Radioimmunotherapy versus autologous hematopoietic stem cell transplantation in relapsed/refractory follicular lymphoma: a Fondazione Italiana Linfomi multicenter, randomized, phase III trial

BACKGROUND

Optimal consolidation for young patilents with relapsed/refractory (R/R) follicular lymphoma (FL) remains uncertain in the rituximab era, with an unclear benefit of autologous stem cell transplantation (ASCT). The multicenter, randomized, phase III FLAZ12 (NCT01827605) trial compared anti-CD20 radioimmunotherapy (RIT) with ASCT as consolidation after chemoimmunotherapy, both followed by rituximab maintenance.

PATIENTS AND METHODS

Patients (age 18-65 years) with R/R FL and without significant comorbidities were enrolled and treated with three courses of conventional, investigator-chosen chemoimmunotherapies. Those experiencing at least a partial response were randomized 1 : 1 to ASCT or RIT before CD34+ collection, and all received postconsolidation rituximab maintenance. Progression-free survival (PFS) was the primary endpoint. The target sample size was 210 (105/group).

RESULTS

Between August 2012 and September 2019, of 164 screened patients, 159 were enrolled [median age 57 (interquartile range 49-62) years, 55% male, 57% stage IV, 20% bulky disease]. The study was closed prematurely because of low accrual. Data were analyzed on 8 June 2023, on an intention-to-treat basis, with a 77-month median follow-up from enrollment. Of the 141 patients (89%), 70 were randomized to ASCT and 71 to RIT. The estimated 3-year PFS in both groups was 62% (hazard ratio 1.11, 95% confidence interval 0.69-1.80, P = 0.6662). The 3-year overall survival also was similar between the two groups. Rates of grade ≥3 hematological toxicity were 94% with ASCT versus 46% with RIT (P < 0.001), and grade ≥3 neutropenia occurred in 94% versus 41%, respectively (P < 0.001). Second cancers occurred in nine patients after ASCT and three after radioimmunotherapy (P = 0.189).

CONCLUSIONS

Even if prematurely discontinued, our study did not demonstrate the superiority of ASCT versus RIT. ASCT was more toxic and demanding for patients and health services. Both strategies yielded similar, favorable long-term outcomes, suggesting that consolidation programs milder than ASCT require further investigation in R/R FL.

Addendum to the consensus opinion from the International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of the parametrium

Preoperative sonographic staging in patients with suspected parametrial endometriosis is essential to plan the surgical intervention and to anticipate the need for a multidisciplinary approach, and hence optimize surgical outcome. The results of a recent metanalysis suggest that defining more accurately the ultrasonographic criteria of parametrial involvement in endometriosis is needed. The aim of this addendum to the IDEA-consensus is to highlight the sonographic characteristics of the parametrium and identify ultrasound techniques to diagnose deep endometriosis in this area. This article is protected by copyright. All rights reserved.

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

O-309 Surgery versus IVF/ICSI in infertile women with rectosigmoid endometriosis: the FERTILITY-RECTOSIGMOID study

Study question

To compare the live birth rate in infertile patients with rectosigmoid endometriosis treated by surgery or IVF/ICSI.

Summary answer

In infertile women with rectosigmoid endometriosis, IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than first-line surgery.

What is known already

The choice between surgery and IVF/ICSI is based on several variables including concomitant infertility factors, presence of (sub)occlusive symptoms, preference of patients. Until now, there is no evidence to favor first-line IVF/ICSI or first-line surgery in women affected by rectosigmoid endometriosis wishing to conceive.

Study design, size, duration

This was a prospective patient’s preference study enrolling infertile women with rectosigmoid endometriosis who underwent first-line surgery or IVF/ICSI. Symptoms and fertility outcomes were compared between the two groups.

Participants/materials, setting, methods

Rectosigmoid endometriosis was diagnosed by transvaginal ultrasonography and magnetic resonance enema. All study patients underwent computed tomographic colonography (CTC) to assess the degree of stenosis of the intestinal lumen. Inclusion criteria were infertility; bilateral tubal patency; age &lt; 40 years. Exclusion criteria were history of surgery for endometriosis; previous IVF/ICSI cycles; oocyte donation or vitrified oocyte procedures; poor ovarian reserve; estimated bowel stenosis &gt; 70% at CTC; (sub)occlusive symptoms; oligospermia (sperm count &lt; 15 million/mL).

