The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes

OBJECTIVE

The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy.

METHODS

This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used.

RESULTS

We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5).

CONCLUSION

This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

Molecular profiles of endometrial cancer tumors among Black patients

OBJECTIVES

Disparate outcomes exist between Black and White patients with endometrial cancer (EC). One contributing factor is the disproportionately low representation of Black patients in clinical trials and in tumor molecular profiling studies. Our objective was to investigate molecular profiles of ECs in a cohort with a high proportion of tumors from Black patients.

METHODS

A total of 248 EC samples and self-reported race data were collected from 6 institutions. Comprehensive tumor profiling and analyses were performed by Caris Life Sciences.

RESULTS

Tumors from 105 (42%) Black and 143 (58%) White patients were included. Serous histology (58% vs 36%) and carcinosarcoma (25% vs 16%), was more common among Black patients, and endometrioid was less common (17% vs 48%) (p < 0.01). Differences in gene mutations between cohorts corresponded to observed histologic differences between races. Specifically, TP53 mutations were predominant in serous tumors. In endometrioid tumors, mutations in ARID1A were the most common, and high rates of MSI-H, MMRd, and TMB-H were observed. In carcinosarcoma tumors, hormone receptor expression was high in tumors of Black patients (PR 23.4%, ER 30.8%). When stratified by histology, there were no significant differences between tumors from Black and White women.

CONCLUSIONS

This cohort had a high proportion of tumors from Black women. Distinct molecular profiles were driven primarily by more aggressive histologic subtypes among Black women. Continued effort is needed to include Black women and other populations under-represented in EC molecular profiling studies as targeted therapies and personalized medicine become mainstream.

Minority participation in phase 1 gynecologic oncology clinical trials: Three decades of inequity

OBJECTIVES

It is important to develop effective therapies in minorities to ensure equity in cancer care. Underrepresentation of minorities in early phase trials may cause therapies that are effective only in majority populations. We evaluated minority participation in gynecologic oncology phase 1 clinical trials.

METHODS

In peer-reviewed published articles of gynecologic oncology phase 1 clinical trials from years 1985 to 2018, we manually abstracted racial distribution of enrolled participants, cancer type, and year published. We calculated expected and observed ratios of racial participation on the basis of age-adjusted cancer incidence for race from the United States Centers for Disease Control and Prevention.

RESULTS

We identified 357 articles of phase 1 trials (total, 9492 participants), including 213 articles on ovarian cancer (60%). Racial distribution of participants was available in 84 articles (23%) that included 2483 participants (26%): 1950 white (79%), 140 black (5%), and 393 other participants (16%). Other nonwhite races exceeded black enrollment in 46 of 84 trials (55%) that listed race. Enrollment of black participants was less than expected from disease incidence for ovarian (incidence-to-enrollment ratio, 18.5; P < .001), endometrial (3.6; P < .001), and cervical cancer (6.8; P < .001). No phase 1 study met expected enrollment for black participants. Frequency of black participants decreased 1.8-fold from 1995 to 1999 (8 of 70 participants [11%]) to 2015-2018 (55 of 892 participants [6%]; P < .025).

CONCLUSIONS

Major racial underrepresentation exists in gynecologic oncology phase 1 clinical trials. Enrollment of more black participants is needed to achieve racial equity.

Redundant surgical publications: tip of the iceberg?

BACKGROUND

A redundant publication is one which duplicates previous, simultaneous, or future publications by the same author or group or, alternatively, could have been combined with the latter into one paper. As there is no information about the extent of this problem in the surgical literature, we set out to assess the incidence, spectrum, and salient characteristics of redundant publications in 3 leading surgical journals.

METHODS

Original articles (excluding reviews, editorials, abstracts, and letters) published during 1998 in the journals Surgery, The British Journal of Surgery, and Archives of Surgery were searched by using the on-line search engine PUBMED. Each original article was scrutinized to identify redundancy by combining the names of the first, second, and last authors with a few key words from the title. Papers were defined as "suspected" redundant publications if they were found to address the same topic as the "index" article and shared some or most of the elements of methodology, results, or conclusions. The full versions of all suspected papers were retrieved and compared with the index articles. A grading system was developed to define several types of redundant publications: A. "dual"; B. "potentially dual"; C. "salami-slicing."

RESULTS

A total of 660 articles were screened. There were 92 index articles (14%) leading to 147 suspected papers found in other journals, representing some potential form of a redundant publication. The vast majority of suspected papers were published within approximately a year of the index paper and were not cited by the latter. Most (69%) of the suspected papers were also published in surgical journals. Only 12 (8.1%) appeared in, or originated from, a "local-foreign" journal. Twenty (13.6%) of the suspected papers met the criteria for dual publications, 50 (34%) for potentially dual publications, and 77 (52.4%) were considered products of salami-slicing.

CONCLUSIONS

Almost 1 in every 6 original articles published in leading surgical journals represents some form of redundancy. Current on-line search technology provides an effective tool for identifying and tracing such publications, but it is not used routinely as part of the peer review process. Redundancies occur in several well-defined patterns; the phenomenon is widespread, and it cuts across the entire spectrum of surgeons in the United States and abroad. Redundant publications must be recognized not as a mere nuisance but as a real threat to the quality and intellectual impact of surgical publishing.

Spontaneous perforation of the hepatic duct in adults

BACKGROUND

Nontraumatic perforations of the extrahepatic biliary ductal system are a rare albeit recognized occurrence in the cystic duct, choledochus and main hepatic duct; the latter appears to be the rarest.

