The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology

Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.

Vulvar Cancer, Version 3.2024, NCCN Clinical Practice Guidelines in Oncology

Vulvar cancer is annually diagnosed in an estimated 6,470 individuals and the vast majority are histologically squamous cell carcinomas. Vulvar cancer accounts for 5% to 8% of gynecologic malignancies. Known risk factors for vulvar cancer include increasing age, infection with human papillomavirus, cigarette smoking, inflammatory conditions affecting the vulva, and immunodeficiency. Most vulvar neoplasias are diagnosed at early stages. Rarer histologies exist and include melanoma, extramammary Paget's disease, Bartholin gland adenocarcinoma, verrucous carcinoma, basal cell carcinoma, and sarcoma. This manuscript discusses recommendations outlined in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for treatments, surveillance, systemic therapy options, and gynecologic survivorship.

NCCN Guidelines® Insights: Cervical Cancer, Version 1.2024

The NCCN Guidelines for Cervical Cancer provide recommendations for all aspects of management for cervical cancer, including the diagnostic workup, staging, pathology, and treatment. The guidelines also include details on histopathologic classification of cervical cancer regarding diagnostic features, molecular profiles, and clinical outcomes. The treatment landscape of advanced cervical cancer is evolving constantly. These NCCN Guidelines Insights provide a summary of recent updates regarding the systemic therapy recommendations for recurrent or metastatic disease.

Pelvic floor dysfunction survivorship needs and referrals in the gynecologic oncology population: a narrative review

The population of survivors of gynecologic malignancies continues to grow. The population of gynecologic oncology survivors has a high prevalence of pelvic floor disorders. Gynecologic oncology patients identify several survivorship needs, including a need for more focused pelvic floor disorder sequelae care. The increasing focus on patient needs following cancer treatment has led to the development of survivorship care plans and other strategies for addressing post-treatment transitions and sequelae. Common themes in patient survivorship care are patient needs for flexible and integrated care, and it is unclear if survivorship care plans in their current state improve patient outcomes. Patient referrals, specifically to urogynecologists, may help address the gaps in survivorship care of pelvic floor dysfunction.The objective of this review is to discuss the burden of pelvic floor disorders in the gynecologic population and to contextualize these needs within broader survivorship needs. The review will then discuss current strategies of survivorship care, including a discussion of whether these methods meet survivorship pelvic floor disorder needs. This review addresses several gaps in the literature by contextualizing pelvic floor disorder needs within other survivorship needs and providing a critical discussion of current survivorship care strategies with a focus on pelvic floor disorders.

Malnutrition, sarcopenia, and cancer cachexia in gynecologic cancer

Patients with gynecologic cancers are at risk for malnutrition, cancer cachexia, and sarcopenia. Accumulating data supports that malnourished patients with gynecologic cancer have worse overall survival, increased healthcare utilization and costs, and a higher incidence of postoperative complications and treatment toxicity than those who are not malnourished. Malnutrition is defined as insufficient energy intake, leading to altered body composition and subsequent impaired physical and cognitive function, and can result in sarcopenia and cachexia, defined as the loss of lean body mass and loss of body weight respectively. The etiology of cancer-related malnutrition is complex, resulting from a systemic pro-inflammatory state of malignancy with upregulation of muscle degradation pathways and metabolic derangements, including lipolysis and proteolysis, that may not respond to nutritional repletion alone. Numerous validated scoring systems and radiographic measures have been described to define and quantify the severity of malnutrition and muscle loss in both clinical and research settings. "Prehabilitation" and optimization of nutrition and functional status early in therapy may combat the development or worsening of malnutrition and associated syndromes and ultimately improve oncologic outcomes, but limited data exist in the context of gynecologic cancer. Multi-modality nutrition and physical activity interventions have been proposed to combat the biophysical losses related to malnutrition. Several trials are underway in gynecologic oncology patients to address these aims, but significant gaps in knowledge persist. Pharmacologic interventions and potential immune targets for combating cachexia related to malignancy are discussed in this review and may provide opportunities to target disease and cachexia. This article reviews currently available data regarding the implications, diagnostics, physiology, and intervention strategies for gynecologic oncology patients with malnutrition and its associated conditions.

"More than a song and dance": Exploration of patient perspectives and educational quality of gynecologic cancer content on TikTok

OBJECTIVE

To investigate themes, quality, and reliability of gynecologic cancer-related content on the social media application TikTok.

METHODS

TikTok was systematically searched for the 100 most popular posts for ovarian cancer (OC), endometrial cancer (EC), cervical cancer (CC), vulvar cancer (VC), and gestational trophoblastic disease (GTD) in August 2022. Data was collected for demographics, tone, and themes. Educational videos were rated for quality and reliability utilizing the modified DISCERN scale. Relationships between content demographics, disease sites, and themes were assessed.

RESULTS

As of August 2022, the top five hashtags for each gynecologic cancer on TikTok had 466.7 million views. 430 of the top 500 posts were eligible for inclusion (OC: n = 86, CC: n = 93, EC: n = 98, GTD: n = 63, VC: n = 90). The majority of creators (n = 323, 75.1%) were White, 33 (7.7%) were Black, 20 (4.6%) were Asian/Pacific Islander (API), 10 (2.3%) were South Asian, 20 (4.7%) were Hispanic/Latino/a, 24 (5.5%) were unable to determine. Eleven central themes were identified, with significant differences when analyzed by disease site and race. The median DISCERN score for all posts was 1.0, indicating poor educational quality and reliability. When compared by race, South Asian/API posters received the highest scores (3, IQR 2.5) versus Black (2: IQR 3), Hispanic/Latino/a (2: IQR 0), and White posters (1, IQR 2) (p = 0.0013).

