Lynda Roman

OvaPrint—A Cell-free DNA Methylation Liquid Biopsy for the Risk Assessment of High-grade Serous Ovarian Cancer

Abstract Purpose: High-grade serous ovarian carcinoma (HGSOC) is the most lethal epithelial ovarian cancer (EOC) and is often diagnosed at late stage. In women with a known pelvic mass, surgery followed by pathologic assessment is the most reliable way to diagnose EOC and there are still no effective screening tools in asymptomatic women. In the current study, we developed a cell-free DNA (cfDNA) methylation liquid biopsy for the risk assessment of early-stage HGSOC. Experimental Design: We performed reduced representation bisulfite sequencing to identify differentially methylated regions (DMR) between HGSOC and normal ovarian and fallopian tube tissue. Next, we performed hybridization probe capture for 1,677 DMRs and constructed a classifier (OvaPrint) on an independent set of cfDNA samples to discriminate HGSOC from benign masses. We also analyzed a series of non-HGSOC EOC, including low-grade and borderline samples to assess the generalizability of OvaPrint. A total of 372 samples (tissue n = 59, plasma n = 313) were analyzed in this study. Results: OvaPrint achieved a positive predictive value of 95% and a negative predictive value of 88% for discriminating HGSOC from benign masses, surpassing other commercial tests. OvaPrint was less sensitive for non-HGSOC EOC, albeit it may have potential utility for identifying low-grade and borderline tumors with higher malignant potential. Conclusions: OvaPrint is a highly sensitive and specific test that can be used for the risk assessment of HGSOC in symptomatic women. Prospective studies are warranted to validate OvaPrint for HGSOC and further develop it for non-HGSOC EOC histotypes in both symptomatic and asymptomatic women with adnexal masses.

Clinical and pathological characteristics and outcomes of small cell neuroendocrine carcinoma of the uterine cervix

To describe the clinical and pathological characteristics and outcomes of small cell neuroendocrine carcinoma of the uterine cervix at the population level in the United States. The National Cancer Institute's Surveillance, Epidemiology, and End Results Program was retrospectively queried. The study population included 54,987 patients with cervical cancer from 2004 to 2021. Descriptive analysis was performed based on histology. Histology types included squamous cell carcinoma (n = 38,145, 69.4%), adenocarcinoma (n = 14,333, 26.1%), adenosquamous carcinoma (n = 1,970, 3.6%), and small cell neuroendocrine carcinoma (n = 539, 1.0%). Over the 18-year study period, the incidence rate of small cell neuroendocrine carcinoma increased by 3.2% per year (95% CI 1.2 to 5.7, p = .003). Based on this trajectory, the incidence of small cell neuroendocrine carcinoma is estimated to reach 2.0% by 2035. Small cell neuroendocrine carcinoma was associated with larger cervical tumors (60 mm versus 27-40 mm), a higher lymph node metastasis ratio (25.0% versus 14.3%-15.4%), higher distant metastasis rate even in small tumor (10 mm, 10.3% versus 0.5-2.6%; and 20 mm, 14.8% versus 3.9-5.3%), and stage IV disease (40.1% versus 11.9%-15.2%) than other histologies (p < .001). Among distant metastasis cases, small cell neuroendocrine carcinoma was more likely to spread to the liver (36.1% versus 14.3%-15.4%) or bone (28.8% versus 17.3%-19.1%) and to involve multiple distant organ metastases (≥2 organs: 37.3% vs 27.8%-30.2%; and ≥3 organs: 18.1% vs 9.2%-10.1%) compared with other histologies (p < .001). Across stages I to IV, small cell neuroendocrine carcinoma had lower 5-year overall survival rates than other histologies: stage I, 58.0% versus 82.5% to 91.3%; stage II, 38.4% versus 60.7% to 64.6%; stage III, 31.3% versus 49.5% to 51.4%; and stage IV, 8.1% versus 18.2% (p < .05). Early-death rates within two months from diagnosis of small cell neuroendocrine carcinoma were substantially higher than other histologies (9.0% vs 2.2%, p < .001). This population-based assessment suggests that, although rare, the incidence of small cell neuroendocrine carcinoma of the uterine cervix is gradually increasing in the United States. Multiple distant organ metastases, especially to the liver and bone, and poor survival outcomes characterize small cell neuroendocrine carcinoma of the uterine cervix.

Modified radical hysterectomy for stage IB1 (≤2 cm) cervical cancer: assessment of temporal trends and oncologic outcomes in the United States

The oncologic safety of less-radical surgery for early-stage cervical cancer is currently being actively investigated. Given the paucity of data, this study assessed the temporal trends and oncologic outcomes associated with modified radical hysterectomy for stage IB1 (≤2 cm) cervical cancer in the United States. This retrospective cohort study used data from the Commission-on-Cancer's National Cancer Database. The study population was 2902 patients with clinical stage IB1 (≤2 cm) cervical cancer from 2010 to 2020. Temporal trends based on hysterectomy modality (radical hysterectomy, modified radical hysterectomy, and simple hysterectomy) were assessed using linear segmented regression with log-transformation, and the overall survival was assessed using a multivariable Cox proportional hazard regression model. There was a statistically significant increase in modified radical hysterectomy from 2013 to 2020 (annual percentage rate increase 4.4, 95% CI 0.7 to 16.0, p=.040) and a decrease in simple hysterectomy from 2012 to 2020 (-2.3, 95% CI -3.7 to -1.3, p<.001). The lymphovascular space invasion rates (26.8%, 26.8%, and 23.1% for the radical, modified radical, and simple hysterectomy groups, respectively, p=.10) and pathological nodal metastasis rates (5.0%, 4.4%, and 4.0%, respectively, p=.54) were similar among the 3 groups. The use of adjuvant radiotherapy was higher in the simple hysterectomy group (13.0%, 13.0%, and 18.2% in the radical, modified radical, and simple hysterectomy groups, respectively, p<.001). The 5-year overall survival rates for radical hysterectomy, modified radical hysterectomy, and simple hysterectomy were 96.6%, 96.3%, and 95.8%, respectively (p=.66). In multivariable analysis, modified radical hysterectomy (adjusted HR 1.23, 95% CI 0.73 to 2.06) and simple hysterectomy (adjusted HR 1.02, 95% CI 0.70 to 1.48) were not associated with decreased overall survival compared with radical hysterectomy. The results of this cohort study in the United States suggest that modified radical hysterectomy for stage IB1 (≤2 cm) may not be associated with overall survival. This observed survival association warrants further investigation for stage IB1 (≤2 cm) cervical cancer that does not meet the low-risk criteria.

Clinico-pathological characteristics and survival outcome associated with uterine leiomyosarcoma variants: epithelioid and myxoid types

Epithelioid and myxoid types represent uterine leiomyosarcoma variants, and their clinico-pathologic characteristics and survival outcomes have been under-studied because of their rarity. The objective of this study was to assess clinico-pathologic characteristics and survival associated with uterine leiomyosarcoma variants. This retrospective cohort study queried the Commission-on-Cancer's National Cancer Database. The study population included 7410 patients with uterine leiomyosarcoma, including conventional, epithelioid, and myxoid types, who had primary hysterectomy from 2010 to 2022. Demographic characteristics were assessed using descriptive analysis; overall survival was assessed using a multivariable Cox proportional hazards regression model. Epithelioid and myxoid types were reported in 478 (6.5%) and 327 (4.4%) patients, respectively. The proportion of the epithelioid variant increased from 5.5% in 2010-2014 to 7.8% in 2019-2022 (p = .005). The epithelioid type was associated with higher rates of lympho-vascular space invasion (33.1% vs 22.0%-23.7%) and nodal metastasis (6.9% vs 3.4%-3.6%), whereas the myxoid type was associated with a higher rate of stage I disease (64.5% vs 56.1%-58.7%) (all, p < .05). Compared with the conventional type, the epithelioid type was associated with improved overall survival (adjusted hazard ratio [aHR] 0.87, 95% confidence interval [CI] 0.75 to 0.99) including stage I (aHR 0.75, 95%CI 0.60 to 0.93) and stage III (aHR 0.59, 95% CI 0.39 to 0.91) disease; the myxoid type was also associated with improved overall survival (aHR 0.68, 95%CI 0.57 to 0.82) including stage I (aHR 0.62, 95% CI 0.47 to 0.82) and stage IV (aHR 0.60, 95% CI 0.41 to 0.88) disease. Across all three types, larger tumor size, lympho-vascular invasion, and higher stage were associated with decreased overall survival, with the survival impact of larger tumor size being more prominent in variants. For stage II to IV epithelioid type, adjuvant chemotherapy was associated with improved overall survival (aHR 0.43, 95% CI 0.29 to 0.64). The results of this cohort study suggest that uterine leiomyosarcoma variants (epithelioid and myxoid) exhibit distinct histopathologic characteristics and survival compared with the conventional type. These data also endorse the importance of accurate diagnosis, research inclusion criteria, and development of collaborative networks.