Main results and the role of chance

Two hundred twenty-nine patients underwent IVF/ICSI. Patients underwent up to 4 IVF/ICSI cycles. Overall, 128 women had a live birth (55.9%; 95% C.I., 49.2%-62.4%). Two bowel sub occlusions occurred during IVF-ICSI. 198 patients underwent surgical treatment of rectosigmoid endometriosis. Nine patients have postoperative complications: four rectovaginal fistula, two anastomotic leakage, two pelvic abscess and one postoperative bleeding. At a median follow-up of 23 months after surgery (range, 12-56 months), 91 women had a live birth (44.9%; 95% C.I., 38.0%-56.1%). The live-birth rate was significantly higher in patients who underwent IVF/ICSI than in those who underwent surgery (p = 0.047). The time to conception that resulted in live birth was significantly shorter in patients who underwent IVF/ICSI (mean ± SD, 11.9 ± 7.6 months) than in those who underwent surgery (18.5 ± 8.1 months; p = 0.037). Six months after surgery or first IVF/ICSI cycle, there was a higher improvement of pain (p &lt; 0.001) and intestinal symptoms (p &lt; 0.001) in women surgically treated. No bowel endometriosis-related complication occurred during pregnancy. There was no difference in perinatal outcomes between the two groups.

Limitations, reasons for caution

The nonrandom allocation to treatments and the relatively small sample sized limits the strength of our results.

Wider implications of the findings

IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than surgery. The disadvantages of IVF/ICSI are potential endometriosis-related complications during the procedure and persistence of symptoms. Surgery improves symptoms but it has a higher risk of postoperative complications, which may negatively impact spontaneous conception.

Trial registration number

CE Liguria - ID 10766 - n. 394 (Approval: 10/2020)

P-621 Different gonadotrophins adopted for controlled ovarian stimulation do not affect metaphase-II oocyte competence. A matched case-control study on 351 patients and 2258 oocytes

Study question

Do different gonadotrophins for controlled-ovarian-stimulation (COS) affect metaphase-II (MII) oocyte competence?

Summary answer

Euploid blastocyst rate (EBR) per cohort of MII-oocytes, live-birth-rate (LBR) per first vitrified-warmed euploid single-embryo-transfer (SET) and cumulative-LBR are independent from the gonadotrophins used.

What is known already

Controlled-ovarian-stimulation (COS) is a cornerstone of IVF. Its purpose is maximizing ovarian reserve exploitation and obtaining ≥1 euploid blastocyst to transfer. Indeed, ovarian reserve decreases and blastocyst aneuploidy rates increase with increasing maternal age, making this task quite complicated in advanced maternal age. Old-fashioned studies suggested an association between COS and embryonic aneuploidy rates. Conversely, recent studies excluded an impact of COS dosage, duration, ovarian response, and ovulation trigger, on blastocyst aneuploidy rate. An aspect, though, needs more clarity: do different gonadotropins impact oocyte competence after COS, comprehensively defined as EBR per cohort of MII-oocytes?

Study design, size, duration

Out of 3169 PGT cycles with ³1 MII oocyte conducted between 2014-2018, we excluded (i)PGT-M/-SR, (ii)women&lt;35yr, (iii)severe-male-factor, (iv)DuoStim or long-active FSH, (v)culture with sequential-media, and (v)multiple cycles. Among the 784 cycles left, a propensity-score-matching (PSM) based on the number of inseminated MII-oocytes was adopted to match patients using recFSH [without (N = 57; 337 MII-oocytes)/with recLH (N = 55; 374 MII-oocytes)] and Human-Menopausal-Gonadotrophin (HMG; N = 127; 835 MII-oocytes). The patients using recFSH+HMG were all included (N = 112; 712 MII-oocytes).

Participants/materials, setting, methods

Only GnRH-antagonist COS, ICSI with fresh MII-oocytes, single culture in continuous-media, trophectoderm biopsy without assisted-hatching, comprehensive-chromosome-testing to assess full-chromosome non-mosaic aneuploidies and vitrified-warmed euploid SET were conducted. Oocyte competence was comprehensively defined as EBR per cohort of MII-oocytes with all intermediate outcomes (fertilization, blastulation and euploidy). LBR per first vitrified-warmed euploid SET and cumulative-LBR per retrieval were also assessed. Generalized-linear-models and multivariate regressions were adopted to adjust the results for confounders. All cycles were concluded.