CONCLUSION(S)

Gynecologic cancer-related content on TikTok is of poor educational quality, and racial disparities in gynecologic cancer extend to social media. Opportunities exist to create more diverse content to support racial and cultural experiences in gynecologic cancer treatment.

Small molecule mediated stabilization of PP2A modulates the Homologous Recombination pathway and potentiates DNA damage-induced cell death

High-Grade Serous Carcinoma (HGSC) is the most common and lethal ovarian cancer subtype. PARP-inhibitors (PARPi) have become the mainstay of HGSC targeted therapy, given that these tumors are driven by a high degree of genomic instability and Homologous Recombination (HR) defects. Nonetheless, ~30% of patients initially respond to treatment, ultimately relapsing with resistant disease. Thus, despite recent advances in drug development and an increased understanding of genetic alterations driving HGSC progression, mortality has not declined, highlighting the need for novel therapies. Using a Small Molecule Activator of Protein Phosphatase 2A (PP2A) (SMAP-061), we investigated the mechanism by which PP2A stabilization induces apoptosis in Patient-Derived HGSC cells and Xenograft (PDX) models alone or in combination with PARPi. We uncovered that PP2A genes essential for cellular transformation (B56,B56 and PR72) and basal phosphatase activity (PP2A-A and -C) are heterozygously lost in the majority of HGSC. Moreover, loss of these PP2A genes correlate with worse overall patient survival. We show that SMAP-061 stabilization of PP2A inhibits the homologous recombination (HR) output by targeting RAD51, leading to chronic accumulation of DNA damage and ultimately apoptosis. Furthermore, combination of SMAP-061 and PARPi leads to enhanced apoptosis in both HR-proficient and HR-deficient cells and in PDX models. Our studies identifies PP2A as a novel regulator of HR and indicates PP2A modulators as a therapeutic therapy for HGSC. In sum, our findings further emphasize the potential of PP2A modulators to overcome PARPi insensitivity, given that targeting RAD51 presents benefits in overcoming PARPi-resistance driven by BRCA1/2 mutation reversions.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

High pre-treatment neutrophil-to-lymphocyte ratio as a prognostic marker for worse survival in patients with recurrent/metastatic cervical cancer treated with immune checkpoint inhibitors

•

Neutrophil-to-lymphocyte ratio was predictive of OS in cervical cancer patients treated with PD-1/PD-L1 inhibitors.

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For those with a NLR < 8 the probability of survival at one year was 57% compared to 26% for those with NLR ≥ 8.

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No significant association between NLR and progression free survival or response to treatment was noted.

•

Assessment of ORR was limited due to 5/14 patients in the NLR ≥ 8 group passing before assessment of disease response.

•

NLR holds promise as a predictive marker for survival in this population and warrants further evaluation.

Objective

To evaluate the association between pre-treatment neutrophil-to-lymphocyte ratio (NLR) and survival outcomes among patients with recurrent/metastatic cervical cancer treated with PD-1/PD-L1 inhibitors.

Methods

A retrospective analysis of patients with recurrent/metastatic cervical cancer treated with PD-1/PD-L1 inhibitors from 2016 to 2021 was conducted. Progression free survival (PFS) and overall survival (OS) outcomes were assessed for patients stratified by NLR (<8 vs ≥ 8) utilizing Kaplan-Meier method. Univariable analysis was performed to compare baseline characteristics between the two groups.

Results

A total of 49 patients were included in analysis. A majority of patients had squamous cell histology (57%), were PD-L1 positive (55%), received ≤ 1 prior lines of systemic therapy (57%), and had distant metastatic disease at the time of treatment (69%). The groups were well-balanced with respect to age, race, histology, smoking status, PD-L1 positivity, prior lines of treatment (≤1 vs > 1), prior radiation therapy, ECOG performance status, and disease distribution for patients with a NLR < 8 (n = 35) compared to those with a NLR ≥ 8 (n = 14). A pre-treatment NLR of < 8 was associated with improved survival (p < 0.01), with 57% (95% CI: 41%, 78%) probability of survival at one year compared to 26% (95% CI: 10%, 66%) for those with NLR ≥ 8. No statistically significant differences in probability of PFS at 1 year were seen between NLR < 8 compared to those with NLR ≥ 8 (p = 0.70).

Conclusions

Pre-treatment NLR may hold prognostic value for patients with metastatic/recurrent cervical cancer treated with PD-1/PD-L1 inhibitors, with NLR < 8 associated with improved survival.

