Journal

Anticancer Research

Papers (251)

Ovarian Serous Carcinoma With a Novel HSP90AB1 Mutation in a Patient With Synchronous Primary Fallopian Tube Serous Carcinoma

Ovarian carcinoma is the fifth leading cause of cancer-related deaths in women in the United States. Serous papillary carcinoma is the most common histological type of ovarian carcinoma that often goes undetected until it has spread within the pelvis and abdomen leading to poor prognosis. Translation of next-generation sequencing (NGS) technology into personalized medicine and identification of new potential targets for therapeutic applications may be helpful. We report a case of a 59-year-old female who initially presented in the emergency department with increasing abdominal girth, and bloating. Computed tomography showed ascites and omental and pelvic masses. Fine needle biopsy of the omental mass showed high-grade papillary adenocarcinoma consistent with high-grade ovarian serous carcinoma. She was treated with chemotherapy followed by debulking surgery. Primary ovarian serous carcinoma and synchronous primary fallopian tube serous carcinoma with multiple leiomyomas were identified in the surgical specimen. Pleural biopsy was also positive for carcinoma. NGS and programmed death-ligand 1 (PD-L1) expression testing were performed in the ovarian serous carcinoma. The results showed mutations of breast cancer type 1 (BRCA1) and type 2 (BRCA2), tumor protein p53 (TP53) (c.524G>A at pR175H), and heat shock protein 90 alpha family class B member 1 (HSP90AB1) (p.R456C), as well as low RNA expression score of PD-L1. Identification of these mutations and PD-L1 abnormality at the diagnosis of ovarian carcinoma may shed light for clinicians to provide targeted therapy with poly (ADP-ribose) polymerase (PARP) inhibitors and immune checkpoint inhibitors for ovarian serous carcinoma. This is the first documented case of ovarian serous carcinoma to have found a HSP90AB1 (p.R456C) mutation.

Results of Definitive (Chemo)radiotherapy Using Computed Tomography-based Brachytherapy for Cervical Cancer

Concurrent cisplatin-based chemoradiotherapy (CCRT) is the standard treatment for locally advanced cervical cancer. Especially, CCRT with magnetic resonance imaging (MRI) or computed tomography-based image-guided brachytherapy (CT-based 3D-IGBT) for cervical cancer has resulted in good LC rates. However, progression-free survival (PFS) and overall survival (OS) rates for locally advanced cervical cancer are still low and could be improved. The aim of the study was to evaluate treatment efficacy and late toxicity of external beam radiotherapy (EBRT) and CT-based IGBT with or without concurrent chemotherapy in patients with squamous cell carcinoma of the uterine cervix and investigate patterns of failure. We retrospectively analyzed clinical data of cervical squamous cell carcinoma patients treated with definitive radiotherapy with or without concurrent chemotherapy at Saitama Medical University International Medical Center. Local control (LC), PFS, patterns of failure, and late toxicity were the evaluated outcomes. Overall, 290 patients were enrolled in the study. Median follow-up was 51.5 months. During follow-up, 74 patients developed recurrence: 10 patients with intra-pelvic failure only, 45 with extra-pelvic failure only, and 19 with both. The 3-year LC was 100% for T1b-T2a, 96.8% for T2b, 89.5% for T3b, and 88.5% for T4 disease. The 3-year PFS was 100% for stage IB-IIA, 89.0% for stage IIB, 70.7% for stage IIIB, 72.6% for stage IIIC1r, and 40.1% for stage IVA. The incidence of grade 3-4 gastrointestinal and genitourinary toxicities was 3.0% and 1.7%, respectively. Combination of EBRT and CT-based IGBT with or without concurrent chemotherapy produced favorable LC with acceptable rates of late toxicities. However, extra-pelvic failures frequently occurred and PFS was less satisfactory in patients with stage III-IVA disease, which indicated the need for additional treatment in these patients.

Effects of Curcumin and Its Analogue Desmethoxycurcumin on miR-133b and Its Target Gene GSTP-1 in Cisplatin-resistant Ovarian Cancer Cells

Ovarian cancer, despite being the fifth most common gynecological malignancy, has the highest mortality rate. Recent clinical studies have explored the potential of natural products, like curcumin (CUR), to enhance conventional chemotherapy by targeting multiple cellular pathways. This study aimed to evaluate the effects of CUR and its analog, demethoxycurcumin (DMC), on human ovarian cancer and cisplatin-resistant ovarian cancer cell proliferation and apoptosis. Additionally, we investigated the expression of a candidate gene (GSTP-1), and microRNA (miR-133b) involvement in glutathione metabolism, a potential resistance mechanism in cisplatin-resistant ovarian cancer cells. Cell proliferation was measured using the WST-1 assay after exposing cisplatin-resistant (A2780cp) and sensitive (A2780) ovarian cancer cell lines to various concentrations of CUR and DMC for different time periods. Apoptosis was quantified using the Annexin V-FITC/PI assay. To understand the underlying mechanisms, we examined the expression levels of GSTP-1 and miR-133b using quantitative RT-PCR. The WST-1 assay revealed that CUR and DMC inhibited cell proliferation in both cell lines, with cisplatin causing a sharper viability decline in A2780cp cells. Annexin V-PI staining detected early apoptosis induced by CUR, DMC, and their combinations in both cell lines at 12 hours, with no necrosis observed. Gene expression analysis showed a significant decrease in GSTP-1 and miR-133b levels in A2780cp cells compared to A2780 cells. The combination treatments, particularly Cur+DMC+Cisplatin, synergistically reduced GSTP-1 and miR-133b expression. This study demonstrated the potential of CUR and DMC to enhance the efficacy of cisplatin in ovarian cancer treatment. The observed decrease in GSTP-1 and miR-133b expression in cisplatin-resistant cells suggests their involvement in drug resistance and highlights their potential as therapeutic targets.

Surgical Treatment and Outcome of Ovarian Cancer Patients With Liver Metastases: Experience of a Tertiary Hepatic and Peritoneal Surface Malignancy Center

The aim of this study was to describe and evaluate the patterns, perioperative outcomes, and survival rates of patients subjected to hepatic resections for ovarian-derived liver metastasis as part of cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Furthermore, we investigated two subgroups of tumor patterns: hematogenous liver metastasis and infiltrative liver metastatic spread. A retrospective study was conducted. Patients from a University Tertiary Hepatic and Peritoneal Surface Malignancy Center with primary or recurrent ovarian cancer, who underwent liver resection as part of cytoreductive surgery between January 1992 and December 2022, were included. Data from 35 patients were analyzed. Both median overall survival (OS) and disease-specific survival (DSS) were 24.97 months. In a multivariate setting, the combined effect of age, peritoneal carcinomatosis index, body mass index, hematogenous liver metastasis vs. infiltrative spread types, and HIPEC (HR=0.2372; 95%CI=0.0719-0.7823; p=0.0181) over OS was tested. Survival analysis revealed no differences between the two metastatic spread types (OS: p=0.9720; DSS: p=0.9610). Younger age (p=0.0301), splenectomy (p=0.0320), lesser omentectomy (p=0.0178), and right upper quadrant peritonectomy (p=0.0373) were more characteristic for those patients with infiltrative liver metastatic spread. Complete cytoreductive surgery, including hepatic resection is a feasible approach with or without additional HIPEC, which may provide survival benefit for patients with advanced and/or recurrent ovarian cancer. If metastatic and infiltrative liver involvement is suspected, liver-specific imaging is recommended.

E2F7/RAD51AP1 Axis Inhibits Endometrial Cancer Sensitivity to 5-FUviathe Fatty Acid Metabolic Pathway

Endometrial cancer (EC) is a frequent gynecological cancer. Studies have demonstrated that the sensitivity of EC toward 5-fluorouracil (5-FU) chemotherapy has decreased, leading to unsatisfactory treatment effects. There is an urgent need to investigate the reasons for the unsatisfactory treatment of EC with 5-FU. The purpose of the study was to investigate the effect of RAD51AP1 after being transcriptionally activated by E2F7 on the sensitivity of EC cells to 5-FU chemotherapy via the fatty acid metabolic pathway. mRNA expression data on EC were downloaded from The Cancer Genome Atlas database, subjected to differential expression analysis, and the target genes were determined based on the bioinformatics analysis and literature consulting. The regulatory transcription factor upstream of RAD51AP1 in EC was predicted using the hTFtarget database. The expression of E2F7 and RAD51AP1 was measured by qRT-PCR and western blot. Then, the transcriptional activation relationship between E2F7 and RAD51AP1 was verified by chromatin immunoprecipitation (ChIP) and dual luciferase assays. The IC Bioinformatics analysis showed that both E2F7 and RAD51AP1 were highly expressed in EC, and the possible binding sites between RAD51AP1 promoter and E2F7 were predicted. ChIP assay and dual luciferase assay confirmed the binding of E2F7 to RAD51AP1 promoter region. Cell experiments showed that overexpressing RAD51AP1 could facilitate the growth and fatty acid metabolism of EC cells, and suppress cell sensitivity to 5-FU, while silencing of E2F7 could reduce the effect of RAD51AP1 overexpression on EC cell growth and sensitivity toward 5-FU. The E2F7/RAD51AP1 axis can promote the growth of EC cells and inhibit cell sensitivity to 5-FU by regulating fatty acid metabolism, suggesting that E2F7/RAD51AP1 axis may be a novel pathway for EC treatment.

Prognostic Significance of Clinical Factors IncludingBRCAMutation in Epithelial Ovarian, Peritoneal, Fallopian Tube Cancer

We analyzed the survival outcomes of patients with epithelial ovarian, peritoneal, or fallopian tube cancer with BRCA1/2 mutations and the clinical factors associated with the prognosis of these cancers. We included patients who had been diagnosed with and treated for epithelial ovarian, peritoneal, or fallopian tube cancer and had undergone germline BRCA testing in six hospitals between January 2012 and December 2019. Of the 378 identified patients, 76 (20.1%) carried a BRCA1/2 mutation. Progression-free survival (PFS) and overall survival (OS) did not differ between patients with and without BRCA1/2 mutation. Multivariate analysis for 18 months after the primary treatment showed higher PFS in the BRCA1/2 mutation group (p=0.024). Subgroup analysis in patients with high-grade serous carcinoma showed that BRCA1/2 mutation was an independent favorable prognostic factor for PFS (p=0.035). Subgroup analysis of patients with stage III or IV disease demonstrated an independent gain in PFS in patients with BRCA1/2 mutation (p=0.015). Neoadjuvant chemotherapy as a primary treatment was related to poor PFS (p<0.001) and reduced OS (p=0.005). Having a germline BRCA1/2 mutation improved short-term PFS in patients with epithelial ovarian, peritoneal, or fallopian tube cancer. Elevated initial CA125 level and primary neoadjuvant chemotherapy were related to poor prognosis.

Efficacy and Safety of Platinum Rechallenge in Patients With Platinum-resistant Ovarian, Fallopian Tube or Primary Peritoneal Cancer: A Multicenter Retrospective Study

Ovarian cancer diagnosed with platinum-resistant recurrence has very poor prognosis and single-agent chemotherapy with no cross-resistance to prior chemotherapy is recommended for its treatment. In this study, we retrospectively evaluated the efficacy and safety of platinum rechallenge therapy for once diagnosed with platinum-resistant ovarian cancer who had a platinum-free interval (PFI) of at least 6 months. The study included 49 patients who received platinum rechallenge therapy for ovarian, fallopian tube or primary peritoneal cancer who were once diagnosed with platinum-resistant recurrence between January 2010 and March 2021 and evaluated the efficacy and safety of this treatment. In addition, patient background factors were identified, and independent prognostic factors for progression-free survival (PFS) and overall survival (OS) were investigated. A complete response was noted in 7 cases, partial response in 21, stable disease in 9, and progressive disease in 10. The response and disease control rates were 55% and 76%, respectively. The median PFS and OS were 8.5 months and 35.8 months, respectively. The independent prognostic factor was PFI for OS, and there was no independent prognostic factor for PFS. Seven patients discontinued chemotherapy owing to serious adverse events, including one patient with treatment-related death. Platinum rechallenge therapy for patients with platinum-resistant recurrence did not cause previously unreported adverse events, and the adverse events were manageable. In addition, high response and disease control rates were observed, as well as long-term OS. Platinum rechallenge therapy for platinum-resistant ovarian cancer may be a viable treatment option.

