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Dinoi G, Ghoniem K, Huang Y, Zanfagnin V, Cucinella G, Langstraat C, Glaser G, Kumar A, Weaver A, McGree M, Fanfani F, Scambia G, Mariani A. Endometrial cancer with positive sentinel lymph nodes: pathologic characteristics of metastases as predictors of extent of lymphatic dissemination and prognosis. Int J Gynecol Cancer 2024:ijgc-2023-005181. [PMID: 38658020 DOI: 10.1136/ijgc-2023-005181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES To assess predictors of extensive lymph node dissemination and non-vaginal recurrence in patients with endometrial cancer with positive sentinel lymph nodes (SLNs). METHODS Patients with endometrial cancer who underwent primary surgery with SLN mapping and had at least one positive node between October 2013 and May 2019 were included. Positive SLNs were reviewed, and cases were classified according to the location of the metastasis (extracapsular vs intracapsular), and the size of the largest SLN metastasis (isolated tumor cells, micrometastasis, macrometastasis). Associations were assessed based on fitting logistic regression models and Cox proportional hazards models. RESULTS A total of 103 patients met the inclusion criteria: including 36 (34.9%) with isolated tumor cells, 27 (26.2%) with micrometastasis, and 40 (38.8%) with macrometastasis. Notably, 71.4% of patients exhibiting extracapsular SLN metastases had multiple positive SLNs (p=0.008). Extracapsular invasion (adjusted odds ratio (aOR) 5.81, 95% CI 1.4 to 23.6) and age (aOR=1.8, 95% CI 1.1 to 3.0) emerged as independent predictors of multiple positive SLNs. Among the 38 patients who underwent a backup pelvic lymphadenectomy, 18 (47.4%) presented with positive pelvic non-SLNs, a phenomenon more prevalent in patients with macrometastasis (p=0.004).Independent predictors of non-vaginal recurrence included SLN macrometastasis (adjusted hazard ratio (aHR) 3.3, 95% CI 1.3 to 8.3), non-endometrioid histology (aHR=3.7, 95% CI 1.5 to 9.3), and cervical stromal invasion (aHR=5.5, 95% CI 2.0 to 14.9). Among the 34 patients with isolated tumor cells and endometrioid histology, 3 (9%) experienced a recurrence, all of whom had not received any adjuvant chemotherapy or external beam radiotherapy. CONCLUSION Patients with positive SLN macrometastasis are independently associated with extensive lymphatic dissemination and distant recurrences. The risk of multiple positive SLNs increases with the extracapsular location of the SLN metastasis and with age. Independent uterine pathologic predictors of non-vaginal recurrence are non-endometrioid histology and cervical stromal invasion.
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Affiliation(s)
- Giorgia Dinoi
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Khaled Ghoniem
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yajue Huang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Valentina Zanfagnin
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Cucinella
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy Weaver
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Francesco Fanfani
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Williams-Brown MY, Summey RM, Newtson A, Burke W, Turner T, Sabu P, Davidson BA, Glaser G. System-level recommendations for improved wellness for gynecologic oncologists: A Society of Gynecologic Oncology Review. Gynecol Oncol 2024; 183:85-92. [PMID: 38554478 DOI: 10.1016/j.ygyno.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024]
Abstract
Burnout and its negative sequelae are a persistent problem in gynecologic oncology, threatening the health of our physician workforce. Individual-level interventions such as stress management training, physical activity, and sleep hygiene only partially address this widespread, systemic crisis rooted in the extended work hours and stressful situations associated with gynecologic oncology practice. There is an urgent need for systematic, institution-level changes to allow gynecologic oncologists to continue the crucial work of caring for people with gynecologic cancer. We present recommendations for institution-level changes which are grounded in the framework presented by the National Plan for Health Workforce Well-Being by the National Academy of Medicine. These are aimed at facilitating gynecologic oncologists' well-being and reduction of burnout. Recommendations include efforts to create a more positive and inclusive work environment, decrease administrative barriers, promote mental health, optimize electronic medical record use, and support a diverse workforce. Implementation and regular evaluation of these interventions, with specific attention to at-risk groups, is an important next step.
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Affiliation(s)
- M Y Williams-Brown
- Department of Women's Health, Dell Medical School at The University of Texas at Austin, Austin, TX, United States of America.
| | - R M Summey
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - A Newtson
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - W Burke
- Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University Cancer Center, Stony Brook, NY, United States of America
| | - T Turner
- St. Luke's Cancer Institute, Boise, ID, United States of America
| | - P Sabu
- Division of Gynecologic Oncology, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - B A Davidson
- Division of Gynecologic Oncology, Duke University, Durham, NC, United States of America
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
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De Vitis LA, Fumagalli D, Schivardi G, Capasso I, Grcevich L, Multinu F, Cucinella G, Occhiali T, Betella I, Guillot BE, Pappalettera G, Shahi M, Fought AJ, McGree M, Reynolds E, Colombo N, Zanagnolo V, Aletti G, Langstraat C, Mariani A, Glaser G. Incidence of sentinel lymph node metastases in apparent early-stage endometrial cancer: a multicenter observational study. Int J Gynecol Cancer 2024:ijgc-2023-005173. [PMID: 38514100 DOI: 10.1136/ijgc-2023-005173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVE Ultrastaging is accurate in detecting nodal metastases, but increases costs and may not be necessary in certain low-risk subgroups. In this study we examined the risk of nodal involvement detected by sentinel lymph node (SLN) biopsy in a large population of apparent early-stage endometrial cancer and stratified by histopathologic characteristics. Furthermore, we aimed to identify a subgroup in which ultrastaging may be omitted. METHODS We retrospectively included patients who underwent SLN (with bilateral mapping and no empty nodal packets on final pathology) ± systematic lymphadenectomy for apparent early-stage endometrial cancer at two referral cancer centers. Lymph node status was determined by SLN only, regardless of non-SLN findings. The incidence of macrometastasis, micrometastasis, and isolated tumor cells (ITC) was measured in the overall population and after stratification by histotype (endometrioid vs serous), myometrial invasion (none, <50%, ≥50%), and grade (G1, G2, G3). RESULTS Bilateral SLN mapping was accomplished in 1570 patients: 1359 endometrioid and 211 non-endometrioid, of which 117 were serous. The incidence of macrometastasis, micrometastasis, and ITC was 3.8%, 3.4%, and 4.8%, respectively. In patients with endometrioid histology (n=1359) there were 2.9% macrometastases, 3.2% micrometastases, and 5.3% ITC. No macro/micrometastases and only one ITC were found in a subset of 274 patients with low-grade (G1-G2) endometrioid endometrial cancer without myometrial invasion (all <1%). The incidence of micro/macrometastasis was higher, 2.8%, in 708 patients with low-grade endometrioid endometrial cancer invading <50% of the myometrium. In patients with serous histology (n=117), the incidence of macrometastases, micrometastasis, and ITC was 11.1%, 6.0%, and 1.7%, respectively. For serous carcinoma without myometrial invasion (n=36), two patients had micrometastases for an incidence of 5.6%. CONCLUSIONS Ultrastaging may be safely omitted in patients with low-grade endometrioid endometrial cancer without myometrial invasion. No other subgroups with a risk of nodal metastasis of less than 1% have been identified.
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Affiliation(s)
- Luigi Antonio De Vitis
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Diletta Fumagalli
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Gabriella Schivardi
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ilaria Capasso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Leah Grcevich
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francesco Multinu
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Cucinella
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Clinic of Obstetrics and Gynecology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Ilaria Betella
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Benedetto E Guillot
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giulia Pappalettera
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Maryam Shahi
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela J Fought
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Evelyn Reynolds
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicoletta Colombo
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Faculty of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Vanna Zanagnolo
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giovanni Aletti
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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Glaser G, Weroha J. What's in your "lunchbox"? Sandwich versus sequential chemotherapy and irradiation for advanced endometrial cancer. Gynecol Oncol 2024; 180:A1-A2. [PMID: 38365324 DOI: 10.1016/j.ygyno.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
- Gretchen Glaser
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
| | - John Weroha
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
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Pasha AS, Breitkopf D, Glaser G. The Impact of Dobbs on US Graduate Medical Education. J Law Med Ethics 2023; 51:497-503. [PMID: 38088612 DOI: 10.1017/jme.2023.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The Dobbs decision will directly affect patients and reproductive rights; it will also impact patients indirectly in many ways, one of which will be changes in the physician workforce through its impact on graduate medical education. Current residency accreditation standards require training in all forms of contraception in addition to training in the provision of abortion. State bans on abortions may diminish access to training as approximately half of obstetrics and gynecology residency programs are in states with significant abortion restrictions. The Dobbs decision creates numerous hurdles for trainees and their programs. Trainees in restrictive states will have to travel to learn in a different program in a protective state. As training opportunities diminish, potentially leading to a decline in clinical skills, knowledge, and experience in the provision of abortion, the rate of complications and maternal mortality are likely to rise. This will likely have a disproportionately negative effect on preexisting disparities in reproductive health fueled by a longstanding history of systemic racism and inequities. This work aims to both define the looming problem in abortion training created by Dobbs and propose solutions to ensure that an adequate workforce is available in the future to serve patient needs.