Main results and the role of chance

Patients using recFSH+recLH and recFSH+HMG (40.7 yr) were older than patients using recFSH-only or HMG-only (40 yr; ANOVA&lt;0.01). No other difference was reported in the 4 patient populations. The overall gonadotrophins dosage (2615±977, 3601±1889, 3818±946 and 2892±911 IU in the recFSH-only, recFSH+recLH, recFSH+HMG and HMG-only groups, respectively) and duration of COS (9.7±1.9, 9.4±1.5, 9.9±1.8 and 10.2±1.8 days) were different (Kruskal-Wallis tests=0.02). The number of cumulus-oocyte-complexes (9.2±6.5) and MII-oocytes collected (6.4±4.4) were instead well-matched across the groups. The EBR per cohort of inseminated MII-oocytes was different in the four groups (20.7±27.1%, 9.6±12.9%, 12.4±18.5% and 16.9±21.8%, respectively), but, when adjusted for maternal age in a generalized-linear-model, the gonadotrophin used for COS did not show any significant association with this outcome (partial-eta2=0.02, p = 0.1, power=0.6). All intermediate embryological outcomes were also similar. The LBR per first vitrified-warmed euploid SET was comparable in the four groups [N = 14/33 (42%), N = 9/22 (41%), N = 26/62 (45%), N = 24/55 (44%), respectively], as confirmed by the logistic regression adjusted for blastocyst quality (multivariate-OR: 0.97, 95%CI 0.73-1.31, adjusted-p=0.9). Lastly, the cumulative-LBRs per retrieval were equivalent [N = 17/57 (30%), N = 14/55 (26%), N = 34/127 (27%), and N = 33/112 (30%), respectively], as confirmed by the logistic regression adjusted for maternal age (multivariate-OR: 1.01, 95%CI 0.8-1.3, adjusted-p=0.9).

Limitations, reasons for caution

The gonadotrophins were chosen based on patient compliance to their administration route and gynecologist judgement, and only qualitative outcomes were assessed. Therefore, randomized-controlled-trials and cost-effectiveness analysis investigating the efficiency in oocyte recruitment and cumulative-LBR per intention-to-treat are needed.

Wider implications of the findings

Different gonadotrophins might not affect MII-oocyte competence. This information is key since, in view of the optimization of follicle recruitment through personalized-COS, it allows more flexibility in the choice of the most suitable protocol. Therefore, gynecologists might ponder also features like patient reproductive history and compliance to different administration routes.

Trial registration number

none

AB1351 FULL LONGITUDINAL NAILFOLD VIDEOCAPILLAROSCOPY ANALYSIS OF MICROVASCULAR CHANGES DURING NORMAL PREGNANCY

Background

During pregnancy profound physiologic changes are required to ensure fetal development and meet maternal needs. Microvascular remodelling is one major responsible for pregnancy haemodynamic adaptation, still it is not routinely evaluated in the obstetric field [1–2].

Objectives

To investigate the role of nailfold capillaroscopy (NCV) as a gold-standard and safe technique in detecting microvascular changes during normal pregnancy and to explore its possible application in clinical obstetric setting.

Methods

A population of 30 healthy pregnant women was longitudinally followed performing clinical assessment and NVC evaluation at each trimester and post-partum. Thirty non-pregnant age-matched healthy women having received at least two NVCs with a minimum 9 to 12-month interval were selected as controls. All NVC images were evaluated by a qualitative and semi-quantitative assessment using current standardised approach [3]. Statistical analyses were conducted to explore NVC parameters trend throughout gestation and its possible association with pregnancy course and clinical macrovascular parameters (i.e., systemic blood pressure, umbilical artery Doppler ultrasound).

Results

A progressive significant increase of capillary neoangiogenesis and a specular reduction in capillary dilations was observed during pregnancy (p<0.05). These statistically significant variations were not found in age-matched controls, who showed stable NVC parameters over a similar time frame (p<0.05). Not any significant association was found between NVC changes and pregnancy course, delivery outcome or macrovascular parameters.

Conclusion

This first comprehensive longitudinal NVC evaluation during normal pregnancy reports significant physiological microvascular variations throughout gestation, suggesting NVC as a safe and promising technique for further investigate and define patterns of microvascular changes in pregnant patients with rheumatic diseases.

References

[1]Thevissen et al. Expert Rev Med Devices. 2017;14(12):961–7.

[2]Abdo et al. Physiol Res 2014;63:395–408.

[3]Smith et al. Autoimmun Rev 2020; 19(3):102458.

