarian cancer, version 3.2012

These NCCN Guidelines Insights focus on the major updates for the 2012 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer by describing how and why the new recommendations were made. The 6 update topics were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials, and include: 1) screening, 2) diagnostic tests for assessing pelvic masses, 3) primary treatment using neoadjuvant chemotherapy, 4) primary adjuvant treatment using bevacizumab in combination with chemotherapy, 5) therapy for recurrent disease, and 6) management of drug/hypersensitivity reactions. These NCCN Guidelines Insights also discuss why some recommendations were not made (eg, panel members did not feel the new data warranted changing the guideline). See "Updates" in the NCCN Guidelines for Ovarian Cancer for a complete list of all the recent revisions.

Progesterone receptor-B induction of BIRC3 protects endometrial cancer cells from AP1-59-mediated apoptosis

Progesterone is a growth inhibitory hormone in the endometrium. While progestins can be used for the treatment of well-differentiated endometrial cancers, resistance to progestin therapy occurs for reasons that remain unclear. We have previously demonstrated that progesterone receptors (PR) A and B differentially regulate apoptosis in response to overexpression of the forkhead transcription factor, FOXO1. In this study, we further examined the PR-isoform-dependent cellular response to the AKT pathway. Treatment of PRA and PRB-expressing Ishikawa cells (PRA14, PRB23), with an AKT inhibitor API-59CJ-OMe (API-59) promoted apoptosis in the presence and absence of the ligand, R5020 preferentially in PRA14 cells. Upon PR knockdown using small interfering RNA, an increase in apoptosis was observed in PRB23 cells treated with API-59 with or without R5020 while there was no influence in PRA14 cells. Using an apoptosis-focused real-time PCR array, genes regulated by API-59 and R5020 were identified both common and unique to PRA14 and PRB23 cells. BIRC3 was identified as the only gene regulated by R5020 which occurred only in PRB cells. Knockdown of BIRC3 in PRB23 cells promoted a decrease in cell viability in response to API-59 + R5020. Furthermore, the important role of inhibitors of apoptosis (IAPs) in the PRB23 cells to promote cell survival was demonstrated using an antagonist to IAPs, a second mitochondria-derived activator of caspase (Smac also known as DIABLO) mimetic. Treatment of PRB23 cells with Smac mimetic increased apoptosis in response to API-59 + R5020. In summary, our findings indicate a mechanism by which PRB can promote cell survival in the setting of high AKT activity in endometrial cancer cells.

Abstract B5: Region Five GMaP/BMaP Network: Preliminary findings from the comprehensive needs assessment principal investigator survey

Background: The Region Five GMaP/BMaP Network is a regional partnership representing 18 NCI funded institutions charged with the development and implementation of a comprehensive needs assessment (CNAT). The goal of the principle investigator (PI) component of the CNAT was to capture in-depth PI opinion on necessary elements to successful health disparities research, barriers to success and required funding and infrastructure elements needed to alleviate those barriers. In addition, we hoped to obtain specific recommendations for our network's development to foster successful research collaborations amongst our many institutions and the diverse populations we serve.

Methods: The CNAT consisted of a mixed methods approach utilizing four instruments: A principal Investigator Survey and PI Interview and a Biospecimen Facility Survey and Interview. This presentation focuses on preliminary findings from the PI Survey. The surveys were conducted online by PI's during the months of March and April 2011. Qualitative interviews will be conducted between July and August 2011. The PI survey consisted of 48 distinct questions, with affiliated subset questions that covered seven core areas: cancer health disparities research/community, minority biospecimens collection, clinical trials recruitment and retention, bioinformatics/advanced & emerging technology, training, visioning the future; and network analysis.

Results: PI online survey was completed by 14 of 18 region five institutions, a 77.8% completion rate. Preliminary findings show our region's investigator expertise is in the areas of CBPR, working with community based organizations, and training CHD researchers, with 84% (11/13) reporting collaborations with institutions and community partners. Most of the populations focused on among the PI's mirrors the populations in institution service areas. Forty-six percent (6/13) of institutions reported having implemented outreach or education strategies in the community to promote biospecimens research, while 69.2% (9/13) reported projects with the aim to improve accrual of minority patients into clinical trials. Four PI's focus 50–100% of their GMaP effort on health disparities programs; while five PI's focus between 50–100% of their GMaP group effort on health disparities research. 84% of PI's collaborate with others to conduct CHD research and community outreach. The most popular areas of CHD research are barriers to cancer screening, health literacy, and cancer (breast, prostate, cervical, and lung).