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Kailasam A, Cucinella G, Fought AJ, Cliby W, Mariani A, Glaser G, Langstraat C. Nonsurgical management of early-stage endometrial cancer due to obesity: a survey of the practice patterns of current Society of Gynecologic Oncology members. Gynecol Oncol Rep 2023; 50:101280. [PMID: 37927533 PMCID: PMC10623145 DOI: 10.1016/j.gore.2023.101280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023] Open
Abstract
Objective Nonsurgical management for endometrial cancer in patients with class 3 obesity (BMI ≥ 40 kg/m2) is a challenging scenario given lack of consensus on patient selection and treatment options. Our objective was to evaluate trends in practice patterns and physician opinions in the Society of Gynecologic Oncology (SGO) on nonsurgical management of endometrial cancer and complex atypical hyperplasia due to obesity. Methods An online survey was sent to all gynecologic oncologist members of the SGO with questions centered on decision-making for nonsurgical approaches for patients with class 3 obesity patients. Fisher's exact tests were used to assess the associations between offering nonsurgical management and geographic region, practice type, and time in practice. Results 255 (19.8 %) members from 6 geographic regions responded, of which 183 (71.8 %) offered primary nonsurgical management of endometrial cancer to patients with class 3 obesity and 72 (28.2 %) do not. The choice to offer initial nonsurgical management did not vary based on geographic region, time in practice or practice type. When asked to select BMI cutoff, the majority (65.2 %) started to offer nonsurgical management was BMI 60-64 kg/m2. Progesterone intrauterine device was the preferred treatment (68.3 %, 125/183). Of those who offered nonsurgical management, 97.3 % (178/183) recommended resampling in 3-6 months. Conclusion Primary nonsurgical management of endometrial cancer in patients with class 3 obesity is offered by most gynecologic oncologists in SGO. However, almost one-third of gynecologic oncologists indicated they do not offer nonsurgical management for endometrial cancer for obesity alone. Additional data are needed to determine the safety of both approaches in these complex patients.
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Affiliation(s)
- Aparna Kailasam
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | | | - Angela J Fought
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - William Cliby
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Andrea Mariani
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Gretchen Glaser
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Carrie Langstraat
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
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Dinoi G, Multinu F, Yost K, AlHilli M, Larish A, Langstraat C, Kumar A, Weaver AL, McGree M, Cheville A, Dowdy S, Mariani A, Glaser G. Impact of comorbidities and extent of lymphadenectomy on quality of life in endometrial cancer patients treated with minimally invasive surgery in the era of sentinel lymph nodes. Int J Gynecol Cancer 2023; 33:1227-1236. [PMID: 37419517 DOI: 10.1136/ijgc-2023-004423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023] Open
Abstract
OBJECTIVE To identify predictors of quality of life (QoL) among patients who undergo surgical staging with sentinel lymph node (SLN) biopsy or lymphadenectomy for endometrial cancer. METHODS Patients who underwent minimally invasive surgery for primary endometrial cancer at the Mayo Clinic from October 2013 to June 2016 were mailed a 30-item QoL in Cancer survey (QLQ-C30) and a validated 13-item lower extremity lymphedema screening questionnaire. Patients who answered <50% of the items or had a pre-operative history of lymphedema were excluded. Multivariable linear regression models were fit to evaluate predictors of QoL using inverse-probability of treatment weighting to adjust for differences at the time of the surgery between the lymphadenectomy and SLN groups. RESULTS The 221 patients included in the analysis were stratified into two groups: patients who underwent (1) bilateral lymphadenectomy as 'backup' after SLN mapping (lymphadenectomy group; n=101) or (2) SLN removal with or without side-specific lymphadenectomy (SLN group; n=120). On multivariable analysis, obesity, lower extremity lymphedema, and kidney disease had significant (p<0.05) and clinically meaningful negative impacts on global QoL. Declines in average adjusted global QoL scores were marked (19.7 points lower) in patients with BMI ≥40 kg/m2 and lower extremity lymphedema compared with non-obese patients without lower extremity lymphedema. In contrast, there was only a 2.9 point difference in the adjusted average global QoL score between the SLN and lymphadenectomy groups. CONCLUSIONS Lower extremity lymphedema coupled with obesity predicts poorer QoL in patients who undergo surgical staging for endometrial cancer. In this population, reduction of lower extremity lymphedema by performing SLN instead of lymphadenectomy and earlier targeted interventions may improve patients' QoL. Future research focusing on targeted interventions is needed.
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Affiliation(s)
- Giorgia Dinoi
- Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Kathleen Yost
- Health Sciences Research, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mariam AlHilli
- Department of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alyssa Larish
- Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanika Kumar
- Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michaela McGree
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andrea Cheville
- Physical Medicine and Rehabilitation, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sean Dowdy
- Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Capasso I, Garzon S, Kumar S, Weaver AL, Mc Gree M, De Vitis LA, Uccella S, Petersen I, Glaser G, Langstraat C, Scambia G, Fanfani F, Mariani A. Prognostic factors in patients with endometrial cancer with isolated lymphatic recurrence. Int J Gynecol Cancer 2023; 33:1169-1178. [PMID: 37321674 DOI: 10.1136/ijgc-2023-004435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE To analyze the clinicopathological features and outcomes in patients with endometrial cancer with isolated lymphatic recurrence after lymphadenectomy, stratified by different isolated lymphatic recurrence sites and treatment approaches. METHODS We retrospectively reviewed all surgically treated patients with endometrial cancer, identifying those with recurrence. We defined primary isolated lymphatic recurrence as the first and unique evidence of recurrence in lymph node-bearing areas, without concomitant vaginal, hematogenous, or peritoneal recurrence. Isolated lymphatic recurrences were classified as pelvic, para-aortic, distant, or multiple sites. Our primary outcome was cause-specific survival after diagnosis of the recurrence. RESULTS Among 4216 patients with surgically staged endometrial cancer, we identified 66 (1.6%) women with isolated lymphatic recurrence. The overall median cause-specific survival for patients with isolated lymphatic recurrence was 24 months. Although cause-specific survival was not significantly different between the four isolated lymphatic recurrence groups (p=0.21), 7 of 15 (47%) patients with isolated lymphatic recurrence in the para-aortic area were long-term survivors. At multivariate Cox regression, the absence of lymphovascular space invasion and grade 1 histology in the primary tumor were significantly associated with improved cause-specific survival. In addition, patients with isolated lymphatic recurrence who underwent surgery for recurrence (with/without other associated therapies) had improved cause-specific survival compared with patients who did not undergo surgery, also after adjusting for age. CONCLUSIONS Low-grade histology and absence of lymphovascular space invasion in the primary tumor were predictors of improved prognosis in patients with endometrial cancer with isolated lymphatic recurrence. In addition, in this retrospective cohort, patients with isolated lymphatic recurrence who were selected for eradicative surgical treatment had improved cause-specific survival.
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Affiliation(s)
- Ilaria Capasso
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Sanjeev Kumar
- Department of Gynecologic Oncology, Baptist Memorial Hospital for Women, Memphis, Tennessee, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela Mc Gree
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giovanni Scambia
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Francesco Fanfani
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Andrea Mariani
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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10
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Robison K, Wohlrab K, Howe CJ, Richter HE, Sung V, Bevis KS, Luis C, McCourt C, Lowder J, Occhino J, Glaser G, Lokich E, Dunivan G, Brown A, Tunitsky-Bitton E, Wethington S, Chen CCG, Rahn D, Carlson M, Cram R, Raker C, Clark MA. Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery. Obstet Gynecol 2023; 141:642-652. [PMID: 36897162 DOI: 10.1097/aog.0000000000005059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone. METHODS A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores. RESULTS Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively. CONCLUSION Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.
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Affiliation(s)
- Katina Robison
- Women & Infants Hospital and Brown University, Providence, Rhode Island; the University of Alabama at Birmingham, Birmingham, Alabama; Washington University of St. Louis Hospital, St. Louis, Missouri; Mayo Clinic, Rochester, Minnesota; the University of New Mexico Hospital, Albuquerque, New Mexico; Hartford Hospital, Hartford, Connecticut; Johns Hopkins Hospital, Baltimore, Maryland; and the University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Shafa A, Mariani A, Glaser G. Knowing when to hold and when to fold: sentinel lymph node biopsy in endometrial intraepithelial neoplasia. Int J Gynecol Cancer 2022; 32:ijgc-2022-003869. [PMID: 35973738 DOI: 10.1136/ijgc-2022-003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Anousheh Shafa
