ARTISTRY-7: phase III trial of nemvaleukin alfa plus pembrolizumab vs chemotherapy for platinum-resistant ovarian cancer

Standard single-agent nonplatinum chemotherapy provides only modest benefit in a small proportion of patients with platinum-resistant/-refractory ovarian cancer, with objective response rates of 6-20% and progression-free survival of ≈3-4 months. Nemvaleukin alfa (nemvaleukin, ALKS 4230) is a novel cytokine designed to capture and expand the therapeutic potential of high-dose interleukin-2 (IL-2) while mitigating its associated toxicity issues. Nemvaleukin preferentially activates cytotoxic CD8+ T cells and natural killer cells with minimal, non-dose-dependent effects on CD4+ regulatory T cells. The global, randomized, open-label, phase III ARTISTRY-7 trial will compare efficacy and safety of nemvaleukin plus pembrolizumab with chemotherapy in patients with platinum-resistant ovarian cancer. The primary end point is investigator-assessed progression-free survival. Clinical Trial Registration: GOG-3063; ENGOT-OV68; NCT05092360 (ClinicalTrials.gov).

Prognostic factors for stage III epithelial ovarian cancer treated with intraperitoneal chemotherapy: a Gynecologic Oncology Group study

OBJECTIVES

To determine prognostic factors for survival in ovarian cancer patients treated with intraperitoneal (IP) chemotherapy using ancillary data from cooperative group clinical trials.

METHODS

Data were collected from 428 patients with stage III ovarian cancer who underwent optimal surgical cytoreduction (<1 cm) followed by IP paclitaxel/platinum chemotherapy. Primary endpoints were progression free survival (PFS) and overall survival (OS). Potential prognostic variables were included in Cox proportional hazard regression models. Multivariate analysis was conducted to identify independent prognostic factors.

RESULTS

Median PFS was 24.9 months (95% CI, 23.0-29.2) and median OS was 61.8 months (95% CI, 55.5-69.8). Predictors for PFS were histology, surgical stage and residual disease. Age, histology, and residual disease were prognostic for OS. There were no differences in the hazard ratio for death or progression between patients with positive, negative, or unknown lymph node status. For patients receiving IP chemotherapy (n=428), 36% of patients had no residual disease with median PFS of 43.2 months (95% CI 32.5-60.4) and median OS of 110 months (95% CI, 60.0-161.3).

CONCLUSIONS

Age, histology, and extent of residual disease were predictors of OS in stage III patients treated with IP chemotherapy following optimal cytoreduction. Patients with no residual disease following primary surgery that are treated with adjuvant platinum based IP chemotherapy have survival measures that exceed any rates previously seen in this population.

Cervical dysplasia among women over 35 years of age

OBJECTIVE

The objective of the study was to review the cytologic and histopathologic features among women 35 years of age or older with cervical dysplasia.

STUDY DESIGN

Patients presenting between 2001 and 2005 were included. Patients were labeled as pre- (PRE) or postmenopausal (POST) based on age younger than or 50 years old or older. Statistics were performed using SAS 8.0.

RESULTS

Three hundred fifty-nine patients were identified: 270 PRE and 89 POST. PRE and POST patients had similar referral cytology with atypical cells of undetermined significance (ASC)/low-grade squamous intraepithelial lesion (LSIL) in 60% and 65% and high-grade squamous intraepithelial lesion (HSIL) in 35% and 27%, respectively. Among patients with ASC/LSIL, POST had significantly more cervical intraepithelial neoplasia (CIN) 3 (41% vs 29%; P = .027) as well as more malignancies (17 vs 0%; P = .002). Among patients referred for loop electrical excisional procedure secondary to HSIL cytology not explained by colposcopy, CIN 2 or greater was identified more often in POST (71 vs 32%; P = .03).

CONCLUSION

Our data demonstrate a high proportion of severe cervical dysplasia in age groups traditionally thought to have less risk than younger patients.

Human tumor antigens Tn and sialyl Tn arise from mutations in Cosmc

Neoplastic lesions typically express specific carbohydrate antigens on glycolipids, mucins, and other glycoproteins. Such antigens are often under epigenetic control and are subject to reversion and loss upon therapeutic selective pressure. We report here that two of the most common tumor-associated carbohydrate antigens, Tn and sialyl Tn (STn), result from somatic mutations in the gene Cosmc that encodes a molecular chaperone required for formation of the active T-synthase. Diverse neoplastic lesions, including colon cancer and melanoma-derived cells lines, expressed both Tn and STn antigen due to loss-of-function mutations in Cosmc. In addition, two human cervical cancer specimens that showed expression of the Tn/STn antigens were also found to have mutations in Cosmc and loss of heterozygosity for the cross-linked Cosmc locus. This is the first example of somatic mutations in multiple types of cancers that cause global alterations in cell surface carbohydrate antigen expression.

