[Primary management of endometrial carcinoma. Joint recommendations of the French society of gynecologic oncology (SFOG) and of the French college of obstetricians and gynecologists (CNGOF)]

OBJECTIVES

The management of endometrial carcinoma is constantly evolving. The SFOG and the CNGOF decided to jointly update the previous French recommendations (Institut national du cancer 2011) and to adapt to the French practice the 2015 recommendations elaborated at the time of joint European consensus conference with the participation of the three concerned European societies (ESGO, ESTRO, ESMO).

MATERIAL AND METHODS

A strict methodology was used. A steering committee was put together. A systematic review of the literature since 2011 has been carried out. A first draft of the recommendations has been elaborated, with emphasis on high level of evidence. An external review by users representing all the concerned discipines and all kinds of practice was completed. Three hundred and four comments were sent by 54 reviewers.

RESULTS

The management of endometrial carcinoma requires a precise preoperative workup. A provisional estimate of the final stage is provided. This estimation impact the level of surgical staging. Surgery should use a minimal invasive approach. The final pathology is the key of the decision concerning adjuvant therapy, which involves surveillance, radiation therapy, brachytherapy, or chemotherapy.

CONCLUSION

The management algorithms allow a fast, state of the art based, answer to the clinical questions raised by the management of endometrial cancer. They must be used only in the setting of a multidisciplinary team at all stages of the management.

Immunohistochemical evaluation of two antibodies against PD-L1 and prognostic significance of PD-L1 expression in epithelioid peritoneal malignant mesothelioma: A RENAPE study

BACKGROUND

Epithelioid peritoneal malignant mesothelioma (EPMM) is the most common subtype of this aggressive tumor. We compared two antibodies against PD-L1, a recent theranostic biomarker, and evaluated the prognostic value of PD-L1 expression by mesothelial and immune cells in EPMM.

METHODS

Immunohistochemistry was performed on 45 EPMM. Clinical and pathological data were extracted from the RENAPE database. Using E1L3N and SP142 clones, inter-observer agreement, PD-L1 expression by mesothelial and immune cells and inter-antibody agreement were evaluated. The prognostic relevance of PD-L1 expression was evaluated in 39 EPMM by univariate and multivariate analysis of overall survival (OS) and progression-free survival (PFS).

RESULTS

Inter-observer agreement on E1L3N immunostaining was moderate for mesothelial and immune cells, and fair for mesothelial and poor for immune cells using SP142. Using E1L3N, 31.1% of mesothelial and 15.6% of immune cells expressed PD-L1, and 22.2% of mesothelial and 26.7% of immune cells using SP142. Inter-antibody agreement was moderate. In most positive cases, 1-5% of tumor cells were positive. Using E1L3N, PD-L1 expression by lymphocytes was associated with better OS and PFS by both univariate and multivariate analysis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy predicted better prognosis than other treatments. Solid subtype was an independent prognostic factor for worse OS.

CONCLUSION

E1L3N appeared easier to use than SP142 to evaluate PD-L1 expression. A minority of EPMM expressed PD-L1, and only a few cells were positive. PD-L1 expression by immune cells evaluated with E1L3N was an independent prognostic factor in EPMM.

Diffuse malignant peritoneal mesothelioma: Evaluation of systemic chemotherapy with comprehensive treatment through the RENAPE Database: Multi-Institutional Retrospective Study

PURPOSE

Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network.

PATIENTS AND METHODS

From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC).

RESULTS

All groups (NA: n = 42; ADJ: n = 16; PO: n = 16; NoC: n = 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P = 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P = 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07-4.94; P = 0.033).

CONCLUSION

This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

[Breast ductal carcinoma in situ with microinvasion: pathological review and clinical implications]

PURPOSE

Recent improvements in the detection of breast cancer at an early stage have resulted in a rising incidence of breast ductal carcinoma in situ with microinvasion. So far, there is no consensus regarding its optimal management. We hereby report on our 10-year single institutional experience in breast ductal carcinoma in situ with microinvasion including pathological reviewing.

PATIENTS AND METHODS

All consecutive patients treated for a ductal carcinoma in situ with microinvasion at the Institut Claudius-Regaud (Toulouse, France) over a 10-year period were included in this study. We reviewed all available histological materials.