Altrenogest treatment reduces the stress response of three-year-old warmblood mares during their initial equestrian training

Horse mares are frequently treated with the progestin altrenogest with the aim to suppress estrous behavior and its negative impact on equestrian performance. Progestogens, however, also have sedative effects in males, and females of different species. The aim of our study was therefore to investigate altrenogest-induced changes in the stress response of female horses during initial equestrian training. Three-yr-old Warmblood mares were randomly assigned to treatment with altrenogest (ALT; 0.044 mg/kg once daily; n = 6) or sunflower oil (CON; n = 5) for 12 wk during training. At predefined steps of the training program (free movement, lunging without and with side reins, lunging with saddle, mounting of a rider, free riding, riding by an unfamiliar rider) salivary cortisol concentration, and heart rate were determined from 60 min before to 120 min after training. The same procedures were performed during repeated gynecologic examinations and 2 novel object tests. Bodyweight and body condition scores (BCS) were assessed at 4-wk intervals. During all training units, salivary cortisol concentration and heart rate increased (P < 0.001), but the increase was smaller in group ALT mares (time x treatment P < 0.001). Gynecologic examinations and novel object tests induced a much smaller increase in cortisol and heart rate (P < 0.001) than equestrian training with no difference between groups ALT and CON. Initially, bodyweight, and BCS decreased during training. The subsequent increase was larger in group ALT vs CON (time x treatment P < 0.05). In conclusion, altrenogest reduced the stress response of 3-yr-old mares to equestrian training. The use of altrenogest during equestrian competitions should therefore be reconsidered.

Skene's Gland Malignancy: A Case Report and Systematic Review

OBJECTIVE

To present a recent clinical case of Skene's gland carcinoma and review all published literature of Skene's gland malignancy with associated treatment and outcomes.

METHODS

We review a new case of metastatic Skene's gland adenocarcinoma. We then performed a systematic search of PubMed and Ovid-Medline through December 2021 and retrieved English language articles for review. Peer-reviewed articles were deemed eligible if they included patients with Skene's gland malignancy. Reports were reviewed for pathologic accuracy, patient characteristics, clinical presentation, tumor pathology, treatment and outcome.

RESULTS

We reviewed 211 articles and included 15 cases from 1974 to 2022. The median patient age was 71 years (range 46-88). The most common presentation was an asymptomatic periurethral or urethral lesion in five cases (33.3%), followed by hematuria or vaginal bleeding in three patients (20.0%). In eight cases, a prostate-specific antigen was measured and found to be elevated, range 0.8-60.8 ng/mL. Treatment approaches varied and included local excision in eight cases, radical surgical resection in two cases, radiation therapy in two cases, and adjunctive androgen deprivation therapy in one case. Pathology was consistent with adenocarcinoma resembling prostate in all cases. In all cases tested, prostate-specific antigen normalized after definitive therapy of any type. Median follow up was 11.5 months, and there were no cases of recurrence or mortality secondary to Skene's gland adenocarcinoma.

CONCLUSION

There are 15 published cases of a Skene's gland malignancy, all adenocarcinoma resembling prostate. Local excision is most often utilized for treatment, with androgen deprivation therapy emerging as a new treatment consideration.

POS0885 HYPOCHROMIC ERYTHROCYTES AS PROGNOSTIC INDICATOR OF SURVIVAL AMONG PATIENTS WITH SYSTEMIC SCLEROSIS SCREENED FOR PULMONARY HYPERTENSION

Background

Iron deficiency is frequent among patients with systemic sclerosis (SSc), particularly among those with pulmonary hypertension (PH). First data indicate prognostic importance of hypochromic erythrocytes (HRC) >2% among patients with PH1. Hence, the aim of this study was to investigate the predictive value of HRC in SSc patients screened for PH.

Objectives

The objective of this study was to investigate the predictive value of HRC in SSc patients screened for PH.

Methods

In this retrospective, single-center cohort study SSc patients screened for PH were included. Clinical characteristics, laboratory and pulmonary functional parameters associated with the prognosis of SSc were analysed using uni- and multivariable analysis.

Results

A total of 280 SSc patients were screened, 171 were included in the analysis having complete data of iron metabolism (79% female, 61.0±12.9 years of age, 73.2% limited cutaneous SSc, 56 manifest PH and 112 pulmonary fibrosis). The patients were followed for 2.4±1.8 (median 2.4) years. HRC >2% at baseline was significantly associated with worse survival in the uni- (p=0.018) and multivariable analysis (p<0.0001). Overall 34.5% of the patients suffered from iron deficiency and 22% received iron substitution during follow-up. HRC >2% was identified as independent predictor of mortality, for patients with and without pulmonary manifestations of SSc.

Conclusion

This study detected for the first time that HRC >2% is an independent prognostic predictor and can possibly be used as a biomarker among SSc-patients. Further studies are needed to confirm these results.

References

[1]Xanthouli P, Theobald V, Benjamin N, Marra AM, D’Agostino A, Egenlauf B, Shaukat M, Ding C, Cittadini A, Bossone E, Kögler M, Grünig E, Muckenthaler MU, Eichstaedt CA. Prognostic impact of hypochromic erythrocytes in patients with pulmonary arterial hypertension. Respir Res. 2021 Nov 9;22(1):288. doi: 10.1186/s12931-021-01884-9.