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Glaser G, Maddy B, Kumar A, Hanson K, Habermann E, Dowdy S. Opioid individualization by pharmacogenomics: the next wave of post-operative prescribing (065). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01282-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Kumar A, Langstraat C, Petersen I, Glaser G, Bakkum-Gamez J, Mariani A, Kulsrud V, Zundel J, Garda A, Cliby W, Haddock M, Dowdy S. Creation of a surgical service line to treat patients with recurrent gynecologic cancer with curative intent: Complex oncologic multidisciplinary pelvic surgery (COMPS) (559). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Rios-Doria E, Abu-Rustum N, Glaser G, McGree M, Eriksson AGZ, Pham M, Soliman P, Ataseven B, Alektiar K, Zamarin D, Leitao M, Mueller J. What matters most in FIGO IIIA endometrial cancer: Involvement of serosa, adnexa, or both? (542). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01763-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Garzon S, Mariani A, Day CN, Habermann EB, Langstraat C, Glaser G, Kumar A, Casarin J, Uccella S, Ghezzi F, Larish A. Overall survival after surgical staging by lymph node dissection versus sentinel lymph node biopsy in endometrial cancer: a national cancer database study. Int J Gynecol Cancer 2021; 32:28-40. [PMID: 34750199 DOI: 10.1136/ijgc-2021-002927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Substituting lymphadenectomy with sentinel lymph node biopsy for staging purposes in endometrial cancer has raised concerns about incomplete nodal resection and detrimental oncological outcomes. Therefore, this study aimed to investigate the association between the type of lymph node assessment and overall survival in endometrial cancer accounting for node status and histology. METHODS Women with stage I-III endometrial cancer who underwent hysterectomy and lymph node assessment from January 2012 to December 2015 were identified in the National Cancer Database. Patients who underwent neoadjuvant therapy, had previous cancer, and whose follow-up was less than 90 days were excluded. Multivariable Cox proportional hazards regression analyses were performed to assess factors associated with overall survival. RESULTS Of 68 614 patients, 64 796 (94.4%) underwent lymphadenectomy, 1777 (2.6%) underwent sentinel node biopsy only, and 2041 (3.0%) underwent both procedures. On multivariable analysis, neither sentinel lymph node biopsy alone nor sentinel node biopsy followed by lymphadenectomy was associated with significantly different overall survival compared with lymphadenectomy alone (HR 0.92, 95% CI 0.73 to 1.17, and HR 0.91, 95% CI 0.77 to 1.08, respectively). When stratified by lymph node status, sentinel node biopsy alone or followed by lymphadenectomy was not associated with different overall survival, both in patients with negative (HR 0.95, 95% CI 0.73 to 1.24, and HR 1.04, 95% CI 0.85 to 1.27, respectively) or positive (HR 0.91, 95% CI 0.54 to 1.52, and HR 0.77, 95% CI 0.57 to 1.04, respectively) lymph nodes. These findings held true when sentinel node biopsy alone and sentinel node biopsy plus lymphadenectomy groups were merged, and on stratification by histotype (type one vs type 2) or inclusion of only complete lymphadenectomy (at least 10 pelvic nodes and at least one para-aortic node removed). In all analyses, age, Charlson-Deyo score, black race, AJCC pathological T stage, grade, lymphovascular invasion, brachytherapy, and adjuvant chemotherapy were independently associated with overall survival. DISCUSSION No difference in overall survival was found in patients with endometrial cancer who underwent sentinel node biopsy alone, sentinel node biopsy followed by lymphadenectomy, or lymphadenectomy alone. This observation remained regardless of node status, histotype, and lymphadenectomy extent.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy.,Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Amanika Kumar
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jvan Casarin
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Obstetrics and Gynecology, University of Insubria Faculty of Medicine and Surgery, Varese, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Alyssa Larish
- Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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16
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Cope A, Willborg B, Lazaro J, Lindstrom E, DeStephano C, Vetter M, Mara K, Glaser G, Langstraat C, Chen A, Martino M, Dinh T, Salani R, Green I. Benchmarks for 3-D Systems (Simbionix) Bladder Flap Module for the Xi Robot: Differentiating Novice from Experienced and Expert Surgeons. J Minim Invasive Gynecol 2021. [DOI: 10.1016/j.jmig.2021.09.693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Dinoi G, Garzon S, Glaser G, Kumar A, Langstraat C, Weaver A, McGree M, Weroha SJ, Scambia G, Fanfani F, Mariani A. Which patients with stage IB endometrioid endometrial cancer are at high risk of distant recurrences? Gynecol Oncol 2021. [DOI: 10.1016/s0090-8258(21)01285-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Garzon S, Mariani A, Grassi T, Weaver A, McGree M, Petersen I, Weroha SJ, Glaser G, Langstraat C, Kollikonda S, Amarnath S, Alhilli M. Not all high-intermediate risk endometrial cancers are created equal: recurrence-free survival and cause-specific survival after observation or vaginal brachytherapy in all possible subgroups of early-stage high-intermediate risk endometrial cancer. Gynecol Oncol 2021. [DOI: 10.1016/s0090-8258(21)01056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Hickman AD, McGarrah PW, Glaser G, Naraev B, Wahner Hendrickson AE, Halfdanarson TR. A multicenter analysis of treatment and outcomes in neuroendocrine carcinoma of the uterine cervix (NCUC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e17518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17518 Background: Morbidity and mortality for patients with cervical cancer has improved significantly over the past few decades with modern multimodal therapy. However, neuroendocrine carcinoma of the uterine cervix (NCUC), which accounts for 1-2% of cervical cancers, remains a deadly subtype. In this study, we combine data from Mayo Clinic (MC) and the University of Iowa Hospitals and Clinics (UIHC) to provide information on tumor characteristics, treatment, and outcomes. Methods: The electronic medical record was reviewed for patients with NCUC from MC and UIHC. Data on diagnosis, treatment, and outcomes were collected through chart review. Primary endpoints included progression-free survival (PFS) and overall survival (OS). Secondary endpoints included median survival, survival at 1 year after surgery, and survival at 1 year by first line chemotherapy agent. Kaplan-Meier survival analysis was used to estimate median PFS, median survival, and OS. Fisher’s test analysis was used to calculate survival at 1 year after surgery and by first line chemotherapy agent. Results: There were 62 patients (MC: 26, UIHCC: 36) with NCUC stage I-IV (stage I: 29, stage II: 9, stage III: 7, stage IV: 14, unknown: 3). Median age of diagnosis was 47 years (range 21-77 years). By subtype, 47 were small cell (76%), 9 were large cell (15%), and 6 were unknown/undetermined (9%). The initial treatment modalities for each patient are outlined in the table. 28 patients had complete/partial response or stable disease from first line treatment, while 10 patients had disease progression. Of the patients who initially responded or had stable disease, 16 later progressed (57%) with a median time to progression of 15 months. Median follow up was 65.1 months with a median OS of 28.5 months. Median survival for those with stage I was 40.9 months, stage II: 54.6 months, stage III: 8.75 months, and stage IV: 11.7 months. There was a significant difference in overall survival at 1 year between those who received surgery and those who did not in stage I/II ( p = 0.01). There was no significant difference in overall survival at 1 year for those who received surgery in stage III/IV. There was no statistical difference in survival at 1 year for carboplatin or cisplatin in combination with etoposide as first line chemotherapy agent. Conclusions: NCUC is an aggressive malignancy that is usually progressive despite multimodal therapy. Our study demonstrated a median overall survival of 28.5 months and 5-year survival rate of 21%. Our study showed a survival benefit at 1 year for those who receive surgery with stage I/II NCUC. There was no significant survival benefit at 1 year between carboplatin or cisplatin in combination with etoposide as first line agent.[Table: see text]
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20
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Narasimhulu DM, Block MS, Weaver AL, McGree M, Kumar A, Langstraat C, Petersen I, Mariani A, Glaser G. Sequencing chemotherapy before radiotherapy for women with stage IIIC endometrial cancer. Int J Gynecol Cancer 2021; 31:702-708. [PMID: 33771845 DOI: 10.1136/ijgc-2020-002158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE It is unclear how to best sequence adjuvant chemotherapy and radiotherapy for advanced endometrial cancer. We studied the outcomes for women treated with chemotherapy before radiotherapy in a chemotherapy-first (chemotherapy for 6 cycles followed radiotherapy) or 'sandwich' approach (chemotherapy for 3 cycles followed by radiotherapy and subsequently chemotherapy for 3 cycles). METHODS Women with stage IIIC endometrial cancer and no gross residual disease treated with chemotherapy before radiotherapy between April 2003 and April 2016 were included. The Kaplan-Meier method was used to estimate recurrence and survival. We performed a meta-analysis of endometrial cancer trials comparing chemotherapy and radiotherapy versus radiotherapy alone. RESULTS A total of 102 patients were included. The mean (SD) age was 63.8 (10.6) years; 84 patients received the chemotherapy-first approach and 18 patients received the 'sandwich' approach. Pelvic and para-aortic nodes were removed in 99% and 88.2%, respectively. Among all the patients, we observed 1 pelvic (1%), 1 para-aortic (1%), and 5 vaginal (4.9%) recurrences. At 3 years, for the 'sandwich' and chemotherapy-first approaches, the vaginal recurrence was 11.8% and 4.2%, pelvic recurrence was 0% and 1.5%, para-aortic recurrence was 0% and 1.2%, distant recurrence was 42.9% and 24.4%, and overall survival was 70.3% and 81.7%, respectively. With 'chemotherapy before radiotherapy' 94.9% completed 4+ chemotherapy cycles (vs 71-90% reported in the literature for 'radiotherapy before chemotherapy'). In a meta-analysis of endometrial cancer trials, distant recurrence rates were reduced with 4+ chemotherapy cycles but not with 3 cycles (p=0.01). CONCLUSION Chemotherapy before radiation sequencing for stage IIIC endometrial cancer was associated with a high proportion of patients completing 4+ chemotherapy cycles and low locoregional lymphatic recurrence rate, despite delaying radiotherapy until after 3-6 cycles of chemotherapy and not administering concurrent cisplatin.
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Affiliation(s)
| | - Matthew S Block
- Department of Medical Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Amy L Weaver
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Amanika Kumar
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ivy Petersen
- Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
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21
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Wenzel L, Osann K, McKinney C, Cella D, Fulci G, Scroggins MJ, Lankes HA, Wang V, Nephew KP, Maxwell GL, Mok SC, Conrads TP, Miller A, Mannel RS, Gray HJ, Hanjani P, Huh WK, Spirtos N, Leitao MM, Glaser G, Sharma SK, Santin AD, Sperduto P, Lele SB, Burger RA, Monk BJ, Birrer M. Quality of Life and Adverse Events: Prognostic Relationships in Long-Term Ovarian Cancer Survival. J Natl Cancer Inst 2021; 113:1369-1378. [PMID: 33729494 DOI: 10.1093/jnci/djab034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/15/2021] [Accepted: 03/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a critical need to identify patient characteristics associated with long-term ovarian cancer survival. METHODS Quality of life (QOL), measured by the Functional Assessment of Cancer Therapy-Ovarian-Trial Outcome Index (FACT-O-TOI), including physical, functional and ovarian-specific subscales, was compared between long-term (LTS) (8+ years) and short-term (STS) (<5 years) survivors of GOG 218 at baseline, before cycles 4, 7, 13, 21, and 6 months post-treatment using linear and longitudinal mixed models adjusted for covariates. Adverse events (AEs) were compared between survivor groups at each assessment using generalized linear models. All p-values are two-sided. RESULTS QOL differed statistically significantly between STS (N = 1115) and LTS (N = 260) (p < .001). Baseline FACT-O-TOI and FACT-O-TOI change were independently associated with long-term survival (OR = 1.05, 95% CI = 1.03-1.06 and OR = 1.06, 95% CI = 1.05-1.07, respectively). A 7-point increase in baseline QOL was associated with a 38.0% increase in probability of LTS, while a 9-point increase in QOL change was associated with a 67.0% increase in odds for LTS. QOL decreased statistically significantly with increasing AE quartiles (cycle 4 quartiles: 0-5 v. 6-8 v. 9-11 v. ≥12 AEs, p = .01; cycle 21 quartiles: 0-2 v. 3 v. 4-5 v. ≥6 AEs, p = .001). Further, LTS reported statistically significantly better QOL compared to STS (p = .03 and p = .01, cycles 4 and 21, respectively), with similar findings across higher AE grades. CONCLUSION Baseline and longitudinal QOL change scores distinguished long versus short-term survivors and are robust prognosticators for long term survival. Results have trial design and supportive care implications, providing meaningful prognostic value in this understudied population.
