Ultrasound features using MUSA terms and definitions in uterine sarcoma and leiomyoma: cohort study.

OBJECTIVES: Timely and accurate preoperative diagnosis of uterine sarcoma will increase patient survival. The primary aim of this study was to describe the ultrasound features of uterine sarcoma compared with those of uterine leiomyoma based on the terms and definitions of the Morphological Uterus Sonographic Assessment (MUSA) group. A secondary aim was to assess the interobserver agreement for reporting on ultrasound features according to MUSA terminology. METHODS: This was a retrospective cohort study of patients with uterine sarcoma or uterine leiomyoma treated in a single tertiary center during the periods 1997-2019 and 2016-2019, respectively. Demographic characteristics, presenting symptoms and surgical outcomes were extracted from patients' files. Ultrasound images were re-evaluated independently by two sonologists using MUSA terms and definitions. Descriptive statistics were calculated and interobserver agreement was assessed using Cohen's κ (with squared weights) or intraclass correlation coefficient, as appropriate. RESULTS: A total of 107 patients were included, of whom 16 had a uterine sarcoma and 91 had a uterine leiomyoma. Abnormal uterine bleeding was the most frequent presenting symptom (69/107 (64%)). Compared with leiomyoma cases, patients with uterine sarcoma were older (median age, 65 (interquartile range (IQR), 60-70) years vs 48 (IQR, 43-52) years) and more likely to be postmenopausal (13/16 (81%) vs 15/91 (16%)). In the uterine sarcoma cohort, leiomyosarcoma was the most frequent histological type (6/16 (38%)), followed by adenosarcoma (4/16 (25%)). On ultrasound evaluation, according to Observers 1 and 2, the tumor border was irregular in most sarcomas (11/16 (69%) and 13/16 (81%) cases, respectively), but regular in most leiomyomas (65/91 (71%) and 82/91 (90%) cases, respectively). Lesion echogenicity was classified as non-uniform in 68/91 (75%) and 51/91 (56%) leiomyomas by Observers 1 and 2, respectively, and 15/16 (94%) uterine sarcomas by both observers. More than 60% of the uterine sarcomas showed acoustic shadows (11/16 (69%) and 10/16 (63%) cases by Observers 1 and 2, respectively), whereas calcifications were reported in a small minority (0/16 (0%) and 2/16 (13%) cases by Observers 1 and 2, respectively). In uterine sarcomas, intralesional vascularity was reported as moderate to abundant in 13/16 (81%) cases by Observer 1 and 15/16 (94%) cases by Observer 2, while circumferential vascularity was scored as moderate to abundant in 6/16 (38%) by both observers. Interobserver agreement for the presence of cystic areas, calcifications, acoustic shadow, central necrosis, color score (overall, intralesional and circumferential) and maximum diameter of the lesion was moderate. The agreement for shape of lesion, tumor border and echogenicity was fair. CONCLUSIONS: A postmenopausal patient presenting with abnormal uterine bleeding and a new or growing mesenchymal mass with irregular tumor borders, moderate-to-abundant intralesional vascularity, cystic areas and an absence of calcifications on ultrasonography is at a higher risk of having a uterine sarcoma. Interobserver agreement for most MUSA terms and definitions is moderate. Future studies should validate the abovementioned clinical and ultrasound findings on uterine mesenchymal tumors in a prospective multicenter fashion. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Benign descriptors and ADNEX in two-step strategy to estimate risk of malignancy in ovarian tumors: retrospective validation in IOTA5 multicenter cohort.

OBJECTIVE: Previous work has suggested that the ultrasound-based benign simple descriptors (BDs) can reliably exclude malignancy in a large proportion of women presenting with an adnexal mass. This study aimed to validate a modified version of the BDs and to validate a two-step strategy to estimate the risk of malignancy, in which the modified BDs are followed by the Assessment of Different NEoplasias in the adneXa (ADNEX) model if modified BDs do not apply. METHODS: This was a retrospective analysis using data from the 2-year interim analysis of the International Ovarian Tumor Analysis (IOTA) Phase-5 study, in which consecutive patients with at least one adnexal mass were recruited irrespective of subsequent management (conservative or surgery). The main outcome was classification of tumors as benign or malignant, based on histology or on clinical and ultrasound information during 1 year of follow-up. Multiple imputation was used when outcome based on follow-up was uncertain according to predefined criteria. RESULTS: A total of 8519 patients were recruited at 36 centers between 2012 and 2015. We excluded patients who were already in follow-up at recruitment and all patients from 19 centers that did not fulfil our criteria for good-quality surgical and follow-up data, leaving 4905 patients across 17 centers for statistical analysis. Overall, 3441 (70%) tumors were benign, 978 (20%) malignant and 486 (10%) uncertain. The modified BDs were applicable in 1798/4905 (37%) tumors, of which 1786 (99.3%) were benign. The two-step strategy based on ADNEX without CA125 had an area under the receiver-operating-characteristics curve (AUC) of 0.94 (95% CI, 0.92-0.96). The risk of malignancy was slightly underestimated, but calibration varied between centers. A sensitivity analysis in which we expanded the definition of uncertain outcome resulted in 1419 (29%) tumors with uncertain outcome and an AUC of the two-step strategy without CA125 of 0.93 (95% CI, 0.91-0.95). CONCLUSION: A large proportion of adnexal masses can be classified as benign by the modified BDs. For the remaining masses, the ADNEX model can be used to estimate the risk of malignancy. This two-step strategy is convenient for clinical use. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of protein biomarkers for preoperative differential diagnosis between benign and malignant ovarian tumors.

OBJECTIVE: To estimate the diagnostic value of tumor and immune related proteins in the discrimination between benign and malignant adnexal masses, and between different subgroups of tumors. METHODS: In this exploratory diagnostic study, 254 patients with an adnexal mass scheduled for surgery were consecutively enrolled at the University Hospitals Leuven (128 benign, 42 borderline, 22 stage I, 55 stage II-IV, and 7 secondary metastatic tumors). The quantification of 33 serum proteins was done preoperatively, using multiplex high throughput immunoassays (Luminex) and electrochemiluminescence immuno-assay (ECLIA). We calculated univariable areas under the Receiver Operating Characteristic Curves (AUCs). To discriminate malignant from benign tumors, multivariable ridge logistic regression with backward elimination was performed, using bootstrapping to validate the resulting AUCs. RESULTS: CA125 had the highest univariable AUC to discriminate malignant from benign tumors (0.85, 95% confidence interval 0.79-0.89). Combining CA125 with CA72.4 and HE4 increased the AUC to 0.87. For benign vs borderline tumors, CA125 had the highest univariable AUC (0.74). For borderline vs stage I malignancy, no proteins were promising. For stage I vs II-IV malignancy, CA125, HE4, CA72.4, CA15.3 and LAP had univariable AUCs ≥0.80. CONCLUSIONS: The results confirm the dominant role of CA125 for identifying malignancy, and suggest that other markers (HE4, CA72.4, CA15.3 and LAP) may help to distinguish between stage I and stage II-IV malignancies. However, further research is needed, also to investigate the added value over clinical and ultrasound predictors of malignancy, focusing on the differentiation between subtypes of malignancy.

Increased Immunosuppression Is Related to Increased Amounts of Ascites and Inferior Prognosis in Ovarian Cancer.

BACKGROUND/AIM: The presence of ascites in ovarian cancer patients is considered a negative prognostic factor. The underlying mechanisms are not clearly understood. MATERIALS AND METHODS: The amount of ascites was evaluated, preferably, using diffusion-weighted MRI at primary diagnosis in a retrospective cohort of 214 women with ovarian cancer, in an ordinal manner (amount of ascites: none, limited, moderate, abundant). In a prospective cohort comprising 45 women with ovarian cancer, IL-10 (interleukin), VEGF (vascular endothelial growth factor), TGF-ß (transforming growth factor) and CCL-2 [chemokine (C-C) motif ligand 2] were measured at diagnosis (and at interval debulking, when available). RESULTS: Gradually increasing amounts of ascites were correlated significantly, even after correction for FIGO stage, with reduced survival (p<0.0001) and stronger immunosuppression (IL10 and VEGF). Neoadjuvant chemotherapy reduced immunosuppression, which was observed as a reduction in CCL-2, IL-10 and VEGF. CONCLUSION: The amount of ascites is an independent predictor of survival and correlates with increased immunosuppression.

Circulating Protein Biomarkers to Differentiate Uterine Sarcomas from Leiomyomas.

Uterine sarcomas are rare but very aggressive. Uterine myomas, on the other hand, are the most common benign tumors of the uterus. Currently there is no diagnostic technique available to distinguish them with certainty. This study aimed to summarize the published literature concerning protein-based biomarkers in the peripheral blood that can assist in this difficult differential diagnosis. In total, 48 articles, published between 1990 and 2017, were included. Most studies (n=37) concerned soft tissue sarcomas, while 11 discussed uterine sarcomas specifically. Vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), interleukins (IL), cancer antigen 125 (CA 125), lactate dehydrogenase, gangliosides (LDH) and growth differentiation factor 15 (GDF-15) are the most studied proteins in soft tissue sarcomas, including uterine sarcomas. Future research on improving sarcoma diagnosis should include these proteins.

Combining conventional therapy with immunotherapy: A risky business?