Disclosure of Interests

Panagiota Xanthouli Speakers bureau: MSD and OMT, outside the submitted work, Ojan Gordjani: None declared, Christina Eichstaedt: None declared, Nicola Benjamin Speakers bureau: Actelion pharmaceuticals, Bayer HealthCare and MSD., Benjamin Egenlauf Speakers bureau: Actelion, MSD, Bayer and OMT outside the submitted work, Satenik Harutyunova Speakers bureau: Bayer, MSD, Actelion and GSK, outside the submitted work., Alberto Marra Speakers bureau: Bayer/MSD outside the submitted work, Vivienne Theobald: None declared, Nicklas Milde: None declared, Christian Nagel Speakers bureau: Actelion, MSD, Boehringer, Novartis, Bayer, and AstraZeneca, Norbert Blank Speakers bureau: MSD, GSK, Actelion and Bayer Vital., Consultant of: MSD, GSK, Actelion and Bayer Vital., Hanns-Martin Lorenz Speakers bureau: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Consultant of: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Ekkehard Grünig Speakers bureau: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House, Consultant of: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House

Availability of child care resources for patients undergoing cancer treatment at NCI-designated cancer centers

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Background: The National Cancer Institute (NCI) estimates that approximately one-quarter of adults with cancer are parents to children less than 18 years. Further, it is estimated that 2.85 million minor children in the United States have a parent undergoing cancer treatment. Previous studies have demonstrated that parents with cancer experience significant stress and disruptions to familial life following a cancer diagnosis. In a study of women with breast, gynecologic cancer and other cancers undergoing cancer therapy, 48.7% of women endorsed needing help with childcare and 64.1% needing help with household management. Despite this evidence supporting both a need for childcare among patients with cancer, data regarding the availability of on-site childcare programs and resources at NCI-designated cancer centers is limited. The objective of this cross-sectional study was to assess the availability of childcare resources for parents who are undergoing cancer treatment at NCI-Designated Cancer Centers. Methods: The availability of childcare resources for parents undergoing cancer treatment at all 51 NCI-designated comprehensive cancer centers and 13 NCI-designated cancer was assessed in January 2021 and February 2021. Childcare resources were assessed via online search and telephone calls. Specifically, centers were queried regarding availability of daycare programs for children of patients undergoing treatment and whether resources were available to assist patients in need of childcare. Descriptive statistics were performed. Results: In total, only 1/64 (1.6%) of NCI-designated cancer centers currently offer childcare resources for patients undergoing cancer treatment. This center offers childcare for children ages 2–8, free of charge with multiple outpatient locations. One additional institution previously provided patients with access to daycare, but has closed due to the COVID-19 pandemic. Further, only 1/64 (1.6%) NCI-designated cancer center offers financial assistance grants to aid patients to subsidizing childcare costs during cancer treatment. Conclusions: Institution sponsored options for childcare for patients undergoing cancer treatments are highly limited, even in the best resourced cancer care settings. The COVID-19 pandemic has limited options further, and many hospitals now restrict visitors under the age of 18. Patient grants or institutionally sponsored childcare provider networks may represent an avenue for supporting parents who are facing a cancer diagnosis. Supporting families of patients with cancer has great potential to impact quality of life, economic and psychological stress.

Identifying ablation targets using regional voltage thresholds in atrial fibrillation patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): We gratefully acknowledge financial support by Deutsche Forschungsgemeinschaft (DFG) through DO637/22-3 and by the Ministerium für Wissenschaft, Forschung und Kunst Baden-Württemberg through the Research Seed Capital (RiSC) program.

Introduction

One treatment option for patients suffering from atrial fibrillation (AF) is to isolate the pulmonary veins, which has a very high success rate in paroxysmal AF patients. However, in patients with persistent AF, the success rate can be as low as 30%. One reason is that the additional arrhythmogenic substrate in the atria is responsible for maintaining the arrhythmia. These areas can be identified by locating low voltage areas &lt;0.5 mV during sinus rhythm (SR), or &lt;0.3-0.5 mV during AF. We recently reported that a high correlation exists between mapping in the two different rhythms. However, this correlation differs between different regions of the atria.

Purpose

To study the differences between mapping in SR and AF in different atrial regions and identify if regional thresholds can improve the cross-rhythm correlation.

Methods

Twenty-eight persistent AF patients underwent high-density voltage mapping during both SR and AF. The electro-anatomical mapping was performed using the CARTO-3 software and a 20-pole Lasso-Nav catheter (electrode size 1mm, spacing 2-6-2mm). A mean left atrial geometry was derived for the cohort and the patient’s voltage values were projected onto this mean anatomical model. The mean voltage across all patients at each mapping site was calculated for both rhythms, then the difference between them was determined. Additionally, the geometry was split into six anatomical regions: left atrial appendage (LAA), anterior, posterior, and lateral wall, roof, and septum. The optimal AF threshold was identified for each region, which correlated to low voltage areas during SR &lt;0.5 mV.

Results

The highest voltages were found in the left atrial appendage, with the anterior wall presenting the lowest voltages during both rhythms. Across the entire atria, the voltage values were lower, differing between 0-1.2 mV, when mapping during AF than SR. However, the difference between rhythms differed across the atria with the lowest agreement between SR and AF voltages observed at the roof and the posterior wall. The difference in voltage between the two rhythms was highly significant (p&lt;0.001) for each region.

Applying regional thresholds had little effect on the cross-rhythm classification agreement at the anterior wall. However, decreasing the threshold by 0.05 mV improved the accuracy on the posterior wall by 10%. Increasing the threshold at the lateral wall improved the accuracy by 5%.

Conclusion

A universal threshold for mapping during AF is sufficient for most regions with a limited reduction in the accuracy compared to SR low voltage &lt;0.5 mV. However, the substrate on the posterior and lateral wall targeted for ablation may be more accurately identified using tailored thresholds during AF mapping.