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Affiliation(s)
- Lari Wenzel
- Department of Medicine and Program in Public Health, University of California, Irvine
| | - Kathryn Osann
- Department of Medicine and Program in Public Health, University of California, Irvine
| | - Chelsea McKinney
- Department of Medicine and Program in Public Health, University of California, Irvine
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Health System
| | | | | | | | - Victoria Wang
- Dana-Farber Cancer Institute, Department of Data Science
| | - Kenneth P Nephew
- Medical Sciences Program, Indiana University School of Medicine-Bloomington
| | - George L Maxwell
- Women's Health Integrated Research Center at Inova Health System, Women's Service Line, Inova Health System
| | - Samuel C Mok
- Department of Gynecological Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center
| | - Thomas P Conrads
- Women's Health Integrated Research Center at Inova Health System, Women's Service Line, Inova Health System
| | | | - Robert S Mannel
- Stephenson Cancer Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma
| | - Heidi J Gray
- Gynecologic Oncology, University of Washington Medical Center
| | | | | | | | - Mario M Leitao
- Memorial Sloan Kettering Cancer and Weill Cornell Medical Center
| | | | | | - Alessandro D Santin
- Department of Obstetrics, Gynecology & Reproductive Services, Yale University School of Medicine
| | - Paul Sperduto
- Minneapolis Radiation Oncology and Metro-Minnesota Community Oncology Research Consortium
| | | | | | - Bradley J Monk
- Division of Gynecologic Oncology, Arizona Oncology (US Oncology Network), University of Arizona College of Medicine
| | - Michael Birrer
- Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences
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22
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Cappuccio S, Li Y, Song C, Liu E, Glaser G, Casarin J, Grassi T, Butler K, Magtibay P, Magrina JF, Scambia G, Mariani A, Langstraat C. The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety. Int J Gynecol Cancer 2021; 31:686-693. [PMID: 33727220 DOI: 10.1136/ijgc-2020-002192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety. METHODS In this retrospective cohort study, patients aged 18 years or older who underwent hysterectomy for endometrial cancer between January 2008 and September 2015 were identified in the Premier Healthcare Database. The surgical approach for hysterectomy was classified as open/abdominal, vaginal, laparoscopic or robotic assisted. We described trends in surgical setting, perioperative costs and safety. The impact of patient, provider and hospital characteristics on outpatient migration was assessed using multivariate logistic regression. RESULTS We identified 41 246 patients who met inclusion criteria. During the time period studied, we observed a 41.3% shift from inpatient to outpatient hysterectomy (p<0.0001), an increase in robotic hysterectomy, and a decrease in abdominal hysterectomy. The robotic hysterectomy approach, more recent procedure (year), and mid-sized hospital were factors that enabled outpatient hysterectomies; while abdominal hysterectomy, older age, Medicare insurance, black ethnicity, higher number of comorbidities, and concomitant procedures were associated with an inpatient setting. The shift towards outpatient hysterectomy led to a $2500 savings per case during the study period, in parallel to the increased robotic hysterectomy rates (p<0.001). The post-discharge 30-day readmission and complications rate after outpatient hysterectomy remained stable at around 2%. CONCLUSIONS A significant shift from inpatient to outpatient setting was observed for hysterectomies performed for endometrial cancer over time. Minimally invasive surgery, particularly the robotic approach, facilitated this migration, preserving clinical outcomes and leading to reduction in costs.
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Affiliation(s)
- Serena Cappuccio
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Woman's, Child's and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Yanli Li
- Global Health Economics and Outcomes Research, Intuitive Surgical Inc, Sunnyvale, California, USA
| | - Chao Song
- Global Health Economics and Outcomes Research, Intuitive Surgical Inc, Sunnyvale, California, USA
| | - Emeline Liu
- Global Health Economics and Outcomes Research, Intuitive Surgical Inc, Sunnyvale, California, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tommaso Grassi
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristina Butler
- Department of Gynecology, Mayo Clinic, Phoenix, Arizona, USA
| | - Paul Magtibay
- Department of Gynecology, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Giovanni Scambia
- Department of Woman's, Child's and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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23
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Glaser G, Dinoi G, Multinu F, Yost K, Al Hilli M, Larish A, Kumar A, McGree M, Weaver AL, Cheville A, Dowdy S, Mariani A. Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer. Int J Gynecol Cancer 2020; 31:85-91. [DOI: 10.1136/ijgc-2020-001924] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022] Open
Abstract
ObjectiveEndometrial cancer surgical staging includes lymph node assessment which can lead to lower extremity lymphedema. The aim of this study was to estimate prevalence after sentinel lymph node biopsy versus lymphadenectomy.MethodsConsecutive patients who underwent minimally invasive surgery at the Mayo Clinic, Rochester, Minnesota, USA, between January 2009 and June 2016 for newly diagnosed endometrial cancer were mailed our validated 13 item lower extremity lymphedema screening questionnaire. We also ascertained via questionnaire whether the patient was ever diagnosed with lower extremity lymphedema.ResultsAmong 378 patients included in the analysis, 127 (33.5%) had sentinel lymph node biopsy with or without side specific lymphadenectomy (sentinel lymph node cohort) and 251 (66.4%) underwent bilateral lymphadenectomy prior to sentinel lymph node biopsy implementation at our institution or as 'backup' after sentinel lymph node mapping (lymphadenectomy cohort). The prevalence of lower extremity lymphedema was 41.5% (157/378), with 69 patients (18.3%) self-reporting a lower extremity lymphedema diagnosis after their endometrial cancer surgery at a median of 54.3 months (interquartile range 31.2–70.1 months), and an additional 88 patients (23.3%) identified by the screening questionnaire. The prevalence of lower extremity lymphedema was significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node group (49.4% (124/251) vs 26.0% (33/127); p<0.001). When the cohorts were restricted to patients surgically managed after the introduction of sentinel lymph node, the prevalence of lower extremity lymphedema was still significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node cohort (39.0% (41/105) vs 26.0% (33/127); p=0.03). In a multivariable analysis adjusted for body mass index, receipt of adjuvant external beam radiation, diabetes, congestive heart failure, and International Federation of Gynecology and Obstetrics grade, the adjusted odds ratio for the association between type of nodal sampling (lymphadenectomy cohort vs sentinel lymph node cohort) and lower extremity lymphedema was 2.75 (95% confidence interval 1.69 to 4.47, p<0.001).ConclusionsSentinel lymph node biopsy was associated with a decreased risk of post-treatment lymphedema compared with lymphadenectomy in patients who underwent surgical staging for endometrial carcinoma.
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Dinoi G, Weaver A, McGree M, Dowdy S, Yost K, Mariani A, Glaser G. Impact of patient comorbidities on quality of life in patients who undergo surgery with sentinel lymph node biopsy for endometrial cancer. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.05.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Larish A, Yin L, Glaser G, Moore E, Bakkum-Gamez J, Routman D, Ma D, Price D, Janus J, Price K, Chintakuntlawar A, Neben-Wittich M, Foote R, Van Abel K. Human Papillomavirus-Associated Anogenital Pathology in Females With HPV-Positive Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2020; 164:369-374. [PMID: 32663054 DOI: 10.1177/0194599820941499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We sought to determine the incidence and location of human papillomavirus (HPV)-associated anogenital disease in women with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) via a retrospective cohort study with prospective contact to update history at Mayo Clinic in Rochester, Minnesota. Females undergoing treatment for nonmetastatic HPV-positive OPSCC from 2011 to 2019 were identified. Clinical history and outcomes were abstracted from medical records. Patients without documented anogenital history were contacted, consented, and administered a survey, and external records were requested and reviewed. Seventeen of 46 patients (37.0%) had a history of anogenital HPV-associated disease, and 16 of 17 (94.1%) required procedures to diagnose or treat HPV lesions. The cervix was the most common site (16/17, 94.1%). Procedures included colposcopy (n = 6), cervical excision (n = 3), cryotherapy (n = 4), and hysterectomy (n = 3). One case of fatal cervical carcinoma was noted, diagnosed 1 year following OPSCC. Three of 17 (17.6%) had HPV-related vulvovaginal disease, and 1 of 17 had anal disease. Patients with a history of HPV-positive OPSCC may be at elevated risk for HPV-associated anogenital disease.