RESULTS

Sixty-three patients were eligible for this study. Two patients presented with a lymph node invasion at diagnosis. Each patient benefited from initial surgical management, which consisted either in mastectomy (n=25) or conservative resection (n=37). Axillary exploration was performed in 52 patients (82%). After a median follow-up of 61.3 months [46.9;69], the 5-year overall survival and disease free survival were 98.2 (95% CI=[88.2;99.7]) and 89.5% (95% CI=[76.3;95.6]) respectively. Two delayed invasive relapses occurred leading to one specific death. The pathological review highlighted a trend towards a loss of HR and HER2 expression (9%) in the microinvasive component in comparison with its surrounded in situ carcinoma.

CONCLUSION

The risk of initial lymph node involvement and delayed invasive local relapse deserve an optimal locoregional management including lymph node evaluation. The non-negligible discrepancy's rate between in situ and microinvasive components justifies HR status and HER2 expression assessment on the microinvasive component.

Abstract P3-05-07: Poor prognosis early breast cancer: pathological characteristics of the Unicancer-PACS08 trial including patients treated with docetaxel or ixabepilone in adjuvant setting

Background: The PACS08 trial aimed to compare adjuvant FEC100-Docetaxel regimen to FEC100-Ixabepilone (Ixa) in poor prognosis early breast cancer (BC). The study population included BC patients presenting with triple-negative (TN) [i.e. estrogen receptor (ER)−/progesterone receptor (PR)−/HER2−] or ER+/PR−/HER2− tumor, which are subgroups significantly associated with worse prognosis. Central review was performed and detailed pathological characteristics of the cohort are reported herein.

Patients and method: Between 2007 and 2010, 762 patients with unilateral TNBC (n = 592, 78%) or ER+/PR−/HER2− BC (n = 170, 22%) were enrolled. Recruitment was interrupted due to BMS decision to stop Ixa development in adjuvant setting. As defined by inclusion criteria, TNBC were either node+ or node-, and ER+/PR−/HER2− BC only node+. Following the validation of ER, PR and HER2 status on whole sections prior to inclusion, paraffin blocks (n = 754) were sent for central pathology review, tissue microarray (TMA) construction and constitution of the trial collection for translational research studies. Review of the cases (n = 754) was performed by a board of expert breast pathologists on a one-week working session with discussion of the difficult cases under a multihead microscope. Tumor characteristics were assessed on whole tissue sections. Immunohistochemical detection of Ki67, EGFR, cytokeratins (CK)5/6 and 14, was performed on TMAs.

Results: TNBC were significantly associated with younger age at diagnosis (median age 51yr vs 57.5yr in the ER+/PR- subgroup, p < 0.001). Most tumors were invasive ductal carcinomas (72%). Distribution of special histological subtypes was significantly different in the TNBC and ER+/PR−/HER2− subgroups, with the former comprising medullary (n = 16/17) and metaplastic (n = 34/34) subtypes while the latter was enriched in invasive lobular carcinomas (n = 27/35, p < 0.0001). TNBC were significantly associated with higher histological grade as compared to ER+/PR−/HER2− subgroup (Table 1). Accordingly, TNBC displayed significantly higher proliferative activity as shown by mitotic count and Ki67 index (p < 0.001). As compared to ER+/PR−/HER2− subgroup, TNBC showed distinct characteristics, and displayed a so-called basal-like phenotype in 80%. Among the ER+/PR−/HER2− subgroup, most tumors were classified as luminal B (64%). Interestingly, the presence of tumor lymphocytic infiltrate was more frequently observed in luminal B (59%) as compared to luminal A (30%) subtype (p < 0.001).

P4-18-05: Ductal Carcinoma In Situ with Microinvasion: Clinical and Pathological Characteristics, Treatments and Outcomes

Background: Ductal carcinoma in situ with microinvasion (DCISM) is a rising rare entity. Because of that and its controversial pathological definition, there is a lack of clear recommendations for treatment. The purpose of this study was to describe the clinical and pathological characteristics, treatments and outcomes of our single institutional experience.

Patients and methods: Individual clinical and pathological data were collected from 63 women, diagnosed and treated for DCISM at the Claudius Regaud Cancer Hospital between January 2000 and April 2010. All available histological material (45 patients) was reviewed by an expert pathologist.