Conclusions: Region Five has significant experience conducting community-based research and community education programs to increase minority/medically underserved population's participation in research. There are opportunities for collaboration among principal investigators and biospecimen facilities around minority biospecimen collection efforts. Region Five has established a formal network called the Cancer Disparities Research Network (CDRN) and is establishing a network website. A result of this preliminary network is the continuation of the collaboration and identification of potential health disparities projects. We anticipate implementing Cancer 102 education and training on research participation, biospecimen donation/biobanking and genetics across our institutions.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B5.

PET/CT in gynecologic cancer: present applications and future prospects--a clinician's perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

An outpatient intraperitoneal chemotherapy regimen for advanced ovarian cancer

OBJECTIVES

To assess the feasibility, associated toxicities, and reasons for early cessation of an outpatient intraperitoneal (IP) chemotherapy regimen for treatment of advanced ovarian cancer following optimal cytoreductive surgery.

METHODS

Between January 2006 and December 2007, 42 patients with stages IIC-IV epithelial ovarian, tubal, or primary peritoneal cancer who had residual disease <1 cm after cytoreductive surgery were treated with an outpatient IP chemotherapy protocol. Patients received intravenous (IV) docetaxel 75 mg/m(2) and IP cisplatin 75-100 mg/m(2) on day 1, followed by IP paclitaxel 60 mg/m(2) on day 8, with the intent to treat patients every 21 days for 6 cycles of chemotherapy. Charts were abstracted for demographic, chemotherapy, and toxicity-related data.

RESULTS

The median age of the 42 patients was 59 years (range 33-70) and the majority of patients had epithelial ovarian cancer (80%), FIGO stage IIIC (83%), and papillary serous histology (74%). Of an intended 252 IP chemotherapy cycles, 172 (68%) were administered. Twenty-nine patients (69%) completed >or=4 cycles and 12 (29%) received all 6 IP cycles. Common grade 3/4 toxicities by patient included neutropenia (43%), infection (21.5%), and gastrointestinal effects (14%). There was one treatment-related death. Reasons for discontinuation were largely chemotherapy (43%) or port (37%) related.

CONCLUSIONS

With supportive measures, such as scheduled hydration and granulocyte colony-stimulating factors, outpatient administration of IP chemotherapy was feasible. This regimen resulted in few hospitalizations or treatment delays and demonstrated less toxicity than previously reported IP chemotherapy regimens. Port-related complications were a leading cause of IP chemotherapy discontinuation.

Ovarian cancer. Clinical practice guidelines in oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer and the fifth most common cause of cancer mortality in women in the United States. Fewer than 40% of women with ovarian cancer are cured, and 70% of patients present with advanced disease; because of the location of the ovaries, ovarian cancer has been difficult to diagnose at earlier stages. Epidemiologic studies have identified risk factors, including family history. The NCCN guidelines discuss epithelial ovarian cancer as well as less common ovarian histopathologies, including germ cell neoplasms, carcinosarcomas (malignant mixed Müllerian tumors of the ovary), and ovarian stromal tumors. For 2008, updates include the addition of platinum-based combination therapy as a possible treatment modality for recurrence and a listing of preferred agents for acceptable recurrence modalities. New information was also added to the section on clinical presentation.

For the most recent version of the guidelines, please visit NCCN.org

Cancer of the cervix: current management and new approaches

This article summarizes the current management of patients with newly diagnosed cervical cancer. The topics range from the management of early-stage disease to the phase III randomized studies that have established the current standard of care for patients with locally advanced cancer of the cervix. New approaches to combined-modality therapy with the goal of improving outcomes and decreasing complications are also described.

Liquid-based cytologic specimen studies to screen for cervical dysplasia in rural El Salvador

OBJECTIVE

To evaluate an alternative tool (ThinPrep; Cytye Corporation, Boxborough, Mass, USA) for cervical cancer screening in rural El Salvador.

METHODS

Cervical samples were obtained from 471 women attending health fairs in rural El Salvador. The samples were read by American and Salvadoran pathologists after a 1-week training course in liquid-based cytologic studies in the United States.

RESULTS

The system evaluated detected a significantly higher number of high-grade and above lesions than conventional cytologic studies (P=0.01). There were 0.4% and 1.7% of high-grade lesions and above detected with conventionally prepared slides in the United States and El Salvador, respectively, and 3.2% and 3.8% of such lesions detected with liquid-based samples in the United States and El Salvador. Intra-observer agreement among the pathologists reading the samples was substantial for the ThinPrep system, with a kappa value of 0.6.

CONCLUSION

A short workshop is effective in training pathologists to use ThinPrep. In the studied population, liquid-based studies appear to offer significant advantages over conventional cytologic studies for detecting high-grade lesions.