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Affiliation(s)
- Alyssa Larish
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie Bakkum-Gamez
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey Janus
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katharine Price
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Robert Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Kalogera E, Suman VJ, Nevala WK, Finnes HD, Schimke J, Strand C, Glaser G, Grudem M, Jatoi A, Klampe C, Kumar A, Langstraat CL, Wahner Hendrickson AE, Weroha SJ, Reid JM, Markovic S, Block MS. A phase I trial of nab-paclitaxel/bevacizumab (AB160) nano-immunoconjugate therapy for metastatic gynecological malignancies: MC1371 (NCT02020707). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e18097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18097 Background: AB160 is a 160 nm nano-immunoconjugate consisting of nab-paclitaxel (NP) nanoparticles non-covalently coated with bevacizumab (BEV) for targeted delivery into tissues expressing high levels of vascular-endothelial growth factor (VEGF). Both taxanes (GOG-0129C, GOG-0126R, GOG-0127V) and BEV (GOG-0229E, AURELIA, GOG-0227C) have demonstrated clinical activity in previously treated metastatic endometrial cancer (EC), ovarian cancer (OC), and cervical cancer (CC), respectively. Methods: A 3+3 phase I trial was conducted in patients with EC, platinum-resistant OC and CC who had prior systemic treatment for metastatic disease to determine the maximum tolerated dose of AB160 administered intravenously on days 1, 8 and 15 of a 28-day cycle. The starting dose level (DL1) was NP at 125 mg/m2 with BEV at 50 mg/m2. There were 2 higher dose levels: DL2 (NP at 150 mg/m2 with BEV at 60 mg/m2) and DL3 (NP at 175 mg/m2 with BEV at 70 mg/m2). Dose limiting toxicities (DLT) included grade (G) 4 neutropenia or anemia, PLT < 25,000, serum creatinine ≥2 times baseline, G2-4 neurologic toxicity or G3-4 non-hematologic toxicities. Disease evaluations were conducted after every 2 treatment cycles using RECIST criteria. Patients were treated until disease progression or intolerability. Samples were collected for pharmacokinetic (PK) studies. Results: Nine women 41 – 74 years of age (median 57) have enrolled (5 with EC and 4 with OC); data are available for the first 8. No DLTs have been observed among the 3 women enrolled on DL1, 3 women on DL2, and 2 women on DL3. All 3 patients on DL3 continue on treatment. The other 6 patients have discontinued due to adverse reactions (3), progression (2), and patient choice (1). The median number of cycles administered is 6 (4-14). The most common severe (G3/4) toxicities include neutropenia (37.5%) and leukopenia (25%). There have been 5 partial responses (62.5%): 1 on DL1 and 2 each on DL2 and DL3. PK evaluation is pending. Conclusions: AB160 therapy is safe and demonstrates promising clinical activity in patients with previously treated metastatic gynecologic malignancies. Further clinical testing is being pursued in this patient population. Clinical trial information: NCT02020707.
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Narasimhulu DM, Cope A, Riaz IB, Petersen I, Cliby W, Langstraat C, Glaser G, Kumar A, Cappuccio S, Murad MH, West C, Mariani A. External beam radiotherapy versus vaginal brachytherapy in patients with stage II endometrial cancer: a systematic review and meta-analysis. Int J Gynecol Cancer 2020; 30:797-805. [DOI: 10.1136/ijgc-2020-001199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
ObjectiveThe choice of adjuvant treatment for women with stage II endometrial cancer is challenging, given the known increase in morbidity with external beam radiation compared with vaginal brachytherapy, and the lack of consensus on its benefits. We summarized the evidence on survival and recurrence for stage II endometrial cancer, defined as cervical stromal invasion, after adjuvant postoperative external beam radiotherapy and vaginal brachytherapy.MethodsWe searched the MEDLINE, EMBASE, CENTRAL, and Scopus databases from inception to January 2019 to identify studies that compared adjuvant postoperative external beam radiotherapy with or without vaginal brachytherapy and vaginal brachytherapy alone in stage II endometrial cancer. Our primary outcome was the locoregional recurrence rate, defined as recurrence in the pelvis or vagina. Secondary outcomes included the rate of recurrence at any site, distant recurrence rate, vaginal recurrence rate, pelvic recurrence rate, and 5 year overall survival. Study selection, assessment, and data abstraction were performed by an independent set of reviewers. Random effects models were used to synthesize quantitative data.ResultsWe included 15 cohort studies reporting data on 1070 women. Most women with stage II endometrial cancer (848/1070, 79.3%) were treated with external beam radiotherapy with or without vaginal brachytherapy. Subgroup analysis was stratified by whether >90% of the women included underwent pelvic lymph node assessment (sampling or full dissection). Locoregional recurrence (pelvic and vaginal recurrence) was significantly reduced with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (14 studies (n=1057); odds ratio (OR) 0.33 (95% confidence interval (CI) 0.16 to 0.68); I2=5%) regardless of pelvic lymph node assessment. Most women (81.8%) who recurred locoregionally had a least one uterine risk factor (grade 3 tumor, myometrial invasion >50%, or lymphovascular invasion). There was no difference in overall survival with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (five studies (n=463); OR 0.78 (95% CI 0.34 to 1.80); I2=48%).ConclusionsExternal beam radiotherapy with or without vaginal brachytherapy decreased the locoregional recurrence threefold for stage II endometrial cancer, regardless of pelvic lymph node assessment. Most women who suffered recurrence locoregionally had a least one high risk factor. Vaginal brachytherapy alone may be sufficient therapy for node negative stage II endometrial cancer without uterine risk factors, while those with uterine risk factors should be considered for external beam radiotherapy with or without vaginal brachytherapy to improve locoregional control.
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Casarin J, Multinu F, Tortorella L, Cappuccio S, Weaver AL, Ghezzi F, Cliby W, Kumar A, Langstraat C, Glaser G, Mariani A. Sentinel lymph node biopsy for robotic-assisted endometrial cancer staging: further improvement of perioperative outcomes. Int J Gynecol Cancer 2019; 30:41-47. [DOI: 10.1136/ijgc-2019-000672] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 12/30/2022] Open
Abstract
ObjectivesIt is unclear if sentinel lymph node biopsy is associated with improved surgical outcomes compared with lymphadenectomy in patients with endometrial cancer. In this study we aimed to compare peri-operative surgical outcomes and treatment-related morbidity in patients who underwent robotic-assisted sentinel lymph node biopsy versus systematic pelvic lymphadenectomy or hysterectomy alone for apparent early-stage endometrial cancer.MethodsRecords were reviewed of consecutive patients with International Federation of Gynecology and Obstetrics stages I–III endometrial cancer undergoing robotic-assisted staging from January 1, 2009, through June 30, 2016. For the purpose of this analysis we focused on the actual patients who had sentinel node biopsy only (ie, excluding those who had an associated lymphadenectomy either for failed mapping or during the learning curve). We also excluded patients who had para-aortic lymph node dissection from the lymphadenectomy group. Perioperative and 30-day surgical outcomes were compared between patients who underwent sentinel lymph node assessment and those who had pelvic lymphadenectomy or hysterectomy alone, respectively. Inverse probability of treatment weighting derived from propensity scores was used to minimize allocation bias in the comparison of outcomes between groups.ResultsA total of 621 patients were analyzed: 188 (30.3%) with sentinel lymph node biopsy, 198 (31.9%) with pelvic lymphadenectomy, and 235 (37.8%) with hysterectomy alone. Inverse probability of treatment weights analysis balanced for baseline characteristics (age, body mass index, American Society of Anesthesiologists score, Charlson co-morbidity index, parity, prior cesarean section, and previous abdominal operation) showed no significant differences in intra-operative and post-operative complications, re-admissions, and re-operations between the groups. Compared with pelvic lymphadenectomy, the sentinel lymph node biopsy group had a shorter mean operative time (138.0 vs 222.8 min, p<0.001) and less median blood loss (50 vs 100 mL, p<0.001). Sentinel lymph node biopsy also was not associated with worse morbidity compared with hysterectomy alone.ConclusionsIntroduction of sentinel lymph node biopsy reduces operative times and improves peri-operative surgical outcomes of robotic-assisted staging for apparent early-stage endometrial cancer without worsening the morbidity of hysterectomy alone.
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Gostout B, Glaser G, Torbenson V. Workplace Harassment and Discrimination in Gynecology: Reflections on the Report of the American Association of Gynecologic Laparoscopists Member Survey. J Minim Invasive Gynecol 2019; 26:785-786. [PMID: 31128283 DOI: 10.1016/j.jmig.2019.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022]
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 375] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Olawaiye AB, Java JJ, Krivak TC, Friedlander M, Mutch DG, Glaser G, Geller M, O'Malley DM, Wenham RM, Lee RB, Bodurka DC, Herzog TJ, Bookman MA. Corrigendum to "Does adjuvant chemotherapy dose modification have an impact on the outcome of patients diagnosed with advanced stage ovarian cancer? An NRG Oncology/Gynecologic Oncology Group study" [Gynecol. Oncol. 151 (2018) 18-23]. Gynecol Oncol 2018; 152:220. [PMID: 30360899 DOI: 10.1016/j.ygyno.2018.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Alexander B Olawaiye
- Division of Gynecologic Oncology, Magee-Womens Hospital of UPMC, Pittsburgh, PA, United States of America.