Results: The median age was 56 years (range 34–83). Seven patients (11.5%) had a personal history of DCIS, 27 patients (42%) a familial history of breast cancer. Fourteen patients (22%) had a clinical sign at the diagnosis. Fifty one patients were mammographically detected (81%). All the patients underwent surgery, mastectomy for 17 patients (27.4%) and conservative surgery for 45 (72.6%). Secondary surgery of the breast was required for 21 patients (46.6%) after conservative surgery, enlarging surgery (N=13) or mastectomy (N=8). Surgical axillary lymph node evaluation was performed on 52 patients (82,5%), axillary dissection alone for 10 patients, sentinel node biopsy alone for 37 patients and the 2 methods for 5 patients. The median size of the DCIS was 16mm (6-80mm) with 37/60 (61.7%) grade III Van Nuys classification. The most histological subtype was comedo carcinoma (68%). Concerning the 45 reviewed biopsies, the size of the microinvasive component was ≤ 1mm for 38 lesions and between 1 and 2 mm for 7 lesions. Hormonal receptor status was positive for 29 (64.4%), 27 (64.3%) for estrogen receptors and 20 (44.4%) for progesterone receptors. HER 2 status was performed for 34 patients, among 12 (35%) of them were found overexpressed on the microinvasive component. Lymph node invasion was found among 2 of the 52 patients (3.8 %) who underwent axillary lymph node evaluation. Radiation therapy was delivered to all the patients after conservative surgery (n=37)(50 Gy with a 10 Gy boost for 22 of them) and 2 after mastectomy (chest wall irradiation (50 Gy)). Adjuvant hormonotherapy was delivered on 11 patients (18%). With a median follow-up of 36,4 months (95%CI=[27.7- 44.16]), 62 patients are alive at the last follow-up and 58/63 free of disease (2 relapses and 3 second cancers).The 3 year disease free survival rate was 91.1 (95%CI=[78.1;96.6] ). During follow-up, two local relapses occurred on patients treated by mastectomy. One of them had local invasive relapse at 43 months and she is still NED after 90 months. The second patient who had local invasive carcinoma with axillary node invasion at 32 months treated by conservative surgery, axillary dissection, radiotherapy and chemotherapy, had metastasis at 51 months and passed away after 70 months.

Conclusion: Mammographic screening programmes increase the rate of small diagnosed tumours, specially DCISM. Despite a priori good prognostic outcome, 2 axillary node involvements and 2 delayed relapses were observed. So, this kind of presentation deserves better evaluation of relapse risk factors to determine adapted adjuvant therapies.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-18-05.

Prognostic significance of low volume sentinel lymph node disease in early-stage cervical cancer

OBJECTIVE

Evaluate prognostic significance of low volume disease detected in sentinel nodes (SN) of patients with early stages cervical cancer. Although pathologic ultrastaging of SN allows for identification of low volume disease, including micro-metastasis and isolated tumor cells (ITC), in up to 15% of cases, prognostic significance of these findings is unknown.

METHODS

A total of 645 records from 8 centers were retrospectively reviewed. Enrolled in our study were patients with early-stage cervical cancer who had undergone surgical treatment including SN biopsy followed by pelvic lymphadenectomy and pathologic ultrastaging of SN.

RESULTS

Macrometastasis, micrometastasis, and ITC were detected by SN ultrastaging in 14.7%, 10.1%, and 4.5% patients respectively. False negativity of SN ultrastaging reached 2.8%. The presence of ITC was not associated with significant risk, both for recurrence free survival and overall survival. Overall survival was significantly reduced in patients with macrometastasis and micrometastasis; hazard ratio for overall survival reached 6.85 (95% CI, 2.59-18.05) and 6.86 (95% CI, 2.09-22.61) respectively. Presence of micrometastasis was an independent prognostic factor for overall survival in a multivariable model.

CONCLUSION

Presence of micrometastasis in SN in patients with early stage cervical cancer was associated with significant reduction of overall survival, which was equivalent to patients with macrometastasis. No prognostic significance was found for ITC. These data highlight the importance of SN biopsy and pathologic ultrastaging for the management of cervical cancer.

Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer

INTRODUCTION

Prognostic value of complete macroscopic resection of primary disease has been reported and confirmed in several publications. Published data indicate that extensive upper abdominal disease involving the hepatic pedicle and celiac trunk is associated with an abortion of the surgical procedure or with suboptimal residual disease.

METHODS

All patients who had disease at the porta hepatis or celiac lymph node resection as part of cytoreductive surgery were included. Medical and operative records with particular emphasis on extent and distribution of disease spread, number of peritonectomy procedures, visceral resections, and lymphadenectomy procedures were examined.

RESULTS

A total of 28 patients who underwent some kind of celiac lymph node resection or resection of metastatic involvement of the porta hepatis were included. Median preoperative serum Ca-125 level was 78U/ml (range, 30-2950U/ml), and median ascites volume was 1900ml (range, 0-10,000ml). Of the 28 patients, 23 underwent supra-radical surgery for diffuse peritoneal carcinomatosis. Median operative time was 252minutes (range, 100-540minutes). Complete cytoreduction to CCO was achieved in all except one case, who was cytoreduced to millimetric residue. Fifteen patients had positive celiac nodes and nineteen patients had peritoneal disease in the porta hepatis region.

DISCUSSION

Resection of enlarged nodes and metastatic disease to the porta hepatis is feasible with an acceptable morbidity. The decision to undergo an aggressive cytoreductive surgery is based on appropriate patient selection depending on the extension of surgical procedure, on medical comorbidities, and on the potential to tolerate an extensive procedure, rather than on specific anatomic locations.

Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage?

INTRODUCTION

Pelvic exenteration (PE) remains one of the most mutilating surgical procedures with important postoperative morbidity. Laparoscopic approach has emerged in an attempt to reduce postoperative complications. The aim of the present study was to compare outcomes between laparoscopic pelvic exenteration combined with a vaginal or perineal approach, versus classical approach.

METHODS

A cohort study was performed by identifying patients who underwent laparoscopic pelvic exenteration, and retrospectively comparing data with open cases from the same period of time, from 2000 to 2008.

RESULTS

Fourteen patients underwent laparoscopic PE and 29 patients underwent an open exenterative procedure. All patients except one (97.6%) had received prior radiotherapy. Eighteen patients (41.9%) underwent total PE, 17 anterior PE (39.5%), and 8 posterior PE (18.6%). Urinary diversion (UD) technique consisted of 24 Miami pouch (68.6%), 9 Bricker diversion (25.7%), 1 Kock pouch (2.9%), and 1 ureterostomy (2.9%). Most frequent postoperative complications were related to the urinary diversion (45%) and bowel reconstruction (27.9%). Median estimated blood loss for the laparoscopy and laparotomy group was 400 ml (range 200-700 ml) and 875 ml (range 200-1600 ml), respectively. Transfusion rate was also significantly higher in the laparotomy group. Operative time, margin status, length of hospital stay, operative and postoperative morbidity, and disease and overall survival were not significantly different between both groups.

CONCLUSIONS

Laparoscopic PE is feasible with curative intent to selected patients. Potential postoperative advantages of laparoscopic approach when compared to classical approach, oncological safety of the procedure, and QOL considerations need to be further investigated.

Breast-conserving surgery with or without radiotherapy vs mastectomy for ductal carcinoma in situ: French Survey experience

From March 2003 to April 2004, 77 physicians throughout France prospectively recruited 1289 ductal carcinoma in situ (DCIS) patients and collected data on diagnosis, patient and tumour characteristics, and treatments. Median age was 56 years (range, 30–84). Ductal carcinoma in situ was diagnosed by mammography in 87.6% of patients. Mastectomy, conservative surgery alone (CS) and CS with radiotherapy (CS+RT) were performed in 30.5, 7.8 and 61.7% of patients, respectively. Thus, 89% of patients treated by CS received adjuvant RT. Sentinel node biopsy (SNB) and axillary dissection (AD) were performed in 21.3 and 10.4% of patients, respectively. Hormone therapy was administered to 13.4% of the patients (80% tamoxifen). Median tumour size was 14.5 mm (6, 11 and 35 mm for CS, CS+RT and mastectomy, respectively, P<0.0001). Nuclear grade was high in 21% of patients, intermediate in 38.5% and low in 40.5%. Excision was considered complete in 92% (CS) and 88.3% (CS+RT) of patients. Oestrogen receptors were positive in 69.8% of assessed cases (31%). Treatment modalities varied widely according to region: mastectomy rate, 20–37%; adjuvant RT, 84–96%; hormone treatment, 6–34%. Our survey on current DCIS management in France has highlighted correlations between pathological features (tumour size, margin and grade) and treatment options, with several similar variations to those observed in recent UK and US studies.

Paratubal endometrioid cystadenocarcinoma: case report and review

BACKGROUND

Paratubal masses are common, but paratubal carcinoma is an extremely rare entity.

CASE

We report a case of a 44-year-old nulliparous female who suffered from abdominal pain for three months. Abdominal and pelvic ultrasound revealed a 30 cm left adnexal mass originally. Laparotomy with bilateral salpingo-oophorectomy was performed. Final pathology indicated a heterogeneous tumor with benign, borderline, and endometrioid carcinoma areas. A repeat surgery was decided in order to complete hysterectomy, omentectomy, pelvic and paraaortic lymphadenectomy. Surgical staging did not reveal residual disease at pathological examination. After 36 months of follow-up, no recurrence has occurred.

