Dosimetry and acute radiation enteritis comparison between prone and supine position in IMRT for gynecological cancers

PURPOSE

To probe the differences of dosimetry and acute radiation enteritis between prone and supine position in gynecological cancer patients treated with intensity-modulate radiotherapy (IMRT).

METHODS

Gynecologic tumor patients who received IMRT from January 2020 to July 2021 were analyzed. 60 patients were enrolled and divided into the supine or prone position group according to different radiotherapy positions, including 34 patients in prone position and 26 patients in supine position. The dose-volume histogram of organs at risk (OARs) and the incidence of acute radiation enteritis were compared between the two groups. Multivariate logistic regression analysis was conducted to show the clinical characteristics and dose volume metrics to the association of acute radiation enteritis.

RESULTS

The percentage of volume receiving 5 Gy, 10 Gy, 15 Gy, 20 Gy, 30 Gy, 40 Gy, and 45 Gy doses for the small intestine were 79.0%, 67.4%, 59.6%, 44.3%, 17.0%, 8.9%, and 6.0%, respectively in the prone group, which were lower than those in the supine group (P < 0.05). The mean radiation dose (Dmean ) of the small intestine exposure in prone group was decreased (P < 0.001). Compared with the supine group, the prone group who suffered from acute radiation enteritis were much less. The probability of indigestion, nausea, vomiting, diarrhea, and abdominal pain in the prone position were 35.29%, 29.41%, 17.65%, 38.24%, and 5.88%, respectively. The differences in indigestion, nausea, and diarrhea between the two groups were statistically significant (P = 0.012, P = 0.029, and P = 0.041). Multivariate logistic regression analysis was shown that prone position was found to be protective against indigestion (P = 0.002), nausea (P = 0.013), vomiting (P = 0.035), and abdominal pain (P = 0.021).

CONCLUSION

Prone position in IMRT for gynecological cancers could significantly reduce radiation dose to the small bowel and colon, which would decrease the occurrence and severity of acute intestinal side effects possibly.

Targeting Cytochrome P450 Enzymes in Ovarian Cancers: New Approaches to Tumor-Selective Intervention

Over the past decade, there have been significant developments in treatment for ovarian cancer, yet the lack of targeted therapy with few side effects still represents a major issue. The cytochrome P450 (CYP) enzyme family plays a vital role in the tumorigenesis process and metabolism of drugs and has a negative impact on therapy outcomes. Gaining more insight into CYP expression is crucial to understanding the pathophysiology of ovarian cancer since many isoforms are essential to the metabolism of xenobiotics and steroid hormones, which drive the disease's development. To the best of our knowledge, no review articles have documented the intratumoral expression of CYPs and their implications in ovarian cancer. Therefore, the purpose of this review is to provide a clear understanding of differential CYP expression in ovarian cancer and its implications for the prognosis of ovarian cancer patients, together with the effects of CYP polymorphisms on chemotherapy metabolism. Finally, we discuss opportunities to exploit metabolic CYP expression for the development of novel therapeutic methods to treat ovarian cancer.

Risk Factors and Prognosis of Stroke in Gynecologic Cancer Patients

Increased life expectancy and cancer prevalence rates expose patients to a higher risk of developing other comorbidities such as stroke. This study aimed to evaluate the risk factors for and prognosis of stroke in patients with gynecological cancers. A single-center retrospective cohort study was conducted on patients with cervical, endometrial, and epithelial ovarian cancers. Patients were classified into three groups based on the period of stroke onset: at least one year before cancer diagnosis, within one year before cancer diagnosis to six months after the last treatment date, and six months after the last treatment date. Among the 644 patients, stroke occurred in 54 (8.4%). In univariate analysis, stroke was significantly associated with overall survival. In contrast, in multivariate analysis, stroke was significantly associated with age and hypertension, but not with overall survival. Age, pulmonary thromboembolism/deep vein thrombosis, histological grade, and tumor stage were significantly associated with overall survival. Therefore, it is important to establish an appropriate examination and treatment plan for patients with gynecologic cancers using a multidisciplinary approach that incorporates the patient's age, medical condition, and tumor characteristics rather than excessively considering the adverse effects of stroke on cancer prognosis.

From Prevention to Care: Unveiling a Parasitic Leiomyoma Within a Gigantic Abdominal Mass

Leiomyomas are non-cancerous tumors emerging from the smooth muscle cells and fibroblasts of the myometrium. They are the most common pelvic tumors in females and are usually asymptomatic. Parasitic leiomyomas have been defined as unusual variants of pedunculated leiomyomas. When symptomatic, leiomyomas can cause abnormal uterine bleeding, pelvic pain/pressure, and reproductive effects, such as infertility or adverse pregnancy outcomes. Treatment varies depending on age, symptoms, and the preference to preserve fertility. In this article, we describe the case of a 58-year-old woman who presented for a scheduled cervical cancer screening in primary healthcare. Upon objective examination, the patient exhibited a distended and tense abdomen, along with edema in the lower limbs. These symptoms were associated with fatigue and weight gain over the last few months. Subsequent investigation led to an exploratory laparotomy which revealed a massive abdominal mass, measuring approximately 45 cm in diameter and weighing 35 kg. The findings were suggestive of a parasitic leiomyoma.

Assessment of dose to vaginal mucosa for gynecologic template interstitial high-dose-rate brachytherapy using Monte Carlo simulation

Purpose

This study investigated reliable vaginal mucosa dose-volume histogram (DVH) metrics in gynecologic template interstitial high-dose-rate brachytherapy (HDR-BT) for the purpose of standardized dose reporting.

Material and methods

Gynecologic template (Syed/Neblett) interstitial HDR-BT patients treated from September 2016 to November 2022 at the study institute were included in the cohort. Each patient implant included a vaginal mucosa contour defined by a 5 mm expansion from vaginal cylinder, then another volume with clinical target volume subtracted. DVH metrics were investigated between D0.1cc to D4cc. Clinical plans were re-calculated using Monte Carlo (MC) simulations both in heterogeneous material and in water.

Results

The patient cohort included 61 patients with clinical plans using conventional homogeneous dose calculation (TG43). Heterogeneous vs. water MC dose differences were between -1.1% and -1.4% for all metrics investigated. DVH metrics D1cc and smaller resulted in > 5% discrepancies between TG43 and MC dose (to water) calculation due to the proximity of source positions in/nearby the vaginal mucosa. Reliability improved when DVH metric volume was larger (D2cc and D4cc). Both D2cc and D4cc presented very high linear correlation between TG43 and MC reported doses for the vagina, and average ± standard deviation dose difference was 4.6 ±2.9% and -3.0 ±1.9%, respectively. Dose differences decreased when the clinical target volume was removed: -1.5 ±3.5% and -0.8 ±2.1% for D2cc and D4cc, respectively.

Conclusions

For perineal template gynecologic HDR-BT procedures, the 2 cc volume is the smallest representative volume that reliably reports vaginal dose and at minimum should be reported to establish dose and outcome evaluation.

Evaluation of the Quality and Reliability of YouTube Videos With Turkish Content as an Information Source for Gynecological Cancers During the COVID-19 Pandemic

Aim During the COVID-19 pandemic, YouTube became a critical information source for people seeking information about several diseases, including benign and malignant gynecological disorders. This study aimed to evaluate the quality and reliability of YouTube videos with Turkish content as an information source for gynecological cancers during the COVID-19 pandemic. Methods The research was performed between December 2nd and 5th, 2020. Two gynecologists searched the terms in Turkish; 'yumurtalık kanseri, COVID-19', 'rahim kanseri, coronavirus', 'rahim ağzı kanseri, COVID-19', 'kadın üreme sistemi kanseri, coronavirus', and 'jinekolojik kanserler, COVID-19'. on YouTube. 'Yumurtalık kanseri', 'rahim kanseri', 'rahim agzı kanseri', 'kadın üreme sistemi kanserleri' and 'jinekolojik kanserler' are the translations for "ovarian cancer, COVID-19", "endometrial cancer, coronavirus", "cervical cancer, COVID-19", "female reproductive system cancers, coronavirus", and "gynecological cancers, COVID-19" in the Turkish language, respectively. Videos were categorized into three groups depending on the upload source: the informative group, the personal experience group, and the news agency group. Moreover, DISCERN, the Medical Information and Content Index (MICI), the Video Information and Quality Index (VIQI) were evaluated. Results A total of 57 videos were categorized as informative. Additionally, 22 videos and 18 videos were classified as patient experience videos and new agency videos, respectively. Patients who experienced videos had a significantly higher view number (p=0.001). The number of dislikes and DISCERN score were markedly better in favor of informative videos (p=0.009 and p=0.001). The MICI score was calculated as 13.0±1.8 for informative videos. The total VIQI score was 11.9 for informative videos, 8.8 for patient experience videos, and 7.2 for new agency videos (p = 0.001). Conclusions YouTube videos with Turkish content about gynecological cancers are easily accessible resources during the COVID-19 pandemic. Patient-published videos are the most preferred YouTube videos by Turkish citizens, and informative videos have a considerably lower dislike rate. According to the MICI score and significantly better DISCERN and VIQI scores, informative videos have acceptable quality.