Induction of parturition in horses - from physiological pathways to clinical applications

Based on the marked variability in physiological equine gestation length, induction of foaling in mares often results in the birth of dysmature foals. Precise prediction of preparedness of the mare for foaling is thus essential. Treatment with glucocorticoids mimics the fetal signal that initiates birth. Repeated daily dexamethasone treatment in late gestation results in birth of mature foals but the time from initiation of treatment to foaling is highly variable and complications such as dystocia have been reported. Contrary to most expectations, treatment of prepartum mares with progestogens does not delay but advances the onset of foaling. Prostaglandin F_2α (PGF_2α) and its analogues are effective to induce foaling but even in mares ready for parturition, foal health remains to some extent unpredictable. This may be caused by a relatively long interval between PGF_2α treatment and birth, exposing the fetus for several hours to uterine contractions. Oxytocin reliably induces foaling towards the end of pregnancy, but when given at high doses is effective also in the pre-viable period of gestation, resulting in birth of premature foals. Recent research has focused on reducing the amount of oxytocin with the aim to induce foaling only in mares prepared for foaling. Mares selected on clinical criteria receive 1 dose of 2.5 to 3.5 IU of oxytocin. Mares not responding to oxytocin are judged not yet ready for foaling and treatment is repeated the earliest after 24 h. This protocol at present is the most reliable and safest way to induce parturition in mares.

Effects of blue monochromatic light directed at one eye of pregnant horse mares on gestation, parturition and foal maturity

Blue light directed at 1 eye advances the equine ovulatory season but may also advance foaling. In this study, effects of blue LED light on pregnancy outcome were assessed. A total of 20 mares with singleton pregnancies were studied over 2 consecutive years in a cross-over design. In 1 year, mares received an extended photoperiod using 50 lux of blue LED light (468 nm) directed at a single eye from 08:00 until 23:00 daily via head-worn light masks starting mid-December and in the other year remained untreated as controls. Gestation was shorter in blue LED light-treated than in control pregnancies (median 333.0 vs 338.5 days, P = 0.036). Foals born to blue LED light-treated mares had lower wither heights (median 103.0 vs 104.5 cm, P = 0.023), similar weights (median 55.8 vs 54.8 kg, P = 0.732) and took less time to stand after birth than control foals (median 35.0 vs 53.5 min, P = 0.036). Foals born to blue LED light-treated mares had reduced hair length compared to controls (median 12.0 vs 20.0 mm, P = 0.009) and hair regrowth in treated mares was reduced (P = 0.036). In conclusion, blue LED light directed at 1 eye advanced foaling and influenced height and hair coat but not weight in foals.

NCCN Guidelines Insights: Cervical Cancer, Version 1.2020

The NCCN Guidelines for Cervical Cancer provide recommendations for diagnostic workup, staging, and treatment of patients with the disease. These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to first- and second-line systemic therapy recommendations for patients with recurrent or metastatic disease, and emerging evidence on a new histopathologic classification system for HPV-related endocervical adenocarcinoma.

Spatial and quantitative assessment of the correlation between sinus rhythm and atrial fibrillation voltage mapping to identify low voltage substrate in persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG) through DO637/22-3 Ministerium für Wissenschaft, Forschung und Kunst Baden-Württemberg through the Research Seed Capital (RiSC) program.

Introduction

Presence of left atrial (LA) fibrotic low voltage substrate (LVS) is associated with high risk for arrhythmia recurrences in patients undergoing pulmonary vein isolation (PVI) for atrial fibrillation (AF). PVI and additional ablation of LVS - as identified by mapping in sinus rhythm (SR) or AF - has been reported to improve SR maintenance rates, despite differences of the extent and distribution of LA-LVS in SR versus AF. 

Aims

To study the relationship between SR and AF voltage maps, we sought to identify the optimal AF voltage threshold providing the highest concordance in the extent and distribution of LVS when comparing voltage maps in SR vs. AF.

Methods

Using the statistical shape modelling software Scalismo, the voltage information from the SR and AF maps (acquired prior to PVI) from 28 patients (66 ± 7 years, 46% male, 82% persistent AF) was projected onto a representative LA-geometry. Sensitivity and specificity of LVS identification were calculated for varying thresholds during AF and the correlation between the SR (threshold 0.5mV) and AF maps was assessed and areas of agreeing LVS classification (SR & AF) were identified for each patient. The data of all 28 patients were combined to a spatial histogram of agreement between SR and AF low voltage maps.

Results

 The correlation between SR and AF maps was high across all patients, with agreement at 60-95% of all mapped sites (Figure A: each red triangle represents one patient and the respective agreement of LVS classification and substrate extent).  The optimal AF threshold - to identify LA-LVS &lt;0.5 mV in SR - was 0.29 mV (Q1-3: 0.20-0.37 mV) and was independent of the underlying extent of LVS during SR (Figure A: each blue asterisk represents one patient and the corresponding AF threshold and substrate extent). Agreement between LVS in AF vs. SR was high across most (&gt;90) patients on the anterior LA, lateral LA and the left atrial appendage. Lower agreement (60% of patients) was observed in the posterior wall (Figure B).

Conclusions

SR and AF voltage maps reveal high spatial concordance in low voltage substrate at the anterior LA, lateral LA and LA appendage, however significant discordances in LVS are found in 40% of patients at the posterior LA. Further studies on an extended patient cohort should assess if regional voltage-thresholds would result in an improved substrate concordance between AF and SR substrate maps. Abstract Figure.

Cervical Cancer, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.

Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.