Alteration of Flavin Homeostasis in Uterine Cancer

Uterine cancer is the fourth most frequently diagnosed cancer in women, and continues to present significant clinical challenges, particularly in older populations. Tumor progression is tightly linked to metabolic adaptations, and emerging evidence points to an association between dysregulated vitamin B2 (riboflavin, Rf) metabolism and cancer development. Rf is an essential precursor of the flavin cofactors flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD), which are critical for cellular energy metabolism and redox balance. The aim of the study was to investigate whether uterine cancer tissues exhibit alterations in the expression of key regulators of flavin homeostasis - riboflavin transporters (RFVT1-3) and FAD synthase (FADS) - and to determine how these changes relate to intracellular flavin levels and to the expression of the FAD-dependent epigenetic enzyme lysine-specific demethylase 1 (LSD1). Paired samples of tumor tissue and surrounding normal mucosa from eight patients with uterine cancer were analyzed to evaluate the expression of: RFVTs by both RT-PCR and western blot; and FADS, and the FAD dependent enzyme lysine specific demethylase 1 (LSD1) by RT-PCR. Furthermore, we evaluated flavin cofactors levels by HPLC. Quantitative analyses revealed a significant up-regulation of A coordinated mechanism where uterine cancer cells adaptively up-regulate RFVTs, FADS, and LSD1 to meet their metabolic demands was revealed. These results provide insights into the metabolic vulnerabilities of uterine cancer and propose Rf metabolism and flavin-dependent processes as potential therapeutic targets.

Role of Stromal CD25+/CD8+ Lymphocyte Ratio in Patients With Grade 2-3 Cervical Intraepithelial Neoplasia (CIN 2-3): A Retrospective Single-center Study

This study aimed to assess the role of the stromal CD25+/CD8+ (Cluster of Differentiation) lymphocyte ratio and other immunohistochemical markers in predicting the risk of recurrence and human papillomavirus (HPV) persistence after Loop Electrosurgical Excision Procedure (LEEP) conization in patients with grade 2-3 cervical intraepithelial neoplasia (CIN2-3). A retrospective analysis was conducted on 72 patients who underwent LEEP for CIN2-3 in our Department. Criteria for enrollment included HPV genotyping before and after surgery and a follow-up time ≥18 months. Immunohistochemical analysis assessed CD8+ cytotoxic T cells and CD25+ regulatory T cells in the cervical stroma, and the CD25+/CD8+ ratio was computed. Recurrence of CIN2-3 and HPV persistence after LEEP were the endpoints of the study. CIN2-3 recurrence occurred in 13.9% of patients with smoking, HPV-16/18 infection, positive surgical margins, and CIN3 histology being significant risk factors. A CD25+/CD8+ ratio >1.25 was associated with a shorter disease-free survival (DFS) ( The CD25+/CD8+ ratio is a promising biomarker for identifying patients at higher risk of CIN2-3 recurrence and HPV persistence post-LEEP. These findings highlight the role of immune profiling in the management of patients affected by CIN2-3 and support the integration of vaccination and personalized follow-up strategies.

Potential Transcriptomic Biomarkers for Predicting Platinum-based Chemotherapy Resistance in Patients With High-grade Serous Ovarian Cancer

Due to the absence of screening protocols, high-grade serous ovarian cancer (HGSOC) patients are frequently diagnosed at an advanced stage, which significantly reduces the survival rate. Moreover, relapse occurs in approximately 70% of HGSOC patients after primary treatment. Predicting resistance to primary chemotherapy remains a challenge. In the research setting, transcriptomic analyses have emerged as powerful tools for predicting which HGSOC patients are likely to benefit from primary treatment. The aim of this review was to investigate the literature demonstrating the potential of transcriptomic signatures as biomarkers for assessing the risk of resistance to platinum-based chemotherapy. We conducted a three-step search process on PubMed to systematically review English-language articles published between 2020 and 2024. From the 123 articles retrieved, we included 11 articles that investigated transcriptomic signatures by RNA sequencing in tissues from chemo-sensitive and -resistant HGSOC patients. We report the clinicopathological data of 727 patients in the experimental cohorts, transcriptomic signatures, and technical aspects. Finally, the review lists 15 publicly available datasets used in the included studies. Furthermore, we investigated the overlap of 167 differentially expressed genes retrieved across the various articles. We believe this review might offer valuable insights for further studies focusing on predicting platinum resistance and personalized treatments. In addition to discussing the latest findings and potential candidates, we highlight the challenges of validating biomarkers across studies and publicly available datasets. Transcriptomic signatures represent a potential tool for patient stratification, prognosis, and the potential adoption of long-term therapies, such as poly (ADP-ribose) polymerase inhibitors (PARPis).

Knockdown of RFC2 Prevents the Proliferation, Migration and Invasion of Cervical Cancer Cells

Replication factor C subunit 2 (RFC2) is a component of the replication factor C (RFC) complex, which plays a critical role in DNA replication and repair. Recent studies have reported the involvement of RFC2 in several cancers. In this study, we investigated the functional role of RFC2 in cervical cancer progression. RFC2 expression in cervical cancer cells was analyzed using quantitative real-time PCR (qRT-PCR) and western blotting. HeLa, ME-180, and SiHa cells were transfected with siRNAs targeting RFC2. Cell viability and proliferation were assessed using the MTT and colony formation assays, and cell cycle distribution was analyzed by flow cytometry. Migration and invasion abilities were evaluated through Transwell assays with or without Matrigel. RFC2 knockdown significantly reduced cell proliferation in cervical cancer cells. Flow cytometry analysis revealed cell cycle arrest at the S phase. Additionally, RFC2 knockdown markedly inhibited the migration and invasion of cervical cancer cells. These results demonstrate the critical involvement of RFC2 in regulating proliferation and metastatic potential in cervical cancer cells. RFC2 plays a pivotal role in promoting cervical cancer progression by enhancing cell growth, regulating the cell cycle, and promoting metastatic behavior. Further studies on the molecular mechanisms of RFC2 in cancer-associated pathways may provide a novel therapeutic target for developing cervical cancer treatment strategies.

Accuracy of Preoperative Magnet Resonance Imaging to Predict Pathologic T-Stage in Patients With Cervical Cancer

The trend in today's surgical gynecological oncology is to provide equal oncological safety with less radical surgery. The SHAPE trial demonstrated the non-inferiority of a simple hysterectomy compared to a radical hysterectomy in low-risk cervical cancer. As a result, the accuracy of preoperative diagnostics has become increasingly important to avoid both under- and overtreatment. The aim of the study was to investigate the accuracy of MRI-based T-stage. Forty-five patients who were surgically treated for an initial diagnosis of a primary cervical carcinoma at the University Hospital Cologne in the Department of Gynecology and Obstetrics between 2015 and 2021 were included in the study. All patients underwent MRI prior to their surgical treatment. In 44.4% of cases, the pathological tumor size in the surgical specimen was consistent with the preoperative tumor size determined by MRI. In 28.9% of the cases, MRI overestimated the final pathologic T-stage while in 26.7% of cases, MRI underestimated it. Furthermore, we were able to show that overall survival was significantly poorer (p<0.05) in patients whose preoperative MRI had underestimated the final T-stage in our study cohort. Preoperative MRI diagnostics alone are not reliable enough for accurate T-stage estimation. Multimodal diagnostic approaches are essential for accurate preoperative staging. Prospective trials are needed to evaluate preoperative staging strategies to optimize sizing accuracy.

Mast Cell-related Prognosis Signature Characterizes Immune Landscape and Predicts Prognosis of Ovarian Cancer

Ovarian cancer (OVC) is a common, aggressive, and heterogeneous malignancy, with a widely variable prognosis. With the advances of modern immunology, mast cells (MCs) have been shown to play a significant role in the prognosis of some malignant tumors. However, the role of mast cells in the prognosis of OVC is unknown. In this study, MC-associated prognostic genes (MRGs) were used to classify OVC from The Cancer Genome Atlas (TCGA)-OVC cohort. Genes were evaluated using univariate cox regression analysis. Twenty-nine prognostic gene signatures were identified using LASSO-COX analysis. COX regression models and principal component analysis (PCA) algorithms were used to construct MRG scores and individual MRGs patterns. External validation was performed in the TCGA-breast cancer (BRCA) and IMvigor210 cohorts. Immunity analysis based on MRGs was performed using CIBERSORT, and GSVA methods, and immunotherapy response was evaluated using the TIDE website. Using TCGA-OVC data, we established a model for constructing MRG scores based on the twenty-nine identified prognostic gene signatures using the PCA algorithm. MRG scores were found to be strongly correlated with immune cell infiltration and were excellent predictors of prognosis in patients with OVC. Low MRG scores were associated with better prognosis and better response to immunotherapy and chemotherapy. MC-related prognosis signature characterizes the immune landscape and predicts the prognosis of OVC. Understanding the correlation between MC-related gene signatures and immunotherapy and chemotherapy may improve the development of personalized clinical treatment strategies.

Kaempferol Inhibits Cervical Cancer Cells by Inducing Apoptosis and AutophagyviaInactivation of the PI3K/AKT/mTOR Signaling Pathway

Kaempferol, a natural flavonoid, occurs abundantly in fruits and vegetables. It has various bioactivities, with antioxidant, anti-inflammatory, and other beneficial properties. The aim of this study was to investigate the in vitro effects of kaempferol on the proliferation, apoptosis, and autophagy of KB cells, a human cervical cancer cell line, and the corresponding action mechanisms. The inhibitory efficacy of kaempferol on KB cervical cancer cells was investigated through 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, migration assay, 4',6-diamidino-2-phenylindole staining, flow cytometry, acridine orange staining and western blotting. Kaempferol reduced KB cell viability and migration in a dose-dependent manner. Additionally, kaempferol-induced apoptosis was confirmed, and kaempferol treatment influenced levels of apoptotic proteins. Autophagy was detected upon visualization of characteristic autophagic vacuoles and acidic vesicular organelles, and verified using western blotting, which revealed elevated levels of autophagy-related proteins. Kaempferol-mediated apoptosis and autophagy were evidently attributable to reduced phosphorylation in the phosphoinositide 3-kinase (PI3K)/serine/threonine kinase 1 (AKT)/mammalian target of rapamycin (mTOR) pathway. This finding was validated using a pharmacological inhibition assay with the PI3K pathway inhibitor LY294002, which promoted KB cell apoptosis and autophagy. Our results suggest that kaempferol induces apoptosis and autophagy by inhibiting the PI3K/AKT/mTOR pathway in human cervical cancer cells, empirically showing the anticancer effects of kaempferol, and thereby presenting it as a potential anticancer therapeutic agent.