Disclosure of Interests

None declared

Use of BTK inhibitors with focus on ibrutinib in mantle cell lymphoma: an expert panel opinion statement

The introduction of BTK inhibitors transformed the management of patients with mantle cell lymphoma (MCL). Ibrutinib, the first-in-class BTK inhibitor is now approved in more than 80 countries and there are over 20 new BTK inhibitors in development. In addition, novel agents show potential clinical activity (alone and in combination) and are in the approval phase and/or being studied in ongoing clinical trials. How does the practicing clinician decide on the optimal therapeutic strategy for this highly heterogenous disease? In July 2020 a group of experts from Italy, convened a meeting to address and provide clarification on a series of outstanding issues in the treatment of MCL with the view of providing clinical guidance on its management. This expert opinion statement represents the panel's collective analysis, evaluation, and recommendations and is made up of a series of questions and answers (in the form of a review of the pertinent literature) designed to replicate those posed by practicing clinicians in Italy but which are applicable to clinical settings worldwide. This article is protected by copyright. All rights reserved.

Use of BTK inhibitors with special focus on ibrutinib in Waldenström macroglobulinemia: an expert panel opinion statement

The pivotal role that ibrutinib plays in the management of Waldenström macroglobulinemia (WM) is undisputed but there are ongoing questions regarding its positioning in the therapeutic algorithm of WM as well as in some peculiar clinical situations. A panel of experts from Italy was convened to provide real world recommendations on the use of BTK inhibitors in lymphoproliferative diseases in general, and in patients with WM in particular. This position paper represents the panel's collective analysis, evaluation, and opinions and is made up of a series of questions frequently asked by practicing clinicians and answers based on currently available evidence. This article is protected by copyright. All rights reserved.

P–606 A second stimulation in the same ovarian cycle rescues advanced-maternal-age patients obtaining ≤ 3 blastocysts after the conventional approach by preventing treatment-discontinuation

Study question

Is double stimulation in the same ovarian cycle (DuoStim) a valuable strategy to rescue advanced-maternal-age patients obtaining ≤ 3 blastocysts for chromosomal-testing after conventional stimulation?

Summary answer

DuoStim is effective to prevent treatment discontinuation thereby increasing the 1-year cumulative-live-birth-rate among advanced-maternal-age patients obtaining 0–3 blastocysts after a first conventional stimulation.

What is known already

Folliculogenesis is characterized by continuous waves of follicular growth. DuoStim approach exploits these dynamics to conduct two stimulations in a single ovarian cycle and improve the prognosis of advanced-maternal-age and/or reduced-ovarian-reserve women. Independent groups worldwide successfully adopted DuoStim with various regimens reporting similar oocyte/embryo competence after both stimulations. Recently, we have demonstrated the fruitful adoption of DuoStim in patients fulfilling the Bologna criteria, especially because of the prevention of treatment discontinuation. Here we aimed at investigating whether DuoStim can be adopted to rescue poor prognosis patients obtaining 0–3 blastocysts after the conventional approach.

Study design, size, duration

Proof-of-concept matched case-control study. All patients obtaining 0–3 blastocysts after conventional-stimulation between 2015–2018 were proposed DuoStim. The 143 couples who accepted were matched for maternal age, sperm factor, cumulus-oocyte-complexes and blastocysts obtained after the first stimulation to 143 couples who did not. The primary outcome was the 1-year cumulative-live-birth-rate. If not delivering, the control group had 1 year to undergo a second attempt with conventional-stimulation. All treatments were concluded (live-birth achieved or no euploid left).

Participants/materials, setting, methods

Only GnRH-antagonist with recombinant-gonadotrophins and agonist trigger stimulation protocols were adopted. All cycles entailed ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing and vitrified-warmed euploid single-embryo-transfer(s). Cumulative-live-birth-rate was calculated per patient considering both stimulations in the same ovarian cycle (DuoStim group) or up to two stimulations in 1 year (control group). Treatment discontinuation rate in the control group was calculated as patients who did not return for a second stimulation among non-pregnant ones.

Main results and the role of chance

Among the 286 couples included (41.0±2.9yr;4.9±3.1 cumulus-oocytes-complexes and 0.8±0.9 blastocysts), 126 (63 per group), 98 (49 per group), 52 (26 per group) and 10 (5 per group) obtained 0,1,2 and 3 blastocysts after the first stimulation, respectively. The cumulative-live-birth-rate was 9% in the control group after the first attempt (N = 13/143). Among the 130 non-pregnant patients, only 12 returned within 1-year (165±95days later;discontinuation rate=118/130,91%), and 3 delivered. Thus, the cumulative-live-birth-rate from two stimulations in 1-year was 11% (N = 16/143). In the DuoStim group, the cumulative-live-birth-rate was 24% (N = 35/143; Fisher’s-exact-test&lt; 0.01,power=80%). The odds-ratio of delivering in the DuoStim versus the control group adjusted for all matching criteria was 3.3,95%CI:1.6–7.0,p&lt;0.01. This difference (0%,22%,15% and 20% in the control versus 10%,31%,46% and 40% in the DuoStim group among patients obtaining 0,1,2 and 3 blastocysts at the first stimulation, respectively) is mainly due to treatment discontinuation in the control group (98%,65%,77% and 80% among patients obtaining 0,1,2 and 3 blastocysts at the first stimulation, respectively) and the further increased maternal age at the time of second retrieval (∼6 months). Notably, 2 patients delivered 2 live-births after DuoStim (none in the control) and 14 patients with a live-birth have euploid blastocysts left (2 in the control).