P3676Hemodynamic phenotypes in systemic sclerosis patients screened for pulmonary hypertension (PH): impact of the new definition of PH

Background

Patients with systemic sclerosis (SSc) are at high risk of developing concomitant pulmonary hypertension (PH) which has a crucial impact on the patients' symptoms, quality of life and prognosis.

Purpose

The aim of this study was to analyse the impact of the new hemodynamic definition of precapillary PH as proposed at the 2018 World Symposium on PH in Nice in patients with SSc. Although recent data suggest that PVR >2 WU could be considered as abnormal in the new definition a conservative cut-off value of PVR ≥3 WU has been used.

Methods

SSc-patients were screened for PH using clinical assessments as WHO-functional class, 6 minute walking distance and right heart catheterisation. Patients were divided into hemodynamic subgroups according to their mean pulmonary arterial pressure (mPAP) values with mPAP ≤20 mmHg, 21–24 mmHg and ≥25 mmHg. These subgroups were further divided according to their pulmonary vascular resistance (PVR) with PVR <3 WU or ≥3 WU.

Results

One-hundred-twenty-two patients (79% female, age 57.6±12.7 years, 6MWD 439.5±98.1 meters, 70% diffuse cutaneous SSc, 30% limited cutaneous SSc, 53% WHO-FC II, 25% WHO-FC III) who were prospectively screened for PH were included in the analysis (Figure 1). Among them 26 had a symptomatic manifest PH using the cut-off value of mPAP ≥25 mmHg. Only half of this group presented with PVR ≥3 WU, the others had PVR <3 WU. Eight of these 26 PH-patients presented with PH due to left heart disease. Out of 21 patients with mildly elevated mPAP 21–24 mmHg, two (10%) met the new definition criteria of PH (pulmonary arterial wedge pressure <15 mmHg, mPAP 23 and 24 mmHg, PVR 3.0 and 3.2 WU, CI 2.2 L/min/m2 both, WHO-FC II both, respectively). Out of 75 patients with mPAP <21 mmHg, three presented with PVR ≥3 WU.

Overview of systemic sclerosis patients

Conclusions

The new definition of precapillary pulmonary hypertension may on the one hand allow detecting an additional 10% of PH patients with mild elevated mPAP. On the other hand, eight of 13 patients (62%), who met the former definition of pulmonary arterial hypertension, would be classified as “normal” due to a lack of increase in PVR according to the new definition. The data of this study suggest that for SSc-patients the cut-off value of mPAP >20 mmHg is useful, but the criteria of PVR ≥3 WU may be too strict.

Further studies with larger sample sizes will be needed to better characterise these hemodynamic subgroups and to define the extent of pulmonary vascular disease and treatability.

Uterine Neoplasms, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology

Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.

Sleep, quality of life, and depression in endometrial cancer survivors with obesity seeking weight loss

PURPOSE

Incidence and mortality rates of uterine cancer are increasing and, obesity, which is also rising, has been associated with uterine cancer development and mortality. A recent study found that poor sleep quality is common among endometrial cancer survivors and those with obesity had more sleep disturbances than those having normal weight. However, it is unclear if higher levels of obesity (Class III, BMI ≥ 40 kg/m²), which are rising rapidly, are differentially associated with sleep as well as depression and quality of life in endometrial cancer survivors.

METHODS

We evaluated sleep, depression, and quality of life in 100 Stage I endometrial cancer survivors with obesity seeking weight loss enrolled in a lifestyle intervention (NCT01870947) at baseline.

RESULTS

The average age was 60 years and mean BMI was 42.1 kg/m² with 58% having a BMI ≥ 40 kg/m². Most survivors (72.3%) had poor sleep quality and most (71.2%) reported sleeping < 7 h/night. Survivors with class III compared with class I obesity had significantly more sleep disturbances and daytime dysfunction; and, those with poor sleep had higher depression and lower quality of life. Survivors with a BMI ≥ 50 kg/m² (~ 25%) had the highest levels of depression and lowest physical and emotional well-being.

CONCLUSIONS

Our results reveal that endometrial cancer survivors with class III compared with class I obesity have poorer sleep quality, higher depression, and lower quality of life. Given the rising rates of obesity and uterine cancer mortality, interventions to combat both obesity and poor sleep are needed.

The Highly Recurrent PP2A Aα-Subunit Mutation P179R Alters Protein Structure and Impairs PP2A Enzyme Function to Promote Endometrial Tumorigenesis

Somatic mutation of the protein phosphatase 2A (PP2A) Aα-subunit gene PPP2R1A is highly prevalent in high-grade endometrial carcinoma. The structural, molecular, and biological basis by which the most recurrent endometrial carcinoma-specific mutation site P179 facilitates features of endometrial carcinoma malignancy has yet to be fully determined. Here, we used a series of structural, biochemical, and biological approaches to investigate the impact of the P179R missense mutation on PP2A function. Enhanced sampling molecular dynamics simulations showed that arginine-to-proline substitution at the P179 residue changes the protein's stable conformation profile. A crystal structure of the tumor-derived PP2A mutant revealed marked changes in A-subunit conformation. Binding to the PP2A catalytic subunit was significantly impaired, disrupting holoenzyme formation and enzymatic activity. Cancer cells were dependent on PP2A disruption for sustained tumorigenic potential, and restoration of wild-type Aα in a patient-derived P179R-mutant cell line restored enzyme function and significantly attenuated tumorigenesis and metastasis in vivo. Furthermore, small molecule-mediated therapeutic reactivation of PP2A significantly inhibited tumorigenicity in vivo. These outcomes implicate PP2A functional inactivation as a critical component of high-grade endometrial carcinoma disease pathogenesis. Moreover, they highlight PP2A reactivation as a potential therapeutic strategy for patients who harbor P179R PPP2R1A mutations. SIGNIFICANCE: This study characterizes a highly recurrent, disease-specific PP2A PPP2R1A mutation as a driver of endometrial carcinoma and a target for novel therapeutic development.See related commentary by Haines and Huang, p. 4009.