METHODS

Recent experience with such a case prompted a thorough review of 26 similar cases previously reported.

RESULTS

It appears that obstruction of the biliary tract by gallstones results in raised intraductal pressure leading to dilatation of the biliary tree, subsequent stasis and infection, causing ascending cholangitis and thrombosis of intramural vessels, leading to necrosis and perforation of the duct wall. Most patients present with an acute abdomen and are operated upon.

CONCLUSIONS

The goals of operation, which should be tailored to the individual patient, are to stop the bile leak, cure choledocholithiasis and cholangitis and reconstruct the bile duct.

A family of epidermoid lung cancer models

A method of sustained release implantation has been developed whereby Silastic cylinders, impregnated with benzo[alpha]pyrene (BP) or methylcholanthrene (MCA) each at 2% (low dose) and 10% (high dose) concentrations, were inserted into the bronchus intermedius of hamsters. High-dose BP and MCA, and low-dose MCA had first-order exponential release rates: the half-time of release was 40 days for high-dose BP, 30 days for high-dose MCA, and 165 days for low-dose MCA. Release rate of low-dose BP was a second-order function: half-time of release was 40 days. Atypical squamous metaplasia was noted by 4 weeks in more than 65% of hamsters after insertion of each high-dose carcinogen but in less than 30% with the low-dose carcinogens. Carcinoma in situ was noted approximately 8 weeks after high-dose BP and 19 weeks after low-dose BP. At about 15 to 17 weeks after a high-dose carcinogen, 64% of animals had invasive epidermoid cancer, whereas after a low-dose carcinogen, only 21% did. After 25 weeks of exposure to a high-dose carcinogen, more than 85% of hamsters had invasive epidermoid cancer; up to 52 weeks were required for invasive epidermoid cancer to develop in 30% after a low-dose carcinogen. Measured by image analysis, nuclear deoxyribonucleic acid content of cells with severe atypical squamous metaplasia was greater than tetraploid (mean +/- standard deviation [SD], 3.77 +/- 1.4), whereas cells with invasive epidermoid cancer were suprahexaploid (mean +/- SD, 6.48 +/- 3.6). These differences are significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Typical and atypical carcinoids within the pulmonary APUD tumor spectrum

The behavior of pulmonary APUD tumors is not constant; management is controversial, and morphology has reached its limit as a tool for prognostic assessment and therapeutic planning. We have studied 24 patients with carcinoids; 17 patients with typical carcinoids presented with Stage I disease, but one patient later died most probably of small cell undifferentiated lung cancer (SCLC). Seven patients with atypical carcinoids included three with Stage III cancers, one patient with simultaneous bilateral carcinoids, and one patient with simultaneous adenocarcinoma. Of 17 patients with typical carcinoids, 16 or 92% are disease free or died of unrelated causes. Of seven patients with atypical carcinoids, five or 71% are disease free. Tumor doubling time of atypical carcinoids, was 79.6 months (45 to 120) or six times shorter than that of typical carcinoids (p less than 0.05). Two of the three deaths from cancer were probably from SCLC and one from a synchronous adenocarcinoma. Review of diagnostic material from 12 patients with SCLC who survived a mean of 41 months (24 to 134) showed that diagnosis had rested on cytology alone in four patients and that, in seven patients, the quality or extent of the original diagnostic material was adequate to make the diagnosis of a malignant tumor but inadequate to permit reclassification. Tumor cells from 11 patients with carcinoids (seven typical and four atypical) and 28 patients with SCLC had DNA measurement by image analysis. The mean DNA content of typical and atypical carcinoids and SCLC is 1.17, 1.25, and 1.94 respectively (p less than 0.001). These findings strongly suggest a relationship between DNA content and atypia or malignancy in APUD lung tumors. We conclude that there are at least two levels of virulence among carcinoids represented by typical and atypical carcinoids. The prognosis for treated Stage I typical and atypical carcinoids is excellent. When deaths occur, they are from systemic cancer. Current evidence indicates that DNA measurements by image analysis may help to discriminate levels of malignancy among APUD pulmonary cancers and thereby help to clarify therapeutic controversies.

Quantitative DNA. Comparative studies of a cellular marker for bronchogenic carcinoma

During the course of induction of bronchogenic carcinoma in a colony of standard-bred beagles, serial cytologic and biopsy material was obtained under direct bronchoscopy. Cytological changes followed the sequence from metaplasia to carcinoma, closely simulating those features observed in humans, but with subtle differences characterized as species variations. Quantitative DNA done by image analysis correlated directly with the severity of cytologic atypia and also corresponded well with data obtained from humans. Equivalent studies in human bronchogenic carcinoma have shown similar results and strongly suggest that graded hyperploidy accurately reflects atypia in the lung and qualifies as an interspecies tumor marker.

A case of osteoblastoma associated with severe systemic toxicity

A case of an osteoblastoma of the proximal femur with a unique local, massive reactive periostitis mimicking osteosarcoma or osteomyelitis and unique systemic manifestations is reported. The severe toxic manifestations included: massive weight loss, chronic fever, anemia, systemic periostosis, and other signs. Due to confusion as to diagnosis, lack of response to numerous antibiotic regimens, and severe cachexia with clinical signs of impending death, an amputation was performed. Pathologic study revealed an osteoblastoma. A thorough review of the case suggests that the signs and symptoms were possibly consequent to an immune response mounted against the tumor rather than to secondary infection, although the latter possibility cannot be completely excluded.