Gynecologic Oncology Group risk groups for vulvar carcinoma: Improvement in survival in the modern era

OBJECTIVE

Patients with vulvar cancer were stratified into risk groups for survival based on surgicopathologic findings from a prospective study conducted by the Gynecologic Oncology Group from 1977-1984. The purpose of this study is to reassess these risk groups in patients treated in an era of contemporary management.

METHODS

Patients with vulvar carcinoma were identified from 1990-2005 for retrospective analysis. Charts were abstracted for clinical, histopathologic and surgical data, and patients stratified into four risk groups for survival based on the clinical size of tumor and extent of lymph node metastasis. Univariate and multivariate characteristics were evaluated and 5-year survival determined by Kaplan-Meier method.

RESULTS

175 patients were identified that underwent surgical management with a median age at diagnosis of 59.9 years. Stage distribution included: I (n=89, 51%), II (n=53, 30%), III (n=29, 17%), and IV (n=4, 2%). Stratification into risk groups included: minimal (n=89, 51%), low (n=69, 40%), intermediate (n=11, 6%), and high (n=6; 3%). The survival rate was 100%, 97%, 82% and 100%, respectively, at median follow-up of 54.5 months. Comparatively, the survival rates for historic groups were 97.9%, 87.4%, 74.8% and 29.0%. Using multivariate analysis, age (p=0.04) and lymph node metastasis (p=0.009) were predictive of survival.

CONCLUSIONS

Survival among the minimal and low risk groups is preserved in spite of less radical surgery. 5-year survival rate for intermediate and high risk patients also appears to be improved. This is likely a result of advancement in adjuvant chemo-radiation and a younger patient population that presents with less advanced disease.

Pathologic findings and outcomes for octogenarians presenting with uterine malignancy

OBJECTIVE

We evaluated prognostic, demographic and outcome data for patients>80 years old with uterine cancer (UC).

METHODS

A retrospective review of clinical records was performed. Categorical data were compared using Fisher's exact test and Kaplan-Meier for survival data.

RESULTS

Sixty-five patients were identified with a mean age of 84 and BMI 27. Sixty-five percent of patients had medical co-morbidities. Forty-two (65%) were Stage I; 10 (15%) were Stage II; 8 (12%) were Stage III; and 5 (8%) were Stage IV. Stage I patients included those identified via hysterectomy with lymph nodes (LND) (30) or clinical impression (12). Comparing clinically Stage I UC to those with LND, the clinical group was older (86 vs. 83; p=0.01) and tended to have more medical co-morbidity (89% vs. 63%; p=0.14). Two-year overall survival (OS) among unstaged vs. staged patients was 62% vs. 77%; p=0.11. Among staged patients with Stage I UC, 21 (70%) met high intermediate risk (HIR) criteria per GOG 99 and 90% received no adjuvant therapy. Three patients (16%) recurred with 1 (5%) locoregional recurrence. Two-year OS is 77%.

CONCLUSION

Elderly patients with UC have features associated with extrauterine spread. Both clinically and surgically staged Stage I patients had excellent OS at 2 years despite no adjuvant therapy. Prevalent medical co-morbidities may impact survival more than recurrence risk. The 23% recurrence rate among HIR patients in GOG 99 was not observed in our data, suggesting that observation for elderly Stage I patients is acceptable.

A LEEP Cervical Conization Is Rarely Indicated for a Two-Step Discrepancy

OBJECTIVES

The current indications for conization of the cervix include a 2-step discrepancy between cervical cytological and histological findings. We sought to determine the utility of a loop electrocautery excision procedure (LEEP) cone for a 2-step discrepancy.

METHODS

A retrospective institutional review board-approved chart review was performed on all women recommended to undergo a LEEP secondary to a discrepancy between a referral high-grade squamous intraepithelial lesion cytological finding and a subsequent colposcopic biopsy result revealing either normal or cervical intraepithelial neoplasia (CIN) 1 histological finding; CIN 2 was excluded from the study. Statistical analysis was performed using SAS 9 (SAS Institute, Inc, Cary, NC). The results were considered significant if a p value less than or equal to.05 was demonstrated.

RESULTS

Fifty-nine patients received a LEEP for a 2-step discrepancy between cytological and histological findings. Twenty-seven patients had a second pass or LEEP cone. Among the patients with a normal cervical biopsy result and a high-grade cytological finding, 10 (29%) of 34 had normal histological findings, as revealed by LEEP, and 14 (41%) of 34 had CIN 3; 16 (64%) of 25 patients with high-grade cytological finding and CIN 1 biopsy finding had CIN 3, as revealed by LEEP. Compared with patients with an initial normal cervical biopsy result, those with CIN 1 on initial biopsy were more likely to have CIN 3 on their LEEP findings (p =.08). Twenty-seven of 59 patients underwent a LEEP cone surgery; 1 of 27 had CIN 3 finding in the second-pass portion. This was associated with a CIN 3 identified on the first pass and associated with positive margins. The second pass of the LEEP cone failed to demonstrate CIN 96% of the time (p < .0001). Patients with a normal or a CIN 1 finding on the first pass had a normal finding on the second pass in 100% of cases.