Common Variants in One-Carbon Metabolism Genes (MTHFR, MTR, MTHFD1) and Depression in Gynecologic Cancers

We investigated the association between methylenetetrahydrofolate reductase (gene MTHFR 677C>T, rs1801133), 5-methyltetrahydrofolate-homocysteine methyltransferase (MTR 2756A>G, rs1805087), and methylenetetrahydrofolate dehydrogenase, cyclohydrolase and formyltetrahydrofolate synthetase 1 (gene MTHFD1 1958G>A, rs2236225)-well-studied functional variants involved in one-carbon metabolism-and gynecologic cancer risk, and the interaction between these polymorphisms and depression. A total of 200 gynecologic cancer cases and 240 healthy controls were recruited to participate in this study. Three single-nucleotide variants (SNVs) (rs1801133, rs1805087, rs2236225) were genotyped using the PCR-restriction fragment length polymorphism method. Depression was assessed in all patients using the Hamilton Depression Scale. Depression was statistically significantly more frequent in women with gynecologic cancers (69.5% vs. 34.2% in controls, p < 0.001). MTHFD1 rs2236225 was associated with an increased risk of gynecologic cancers (in dominant OR = 1.53, p = 0.033, and in log-additive models OR = 1.37, p = 0.024). Moreover, an association was found between depression risk and MTHFR rs1801133 genotypes in the controls but not in women with gynecologic cancers (in codominant model CC vs. TT: OR = 3.39, 95%: 1.49-7.74, p = 0.011). Cancers of the female reproductive system are associated with the occurrence of depression, and ovarian cancer may be associated with the rs2236225 variant of the MTHFD1 gene. In addition, in healthy aging women in the Polish population, the rs1801133 variant of the MTHFR gene is associated with depression.

Research progress of LINE-1 in the diagnosis, prognosis, and treatment of gynecologic tumors

The retrotransposon known as long interspersed nuclear element-1 (LINE-1), which is currently the sole autonomously mobile transposon in the human genome, can result in insertional mutations, chromosomal rearrangements, and genomic instability. In recent years, numerous studies have shown that LINE-1 is involved in the development of various diseases and also plays an important role in the immune regulation of the organism. The expression of LINE-1 in gynecologic tumors suggests that it is expected to be an independent indicator for early diagnosis and prognosis, and also, as a therapeutic target, LINE-1 is closely associated with gynecologic tumor prognosis. This article discusses the function of LINE-1 in the diagnosis, treatment, and prognosis of ovarian, cervical, and endometrial malignancies, as well as other gynecologic malignancies. It offers fresh perspectives on the early detection of tumors and the creation of novel anti-tumor medications.

Crosstalk between ferroptosis and steroid hormone signaling in gynecologic cancers

Ferroptosis is a novel types of regulated cell death and is widely studied in cancers and many other diseases in recent years. It is characterized by iron accumulation and intense lipid peroxidation that ultimately inducing oxidative damage. So far, signaling pathways related to ferroptosis are involved in all aspects of determining cell fate, including oxidative phosphorylation, metal-ion transport, energy metabolism and cholesterol synthesis progress, et al. Recently, accumulated studies have demonstrated that ferroptosis is associated with gynecological oncology related to steroid hormone signaling. This review trends to summarize the mechanisms and applications of ferroptosis in cancers related to estrogen and progesterone, which is expected to provide a theoretical basis for the prevention and treatment of gynecologic cancers.

Circular RNAs in gynecologic cancers: mechanisms and implications for chemotherapy resistance

Chemotherapy resistance remains a major challenge in the treatment of gynecologic malignancies. Increasing evidence suggests that circular RNAs (circRNAs) play a significant role in conferring chemoresistance in these cancers. In this review, we summarize the current understanding of the mechanisms by which circRNAs regulate chemotherapy sensitivity and resistance in gynecologic malignancies. We also discuss the potential clinical implications of these findings and highlight areas for future research. CircRNAs are a novel class of RNA molecules that are characterized by their unique circular structure, which confers increased stability and resistance to degradation by exonucleases. Recent studies have shown that circRNAs can act as miRNA sponges, sequestering miRNAs and preventing them from binding to their target mRNAs. This can lead to upregulation of genes involved in drug resistance pathways, ultimately resulting in decreased sensitivity to chemotherapy. We discuss several specific examples of circRNAs that have been implicated in chemoresistance in gynecologic cancers, including cervical cancer, ovarian cancer, and endometrial cancer. We also highlight the potential clinical applications of circRNA-based biomarkers for predicting chemotherapy response and guiding treatment decisions. Overall, this review provides a comprehensive overview of the current state of knowledge regarding the role of circRNAs in chemotherapy resistance in gynecologic malignancies. By elucidating the underlying mechanisms by which circRNAs regulate drug sensitivity, this work has important implications for improving patient outcomes and developing more effective therapeutic strategies for these challenging cancers.

A 3D-Printable, Low-Cost Obturator for Less Invasive Gynecologic Brachytherapy

The purpose of this report is to design, develop, and evaluate a cost-effective applicator for interstitial brachytherapy (ISBT) to minimize patient morbidity and facilitate access to curative radiation treatment for gynecologic cancers, especially in low-resource settings. A computer-aided design and prototype were developed of a proposed applicator that incorporates 44 slotted channels to gently guide needles, with or without a tandem, through the vaginal canal, effectively eliminating the need for transcutaneous needle insertions typically employed during ISBT of advanced gynecologic cancer and thus reducing the risk of vaginal laceration and bladder or rectal injury. The tested prototype was developed using AutoCAD software (Autodesk, San Francisco, CA) and 3D printed in Accura Xtreme Gray material using stereolithography. Small-scale iterative tests using a gelatin phantom were conducted on this prototype to confirm the efficacy of the applicator through inter-operator usability, needle stability, and needle arrangement. A promising prototype was developed aimed at addressing key issues with traditional perineum-based templates to facilitate ISBT, including being able to cover bulky tumors with parametrial extension reliably, decrease the risk of tissue or organ injury, and treat women with a prior hysterectomy. Results of preclinical testing demonstrated that the applicator met its purpose, suggesting that it may facilitate ISBT without the morbidity typically associated with the procedure, especially by addressing concerns associated with implementing the procedure in low-resource settings. The applicator shows substantial promise in the treatment of advanced gynecologic cancer. While further testing remains necessary to confirm its translatability to the clinical setting, the applicator appears capable of meeting its design objectives, representing its potential for improving upon current methods.

The Role of FBXW7 in Gynecologic Malignancies

The F-Box and WD Repeat Domain Containing 7 (FBXW7) protein has been shown to regulate cellular growth and act as a tumor suppressor. This protein, also known as FBW7, hCDC4, SEL10 or hAGO, is encoded by the gene FBXW7. It is a crucial component of the Skp1-Cullin1-F-box (SCF) complex, which is a ubiquitin ligase. This complex aids in the degradation of many oncoproteins, such as cyclin E, c-JUN, c-MYC, NOTCH, and MCL1, via the ubiquitin-proteasome system (UPS). The FBXW7 gene is commonly mutated or deleted in numerous types of cancer, including gynecologic cancers (GCs). Such FBXW7 mutations are linked to a poor prognosis due to increased treatment resistance. Hence, detection of the FBXW7 mutation may possibly be an appropriate diagnostic and prognostic biomarker that plays a central role in determining suitable individualized management. Recent studies also suggest that, under specific circumstances, FBXW7 may act as an oncogene. There is mounting evidence indicating that the aberrant expression of FBXW7 is involved in the development of GCs. The aim of this review is to give an update on the role of FBXW7 as a potential biomarker and also as a therapeutic target for novel treatments, particularly in the management of GCs.