SIRT4 Has an Anti-Cancer Role in Cervical Cancer by Inhibiting Glutamine Metabolismviathe MEK/ERK/C-Myc Axis

Glutamine metabolism is crucial in cell proliferation, aging, and apoptosis across various cancer types. Existing research indicates that Sirtuin 4 (SIRT4), primarily located in mitochondria, modulates this process. This study aimed to clarify the regulatory relationship between SIRT4 and glutamine metabolism in cervical cancer. SIRT4 mRNA levels and their clinical correlation to cervical cancer were analyzed using the UALCAN database. Immunohistochemistry (IHC) was performed to assess SIRT4 protein expression in tissue samples from cervical cancer patients. Transient transfection was employed to create Hela and Siha cell lines with overexpressed SIRT4, mitogen-activated extracellular signal-regulated kinase (MEK), and glutaminase 1 (GLS1). The impact on cellular functions was studied using MTT, soft agar, transwell, and western blotting assays. Glutamate and ATP levels were also measured to evaluate metabolic changes. Low levels of SIRT4 mRNA in cervical cancer tissues correlated with tumor metastasis and poor survival rates. Overexpression of SIRT4 led to suppressed cell proliferation, colony growth, and motility, along with significant down-regulation of GLS expression, a key contributor to glutamine metabolism. Additionally, SIRT4 overexpression resulted in the inactivation of the MEK/ERK/c-myc signaling pathway, while overexpression of MEK reversed these effects. Notably, the inhibitory effects of SIRT4 on cell proliferation, colony formation, migration, and invasion in Hela and Siha cells were significantly attenuated following GLS1 overexpression. SIRT4 acts as an anti-cancer agent in cervical cancer by inhibiting glutamine metabolism through the MEK/ERK/c-myc signaling pathway, providing a novel sight for cervical cancer therapy.

Interval Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy for Ovarian Cancer: Report of a Single-center Experience

Emerging data suggest that addition of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of interval cytoreduction for patients with metastatic ovarian cancer is associated with a survival benefit. However, the implementation of this treatment is affected by concerns related to its potential morbidity. We present data from the first centre in the UK implementing HIPEC as part of treatment for patients with advanced ovarian cancer undergoing interval cytoreductive surgery. This is a prospective study of patients planned to undergo cytoreductive surgery and HIPEC for advanced ovarian cancer over a 30-month period. All patients had undergone neoadjuvant chemotherapy prior to surgery. Patients with stage III/IV ovarian cancer who underwent complete or near complete cytoreduction (<2.5 mm residual disease) received HIPEC using a closed technique. A total of 31 patients were included in the study, of which 30 had complete cytoreduction and 1 patient had residual disease <2.5 mm. The mean age of the patients was 63.7±2.8 years. Median peritoneal cancer index score was 9 (range=3-31). The mean operating time was 515.4±55.1 min. The mean length of hospital stay was 7.6±0.8 days. In total, 24 complications were observed in 18 patients (58.1%), while 6.5% of the patients experienced grade 3/4 complications. There were no deaths within 30-days from the surgery. Age was found to be an independent predictor of both postoperative complications of any grade and prolonged hospital stay. Interval cytoreductive surgery and HIPEC for patients with advanced ovarian cancer is associated with low perioperative morbidity.

Clinical Significance of Serum SCC Levels Before Treatment for Locally Advanced Cervical Squamous Cell Carcinoma

Although serum squamous cell carcinoma (SCC) antigen values are known to be useful in predicting the prognosis of cervical SCC, they have only been examined in a cursory manner. This study aimed to meticulously investigate the clinical significance of serum SCC antigen levels in patients with locally advanced cervical squamous cell carcinoma (LACSC). The study included patients who were diagnosed with local stage (T-stage) 1b3/2/3 LACSC and underwent initial treatment at our institute between January 2006 and December 2016 (T-1b3: n=30; T-2: n=75; T-3: n=34). The patients were divided into three groups based on pre-treatment SCC values, and differences in clinical background, laboratory and pathology findings, and prognosis were examined. No significant difference in the SCC distribution was observed among the T-1b3/2/3 cases with elevated SCC levels. In stages T-1b3, T-2, and T-3, most recurrences in the SCC-High group were distant (T-1b3: three out of five recurrences; T-2: six out of seven recurrences; T-3: four out of eight recurrences), while most recurrences in the SCC-Low group were pelvic (T-1b3: two out of three recurrences; T-2: eight out of eight recurrences; T-3: three out of three recurrences). In LACSC, serum SCC antigen levels before treatment correlate strongly with the recurrence site. Patients with low levels should be closely monitored for local recurrence, whereas those with high levels warrant vigilance for distant recurrence.

Parkin Enhances Gefitinib-induced Anoikis in HeLa Cervical Cancer Cells

Gefitinib exhibits anticancer activity against cervical cancer cells via anoikis, a type of apoptosis induced by cell detachment from the extracellular matrix. Previous studies have reported that Parkin expression affects the efficacy of anticancer drugs. However, the impact of Parkin expression on the therapeutic effects of gefitinib in human cervical cancer remains unclear. Thus, this study aimed to evaluate whether Parkin over-expression improves the therapeutic effects of gefitinib against HeLa cervical cancer cells. Cell viability and apoptotic death of HeLa cells were measured by trypan blue dye exclusion assay and flow cytometry. Cell detachment, adhesion, spreading, and cell-cell interaction were observed by inverted microscopy. Alteration of adhesion-related molecules was evaluated by confocal microscopy and western blot assay. Parkin expression potentiated gefitinib-induced cell detachment by affecting the organization of the actin cytoskeleton. In addition, Parkin expression induced a further reduction in the reattachment of and interaction between detached cells. The therapeutic efficacy of low-dose gefitinib combined with Parkin expression was equivalent to that of high-dose gefitinib alone. Parkin expression promotes gefitinib-induced anoikis, consequently increasing the efficacy of gefitinib against HeLa human cervical cancer cells. Based on our results, we propose that Parkin can be used to increase the anti-cancer effect of gefitinib on cervical cancer cells.

Positive Ascites Cytology, Postoperative Chemotherapy and Prognosis of Stage I Ovarian Clear Cell Carcinoma

Ovarian clear cell carcinoma (CCC) is associated with a poor prognosis and is resistant to chemotherapy. The aim of this study was to investigate the prognosis of CCC in Mie prefecture and to identify poor prognostic factors. In this multi-center retrospective study, we analyzed the data of patients with CCC between February 2012 and December 2020. Patients were staged according to the International Federation of Gynecology and Obstetrics (FIGO) 2014 system. Statistical analyses were performed using the Kaplan-Meier method and compared between the two groups using the log-rank test. A total of 112 patients were included and the median follow-up time was 48 months. There was no difference in the prognosis between stages IA, IC1, and IC2. For patients at stages IA, IC1, and IC2, there was no difference in progression-free survival (PFS) and overall survival between the adjuvant chemotherapy and no chemotherapy groups. Median postrecurrent survival was 18 and 20 months in the stages I-II and III-IV groups, respectively. Multivariate analysis revealed that positive ascites cytology (p=0.006) was associated with PFS for patients at stages I-II and that the stage (p=0.039) was associated with PFS for patients at stages III-IV. Positive ascites cytology was a poor prognostic factor for patients at an early stage of CCC. Postoperative chemotherapy could be omitted for patients in stages IA and IC1. Relapsed patients did not respond to the standard treatment and had a poor prognosis regardless of the primary stage.

Tissue Expression and Prognostic Role of CXCL12 and CXCR4 in High-grade Serous Ovarian Carcinoma

The complex of C-X-C motif chemokine receptor 4 (CXCR4) and its ligand, C-X-C motif chemokine ligand 12 (CXCL12), plays an essential role in cancer cell proliferation, invasion, and metastasis. These are emerging therapeutic targets, and recent studies have reported that inhibition of CXCL12-CXCR4 signaling pathway enhances the effects of immune checkpoint inhibitors. Thus, we aimed to investigate tissue expression of CXCL12 and CXCR4 in high-grade serous ovarian carcinoma (HGSOC) and to determine their potential as prognostic markers. We used chemotherapy-naïve, formalin-fixed paraffin-embedded primary ovarian cancer tissues obtained from patients with advanced-stage HGSOC at the time of primary cytoreductive surgery. After histological reassessment, we constructed a tissue microarray and performed immunohistochemical staining for CXCL12 and CXCR4. Thereafter, clinicopathological characteristics and survival outcomes were compared between the high- and low-expression groups. A total of 97 patients with FIGO stage IIIC-IV HGSOC were included: 15 (15.5%), 66 (68.0%), and 13 (13.4%) patients showed high expression of CXCL12, CXCR4, and both, respectively. The expression level of each protein was not associated with germline BRCA1/2 mutational status, FIGO stage, or residual tumor after primary cytoreductive surgery. In multivariate analysis adjusted for confounders, high CXCL12 expression was identified as an independent poor prognostic biomarker for progression-free survival (adjusted hazards ratio, 1.990; 95% confidence interval=1.090-3.633; p=0.025). However, CXCR4 expression was not associated with patient survival outcomes. The CXCL12 expression level may represent a prognostic biomarker for HGSOC. Proteins related to the CXCL12/CXCR4 complex may serve as therapeutic targets in HGSOC treatment.

Prevalence of PD-L1 in Cervical Cancer Patients and the Potential for Combining an Immune Checkpoint Inhibitor With Lenvatinib

Cervical cancer is the fourth most common cause of cancer-related deaths in women worldwide. The potential for targeted therapy against the immune checkpoint programmed death 1 (PD-1)/programmed death-ligand 1 (PD-L1) and receptor tyrosine kinases was examined in cervical cancer patients and cell lines. On tissue microarrays, PD-L1 was analyzed in 123 samples of patients with cervical cancer using immunohistochemistry. In SiHa, HeLa, and CaSki cervical cancer cell lines we examined the combination of lenvatinib with a PD-1/PD-L1 inhibitor using cell viability assays, the activation of cell signaling pathway proteins using western blots and gene expression using quantitative reverse transcriptase-PCR. Of 113 evaluable samples, 90 (79.6%) had more than 1% PD-L1 positive cells. The single treatment with the PD-1/PD-L1 inhibitor resulted in the greatest reduction in growth for CaSki and lenvatinib in HeLa cells. In contrast, the combined treatment of lenvatinib with the PD-1/PD-L1 inhibitor demonstrated a significantly stronger impeded proliferation compared to the single treatment in all three cell lines. Moreover, the combined treatment caused significantly less phosphorylation of the signaling molecules ERK and S6 in SiHa and of S6 and STAT3 in HeLa cells but not in CaSki. All treatments diminished the mRNA levels of PD-L1, Il-8, and FGFR in SiHa cells. PD1 is frequently expressed in cervical cancer samples. Combining lenvatinib with a PD-1/PD-L1 inhibitor diminished proliferation of cervical cancer cell lines. Consequently, this combination might be a promising option to treat cervical cancer. Signaling pathways involved in tumor cell growth are blocked by the combined treatment but still a model of the underlying mechanism cannot be drawn.