Abstract A85: Receipt of adjuvant endometrial carcinoma treatment according to race: An NRG Oncology/Gynecologic Oncology Group 210 Study

Background: Black women diagnosed with endometrial cancer (EC) experience worse outcomes compared with white women. Differences in receipt of treatment are postulated to contribute to this disparity. While underuse of surgical treatment among black women is well documented, we know less about racial differences in adjuvant treatment. We therefore examined receipt of adjuvant treatment among black and white women in the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study, a large prospective cohort of women with EC who received uniform surgical treatment but varying adjuvant therapy regimens.

Methods: Our analysis included 615 black and 4,283 white women with EC who underwent either an abdominal hysterectomy or laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy and lymph node dissection. At study enrollment, women completed a questionnaire that assessed race as well as risk factors for EC. Tumor characteristics were available from surgical pathology reports and a centralized review by pathologists with expertise in gynecologic cancers. Adjuvant treatment was documented at the time of the postoperative clinical visits and was categorized as none (54.3%), radiotherapy only (16.5%), chemotherapy only (n=15.2%), and radiotherapy and chemotherapy (14.0%). We used polytomous logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between race and receipt of adjuvant therapy in the overall study population and stratified by tumor subtype (combination of histology and grade) adjusted for age, income, education, and stage.

Results: Black compared with white women had higher odds of receiving combination radiotherapy and chemotherapy compared to no adjuvant therapy (OR=1.35, 95% CI=1.01-1.79) but no difference in receipt of radiotherapy only (OR=0.95, 95% CI=0.72-1.25) or chemotherapy only (OR=0.88 (0.64-1.20) was observed. In tumor-subtype stratified models, black women diagnosed with low-grade endometrioid (OR=2.04, 95% CI=1.06-3.93) or serous tumors (OR=1.81, 95% CI=1.07-3.08) had higher odds of receiving radiotherapy and chemotherapy than white women, but race was not associated with receipt of radiotherapy and chemotherapy for women with high-grade endometrioid, carcinosarcoma, mixed-cell, or clear-cell tumors. Moreover, the tumor-subtype stratified analyses revealed no racial differences in receipt of radiotherapy-only or chemotherapy-only regimens.

Conclusions: In this study of women with EC who received uniform surgical treatment, we observed racial differences in receipt of some adjuvant treatment regimens but not others. Among women with indolent (i.e., low-grade endometrioid) or aggressive (i.e., serous) tumors, black women had higher odds of receiving radiotherapy and chemotherapy compared to white women. Radiotherapy and chemotherapy treatment is potentially contraindicated for women with indolent tumors, which suggests a need to understand the reasons why clinicians might overprescribe these therapies for black women. Overall, our results suggest racial differences in receipt of radiotherapy and chemotherapy, but not for other regimens.

Citation Format: Ashley Felix, David Cohn, Theodore Brasky, David Mutch, William Creasman, Premal Thaker, Joan Walker, Richard Moore, Shashikant Lele, Saketh Guntupalli, Levi Downs, Christa Nagel, John Boggess, Michael Pearl, Olga Ioffe, Wei Deng, Marcus Randall, Louise Brinton. Receipt of adjuvant endometrial carcinoma treatment according to race: An NRG Oncology/Gynecologic Oncology Group 210 Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A85.

3T multiparametric MRI-guided high-dose-rate combined intracavitary and interstitial adaptive brachytherapy for the treatment of cervical cancer with a novel split-ring applicator

PURPOSE

To evaluate the role of 3T-MRI-guided adaptive high-dose-rate (HDR) combined intracavitary and interstitial brachytherapy for cervical cancer using a novel intracavitary split-ring (ICSR) applicator adapter.

METHODS AND MATERIALS

We retrospectively reviewed all HDR brachytherapy cases from 2013 to 2015 using an ICSR applicator. Initial optimization was performed using 3T multiparametric MRI (mpMRI) series with an applicator in place. The mpMRI series were discretionarily acquired before subsequent fractions for possible target adaptation. When necessary, interstitial needles (ISNs) were inserted through a novel ICSR adapter or freehand. Dosimetric parameters, clinical outcomes, and toxicities were compared between groups.

RESULTS

Seventeen patients were included, with a mean followup of 32 months. An mpMRI series preceded each initial fraction and 52.9% of patients underwent ≥1 additional pretreatment mpMRI. Among these subsequent fractions, the high-risk clinical target volume was reduced in 80% vs. 41% without pretreatment mpMRI. Five patients had ISN placement (seven insertions) to improve extracervical target coverage. Mean D₉₀ (Gy) per fraction to the high-risk clinical target volume and intermediate-risk clinical target volume with and without an ISN were 7.51 ± 1.07 vs. 6.14 ± 0.52 (p = 0.028) and 6.35 ± 0.75 vs. 5.21 ± 0.49 (p = 0.007), respectively. Mean fractional D_2cc (Gy) for organs at risk was comparable. No Grades 3-4 toxicity was reported. Disease-free survival and local control for the ICSR-ISN and ICSR-alone groups were 29.8 months/80.0% and 31.2 months/83.3%, respectively.