Exfoliative cytology of primary poorly differentiated (small-cell) neuroendocrine carcinoma of the uterine cervix in ThinPrep material: a case report

Poorly differentiated neuroendocrine (small-cell) carcinoma of cervical origin is a rare neoplasm that frequently metastasizes. Although the cytologic features have been described for conventional cervical smears, we know of no reports of its appearance in ThinPrep (TP) material. Therefore, we present a TP case of primary, small-cell carcinoma arising in a 46-yr-old female, confirmed by histologic and immunohistochemical analysis. Similar to conventional smears, the neoplastic cells occurred either individually or in small clusters. The cells were relatively monomorphic, with stippled chromatin and minimal amounts of cytoplasm. Unlike conventional smears, nuclear molding was not prominent (although overlap was observed), and nuclear smearing was not identified. The features are compared to TP cases of squamous-cell carcinoma, small-cell type, and endometrioid adenocarcinoma, which are close mimics of small-cell carcinoma. We conclude that correct diagnosis of small-cell carcinoma in TP is difficult, requiring a high degree of suspicion and immunohistochemical confirmation.

Phase I study of continuous-infusion L-S,R-buthionine sulfoximine with intravenous melphalan

BACKGROUND

Increased intracellular glutathione has long been associated with tumor cell resistance to various cytotoxic agents. An inhibitor of glutathione biosynthesis, L-S,R-buthionine sulfoximine (BSO), has been shown to enhance the cytotoxicity of chemotherapeutic agents in vitro and in vivo. We performed a phase I study of BSO administered with the anticancer drug melphalan to determine the combination's safety/tolerability and to determine clinically whether BSO produced the desired biochemical end point of glutathione depletion (<10% of pretreatment value).

METHODS

Twenty-one patients with advanced cancers received an initial 30-minute infusion of BSO totaling 3.0 g/m2 and immediately received a continuous infusion of BSO on one of the following schedules: 1) 0.75 g/m2 per hour for 24 hours (four patients); 2) the same dose rate for 48 hours (four patients); 3) the same dose rate for 72 hours (10 patients); or 4) 1.5 g/m2 per hour for 48 hours (three patients). During week 1, the patients received BSO alone; during weeks 2 or 3, they received BSO plus melphalan (15 mg/m2); thereafter, the patients received BSO plus melphalan every 4 weeks. Glutathione concentrations in peripheral blood lymphocytes were determined for all patients; in 10 patients on three of the administration schedules, these measurements were made in multiple sections from tumor biopsy specimens taken before, during, and after continuous-infusion BSO.

RESULTS

Continuous-infusion BSO alone produced minimal toxic effects, although BSO plus melphalan produced occasional severe myelosuppression (grade 4) and frequent low-grade nausea/vomiting (grade 1-2). This treatment also produced consistent, profound glutathione depletion (<10% of pretreatment value). The degree of glutathione depletion in peripheral lymphocytes was considerably less than that observed in tumor sections.

CONCLUSIONS

Continuous-infusion BSO is relatively nontoxic and results in depletion of tumor glutathione.

Phase 1 trial of intraperitoneal AD-32 in gynecologic malignancies

AD-32 (N-trifluoroacetyladriamycin-14-valerate), an analogue of doxorubicin, was examined for intraperitoneal (ip) administration in a phase 2 trial involving 25 patients with advanced gynecologic malignancies. At an AD-32 dose of 600 mg/m2, the limiting toxicity was grade 4 neutropenia (64% of patients), while severe abdominal pain was relatively uncommon (12%). Intraperitoneal AD-32 administration was associated with a 200-fold pharmacokinetic advantage for cavity exposure, compared to the systemic compartment. At the 600 mg/m2 dose level, 4 of 9 patients (44%) with ascites experienced control of malignant fluid reaccumulation. Based on the results of this phase 1 trial, further exploration of a possible role for the ip administration of AD-32 in individuals with gynecological malignancies appears indicated, particularly in patients with either small volume residual disease after initial systemic chemotherapy or in those with intractable ascites.

Comparison of three tests for virulent Yersinia enterocolitica

Magnesium oxalate agar was found to select against virulent types of Yersinia enterocolitica. Small colonies isolated from magnesium oxalate agar which were presumably virulent generally contained no detectable virulence-specific plasmids, did not agglutinate with virulence-specific antiserum, and exhibited various degrees of virulence in mice. Results indicate that the virulence potential of a Y. enterocolitica isolate cannot always be identified by these in vitro methods and suggest that virulence also involves other factors yet to be identified.