Sentinel lymph node biopsy utilization in early-stage vulvar cancer: A National Cancer Database Study

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Background: Since 2012, sentinel lymph node biopsy (SLNB) has been considered equivalent in terms of survival to standard inguinofemoral lymphadenectomy (IFLD) in patients with early-stage vulvar cancer. Moreover, SLNB is associated with lower rates of postoperative short-term and long-term morbidity. However, uptake of SLNB has been limited and little information exists about factors associated with access to SLNB in vulvar cancer. Methods: Between 2012-2018, women with stage IB vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients who underwent SLNB versus IFLD. Multivariable logistic regression analyses, adjusted for patient, facility, and disease characteristics were used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. Results: Of the 3,454 patients, 1,094 (31.6%) did not undergo lymph node evaluation (LNE) and 2,360 (68.3%) underwent LNE, with 1,668 (82.0%) undergoing IFLD and 692 (29.3%) SLNB. On multivariable analysis, patients diagnosed between 2015-2018 were more likely to undergo SLNB than patients diagnosed 2012-2014 (OR 1.86, 95% CI 1.50-2.31). Patients residing in zip codes with the highest proportion of high school graduates were more likely to undergo SLNB than those residing in regions with lower levels of education (OR 2.00, 95% CI 1.28-3.13). Midwestern patients were less likely to undergo SLNB than those in the Northeast (OR 0.70, 95% CI 0.50-0.96). Hospital volume was significantly associated with SLNB rates, with low-volume hospitals defined as those performing 0-8 vulvectomies/year, moderate-volume performing 8-16, and high-volume performing 16-45. Moderate (OR 1.58, 95%CI 1.18-2.09) and high (OR 2.12, 95% CI 1.56-2.88) volume hospitals were associated with higher rates of SLNB compared to low-volume hospitals. Patients with tumors > 3cm in size were less likely to undergo SLNB than those < 1cm in size (OR 0.69, 95% CI 0.50-0.94). After controlling for patient and tumor characteristics, there was no difference in overall survival (OS) between patients who underwent SLNB and those who underwent IFLD with negative nodes (HR 0.90, 95% CI 0.70-1.15). Similarly, there was no difference in OS between patients who underwent SLNB (with or without subsequent IFLD) and those who underwent IFLD alone with positive nodes (HR 0.99, 95% CI 0.60-1.61). Conclusions: Utilization of SLNB in early-stage vulvar cancer continues to increase over time but significant variation in its use exists at the patient, hospital, and regional level. The lack of survival difference between the two procedures suggests overtreatment in the 71% of node-negative women who underwent IFLD. Further work is needed to de-escalate care that has previously been associated with worse postoperative outcomes in this population.

Patient reported outcomes after risk-reducing surgery in patients at increased risk of ovarian cancer

OBJECTIVE

To describe the quality of life of women at an increased risk of ovarian cancer undergoing risk-reducing bilateral salpingo-oophorectomy (RRBSO).

METHODS

Patients evaluated in our gynecologic oncology ambulatory practice between January 2018-December 2019 for an increased risk of ovarian cancer were included. Patients received the EORTC QLQ-C30 and PROMIS emotional and instrumental support questionnaires along with a disease-specific measure (PROM). First and last and pre- and post-surgical PROM responses in each group were compared as were PROMs between at-risk patients and patients with other ovarian diseases.

RESULTS

195 patients with an increased risk of ovarian cancer were identified, 155 completed PROMs (79.5%). BRCA1 or BRCA2 mutations were noted in 52.8%. Also included were 469 patients with benign ovarian disease and 455 with ovarian neoplasms. Seventy-two at-risk patients (46.5%) had surgery and 36 had both pre- and post-operative PROMs. Post-operatively, these patients reported significantly less tension (p = 0.011) and health-related worry (p = 0.021) but also decreased levels of health (p = 0.018) and quality of life <7d (0.001), less interest in sex (p = 0.014) and feeling less physically attractive (p = 0.046). No differences in body image or physical/sexual health were noted in at-risk patients who did not have surgery. When compared to patients with ovarian neoplasms, at-risk patients reported lower levels of disease-related life interference and treatment burden, less worry, and better overall health.

CONCLUSIONS

In patients with an increased risk of ovarian cancer, RRBSO is associated with decreased health-related worry and tension, increased sexual dysfunction and poorer short-term quality of life. Patients with ovarian neoplasms suffer to a greater extent than at-risk patients and report higher levels of treatment burden and disease-related anxiety.

The use of neoadjuvant chemotherapy in advanced endometrial cancer

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Neoadjuvant chemotherapy is a feasible treatment option in advanced endometrial cancer not amenable to primary surgery.

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High rates of subsequent interval cytoreductive surgery are achievable.

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Cytoreductive surgery after chemotherapy results in improved progression-free and overall survival.

The objective of this retrospective cohort study was to review the use of neoadjuvant chemotherapy followed by interval cytoreductive surgery in patients presenting with advanced, unresectable endometrial cancer at two large cancer centers. Patients with advanced endometrial cancer treated with neoadjuvant chemotherapy between 2008 and 2015 were identified from an institutional database. Clinical and surgical variables were analyzed and time to recurrence and death was calculated and compared between surgical groups. Thirty-three patients were identified (mean age 64.8 (range 42–86 years)). Overall, 28% of patients had endometrioid histology, 48% serous, 4% clear cell, 4% carcinosarcoma, 12% mixed and 4% other. Ineligibility for primary surgery was due to unresectable disease (85%), comorbidities (6%) and unknown reasons (9%). All patients received neoadjuvant chemotherapy with 91% of patients receiving carboplatin and paclitaxel. On reimaging, 12% of patients had progressed, 76% had a partial response and 3% had a complete response to chemotherapy. 76% of patients underwent interval surgery, with cytoreduction to no visible residual disease achieved in 52%. Overall, 91% of patients recurred and 85% died during follow-up. Patients undergoing surgery after chemotherapy had significantly longer progression-free survival (11.53 vs. 4.99 months, p = 0.0096) and overall survival (24.13 vs. 7.04 months, p = 0.0042) when compared to patients who did not have surgery. Neoadjuvant chemotherapy is a feasible treatment option to allow for interval cytoreductive surgery in patients with advanced endometrial cancer not amenable to primary debulking. Patients who undergo surgery after chemotherapy have significantly improved progression free and overall survival.

Effect of surgical approach on risk of recurrence after vaginal brachytherapy in early-stage high-intermediate risk endometrial cancer

OBJECTIVE

The objective was to determine if surgical approach affects time to recurrence in early-stage high-intermediate risk endometrial cancer (HIR-EC) treated with adjuvant vaginal brachytherapy (VBT).

METHODS

In this retrospective cohort study, HIR-EC patients treated with VBT between 2005 and 2017 were identified and those who received open or minimally invasive hysterectomies (MIS) were included. Clinical and surgical variables were analyzed and time to recurrence was compared between surgical groups.

RESULTS

We identified 494 patients, of which 363 had MIS hysterectomies, 92.5% had endometrioid histology, 45.7% were stage IA and 48.0% stage IB. Open hysterectomy patients had higher BMIs (p = 0.007), lower rates of lymph node sampling (p < 0.001) and lymphovascular space invasion (LVSI) (p = 0.036), however in patients who recurred, no differences were noted between groups. Overall, 65 patients (13.2%) recurred, 14 in the open group (10.7%) and 51 in the MIS group (14.0%) (p = 0.58), while vaginal recurrences were noted in 4.6% and 6.1% respectively. When compared to the open group, the MIS group had a significantly shorter time to any recurrence (p = 0.022), to pelvic (p = 0.05) and locoregional recurrence (p = 0.021) and to death from any cause (p = 0.039). After adjusting for age, BMI, grade, LVSI and surgery date, the MIS group had a higher risk of any recurrence (HR 2.29 (1.07-4.92), p = 0.034) and locoregional recurrence (HR 4.18 (1.44-12.1), p = 0.008).

CONCLUSIONS

Patients with HIR-EC treated with VBT after MIS hysterectomy have a shorter time to recurrence and higher risk of recurrence when compared to open hysterectomy patients. Further studies into the safety of MIS in high-intermediate risk patients are required.

Outcomes of minimally invasive versus open abdominal hysterectomy in patients with gestational trophoblastic disease

OBJECTIVE

The aim of this study is to compare surgical and oncologic outcomes for women undergoing MIH or open abdominal hysterectomy (OAH) for management of gestational trophoblastic disease (GTD).

METHODS

Patients who underwent hysterectomy for GTD between January 1, 2009 and December 31, 2018 were identified using an institutional database and tumor registry. Patients were stratified based on indication for and mode of hysterectomy.

RESULTS

39 patients underwent hysterectomy for GTD - 22 MIH and 17 OAH. 26 hysterectomies (66.7%) were performed for primary treatment of GTD, 7 (17.9%) for chemoresistance, 2 (5.1%) for uterine hemorrhage, and 4 (10.3%) for other indications. Mean tumor size (4.2 vs 4.6 cm; p = .81) and operative time (136 vs 163 mins; p = .42) were similar in both groups. MIH was associated with significantly less blood loss (71.5 vs 427.3 ml; p = .03) and shorter hospital stay (1.5 vs 3.9 days, p = .02) than OAH. Postoperative histology comprised 12 complete moles (6 invasive), 8 choriocarcinomas, 9 placental site trophoblastic tumors and 9 epithelioid trophoblastic tumors. Median follow-up was 67.2 months (50.2 MIH, 79.3 OAH; range 11.1-131.2) and there was no difference in remission (81.8% MIH vs 76.5% OAH; p = .68). There were 7 recurrences (4 MIH, 3 OAH) and 3 deaths (2 MIH, 1 OAH). Overall survival was 97.3% at 2 years and 88.5% at 5 years. There was no significant difference in 5-year survival by mode of surgery (MIH 90.9%, OAH 83.3%; p = .40).

CONCLUSIONS

Patients undergoing MIH at our centers have similar oncologic outcomes, lower surgical blood loss and shorter hospital stay compared to those undergoing OAH. Overall survival is similar regardless of mode of surgery.

Phase 2, two-group, two-stage study of avelumab in patients (pts) with microsatellite stable (MSS), microsatellite instable (MSI), and polymerase epsilon (POLE) mutated recurrent/persistent endometrial cancer (EC)

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Background: This non-randomized phase 2 study evaluated the PD-L1 inhibitor avelumab in two cohorts of EC: i) MSI/ POLE cohort including ECs with immunohistochemical (IHC) loss of expression of at least one of the mismatch repair (MMR) proteins and/or documented mutation in the exonuclease domain of POLE and ii) MSS cohort including ECs with normal IHC expression of all MMR proteins. Methods: Eligibility criteria included measurable disease, unlimited prior therapies, and any EC histology. Co-primary endpoints were confirmed objective response (OR) and progression-free survival rate at 6 months (PFS6). Avelumab 10 mg/kg IV was given every 2 weeks until progression or unacceptable toxicity. In the 1st stage, 16 pts were enrolled in each cohort; if there were ≥2 ORs or ≥2 PFS6 responses, accrual would continue to the 2nd stage with enrollment of 19 additional pts. Overall, if there are ≥4 ORs or ≥8 PFS6 responses, avelumab would be considered worthy of further study in each cohort. Results: As of 12/2018, 33 pts were enrolled. The MSS cohort was closed at the 1st stage due to futility; of 16 pts in the MSS cohort, only 1 pt exhibited an OR and PFS6 response [ORR and PFS6 rate 6.25% (95% CI 0.16%-30.2%)]. Conversely, the MSI/POLE cohort reached the primary endpoint of 4 ORs after accrual of only 17 pts. Two pts in the MSI/POLE cohort did not initiate protocol therapy and were excluded from all analyses. Of 15 pts in the MSI/POLE cohort, 4 pts exhibited OR [1CR+3PRs, OR rate (ORR) 26.7% (95% CI 7.8%-55.1%)] and 6 pts (including the 4 pts with OR) exhibited PFS6 responses [PFS6 rate 40.0% (95% CI 16.3%-66.7%)], 4 ongoing and 3 approaching 2 yrs. Twenty-two pts (71%) reported treatment related toxicities, 6 patients (19%) G3 toxicities; there were no treatment-related G4 and G5 toxicities. In the MSI/POLE cohort, 5 of 6 PFS6 responses were observed in pts with ≥3 lines of prior therapy (p = 0.011) and in tumors who were PD-L1 negative by IHC. Further correlative work will be reported at the meeting. Conclusions: In EC pts stratified by MSI/POLE status, MSI vs MSS status appears to be correlated with avelumab response even in PD-L1 negative tumors. Responses in the MSI/POLE cohort were more frequent in more heavily pretreated patients, a finding that warrants further investigation. Clinical trial information: NCT02912572.

Patient, treatment and discharge factors associated with hospital readmission within 30days after surgery for vulvar cancer

OBJECTIVES

The majority of hospital readmissions are unexpected and considered adverse events. The goal of this study was to examine the factors associated with unplanned readmission after surgery for vulvar cancer.

METHODS

Patient demographic, treatment, and discharge factors were collected on 363 patients with squamous cell carcinoma in situ or invasive cancer who underwent vulvectomy at our institution between January 2001 and June 2014. Clinical variables were correlated using χ² test and Student's t-test as appropriate for univariate analysis. Multivariate analysis was then performed.

RESULTS

Of 363 eligible patients, 35.6% had in situ disease and 64.5% had invasive disease. Radical vulvectomy was performed in 39.1% and 23.4% underwent lymph node assessment. Seventeen patients (4.7%) were readmitted within 30days, with length of stay ranging 2 to 37days and 35% of these patients required a re-operation. On univariate analyses comorbidities, radical vulvectomy, nodal assessment, initial length of stay, and discharge to a post acute care facility (PACF) were associated with hospital readmission. On multivariate analysis, only discharge to a PACF was significantly associated with readmission (OR 6.30, CI 1.12-35.53, P=0.04). Of those who were readmitted within 30days, 29.4% had been at a PACF whereas only 6.6% of the no readmission group had been discharged to PACF (P=0.003).

CONCLUSIONS

Readmission affected 4.7% of our population, and was associated with lengthy hospitalization and reoperation. After controlling for patient comorbidities and surgical radicality, multivariate analysis suggested that discharge to a PACF was significantly associated with risk of readmission.

A SNaPshot of potentially personalized care: Molecular diagnostics in gynecologic cancer

BACKGROUND

Genetic abnormalities underlie the development and progression of cancer, and represent potential opportunities for personalized cancer therapy in Gyn malignancies.

METHODS

We identified Gyn oncology patients at the MGH Cancer Center with tumors genotyped for a panel of mutations by SNaPshot, a CLIA approved assay, validated in lung cancer, that uses SNP genotyping in degraded DNA from FFPE tissue to identify 160 described mutations across 15 cancer genes (AKT1, APC, BRAF, CTNNB1, EGFR, ERBB2, IDH1, KIT, KRAS, MAP2KI, NOTCH1, NRAS, PIK3CA, PTEN, TP53).

RESULTS

Between 5/17/10 and 8/8/13, 249 pts consented to SNaPshot analysis. Median age 60 (29-84) yrs. Tumors were ovarian 123 (49%), uterine 74(30%), cervical 14(6%), fallopian 9(4%), primary peritoneal 13(5%), or rare 16(6%) with the incidence of testing high grade serous ovarian cancer (HGSOC) halving over time. SNaPshot was positive in 75 (30%), with 18 of these (24%) having 2 or 3 (n=5) mutations identified. TP53 mutations are most common in high-grade serous cancers yet a low detection rate (17%) was likely related to the assay. However, 4 of the 7 purely endometrioid ovarian tumors (57%) harbored a p53 mutation. Of the 38 endometrioid uterine tumors, 18 mutations (47%) in the PI3Kinase pathway were identified. Only 9 of 122 purely serous (7%) tumors across all tumor types harbored a 'drugable' mutation, compared with 20 of 45 (44%) of endometrioid tumors (p<0.0001). 17 pts subsequently enrolled on a clinical trial; all but 4 of whom had PIK3CA pathway mutations. Eight of 14 (47%) cervical tumors harbored a 'drugable' mutation.

CONCLUSION

Although SNaPshot can identify potentially important therapeutic targets, the incidence of 'drugable' targets in ovarian cancer is low. In this cohort, only 7% of subjects eventually were treated on a relevant clinical trial. Geneotyping should be used judiciously and reflect histologic subtype and available platform.

Racial disparities in cervical cancer mortality over time

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Background: The aim of this study is to examine changes over time in survival for African-American (AA) and white women diagnosed with cervical cancer (CeCa). Methods: Surveillance, Epidemiology, and End Results (SEER) Program data 9 for 1983-2007 were used for this analysis. Kaplan–Meier and Cox proportional hazards survival methods were used to assess differences in survival by race at 5-year intervals. Results: The study included 23,722 women; including 19,777 whites and 3,945 AA. AAs were older (51.4 vs. 49 years; p<0.001), had a higher rate of regional (38.3% vs. 31.7; p<0.001) and distant metastasis (10.5% vs. 8.5; p<0.001). AAs received less frequently cancer-directed surgery (53.1% vs. 65.7%; p<0.001), and more frequently radiotherapy (56.9% vs. 47.3%; p<0.001). AAs had a hazard ratio (HR) of 1.40 (95% CI, 1.31-1.49) of CeCa mortality compared to whites. Adjusting for SEER registry, marital status, stage, age, surgery, radiotherapy, grade and histology, AA women had a HR of 1.15 (95% CI, 1.07-1.24) of CeCa related mortality. AAs had a higher HR of all cause mortality and CeCa related mortality for all the five-year diagnosis cohorts (Table). After adjusting for the same variables, there was a significant difference in survival in the 1988-1992 group (HR 1.26; 95% CI 1.09-1.47). Conclusions: The present data indicates significant survival differences by race for women with invasive CeCa. After adjusting for SEER registry, marital status, stage, age, surgery, radiotherapy, grade and histology, only between 1988-1992 there was a difference in survival between the groups. [Table: see text]

Inhibition of gamma-secretase activity in combination with paclitaxel to reduce platinum-resistant ovarian tumor growth

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Background: Ovarian cancer (OvCa) is the most lethal gynecologic malignancy in the United States. Chemotherapy is effective but seldom curative, mainly due to the development of chemoresistant recurrent disease. Our current research investigates the efficacy of inhibiting the Notch pathway with a gamma-secretase inhibitor (GSI), MRK-003, in an OvCa xenograft model as a single agent therapy and in combination with standard chemotherapy. Methods: Mice bearing xenografts derived from clinically platinum sensitive human ovarian serous carcinomas were treated with GSI or vehicle, or with either vehicle, GSI alone, paclitaxel and carboplatinum (T/C) alone, or the combination of GSI and T/C. In addition, mice bearing xenografts derived from patients with clinically platinum resistant disease were given GSI with or without paclitaxel. Gene transcript levels of several factors in the Notch pathway were analyzed using RT-PCR. Notch1 and Notch3 protein levels were evaluated by western blotting. The Wilcoxon rank-sum test was used to assess significance between the different treatment groups. Results: Expression of Notch1 and Notch3 was highly variable across all analyzed OvCa samples. Treatment with GSI alone significantly decreased tumor growth in 3 of 4 platinum sensitive ovarian tumors (all p < 0.05), as well as in 1 of 3 platinum resistant tumors (p = 0.04). Furthermore, the combination of GSI and paclitaxel was significantly more effective than GSI alone and paclitaxel alone in all platinum resistant ovarian tumors (all p < 0.05). The addition of GSI did not alter the effect of T/C in platinum sensitive tumors. Although the response of each tumor to GSI did not correlate with its endogenous level of Notch expression, 2 of the 3 tumors resistant to paclitaxel but sensitive to the combination of GSI and paclitaxel showed elevated Notch activity by RT-PCR. Conclusions: Inhibition of the Notch signaling cascade with a gamma-secretase inhibitor reduces tumor growth in vivo, most notably in combination with paclitaxel in a platinum resistant setting. These promising findings underscore the need for further investigation of the preclinical and clinical effectiveness of Notch inhibitors in OvCa.

Targeting the PI3K signaling cascade in PIK3CA mutated endometrial cancer in a primary human xenograft model

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Background: Alterations in the PI3K pathway are highly prevalent in endometrial cancer due to PIK3CA mutation and loss of PTEN. Given these data, we investigated the anti-tumor activity of the PI3K inhibitor NVP-BKM120 (BKM) as a single agent and in combination with standard cytotoxic chemotherapy in a human primary endometrial xenograft model. Methods: NOD/SCID mice bearing xenografts of primary human tumors with and without PIK3CA gene mutations were randomly divided into two- and four-arm cohorts with equivalent tumor volumes. Three single agent experiments tested the effectiveness of NVP-BKM120 against two endometrioid (PIK3CA wild type and H1047L mutant) and one carcinosarcoma (PIK3CA R88Q mutant) endometrial cancer. Three four arm experiments tested NVP-BKM120 alone and in combination with paclitaxel and carboplatin (P/C) in two endometrioid tumors (both R88Q) and one carcinosarcoma (no PIK3CA mutation detected). Following in vivo study, tumors from the NVP-BKM120 , P/C, P/C+ NVP-BKM120 and vehicle treated mice were processed for determination of PI3K/AKT/mTOR pathway activation. Wilcoxan rank sum analysis was utilized to compare tumor growth across all treatment experiments. Results: In endometrioid single agent experiments, NVP-BKM120 resulted in tumor growth suppression starting at days 5-10 compared to the linear growth observed in vehicle treated tumors (p<0.04 in all experiments). In all experiments, tumor resurgence manifested between days 14-25 (p<0.03). When combined with P/C, the NVP-BKM120 resistance pattern failed to develop in all three xenograft lines (p<0.05) while synergistic tumor growth suppression (p< 0.05) of only one xenograft tumor harboring the R88Q mutation was observed. Acute treatment with NVP-BKM120 led to a decrease in pAKT, whereas, there was no difference in pAKT levels following chronic therapy compared to vehicle. Conclusions: These data suggest that NVP-BKM120 mediated inhibition of the PI3K pathway in endometrial tumors with and without a PIK3CA mutation precludes tumor growth in a primary xenograft model. While a pattern of resistance emerges, this effect appears to be mitigated by the addition of conventional cytotoxic chemotherapy.

Hospital readmission after surgical cytoreduction for epithelial ovarian carcinoma: An assessment of risk

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Background: Hospital readmissions are common, possibly avoidable, and may be used as a metric for assessing an institution’s quality of care. We performed a retrospective analysis to determine risk factors associated with readmission after ovarian cancer cytoreduction surgery. Methods: We identified all patients with stage II-IV ovarian cancer who underwent cytoreduction at our institution between 2003-2011. A retrospective chart review was performed and clinical variables extracted. Utilizing linear and logistic regression these variables were correlated with risk of readmission. Results: A total of 463 patients were included in the analysis. Average age was 62 years. Median length of stay was 8.6 days (range 2-55). Optimal cytoreduction (<1.0cm residual disease) was obtained in 368 patients (81%) and 233 patients (50%) underwent bowel resection or radical upper abdominal procedure (splenectomy, liver resection, diaphragmatic surgery). Perioperative complications were observed in 148 patients (32%). A large proportion of our cohort was discharged to rehabilitation facilities (12%) or with a visiting nurse (38%). Of the entire cohort, 55 (12%) were readmitted within 30 days. Readmission was significantly associated with increased length of stay (OR 1.05, 95% 1.01 – 1.1) and perioperative complications (OR 3.5, 95% 2.0 – 6.3). Radical surgery was associated with an increased length of stay (p <0.001) but not with readmission (p = 0.8). Multivariate logistic regression revealed that complications were the only independent factor associated with readmission (OR 3.2, 95% 1.7- 6.0). Further multivariate analysis revealed that reoperation was associated with the greatest risk (OR 8.4, 95% 3.3 -21.1) of readmission. Conclusions: Readmission after ovarian cancer cytoreduction affected 12% of our population. While perioperative complications and increased length of stay were associated with an increased risk of readmission, multivariate analyses suggested that perioperative complications, specifically reoperation, placed the patient at the greatest risk. Comorbidities, radical surgery and the use of ancillary/rehabilitation services had no significant effects on the risk of readmission.

Primary debulking surgery (PDS) for stage IIIc ovarian cancer: Quo vadis?

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Background: The efficacy of PDS for advanced ovarian cancer has recently been challenged by data suggesting equivalent clinical outcomes for neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS). The strongest known predictor of prolonged survival in either group is the ability to achieve complete resection (CR) to no residual disease. PDS that results in a CR is associated with the longest overall survival of any sequence of treatment. The aim of this study was to determine what type of surgical approach is required to successfully perform PDS. Methods: All women with newly diagnosed stage IIIC epithelial ovarian carcinoma treated at our institution from 2000 to 2010 were identified. Pathology was prospectively reviewed by a faculty gynecologic pathologist. Treatment planning was discussed and documented at our weekly multidisciplinary tumor board conference. Data was retrospectively extracted from computerized medical records. Results: 344 (86%) of 401 women underwent PDS. Optimal debulking was achieved in 278 patients (81%): 35% had CR while 46% had 0.1-1.0 cm residual disease. 56 stage IIIC pts (19%) had a suboptimal surgical outcome with ≥ 1.0 cm. Compared to those having a CR, patients with 0.1-1.0 cm residual were more likely to require splenectomy (17 v 5%; P = 0.002) and transverse colectomy (19 v 10%; P = 0.042), with comparable rates of rectosigmoid resection (41 v 39%; P = 0.712) and en bloc pelvic resection including total peritonectomy (26 v 30%; P = 0.050). Patients undergoing CR were more likely to have diaphragmatic surgery (31 v 20; P = 0.068) and lymphadenectomy (67 v 33%; P < 0.001). Conclusions: PDS is the preferred treatment of stage IIIC epithelial ovarian cancer at high-volume centers demonstrating >75% rates of optimal cytoreduction. Tumor biology may lead to the need for more aggressive upper abdominal procedures in patients with 0.1-1.0 residual. Diaphragm resection, stripping or ablation is more often required in order to achieve CR. Since subclinical macroscopic nodal metastases are often present, lymphadenectomy is also frequently performed to ensure that all possible disease has been resected.

A snapshot of potentially personalized care: Molecular diagnostics in gynecologic cancer

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Background: Genetic abnormalities underlie the development of cancer. It has been proposed that tumors be recategorized by gene mutation such as BRAF in LG serous, TP53 in HG serous, and PIK3CA in clear cell and endometrioid tumors. These targets potentially represent an opportunity for personalizing cancer therapy. Methods: Gynecologic Oncology patients at the MGH Cancer Center can have their tumor genotyped for a panel of mutations by SNaPshot, a validated, CLIA approved assay developed by MGH that uses DNA from FFPE tissue to interrogate 160 site-specific mutations across 15 genes (AKT1, APC, BRAF, CTNNB1, EGFR, ERBB2, IDH1, KIT, KRAS, MAP2K1, NOTCH1, NRAS, PIK3CA, PTEN, TP53). At present SNaPshot has no validated endpoints in GYN Cancers but may help identify a useful clinical trial. Results: Between 5/17/10 and 10/17/11, 125 patients consented to SNaPshot genotyping. Patients had a median age of 59 (24-78) yrs. Tumors were ovarian 70(56%), uterine clear, UPSC, or MMMT 16(13%), uterine endometrioid 10(8%), fallopian tube 8(6%), PPC 7(6%), cervical 6(5%), uterine sarcomas (3), ACUP (2), vulvovaginal (2), metastatic (1). A mutation was identified in 41(33%), with 9 of these (23%) having 2 or 3 (n=2) mutations. In the 85 ovarian, FT, and PPC cancers 33% were +ve, but 50% were in TP53. The low mutation rate for TP53 is likely explained by copy number abnormalities (Amplification). 50% of the 10 uterine tumors were +ve, with 3 of those 5 having multiple mutations in the PIK3CA pathway, while 69% of the non-endometrioid uterine tumors had mutations. Only 20% of the vulvo-vaginal and Cx tumors had mutations, both PIK3CA. 19% of the purely serous tumors (n=58) had TP53 mutations, and 37% of the purely clear/endometrioid tumors (n=19) had mutations in PIK3CA, PTEN or AKT. Certain rare tumors did not have identifiable mutations: granulosa cell tumors (2), ovarian small cell (2). 5 pts with a PIK3CA mutation were enrolled on a clinical trial (2 phase II, 3 phase I, 3 uterine, 1 ovary, 1 cervix). Conclusions: SNaPshot can identify potentially important therapeutic targets. However, the incidence of "drugable" targets in ovarian cancer is low, and <5% subjects eventually were treated on a relevant clinical trial.

A comparison of outcome in patients with stage 1 clear cell and grade 3 endometrioid adenocarcinoma of the endometrium with and without adjuvant therapy

OBJECTIVE

To determine the outcomes in patients with Stage I uterine clear cell carcinoma (UCCC) treated with and without adjuvant therapy, and to compare the outcomes in these patients to that of matched controls, patients with Stage I, grade 3, endometrioid adenocarcinoma of the endometrium (EC).

METHODS

Patients with FIGO Stage I UCCC who underwent comprehensive surgical staging between January 1996 and January 2007 were identified. Cases (UCCC) were matched by age, stage, adjuvant therapy, and year of diagnosis to controls consisting of patients with grade 3 EC. Recurrence and survival were analyzed using the Kaplan-Meier method.

RESULTS

25 patients with Stage I UCCC were identified of whom 13 (52%) received no adjuvant therapy and 12 (48%) received adjuvant radiation therapy (XRT). The 5-year disease-free survival and overall survival rates for the observation and the XRT groups were 78% and 75%, (p = 0.7) and 85% and 82% (p = 0.1), respectively. When compared to controls, the 5-year disease-free survival rates and overall survival rates of patients with Stage I UCCC were not significantly different, 77% vs 75% (p = 0.8) and 84% vs 88% (p = 0.5), respectively.

CONCLUSIONS

In patients with Stage I UCCC tumors there was no clear benefit to adjuvant radiation given the absence of improvement in recurrence risk or any survival benefit. These data question the benefit of radiation therapy in UCCC patients with disease confined to the uterus.

Extent of extracranial disease is a powerful predictor of survival in patients with brain metastases from gynecological cancer

Central nervous system metastasis from gynecological malignancy is a rare phenomenon that has been described in the past 30 years. The objective of this study is to analyze the treatment modalities and prognostic factors for brain metastases from gynecological tumors that predict prolonged survival. A retrospective chart and pathology review of 47 patients diagnosed with a gynecological tumor with brain metastasis in 1994-2004 was performed. Thirty patients had undergone initial diagnosis and treatment at our institution, and 17 patients were referred following primary treatment at an outside institution. Adjusted Chi-square, Kaplan-Meier survival estimates, log-rank tests, and Cox regression analysis were utilized for statistical analysis of the total cohort. Of the 3146 patients with newly diagnosed gynecological cancer in this 10-year period, 30 developed brain metastasis demonstrating an incidence of 0.95%. Overall median survival from the time of diagnosis of brain metastasis was 7.5 months (95% CI 4-15, range 9 days-64 months) and 40% survival at 1 year. Multivariate analysis revealed evidence of extracranial disease at time of metastasis diagnosis predicted decreased survival (hazard ratio 6.207), while papillary serous histology (hazard ratio 0.42), and use of any chemotherapy (hazard ratio 0.24) predicted longer survival. No other patient or tumor characteristics were found to be independent prognostic indicators affecting survival. Despite the ominous prognosis associated with the development of brain metastasis, these retrospective data suggest that multimodal therapy with whole brain radiation therapy, chemotherapy, and surgical resection of metastases in selected patients without evidence of extracranial and with solitary or multiple lesions can prolong survival.

Clinicopathologic correlates in temporal cortex in dementia with Lewy bodies

OBJECTIVE

To address the relationship between dementia and neuropathologic findings in dementia with Lewy bodies (DLB) in comparison with AD.

METHODS

We evaluated the clinical presentation of autopsy-confirmed DLB in comparison with AD according to new Consortium on DLB criteria and compared the two conditions using quantitative neuropathologic techniques. This clinicopathologic series included 81 individuals with AD, 20 with DLB (7 "pure" DLB and 13 "DLB/AD"), and 33 controls. We counted number of LB, neurons, senile plaques (SP), and neurofibrillary tangles (NFT) in a high order association cortex, the superior temporal sulcus (STS), using stereologic counting techniques.

RESULTS

The sensitivity and specificity of Consortium on DLB clinical criteria in this series for dementia, hallucinations, and parkinsonism are 53% and 83%, respectively, at the patient's initial visit and 90% and 68%, respectively, if data from all clinic visits are considered. In pathologically confirmed DLB brains, LB formation in an association cortical area does not significantly correlate with duration of illness, neuronal loss, or concomitant AD-type pathology. Unlike AD, there is no significant neuronal loss in the STS of DLB brains unless there is concomitant AD pathology (neuritic SP and NFT).

CONCLUSIONS

The evaluation of new Consortium on DLB criteria in this series highlights their utility and applicability in clinicopathologic studies but suggests that sensitivity and specificity, especially at the time of the first clinical evaluation, are modest. The lack of a relationship of LB formation to the amount of Alzheimer-type changes in this series suggests that DLB is a distinct pathology rather than a variant of AD.