CONCLUSIONS

The mpMRI acquisition with ICSR applicator in place immediately before HDR brachytherapy for cervical cancer guided successful adaptive treatment optimization and delivery. Our initial experience with a novel interstitial adapter for the split-ring applicator demonstrated excellent target coverage without compromising organs at risk, resulting in good local control and disease-free survival.

Vulvar Cancer, Version 1.2017, NCCN Clinical Practice Guidelines in Oncology

Vulvar cancer is a rare gynecologic malignancy. Ninety percent of vulvar cancers are predominantly squamous cell carcinomas (SCCs), which can arise through human papilloma virus (HPV)-dependent and HPV-independent pathways. The NCCN Vulvar Cancer panel is an interdisciplinary group of representatives from NCCN Member Institutions consisting of specialists in gynecological oncology, medical oncology, radiation oncology, and pathology. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Vulvar Cancer provide an evidence- and consensus-based approach for the management of patients with vulvar SCC. This manuscript discusses the recommendations outlined in the NCCN Guidelines for diagnosis, staging, treatment, and follow-up.

Abstract C44: Endometrial carcinoma recurrence in black and white women in the NRG Oncology/Gynecologic Oncology Group 210 trial

BACKGROUND: Black women diagnosed with endometrial carcinoma have a higher risk of recurrence compared with white women. Higher recurrence risk among black women is due, in part, to a greater frequency of aggressive tumor characteristics including non-endometrioid histologies and advanced stage tumors. The risk of recurrence for black and white women within distinct tumor groupings has not been well-examined due to low numbers of black women and under-representation of aggressive histologic subtypes in single institution studies. Therefore, we examined the association between self-reported race and recurrence risk stratified by histologic subtype in the NRG Oncology/Gynecology Oncology Group (GOG) 210, a prospective observational study that enrolled 6,124 newly diagnosed endometrial carcinoma patients between 2003 and 2011.

METHODS: We restricted this analysis to 618 black and 4,316 white women with endometrial carcinoma. At study enrollment, women completed a questionnaire that assessed risk factors for gynecologic cancers. Recurrence, defined as evidence of disease following complete response to primary therapy, was abstracted from medical records. Tumor characteristics were available from surgical pathology reports and a centralized review by pathologists with expertise in gynecologic cancers. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between race (black vs. white) and recurrence risk in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed epithelial, carcinosarcoma, clear cell) and adjusted for stage (I, II, III, IV), age at diagnosis (continuous), and adjuvant therapy (none, chemotherapy, radiation, chemotherapy and radiation, unknown). We also examined income ($20,000-$39,999, $40,000-$69,999, ≥$70,000) and education (high school/GED, some college/technical school, college graduate/beyond) as potential mediators of the association between race and endometrial carcinoma recurrence risk using the Baron-Kenny method. Median follow-up time was 5 years.

RESULTS: Black women were more frequently diagnosed with non-endometrioid (52.9% vs. 31.8%) and advanced stage (Stage III or IV: 29.0% vs. 21.1%) tumors compared with white women. Recurrence was documented in 26% of black and 17% of white endometrial carcinoma patients. In histologic subtype-stratified models adjusted for stage, age, and adjuvant therapy, a higher risk of recurrence was noted in black women with low-grade endometrioid (HR=1.65, 95% CI=1.07-2.54), mixed epithelial (HR=1.75, 95% CI=1.13-2.71), or carcinosarcomas (HR=1.55, 95% CI=1.03-2.31) compared with white women. No significant race-recurrence relationships were observed among women diagnosed with high-grade endometrioid, serous, or clear cell tumors. After adjustment for income and education, the association of black race and recurrence risk remained elevated, but was not statistically significant: low-grade endometrioid (HR=1.52, 95% CI=0.97-2.38), mixed epithelial (HR=1.56, 95% CI=0.98-2.50), and carcinosarcoma (HR=1.48, 95% CI=0.98-2.25). Further, neither income nor education were significantly associated with recurrence risk in the multivariable models.

CONCLUSIONS: Our study provides evidence that racial disparities in endometrial carcinoma recurrence risk vary by histologic subtype. Socioeconomic factors do not explain black-white differences in endometrial carcinoma recurrence risk. Future studies exploring the role of biological factors and post-diagnosis surveillance contributing to racial differences in endometrial carcinoma recurrence are warranted.

Citation Format: Ashley S. Felix, Theodore Brasky, David Cohn, Scott McMeekin, David Mutch, Creasman William, Premal Thaker, Joan Walker, Richard Moore, Shashikant Lele, Saketh Guntupalli, Levi Downs, Christa Nagel, John Boggess, Michael Pearl, Olga Ioffe, Kay Park, Shamshad Ali, Louise Brinton. Endometrial carcinoma recurrence in black and white women in the NRG Oncology/Gynecologic Oncology Group 210 trial. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C44.

[Decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the management of decompensated right heart failure, intensive care management and perioperative management in patients with pulmonary hypertension. This article summarizes the results and recommendations of the working group on decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension.