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At first recurrence, platinum-sensitive ovarian cancer (PSOC) is frequently treated with platinum-based chemotherapy doublets plus bevacizumab, then single-agent bevacizumab. Most patients' disease progresses within a year after chemotherapy, emphasizing the need for novel strategies. Mirvetuximab soravtansine-gynx (MIRV), an antibody-drug conjugate, comprises a folate receptor alpha (FRα)-binding antibody and tubulin-targeting payload (maytansinoid DM4). In FRα-high PSOC, MIRV plus bevacizumab previously showed promising efficacy (objective response rate, 69% [95% CI: 41-89]; median progression-free survival, 13.3 months [95% CI: 8.3-18.3]; median duration of response, 12.9 months [95% CI: 6.5-15.7]) and safety. The Phase III randomized GLORIOSA trial will evaluate MIRV plus bevacizumab vs. bevacizumab alone as maintenance therapy in patients with FRα-high PSOC who did not have disease progression following second-line platinum-based doublet chemotherapy plus bevacizumab.Clinical Trial Registration: ClinicalTrials.gov ID: NCT05445778; GOG.org ID: GOG-3078; ENGOT.ESGO.org ID: ENGOT-ov76.
Most patients with ovarian cancer are initially treated with platinum-based chemotherapy. If the cancer reappears/recurs after more than 6 months following this therapy, it is called platinum-sensitive ovarian cancer (PSOC). Patients with PSOC usually receive additional platinum-based chemotherapy along with bevacizumab, a drug that reduces tumor growth by decreasing its blood supply. If patients improve or are stable on this therapy, they are usually kept on bevacizumab alone for 'maintenance therapy'. Unfortunately, this maintenance therapy does not work long-term in all patients, so better long-term treatments are needed. The GLORIOSA (NCT05445778) clinical trial will compare maintenance therapy with bevacizumab alone to maintenance therapy with bevacizumab plus a drug called mirvetuximab soravtansine-gynx (MIRV) to determine which therapy leads to better results in patients with PSOC. MIRV is made up of an antibody that binds to a specific protein (folate receptor alpha [FRα]) on cancer cells to directly deliver a cancer-killing drug. MIRV received US FDA approval to be used as a therapy for patients with ovarian cancer who are resistant to platinum-based chemotherapy and express high levels of FRα. The GLORIOSA trial will study maintenance therapy with MIRV plus bevacizumab in patients with PSOC who have not had cancer progression after second-line platinum-based chemotherapy plus bevacizumab, and whose cancer expresses high amounts of FRα. The main purpose of this trial is to determine if MIRV plus bevacizumab leads to better patient survival and decreases cancer growth and spread when compared with bevacizumab alone.
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High-grade endometrial stromal sarcoma is a rare and aggressive soft tissue tumor characterized by YWHAE::NUTM2A/B translocations, diagnosis at a median of 50-60 years, and a poor prognosis (overall survival 30%-40%). We describe a 16-year-old patient with high-grade endometrial stromal sarcoma and regional nodal and pulmonary metastases who is a long-term survivor after grossly complete tumor resection, intensive chemotherapy, and pelvic radiotherapy. We discovered a previously undescribed YWHAE::NUTM2E translocation in the tumor. Our patient's favorable outcome suggests that intensive multimodality therapy with curative intent is appropriate for young patients with high-grade endometrial stromal sarcoma and highlights the importance of fertility preservation.
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Neoplasias Endometriales , Sarcoma Estromático Endometrial , Humanos , Femenino , Adolescente , Sarcoma Estromático Endometrial/patología , Sarcoma Estromático Endometrial/terapia , Neoplasias Endometriales/patología , Neoplasias Endometriales/terapia , Translocación Genética , Terapia Combinada , Pronóstico , Preservación de la FertilidadRESUMEN
PURPOSE: To report the results of OPAL (ClinicalTrials.gov identifier: NCT03574779) cohort A, a single-arm substudy of niraparib plus dostarlimab and bevacizumab for the treatment of advanced, platinum-resistant ovarian cancer (PROC). METHODS: Participants with PROC who received 1-2 previous lines of therapy were treated with niraparib (200 or 300 mg once daily), dostarlimab (500 mg once every 3 weeks for four 21-day cycles, followed by 1,000 mg once every 6 weeks), and bevacizumab (15 mg/kg once every 3 weeks). The primary end point was investigator-assessed objective response rate (ORR) per RECIST v1.1. Safety was also assessed. Exploratory biomarker end points included evaluation of changes in the tumor molecular profile and microenvironment using baseline and on-treatment tumor samples. RESULTS: Of 41 enrolled participants (median age, 66.0 years [range, 37-83 years]), 9.8% had tumors that were BRCA-mutated, 19.5% were homologous recombination (HR)-deficient, and 17.1% were HR repair (HRR)-mutated. As of the cutoff date, all participants discontinued treatment. The ORR was 17.1% (80% CI, 9.8 to 27.0), including one complete response (2.4%); the disease control rate was 73.2% (80% CI, 62.3 to 82.2). Two participants withdrew before first postbaseline scan because of adverse events (AEs). Grade ≥3 treatment-emergent AEs were reported in 92.7% of participants, with the most common being hypertension (26.8%). Response was not correlated with BRCA, HRR, HR deficiency (HRD), or PD-L1 status. Changes suggesting immune activation were observed in on-treatment samples after triplet therapy. CONCLUSION: Results demonstrated modest activity of niraparib, dostarlimab, and bevacizumab in participants with PROC, many of whom had prognostic factors for poor treatment response. Most participants with response were bevacizumab-naïve. No association was found with HRD, BRCA, or PD-L1 status. AEs were consistent with previous monotherapy reports, except that hypertension was reported more frequently.
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Protocolos de Quimioterapia Combinada Antineoplásica , Bevacizumab , Resistencia a Antineoplásicos , Indazoles , Neoplasias Ováricas , Piperidinas , Humanos , Femenino , Persona de Mediana Edad , Neoplasias Ováricas/tratamiento farmacológico , Anciano , Bevacizumab/uso terapéutico , Adulto , Indazoles/uso terapéutico , Anciano de 80 o más Años , Piperidinas/uso terapéutico , Piperidinas/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Estudios de CohortesRESUMEN
OBJECTIVE: Aberrant ß-catenin distribution has been theorized as a predictive biomarker for recurrence in early stage, low grade endometrioid endometrial cancer. METHODS: This retrospective single-institution cohort study reviewed 410 patients with endometrial cancer from May 2018 to May 2022. Only endometrioid histology was included. Demographic and clinicopathological data were collected from the medical records. Univariate and multivariate logistic regressions, and sensitivity analyses for early stage, low grade and no specific molecular profile (NSMP) tumors were performed. RESULTS: 297 patients were included for analysis. Most patients were over 60 years old, White, and with a BMI >30 and early stage low grade disease. Aberrant ß-catenin distribution was found in 135 patients (45.5%) and wild type membranous ß-catenin distribution in 162 (54.5%). While TP53 mutation correlated with endometrial cancer recurrence in this cohort (OR = 4.78), aberrant ß-catenin distribution did not correlate in the overall population (OR = 0.75), the early stage low grade cancers (OR = 0.84), or the NSMP group (OR = 1.41) on univariate or multivariate analysis. No correlation between ß-catenin distribution and local (OR = 0.61) or distant recurrences (OR = 0.90) was detected. CONCLUSIONS: Aberrant ß-catenin distribution did not significantly correlate with recurrence in endometrioid endometrial cancer, nor in the early stage, low grade and NSMP sub-cohorts.
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Carcinoma Endometrioide , Neoplasias Endometriales , Femenino , Humanos , Persona de Mediana Edad , beta Catenina/genética , Cateninas , Estudios Retrospectivos , Estudios de Cohortes , Recurrencia Local de Neoplasia/patología , Carcinoma Endometrioide/genética , Carcinoma Endometrioide/patología , Neoplasias Endometriales/genética , Neoplasias Endometriales/patologíaRESUMEN
As a critical tumor suppressor, PTEN has gained much attention in cancer research. Emerging evidence suggests an association between PTEN status and clinical outcome in certain tumors, and may be predictive of response to several therapies. However, the significance of PTEN deficiency in tubo-ovarian high-grade serous carcinomas (HGSCs) is still poorly understood. We evaluated PTEN expression in HGSCs and determined its clinical relevance. A cohort of 76 HGSC specimens was profiled using tissue microarray. Immunohistochemistry (IHC) of PTEN, ER, PR, AR, CD8, FOXP3, and PD-L1 was performed. Targeted gene panel testing by massively parallel sequencing was performed in 51 cases. PTEN deficiency (complete or subclonal loss) detected by IHC was identified in 13 of the 62 HGSCs (21%) and was significantly correlated with reduced expression of ER and worse first progression-free survival (P < .05) but not with PD-L1 expression, the density of intratumoral T lymphocytes, or overall survival. In our cohort, tumor progression within 1 year of PARP inhibitor therapy was found more frequently in PTEN-deficient cases than in PTEN-intact cases (100% vs 52%). Molecular profiling showed that intragenic mutation or deletion was not the predominant mechanism for PTEN inactivation in HGSCs. In addition, CCNE1 amplification was found to be mutually exclusive with PTEN deficiency at both protein and DNA levels. An analysis of the genomic data from 1702 HGSC samples deposited with The Cancer Genome Atlas database obtained from cBioPortal confirmed the low rate of detection of PTEN gene alterations and the mutually exclusive nature of PTEN loss and CCNE1 amplification in HGSCs. These findings indicate that PTEN deficiency defines a distinct clinically significant subgroup of HGSCs with a tendency for ER negativity, wild-type CCNE1 status, inferior clinical outcomes, and potential drug resistance. These tumors may benefit from PI3K pathway inhibitors in combination with other ovarian cancer regimens, which deserves further investigation.
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Carcinoma , Cistadenocarcinoma Seroso , Neoplasias Ováricas , Femenino , Humanos , Supervivencia sin Progresión , Antígeno B7-H1/genética , Fosfatidilinositol 3-Quinasas , Neoplasias Ováricas/genética , Neoplasias Ováricas/patología , Cistadenocarcinoma Seroso/patología , Proteínas Oncogénicas/genética , Ciclina E/genética , Fosfohidrolasa PTEN/genéticaRESUMEN
Background: Technetium Tc 99m tilmanocept is a synthetic radiotracer specifically designed for sentinel lymph node (SLN) mapping that has been FDA-approved in breast cancer, melanoma, and head and neck cancer. No published studies exist for the use of this radiotracer in endometrial cancer. Objective: The primary objective was to determine the detection rate of bilateral SLNs in endometrial cancer with the concurrent use of technetium Tc 99m tilmanocept and ICG. Methods: An open-label, single cohort, prospective feasibility study was conducted with participants receiving preoperative cervical injections of technetium Tc 99m tilmanocept followed by subsequent imaging and SPECT/CT. Intraoperative ICG injections were administered for all patients with near-infrared imaging used to visualize lymphatic vessels and nodes. A laparoscopic gamma counter was used to detect radioactive SLN intraoperatively. Results: All six evaluated patients had FIGO grade 1 or 2 endometrioid histology. Stage IA/IB were in 33% and 66% of patients, respectively. Tilmanocept did not map any SLN in the first six patients but instead showed retention of the tracer in the cervical stroma, leading to study discontinuation for futility. ICG mapped bilateral SLN in all patients with the most common location being the external iliac region, followed by the obturator and common iliac areas. All patients had CD206 positive staining throughout the full wall thickness of ectocervix, transformation zone, endocervix, and lymphatic vessels. No patients experienced adverse events. Conclusion: Technetium Tc 99m tilmanocept did not detect SLN in early stage endometrial cancers and is unlikely to improve bilateral detection rate compared to ICG alone. ICG remains a standard technique for SLN detection in low stage, low grade endometrial cancer.
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The comprehensive genomic analysis of endometrial carcinoma (EC) by The Cancer Genome Atlas (TCGA) led to the discovery of four distinct and prognostically significant molecular subgroups. Molecular classification has the potential to improve risk-stratification when integrated with clinicopathologic features and has recently been included in national and international patient management EC guidelines. Thus, the adoption of molecular classification into routine pathologic and clinical practice is likely to grow significantly in the upcoming years. Establishing an efficient and standardized workflow for performing molecular classification on ECs, and reporting both the molecular and histologic findings in an integrative manner, is imperative. Here we describe our effort to implement rapid and routine molecular classification on all ECs diagnosed at our institution. To this effect, we performed immunohistochemistry as a surrogate marker for identifying genetic and/or epigenetic alterations in DNA mismatch repair (e.g., MLH1, PMS2, MSH6, MSH2), and TP53 genes. In addition, we have developed and employed a single-gene POLE SNaPshot assay, which is a rapid and analytically sensitive method for detecting select POLE exonuclease domain mutations (EDMs). We report our molecular testing workflow and integrative reporting system as well as the clinicopathologic and molecular features of 310 ECs that underwent routine molecular classification at our institution. The 310 ECs were molecularly classified as follows: 15 (5%) POLE mutant (POLEmut), 79 (25%) mismatch repair-deficient (MMRd), 135 (44%) no specific molecular profile (NSMP), and 81 (26%) p53 abnormal (p53abnl). This work provides an initial framework for implementing routine molecular classification of ECs.
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Neoplasias Endometriales , Biomarcadores de Tumor/genética , Reparación de la Incompatibilidad de ADN , Neoplasias Endometriales/patología , Femenino , Genes p53 , Humanos , Inmunohistoquímica , Mutación , Estudios ProspectivosRESUMEN
The NCCN Guidelines for Uterine Neoplasms provide recommendations for diagnostic workup, clinical staging, and treatment options for patients with endometrial cancer or uterine sarcoma. These NCCN Guidelines Insights focus on the recent addition of molecular profiling information to aid in accurate diagnosis, classification, and treatment of uterine sarcomas.
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Neoplasias Endometriales , Sarcoma , Neoplasias Uterinas , Neoplasias Endometriales/diagnóstico , Neoplasias Endometriales/genética , Neoplasias Endometriales/terapia , Femenino , Humanos , Sarcoma/diagnóstico , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/genética , Neoplasias Uterinas/terapiaRESUMEN
BACKGROUND: Despite the favorable prognosis of early stage endometrial cancer, mortality from cardiovascular disease is high. We aimed to evaluate the efficacy of a Fitbit program to improve physical activity in endometrial cancer survivors. METHODS: Eligible patients were diagnosed with stage IA-IIIA endometrial adenocarcinoma, ≥3 months out from treatment. Participants received a Fitbit Alta and were randomized to receive communication via telephone or electronic methods (email/text). Communication was every two weeks for two months, then once during months four and five. Average daily steps were assessed weekly for nine months. RESULTS: The 46 analyzable patients demonstrated a baseline of 5641 median daily average steps. Average steps increased by 22% at 6 months but decreased to baseline by nine months. Baseline activity level (daily steps and walks per week) was the greatest predictor of activity level. Only the telephone intervention participants demonstrated increased activity level at several timepoints, although not maintained by nine months. BMI was unchanged. There was mild improvement in physical and social well-being in those with low baseline well-being (p = 0.009 and 0.014, respectively), regardless of intervention group. Emotional well-being correlated with step count (p = 0.005). CONCLUSIONS: Activity level was low and mildly improved on the Fitbit program with the telephone intervention, but effects did not persist by study completion. The program had the greatest impact on a select group of telephone intervention patients with high baseline walking frequency and low baseline step count. Others may require more intense intervention to promote more robust/persistent lifestyle changes.
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Carcinoma Endometrioide/rehabilitación , Neoplasias Endometriales/rehabilitación , Ejercicio Físico , Monitores de Ejercicio , Sistemas Recordatorios , Adulto , Anciano , Supervivientes de Cáncer , Carcinoma Endometrioide/terapia , Neoplasias Endometriales/terapia , Femenino , Humanos , Persona de Mediana Edad , Calidad de Vida , Envío de Mensajes de Texto , Caminata/fisiologíaRESUMEN
BACKGROUND: Brain metastases from endometrial cancer are rare and poorly described. We aimed to estimate the proportion of brain metastases at our institution that arose from endometrial cancer, and to detail clinicopathologic features and survival outcomes. METHODS: We retrospectively identified and reviewed the charts of 30 patients with brain metastases from endometrial cancer seen at Stanford Hospital from 2008 to 2018. RESULTS: Among all patients with brain metastases, the proportion arising from endometrial cancer was 0.84%. The median age at diagnosis was 62 years (range, 39-79 years), and the median overall survival from brain metastasis diagnosis was 6.8 months (range, 1.0-58.2 months). Most patients harbored endometrioid histology (53.3%), and some had concurrent metastases to lung (50.0%), bone (36.7%), and liver (20.0%). The median time from endometrial cancer diagnosis to brain metastasis development was 20.8 months (range, 1.4 months to 11.2 years), and the median number of brain metastases was 2 (range, 1-20). Patients with non-endometrioid histologies had more brain metastases than those with endometrioid histology (6.21 vs. 2.44, P = 0.029). There was no difference in overall survival by histology. CONCLUSIONS: We describe the largest cohort to date of patients with brain metastases originating from endometrial cancer. These patients represent a small fraction of all patients with brain metastases and have poor prognoses. These data enable providers caring for patients with brain metastases from endometrial cancer to appropriately counsel their patients.