CONCLUSION

To our knowledge, no case of paratubal invasive endometrioid adenocarcinoma has previously been described. This case has been managed according to the recommendations of ovarian cancer, which seems to be an acceptable option.

Chromatographic alignment combined with chemometrics profile reconstruction approaches applied to LC-MS data

This paper presents a full proteomics analysis LC-MS (Liquid Chromatography-Mass Spectrometry) chain combining bio, nano and information technologies in order to quantify targeted proteins in blood sample. The objective is to enable an early detection of pancreatic cancer. We focus on the data processing step which estimates the proteins' concentration. First, we pre-process the data in order to correct time shift between the experiments. We propose to use block matching algorithm. Second, quantification of protein is performed using chemometrics approaches and more precisely CLS, PLS, N-PLS and PARAFAC algorithms. Performances of the various methods have been compared on cytochrome c protein LC-MS analyses.

Selective inhibition of HER2 inhibits AKT signal transduction and prolongs disease-free survival in a micrometastasis model of ovarian carcinoma

Although first-line chemotherapy induces complete clinical remission in many cases of epithelial ovarian cancer, relapse usually occurs 18-28 months from diagnosis owing to micrometastases. The present study aimed to evaluate the effect of trastuzumab on disease-free and overall survival in a specially designed murine model of ovarian cancer (OVCAR-3), which mimicked the natural history of human micrometastatic disease. Trastuzumab can cure the mice if started soon after induction chemotherapy. It can modestly inhibit the proliferation through mitogen-activated protein kinase signal transduction and clearly inhibit AKT phosphorylation, which is involved in survival pathway. As OVCAR-3 cell lines show no HER2 amplification or overexpression, these results warrant further studies to assess the efficacy of trastuzumab in the early stage of relapse in cancer models other than those overexpressing HER2.

Carcinocythemia as the single extension of breast cancer: report of a case and review of the literature

Carcinocythemia (carcinoma cell leukemia) has been previously described as a rare, late and dramatic event occurring in widespread tumoral disease. We report a case of carcinocythemia occurring in a patient with a particularly indolent breast cancer. When a large amount of circulating tumor cells (CTC) appeared in the blood smears, neither visceral macrometastases nor massive bone marrow infiltration could be detected. We isolated CTC to perform cell cycle analysis and to study the expression of adhesion molecules. A fraction of the CTC was proliferating in the bloodstream but we detected no relevant anomaly of adhesion properties in the CTC. A post-mortem biopsy disclosed an exclusive sinusoidal infiltration of the liver. We propose that in this case, carcinocythemia resulted from the release of CTC from the visceral microcirculation where the proliferation occurred.

[Value of imaging in the management of advanced stage ovarian cancer "experience of 72 computed tomographic examinations"]

OBJECTIVE OF THE STUDY

To place computed tomography (CT) in the evaluation of advanced stages of ovarian tumors throughout two years experience (1991-1992) of a Cancer Medical Center.

MATERIALS AND METHODS

Study of 72 pelvic-abdominal CT examinations of 47 patients in stages III and IV, at the time of the initial diagnosis or during the treatment. The equipment used is a General Electric CE 10,000. The technique was conventional (digestive and intravenous opacification). These examinations were performed by practicing radiologists exclusively in cancerological units.

RESULTS

Carried out in immediate post-operative patients incompletely surgically examined, CT allows the quantification of residue and therefore a new staging in two-thirds of the cases. In the process of adjuvant chemotherapy, CT reveals the persistence of residue in 71% of the cases with therapy implications. At the time of follow-up, CT is revealing of abnormalities in 74% of the cases carried out to systematic content, in 60% of the cases with concomitant elevation of CA 125 level. Abnormalities are always present when CT is carried out from clinical symptoms and elevation of CA 125 level (3 cases in 3). Localized recurrence was only described in 7.6% of the cases.

CONCLUSION

CT is of relative usefulness for the assessment and surveillance of advanced stages of cancers. It contributes with accordance to the literature clarifying the criteria as "impossibility of resection" and according to our series, it contributes in redefining the stage; it participates, during the process of adjuvant therapy of avoiding the unuseful second-look procedures, without predicting "complete response"; finally it participates during the follow-up to the collection of the localized recurrence only situation susceptible to benefit from an efficient surgical treatment.