Intersectionality Between Epigenetics and Cancer Health Disparities Stemming from Social Determinants of Health (SDoH) Through a Gynecologic Oncology Lens: A Narrative Review

Racial health disparities within gynecologic cancers persist. We aim to explore the impact of epigenetics on these disparities and how social determinants of health fuel this effect. We queried PubMed with terms associated with social determinants of health and epigenetics in the scope of 3 gynecologic cancers: ovarian, endometrial, and cervical. Using the publications found, we highlight various socioeconomic and environmental factors that may influence epigenetic mechanisms and further disparities in cancer incidence, mortality, and treatment. This narrative review exposes existing gaps in evidence and provides recommendations of future preventive efforts that can target the mitigation of gynecologic cancer disparities.

Associations Between Social Determinants of Health and Psychoneurologic Symptom Clusters in Women With Gynecologic Cancers: A Longitudinal Study

OBJECTIVES

To evaluate the associations between social determinants of health (SDOH) and psychoneurologic symptom (PNS) clusters in women with gynecologic cancers during cancer treatment.

SAMPLE & SETTING

67 women with gynecologic cancers who received radiation therapy were assessed at baseline, six to eight weeks after treatment, and six months after treatment at oncology clinics in Georgia.

METHODS & VARIABLES

Fatigue, pain, sleep disturbances, cognitive impairment, and depressive symptoms were measured to determine a PNS cluster score. Associations between SDOH and PNS cluster scores were assessed using mixed-effect models.

RESULTS

Larger mean PNS cluster scores were reported in individuals with less education, lower income, and unemployment, as well as in those living in more disadvantaged neighborhoods.

IMPLICATIONS FOR NURSING

Individual- and community-level SDOH and their interactions were associated with more PNS clusters. Studying SDOH at multiple levels depicts how various social disadvantages can exacerbate poor health outcomes.

Fertility after Cancer: Risks and Successes

Simple Summary

Approximately one million new cases of cancer are diagnosed in women of reproductive age every year. In the last few decades, advances in early diagnosis and treatment have improved the survival rate. However, the adverse effects of anticancer therapy on the ovaries and uterus have a significant impact on future fertility and may affect the quality of life of cancer survivors. Unfortunately, evidence about the trend of ovarian reserve loss over time is insufficient for predicting the duration of the fertile period. Currently, impaired fertility in cancer survivors is a growing issue that is complicated by an increasing number of women delaying childbearing. This review focuses on the detrimental effects of chemotherapy, radiotherapy, and surgery on reproductive functions and describes the mechanisms causing reduced fertility in cancer survivors. Moreover, in this review, the available fertility preservation strategies to guarantee the chance of motherhood in cancer survivors are illustrated.

Abstract

The incidence of cancer in reproductive-aged women is 7%, but, despite the increased number of cancer cases, advances in early diagnosis and treatment have raised the survival rate. Furthermore, in the last four decades, there has been a rising trend of delaying childbearing. There has been an increasing number of couples referred to Reproductive Medicine Centers for infertility problems after one partner has been treated for cancer. In these cases, the main cause of reduced fertility derives from treatments. In this review, we describe the effects and the risks of chemotherapy, radiotherapy, and surgery in women with cancer, and we will focus on available fertility preservation techniques and their efficacy in terms of success in pregnancy and live birth rates.

Japanese Society for Radiation Oncology Consensus Guidelines of combined intracavitary and interstitial brachytherapy for gynecological cancers

It has been postulated that the combination of intracavitary and interstitial brachytherapy (IC/IS) is effective and safe for large and irregularly shaped uterine cervical cancer patients. However, due to its invasiveness compared to conventional intracavitary brachytherapy (ICBT), it has to be said that the implementation speed of IC/IS is slow. Until now, there have been no guidelines for required equipment, human resources, and procedural guide focusing solely on IC/IS. The purpose of this guideline is to provide radiation oncologists and medical physicists who wish to start IC/IS with practical and comprehensive guidance for a safe IC/IS introduction and to help accelerate the spread of the utilization of IC/IS nationwide. This is the English translation of the Japanese IC/IS Guidelines, and it was created in an effort to share the Japanese approach to the management of locally advanced uterine cervical cancer worldwide.

Using a Weekly Patient-Reported Outcome Questionnaire to Track Acute Toxicity in Patients Undergoing Pelvic Radiotherapy for Gynecologic Cancers

There are limited patient-reported outcome (PRO) data tracking changes in toxicity in patients actively undergoing radiotherapy. Between 2015−2019, acute toxicity was prospectively measured in 698 patients undergoing a 5-week course of pelvic radiotherapy for gynecologic cancers using a weekly PRO questionnaire. Our questionnaire was able detect a pattern of onset and resolution of acute gastrointestinal (GI) and genitourinary (GU) toxicity in 27 out of 32 questions. Logistic regression analysis showed that increasing GI and GU toxicity at week 2 could predict for severe toxicity at week 5. However, due to a low number of severe events, univariate results could not be productively added to a multivariate model. We observed a >70% response rate for all sections of the questionnaire, except for questions on sexual and vaginal health, which had a 13% average response rate. By demonstrating that PRO data can be used to track acute toxicity during radiotherapy, there is a need to further examine how this tool may be implemented in the clinic to provide complex, adaptive care, such as early side effect management, and modifying radiation delivery in real-time.

Plant Fragrances Are Like Music for Our Senses: A Scoping Review of Aromatherapy in Gynecologic Cancers and Breast Cancer Care

Introduction: Essential oil (EO) applications via inhalation and/or absorption through the skin-often referred to as aromatherapy-have particular relevance as complementary to cancer treatment and follow-up care. Aromatherapy is of particular interest for controlling symptoms and enhancing the general well-being of people with cancer. This is indicated by the increasing number of empirical studies on this topic. Although numerous reviews have summarized the extensive primary research about aromatherapy and cancer, no review on aromatherapy use targeting women with gynecologic and breast cancers currently exists. Our scoping review aims at giving an overview of the state of research about aromatherapy in this specific target group. By summarizing and describing study characteristics, based on methodological decisions and content, we intend to offer implications for future research, focused on the use of EO in women with gynecologic and breast cancers. Methods: A systematic scoping review was conducted, based on the literature, and using the extension of the PRISMA statement for scoping reviews (PRISMA-ScR). The databases PubMed and CINHAHL were searched in a multi-stage, iterative process taking the most relevant terms under consideration, given our research interest and Boolean operators. The included studies were analyzed and summarized through (1) a table matrix including categories of interest and (2) qualitative content analysis. Results: One hundred seventy studies were examined, and 10 were included in this review. They show high heterogeneity in how the term aromatherapy is defined, in content, research design, EO used, application, and outcomes. However, all 10 studies exclusively targeted women with breast cancer in different states of cancer treatment. Conclusions: Challenges of research within this field point to the heterogeneous use and classification of the term aromatherapy, the differentiation of the principle of action of EO, the lack of transparency in how EO are reported and described (e.g., botanical names, company, dosage, mixing ratios), and the need to include subjective perceptions. Ten implications for future research based on these challenges are given.

A phase 2 evaluation of pembrolizumab for recurrent Lynch-like versus sporadic endometrial cancers with microsatellite instability

BACKGROUND

Microsatellite instability-high (MSI-H)/mismatch repair deficiency (dMMR) is a biomarker for responses to immune checkpoint inhibitors (ICIs). Whether mechanisms underlying microsatellite instability alter responses to ICIs is unclear. This article reports data from a prospective phase 2 pilot study of pembrolizumab in patients with recurrent MSI-H endometrial cancer (EC) analyzed by whole exome sequencing (WES) and potential mechanisms of primary/secondary ICI resistance (NCT02899793).

METHODS

Patients with measurable MSI-H/dMMR EC confirmed by polymerase chain reaction/immunohistochemistry were evaluated by WES and received 200 mg of pembrolizumab every 3 weeks for ≤2 years. The primary end point was the objective response rate (ORR). Secondary end points included progression-free survival (PFS) and overall survival (OS).