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Neoplasias Encefálicas/secundario , Carcinoma Endometrioide/secundario , Carcinosarcoma/secundario , Neoplasias Endometriales/patología , Neoplasias Quísticas, Mucinosas y Serosas/secundario , Adulto , Anciano , Enfermedades Asintomáticas , Ataxia/fisiopatología , Neoplasias Óseas/secundario , Neoplasias Encefálicas/fisiopatología , Neoplasias Encefálicas/terapia , Carcinoma Endometrioide/fisiopatología , Carcinoma Endometrioide/terapia , Carcinosarcoma/fisiopatología , Carcinosarcoma/terapia , Enfermedades de los Nervios Craneales/fisiopatología , Femenino , Cefalea/fisiopatología , Humanos , Estado de Ejecución de Karnofsky , Neoplasias Hepáticas/secundario , Neoplasias Pulmonares/secundario , Metastasectomía , Persona de Mediana Edad , Debilidad Muscular/fisiopatología , Clasificación del Tumor , Neoplasias Quísticas, Mucinosas y Serosas/fisiopatología , Neoplasias Quísticas, Mucinosas y Serosas/terapia , Procedimientos Neuroquirúrgicos , Radiocirugia , Tasa de Supervivencia , Factores de TiempoRESUMEN
INTRODUCTION: Fifteen per cent of women with cervical cancer are diagnosed with advanced disease and carry a 5 year survival rate of only 17%. Cervical cancer may lead to particularly severe symptoms that interfere with quality of life, yet few studies have examined the rate of palliative care referral in this population. This study aims to examine the impact of palliative care referral on women who have died from cervical cancer in two tertiary care centers. METHODS: We conducted a retrospective review of cervical cancer decedents at two tertiary institutions from January 2000 to February 2017. We examined how aggressive measures of care at the end of life, metrics defined by the National Quality Forum, interacted with clinical variables to understand if end-of-life care was affected. Univariate and multivariate parametric and non-parametric testing was used, and linear regression models were generated to determine unadjusted and adjusted associations between aggressive measures of care at the end of life with receipt of palliative care as the main exposure. RESULTS: Of 153 cervical cancer decedents, 73 (47%) received a palliative care referral and the majority (57%) of referrals occurred during an inpatient admission. The median time from palliative care consultation to death was 2.3 months and 34% were referred to palliative care in the last 30 days of life. Palliative care referral was associated with fewer emergency department visits (OR 0.18, 95% CI 0.05 to 0.56), inpatient stays (OR 0.21, 95% CI 0.07 to 0.61), and intensive care unit admissions (OR 0.24, 95% CI 0.06 to 0.93) in the last 30 days of life. Palliative care did not affect chemotherapy or radiation administration within 14 days of death (p=0.36). Women evaluated by palliative care providers were less likely to die in the acute care setting (OR 0.19, 95% CI 0.07 to 0.51). DISCUSSION: In two tertiary care centers, less than half of cervical cancer decedents received palliative care consultations, and those referred to palliative care were often evaluated late in their disease course. Palliative care utilization was also associated with a lower incidence of poor-quality end-of-life care.
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Cuidados Paliativos/estadística & datos numéricos , Calidad de Vida , Derivación y Consulta/estadística & datos numéricos , Neoplasias del Cuello Uterino/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Estimación de Kaplan-Meier , Oncología Médica/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Cuidado Terminal/métodos , Factores de Tiempo , Neoplasias del Cuello Uterino/mortalidadRESUMEN
OBJECTIVE: Gestational trophoblastic neoplasia are a group of diseases with few data given their rarity. The aim of this study was to determine the age and racial differences in the presentation and survival of patients with gestational trophoblastic neoplasia in the United States. METHODS: Data were collected from the National Cancer Database from January 2004 to December 2014. Chi-square tests, Cox regression, and Kaplan-Meier models were performed. Demographic characteristics included age at diagnosis, race, insurance status, facility location and type, community median income, high school dropout rate, education, income, and population density data. RESULTS: There were 1004 eligible patients including 64% white (n=645), 23% black (n=233), and 8.3% Asian patients (n=83). Median age was 30.8 (range 14-59) years. Stage I, II, III, IV, and unknown were diagnosed in 32%, 5.4%, 30%, 18%, and 15% of patients, respectively, with 5-year survival of 99%, 93%, 94%, 72%, and 95%, respectively (p<0.001). Compared with national birth rates, those with gestational trophoblastic neoplasia were overrepresented at younger (age 10-19 years: 8.2% vs 4.8%) and older ages (age 40-54 years: 17% vs 3.3%). The extremes of age at presentation were more pronounced in black patients with gestational trophoblastic neoplasia (age 10-19 years: 11% vs 6.9%, 40-54 years: 18% vs 3.2%), and black patients constituted 23% of patients compared with 15% of births nationwide. Some 59% of patients were treated at Academic/Research Programs. Only 6/448 (1.3%) facilities treated more than one patient per year, and only 9% (n=92) of patients were treated at one of these high-volume facilities. On multivariable analysis, older age, higher Charlson/Deyo co-morbidity score, and higher stage disease were independently associated with worse survival (all p<0.001). CONCLUSIONS: Gestational trophoblastic neoplasia was disproportionately higher in those at extremes of age and in black women as compared with United States national data. The lack of centralization of care justifies the need to develop regional centers of excellence for this rare malignancy.
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Enfermedad Trofoblástica Gestacional/etnología , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Niño , Bases de Datos Factuales , Supervivencia sin Enfermedad , Femenino , Enfermedad Trofoblástica Gestacional/tratamiento farmacológico , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Embarazo , Modelos de Riesgos Proporcionales , Factores Raciales , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: To determine the long-term potential benefit of adjuvant chemotherapy in subgroups of high-risk stage I mucinous ovarian cancer patients using a predictive scoring algorithm. METHODS: Data were collected from the National Cancer Database from 2004 to 2014. Based on demographic and surgical characteristics, a novel 10-year survival prognostic scoring system was developed using Cox regression. RESULTS: There were 2041 eligible patients with stage I mucinous ovarian cancer including 1362 (67%) with stage IA/IB disease, 598 (29%) with stage IC disease, and 81 (4%) with stage I disease not otherwise specified. Median age was 52 with a range of 13-90 years old. 737 (36%) patients were treated with adjuvant chemotherapy. Adjuvant chemotherapy was more common in patients with stage IC relative to stage IA/IB disease (69% vs. 21%, P < 0.001) or with poorly-differentiated relative to well-differentiated tumors (69% vs. 23%, P < 0.001). Unadjusted 10-year survival was 81% relative to 79% for patients treated with vs. without chemotherapy, respectively (P = 0.46). Patients were predicted to exhibit a low- or a high-risk of death using a multivariate Cox regression model with age, stage, grade, lymphovascular space invasion and ascites. Risk of death without vs. with adjuvant chemotherapy was similar in low-risk patients (88% vs. 84%; HR = 0.80, 95%CI = 0.56-1.15, P = 0.23) and worse in high-risk patients (51% vs. 74%; HR = 1.58, 95%CI: 1.05-2.38, P = 0.03) with stage I mucinous ovarian cancer. CONCLUSIONS: A predictive scoring algorithm may provide prognostic information on long-term survival and identify high-risk stage I mucinous ovarian cancer patients who might achieve a survival benefit from adjuvant chemotherapy.
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Adenocarcinoma Mucinoso/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Técnicas de Apoyo para la Decisión , Nomogramas , Neoplasias Ováricas/terapia , Adenocarcinoma Mucinoso/diagnóstico , Adenocarcinoma Mucinoso/mortalidad , Adenocarcinoma Mucinoso/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Quimioterapia Adyuvante/estadística & datos numéricos , Toma de Decisiones Clínicas/métodos , Femenino , Humanos , Histerectomía/estadística & datos numéricos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Ováricas/diagnóstico , Neoplasias Ováricas/mortalidad , Neoplasias Ováricas/patología , Ovario/patología , Ovario/cirugía , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo/estadística & datos numéricos , Salpingooforectomía/estadística & datos numéricos , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: Vulvar cancers account for 5% of all gynecologic malignancies; only 1%-3% of those vulvar cancers are primary vulvar sarcomas. Given the rarity of vulvar sarcomas, outcome data specific to histopathologic subtypes are sparse. The aim of this study was to identify clinical and pathologic factors of primary vulvar sarcomas that are associated with survival and may inform treatment decisions. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was searched for women diagnosed with vulvar sarcoma between 1973 and 2018. We identified 315 patients and reviewed their demographic, clinicopathologic, surgical, and survival information. Statistical analyses included χ2 and t-tests, Kaplan-Meier survival, and Cox regression analyses. RESULTS: The most common histopathologies of vulvar sarcomas were dermatofibrosarcomas (85/315, 27%) and leiomyosarcomas (72/315, 22.9%). Rhabdomyosarcomas (18/315, 5.7%), liposarcomas (16/315, 5.1%), and malignant fibrous histiocytomas (16/315, 5.1%) were less frequent. The majority of patients underwent surgery (292/315, 92.7%), which included lymph node dissections in 21.6% (63/292). Survival and lymph node involvement varied significantly with histologic subtype. The 5-year disease-specific survival for dermatofibrosarcomas, liposarcomas, and fibrosarcomas was 100% and only 60.3% and 62.5% for malignant fibrous histiocytomas and rhabdomyosarcomas, respectively. None of the patients with (dermato)fibrosarcomas, liposarcomas, or leiomyosarcomas had positive lymph nodes, in contrast to rhabdomyosarcomas and malignant fibrous histiocytomas with 77.8% and 40% positive lymph nodes, respectively. The 5-year disease-specific survival for women with positive lymph nodes was 0%. CONCLUSIONS: Vulvar sarcomas are heterogeneous with survival highly dependent on the histopathologic subtype. While surgical excision is the mainstay of treatment for all vulvar sarcomas, staging lymphadenectomy should be deferred for (dermato)fibrosarcomas, liposarcomas, and leiomyosarcomas as there were no cases of lymph nodes metastases.
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Sarcoma/mortalidad , Sarcoma/secundario , Neoplasias de la Vulva/mortalidad , Neoplasias de la Vulva/patología , Antineoplásicos/uso terapéutico , Dermatofibrosarcoma/mortalidad , Dermatofibrosarcoma/secundario , Femenino , Histiocitoma Fibroso Maligno/mortalidad , Histiocitoma Fibroso Maligno/secundario , Humanos , Estimación de Kaplan-Meier , Leiomiosarcoma/mortalidad , Leiomiosarcoma/secundario , Liposarcoma/mortalidad , Liposarcoma/secundario , Escisión del Ganglio Linfático , Metástasis Linfática , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Radioterapia , Rabdomiosarcoma/mortalidad , Rabdomiosarcoma/secundario , Programa de VERF , Sarcoma/terapia , Tasa de Supervivencia , Estados Unidos/epidemiología , Neoplasias de la Vulva/terapia , VulvectomíaRESUMEN
STUDY OBJECTIVE: To evaluate practice patterns among gynecologic oncologists with regard to sentinel lymph node injection and biopsy in endometrial cancer. DESIGN: An observational study with no control group. SETTING AND PATIENTS: Active members of the Society of Gynecologic Oncology. INTERVENTIONS: After institutional review board approval, we performed an online survey among active members of the Society of Gynecologic Oncology. Members were contacted via e-mail and their answers anonymously captured. Study data were collected using REDCap (REDCap developed by Vanderbilt University, Nashville TN). MEASUREMENTS AND MAIN RESULTS: Three hundred eighteen of 1216 listed members completed the online survey. The majority of respondents (82.7%) perform sentinel lymph node sampling for endometrial cancer staging. Most technical aspects of sentinel lymph node sampling were consistently applied by the vast majority of respondents, including the choice of indocyanine green as a lymphatic tracer (97.3%) and its injection into the cervix (100%). Other technical aspects of sentinel lymph node sampling, such as the depth of injection, varied among respondents. Although 50.9% of the respondents perform an intraoperative assessment of the uterus by frozen section, only 17.9% assess sentinel lymph nodes by frozen section and/or touch prep. Some of the respondents' approaches are based on limited data, including (1) the use of sentinel lymph node injection and biopsy for high-risk histologies (performed by 69%-75% of the respondents dependent on the histology), (2) omitting side-specific completion lymphadenectomy in the absence of sentinel node mapping (in up to 57.8%), or (3) when lymph node metastases are present (in 39.9%). CONCLUSION: In summary, despite the growing use of sentinel lymph node injection and biopsy in endometrial cancer, practice patterns vary considerably among providers sampled by this survey. Some of the decisions are based on limited evidence and, in some instances, deviate from current published guidelines.
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Adenocarcinoma/patología , Neoplasias Endometriales/patología , Ginecología/estadística & datos numéricos , Oncólogos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Biopsia del Ganglio Linfático Centinela/estadística & datos numéricos , Adenocarcinoma/epidemiología , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Endometriales/epidemiología , Neoplasias Endometriales/cirugía , Femenino , Humanos , Periodo Intraoperatorio , Escisión del Ganglio Linfático/estadística & datos numéricos , Metástasis Linfática , Persona de Mediana Edad , Estadificación de Neoplasias , Ganglio Linfático Centinela/patología , Biopsia del Ganglio Linfático Centinela/métodos , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: This study aims to understand the treatment patterns and clinical outcomes of older women with cervical cancer compared to younger women. METHODS: Women undergoing care for cervical cancer between 2000 and 2013 at two academic institutions were identified. The cohort of older patients was defined as >65â¯years old at diagnosis. Patient charts were retrospectively reviewed, and clinical variables were extracted. Fisher's exact tests, logistic regression, and Kaplan-Meier analyses were performed. RESULTS: From 2000 to 2013 1119 women with cervical cancer were identified. Of these, 191 (17.0%) were >65â¯years old at the time of diagnosis. Older women were more likely to present with higher stage disease (pâ¯<â¯0.001). Controlling for stage, older women were less likely to undergo surgery during their treatment course (38% versus 70%, pâ¯<â¯0.001) and more likely to undergo radiation (77% versus 52%, pâ¯<â¯0.001), but no more likely to receive chemotherapy (pâ¯=â¯0.34). If they did undergo surgery, older women were less likely to have a pelvic lymph node dissection performed (41% versus 61%, pâ¯=â¯0.04), though the rate of positive pelvic lymph nodes was not different (pâ¯=â¯0.80). Overall survival was decreased in the older cohort (pâ¯<â¯0.001). A multivariate model identified ageâ¯>â¯65 (HR 1.76, 95%CI 1.30-2.40), stage (HR 2.77, 95%CI 2.40-3.21), and ever undergoing surgery (HR 0.60, 95%CI 0.44-0.82) as independently associated with overall survival. CONCLUSIONS: Women over age 65 with cervical cancer are less likely to undergo surgical management and were observed to have a decreased overall survival, even when controlling for use of surgery and stage of disease.
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Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Neoplasias del Cuello Uterino/terapia , Adenocarcinoma/mortalidad , Factores de Edad , Anciano , Carcinoma de Células Escamosas/mortalidad , Toma de Decisiones Clínicas , Femenino , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Neoplasias del Cuello Uterino/mortalidadRESUMEN
BACKGROUND: The American Society of Clinical Oncology recommends that patients with advanced cancer receive dedicated palliative care services early in their disease course. This investigation serves to understand how palliative care services are utilized for ovarian cancer patients in a tertiary referral center. METHODS: We conducted a retrospective review of women treated for ovarian cancer at our institution from 2010 through 2015. Clinical variables included presence and timing of palliative care referral. Data were correlated utilizing univariable and multivariable parametric and non-parametric testing, and survivals were analyzed using the Kaplan-Meier method and cox-proportional hazard models. RESULTS: We identified 391 women treated for ovarian cancer, of whom 68% were diagnosed with stage III or IV disease. Palliative care referral was utilized in 28% in the outpatient (42%) and inpatient (58%) settings. Earlier use of referral was observed in those who never underwent surgical cytoreduction or had interval cytoreductive surgery (pâ¯<â¯0.001). Palliative care referral was independently associated with advanced stage (OR 1.7, pâ¯=â¯0.02), recurrence (OR 2.0, pâ¯=â¯0.002) and hospice referral (OR 6.0, pâ¯<â¯0.001). In 38% of women referral occurred within 30â¯days of death, and 17% within one week of death. Outpatient initial consultation was associated with an unadjusted 1â¯year overall survival benefit (pâ¯<â¯0.01) compared to inpatient consultation. CONCLUSIONS: The outcomes in this study suggest a late use of palliative care that is reactionary to patient needs and not a routine component of ovarian cancer care as national guidelines recommend.
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Adenocarcinoma/terapia , Carcinosarcoma/terapia , Neoplasias Quísticas, Mucinosas y Serosas/terapia , Neoplasias de Células Germinales y Embrionarias/terapia , Neoplasias Ováricas/terapia , Cuidados Paliativos , Derivación y Consulta/estadística & datos numéricos , Tumores de los Cordones Sexuales y Estroma de las Gónadas/terapia , Adenocarcinoma/patología , Adenocarcinoma de Células Claras/patología , Adenocarcinoma de Células Claras/terapia , Adenocarcinoma Mucinoso/patología , Adenocarcinoma Mucinoso/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Carcinoma Endometrioide/patología , Carcinoma Endometrioide/terapia , Carcinosarcoma/patología , Procedimientos Quirúrgicos de Citorreducción/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Neoplasias Quísticas, Mucinosas y Serosas/patología , Neoplasias de Células Germinales y Embrionarias/patología , Oportunidad Relativa , Neoplasias Ováricas/patología , Pronóstico , Modelos de Riesgos Proporcionales , Calidad de Vida , Estudios Retrospectivos , Tumores de los Cordones Sexuales y Estroma de las Gónadas/patología , Tasa de Supervivencia , Factores de Tiempo , Adulto JovenRESUMEN
PURPOSE: To identify clinical and non-clinical factors associated with utilization of primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) in women with advanced stage epithelial ovarian cancer (EOC). METHODS: Using the National Cancer Database, we identified women with stage IIIC and IV EOC diagnosed from 2012 to 2014. The primary outcome was receipt of NACT, defined in the primary analysis as utilization of chemotherapy as the first cancer-directed therapy, irrespective of whether interval surgery was performed. Univariable and multivariable associations between clinical and non-clinical factors and receipt of NACT were investigated using mixed-effect logistic regression models. A secondary analysis excluded women who received primary chemotherapy but did not receive interval cytoreductive surgery. RESULTS: Among 17,302 eligible women, 10,948 (63.3%) underwent PCS and 6354 (36.7%) received NACT. Older age, stage IV disease, high-grade, and serous histology were associated with receipt of NACT in univariate (p<0.001) and multivariable analyses (p<0.001). Analysis of non-clinical factors revealed that residency in the Northeast region and receipt of treatment closer to home were associated with NACT in univariate (p<0.05) but not multivariable analysis (p>0.05). In multivariable analysis, African-American race/ethnicity (p=0.04), low-income level (p=0.02), treatment in high-volume centers (p<0.01), and insurance by Medicare or other government insurance (p<0.001) were associated with receipt of NACT. When women who received no surgery were excluded, all factors that were independent predictors of NACT in the main analysis remained significant, except for race/ethnicity. CONCLUSIONS: Non-clinical factors were associated with the use of NACT at a magnitude similar to that of clinically relevant factors.