| | - James J Java
- NRG Oncology, Clinical Trial Development Division, Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, United States of America
| | - Thomas C Krivak
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Western Pennsylvania Hospital, Pittsburgh, PA, United States of America
| | - Michael Friedlander
- Prince of Wales Clinical School UNSW, Department of Medical Oncology, The Prince of Wales Hospital, Sydney, Australia
| | - David G Mutch
- Dept. of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, MO 63110, United States of America
| | - Gretchen Glaser
- Gynecologic Oncology, Carilion Clinic Gynecological Oncology, Roanoke, VA 24016, United States of America
| | - Melissa Geller
- Dept. of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical Center-Fairview, Minneapolis, MN 55455, United States of America
| | - David M O'Malley
- Dept. of Obstetrics and Gynecology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States of America
| | - Robert M Wenham
- Department of Gynecologic Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, United States of America
| | - Roger B Lee
- Tacoma General Hospital, Tacoma,WA, United States of America
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America
| | - Thomas J Herzog
- Dept. of Obstetrics & Gynecology, University of Cincinnati Cancer Institute, University of Cincinnati, Cincinnati, OH 45267, United States of America
| | - Michael A Bookman
- The Permanente Medical Group, Inc., 2350 Geary Blvd, Room 115, San Francisco, CA 94115, United States of America
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Affiliation(s)
- Gretchen Glaser
- Division of Gynecologic Oncology; Mayo Clinic; Rochester MN USA
| | - Sean C. Dowdy
- Division of Gynecologic Oncology; Mayo Clinic; Rochester MN USA
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Casarin J, Glaser G. Frozen Section to Detect Empty Nodes and Improve the Accuracy of the Sentinel Lymph Node Biopsy in Endometrial Cancer. Ann Surg Oncol 2018; 25:3699-3700. [DOI: 10.1245/s10434-018-6770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Indexed: 11/18/2022]
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Olawaiye AB, Java JJ, Krivak TC, Friedlander M, Mutch DG, Glaser G, Geller M, O'Malley DM, Wenham RM, Lee RB, Bodurka DC, Herzog TJ, Bookman MA. Does adjuvant chemotherapy dose modification have an impact on the outcome of patients diagnosed with advanced stage ovarian cancer? An NRG Oncology/Gynecologic Oncology Group study. Gynecol Oncol 2018; 151:18-23. [PMID: 30135020 DOI: 10.1016/j.ygyno.2018.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/24/2018] [Accepted: 07/29/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To determine the relationship between chemotherapy dose modification (dose adjustment or treatment delay), overall survival (OS) and progression-free survival (PFS) for women with advanced-stage epithelial ovarian carcinoma (EOC) and primary peritoneal carcinoma (PPC) who receive carboplatin and paclitaxel. METHODS Women with stages III and IV EOC and PPC treated on the Gynecologic Oncology Group phase III trial, protocol 182, who completed eight cycles of carboplatin with paclitaxel were evaluated in this study. The patients were grouped per dose modification and use of granulocyte colony stimulating factor (G-CSF). The primary end point was OS; Hazard ratios (HR) for PFS and OS were calculated for patients who completed eight cycles of chemotherapy. Patients without dose modification were the referent group. All statistical analyses were performed using the R programming language and environment. RESULTS A total of 738 patients were included in this study; 229 (31%) required dose modification, 509 did not. The two groups were well-balanced for demographic and prognostic factors. The adjusted hazard ratios (HR) for disease progression and death among dose-modified patients were: 1.43 (95% CI, 1.19-1.72, P < 0.001) and 1.26 (95% CI, 1.04-1.54, P = 0.021), respectively. Use of G-CSF was more frequent in dose-modified patients with an odds ratio (OR) of 3.63 (95% CI: 2.51-5.26, P < 0.001) compared to dose-unmodified patients. CONCLUSION Dose-modified patients were at a higher risk of disease progression and death. The need for chemotherapy dose modification may identify patients at greater risk for adverse outcomes in advanced stage EOC and PPC.
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Affiliation(s)
- Alexander B Olawaiye
- Division of Gynecologic Oncology, Magee-Womens Hospital of UPMC, Pittsburgh, PA, United States of America.
| | - James J Java
- NRG Oncology, Clinical Trial Development Division, Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, United States of America
| | - Thomas C Krivak
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Western Pennsylvania Hospital, Pittsburgh, PA, United States of America.
| | - Michael Friedlander
- Prince of Wales Clinical School UNSW, Department of Medical Oncology, The Prince of Wales Hospital, Sydney, Australia.
| | - David G Mutch
- Dept. of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, MO 63110, United States of America.
| | - Gretchen Glaser
- Gynecologic Oncology, Carilion Clinic Gynecological Oncology, Roanoke, VA 24016, United States of America.
| | - Melissa Geller
- Dept. of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical Center-Fairview, Minneapolis, MN 55455, United States of America.
| | - David M O'Malley
- Dept. of Obstetrics and Gynecology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States of America.
| | - Robert M Wenham
- Department of Gynecologic Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, United States of America.
| | - Roger B Lee
- Tacoma General Hospital, Tacoma, WA, United States of America
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America.
| | - Thomas J Herzog
- Dept. of Obstetrics & Gynecology, University of Cincinnati Cancer Institute, University of Cincinnati, Cincinnati, OH 45267, United States of America.
| | - Michael A Bookman
- The Permanente Medical Group, Inc. 2350 Geary Blvd, Room 115 San Francisco, CA 94115, United States of America.
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Casarin J, Multinu F, Pasupathy K, Weaver A, McGree M, Tortorella L, Torres D, Kumar A, Langstraat C, Huang Y, Ghezzi F, Mariani A, Glaser G. Frozen Section for Detection of Lymph Nodes After Cervical Injection with Indocyanine Green (ICG) for Sentinel Lymph Node Technique in Endometrial Cancer Staging. Ann Surg Oncol 2018; 25:3692-3698. [PMID: 30116949 DOI: 10.1245/s10434-018-6698-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to assess the role of frozen section (FS) in identifying an absence of lymph nodes during sentinel lymph node (SLN) biopsy for apparent early-stage endometrial cancer (EC). METHODS Consecutive apparent early-stage EC patients who had SLNs removed after cervical injection with indocyanine green (ICG) from 1 June 2014 to 30 June 2016 were analyzed. An empty node (EN) was defined as an SLN specimen without evidence of lymph node(s). The association of tumor and patient characteristics with an EN was evaluated, and trend analysis to compare the rate of ENs over calendar quarters was performed. A decision-tree model was then created to compare the use of FS versus no FS for SLN evaluation in the hypothetical cohort affected by early-stage EC in the US each year. RESULTS Over the study period, 300 patients met the inclusion criteria. FS revealed ENs in 24 (8%) patients. No association between patient demographic characteristics (age, body mass index, prior abdominopelvic surgery, international federation of gynecology and obstetrics (FIGO) stage, histology, myometrial invasion, cervical stromal invasion) and presence of ENs was observed. The rate of ENs at FS did not change over time (p = 0.68). The hypothetical analysis showed a 4.3% decrease of inappropriately staged patients with the use of FS on the SLN (95% confidence interval 4.1-4.5). CONCLUSIONS ENs during SLN biopsy for EC staging is not a rare event and can be easily detected with FS. The implementation of FS of SLN might reduce inadequate staging of EC. Individual institutions may want to examine their own EN rates and determine if this would assist them in their SLN practices for EC.
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Affiliation(s)
- Jvan Casarin
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Francesco Multinu
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Gynecology, Division of Gynecologic Oncology, European Institute of Oncology, University of Milan, Milan, Italy
| | - Kalyan Pasupathy
- Health Care Systems Engineering, Mayo Clinic, Rochester, MN, USA
| | - Amy Weaver
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michaela McGree
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lucia Tortorella
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Diogo Torres
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amanika Kumar
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Yajue Huang
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Andrea Mariani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gretchen Glaser
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Norquist BM, Brady MF, Harrell MI, Walsh T, Lee MK, Gulsuner S, Bernards SS, Casadei S, Burger RA, Tewari KS, Backes F, Mannel RS, Glaser G, Bailey C, Rubin S, Soper J, Lankes HA, Ramirez NC, King MC, Birrer MJ, Swisher EM. Mutations in Homologous Recombination Genes and Outcomes in Ovarian Carcinoma Patients in GOG 218: An NRG Oncology/Gynecologic Oncology Group Study. Clin Cancer Res 2017; 24:777-783. [PMID: 29191972 DOI: 10.1158/1078-0432.ccr-17-1327] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/26/2017] [Accepted: 11/21/2017] [Indexed: 12/30/2022]
Abstract
Purpose: We hypothesized that mutations in homologous recombination repair (HRR) genes beyond BRCA1 and BRCA2 improve outcomes for ovarian carcinoma patients treated with platinum therapy and would impact the relative benefit of adding prolonged bevacizumab.Experimental Design: We sequenced DNA from blood and/or neoplasm from 1,195 women enrolled in GOG-0218, a randomized phase III trial in advanced ovarian carcinoma of bevacizumab added to carboplatin and paclitaxel. Defects in HRR were defined as damaging mutations in 16 genes. Proportional hazards models were used to estimate relative hazards for progression-free survival (PFS) and overall survival (OS).Results: Of 1,195 women with ovarian carcinoma, HRR mutations were identified in 307 (25.7%). Adjusted hazards for progression and death compared with those without mutations were lower for women with non-BRCA HRR mutations [HR = 0.73; 95% confidence interval (CI), 0.57-0.94; P = 0.01 for PFS; HR = 0.67; 95% CI, 0.50-0.90; P = 0.007 for OS] and BRCA1 mutations (HR = 0.80; 95% CI, 0.66-0.97; P = 0.02 for PFS; HR = 0.74; 95% CI, 0.59-0.94; P = 0.01 for OS) and were lowest for BRCA2 mutations (HR = 0.52; 95% CI, 0.40-0.67; P < 0.0001 for PFS; HR = 0.36; 95% CI, 0.25-0.53; P < 0.0001 for OS). A test of interaction showed no difference in the effect of bevacizumab on PFS between cases with and without mutations.Conclusions: HRR mutations, including non-BRCA genes, significantly prolong PFS and OS in ovarian carcinoma and should be stratified for in clinical trials. The benefit of adding bevacizumab was not significantly modified by mutation status. Clin Cancer Res; 24(4); 777-83. ©2017 AACR.