RESULTS

Twenty-five patients (24 evaluable) were treated. Six patients (25%) harbored Lynch/Lynch-like tumors, whereas 18 (75%) had sporadic EC. The tumor mutation burden was higher in Lynch-like tumors (median, 2939 mutations/megabase [Mut/Mb]; interquartile range [IQR], 867-5108 Mut/Mb) than sporadic tumors (median, 604 Mut/Mb; IQR, 411-798 Mut/Mb; P = .0076). The ORR was 100% in Lynch/Lynch-like patients but only 44% in sporadic patients (P = .024). The 3-year PFS and OS proportions were 100% versus 30% (P = .017) and 100% versus 43% (P = .043), respectively.

CONCLUSIONS

This study suggests prognostic significance of Lynch-like cancers versus sporadic MSI-H/dMMR ECs for ORR, PFS, and OS when patients are treated with pembrolizumab. Larger confirmatory studies in ECs and other MSI-H/dMMR tumors are necessary. Defective antigen processing/presentation and deranged induction in interferon responses serve as mechanisms of resistance in sporadic MSI-H ECs. Oligoprogression in MSI-H/dMMR patients appears salvageable with surgical resection and/or local treatment and the continuation of pembrolizumab off study. Clinical studies evaluating separate MSI-H/dMMR EC subtypes treated with ICIs are warranted.

Surgical Outcomes of Transperitoneal Para-Aortic Lymphadenectomy Compared With Extraperitoneal Approach in Gynecologic Cancers: A Systematic Review and Meta-Analysis

Purpose: The optimal surgical approach for para-aortic lymphadenectomy (PALND) in gynecologic cancers using minimally invasive surgery (laparoscopy or robotic-assisted) is controversial. This study summarizes the current evidence on the extraperitoneal (EP) approach and compares its perioperative, surgical outcomes, and complications to the transperitoneal (TP) approach in an updated meta-analysis. Methods: We performed a systematic search in PubMed, Embase, Web of Science, Cochrane Library database for randomized controlled trials (RCTs) and non-RCTs that compare EP to TP for PALND. The main outcomes included surgical, perioperative outcomes, and complications. The weighted mean difference (WMD) and odds ratio (OR) were applied for the comparison of continuous and dichotomous variables with 95% CIs. Three RCTs and 10 non-RCTs trials, including 2,354 patients were identified and enrolled in the meta-analysis. Results: A total of three RCTs and ten non-RCTs trials, including 2,354 patients were identified and enrolled in the meta-analysis. We reported similar results for EP and TP in terms of the hospital stay, estimated blood loss, blood transfusion, conversion to laparotomy, total operative time, and postoperative complications (Clavien grade ≥ 1 and Clavien grade ≥ 3). However, the PALND operative time (WMD -10.46 min, 95% CI -19.04, -1.88; p = 0.02) and intraoperative complications (OR 0.40, 95% CI 0.23, 0.69; p = 0.001) were less with EP. Also, more nodes were removed in EP compared with the TP (WMD 1.45, 95% CI 0.05, 2.86; p = 0.04). Conclusions: The EP approach did not show differences regarding surgical and perioperative parameters compared with the TP approach. However, the number of aortic nodes retrieved was higher. Furthermore, The PALND operative time and intraoperative complications were less in EP.

Prevalence of Anemia Among Gynecologic Cancer Patients Who Received Chemotherapy, Radiotherapy, or a Combination of Both at King Abdulaziz Medical City, Jeddah

OBJECTIVE

The aim of this study is to calculate hemoglobin (Hb) levels and find the prevalence of anemia in gynecological cancer patients undergoing cancer treatments including chemotherapy and radiotherapy attending Princess Noorah Oncology Center in King Abdul Aziz Medical City in Jeddah.

METHOD

A cross-sectional chart review study was conducted in gynecological cancer patients receiving chemotherapy/radiotherapy to find the prevalence of anemia in the period between 2016 and 2018. All data were collected from the electronic medical records using a data collection sheet.

RESULTS

A total of 107 female patients who had gynecologic cancers and received chemotherapy/radiotherapy were included. Ninety percent (90.7%) of them developed anemia during the treatment course.

CONCLUSION

The prevalence of anemia in patients with gynecological cancers during their active treatment was high. This is attributed to the chemotherapy and radiotherapy they were receiving that affected their Hb levels. Better monitoring and, in severe cases, blood transfusion could be beneficial.

The Therapeutic Potential of MEK1/2 Inhibitors in the Treatment of Gynecological Cancers: Rational Strategies and Recent Progress

The mitogen-activated protein kinase (MAPK) pathway is among the key factors in numerous cellular processes involved in tumorigenesis, suggesting it as a potential therapeutic target in gynecological cancer. MAPKs connect gene expression pathways and external stimulations. They include a network consisting of Ras, Raf or MAP3K, MEK or MAP2K, ERK or MAPK. Among these, MEK is an attractive molecular target of novel cancer therapeutics as it joints upstream activators and their corresponding downstream targets. MEK inhibitors were among the first inhibitors of the MAPK pathway entering into clinical trials. Several drugs have recently been developed as MEK inhibitors. MEK1/2 inhibitors demonstrate promising efficacy and anticancer activity to treat this malignancy and captured much attention in the past decade. Here, we summarize the role of MAPK/MEK/ERK pathway in the pathogenesis of gynecological cancer, with particular emphasis on MEK inhibitors in clinical settings, including PD-0325901, Selumetinib, Cobimetinib, Refametinib, Trametinib, Pimasertib, MEK162 and WX-554 in gynecologic cancers.

Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004-2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III-IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53-2.12), and cervical (aOR: 1.45,95% CI: 1.26-1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48-0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60-0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58-0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.

Cross-sectional study of psychosocial well-being among lesbian, gay, bisexual, and heterosexual gynecologic cancer survivors

Background

Delays in care and increased risk for mental health diagnoses put individuals identifying as a sexual minority with cancer at risk for decreased quality of life.

Aim

To assess psychosocial health among sexual minority gynecologic cancer survivors, we compared self‐reported quality of life and psychosocial measures between individuals diagnosed with gynecologic cancers identifying as lesbian/gay/bisexual (LGB) and heterosexual.

Methods and Results

English‐speaking adults with gynecologic cancers were invited to participate in an ongoing cohort survey study. Quality of life and psychosocial measures included the Functional Assessment of Cancer Therapy‐General, Distress Thermometer (distress), Patient Health Questionnaire‐8 (depression), General Anxiety Disorder‐7 (anxiety), and Post‐traumatic Stress Disorder Checklist for DSM‐5 (post‐traumatic stress disorder; PTSD). Measures were compared by self‐reported sexual orientation (heterosexual vs. LGB) using descriptive statistics (frequencies and means) and linear and logistic regression models, adjusting for college education.

Of 814 patients invited, 457 enrolled (56.1%) and 401 (92.6%) completed the survey and provided information on their sexuality. All but one self‐identified as cisgender women and 22 (5.5%) as LGB. LGB participants were more likely to have completed college (68.2% vs. 40.1%, p = .009) but were otherwise similar across demographic and clinical characteristics. Quality of life and distress scores were similar between groups. LGB participants, compared to heterosexual, reported higher rates of depression (31.8% vs. 10.6%, adjusted odds ratio [OR] = 4.1 [95% confidence interval [CI]: 1.6–11.0], p = .004), anxiety (25.0% vs. 7.1%, adjusted OR = 5.4 [95% CI: 1.7–16.7], p= .004), and PTSD (13.6% vs. 3.5%, adjusted OR = 4.2 [95% CI: 1.1–16.3], p = .04).

Conclusion

LGB participants reported poorer emotional health following a gynecologic cancer diagnosis than heterosexual participants. Our data suggest this population may need additional resources and support during and after their cancer diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population.

Prognostic significance of the expression of metastasis-associated in colon cancer-1 in gynecologic cancers and breast cancer: A protocol for systematic review and meta-analysis

BACKGROUND

The prognostic role of the expression of metastasis-associated in colon cancer-1 (MACC1) in gynecologic cancers and breast cancer remains unclear. The aim of this systematic review and meta-analysis was to determine the prognostic significance of MACC1 expression in gynecologic cancers and breast cancer.

MATERIALS AND METHODS

PubMed, Web of Science and Embase were comprehensively searched up to February 9, 2020. Studies focusing on the relationship between the expression of MACC1 and prognosis in gynecologic cancers and breast cancer were included into the analysis. Pooled hazard ratio (HR) or odd ratio with 95% confidence interval (CI) was used to estimate the prognostic value of the expression of MACC1.

RESULTS

A total of 1,811patients with gynecologic cancers or breast cancer were included into the analysis. Patients with high expression of MACC1 tended to suffer a shorter overall survival (HR = 2.76, 95%CI = 2.12-3.59, P < .01) and recurrence-free survival (HR = 2.37, 95%CI = 1.44-3.90, P < .01) compared to those with low expression of MACC1. High expression of MACC1 was significantly associated with worse tumor differentiation (P = .04), more advanced FIGO stage (P < .01) and earlier lymph node metastasis (P < .01) compared to low expression of MACC1.

CONCLUSION

Compared to low expression of MACC1, high expression of MACC1 predicts a worse prognosis of gynecologic cancers and breast cancer. The expression of MACC1 can serve as a prognostic indicator of gynecologic cancers and breast cancer.

The clinical impact of removing rectal gas on high-dose-rate brachytherapy dose distributions for gynecologic cancers

Purpose

To evaluate the impact of gas removal on bladder and rectal doses during intracavitary and interstitial high‐dose‐rate brachytherapy (HDRB) for gynecologic cancers.

Material and Methods

Fifteen patients treated with definitive external beam radiation followed by HDRB for gynecologic cancers for a total of 21 fractions, presented with a significant amount of rectal gas at initial CT imaging (CT_GAS) after implantation. The gas was removed via rectal tubing followed by subsequent scan acquisition (CT_CLINICAL), which was used for planning and treatment delivery. To assess the effect of gas removal on dosimetry, both bladder and rectum volumes were recontoured on CT_GAS. In order to evaluate the clinical impact on the total Equivalent‐Dose‐in‐2Gy‐fraction (EQD₂), each fraction was also replanned to maintain clinically delivered target coverage (HRCTV D90). EQD₂ D2cm³ for bladder and rectum were compared between plans. The Wilcoxon signed rank test was performed to evaluate statistically significant differences for all comparisons (P < 0.05).

Results

Mean rectum and bladder D_max, D0.1cm³, D1cm³, D2cm³, and D5cm³ were significantly different between CT_GAS and CT_CLINICAL. The mean percent increases on CT_GAS for bladder were 12.3, 8.4, 9.9, 10.2, and 9.5% respectively and for rectum were 27.0, 19.6, 18.1, 18.5, and 19.4%, respectively. After replanning with CT_GAS to maintain HRCTV D90 EQD₂, bladder and rectum EQD₂ D2 cm³ resulted in significantly higher doses. The mean EQD₂ D2 cm³ difference was 2.4 and 4.1 Gy for bladder and rectum, revealing a higher impact of gas removal on rectal DVH.

Conclusion

Rectal gas removal resulted in statistically significant differences for both bladder and rectum. The resulting larger EQD₂ D2 cm³ for bladder and rectum demonstrates that if patients were treated without removing gas, target coverage would need to be sacrificed to satisfy the rectum constraints and prevent toxicities. Therefore, this study demonstrates the importance of gas removal for gynecologic HDRB patients.

Skin dose measurement and estimating the dosimetric effect of applicator misplacement in gynecological brachytherapy: A patient and phantom study

OBJECTIVES

To evaluate skin dose differences between TPS (treatment planning system) calculations and TLD (thermo-luminescent dosimeters) measurements along with the dosimetric effect of applicator misplacement for patients diagnosed with gynecological (GYN) cancers undergoing brachytherapy.

METHODS

The skin doses were measured using TLDs attached in different locations on patients' skin in pelvic regions (anterior, left, and right) for 20 patients, as well as on a phantom. In addition, the applicator surface dose was calculated with TLDs attached to the applicator. The measured doses were compared with TPS calculations to find TPS accuracy. For the phantom, different applicator shifts were applied to find the effect of applicator misplacement on the surface dose.

RESULTS

The mean absolute dose differences between the TPS and TLDs results for anterior, left, and right points were 3.14±1.03, 6.25±1.88, and 6.20±1.97 %, respectively. The mean difference on the applicator surface was obtained 1.92±0.46 %. Applicator misplacements of 0.5, 2, and 4 cm (average of three locations) resulted in 9, 36, and 61%, dose errors respectively.

CONCLUSIONS

The surface/skin differences between the calculations and measurements are higher in the left and right regions, which relate to the higher uncertainty of TPS dose calculation in these regions. Furthermore, applicator misplacements can result in high skin dose variations, therefore it can be an appropriate quality assurance method for future research.

Immune Checkpoint Blockade in Gynecologic Cancers: State of Affairs

Simple Summary

Most endometrial cancer patients are diagnosed at an early stage, receive standard treatment, and survive well. Ovarian cancer has no specific symptoms and usually escapes diagnosis until the patient has advanced disease. This disease results in the highest number of deaths of gynecologic cancers. Current treatments for gynecologic cancers in the advanced stage are not sufficiently effective for good outcome in most patients. This review discusses two novel treatments, which are immune checkpoint inhibitor antibodies that block immune checkpoint molecules cytotoxic T lymphocyte associated protein-4 (CTLA-4) and programmed death-1 (PD-1) in patients. The antibody blocking of CTLA-4 or PD-1 alone is promising treatment for some categories of advanced disease endometrial cancer, but it has little effect against ovarian cancer. Our study primarily discusses the status of clinical trials for these two diseases and the biological parameters governing the different outcomes to these therapies. We also propose mechanisms whereby blocking CTLA-4 and PD-1 may be used in combination with other agents to give much better survival in advanced disease ovarian cancer patients.

Abstract

This review provides an update on the current use of immune checkpoint inhibitors (ICI) in female gynecologic cancers, and it addresses the potential of these agents to provide therapy options for disease management and long-term remission in advanced disease patients, where surgery, chemotherapy, and/or radiation fail to meet this goal. The topic of immune checkpoint inhibitors (ICI) blocking cytotoxic T lymphocyte associated protein-4 (CTLA-4) and the programmed death-1 (PD-1) axis has come to the forefront of translational medicine over the last decade for several malignancies. The text will focus primarily on a discussion of ovarian cancer, which is the most frequent cause of death of gynecologic cancers; endometrial cancer, which is the most often diagnosed gynecologic cancer; and cervical cancer, which is the third most common female gynecologic malignancy, all of which unfavorably alter the lives of many women. We will address the critical factors that regulate the outcome of these cancer types to ICI therapy, the ongoing clinical trials in this area, as well as the adverse immune responses that impact the outcome of patients given ICI regimens.

Senescence-Associated Secretory Phenotype Determines Survival and Therapeutic Response in Cervical Cancer

Simple Summary

Cervical cancer is the most common gynecological cancer caused by persistent infections with human papilloma viruses. Over time, this infection leads to secretion of inflammatory proteins in the cervix, which exacerbates the neoplastic and senescent changes to the cervical epithelial lining. We measured nineteen serum proteins in retrospectively collected samples from cervical cancer patients. We show here that 10 out of 19 proteins are associated with senescence phenotype in cervical cancer patients. This senescence associated protein signature influences how cervical cancer patients responds to therapy.

Abstract

Molecular biomarkers that can predict survival and therapeutic outcome are still lacking for cervical cancer. Here we measured a panel of 19 serum proteins in sera from 565 patients with stage II or III cervical cancer and identified 10 proteins that have an impact on disease specific survival (DSS) (Hazzard’s ratio; HR = 1.51–2.1). Surprisingly, all ten proteins are implicated in senescence-associated secreted phenotype (SASP), a hallmark of cellular senescence. Machine learning using Ridge regression of these SASP proteins can robustly stratify patients with high SASP, which is associated with poor survival, and patients with low SASP associated with good survival (HR = 3.09–4.52). Furthermore, brachytherapy, an effective therapy for cervical cancer, greatly improves survival in SASP-high patients (HR = 3.3, p < 5 × 10⁻⁵) but has little impact on survival of SASP-low patients (HR = 1.5, p = 0.31). These results demonstrate that cellular senescence is a major determining factor for survival and therapeutic response in cervical cancer and suggest that senescence reduction therapy may be an efficacious strategy to improve the therapeutic outcome of cervical cancer.