Lack of independent associations of apolipoprotein E promoter and intron 1 polymorphisms with Alzheimer's disease

Several studies have demonstrated genetic associations between Alzheimer's disease (AD) and polymorphisms in the promoter/enhancer regions of the apolipoprotein E (APOE) gene. These studies raise the possibility that APOE transcription control may be involved in altered risks for AD. We evaluated polymorphic sites in the intron-1 enhancer element (IE-1G/C) and in the APOE promoter (-219G/T). For the IE-1 polymorphism, we analyzed 433 individuals (183 AD and 250 controls), and found a strong linkage between the IE-1G allele and APOE-epsilon4. When we controlled for this linkage using log-linear model analysis, we found no independent association between the IE-1 polymorphism and AD. For the -219 polymorphism, we analyzed 475 individuals (168 AD cases, 234 controls, and 73 cases of cerebral amyloid angiopathy (CAA)). We found strong linkages between the -219G allele and APOE-epsilon2 and between the -219 T allele and APOE-epsilon4. Controlling for these linkages, we found no independent association between the -219 polymorphism and AD or CAA. Thus, our studies do not support independent associations between AD and either the IE-1 or the -219 polymorphisms.

Lack of allelic imbalance in APOE epsilon3/4 brain mRNA expression in Alzheimer's disease

Although the APOE epsilon4 allele is a strong risk factor for Alzheimer's disease (AD), it is not deterministic, as many APOE epsilon3/4 individuals do not develop AD. It has been hypothesized that this incomplete penetrance is due, in part, to an imbalance of allele expression in heterozygous individuals. In this regard, Lambert et al. (1998) reported that AD individuals have a higher APOE epsilon4/total APOE ratio than non-demented control subjects. We tested this hypothesis using radioactive RT-PCR to quantitate APOE epsilon3 and epsilon4 allele expression levels in AD and non-AD brain samples from APOE epsilon3/4 individuals. Quantitative analyses of amplified products within the linear range of amplification (18-20 cycles) revealed no difference from the expected 1:1 ratio in genomic DNA and in cDNA from AD and control brains. Using high PCR cycle numbers (approximately 30), we observed an artificial elevation of the APOE epsilon3/total APOE ratio in both DNA and cDNA samples, possibly due to DNA heteroduplex formation. Our results do not support the hypothesis that allelic imbalance contributes to the risk of developing AD among APOE epsilon3/4 heterozygote individuals.

The impact of different presenilin 1 andpresenilin 2 mutations on amyloid deposition, neurofibrillary changes and neuronal loss in the familial Alzheimer's disease brain: evidence for other phenotype-modifying factors

To assess the influence of the presenilin 1 (PS1) and 2 (PS2) mutations on amyloid deposition, neurofibrillary tangle (NFT) formation and neuronal loss, we performed stereologically based counts in a high-order association cortex, the superior temporal sulcus, of 30 familial Alzheimer's disease cases carrying 10 different PS1 and PS2 mutations, 51 sporadic Alzheimer's disease cases and 33 non-demented control subjects. All the PS1 and PS2 mutations assessed in this series led to enhanced deposition of total Abeta and Abeta(x-42/43) but not Abeta(x-40) senile plaques in the superior temporal sulcus when compared with brains from sporadic Alzheimer's disease patients. Some of the PS1 mutations studied (M139V, I143F, G209V, R269H, E280A), but not others, were also associated with faster rates of NFT formation and accelerated neuronal loss in the majority of the patients who harboured them when compared with sporadic Alzheimer's disease patients. In addition, our analysis showed that dramatic quantitative differences in clinical and neuropathological features can exist even among family members with the identical PS mutation. This suggests that further individual or pedigree genetic or epigenetic factors are likely to modulate PS phenotypes strongly.

A novel presenilin-1 mutation: increased beta-amyloid and neurofibrillary changes

The prevalence of known mutations in presenilin genes (PS1 and PS2) causing early-onset familial Alzheimer's disease (FAD) was assessed in a population of 98 singleton early-onset AD cases, 29 early-onset FAD cases, and 15 late-onset FAD cases. None of the cases tested positive for the eight mutations initially reported, and none of these mutations were observed in 60 age-matched controls. A novel mutation (R269H) in PS1 was found in a single case of early-onset AD but not in any other AD or control case. Thus, the PS mutations tested are quite rare in early-onset AD. Amyloid beta protein (A beta) deposition was investigated in the temporal cortex of the R269H mutation case using end-specific monoclonal antibodies to detect the presence of A beta x-40 and A beta x-42 subspecies. Stereologically unbiased tangle and neuropil thread counts were obtained from the same region. R269H PS1 mutation was associated with early age of dementia onset, higher amounts of total A beta and A beta x-42, and increased neuronal cytoskeletal changes. Thus, if the changes observed on this case prove to be typical of PS1 mutations, PS1 mutations may impact both amyloid deposition and neurofibrillary pathology.