Limitations, reasons for caution

Randomized-controlled-trials and cost-effectiveness analyses are desirable to confirm these data. Moreover, 75% of the patients included were &gt;39yr and 44% obtained no blastocyst after the first stimulation. Therefore future studies among younger women and/or more women obtaining ≥1 blastocyst are advisable to set reasonable cut-off values to apply this strategy.

Wider implications of the findings: A second stimulation in the same ovarian cycle might be envisioned as a rescue strategy for poor IVF outcomes after a first stimulation, so to prevent treatment discontinuation and increase the cumulative-live-birth-rate. This is feasible since 6–7 days span the first and the second stimulation in the DuoStim protocol.

Trial registration number

none

Lung Transplantation for Acute Respiratory Distress Syndrome Related to COVID-19: The Lesson Learned from the First Two Cases

Purpose

The respiratory system, and namely the lung, is undoubtedly the preferential target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical pictures are extremely various, up to the intensive care unit (ICU) admission for acute respiratory distress syndrome (ARDS). Lung transplantation (LT) is a consolidate therapeutic option for end-stage chronic respiratory diseases. Its role in an acute setting is questionable, particularly due to lack of experiences, donor shortage, and the difficulty to fully evaluate the potential recipient. We report our preliminary experience with the first two cases of LT for SARS-CoV-2 related ARDS, trying to provide some food for thought.

Methods

We retrospectively analysed our first two cases of bilateral LT for ARDS after COVID-19. We recorded data on pre-transplantation clinical course, transplantation management and outcomes.

Results

The two patients had a similar clinical evolution of COVID-19. Transplantations were successful in both cases; the first patient is alive and in good condition 5 months after transplantation, while the second died 62 days after surgery. Table 1 shows clinical details and relevant time-points.

Conclusion

Our experience showed that LT for COVID-19 is feasible. Importantly, observing a dedicated protocol made the procedure safe for the healthcare staff involved. On the other hand, our second unsuccessful case poses relevant questions: first of all, lung transplantation should be reserved to highly selected patient, after careful clinical, infective as well as psychiatric evaluation. The ethical aspects should also be considered in this situation, with regard to the centre rate mortality on waiting list. Anyway, the potential role of LT in the acute and sub-acute/chronic settings suggests the need for maintaining LT centre active during pandemic. Finally, COVID-19, once more, imposes to share clinical experiences.

Lung Allograft Dysfunction in a COVID-19 Transplanted Patient is Associated with a Peculiar Immunopathological Phenotype

Purpose

Lung transplantation (LT) after severe SARS-CoV-2 infection is emerging as a life-saving medical procedure for selected patients who experience acute respiratory distress syndrome (ARDS). We present the first immunopathological evaluation of a lung allograft rejection in a patient who underwent LT because of irreversible ARDS related to COVID-19.

Methods

Two male patients with irreversible ARDS caused by COVID-19 underwent bilateral LT at our Institution. A surveillance transbronchial biopsy (TBB) was performed 2 months after LT in the first patient (Pt#1), while the second patient (Pt#2) died because of allograft rejection at day 62 post LT and explanted lungs were retrieved. CT imaging of the lungs was performed three days before death. Morphological examination was performed by H&E, whereas the immunophenotyping was performed by immunohistochemistry.

Results

Imaging and morphological examination of Pt#2 lungs indicated the presence of a graft dysfunction with features of a restrictive, widespread usual interstitial pneumonia-like syndrome (Fig. 1A, B). The immunophenotyping showed that B-lymphocytes (CD20-positive) were nearly absent, CD8-T-cells were not particularly expanded (mean positive cells within the lung stroma=13.8%; Fig. 1C), and the CD4/CD8 ratio was not decreased (Fig. 1D). The T-regs (Foxp3-positive) were 6% of the overall population (Fig. 1E). Analysis of the immune checkpoint molecules PD1, Tigit, CTLA4 and PDL1 showed that the expression of PD-L1 alone was highly increased in vases and in alveolar cells of rejected lungs, whereas it was nearly undetectable in the TBB from Pt#1 (Fig. 1F, G).