CONCLUSIONS

A LEEP cone is rarely indicated for the evaluation of a 2-step discrepancy. A randomized trial of this finding is warranted.

Second trimester placental location as a predictor of an adverse pregnancy outcome

OBJECTIVE

To determine if the second trimester placental location is associated with perinatal outcomes.

MATERIALS AND METHODS

Observational study of placental location and the subsequent risk of an adverse pregnancy outcome. Placental location was divided into three categories, low, high lateral and high fundal.

RESULTS

There were 3336 pregnancies analyzed in this study. Low implantation sites had a greater risk of preterm labor (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.38 to 2.90, P<0.001), preterm delivery (OR 1.86, 95% CI 1.36 to 2.54, P<0.001), fewer fetuses with macrosomia (OR 0.56, 95% CI 0.38 to 0.83, P=0.010) and reduced risk of postpartum hemorrhage (OR 0.56, 95% CI 0.46 to 0.95, P=0.026). High lateral implantations had a greater risk of low 1-min (OR 1.80, 95% CI 1.11 to 2.93, P=0.017) and 5-min (OR 3.49, 95% CI 1.46 to 8.36, P=0.005) Apgar scores.

CONCLUSIONS

Low placental implantation was associated with an increased risk of preterm labor, preterm delivery and a reduced risk of postpartum hemorrhage, and of a macrosomic fetus. High lateral implantation was associated with low Apgar scores.

Well-differentiated papillary mesothelioma of the uterine serosa identified at cesarean section: a case report

BACKGROUND

Peritoneal mesotheliomas encompass a variety of benign and malignant neoplasms. Well-differentiated papillary mesothelioma (WDPM) is uncommon, is thought to be of low malignant potential and is often discovered incidentally during abdominal or pelvic surgery. We describe a highly unusual case in which WDPM arising from the uterine serosa was identified at the time of cesarean delivery.

CASE

A 21-year-old primigravida underwent cesarean delivery at term for arrest of the active phase of labor. A 2-cm, polypoid lesion was excised from the posterior uterine fundus; final pathology showed well-differentiated papillary mesothelioma. Subsequent examination and computed tomography were negative. A follow-up laparoscopic examination with abdominal washing for cytology and peritoneal biopsies revealed no residual disease.

CONCLUSION

Survey of the pelvic cavity during cesarean section is important. Knowledge of the variable disease spectrum of mesothelioma is important in patient counseling and management. Differentiating between WDPM and malignant mesothelioma, other peritoneal tumors and implants from primary sites is necessary to avoid overtreatment.

Third Stage of Labor

All staff involved in obstetric care should be competent in performing active management of the third stage of labor. Active management has been shown to be clearly superior to physiologic or expectant management. Comparison of the various uterotonic agents has pointed to misoprostol as a potential first-line agent in treating obstetric hemorrhage. Its cost, routes of delivery, and efficacy make it an appealing drug in urban and rural settings. By being facile with the active management of labor and the prompt recognition and treatment of postpartum hemorrhage, the morbidity from significant blood loss and subsequent surgery can be reduced significantly.

Dye-determined amniotic fluid volume and intrapartum/neonatal outcome

OBJECTIVE

To ascertain if a dye-determined amniotic fluid volume was predictive of intrapartum and perinatal outcome.

MATERIALS AND METHODS

The low and normal amniotic fluid volumes (< 5th percentile and > or =5th percentile for gestational age) and the raw dye-determined amniotic fluid distributions were correlated with 10 clinical outcome measures in 74 pregnancies.

RESULTS

In this observational study, median gestational age at delivery was 36 weeks (range 26 to 41) and 16 deliveries were for fetal distress (14 Cesarean and two forceps). There were no differences between the outcomes of pregnancies with low and normal amniotic fluid volumes for any of the clinical outcomes (variable decelerations influencing delivery, p=0.381; late decelerations, p=0.875; Cesarean births for fetal intolerance of labor, p=0.259; intrauterine growth restriction, p=0.998; or umbilical cord arterial pH< 7.2, p=0.259). Analogous results were obtained when the gestational age-adjusted amniotic fluid volumes were compared directly between the pregnancies with normal and abnormal outcomes. There was no difference between the mean amniotic fluid volumes in those pregnancies with variable decelerations influencing delivery (p=0.287), late decelerations (p=0.555), Cesarean births for fetal intolerance of labor (p=0.310), intrauterine growth restriction (p=0.267) or umbilical cord arterial pH< 7.2, and the pregnancies without these intrapartum events. Reduced variability was more commonly observed in pregnancies with higher amniotic fluid volumes (p=0.038, 771 ml, 95% CI 468 to 1269, compared to those without normal variability 444 ml, 95% CI 374 to 526).

CONCLUSIONS

Dye-determined amniotic fluid volume does not appear to be predictive of adverse intrapartum and neonatal outcome.