The Latest Findings of PD-1/PD-L1 Inhibitor Application in Gynecologic Cancers

Gynecologic cancers account for approximately 11% of the newly diagnosed cancers in women in the United States and for 18% globally. The presence of tumor-infiltrating lymphocytes (TILs) influences the clinical outcome of cancer patients and immune checkpoint inhibitors (ICIs), including anti programmed cell death protein-1 (anti-PD-1), anti-programmed death-ligand 1 (anti-PD-L1), and anticytotoxic T-lymphocyte antigen 4 (anti-CTLA-4), which have been approved for treating different types of malignancies. Antibodies targeting the PD-1/PD-L1 checkpoint have shown dynamic and durable tumor regressions, suggesting a rebalancing of the host-tumor interaction. There are several the US food and drug administration (FDA)-approved ICIs targeting PD-1, including pembrolizumab and nivolumab, as well as those targeting PD-L1, including avelumab, atezolizumab, and durvalumab for melanoma, renal cell cancer, colorectal cancer, head and neck cancer, cervix cancer, urothelial cancer, and lung cancer. Current pre-clinical and clinical studies assessing PD-1/PD-L1 inhibitors in several gynecologic cancers have reported significant antitumor activity. In this review, we investigate pre-clinical and clinical studies that describe the safety and efficacy of anti-PD-1/PD-L1 antibodies, with a particular focus on ongoing clinical trials, analyzing the oncological outcome and adverse effects of ICIs in gynecologic cancers.

The Application of Patient-Derived Xenograft Models in Gynecologic Cancers

Recently, due to the limitations of cell line models and animal models in the preclinical research with insufficient reflecting the physiological situation of humans, patient-derived xenograft (PDX) models of many cancers have been widely developed because of their better representation of the tumor heterogeneity and tumor microenvironment with retention of the cellular complexity, cytogenetics, and stromal architecture. PDX models now have been identified as a powerful tool for determining cancer characteristics, developing new treatment, and predicting drug efficacy. An increase in attempts to generate PDX models in gynecologic cancers has emerged in recent years to understand tumorigenesis. Hence, this review summarized the generation of PDX models and engraftment success of PDX models in gynecologic cancers. Furthermore, we illustrated the similarity between PDX model and original tumor, and described preclinical utilization of PDX models in gynecologic cancers. It would help supply better personalized therapy for gynecologic cancer patients.

Increasing NIH funding for academic departments of obstetrics and gynecology: a call to action

The National Institutes of Health funding for reproductive sciences research, specifically in academic departments of obstetrics and gynecology, is disproportionately low. Research is one of the most important pillars in advancing healthcare. Despite US Congress' vision in providing increased funding to the National Institutes of Health as a whole, underfunding for research in the departments of obstetrics and gynecology remains one of the several critical drivers in the decline in reproductive health and healthcare for women in the United States.

[Correlation Among Anxiety, Depression, and Quality of Life in Women With Gynecologic Cancer]

BACKGROUND

Anxiety and depression are common emotional distresses experienced by women during gynecologic cancer treatment. These often have dangerous effects on physical and mental health and may impact quality of life (QoL).

PURPOSE

To investigate the factors influencing anxiety, depression, social support, and QoL in women with gynecologic cancer.

METHODS

This was a cross-sectional correlational study. A total of 111 women with gynecologic cancer receiving treatment at a medical center in central Taiwan were selected as subjects using convenience sampling. A demographic characteristics questionnaire, the World Health Organization Quality of Life-Brief-Taiwan version (WHOQOL-BREF-Taiwan version) questionnaire, the International Support Evaluation List (ISEL), and the Hospital Anxiety and Depression Scale (HADS) were used for data collection.

RESULTS

Of the 111 subjects, 41.4% and 24.3% had tendencies for anxiety and depression, respectively, and a moderate QoL score (mean = 3.46; SD = 0.73). The physical health domain had the highest mean QoL score (14.93; SD = 2.24), followed by environmental health (14.76; SD = 1.97), social relationships (14.13; SD = 2.33), and psychological health (13.92; SD = 2.44). Anxiety, depression, marital status, and social support respectively explained 18.5%-37.0% of the total variation in QoL scores. Of the four QoL domains examined in this study, anxiety was the most significant predictor of QoL.

CONCLUSIONS / IMPLICATIONS FOR PRACTICE

It is recommended that healthcare professionals strengthen the early assessment of anxiety, depression, and social support in women with gynecologic cancer. In addition, sensitivity towards emotional status should be increased in these cases. Healthcare professionals should provide care, support, and timely completion of referrals. Finally, psychological and social support and related interventions should be provided based on patient needs in order to maintain QoL.

Advancing Drug Development in Gynecologic Malignancies

Gynecologic malignancies continue to be a major cause of morbidity and mortality in the United States despite recent advances in oncologic therapies. To realize the promise of immunotherapy and biomarker-driven approaches to improve clinical outcomes for patients, better communication among stakeholders in the drug development and approval pathways is needed. To this end, the FDA-AACR-SGO Drug Development in Gynecologic Malignancies Workshop brought together clinicians, patient advocates, researchers, industry representatives, and regulators in June 2018, to review the state of the science in gynecologic cancers and explore how scientific advances impact approval processes. Topics of discussion and key takeaways are summarized in this Perspectives in Regulatory Science and Policy article. Single-agent immunotherapies have demonstrated variable and often modest response rates among gynecologic cancers. Combination therapies and other novel approaches, such as cell-based therapies, may show improved efficacy compared with single-agent immunotherapies; however, utilizing innovative clinical trial designs will be necessary to progress further. Companion and complementary diagnostics inform physicians of potential benefits of specific therapeutics for patients; however, they serve different functions that have important regulatory implications, thus trialists should understand the distinctions between diagnostic types. PARP inhibitors hold great promise for treating ovarian cancers, both as monotherapies and in combination with chemotherapeutics, other targeted agents, and immunotherapies. Rare gynecologic cancers often exhibit unique molecular characteristics that can serve as effective targets to which novel therapeutics can be developed. This workshop highlighted the importance of future open discussions on scientific and regulatory challenges in drug development for gynecologic malignancies.

Impact of molecular testing in clinical practice in gynecologic cancers

Background

With the growing understanding of the molecular and genetic profiles of cancers, targeted treatments are increasingly utilized in personalized cancer care. The objective of this study was to determine how these advances have translated into practice by examining how often molecular profiling of gynecological tumors led to treatment changes.

Methods

We identified women with gynecological cancers at our institution who had molecular tumor testing performed from November 2014 to June 2017. Clinicopathologic data were extracted from medical records. We determined (a) if molecular profiling identified actionable targets for which therapy is available, and (b) whether the patient's treatment course changed as a result of molecular profiling. Chi‐square, Wilcoxon rank‐sum, and Fisher's exact tests were used with a P < 0.05 considered statistically significant.

Results

We identified 152 patients with gynecologic cancers who underwent molecular profiling. Of the 152 patients, 116 (76.3%) had actionable mutations identified, with 41 (35.3%) patients having a treatment change. Stratified by cancer type, molecular profiling most frequently identified an actionable target in patients with endometrial cancer (73.6%). Changes in treatment occurred most frequently in patients with endometrial cancer, 22 (56.4%), and ovarian cancers, 16 (39%), as compared to patients with cervical and vulvar cancer (P = 0.02). Of those patients who received a change in treatment, 39 patients (95.1%) received an FDA‐approved therapeutic agent, while two patients (4.8%) were enrolled in a clinical trial.

Conclusion

Molecular profiling in gynecologic cancers often identified at least one actionable mutation; however, only in a minority of these cases was the course of treatment changed. Further studies are needed to elucidate optimal timing for testing to best utilize actionable information.

Chemotherapy-related cognitive dysfunction and effects on quality of life in gynecologic cancer patients

Introduction

chemotherapy-related cognitive dysfunction (CRCD) is a growing problem due to rising cancer rates and increasing numbers of cancer survivors. upwards of 70% of ovarian cancer patients report cognitive-changes following treatment for their cancer.

Areas covered

the underlying mechanisms of CRCD are a subject of active research and debate. the initial insult may start with the diagnosis of cancer itself, both in the number of peripheral cytokines it produces but also in the psychological changes caused by stress and anxiety associated with the diagnosis. chemotherapy, in its ability to alter dna in the replication cycle, has been shown to damage neurons and their stem cell precursors.

Expert commentary

based on proposed mechanisms and advancements in other neuropsychological diseases, various pharmacologic and behavioral interventions have been demonstrated to show improvements in patient's quality of life and in their perceived cognitive abilities and memory. further research is necessary to be able to determine when and how these cognitive changes occur, and if their multiple potential biological underpinnings can synergize toward deleterious cognitive effects. future therapies will include prevention strategies to avert CRCD's effects on patients.

Sperm-Hybrid Micromotor for Targeted Drug Delivery

A sperm-driven micromotor is presented as a targeted drug delivery system, which is appealing to potentially treat diseases in the female reproductive tract. This system is demonstrated to be an efficient drug delivery vehicle by first loading a motile sperm cell with an anticancer drug (doxorubicin hydrochloride), guiding it magnetically, to an in vitro cultured tumor spheroid, and finally freeing the sperm cell to deliver the drug locally. The sperm release mechanism is designed to liberate the sperm when the biohybrid micromotor hits the tumor walls, allowing it to swim into the tumor and deliver the drug through the sperm-cancer cell membrane fusion. In our experiments, the sperm cells exhibited a high drug encapsulation capability and drug carrying stability, conveniently minimizing  toxic side effects and unwanted drug accumulation in healthy tissues. Overall, sperm cells are excellent candidates to operate in physiological environments, as they neither express pathogenic proteins nor proliferate to form undesirable colonies, unlike other cells or microorganisms. This sperm-hybrid micromotor is a biocompatible platform with potential application in gynecological healthcare, treating or detecting cancer or other diseases in the female reproductive system.

Therapeutic Roles of Statins in Gynecology and Obstetrics: The Current Evidence

INTRODUCTION

Statins are a class of drugs, which act by inhibiting the rate-limiting enzyme of cholesterol biosynthesis (3-hydroxy-3-methyl-glutaryl-CoA reductase). The inhibition of mevalonate synthesis leads to subsequent inhibition of downstream products of this pathway, which explains the pleiotropic effects of these agents in addition to their well-known lipid-lowering effects. Accumulating evidence suggests that statins might be beneficial in various obstetric and gynecologic conditions.

METHODS

Literature searches were performed in PubMed and EMBASE for articles with content related to statins in obstetrics and gynecology. The findings are hereby reviewed and discussed.

RESULTS

Inhibition of mevalonate pathway leads to subsequent inhibition of downstream products such as geranyl pyrophosphate, farnesyl pyrophosphate, and geranylgeranyl pyrophosphate. These products are required for proper intracellular localization of several proteins, which play important roles in signaling pathways by regulating membrane trafficking, motility, proliferation, differentiation, and cytoskeletal organization. The pleiotropic effects of statins can be summarized in 4 categories: antiproliferative, anti-invasive, anti-inflammatory, and antiangiogenic. The growing body of evidence is promising for these agents to be beneficial in endometriosis, polycystic ovary syndrome, adhesion prevention, ovarian cancer, preeclampsia, and antiphospholipid syndrome. Although in vivo studies showed varying degrees of benefit on fibroids and preterm birth, appropriately designed clinical trials are needed to make definitive conclusions.

CONCLUSION

Statins might play a role in the treatment of endometriosis, polycystic ovary syndrome, adhesion prevention, ovarian cancer, preeclampsia, and antiphospholipid syndrome.

The Role of the Insulin-Like Growth Factor 1 Pathway in Immune Tumor Microenvironment and Its Clinical Ramifications in Gynecologic Malignancies

Treatment of patients with gynecologic malignancies diagnosed at advanced stages remains a therapeutic challenge. Survival rates of these patients remain significantly low, despite surgery and chemotherapy. Advances in understanding the role of the immune system in the pathogenesis of cancer have led to the rapid evolution of immunotherapeutic approaches. Immunotherapeutic strategies, including targeting specific immune checkpoints, as well as dendritic cell (DC) immunotherapy are being investigated in several malignancies, including gynecological cancers. Another important approach in cancer therapy is to inhibit molecular pathways that are crucial for tumor growth and maintenance, such as the insulin-like growth factor-1 (IGF1) pathway. The IGF axis has been shown to play a significant role in carcinogenesis of several types of tissue, including ovarian cancer. Preclinical studies reported significant anti-proliferative activity of IGF1 receptor (IGF1R) inhibitors in gynecologic malignancies. However, recent clinical studies have shown variable response rates with advanced solid tumors. This study provides an overview on current immunotherapy strategies and on IGF-targeted therapy for gynecologic malignancies. We focus on the involvement of IGF1R signaling in DCs and present our preliminary results which imply that the IGF axis contributes to an immunosuppressive tumor microenvironment (TME). For the long term, we believe that restoring the TME function by IGF1R targeting in combination with immunotherapy can serve as a new clinical approach for gynecological cancers.

The clinical significance of occult gynecologic primary tumours in metastatic cancer

OBJECTIVE

We estimated the frequency of occult gynecologic primary tumours (gpts) in patients with metastatic cancer from an uncertain primary and evaluated the effect on disease management and overall survival (os).

METHODS

We used Manitoba administrative health databases to identify all patients initially diagnosed with metastatic cancer during 2002-2011. We defined patients as having an "occult" primary tumour if the primary was classified at least 6 months after the initial diagnosis. Otherwise, we considered patients to have "obvious" primaries. We then compared clinicopathologic and treatment characteristics and 2-year os for women with occult and with obvious gpts. We used Cox regression adjustment and propensity score methods to assess the effect on os of having an occult gpt.

RESULTS

Among the 5953 patients diagnosed with metastatic cancer, occult primary tumours were more common in women (n = 285 of 2552, 11.2%) than in men (n = 244 of 3401, 7.2%). In women, gpts were the most frequent occult primary tumours (n = 55 of 285, 19.3%). Compared with their counterparts having obvious gpts, women with occult gpts (n = 55) presented with similar histologic and metastatic patterns but received fewer gynecologic diagnostic examinations during diagnostic work-up. Women with occult gpts were less likely to undergo surgery, waited longer for radiotherapy, and received a lesser variety of chemotherapeutic agents. Having an occult compared with an obvious gpt was associated with decreased os (hazard ratio: 1.62; 95% confidence interval: 1.2 to 2.35). Similar results were observed in adjusted analyses.

CONCLUSIONS

In women with metastatic cancer from an uncertain primary, gpts constitute the largest clinical entity. Accurate diagnosis of occult gpts early in the course of metastatic cancer might lead to more effective treatment decisions and improved survival outcomes.

HE4-test of urine and body fluids for diagnosis of gynecologic cancer

Serum epididymis protein 4 (HE4) level is a useful biomarker for the management of ovarian and endometrial cancer patients. Urine HE4-test, with its easier access than serum test, has emerged as a new method with promising application for the diagnosis of ovarian cancer. Areas covered: This review summarizes data regarding the detection and alteration of HE4 in urine samples collected from ovarian cancer patients and controls. The performance and limitation of the assay and potential direction of future study are also discussed. Expert commentary: Several studies have demonstrated an appreciable efficiency of urine HE4-test in the discrimination of ovarian cancer patients from general population. However, the data is based on small cohorts, and the performance of urine HE4-test need to be validated in larger groups. An algorithm incorporating other important factors may allow a quantitative assessment of cancer possibility. Future studies on the HE4 renal secretion and HE4 degradation dynamics in urine are also required for the establishment of standard protocols for the application of urine HE4-test in clinical settings.

Serum HE4 Level as a Biomarker to Predict the Recurrence of Gynecologic Cancers

BACKGROUND

HE4 may be a valuable early indicator of the recurrence of gynecologic cancers. Numerous studies have shown that high expression levels of serum HE4 correlate with ovarian and endometrial cancer recurrence. High HE4 levels may be an independent factor to predict these cancers' poor prognosis.