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Affiliation(s)
- Barbara M Norquist
- Division of Gynecologic Oncology, University of Washington, Seattle, Washington.
| | - Mark F Brady
- The NRG Oncology Statistical and Data Center, Roswell Park Cancer Center Institute, Buffalo, New York
| | - Maria I Harrell
- Division of Gynecologic Oncology, University of Washington, Seattle, Washington
| | - Tom Walsh
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Ming K Lee
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Suleyman Gulsuner
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Sarah S Bernards
- Division of Gynecologic Oncology, University of Washington, Seattle, Washington
| | - Silvia Casadei
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Robert A Burger
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Krishnansu S Tewari
- Division of Gynecologic Oncology, University of California at Irvine, Orange, California
| | - Floor Backes
- Division of Gynecologic Oncology, The Ohio State University Medical Center, Columbus, Ohio
| | - Robert S Mannel
- Division of Gynecologic Oncology, University of Oklahoma, Oklahoma City, Oklahoma
| | - Gretchen Glaser
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cheryl Bailey
- Division of Gynecologic Oncology, Minnesota Oncology, Minneapolis, Minnesota
| | - Stephen Rubin
- Division of Gynecologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - John Soper
- Division of Gynecologic Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Heather A Lankes
- Department of Pathology and Laboratory Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Nilsa C Ramirez
- Department of Pathology and Laboratory Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Mary Claire King
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Michael J Birrer
- Division of Hematology/Oncology, University of Alabama, Birmingham, Alabama
| | - Elizabeth M Swisher
- Division of Gynecologic Oncology, University of Washington, Seattle, Washington.,Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington
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Glaser G, Weroha SJ, Becker MA, Hou X, Enderica-Gonzalez S, Harrington SC, Haluska P. Conventional chemotherapy and oncogenic pathway targeting in ovarian carcinosarcoma using a patient-derived tumorgraft. PLoS One 2015; 10:e0126867. [PMID: 25962155 PMCID: PMC4427104 DOI: 10.1371/journal.pone.0126867] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 04/08/2015] [Indexed: 11/18/2022] Open
Abstract
Ovarian carcinosarcoma is a rare subtype of ovarian cancer with poor clinical outcomes. The low incidence of this disease makes accrual to large clinical trials challenging. However, studies have shown that treatment responses in patient-derived xenograft (PDX) models correlate with matched-patient responses in the clinic, supporting their use for preclinical testing of standard and novel therapies. An ovarian carcinosarcoma PDX is presented herein and showed resistance to carboplatin and paclitaxel (similar to the patient) but exhibited significant sensitivity to ifosfamide and paclitaxel. The PDX demonstrated overexpression of EGFR mRNA and gene amplification by array comparative genomic hybridization (log2 ratio 0.399). EGFR phosphorylation was also detected. Angiogensis and insulin-like growth factor pathways were also implicated by overexpression of VEGFC and IRS1. In order to improve response to chemotherapy, the PDX was treated with carboplatin/paclitaxel with or without a pan-HER and VEGF inhibitor (BMS-690514) but there was no tumor growth inhibition or improved animal survival, which may be explained by a KRAS mutation. Resistance was also observed when the IGF-1R inhibitor BMS-754807 was combined with carboplatin/paclitaxel. Because poly (ADP-ribose) polymerase inhibitors have activity in ovarian cancer patients, with and without BRCA mutations, ABT-888 was also tested but found to have no activity. Pathogenic mutations were also detected in TP53 and PIK3CA. In conclusion, ifosfamide/paclitaxel was superior to carboplatin/paclitaxel in this ovarian carcinosarcoma PDX and gene overexpression or amplification alone was not sufficient to predict response to targeted therapy. Better predictive markers of response are needed.
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Affiliation(s)
- Gretchen Glaser
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - S. John Weroha
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
| | - Marc A. Becker
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Xiaonan Hou
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | | | - Sean C. Harrington
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Paul Haluska
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
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Janco JMT, Glaser G, Kim B, McGree ME, Weaver AL, Cliby WA, Dowdy SC, Bakkum-Gamez JN. Development of a prediction model for residual disease in newly diagnosed advanced ovarian cancer. Gynecol Oncol 2015; 138:70-7. [PMID: 25913130 DOI: 10.1016/j.ygyno.2015.04.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To construct a tool, using computed tomography (CT) imaging and preoperative clinical variables, to estimate successful primary cytoreduction for advanced epithelial ovarian cancer (EOC). METHODS Women who underwent primary cytoreductive surgery for stage IIIC/IV EOC at Mayo Clinic between 1/2/2003 and 12/30/2011 and had preoperative CT images of the abdomen and pelvis within 90days prior to their surgery available for review were included. CT images were reviewed for large-volume ascites, diffuse peritoneal thickening (DPT), omental cake, lymphadenopathy (LP), and spleen or liver involvement. Preoperative factors included age, body mass index (BMI), Eastern Cooperative Oncology Group performance status (ECOG PS), American Society of Anesthesiologists (ASA) score, albumin, CA-125, and thrombocytosis. Two prediction models were developed to estimate the probability of (i) complete and (ii) suboptimal cytoreduction (residual disease (RD) >1cm) using multivariable logistic analysis with backward and stepwise variable selection methods. Internal validation was assessed using bootstrap resampling to derive an optimism-corrected estimate of the c-index. RESULTS 279 patients met inclusion criteria: 143 had complete cytoreduction, 26 had suboptimal cytoreduction (RD>1cm), and 110 had measurable RD ≤1cm. On multivariable analysis, age, absence of ascites, omental cake, and DPT on CT imaging independently predicted complete cytoreduction (c-index=0.748). Conversely, predictors of suboptimal cytoreduction were ECOG PS, DPT, and LP on preoperative CT imaging (c-index=0.685). CONCLUSIONS The generated models serve as preoperative evaluation tools that may improve counseling and selection for primary surgery, but need to be externally validated.
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Affiliation(s)
| | | | - Bohyun Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - William A Cliby
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Hendrickson AEW, Oberg AL, Glaser G, Camoriano JK, Peethambaram PP, Colon-Otero G, Erlichman C, Ivy SP, Kaufmann SH, Karnitz LM, Haluska P. A phase II study of gemcitabine in combination with tanespimycin in advanced epithelial ovarian and primary peritoneal carcinoma. Gynecol Oncol 2011; 124:210-5. [PMID: 22047770 DOI: 10.1016/j.ygyno.2011.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/30/2011] [Accepted: 10/03/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy and biological effects of the gemcitabine/tanespimycin combination in patients with advanced ovarian and peritoneal cancer. To assess the effect of tanespimycin on tumor cells, levels of the chaperone proteins HSP90 and HSP70 were examined in peripheral blood mononuclear cells (PBMC) and paired tumor biopsy lysates. METHODS Two-cohort phase II clinical trial. Patients were grouped according to prior gemcitabine therapy. All participants received tanespimycin 154 mg/m(2) on days 1 and 9 of cycle 1 and days 2 and 9 of subsequent cycles. Patients also received gemcitabine 750 mg/m(2) on day 8 of the first treatment cycle and days 1 and 8 of subsequent cycles. RESULTS The tanespimycin/gemcitabine combination induced a partial response in 1 gemcitabine naïve patient and no partial responses in gemcitabine resistant patients. Stable disease was seen in 6 patients (2 gemcitabine naïve and 4 gemcitabine resistant). The most common toxicities were hematologic (anemia and neutropenia) as well as nausea and vomiting. Immunoblotting demonstrated limited upregulation of HSP70 but little or no change in levels of most client proteins in PBMC and paired tumor samples. CONCLUSIONS Although well tolerated, the tanespimycin/gemcitabine combination exhibited limited anticancer activity in patients with advanced epithelial ovarian and primary peritoneal carcinoma, perhaps because of failure to significantly downregulate the client proteins at clinically achievable exposures.
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40
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Sat B, Hazan R, Fisher T, Khaner H, Glaser G, Engelberg-Kulka H. Programmed cell death in Escherichia coli: some antibiotics can trigger mazEF lethality. J Bacteriol 2001; 183:2041-5. [PMID: 11222603 PMCID: PMC95100 DOI: 10.1128/jb.183.6.2041-2045.2001] [Citation(s) in RCA: 198] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2000] [Accepted: 01/03/2001] [Indexed: 11/20/2022] Open
Abstract
The discovery of toxin-antitoxin gene pairs (also called addiction modules) on extrachromosomal elements of Escherichia coli, and particularly the discovery of homologous modules on the bacterial chromosome, suggest that a potential for programmed cell death may be inherent in bacterial cultures. We have reported on the E. coli mazEF system, a regulatable addiction module located on the bacterial chromosome. MazF is a stable toxin and MazE is a labile antitoxin. Here we show that cell death mediated by the E. coli mazEF module can be triggered by several antibiotics (rifampicin, chloramphenicol, and spectinomycin) that are general inhibitors of transcription and/or translation. These antibiotics inhibit the continuous expression of the labile antitoxin MazE, and as a result, the stable toxin MazF causes cell death. Our results have implications for the possible mode(s) of action of this group of antibiotics.
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Affiliation(s)
- B Sat
- Department of Molecular Biology, The Hebrew University-Hadassah Medical School, Jerusalem 91120, Israel
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41
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Marianovsky I, Aizenman E, Engelberg-Kulka H, Glaser G. The regulation of the Escherichia coli mazEF promoter involves an unusual alternating palindrome. J Biol Chem 2001; 276:5975-84. [PMID: 11071896 DOI: 10.1074/jbc.m008832200] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The Escherichia coli mazEF system is a chromosomal "addiction module" that, under starvation conditions in which guanosine-3',5'-bispyrophosphate (ppGpp) is produced, is responsible for programmed cell death. This module specifies for the toxic stable protein MazF and the labile antitoxic protein MazE. Upstream from the mazEF module are two promoters, P(2) and P(3) that are strongly negatively autoregulated by MazE and MazF. We show that the expression of this module is positively regulated by the factor for inversion stimulation. What seems to be responsible for the negative autoregulation of mazEF is an unusual DNA structure, which we have called an "alternating palindrome." The middle part, "a," of this structure may complement either the downstream fragment, "b," or the upstream fragment, "c". When the MazE.MazF complex binds either of these arms of the alternating palindrome, strong negative autoregulation results. We suggest that the combined presence of the two promoters, the alternating palindrome structure and the factor for inversion stimulation-binding site, all permit the expression of the mazEF module to be sensitively regulated under various growth conditions.