Comprehensive Genomic Profiling Detects Hereditary Cancers and Confers Survival Advantage in Patients With Gynaecological Cancers

The clinical benefits of comprehensive genomic profiling (CGP) of tumours in patients with gynaecological cancers remain unknown. We investigated the utility of CGP in assessing patient survival and its efficacy in detecting hereditary cancers in gynaecological patients. We retrospectively analysed the medical records of 104 gynaecological patients who underwent CGP between August 2018 and December 2022. The detection of actionable and accessible genomic alterations and administration of targeted therapy, as recommended by the molecular tumour board (MTB), were assessed. The overall survival (after second-line treatment in cervical and endometrial carcinomas and after platinum-resistant recurrence in ovarian carcinoma) was compared between patients with or without administration of MTB-recommended genotype-matched therapy. Germline findings were assessed using a variant allele frequency-tumour content graph. Among 104 patients, actionable and accessible genomic alterations were observed in 53 patients. Matched therapy was applied in 21 patients, comprising administration of repurposing itraconazole (n=7), immune checkpoint inhibitors (n=7), poly (ADP-ribose) polymerase inhibitors (n=5), and others (n=2). The median overall survival of patients receiving and not receiving matched therapy were 19.3 months and 11.2 months, respectively (p=0.036, hazard ratio=0.48). Among 12 patients with hereditary cancers, 11 patients were previously undiagnosed. Seven patients had hereditary breast and ovarian cancer, and five had other cancer. The implementation of CGP testing prolonged overall survival in gynaecological cancer as well as provided an opportunity for genetic counselling for newly-diagnosed patients with hereditary cancers and their families.

Complete Response to Immune Checkpoint Inhibition in a Platinum Resistant Primary Ovarian Cancer Patient With Lynch Syndrome: A Case Report and Review of the Literature

Lynch syndrome (LS) is the secondary cause of hereditary ovarian cancer (OC). Germline mutations in the DNA-mismatch repair (MMR) genes cause tumorigenesis and a high immunogenicity. Recent studies showed a promising use of immunotherapy in MMR deficient (MMRd) tumors. This is a case report of a patient with LS-associated OC and a complete response to pembrolizumab. A 44-year-old patient was admitted to the hospital with lower abdominal pain. The patient's history showed LS with a germline mutation in the MSH2-gene. Initial diagnostics showed a pelvic tumor mass and a highly elevated cancer antigen 125. After debulking surgery, histopathological findings showed a high-grade serous OC with mutations in the MSH2 and MSH6 genes. Only 5 weeks after operation with no residual tumor mass, a quick and significant intraabdominal progression of the disease was diagnosed. Adjuvant therapy with carboplatin and paclitaxel in a weekly course did not lead to sustainable response. An anti-PD-L1 antibody therapy with pembrolizumab was initiated. After only two courses of therapy, the laboratory results and clinical status of the patient improved tremendously. Shortly after, a complete response was detected, and therapy is still ongoing. The patient remains tumor free for 21 months now. The significance of germline compared to somatic mutations has not yet been sufficiently investigated. To our knowledge, this is the first case with complete response to checkpoint inhibition in OC associated with LS. Regarding LS-associated OC, immune checkpoint inhibition is an efficient therapy in tumors nonresponsive to standard therapy.

Clinical Impact of Pelvic Sentinel Lymph Node Biopsy for Vulvar Squamous Cell Carcinoma

This study investigated the clinical impact of resection of pelvic sentinel lymph nodes (PSLNs) in squamous cell vulvar cancer (SCVC). Sixty-two groins of 33 patients with SCVC who underwent sentinel lymph node (SLN) resection between 2010 and 2021 at the University Hospital of Cologne, Germany, were analyzed in this retrospective cohort study. The frequency of additionally resectable PSLNs, histological findings, and count rates were analyzed and compared to the findings for inguinal sentinel lymph nodes (ISLNs). In all patients and in 61 (98%) of the 62 radiolabeled groins, at least one SLN could be resected. Five (8%) of the 62 groins had histologically confirmed lymph node metastases (4/33 patients, 12%). Twenty (33%) of the 62 groins underwent additional PSLN resection. Resection of these PSLNs was feasible without causing an additional burden for the patients. None of the PSLNs showed signs of tumor infiltration. Information on the extent of radioactivity for ISLNs and simultaneously for PSLNs, expressed as count rate of intraoperative measurement with the gamma probe, was available for 20 (32%) groins. In three (15%) of these cases, the highest count rate in a SLN was found in a PSLN and not in an ISLN. Resection of PSLNs is feasible and can be performed without short-term complications. In patients with early SCVC, resection of PSLNs is not necessary, even in those with early infiltration of inguinal lymph nodes. The intraoperative count rate of SLN is not relevant for the decision to perform resection.

A Case of Anti-3-hydroxy-3-methylglutaryl-coenzyme A Reductase Myopathy Associated With Advanced Cervical Carcinoma

Necrotizing autoimmune myopathy is characterized by skeletal muscle weakness and is frequently associated with cancer. Absence of treatment can lead to severe muscular atrophy but initial symptoms may be insidious and delay the diagnosis. Here, we describe the case of a 70-year-old woman who was diagnosed with mnti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy during chemotherapy course for cervical cancer. A 70-year-old woman received chemotherapy for an advanced cervical carcinoma. She had no other relevant medical history and did not take statins. During the treatment she presented muscle weakness and myalgia. Biological tests showed elevated creatine phosphokinase level (3750 IU/l) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibodies were detected in the serum. The electroneuromyogram showed short myotonic bursts in the upper limbs, with a myogenic appearance. A muscle biopsy was performed and confirmed the diagnosis of necrotizing autoimmune myopathy. The patient showed improvements after treatment with intravenous immunoglobulin and corticosteroid therapy. Then, the patient was successfully treated with subcutaneous methotrexate, which controlled the disease and demonstrated its value as maintenance treatment. This case highlights the importance of screening for rare myopathies in patients suffering from cancer with myalgias and muscle weakness and the importance of electroneuromyogram and magnetic resonance imaging in the early onset of symptoms to make the correct diagnosis.

Paclitaxel, Carboplatin and 1,25-D3 Inhibit Proliferation of Ovarian Cancer Cells In Vitro

The combination of paclitaxel and carboplatin is the standard chemotherapy for ovarian cancer. Previous studies have implied that vitamin D (1,25-D3) may have growth inhibitory effects in ovarian cancer. This study aimed to investigate the effect of paclitaxel, carboplatin and 1,25-D3 on the growth of ovarian cancer cells in vitro, based on the hypothesis that 1,25-D3 might potentiate the effect of paclitaxel and/or carboplatin. Three non-commercial ovarian carcinoma cell lines UT-OV-1(mucinous), UT-OV-3B (serous) and UT-OV-4 (endometrioid) were exposed to different concentrations of 1,25-D3, paclitaxel and carboplatin, respectively. The cell viability was measured using a Crystal violet assay kit. The cellular vitamin D receptor (VDR) mRNA levels were measured by qRT-PCR using the LightCycler equipment. The growth-inhibitory effect of the combination of paclitaxel and carboplatin was 56% in UT-OV-1, 33% in UT-OV-3B and 47% in UT-OV-4 cells. Single 1,25-D3 (10 μM) inhibited the growth of UT-OV-3B and UT-OV-4 by 23% and 28%, respectively, whereas no effect was seen in UT-OV-1 cells. These results are in line with the finding that the expression of VDR was high in UT-OV-3B and UT-OV-4, but very low in UT-OV-1. The combination of 1,25-D3, paclitaxel and carboplatin resulted in 61%, 46% and 58% growth reduction in UT-OV-1, UT-OV-3B and UT-OV-4 cells, respectively. The additive effect of 1,25-D3 was 21% in UT-OV-4, 20% in UT-OV-3B and 12% in UT-OV-1 cell line. The results imply that combining 1,25-D3 with paclitaxel and carboplatin may potentiate their growth inhibitory effect on ovarian cancer cells with high VDR expression.

Evaluation of the Diagnostic Potential of Circulating MicroRNAsmiR-1andmiR-21in Patients With Ovarian Cancer

MicroRNA (miR) is implicated in the development of ovarian cancer (OC), the emergence of therapy resistance, and metastatic spread. In the past decade, a variety of relevant miRs have been identified in the context of OC, including miR-1 and miR-21. miR-21 plays a crucial role in OC carcinogenesis via activation of phosphatidylinositol-4,5-bisphosphate 3-kinase signaling and development of platinum resistance, and has prognostic value. miR-1 has been identified as a tumor suppressor across various cancer entities, with reduced expression in malignant tissue compared to benign. This evidence highlights the potential of miR-1 and miR-21 to serve as diagnostic and prognostic biomarkers in OC. We studied the diagnostic potential of serum expression of miR-1 and miR-21 in a cohort comprising patients with malignant and benign ovarian tumors. Furthermore, levels of miR expression were analyzed with regard to clinical outcomes in patients with malignant ovarian tumors to evaluate their prognostic value. We identified significant differential expression of miR-1 (p=0.0397) and miR-21 (p=0.0154) in malignant and benign ovarian tumors: Higher expression of miR-1 was found in patients with benign ovarian tumors, whereas expression of miR-21 was higher in patients with malignant ovarian tumors. In receiver operating characteristic analyses, the diagnostic potential of both miRs was confirmed, however, diagnostic significance was inferior to that of cancer antigen 125. No further value, in particular no prognostic value, was obtained for miR-1 and miR-21 in patients with malignant ovarian tumors. Serum levels of miR-1 and miR-21 might serve as promising biomarkers in the diagnosis of ovarian cancer.

Correlation Between Colposcopic Patterns and Histological Grade of Vaginal Intraepithelial Neoplasia: A Retrospective Cohort Study

Vaginal intraepithelial neoplasia (VaIN) is a rare human papillomavirus (HPV)- related premalignant condition. VaIN lesions are diagnosed histologically through colposcopy-guided biopsies of suspicious areas, conduced by gynecologists with expertise in lower genital tract diseases. The present study aimed to evaluate the accuracy of colposcopy in the diagnosis of VaIN of any grade. We conducted a retrospective analysis on a cohort of 149 women diagnosed with low grade (LG)-VaIN (VaIN1) and high grade (HG)-VaIN (VaIN2-3) between 2010 and 2022 at the "Regional Referral Center for Prevention, Diagnosis and Treatment of HPV-related Genital Disorders", Ospedale Maggiore Policlinico, Milan, Italy. All women had been referred to our center for an abnormal Pap smear or as part of routine follow-up of other HPV-related diseases and had undergone a vaginal biopsy under colposcopic guidance. The distribution of the histological grades of VaIN lesions was the following: 62 women (41.6%) were diagnosed with VaIN1, 51 (34.2%) with VaIN2, and 36 (24.2%) with VaIN3. Grade II (major) abnormal colposcopic patterns were recorded in 71 cases (47.7%) and were more commonly observed in women with VaIN3 (80.6%). However, we found a poor and not statistically significant association between colposcopic and histological grade of VaIN. The sensitivity, specificity, positive predictive value, and negative predictive value of colposcopy for histologically confirmed VaIN were 56.3%, 64.5%, 69% and 51.2%, respectively. The overall diagnostic accuracy of colposcopy was 59.7%. Colposcopy-guided biopsy plays an important role in the diagnosis of VaIN and in the distinction between low and high-grade lesions. Our data show that major colposcopic abnormalities moderately correlate with HG-VaIN and that grade I colposcopic findings do not exclude HG-VaIN, especially VaIN2. Targeted biopsies of suspicious vaginal areas must be performed in all women with an abnormal Pap smear.

Up-regulation of HDAC6 Results in Poor Prognosis and Chemoresistance in Patients With Advanced Ovarian High-grade Serous Carcinoma

Ovarian high-grade serous carcinoma (HGSC) gradually acquires chemoresistance after recurrence. Our previous study on ovarian clear-cell carcinoma found histone deacetylase 6 (HDAC6) overexpression led to chemoresistance. This study aimed to evaluate HDAC6 as a predictor of chemoresistance and a therapeutic target for ovarian HGSC. The clinical significance of HDAC6 as a predictor of prognosis and chemoresistance in HGSC was immunohistochemically evaluated. In addition, expression of programmed cell death ligand-1 (PD-L1), and hypoxia-inducible factor-1α (HIF1α) were analyzed using clinical samples from 88 patients with ovarian HGSC, and their clinicopathological characteristics were reviewed. Twenty-three patients had high HDAC6 expression, 10 positive PD-L1 expression, and 33 high HIF-1α expression. HDAC6 up-regulation was correlated with not undergoing interval debulking surgery (p<0.001), incomplete surgical resection (p=0.002), and frequent occurrence of stable disease/progressive disease according to the Response Evaluation Criteria in Solid Tumors (p=0.005) criteria. On Kaplan-Meier analysis, high HDAC6 expression was significantly associated with reduced progression-free (p=0.001) and overall (p=0.008) survival. On multivariate analysis, high HDAC6 expression (hazard ratio=1.65, 95% confidence interval 1.03-2.66; p=0.039) and surgery status were independent prognostic factors of progression-free survival. PD-L1 and HIF1α expression positively correlated with that of HDAC6. HDAC6 may become a potential therapeutic target in patients with ovarian HGSC since its up-regulation is considered to be associated with a poor prognosis in patients with this cancer.

The Activity of Vitamin C Against Ovarian Cancer Cells Is Enhanced by Hyperthermia

Vitamin C is essential for the proper functioning of the human body and plays a crucial role in many biological processes as a cofactor for enzymes. The anticancer activity of vitamin C has been indicated for years. Hyperthermia used in clinics allows increasing the effectiveness of anticancer therapies and may also be useful in enhancing the action of other substances. The purpose of this study was to enhance the anticancer activity of vitamin C through hyperthermia against ovarian cancer cells. The ovarian cancer cell lines Caov-3, NIH:OVCAR-3, and human fibroblasts CCD-1064Sk were tested in the present study. Vitamin C was used in the following concentrations: 0.24, 2.50 and 5.25 mM. Each of the selected concentrations was combined with the different temperatures (37°C, 40°C and 43°C). Cell survival, adhesion and changes at the molecular level were assessed. The obtained results revealed that hyperthermia enhances the anticancer activity of vitamin C. Ovarian cancer cells showed greater sensitivity to vitamin C at elevated temperatures. Cells may have different sensitivity to vitamin C due to the activation of different gene signatures associated with redox reactions and apoptosis, therefore we examined the following genes: BCAP31, BCL2L13, BID, CASP7, FADD and HTRA2. The increase in expression of these genes in cancer cells generated a stronger proapoptotic response. The present study showed that hyperthermia enhanced the anticancer activity of vitamin C in vitro.

Radical Surgery After Neoadjuvant Chemotherapy for Locally Advanced Neuroendocrine Cancer of the Cervix

Although still controversial, the current treatment for locally advanced neuroendocrine carcinoma of the cervix (NECC) relies on chemoradiation (CRT). The aim of this study is to evaluate the alternative role of combined chemotherapy and surgery in treating NECC. This is a retrospective series of patients undergoing radical surgery after neoadjuvant chemotherapy (NACT) for locally advanced NECC (stages IIB-IVA). Histological examination and immunohistochemistry were performed on surgical specimens to confirm diagnosis. Systematic literature search was conducted to identify other cases treated with chemotherapy and surgery. Seven patients with a mean age of 49 years were identified. The mean greatest diameter at diagnosis was 59.3±24.7 mm. FIGO stage was IIB in 14.3% of patients, IIIB in 28.6%, IIIC in 42.9%, and IVA in 14.3%. The response to NACT was partial, ranging from 50% to 80%. Neuroendocrine markers were expressed in all cases. The mean progression-free survival (PFS) and overall survival (OS) were 15.0±30.6 months and 26.3±36.4 months, respectively. Eleven studies encompassing a total of 27 patients met eligibility criteria for the systematic review. Surgery after NACT for locally advanced NECC may yield similar outcomes compared to CRT. The benefit of performing surgery as a primary approach could lie in the possibility of reserving CRT for recurrences. Since randomized clinical trials are difficult to be designed, an expert consensus is required to address the non-inferiority of radical surgery over CRT.

Mangosteen Inhibits Growth and Survival of Cervical Cancer Cells

Cervical cancer is the most common cancer of the female reproductive system. Late-stage cervical cancer treatment has been largely unsuccessful, and urgent anti-cancer therapy is needed. Mangosteen, a tropical fruit, has been studied and found to be rich in xanthones, known anti-cancer compounds. This study was designed to investigate the effect of mangosteen extract (ME) on SiHa cervical cancer cells and to explore the underlying molecular mechanisms. Clonogenic survival assay, Quick Cell Proliferation Assay, terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) staining, and caspase-3 activity kits were used to investigate the in vitro role of ME treatment in SiHa cervical cancer cell growth. We further investigated the possible molecular mechanisms using RT-PCR. Statistical analysis was done with unpaired two-tailed Student's t-test and significance at p-value <0.05; each experiment was repeated three times. Our study found that the growth and proliferation of SiHa cervical cancer cells was inhibited by ME. ME also induced apoptosis in SiHa cervical cancer cells. The anti-proliferative effect of ME on cervical cancer cells was associated with statistically significant (p<0.05) down-regulation of the pro-proliferative molecules cyclin B, cyclin D and cyclin E. The pro-apoptotic effect of ME was associated with statistically significant (p<0.05) down-regulation of the anti-apoptotic molecules flice-like inhibitory protein (FLIP) and survivin. ME impedes the growth and survival of SiHa cervical cancer cells by down-regulating cyclin B, cyclin D, cyclin E as well as FLIP and survivin. ME may be a promising strategy for targeted cancer immunotherapy development.

Control and Risk Factors of Nausea and Vomiting in Patients With Cervical Cancer Receiving Radiotherapy

Nausea and vomiting are two of the most distressing adverse events of cancer radiotherapy. The aim of this study was to examine the control rate and risk factors associated with nausea and vomiting in patients with cervical cancer receiving radiotherapy. This retrospective study examined patients with cervical cancer who received radiotherapy alone or with concomitant cisplatin. Patients who received radiotherapy alone were not administered antiemetic premedication, while patients who received radiotherapy with concomitant weekly cisplatin (40 mg/m Multivariate analysis indicated that younger age and concomitant weekly cisplatin were significant factors associated with non-CR across 5 weeks of treatment in patients who received radiotherapy. The proportion achieving CR among younger patients (<65 years) who received radiotherapy alone or with concomitant cisplatin was significantly lower than that among older patients (≥65 years) (Concomitant cisplatin: 27% vs. 67%, p=0.049; Radiotherapy alone: 62% vs. 91%, p=0.166). However, the proportion of patients achieving CR across 5 weeks of treatment was insufficient in all groups except for those aged ≥ 65 years who received radiotherapy alone. Antiemetic prophylaxis should be considered for younger patients with cervical cancer undergoing radiotherapy alone. Further, neurokinin-1 receptor antagonist should be added to 5-hydroxytryptamine type-3 receptor antagonist and dexamethasone as antiemetic prophylactic therapy for patients with cervical cancer undergoing radiotherapy with concomitant weekly doses of 40 mg/m

Significance of Altered Fatty Acid Transporter Expressions in Uterine Cervical Cancer and Its Precursor Lesions

High-risk human papilloma virus (HR HPV) infection is a major factor leading to the development of uterine cervical cancer. Data suggest that alterations in lipid metabolism are related to the pathogenesis of cervical cancer. Specifically, the uptake of exogenous fatty acids and their intracellular storage in lipid droplets enables cancer cells to survive and adapt to the changing tumor environment. We compared the immunohistochemical expression of fatty acid transport protein 4 (FATP4), and cluster of differentiation 36/fatty acid translocase (CD36/FAT) in normal cervical epithelium, low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous cell carcinoma (SCC) tissues of the uterine cervix. We also investigated the clinicopathological implications of these fatty acid transporters in SCC. Compared with that in normal cervical tissues, the expression of FATP4 was lower in LSIL (p=0.002), HSIL (p=0.006), and SCC (p=0.001). In contrast, CD36 expression was higher in SCC tissues than in normal cervical tissues (p<0.001). In normal cervical tissues, HR HPV-infected lesions exhibited a decrease in FATP4 (p<0.001) and an increase of CD36 (p=0.134), compared to those that were not infected with HR HPV. High CD36 expression was associated with a shorter recurrence-free survival (p<0.001). However, high FATP4 levels showed no significant correlation with the clinicopathological parameters of SCC. Altered expression levels of FATP4 and CD36 are unique features that might be related to HR HPV infection and promote tumorigenesis and progression of cervical cancer.

Stratified Mucin-producing Intraepithelial Lesions of the Cervix: Clinical Diversity of Cases and Literature Review

This report discusses the current literature on both non-invasive and invasive SMILE ((i)SMILE) lesions of the cervix with focus on the pathology and its related clinical diversity in several cases. Currently, the knowledge on (i)SMILE is limited to single case reports and series. As a consequence, consensus guidelines regarding the management are lacking. Although there is overlap with both high grade squamous intra-epithelial lesion (HSIL) and adenocarcinoma in situ (AIS) on immunohistochemical analyses, it is recommended to treat SMILE like AIS and further excision is needed when surgical margins are positive for SMILE on conization. (i)SMILE, should be considered as a rare subtype of adenocarcinoma of the cervix, and should be treated as such. We describe a case with a SMILE lesion undergoing a subsequent robotic hysterectomy after conization and two cases with iSMILE: one case with an early FIGO-stage 1B1 iSMILE tumor, undergoing a robotic radical hysterectomy with sentinel procedure, and one case undergoing a robotic-assisted pelvic/para-aortic lymph node staging dissection, confirming a metastatic FIGO-stage 3C2 (for primary chemo-radiotherapy treatment). Here, we report for the first time a few cases of (i)SMILE with different clinical presentations, their management and follow-up. Immunohistochemical characteristics are given for both primary lesions as well as the metastases.

Fostamatinib Inhibits the Proliferation of Ovarian Cancer Cells Through Apoptosis Induction

Ovarian cancer remains a significant challenge due to its high mortality rate and poor prognosis, especially in advanced stages. Despite treatment advancements, issues with resistance and recurrence persist, highlighting the urgent need for new and effective therapies. This study aimed to evaluate fostamatinib, an oral spleen tyrosine kinase inhibitor initially developed for autoimmune diseases, as a potential treatment for ovarian cancer. The effects of fostamatinib on ovarian cancer cell lines were assessed using WST-1 assays for cell proliferation. Apoptosis was evaluated through TUNEL assays, DNA fragmentation analysis, and flow cytometry. Western blot analysis was used to detect cleavage of apoptotic proteins, including caspase-3 and PARP, and flow cytometry analyzed cell cycle changes. Fostamatinib treatment resulted in a dose- and time-dependent reduction in ovarian cancer cell growth and induced apoptosis, as indicated by increased TUNEL-positive cells, DNA fragmentation, and rises in both early and late apoptosis. Western blot analysis showed increased cleavage of apoptotic proteins, including caspase-3 and PARP. Flow cytometry also demonstrated an increase in the sub-G1 phase of the cell cycle, further supporting apoptosis induction. Fostamatinib, by inhibiting cell proliferation and inducing apoptosis, shows promise as a repurposed therapeutic agent for ovarian cancer, potentially offering a new approach to improve patient outcomes.

Immunohistochemical Expression and Significance of Preferentially Expressed Antigen in Melanoma (PRAME) in Gynecological Tumors: A Single-institution Retrospective Analysis

Although preferentially expressed antigen in melanoma (PRAME) has been used as a diagnostic marker for malignant melanoma (MM), it is also expressed in various other malignancies. PRAME expression is rarely reported in female genital tumors. This study aimed to evaluate PRAME expression and its significance in gynecological malignancies. We conducted PRAME immunostaining in 135 specimens, including 85 endometrial carcinomas (ECs), five uterine sarcomas (USs), 28 cervical carcinomas (CCs), and 17 ovarian carcinomas (OCs). PRAME immunoreactivity was evaluated using a semi-quantitative histoscore method. PRAME was expressed in 82 (96.5%) ECs, 15 (88.2%) OCs, three (60.0%) USs, and eight (28.6%) CCs, with mean histoscores of 174.6, 108.9, 32.2, and 27.5, respectively. EC exhibited elevated PRAME expression levels compared to other tumors, with immunoreactivity being higher in endometrial endometrioid carcinoma (EEC) than that in other EC types. Grade 1 EEC exhibited higher PRAME expression levels than grade 2-3 EECs. PRAME over-expression in gynecological tumors supports the notion that this marker should not be regarded as specific to MM alone. EC exhibited higher PRAME expression than CC and OC, and low-grade EEC displayed higher PRAME immunoreactivity than other EC types. Our findings suggest that PRAME immunostaining can be useful to distinguish EEC from ovarian endometrioid carcinoma and endocervical adenocarcinoma. PRAME over-expression can also help differentiate non-aggressive EC from aggressive EC.

Efficacy of Platinum-based Chemotherapy for Platinum-sensitive Recurrent Ovarian Cancer During PARP Inhibitor Treatment: A Multicenter Retrospective Study

Previous studies have demonstrated low response rates and short progression-free survival (PFS) for platinum-based chemotherapy in patients with platinum-sensitive recurrent ovarian cancer during treatment with poly ADP-ribose polymerase (PARP) inhibitors. This retrospective study aimed to evaluate treatment outcomes in Japanese patients. The efficacy and safety of treatment were evaluated in 30 patients with ovarian, fallopian tube, or primary peritoneal cancers diagnosed with platinum-sensitive recurrence during PARP inhibitor treatment (administered between April 2019 and March 2025). Platinum-based chemotherapies included paclitaxel with carboplatin, paclitaxel with cisplatin, docetaxel with carboplatin, doxorubicin with carboplatin, or paclitaxel with nedaplatin. Chemotherapy was administered for six cycles, and PARP inhibitor rechallenge was performed when a treatment response was observed. The median number of platinum-based chemotherapy cycles was five (range=1-9). The objective response and disease control rates were 23.3% and 43.3%, respectively. The median PFS and overall survival were 4.5 months and 26 months, respectively. Grade 3 or higher hematological toxicities were observed, including leukopenia in 14 patients, neutropenia in 16, anemia in four, and thrombocytopenia in six. Non-hematological toxicities included nausea and constipation in one patient, hypertension in two, and carboplatin hypersensitivity in two. None of the patients discontinued chemotherapy owing to adverse events or treatment-related deaths. Subsequent platinum-based chemotherapy in patients with platinum-sensitive recurrence during PARP inhibitor treatment demonstrated a low response rate and short PFS.

Potential Role of PTEN and AKT/PKB Proteins in the Pathogenesis of Ovarian Mature Teratomas

Mature teratomas constitute over 95% of ovarian teratomas and account for more than 44% of all ovarian tumors and over 58% of benign ovarian lesions. The pathogenesis of these tumors is hypothesized to involve disruptions in primary germ cell development, with the PI3K/AKT signaling pathway potentially playing a crucial role. This study aimed to analyze the importance of the PTEN protein and its associated signalling pathway, particularly in relation to AKT kinase activation, in the pathogenesis of mature ovarian teratomas. Surgical specimens from 117 patients with mature ovarian teratomas and control tissues from contralateral ovaries were analyzed. Immunohistochemical analysis was conducted to evaluate the expression of PTEN and phosphorylated AKT (P-AKT/PKB), a key component of the PI3K/AKT pathway regulated by PTEN. Expression levels were assessed using the semi-quantitative Remmele Immunoreactive Score (IRS). An inverse pattern was observed in PTEN expression, with a higher overall IRS score in the study group despite a lower proportion of PTEN-positive cells. The expression of P-AKT protein was elevated in the studied group, both in terms of IRS score and the percentage of P-AKT reactive cells. The study supports a potential role of the PI3K/AKT pathway in the pathogenesis of mature ovarian teratomas, as evidenced by increased P-AKT expression. The role of PTEN, however, remains unclear due to contradictory findings. Further research with larger control groups is warranted to clarify these observations.

Diagnosis and Treatment of Gestational Non-Epithelial Ovarian Cancer: A Systematic Review

Ovarian cancer is categorized into epithelial ovarian cancer and non-epithelial ovarian cancer (NEOC), with NEOC accounting for approximately 10% of cases, predominantly affecting young women and adolescents. The incidence of gestational ovarian cancer is expected to rise in developed nations due to delayed childbearing. NEOC in pregnancy presents various risks, including spontaneous abortion, ventriculomegaly, respiratory distress, and maternal-fetal mortality. This review aims to evaluate the diagnostic tools and management strategies for early NEOC detection during pregnancy to improve maternal and fetal outcomes. A systematic literature search was conducted in PubMed and Embase, covering studies from January 2019 to January 2024. The search terms included "pregnan*" AND "non-epithelial ovarian cancer" AND "diagnos*" AND "manage*" to identify relevant studies. Only articles addressing the diagnosis and management of NEOC during pregnancy were included. Four relevant articles published between 2019 and 2021 were identified, reporting a total of 44 NEOC cases during pregnancy. In 34 of these cases, NEOC was diagnosed at International Federation of Gynecology and Obstetrics (FIGO) stage I, primarily through routine ultrasonography. Fertility-sparing unilateral salpingo-oophorectomy (USO), often combined with adjuvant platinum-based chemotherapy, was the standard treatment for stage I cases. Currently, no standardized management guidelines exist for NEOC during pregnancy, due to factors such as FIGO staging, gestational age, and maternal preferences. Routine ultrasonography is effective for the early identification of NEOC, particularly in asymptomatic patients. For pregnant women with stage I NEOC who wish to continue their pregnancy and preserve fertility, fertility-sparing surgery with chemotherapy represents a promising treatment approach.

Use of Indocyanine Green Fluorescence Angiography to Assess Bowel Anastomosis in Ovarian Cancer Surgery

The aim of this study was to investigate the efficacy of indocyanine green (ICG) fluorescence angiography in preventing anastomotic leaks and reducing the need for ostomies during cytoreductive surgery in ovarian cancer. This was a retrospective study of patients with 2014 International Federation of Obstetrics and Gynecology stage IIB-IVB ovarian cancer requiring a bowel resection during primary or secondary cytoreductive surgery at our institution between July 2021 to April 2023. Rates of ostomy performance and anastomotic leak were assessed in the ICG angiography group and the non-ICG angiography group. Frequency distributions between categorical variables were compared using Fisher's exact or Chi-squared test. Wilcoxon rank-sum test and t-test were used to compare continuous variables. During the study period, we reviewed the data of 59 consecutive patients with ovarian cancer with bowel resection; in 30 (50.85%) patients, bowel anastomosis was assessed using ICG angiography and in 29 (49.15%) patients, bowel anastomosis was not assessed using ICG angiography. Anastomotic leak rate was found to be 6.9% (n=2) in the non-ICG angiography group, and 3.33% in the ICG angiography group (n=1) (p=0.612). More diverting ostomies were performed in the non-ICG angiography group (n=6, 20.69%) compared to the ICG angiography group in which no ostomies were performed (p=0.011). ICG angiography is not associated with a decrease in anastomotic leak rates, but it may avoid ostomy formation.

Factors Limiting Ostomy Reversal After Cytoreductive Surgery for Ovarian Cancer: A Retrospective Study

To investigate the factors related to non-reversal of ostomy after cytoreductive surgery in ovarian cancer. In many women with ovarian cancer, transitory ostomies are performed to limit the consequences of anastomotic leak. Although intended to be temporary, a proportion of these ostomies might never be reversed. This was a retrospective study of patients with 2014 International Federation of Obstetrics and Gynecology stage IIB-IVB ovarian cancer requiring a transitory ostomy during primary or secondary cytoreductive surgery at the Bergonie Institute, France, and the University Hospital of Las Palmas, Spain, between January 2012 and December 2022. Rate of ostomy reversal, its timing (weeks) and postoperative complications were assessed. Multivariate logistic regression analysis was performed to identify limiting factors for ostomy reversal. During the study period, we reviewed data on 181 consecutive patients with ovarian cancer with transitory ostomy creation; 89 (49.2%) patients were not candidates for an ostomy reversal surgery because of disease progression (n=65), death (n=16), and patient's refusal of surgery (n=8). A total of 92 patients were candidates for reversal surgery and were therefore included in the final analysis. In total, 57 (62%) patients had their ostomy reversed. The mean time from ostomy creation to ostomy closure was 47.7 (standard deviation=33.1) weeks. Hartmann's procedure (leaving a rectal stump of 5-6 cm) was identified as an independent predictive factor for non-reversal of ostomy (odds ratio=6.42, 95% confidence interval=1.61-25.53; p=0.008). Complications after ostomy reversal occurred in 32 patients (34.8%). Hartmann's procedure is a limiting factor for ostomy reversal in patients with ovarian cancer. We recommend avoiding Hartmann's procedure during cytoreductive surgery, even after colorectal anastomotic leak.

BBT-877, a Novel Autotaxin Inhibitor, Abrogates Drug Resistance in Epithelial Ovarian Cancer Stem Cells

Cancer stem cells (CSCs) contribute significantly to the poor prognosis of patients with epithelial ovarian cancer (EOC) due to their roles in drug resistance and tumor metastasis. Autotaxin (ATX) plays a pivotal role in the maintenance of the CSC-like properties of EOC tumors. BBT-877 is a novel ATX inhibitor used in clinical treatment of idiopathic pulmonary fibrosis. However, the effects of BBT-877 on drug resistance and metastasis in ovarian CSCs remain unknown. In this study, we aimed to investigate the effects of BBT-877 on drug resistance and intraperitoneal metastasis of EOC. Spheroid-forming CSCs, which were isolated from two EOC cell lines, A2780 and SKOV3, were investigated by cell viability, western blot, PCR, Spheroid-forming assay, and in vivo experiments. Spheroid-forming CSCs exhibited increased CSC-like properties and paclitaxel (PTX) resistance. BBT-877 treatment inhibited the viability of spheroid-forming CSCs more potently than that of adherent ovarian cancer cell lines. Combinatorial treatment with BBT-877 and PTX significantly attenuated the viability of spheroid-forming CSCs. In a SKOV3 cells-derived intraperitoneal metastasis model, BBT-877 treatment reduced the number of metastatic tumor nodes, while combinatorial treatment with BBT-877 and PTX more potently attenuated the formation of metastatic nodes and accumulation of ascitic fluid. These results suggest that BBT-877 can be combined with conventional anticancer drugs for the treatment of patients with recurrent or drug-resistant EOC.

Post-traumatic Stress and Depressive Symptoms in Women With Ovarian Cancer 3-6 Months After Diagnosis

The potentially traumatic role of severe life-threatening medical conditions is still debated in psychiatry and not yet recognized, particularly among post-traumatic stress disorders. However, increasing evidence suggests the psychopathological impact of severe medical conditions related to their poor prognosis, high lethality, treatments heaviness and invasiveness. Ovarian cancer (OC) is one of the malignancies with the highest mortality and the aim of this study was to investigate post-traumatic stress and depressive symptoms in women 3 to 6 months after diagnosis. A sample of 83 women diagnosed with OC at different stages (from AI to IV) was recruited and assessed by means of the: Structural Clinical Interview for Mental Disorders according to DSM-5 (SCID-5), Trauma and Loss Spectrum Self-Report (TALS-SR), Impact Event Scale-Revised (IES-R), Hamilton Rating Scale for Depression (HAM-D), Mood Spectrum-Self Report (MOOD-SR), Work and Social Adjustment Scale (WSAS). Full data on the psychiatric assessments were available for 45 patients: 13 (28.9%) patients reported a diagnosis of PTSD. Patients with PTSD reported statistically significant higher depressive symptoms and more severe impact on work and social functioning compared to those without PTSD. Our results highlight the need to carefully assess the potentially traumatic burden of a diagnosis of OC and its association with depressive symptoms for their impact on patients' global functioning, in order to provide appropriate preventive and therapeutic interventions.

Calcitriol Combined With Platinum-based Chemotherapy Suppresses Growth and Expression of Vascular Endothelial Growth Factor of SKOV-3 Ovarian Cancer Cells

To evaluate the effects of the combination of calcitriol and chemotherapy and to identify the molecular mechanisms underlying the effect of calcitriol on ovarian cancer cells. SKOV-3 cells were treated with calcitriol and cisplatin, and their effects alone and in combination in a dose-dependent manner were compared. Cell viability, cell proliferation, and apoptosis were assessed using the following assays: PrestoBlue, intracellular adenosine triphosphate, caspase-3/7 activity, annexin V, and immunoblotting, respectively. Calcitriol alone caused dose-dependent inhibition of cell survival and proliferation, and induced apoptotic cell death of SKOV-3 cells. We confirmed that the expression of vitamin D receptor was increased in a dose-dependent manner by calcitriol. Combination treatment using calcitriol at a physiological concentration of 10-100 nM plus cisplatin significantly suppressed cell survival and induced apoptosis. Furthermore, when calcitriol was administered alone, the activity of vascular endothelial growth factor decreased in a dose-dependent manner, and when combined with cisplatin, activity was more suppressed. In SKOV-3 ovarian cancer cells, calcitriol plus cisplatin exerted greater antiproliferative, apoptotic, and anti-angiogenic effects than cisplatin alone. Adding calcitriol to platinum-based chemotherapy might be beneficial to patients with ovarian cancer.

MRI Texture Analysis of Inguinal Lymph Node Metastasis in Vulvar Cancer – Associations With Histopathology

Texture analysis is a quantitative imaging technique that provides novel biomarkers beyond conventional image reading. This study aimed to investigate the correlation between texture parameters and histopathological features of lymph nodes in patients with vulvar cancer. Overall, nine female patients (mean age 70.1±13.4 years, range=39-87 years) were included in the analysis. All patients had squamous cell carcinomas and underwent upfront surgery with inguinal lymph node resection. Immunohistochemical assessment was performed using several markers of the epithelial-mesenchymal transition. The presurgical magnetic resonance imaging (MRI) was analyzed with the MaZda package. In discrimination analysis, several parameters derived from T1-weighted images showed statistically significant differences between non-metastatic and metastatic lymph nodes. The highest statistical significance was reached by the texture feature "S(0,3)InvDfMom" (p=0.016). In correlation analysis, significant associations were found between MRI texture parameters derived from both T1-weighted and T2-weighted images and the investigated histopathological features. Notably, S(0,3)InvDfMom derived from T1-weighted images highly correlated with the Vimentin-score (r=0.908, p=0.001). Several associations between MRI texture analysis and immunohistochemical parameters were identified in metastasized lymph nodes of cases with vulvar cancer.

Multidisciplinary Therapy of Uterine Ewing’s Sarcoma With the Preservation of Uterus and Ovarian Function by Laparoscopy: A Case Report and Literature Review

Primary uterine Ewing's Sarcoma is an extremely rare and aggressive tumor. Due to its rarity, there is no established standard treatment, and most cases involve radical surgery, often compromising fertility and ovarian function. Recent advances in multimodal therapy have introduced fertility-preserving approaches for young patients. An 18-year-old woman visited our hospital for a detailed examination of a 10 cm-sized uterine tumor initially diagnosed as a leiomyoma by MRI. A GnRH agonist was administered to treat presumed myoma and associated anemia. Despite the administration of three cycles of the GnRH agonist, the patient's anemia did not improve. The size of the tumor was not reduced, and the inner structure of the tumor became irregular. A tumorectomy was performed and the uterus was repaired. Histological examination, including immunohistochemical staining, suggested Ewing's Sarcoma based on hematoxylin-eosin findings and strong CD99 positivity. Fluorescence in situ hybridization confirmed ESWR1 gene rearrangement in the tumor cells, leading to a definitive diagnosis of Ewing's Sarcoma. Since PET-CT showed pelvic and para-aortic lymph metastasis after laparotomy, VDC-IE chemotherapy was performed after oocyte cryopreservation. The multiple swellings of the lymph nodes were improved. To enhance curative potential, proton therapy was administered to the whole pelvis and para-aortic lymph nodes. To preserve ovarian function, a laparoscopic ovarian transposition was performed before proton therapy. Her right ovary was mobilized to the peritoneum at the level of the upper lobe of the right kidney This case of primary uterine Ewing's Sarcoma was treated with multimodal therapy, achieving curative outcome while preserving ovarian function and fertility through laparoscopic ovarian transposition.

Anticancer Effects of BAF312 (Siponimod) in Epithelial Ovarian Cancer

Epithelial ovarian cancer (EOC) is a lethal disease that is the fifth leading cause of cancer-related death in women. BAF312 (siponimod) is a potent and selective sphingosine-1-phosphate (S1P) receptor modulator that has been approved as a treatment for multiple sclerosis. In addition to its immunomodulatory action, BAF312 shows preclinical antitumor effects in several cancer types. This study sought to determine whether BAF312 had anticancer properties against EOC using in vitro and in vivo models. EOC cell lines A2780, SKOV3ip1, A2780-CP20, and SKOV3-TR were treated with BAF312 and tested for cell proliferation, apoptosis, and migration using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, fluorescence-activated cell sorting, and migration assays. We investigated the expression of sphingosine-1-phosphate receptor 1 (S1PR1) in most EOC cell lines through western blot analysis. To investigate potential mechanisms, western blot analysis was used to assess the expression of AKT serine/threonine kinase 1 (AKT) and extracellular-regulated kinase (ERK) after BAF312 treatment. We also created poly(D,L-lactide-co-glycolide) nanoparticles encapsulating BAF312 (PLGA-NP-BAF312) for in vivo therapy. The average size and zeta potential of PLGA-NP-BAF312 were determined using dynamic light scattering. The therapeutic efficacy of PLGA-NP-BAF312 was tested in an A2780 tumor-bearing orthotopic mouse model of EOC. S1PR1 was overexpressed in most EOC cell lines. BAF312 significantly reduced cell proliferation and migration while inducing significant apoptosis in all EOC cell lines. PLGA-NP-BAF312 treatment significantly reduced tumor weights in A2780 tumor-bearing mice. Furthermore, the anticancer effects of BAF312 were associated with reduced phosphorylation of ERK and AKT. Our findings show that BAF312 has significant anticancer effects in EOC cells by inhibiting the ERK and AKT pathways, and might potentially be used to treat EOCs.

Efficacy and Safety of Platinum-based Chemotherapy With Bevacizumab Followed by Bevacizumab Maintenance for Recurrent Ovarian, Fallopian Tube, and Primary Peritoneal Cancer During PARP Inhibitor Therapy: A Multicenter Retrospective Study

In recent years, the usefulness of poly ADP-ribose polymerase (PARP) inhibitors as subsequent maintenance therapy with poly ADP-ribose polymerase (PARP) inhibitors has been reported. However, it has been reported shown that platinum-based chemotherapy has a low response rate and short progression-free survival for recurrent platinum-sensitive ovarian cancer during treatment with PARP inhibitor therapy. This retrospective study evaluated platinum-based chemotherapy with bevacizumab (BEV) followed by BEV maintenance in these recurrent patients. Efficacy and safety were evaluated in 23 patients with ovarian, fallopian tube, or primary peritoneal cancer diagnosed with platinum-sensitive recurrence during PARP inhibitor treatment (administered from April 2019 to December 2022). Platinum-based chemotherapy included either paclitaxel with carboplatin, paclitaxel with cisplatin, docetaxel with carboplatin, or doxorubicin with carboplatin. BEV was administered in combination with any of these chemotherapies agents. Chemotherapy was administered for 6 cycles and BEV was administered up to 21 cycles. The median numbers of cycles of platinum-based chemotherapy and BEV administration were 6 and 8, respectively. Complete response was observed in four patients (17.4%), partial response in 15 (65.2%), stable disease in two (8.7%), and progressive disease in two (8.7%). Objective response and disease control rates were 82.6% and 91.3%, respectively. Grade 3 or higher hematological toxicity occurred in 8 patients, with leukopenia, neutropenia in 14, anemia in 5, and thrombocytopenia in 4. On the other hand, non-hematological toxicities included hypertension in three patients, proteinuria in two, constipation in one, and carboplatin hypersensitivity in four. Only one patient discontinued chemotherapy due to an adverse event of proteinuria. No treatment-related deaths occurred. Platinum-based chemotherapy with BEV followed by BEV maintenance for platinum-sensitive recurrence during PARP inhibitor treatment was shown to be efficacious and safe. This combination should be further evaluated in larger randomized clinical trials.

Hyperthermic Intraperitoneal Chemotherapy in the Management of Primary Epithelial Ovarian Cancer: A Debated Issue for Gynecologic Oncologists

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely investigated in patients with peritoneal carcinomatosis, including those with epithelial ovarian cancer (EOC), with conflicting results. The hyperthermia enhances drug tissue penetration, synergizes with several cytotoxic drugs including cisplatin, degrades BRCA2, suppresses homologous recombination, and elicits an anticancer immune response. A meta-analysis of retrospective studies including both patients with primary advanced EOC and those with recurrent platinum-sensitive EOC failed to detect a benefit in terms of progression-free survival (PFS) or overall survival (OS) from the addition of HIPEC after surgery. The aim of the present review was to analyze the recent randomized clinical trials designed to assess the value of HIPEC in the management of patients with primary advanced EOC. Although not free from criticism and bias, the available data from two phase III trials seem to suggest that the addition of HIPEC to interval debulking surgery after neoadjuvant chemotherapy significantly improves PFS and OS. Conversely, HIPEC does not appear to offer any advantage after primary debulking surgery. Several phase III trials are currently ongoing on these issues and the use of HIPEC is still a matter of debate in the scientific community. Additional translational research is strongly warranted to detect biological variables able to identify a subset of patients who may have a major benefit from this therapeutic approach. In particular, the clinical outcome of patients who undergo HIPEC should be correlated with BRCA status and homologous recombination repair status.

Reappraisal of a Renovated Cell-free and Concentrated Ascites Reinfusion Therapy for Malignant Ascites

Cell-free and concentrated ascites reinfusion therapy (CART) was established for refractory ascites and renovated CART (Keisuke Matsusaki (KM) -CART) has been recently developed especially for malignant ascites; however, the actual clinical efficacy of KM-CART has been rarely reported. We performed 226 KM-CART procedures in 104 patients with malignant ascites in three hospitals from August 2013 to September 2018. Medical records were retrospectively reviewed for ascites data, related complications, symptoms before and after each CART and prognosis after the first CART. The modified Glasgow Prognostic Score (mGPS) was reviewed before every procedure, as an indicator of nutritional status. Pancreatic cancer was the most common indication for the KM-CART procedure, followed by gastric cancer, hepatocellular carcinoma, ovarian cancer, and cholangiocarcinoma (five major diseases). The 50% survival times of these five major diseases after the first procedure were 25, 39, 31, 49, and 33 days, respectively. The mean survival time for all patients was 73.5 days, and 75.6 days for those with the five major diseases. All patients experienced symptomatic relief, and complications were rare. Repeated KM-CART was performed in 47.1% of the patients, most often in those with ovarian cancer (66.7%). Regarding the mGPS at the first CART procedure, 89% of patients were in the group with the poorest nutritional status. Patients who underwent KM-CART three or more times had longer survival than those who were treated once or twice. Repeated KM-CART provides a survival benefit for patients with malignant ascites, even in cases of poor nutritional status.