OBJECTIVE

This literature review investigates the relationship between serum HE4 levels and the recurrence of ovarian and endometrial cancer.

CONCLUSION

HE4 displays malignant behavior by promoting cancer cells to skip from G1 phase to S phase, maintaining cell viability, encouraging cell proliferation, inhibiting cell apoptosis, and increasing resistance to drug treatments. Further studies are required to verify that elevated serum HE4 levels correlate with the recurrence of ovarian and endometrial cancer.

Physiopathological factors affecting the diagnostic value of serum HE4-test for gynecologic malignancies

Serum epididymis protein 4 (HE4) represents a useful biomarker for the management of ovarian cancer and endometrial cancer patients. However, HE4 levels are affected by many physiopathological conditions or disorders that should be taken into consideration for an efficient application of this biomarker. Areas covered: The review provides an up-to-date reference on the multiple physiopathological factors that cause fluctuation of HE4 serum levels, and evaluates their impact on HE4-test in clinical settings. Potential mechanisms underlying the regulation of HE4 expression are also discussed. The review is based on data from literature search of PubMed and the author's opinions. Expert commentary: Studies have shown that physiopathological factors such as age, infection/inflammation, renal function, menopause and hormonal levels impose significant impacts on HE4 serum levels. HE4 amount shed into the circulation is related to HE4 expression and secretion by tumor as well as normal tissues, which is affected by cancer heterogeneity, vascular permeability, renal clearance and HE4 degradation. Investigation on interfering factors builds a basis for the construction of a quantitative logarithm for individualized application of HE4-test in clinical settings.

Zinc Finger and X-Linked Factor (ZFX) Binds to Human SET Transcript 2 Promoter and Transactivates SET Expression

SET (SE Translocation) protein carries out multiple functions including those for protein phosphatase 2A (PP2A) inhibition, histone modification, DNA repair, and gene regulation. SET overexpression has been detected in brain neurons of patients suffering Alzheimer's disease, follicle theca cells of Polycystic Ovary Syndrome (PCOS) patients, and ovarian cancer cells, indicating that SET may play a pathological role for these disorders. SET transcript 2, produced by a specific promoter, represents a major transcript variant in different cell types. In this study, we characterized the transcriptional activation of human SET transcript 2 promoter in HeLa cells. Promoter deletion experiments and co-transfection assays indicated that ZFX, the Zinc finger and X-linked transcription factor, was able to transactivate the SET promoter. A proximal promoter region containing four ZFX-binding sites was found to be critical for the ZFX-mediated transactivation. Mutagenesis study indicated that the ZFX-binding site located the closest to the transcription start site accounted for most of the ZFX-mediated transactivity. Manipulation of ZFX levels by overexpression or siRNA knockdown confirmed the significance and specificity of the ZFX-mediated SET promoter activation. Chromatin immunoprecipitation results verified the binding of ZFX to its cognate sites in the SET promoter. These findings have led to identification of ZFX as an upstream factor regulating SET gene expression. More studies are required to define the in vivo significance of this mechanism, and specifically, its implication for several benign and malignant diseases related to SET dysregulation.

Rational study endpoints in anti-neoplastic agent regulatory approval trials in the gynecologic malignancies

A discussion of rational endpoints in clinical trials seeking regulatory approval for new anti-neoplastic agents involving the three major gynecologic malignancies, cancers of the ovary, cervix, and endometrial, is particularly interesting as (in the opinion of this commentator) the conclusion will be different in the individual cancers.

Characterizing gradient echo signal decays in gynecologic cancers at 3T using a Gaussian augmentation of the monoexponential (GAME) model

PURPOSE

To assess whether R2* mapping with a standard Monoexponential (ME) or a Gaussian Augmentation of the Monoexponential (GAME) decay model better characterizes gradient-echo signal decays in gynecological cancers after external beam radiation therapy at 3T, and evaluate implications of modeling for noninvasive identification of intratumoral hypoxia.

MATERIALS AND METHODS

Multi-gradient-echo signals were acquired on 25 consecutive patients with gynecologic cancers and three healthy participants during inhalation of different oxygen concentrations at 3T. Data were fitted with both ME and GAME models. Models were compared using F-tests in tumors and muscles in patients, muscles, cervix, and uterus in healthy participants, and across oxygenation levels.

RESULTS

GAME significantly improved fitting over ME (P < 0.05): Improvements with GAME covered 34% of tumor regions-of-interest on average, ranging from 6% (of a vaginal tumor) to 68% (of a cervical tumor) in individual tumors. Improvements with GAME were more prominent in areas that would be assumed hypoxic based on ME alone, reaching 90% as ME R2* approached 100 Hz. Gradient echo decay parameters at different oxygenation levels were not significantly different (P = 0.81).

CONCLUSION

R2* may prove sensitive to hypoxia; however, inaccurate representations of underlying data may limit the success of quantitative assessments. Although the degree to which R2 or σ values correlate with hypoxia remains unknown, improved characterization with GAME increases the potential for determining any correlates of fit parameters with biomarkers, such as oxygenation status. J. MAGN. RESON. IMAGING 2016;44:1020-1030.

Association between the low-dose irinotecan regimen-induced occurrence of grade 4 neutropenia and genetic variants of UGT1A1 in patients with gynecological cancers

The occurrence of severe neutropenia during treatment with irinotecan (CPT-11) is associated with the *6 and *28 alleles of uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1). However, the correlation between these variants and the occurrence of severe neutropenia in a low-dose CPT-11 regimen for the treatment of gynecological cancers has not been extensively studied. There are also no studies regarding the association between the 421C>A mutation in ATP-binding cassette sub-family G member 2 (ABCG2) and the occurrence of severe neutropenia in CPT-11-treated patients with gynecological cancers. The present study was designed to determine the factors associated with the occurrence of grade 4 neutropenia during chemotherapy for gynecological cancers with combinations of CPT-11 and cisplatin or mitomycin C. In total, 44 patients with gynecological cancer were enrolled in the study. The association between the absolute neutrophil count (ANC) nadir values, the total dose of CPT-11 and the genotypes of UGT1A1 or ABCG2 was studied. No correlation was observed between the ANC nadir values and the total dose of CPT-11. The ANC nadir values in the UGT1A1*6/*28 and *6/*6 groups were significantly lower compared with those in the *1/*1 group (P<0.01). Univariate analysis showed no association between the occurrence of grade 4 neutropenia and the ABCG2 421C>A mutation. Subsequent to narrowing the factors by univariate analysis, multivariate logistic regression analysis only detected significant correlations between the occurrence of grade 4 neutropenia and the UGT1A1*6/*6 and *6/*28 groups (P=0.029; odds ratio, 6.90; 95% confidence interval, 1.22-38.99). No associations were detected between the occurrence of grade 4 neutropenia and the heterozygous variant (*1/*6 or *1/*28) genotype, type of regimen or age. In conclusion, the UGT1A1*6/*28 and *6/*6 genotypes were found to be associated with the occurrence of severe neutropenia in the low-dose CPT-11 regimen for gynecological cancers. This finding indicates that the determination of UGT1A1 variants may be as useful in CPT-11 chemotherapy for gynecological conditions as it is in colorectal and lung cancer patients treated with this drug.

Pilot study: alteration of deleted in liver cancer1 and phosphorylated focal adhesion kinase Y397 cytoplasmic expression and the prognostic value in advanced epithelial ovarian carcinoma

Background

Deletion in liver cancer gene (DLC1) and phosphorylated focal adhesion kinase (p-FAK) have recently been reported as metastasis-related genes. However, the roles and prognostic values of their expression in epithelial ovarian carcinomas (EOCs) remain unclear.

Methods

The expression and prognostic value of DLC1 and p-FAK Y397 in EOC were evaluated by immunohistochemistry and multivariate analysis.

Results

Low expression of DLC1 and high expression of p-FAK Y397 were found in the 76 cases of EOC. The expression of DLC1 and p-FAK Y397 were negatively correlated. Multivariate analysis showed that the combination of them was an independent prognostic marker of EOC (P = 0.0319).

Conclusions

DLC1 and pFAK Y397 had an association with the clinicopathologic characteristics of EOC. Expression of neither of these genes was a prognostic factor alone, but the combination revealed a significant prognostic value in the 60 cases of advanced stage EOC.