Because of the failure of immunotherapy as single agent in a number of cancers, current clinical trials are focusing on combining immunotherapy with other therapies. The most frequently chosen combination for immunotherapy is chemotherapy. However, almost no preclinical data on this combination is available. Some studies even showed a dismal effect of combining chemotherapy with immunotherapy. Taken into account that each of the therapies chosen in a combination will influence the cancer cells but also immune effector cells as well as immunosuppressive cells, and that these three partners will also interact with each other, launching a combination to the patient without proper immune monitoring and preclinical evidence might be devastating.

Differences in ultrasound features of papillations in unilocular-solid adnexal cysts: a retrospective international multicenter study.

OBJECTIVES: To identify ultrasound features of papillations or of the cyst wall that can discriminate between benign and malignant unilocular-solid cysts with papillations but no other solid components. METHODS: From the International Ovarian Tumor Analysis (IOTA) database derived from seven ultrasound centers, we identified patients with an adnexal lesion described at ultrasonography as unilocular-solid with papillations but no other solid components. All patients had undergone transvaginal ultrasound between 1999 and 2007 or 2009 and 2012, by an experienced examiner following the IOTA research protocol. Information on four ultrasound features of papillations had been collected prospectively. Information on a further seven ultrasound features was collected retrospectively from electronic or paper ultrasound images of good quality. The histological diagnosis of the surgically removed adnexal lesion was considered the gold standard. RESULTS: Of 204 masses included, 131 (64.2%) were benign, 42 (20.6%) were borderline tumors, 30 (14.7%) were primary invasive tumors and one (0.5%) was a metastasis. Multivariate logistic regression analysis showed the following ultrasound features to be associated independently with malignancy: height of the largest papillation, presence of blood flow in papillations, papillation confluence or dissemination, and shadows behind papillations. Shadows decreased the odds of malignancy, while the other features increased them. CONCLUSION: We have identified ultrasound features that can help to discriminate between benign and malignant unilocular-solid cysts with papillations but no other solid components. Our results need to be confirmed in prospective studies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

The Use of Toll-like Receptor 4 Agonist to Reshape the Immune Signature in Ovarian Cancer.

BACKGROUND: Dendritic cell (DC) mono-immunotherapy has not been successful so far in ovarian cancer. The addition of a toll-like receptor (TLR) agonist has the potential to boost the innate immune system, in addition to the adoptive immune response initiated by DCs. MATERIALS AND METHODS: ID8-fLuc C57BL/6 mice were injected with DCs loaded with hypericin-based photodynamic therapy-treated tumor lysate. A TLR4 agonist [lipopolysaccharide (LPS)] was administered by different schedules). After two and three DC vaccinations, immune analysis was performed. RESULTS: There was no survival benefit from therapy with TLR4 agonist. Moreover, if LPS administrations started one week after tumor inoculation, the overall survival was even worse than that of untreated controls. Immune analyses revealed an intratumoral increase in natural killer cells and a decrease in regulatory T-cells, but an immunosuppressive signature in the ascites. CONCLUSION: Addition of LPS as an adjuvant to DC immunotherapy of ovarian cancer does not result in survival benefit.

In Vitro Generation of Murine Dendritic Cells for Cancer Immunotherapy: An Optimized Protocol.

BACKGROUND/AIM: Dendritic cell (DC) immunotherapy induces tumor-reactive T-cells. We optimized the maturation of murine DC against ovarian cancer. MATERIALS AND METHODS: Immature DC were generated from bone-marrow progenitor cells and loaded with hypericin-photodynamic-treated (Hyp-PDT) tumor cells (primary maturation). Lipopolysacharide (LPS 1 µg/ml) was used as a secondary maturation stimulus. After 24 h, maturation was assessed using flow cytometry. For in vivo experiments, C57BL/6 mice were vaccinated subcutaneously with matured, loaded mature DC. Immune response was evaluated through immunohistochemistry and cytometric bead array. RESULTS: Based on the existing protocols for DC generation, therapeutic vaccination of tumor-bearing mice with mature ID8-fLuc Hyp-PDT DC induces an immunogenic response, but provides no survival benefit. As loading with Hyp-PDT lysate induces partial primary maturation, we reduced the dose of LPS to 0.125 µg/ml and the duration of maturation to 6 hours, improving viability of mature DC. CONCLUSION: We optimized Hyp-PDT-based ID8-fLuc DC vaccine by reducing the amount of LPS and the duration of maturation.

Ovarian cancer in children and adolescents: A rare disease that needs more attention.