Conclusion

PDL1 expression in vases was previously documented as a sign of indirect ARDS. Together with our preliminary data, we can hypothesize that PDL1 may play a role in tissue effacement and graft failure, possibly indicating poor allograft prognosis.

Trabectedin for the therapy of ovarian cancer

Trabectedin is a marine-derivate antitumor drug with a relevant cytotoxic activity and good safety profile. It has been investigated for the treatment of solid diseases, including ovarian cancer (OC), breast cancer, and soft-tissue sarcoma. In 2009, results from the pivotal trial OVA-301 led the European Medicines Agency (EMA) to the approval of trabectedin in combination with PEGylated liposomal doxorubicin for the treatment of platinum-sensitive recurrent OC; further studies revealed an additional benefit also in the subgroup of patients with partially platinum-sensitive disease and in those with a BRCA-mutated status. Additionally, trabectedin demonstrated to prolong the time interval to the subsequent chemotherapy line. Recently, the improved understanding of the antitumor action exerted by trabectedin paved the way to new investigational trials exploring its combination with targeted therapies.

Relugolix for the treatment of uterine fibroids

Uterine leiomyomas represent the most common form of benign gynecological tumors affecting 20-40% of women during their life. Several therapeutic options are available for treating these patients. The use of medical treatment for myomas has largely grown in the last years, in particular for women who would refuse, postpone or are not candidates for surgery. In the last years, the clinical investigation of gonadotropin-releasing hormone (GnRH) antagonists (GnRH-ants) has emerged. This class of drugs exerts pure competitive antagonistic activity on the GnRH receptor at the pituitary gland, producing an immediate stop in the release of gonadotropins and sex steroids. Relugolix is an orally active nonpeptide GnRH-ant, recently licensed for marketing in Japan for the treatment of symptoms related to uterine myomas. Currently, several phase III clinical trials are ongoing to evaluate this molecule in this setting in the U.S. and Europe.

Elagolix sodium for the treatment of women with moderate to severe endometriosis-associated pain

First-line medical therapies for treating pain associated with endometriosis mainly consist in combined oral contraceptives and progestins. However, some women, having persistence of symptoms, may require further therapeutic options. Among these, gonadotropin-releasing hormone (GnRH) agonists (GnRH-as) have been widely employed in the last 30 years, despite being characterized by an unfavorable safety profile. Currently, new alternative investigational options are being investigated to treat this benign chronic disease. GnRH antagonists (GnRH-ants) are innovative hormonal drugs that do not induce flare-up effects and present also a limited onset of hypoestrogenic symptoms; in fact, their pharmacological mechanism of action, which consists in pure antagonistic activity, differs from that of traditional GnRH-as. In July 2018, the U.S. Food and Drug Administration (FDA) approved elagolix sodium for the management of moderate to severe pain associated with endometriosis, after the drug showed promising efficacy and safety results in previous phase III trials. This monograph aims to provide a complete overview of the pharmacokinetics, clinical efficacy and safety of this GnRH-ant for treat¬ing patients with endometriosis.

Transvaginal sonography with vs without bowel preparation in diagnosis of rectosigmoid endometriosis: prospective study

OBJECTIVES

The primary aim of this study was to compare the diagnostic accuracy of transvaginal sonography (TVS) with vs without bowel preparation (BP) in detecting the presence of rectosigmoid endometriosis. Secondary objectives were to compare the diagnostic accuracy of the two techniques in estimating infiltration of the submucosa, length of the largest rectosigmoid nodules, distance of the nodules from the anal verge and presence of multifocal disease.

METHODS

This was a prospective study of patients with symptoms of pelvic pain for more than 6 months and/or suspicion of endometriosis referred to our institution between October 2016 and April 2018. Participants underwent a first TVS without BP followed by TVS with BP within a time interval of 1 week to 3 months. The examinations were performed independently and blindly by two sonographers. Only patients who underwent laparoscopy within the 6 months following the second ultrasound examination were included. Ultrasound results using the two techniques were compared with surgical and histological findings.

RESULTS

Of the 262 patients included in the study, 118 had rectosigmoid endometriosis confirmed at surgery. There was no significant difference in accuracy between TVS with and that without BP in diagnosing the presence of rectosigmoid endometriosis (93.5% vs 92.3%; P = 0.453). No significant difference was observed in accuracy between TVS with and that without BP in diagnosing submucosal infiltration (88.8% vs 84.6%; P = 0.238) and multifocal disease (97.2% vs 95.2%; P = 0.727) in patients diagnosed sonographically with rectosigmoid endometriosis. The accuracy of TVS with BP was similar to that of TVS without BP in estimating the maximum diameter of the largest nodule (P = 0.644) and the distance between the more caudal rectosigmoid nodule and the anal verge (P = 0.162).