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Affiliation(s)
- I Marianovsky
- Department of Cellular Biochemistry, Hebrew University-Hadassah Medical School, Ein Kerem, Jerusalem, 91120 Israel
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Abstract
The E. coli RelA protein is a ribosome-dependent (p)ppGpp synthetase that is activated in response to amino acid starvation. RelA can be dissected both functionally and physically into two domains: The N-terminal domain (NTD) (amino acids [aa] 1 to 455) contains the catalytic domain of RelA, and the C-terminal domain (CTD) (aa 455 to 744) is involved in regulating RelA activity. We used mutational analysis to localize sites important for RelA activity and control in these two domains. We inserted two separate mutations into the NTD, which resulted in mutated RelA proteins that were impaired in their ability to synthesize (p)ppGpp. When we caused the CTD in relA(+) cells to be overexpressed, (p)ppGpp accumulation during amino acid starvation was negatively affected. Mutational analysis showed that Cys-612, Asp-637, and Cys-638, found in a conserved amino acid sequence (aa 612 to 638), are essential for this negative effect of the CTD. When mutations corresponding to these residues were inserted into the full-length relA gene, the mutated RelA proteins were impaired in their regulation. In attempting to clarify the mechanism through which the CTD regulates RelA activity, we found no evidence for competition for ribosomal binding between the normal RelA and the overexpressed CTD. Results from CyaA complementation experiments of the bacterial two-hybrid system fusion plasmids (G. Karimova, J. Pidoux, A. Ullmann, and D. Ladant, Proc. Natl. Acad. Sci. USA 95:5752-5756, 1998) indicated that the CTD (aa 564 to 744) is involved in RelA-RelA interactions. Our findings support a model in which RelA activation is regulated by its oligomerization state.
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Affiliation(s)
- M Gropp
- Department of Cellular Biochemistry, The Hebrew University-Hadassah Medical School, Jerusalem 90101, Israel
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Abstract
In bacteria, programmed cell death is mediated through "addiction modules" consisting of two genes. The product of the second gene is a stable toxin, whereas the product of the first is a labile antitoxin. Here we extensively review what is known about those modules that are borne by one of a number of Escherichia coli extrachromosomal elements and are responsible for the postsegregational killing effect. We focus on a recently discovered chromosomally borne regulatable addiction module in E. coli that responds to nutritional stress and also on an antideath gene of the E. coli bacteriophage lambda. We consider the relation of these two to programmed cell death and antideath in bacterial cultures. Finally, we discuss the similarities between basic features of programmed cell death and antideath in both prokaryotes and eukaryotes and the possibility that they share a common evolutionary origin.
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Affiliation(s)
- H Engelberg-Kulka
- Department of Molecular Biology, Hebrew University Hadassah-Medical School, Jerusalem, Israel.
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Engelberg-Kulka H, Reches M, Narasimhan S, Schoulaker-Schwarz R, Klemes Y, Aizenman E, Glaser G. rexB of bacteriophage lambda is an anti-cell death gene. Proc Natl Acad Sci U S A 1998; 95:15481-6. [PMID: 9860994 PMCID: PMC28068 DOI: 10.1073/pnas.95.26.15481] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In Escherichia coli, programmed cell death is mediated through "addiction modules" consisting of two genes; the product of one gene is long-lived and toxic, whereas the product of the other is short-lived and antagonizes the toxic effect. Here we show that the product of lambdarexB, one of the few genes expressed in the lysogenic state of bacteriophage lambda, prevents cell death directed by each of two addiction modules, phd-doc of plasmid prophage P1 and the rel mazEF of E. coli, which is induced by the signal molecule guanosine 3',5'-bispyrophosphate (ppGpp) and thus by amino acid starvation. lambdaRexB inhibits the degradation of the antitoxic labile components Phd and MazE of these systems, which are substrates of ClpP proteases. We present a model for this anti-cell death effect of lambdaRexB through its action on the ClpP proteolytic subunit. We also propose that the lambdarex operon has an additional function to the well known phenomenon of exclusion of other phages; it can prevent the death of lysogenized cells under conditions of nutrient starvation. Thus, the rex operon may be considered as the "survival operon" of phage lambda.
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Affiliation(s)
- H Engelberg-Kulka
- Department of Molecular Biology, Hebrew University-Hadassah Medical School, Jerusalem 91120 Israel.
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Abstract
The immediate early BRLF1 and BZLF1 promoters of Epstein-Barr virus are crucial for triggering the replicative cycle of the virus. To better understand the cell type dependence of the lytic cycle we conducted an analysis of the BRLF1-promoter in the epithelial cell line HeLa and the lymphoid cell line IM9. To analyze promoter activities, transient transfections with 5'-deletions of the BRLF1-promoter in front of luciferase as reporter gene were conducted. Besides the already known cis-acting elements of the promoter close to the TATA-box, more distal elements were located and functionally tested. A nuclear factor 1 consensus site was found to act positively in HeLa cells, but did not in lymphoid IM9 cells. The NF1 site was shown to bind protein by electrophoretic mobility shift assays, antibody-supershifts and in vitro footprinting. Thus, a protein belonging to the nuclear factor 1 family of proteins was identified as additional cellular trans-acting factor for the BRLF1-promoter besides the already described factors Sp1, Zta and Zif268.
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Affiliation(s)
- G Glaser
- Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensburg, Germany
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46
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Vogel M, Wittmann K, Endl E, Glaser G, Knüchel R, Wolf H, Niller HH. Plasmid maintenance assay based on green fluorescent protein and FACS of mammalian cells. Biotechniques 1998; 24:540-2, 544. [PMID: 9564517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- M Vogel
- Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensburg, Germany
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Aviv M, Giladi H, Oppenheim AB, Glaser G. Analysis of the shut-off of ribosomal RNA promoters in Escherichia coli upon entering the stationary phase of growth. FEMS Microbiol Lett 1996; 140:71-6. [PMID: 8666203 DOI: 10.1111/j.1574-6968.1996.tb08317.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Most bacterial RNA consists of stable RNA which is composed of rRNA and tRNA. We have followed by primer extension analysis the level of ribosomal RNA synthesis along the growth phases of a cell culture. A sharp drop in rRNA synthesis was observed upon the transition from the exponential to the stationary phase of growth. Our results demonstrate that an effective shut-off of rRNA synthesis occurs also in the absence of ppGpp. Mutations in the host factors Fis and H-NS, which are known to regulate rrn P1 promoters, did not affect the shut-off process of ribosomal RNA promoters. We also tested the effect of RpoS, the sigma factor known to induce a number of genes in the stationary phase. It was shown that the host factors Fis, H-NS and RpoS do not play a major role in the regulation of the shut-off process of rRNA synthesis. The results presented demonstrate that the rate of rRNA synthesis provides a sensitive measure of the growth phase of the bacterial culture.
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Affiliation(s)
- M Aviv
- Department of Cellular Biochemistry, Hebrew University--Hadassah Medical School, Jerusalem, Israel
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48
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Aizenman E, Engelberg-Kulka H, Glaser G. An Escherichia coli chromosomal "addiction module" regulated by guanosine [corrected] 3',5'-bispyrophosphate: a model for programmed bacterial cell death. Proc Natl Acad Sci U S A 1996; 93:6059-63. [PMID: 8650219 PMCID: PMC39188 DOI: 10.1073/pnas.93.12.6059] [Citation(s) in RCA: 475] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
"Addiction modules" consist of two genes. In most of them the product of one is long lived and toxic while the product of the second is short lived and antagonizes the toxic effect; so far, they have been described mainly in a number of prokaryotic extrachromosomal elements responsible for the postsegregational killing effect. Here we show that the chromosomal genes mazE and mazF, located in the Escherichia coli rel operon, have all of the properties required for an addiction module. Furthermore, the expression of mazEF is regulated by the cellular level of guanosine [corrected] 3',5'-bispyrophosphate, the product of the RelA protein under amino acid starvation. These properties suggest that the mazEF system may be responsible for programmed cell death in E. coli and thus may have a role in the physiology of starvation.
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Affiliation(s)
- E Aizenman
- Department of Cellular Biochemistry, The Hebrew University, Hadassah Medical School, Jerusalem, Israel
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Wolff C, Sommer R, Schröder R, Glaser G, Tautz D. Conserved and divergent expression aspects of the Drosophila segmentation gene hunchback in the short germ band embryo of the flour beetle Tribolium. Development 1995; 121:4227-36. [PMID: 8575322 DOI: 10.1242/dev.121.12.4227] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The segmentation gene hunchback (hb) plays a central role in determining the anterior-posterior pattern in the Drosophila embryo. We have cloned the homologue of hb from the flour beetle Tribolium and show that, on the basis of its expression pattern, most of its functions seem to be conserved between these two species. Like Drosophila, Tribolium has a maternal hb expression that appears to be under translational control by a factor at the posterior pole of the embryo. The maternal expression is followed by a zygotic expression in the region of the developing head and thoracic segments. During germ band extension, a posterior expression domain appears that is likely to be homologous to the posterior blastoderm expression of hb in Drosophila. These observations suggest that hb may have the same functions in early Drosophila and Tribolium development, despite the different types of embryogenesis in these two species (long versus short germ development). One differing aspect of hb expression in Tribolium concerns a structure that is not present in Drosophila, namely the serosa. An hb expression domain at the anterior pole precisely demarcates the border between the extraembryonic serosa and the embryonic field in the Tribolium embryo at an early stage, and hb protein remains expressed in the serosa cells until the end of embryogenesis.
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Affiliation(s)
- C Wolff
- Zoologisches Institut, Universität München, Germany
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Abstract
Understanding protein-DNA interactions in vivo at origins of DNA replication throughout the cell cycle may shed further insight on the mechanisms of initiation and replication control. The Burkitt's lymphoma cell line Raji harbors multiple copies of latent Epstein-Barr virus. Once per cell cycle the origin of plasmid replication of Epstein-Barr virus provides replication function in cis for the viral DNA. Here we examined in vivo nucleoprotein complexes on the initiator element of the origin before and after DNA synthesis. For this purpose Raji cells were synchronously growth arrested in G1 phase by mimosine and in mitosis by colchicine, respectively. The association of the initiator element with proteins was visualized by footprinting with dimethyl sulfate and ligation mediated polymerase chain reaction. Methylation patterns indicated a novel binding activity within each element of a nonamer repeated three times at the initiator element. This activity was strongly diminished in mitotic cells. Furthermore, 5'-ends of Epstein-Barr virus DNA were mapped to the nonamers by ligation mediated polymerase chain reaction, suggesting potential initiation sites for replication from DS.
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Affiliation(s)
- H H Niller
- Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensburg, Germany
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