Ovarian cancer is rare in childhood. This explains why there are only scattered reports on it in the literature and why there is a lack of specific pediatric treatment. This paper gives an overview of the Belgian data from 2004 to 2013 and reviews the literature. To index ovarian masses and malignancies in children better in the future, worldwide data collection should be improved and reproducible definitions of 'childhood', 'malignancy' and 'ovarian mass' need to be adopted.

Immunological parameters as a new lead in the diagnosis of ovarian cancer.

Ovarian cancer is the leading cause of pelvic gynecological cancer death in Europe. Prognosis is poor in women diagnosed at stage III to IV or in case disease recurs. Platin-based chemotherapy and radical surgery have already improved prognosis significantly. Novel strategies in the treatment of ovarian cancer are being searched for. The study of the immune system as a valuable parameter in the development of ovarian cancer has been neglected for a long time. Nevertheless, this is a field in full progression and might open new perspectives in the diagnosis and prognosis of ovarian cancer patients and could lead to a more motivated choice of targeted therapies.

A view on dendritic cell immunotherapy in ovarian cancer: how far have we come?

Ovarian cancer is the second most important pelvic gynaecologic malignancy and nowadays still kills 80% of patients. New treatment options are mandatory. Although it has been shown that ovarian cancer is an immunogenic tumor, the possibility of developing immunotherapy has been neglected for a long time. This article focuses on the importance of the immune system in the development and progression of cancer and the possibilities and problems of dendritic cell-based immunotherapy to influence the immune system.

Wilms' tumor gene 1 immunotherapy in pelvic gynecological malignancies.

Pelvic gynecological malignancies account for 6% of all cancers. In the relapsed state, classical treatments are limited. There is an urgent need for new and personalized treatment. Wilms' tumor gene 1 (WT1) is the most important tumor-associated antigen. Although highly present in gynecological tumors, active immunotherapy against it is still underexplored. This review gives an insight into the importance of WT1 in pelvic gynecological malignancies and the first taken steps into the world of WT1 immunotherapy.

Wilms' Tumour gene 1 (WT1) as an immunotherapeutic target.

High grade uterine sarcoma and recurrent endometrial carcinoma are aggressive cancers with limited treatment options, resulting in a poor prognosis. In this research we focused in the first place on the detection of a highly immunogenic tumour-associated antigen Wilms' tumour gene 1 (WT1) in uterine tumours. We were able to reveal its overexpression in the tumour cells of high grade sarcomas and carcinosarcomas . Moreover, patients with WT1 positive tumours had a significantly worse prognosis than patients who were WT1 negative. For carcinomas, WT1 was present in only a minority of tumour cells, but in the majority of intratumoural blood vessels. Small blood vessels in the normal tissue surrounding the carcinoma were also WT1 positive, suggesting a role for WT1 in angiogenesis. WT1 was hardly expressed or absent in the non-tumour or benign tumoural uterus (myoma, polyp). The next step was to develop a targeted treatment against WT1. We opted for dendritic cell (DC) based immunotherapy. Nevertheless a basal expression of WT1 in monocytes and in vitro cultured unloaded DC was observed, the electroporation of in vitro cultured DC with WT1-mRNA resulted in a higher expression of WT1 by the DC. WT1-mRNA loaded DC were used for in vivo stimulations of T cells, resulting in the rise of WT1-specific T cells and a transient molecular response (decrease of CA125) in an end stage endometrial carcinoma patient. No toxic side effects were reported. Future in vivo research, carried out in a phase I clinical trial in our center, will reveal the ability of this new therapy to induce an immunological and possible clinical response in WT1 positive uterine cancer patients.

Upregulation of Wilms' tumour gene 1 (WT1) in uterine sarcomas.

AIM: Overexpression of Wilms' tumour gene (WT1) has been proven in several tumours. Previous research of our group on the cell cycle of uterine leiomyosarcoma (LMS) and carcinosarcoma (CS) suggested a possible role for WT1. We therefore intended to further explore the expression pattern of WT1 in uterine sarcomas. METHODS: 27 CS, 38 LMS, 15 endometrial stromal sarcomas (ESS) and seven undifferentiated sarcomas (US) were collected. WT1 expression was evaluated by immunohistochemistry (IHC) in 87 samples, by RT-PCR (m-RNA expression) in 23 random selected samples and by Western blotting in 12 samples, separating cytoplasmic and nuclear proteins. A pilot study to detect mutations (exons 7-10) was performed on eight samples. RESULTS: IHC showed WT1 positivity in 12/27 CS, 29/38 LMS, 7/15 ESS and 4/7 US. All-but-one sample had a positive RT-PCR. All Western blottings were positive with more cytoplasmic expression in 9/12 cases. No mutations were found. CONCLUSIONS: WT1 is overexpressed in uterine sarcomas. Since increased levels of mRNA determine the biological role, WT1 might contribute to uterine sarcoma tumour biology.