CONCLUSION

BP does not improve the diagnostic performance of TVS in detecting rectosigmoid endometriosis and in assessing characteristics of endometriotic nodules. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Abstract P2-08-21: Mismatch repair protein loss is a prognostic and predictive biomarker in breast cancers regardless of microsatellite instability

Despite the approval of pembrolizumab in all tumors showing mismatch-repair (MMR) deficiency and/or microsatellite instability (MSI), there are currently no companion diagnostics for MMR status assessment in breast cancer. Here, we sought to define the diagnostic and prognostic role of MMR and MSI testing in breast cancer patients.

We subjected 444 breast cancers to MMR immunohistochemistry (IHC) and MSI analysis. Cases were classified as MMR-proficient (pMMR), MMR-deficient (dMMR), and MMR-heterogeneous (hMMR) based on the loss of immunoreactivity; MSI was defined by the instability in the five indicators recommended by the National Cancer Institute for endometrial and colorectal cancers. Correlation of MMR status with patients' survival was assessed using the Kaplan-Meier estimator.

In 75 patients (17%) the loss of MMR proteins was homogeneous, classified as dMMR, while 55 cases (12%) were hMMR. The prevalence of cancers with loss of the MMR proteins was homogeneous across ER+ breast cancers (15-19% for dMMR and 10-18% for hMMR tumors). The level of overlap between IHC and MSI analysis was 9% (p&lt;0.0001). Among ER+/HER2- carcinomas, pMMR and hMMR patients displayed better survival rates (p=0.008). In chemo-treated ER-/HER2- breast cancers, the dMMR status was a marker of good prognosis (p&lt;0.001).

Our study documents the clinical impact of MMR testing in a large series of breast cancers, using the most commonly adopted diagnostic tools and criteria. We show that MMR protein loss is a rather common event in breast cancer and has a remarkable degree of intra-tumor heterogeneity, therefore making the analysis of a small area of the tumor, or a small biopsy, of little clinical value. Our investigation supports the concept that MSI occurs rarely in breast cancer and demonstrate that this condition is restricted to a minority of tumors with MMR protein loss. These data suggest that MMR IHC and MSI analysis should not be considered as interchangeable tests in the diagnostic workup of breast carcinomas. Finally, our observations indicate that the complete loss of at least one of the MMR proteins assessed by IHC is able to identify high-risk ER+/HER2- breast cancers that can potentially benefit from pembrolizumab therapy, whereas first-line chemotherapy shows comparatively good results in dMMR ER-/HER2- breast cancers.

Citation Format: Fusco N, Lopez G, Corti C, Pesenti C, Colapietro P, Ercoli G, Gaudioso G, Faversani A, Gambini D, Despini L, Blundo C, Vaira V, Miozzo M, Ferrero S, Bosari S. Mismatch repair protein loss is a prognostic and predictive biomarker in breast cancers regardless of microsatellite instability [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-21.

Influence of adenomyosis on pregnancy and perinatal outcomes in women with endometriosis

OBJECTIVES

Several studies have investigated the correlation between endometriosis and adverse pregnancy and perinatal outcomes. However, the role of adenomyosis as a risk factor for adverse perinatal outcome in women with endometriosis has yet to be established. The aim of this study was to explore if fetal and maternal outcomes, in particular the incidence of a small-for-gestational-age (SGA) infant, are different in pregnant women with endometriosis only from in those with the concomitant presence of diffuse or focal adenomyosis.

METHODS

This was a retrospective analysis of data collected prospectively during a 3-year period. We included 206 pregnant women with endometriosis: 148 (71.8%) with endometriosis only, 38 (18.4%) with focal adenomyosis and 20 (9.7%) with diffuse adenomyosis. Adenomyosis was diagnosed using ultrasonography and was classified as focal or diffuse. The study included patients who conceived spontaneously or by an assisted reproductive technique. Demographics, ultrasound variables and outcome were compared between women with endometriosis only and those with diffuse and those with focal adenomyosis. Logistic regression analysis was performed to assess the association of variables with SGA at birth in women with diffuse and those with focal adenomyosis.