Assessment of overall survival in reproductive-age patients with 2023 International Federation of Gynecology and Obstetrics stage IA1 grade 1 endometrioid endometrial cancer

This study aimed to assess the overall survival of reproductive-age patients with non-myoinvasive stage IA1 grade 1 endometrioid endometrial cancer. This retrospective cohort study queried the Commission-on-Cancer's National Cancer Database. The study population included 21,248 patients with grade 1 endometrioid endometrial cancer with the 2023 International Federation of Gynecology and Obstetrics stage IA1 (tumor with no myoinvasion; n = 6249), IA2 (tumor with inner-half myoinvasion; n = 11,113), and IB (tumor with outer-half myoinvasion; n = 3886), who had primary hysterectomy from 2010 to 2015. The main outcome measures were 5- and 10-year overall survival rates according to patient age (<40, 40-49, and ≥50 years) and cancer stage (IA1, IA2, and IB) stratifications. Stage IA1 was the most frequent sub-stage until age 45 years. The median follow-up was 8.3 (interquartile range; 6.8-10.0) years. Among patients aged <40 years, the 5- and 10-year overall survival rates were 100% and 98.7% (95% confidence interval [CI] 94.7 to 99.7) for stage IA1, 97.6% (95% Cl 94.7 to 98.9) and 94.4% (95% CI 88.1 to 97.4) for stage IA2, and 100% and 95.2% (95% CI 82.3 to 98.8) for stage IB, respectively (p-overall = .009). Among patients aged 40 to 49 years, the 5- and 10-year overall survival rates were 99.3% (95% CI 98.4 to 99.7) and 96.5% (95% CI 94.4 to 97.8) for stage IA1, 98.1% (95% Cl 96.9 to 98.8) and 94.4% (95% CI 92.1 to 96.0) for stage IA2 and 96.0% (95% CI 90.6 to 98.3) and 86.5% (95% CI 77.5 to 92.0) for stage IB, respectively (p-overall < .001). Among patients aged ≥50 years, the 5- and 10-year overall survival rates were 96.2% (95% CI 85.6 to 96.7) and 88.5% (95% CI 87.3 to 89.6) for stage IA1, 94.9% (95% CI 94.4 to 95.3) and 85.7% (95% CI 84.8 to 86.6) for stage IA2, and 92.1% (95% CI 91.2 to 93.0) and 78.0% (95% CI 76.3 to 79.6) for stage IB, respectively (p-overall < .001). This cohort study found that reproductive-age patients, particularly, adolescent and young adults, with non-myoinvasive stage IA1 grade 1 endometrioid endometrial cancer have favorable prognosis. These data may be used as the benchmark setting the foundation for future investigation on fertility-sparing options.

Identifying the possible candidate population for adjuvant radiotherapy de-escalation for intermediate-risk cervical cancer.

To explore whether there is a possible candidate population for treatment de-escalation with active surveillance without adjuvant radiotherapy for patients with stage IB cervical cancer meeting the intermediate-risk criteria. This retrospective cohort study queried the Commission-on-Cancer's National Cancer Database in the United States. The study population included 1133 patients with node-negative, parametria-free, surgical margin-uninvolved, stage IB intermediate-risk cervical cancer (tumor size 2-4 cm with lymphovascular space invasion, or tumor size of >4 cm regardless of lymphovascular space invasion) who had primary radical hysterectomy and lymph node evaluation from 2010 to 2022. Exposure was adjuvant radiotherapy status: external beam radiotherapy with or without chemotherapy (n = 642) or active surveillance without radiotherapy (n = 491). The main outcome measure was overall survival, assessed in a propensity score inverse probability of treatment weighting cohort. At the whole-cohort level, hazard ratio (HR) for all-cause mortality comparing adjuvant radiotherapy de-escalation to adjuvant radiotherapy was 1.31 (95% confidence interval [CI] 0.92 to 1.86, p = .13). When stratified by histology type, adjuvant radiotherapy de-escalation was associated with increased all-cause mortality risk in squamous cell carcinoma (HR 1.55, 95% CI 1.02 to 2.34, p = .038) but not in adenocarcinoma or adenosquamous carcinoma (HR, 0.90; 95% CI 0.46 to 1.75, p = .75). When stratified by tumor differentiation, adjuvant radiotherapy de-escalation was associated with increased all-cause mortality risk in poorly-differentiated tumors (HR, 2.11; 95% CI 1.29 to 3.42, p =.003) but not in well- to moderately-differentiated tumors (HR, 0.83; 95% CI 0.50 to 1.37, p = .47). The results of this cohort study in the United States suggest that overall survival benefits of adjuvant radiotherapy for study-defined intermediate-risk stage IB cervical cancer may vary based on histology type and tumor differentiation. Specifically, patients with squamous cell carcinoma or poorly-differentiated tumors benefited from receiving adjuvant radiotherapy, while those with adenocarcinoma/adenosquamous carcinoma or well- to moderately-differentiated tumors did not. Whether there may be candidates for treatment de-escalation in intermediate-risk cervical cancer warrants further investigation with a prospective design.

Estimating high-grade serous fallopian tubal carcinoma in the era of tubal hypothesis

In the era of the serous tubal intraepithelial carcinoma hypothesis, investigation continues as to what proportions of high-grade serous tubo-ovarian carcinomas originate in the distal fallopian tube versus in the ovary. In this retrospective cohort study of 118,619 patients with high-grade serous tubo-ovarian carcinoma identified in the Commission-on-Cancer's National Cancer Database from 2004 to 2021, a diagnosis shift from high-grade serous ovarian carcinoma to high-grade serous fallopian tubal carcinoma occurred from 2004 to 2018 that the proportional distribution of high-grade serous fallopian tubal carcinoma increased 6.1-fold from 4.5% in 2004 to 27.6% in 2018 (p-trend < .001). This rapid diagnosis shift from high-grade serous ovarian carcinoma to high-grade serous fallopian tubal carcinoma reached a plateau at 2018, followed by steady proportional distribution of high-grade serous fallopian tubal carcinoma among the high-grade serous tubo-ovarian carcinomas for 4 consecutive years (27.6% in 2018 to 28.0% in 2021, p-trend = .801). The average rate of tubal carcinomas during this post-plateau period was 27.7%. In conclusion, the diagnosis shift in the primary site of high-grade serous tubo-ovarian carcinoma from the ovary to the fallopian tube may have ended in the late 2010s. After the implementation of College of American Pathologists diagnosis criteria, 1 in 3 to 4 high-grade serous tubo-ovarian carcinomas were classified as of fallopian tube origin.

Integrated Single-Cell Whole-Genome Sequencing and Spatial Transcriptomics Reveal Intratumoral Heterogeneity in Ovarian Cancer.

The mortality rate of ovarian cancer remains disproportionately high compared with its incidence. This is partly due to a high level of intratumoral heterogeneity, driven by genomic instability, that promotes disease recurrence and treatment failure. In this study, we describe degrees of heterogeneity revealed by single-cell whole-genome sequencing and spatial transcriptomics (ST) of five late-stage, treatment-naïve primary epithelial ovarian carcinomas, including high-grade serous and clear-cell subtypes. All samples exhibited widespread copy-number (CN) aberrations, with the greatest intraspecimen diversification in regions of CN gain. Diversification was also associated with whole-genome doubling in all samples. In two samples, we identify persistent, clonal pseudodiploid cells evolutionarily consistent with a premalignant phenotype. In multiclonal samples, we interpret clonal evolution in the context of single-cell CN, loss of heterozygosity analysis, and somatic mutations and correlate these with tissue histology and gene expression programs. In one high-grade serous carcinoma, we identify functionally consequential CN alterations that contribute to molecular diversity, cell proliferation, and inflammation in a minor clone that persisted without major expansion alongside a more complex major clone. In another clear-cell carcinoma, we describe a complex evolutionary history, including a spontaneous functional reversion of a CTNNB1 driver mutation in a secondary clone, which correlated with a switch in oncogenic expression programs. These examples highlight various consequences of genomic instability on clonal heterogeneity and plasticity in ovarian cancer. We utilize single-cell DNA sequencing and ST to illustrate the wide extent of intratumoral heterogeneity within late-stage ovarian tumors. We describe several consequences of chromosomal instability, including divergent biology in multiclonal tumors, persistence of a premalignant cell population, and functional reversion of an oncogenic driver mutation.