RESULTS

The three groups were similar in demographic characteristics (age, body mass index, mode of conception). Patients with diffuse adenomyosis compared with those with endometriosis only had significantly lower pregnancy-associated plasma protein A (0.61 vs 0.88 multiple of the median, P < 0.001), higher mean uterine artery pulsatility index in the first (2.23 vs 1.67, P < 0.001) and second (1.30 vs 0.94, P < 0.001) trimesters of pregnancy, and higher incidence of SGA (40% vs 10.8%, P < 0.001). No statistically significant differences were found in patients with focal adenomyosis compared with those with endometriosis only. Logistic regression analysis demonstrated that diffuse adenomyosis (odds ratio = 3.744; 95% CI, 1.158-12.099; P = 0.027) was the only independent risk factor for SGA.

CONCLUSIONS

The presence of diffuse adenomyosis in pregnant women with endometriosis is strongly associated with delivery of a SGA infant. Women with diffuse adenomyosis should be treated as being at high risk of placental dysfunction, and these pregnancies might therefore need closer monitoring. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Bronchial Carcinoid with S-100 Positive Sustentacular Cells

A case of double bronchial typical carcinoid of the central type, with a nodal metastasis and paraneoplastic Cushing syndrome is reported. The case is remarkable because both the primary tumors and nodal metastasis were composed of a duoble cell population: one was arranged in nests, was argyrophilic, immunostained with PHE-5 monoclonal antibody, and contained neurosecretory granules; the other one was neither argyrophilic nor PHE-5-immunoreactive, but was strongly immunoreactive for S-100 protein, had a stellate morphology and was at the periphery of the nests of the other cells. The S-100 immunoreactive cells were regarded as a sort of « sustentacular » or « satellite » cells, which are themselves neoplastic. Bronchial carcinoids with S-100 positive cells, although strictly related with other bronchial carcinoids, may in fact represent a group of tumors with different histogenesis and/or differentiative pattern. More work should be done to elucidate whether there is any relevant clinical difference between bronchial carcinoids with or without S-100 reactive cells.

Ficoll-hypaque separation vs whole blood lysis: Comparison of efficiency and impact on minimal residual disease analysis

INTRODUCTION

The high-throughput era remarkably changed molecular laboratory practice. Actually, the increasing number of processed samples requires to reduce the risk of operator biases, by automating or simplifying as much as possible both the analytical and the pre-analytical phases. Minimal residual disease (MRD) studies in hematology often require a simultaneous processing of many bone marrow and peripheral blood samples from patients enrolled in prospective, multicenter, clinical trials, monitored at several planned time points.

METHODS

In this study, we demonstrate that red blood cell lysis (RBL) pre-analytical procedure can replace the time-consuming Ficoll stratification as cell recovering step. Here, we show a MRD comparison study using both total white blood cells and mononuclear cells recovered by the 2 procedures from 46 follicular lymphoma (FL), 15 multiple myeloma (MM), and 11 mantle cell lymphoma (MCL) patients enrolled in prospective clinical trials.

RESULTS

The experiments were performed in the 4 laboratories of the Fondazione Italiana Linfomi (FIL) MRD Network and showed superimposable results, in terms of good correlation (R = 0.87) of the MRD data obtained by recovering blood cells by the 2 approaches.

CONCLUSION

Based on these results, the FIL MRD Network suggests to optimize the pre-analytical phases introducing RBL approach for cell recovery in the clinical trials including MRD analysis.

Mixed malignant mullerian tumor with neuroendocrine features in an irradiated uterus for cervical carcinoma. A unique association? A morphological, immunohistochemisty and ultrastructural study

Chemo-radiation represents an effective therapy for carcinoma of the uterine cervix. The endometrium may however receive a consistent dose of mutagenic radiations and patients may have an increased risk of secondary malignancies. Endometrial mixed malignant mullerian tumor (MMMT) is a rare, highly aggressive disease, and neuroendocrine features are even rarer. A 68 years old woman underwent radio-chemotherapy for a squamous cell carcinoma of the cervix. Follow up was uneventful until, eight years after radio-chemotherapy, imaging exams detected a diffuse enlargement of the uterine body. Radical hysterectomy revealed a multiphasic lesion with both sarcomatous and mixed carcinomatous components. The carcinomatous, component presented neuroendocrine histologic and ultrastuctural features and an intense expression of neuroendocrine immunohistochemistry markers. No residual cervical carcinoma was documented (pR0). The patient died of disease after 9 months. Reported cases further demonstrate how the irradiation of the uterus for cervical cancer carries a not negligible risk of developing a second endometrial cancer. The second cancer may develop years after initial therapy and may have aggressive histologic and clinical features. This case underlines the importance for a long follow-up in women having received radio-chemotherapy alone.