Programmed Cell Death Ligand-1 (PDL-1) Correlates With Tumor Infiltration by Immune Cells and Represents a Promising Target for Immunotherapy in Endometrial Cancer

Endometrial carcinoma (EC) is one of the most common gynecological cancers in the Western Hemisphere. Nevertheless, there are not enough appropriate treatment options, especially for advanced stages. The immune checkpoint blockade represents a promising alternative to established cancer therapies by suppressing the immune-inhibitory activity of the immune checkpoint factors programmed cell death-1 (PD-1) and programmed cell death ligand-1 (PD-L1). In the present study, we characterized the clinical relevance of the biomarker PD-L1 expression in terms of its prognostic capabilities in EC. Tumor tissue samples from 87 EC patients were retrospectively analyzed by immunohistochemistry (PD-L1, p16, estrogen receptor, progesterone receptor, HER2/neu, Ki-67, CD3, CD20, CD68). A total of 17.3% of EC patients were PD-L1 positive. PD-L1 status did not represent a suitable prognostic marker in EC, but correlated with T3/T4stage, positive lymph node status, p16 expression, and absence of estrogen and progesterone receptor. PD-L1 positive tissues showed increased infiltration with lymphocytes, monocytes, and macrophages, although not statistically significant in every case. In EC, PD-L1 expression has no prognostic significance, but correlates with other oncogenic factors and indicates increased infiltration of the tumor with immune cells. Thus, PD-1/PD-L1 immunecheckpoint blockade seems to be very promising, at least in a subset of EC patients.

Prognostic Significance of the Detection of Human Papilloma Virus L1 Protein in Smears of Cervical Intraepithelial Neoplasia Grade 3 in Pregnant Women

Cervical intraepithelial neoplasia (CIN) III/high-grade squamous lesions (HSIL) remains a significant challenge during pregnancy. Current data on the course of disease are contradictory, with cases of progression to cervical cancer (CC) during pregnancy being observed. Evidence suggests that the expression of L1 capsid protein is associated with a favorable prognosis in non-pregnant women. The aim of this study was to evaluate L1 expression in pregnant women with CIN III/HSIL. Between 2008 and 2021, the conventional PAP-smears from pregnant women were retrospectively analyzed for the expression of L1. Only women with histologically confirmed CIN III/HSIL during pregnancy were included. A total of 161 women were included in this study; among them, 32 women (19.9%) had regressive disease postpartum. The majority of women (n=123, 76.4%) had persistent disease. In six cases, invasive CC was histologically proven postpartum (3.7%). In 113 women (70.2%) the PAP-Smears were L1- and 29.2% (n=48) of women were L1+. The rates of regression for L1+ were higher than for L1-, 25% vs. 17.7%, respectively. Rates for persistence were similar, at 75% and 78%, respectively. All cases of progression to CC were L1 negative during pregnancy. In pregnant women, the rates of regression were higher in L1+ CIN III/HSIL cases. All women who progressed to CC were L1-. Therefore, detecting L1 expression could serve as a valuable test to rule out progression to CC in pregnant women. This approach may provide reassurance to women, allowing them to continue their pregnancies with reduced fear and anxiety about CIN III/HSIL during pregnancy.

Comprehensive Clinicopathological and Immunohistochemical Analysis of Human Papillomavirus-independent Squamous Cell Carcinoma and Adenosquamous Carcinoma of the Uterine Cervix

Human papillomavirus-independent (HPVI) squamous cell carcinoma (SCC) and adenosquamous carcinoma (ASC) of the uterine cervix are extremely rare. The aim of this study was to comprehensively describe the clinicopathological features, patient outcomes, and immunophenotypes of HPVI SCC and ASC. We found four and two patients with HPVI SCC and ASC, respectively, and reviewed their electronic medical records and pathology slides. We also performed immunostaining for p16 and p53. All except one patient underwent surgery. Two, one, and one patients with HPVI SCC were diagnosed as having IIIC1, IVA, and IVB diseases, respectively. Two patients with HPVI SCC experienced recurrences, and died of disease within nine months after treatment initiation. Both patients with HPVI ASC developed lung metastasis at four months post-operatively. HPVI SCCs and the squamous component of HPVI ASCs showed keratinizing, condylomatous, or poorly differentiated morphology. The glandular component of HPVI ASCs was gastric-type endocervical adenocarcinoma. None of the six tumors exhibited block positivity for p16. Two HPVI SCCs and one HPVI ASC displayed aberrant p53 expression. HPVI SCC is a rare and aggressive cervical malignancy that presents initially as advanced-stage disease with poor prognosis. Although the patients with initial stage I and II HPVI ASC were treated with curative intent, distant metastases appeared in the lungs during the early course of treatment. Further investigations are necessary to clarify the association between histological features and clinical behavior of HPVI ASC.

Invasive Stratified Mucin-producing Carcinoma of the Uterine Cervix: Comparison of Its Clinicopathological Characteristics and Programmed Death-ligand 1 Expression Status With Those of Other Endocervical Adenocarcinomas

Invasive stratified mucin-producing carcinoma (ISMC) is a rare but aggressive variant of endocervical adenocarcinoma (EAC). The aim of this study was to investigate the differences in clinicopathological features, patient outcomes, and programmed death-ligand 1 (PD-L1) expression among ISMC, usual-type EAC (UEA), and gastric-type EAC (GEA). PD-L1 22C3 immunostaining was performed using 20 ISMCs, 20 UEAs, and 20 GEAs. Combined positive score (CPS) method was used to assess PD-L1 immunoreactivity. ISMC was diagnosed at a younger age and showed a more advanced stage and shorter survival than UEA. The disease-free survival (DFS) and overall survival (OS) rates of ISMC patients were lower than those of UEA but comparable to those of GEA. ISMC type was an independent prognostic factor for predicting short DFS [hazard ratio (HR)=2.790, 95% confidence interval (CI)=1.153-6.756] and OS (HR=6.071, 95%CI=1.257-29.327). All ISMCs showed PD-L1 over-expression with a mean CPS of 44.5 (range=10-100), which was higher than those of UEA (mean CPS=8.2) and GEA (mean CPS=6.5). PD-L1 positivity (CPS≥1) was also an independent prognostic factor for worse OS (HR=2.472, 95%CI=1.097-5.570). Despite PD-L1 over-expression, ISMC patients treated with pembrolizumab showed no clinical response. All examined ISMCs over-expressed PD-L1. ISMC showed higher PD-L1 expression than UEA and GEA and worse survival than UEA. PD-L1 over-expression was found to be a significant predictor for worse DFS and OS in patients with ISMC. Our data suggest that PD-L1 over-expression is associated with poor ISMC prognosis.

Investigation of the Efficacy of Nowarta110 in the Treatment of HPV-16 and HPV-18 Oncogenically-transformed Human Cells and Cancer-implanted Animal Models

Cervical cancer is the third leading cause of cancer-related death in women worldwide. Nearly all cases of cervical cancer are due to infection with human papillomavirus (HPV). Nowarta110 has shown breakthrough therapeutic efficacy in phase II clinical study against plantar warts, with no reported side effects. This study evaluated the effectiveness of Nowarta110 in killing cultured HPV-transformed cancer cells and its anti-cancer effects in mice, using both vaginally engrafted and subcutaneously implanted animal cancer models. Nowarta110 is a novel compound composed of colloidal silver and fig extract. The cytotoxic properties of Nowarta110 were evaluated on HPV-16 and HPV-18-transformed human cancer cells (ARPE-19/HPV-16 and HeLa cells, respectively). The therapeutic potential of Nowarta110 in vivo was evaluated following the engraftment of ME-180 epidermoid carcinoma cells in the mouse vagina or their subcutaneous implantation. Nowarta110 treatment was initiated when the tumor reached an approximate volume of 65 mm Nowarta110 effectively induced cell death in HPV-16 and HPV-18-transformed human cancer cells. It also effectively induced tumor regression in mouse models with intravaginally engrafted or subcutaneously implanted cancer cells. Considering the high prevalence of HPV-induced cervical dysplasia and cancer and the lack of treatment, clinical studies to promote the implementation of Nowarta110 are warranted.

The Role of SARS-CoV-2 Spike Protein in the Growth of Cervical Cancer Cells

Recently developed vaccines for the SARS-CoV-2 virus utilize endogenous production of the virus' spike protein (SP), allowing the host to develop an immune response. As a result of the novelty of this virus and its vaccines, little is known overall about the potential effects of the SP on the pathogenesis of neoplasia, either from vaccination or from infection. This study was designed to investigate whether SARS-CoV-2 SP has any direct effect on SiHa cervical cancer cells. The effects of SARS-CoV-2 SP on cervical cancer cell proliferation and apoptosis were investigated by using clonogenic cell survival assay, quick cell proliferation assay, and caspase-3 activity kits in a widely-used cervical cancer cell line, SiHa. RT-PCR and immunohistochemistry were also performed to determine the potential molecular mechanisms. The growth and proliferation of SiHa cancer cells were inhibited by SARS-CoV-2 SP. SARS-CoV-2 SP also induced apoptosis in SiHa cancer cells. The anti-proliferative effect of SARS-CoV-2 SP on SiHa cancer cells was associated with the up-regulation of the anti-proliferative molecule p53. The pro-apoptotic effect of SARS-CoV-2 SP on SiHa cells was associated with the up-regulation of the pro-apoptotic molecule TRAIL. SARS-CoV-2 SP inhibits the growth of cervical cancer via up-regulation of p53 and TRAIL. Further studies are needed to elaborate on the potential effects of the SARS-CoV-2 SP on other cancer cell lines and normal physiological cell lines for comparison.

Association of UBE2L6 and ABCB6 Expression With Platinum Resistance in Serous Ovarian Carcinoma

Platinum-based drugs are the standard treatment for ovarian cancer, and platinum resistance is a major problem. A previous study has reported that the UBE2L6 expression is elevated in cisplatin-resistant cells, which in turn leads to cisplatin resistance by modulating the transcriptional expression of ABCB6. The present study aimed to investigate the expression of UBE2L6 and ABCB6 in ovarian carcinoma and to evaluate the association between these markers and platinum resistance. Ninety-two patients diagnosed with serous ovarian carcinoma (SOC) were enrolled in this study. Tissue samples were collected from these patients and analysed using immunohistochemistry to assess the expression of UBE2L6 and ABCB6. UBE2L6 and ABCB6 staining was positive in 41 (44.6%) and 46 (50.0%) cases, respectively. UBE2L6 expression was statistically significantly associated with International Federation of Gynecology and Obstetrics (FIGO) stage (p=0.008). Both UBE2L6 and ABCB6 were significantly associated with platinum sensitivity (p<0.001 and p<0.001). A positive correlation was observed between the expression levels of UBE2L6 and ABCB6 (r=0.673, p<0.001). Progression-free survival (PFS) was significantly longer in the UBE2L6 negative group than that in the positive group (median PFS, 31.4 vs. 11.1 months, p<0.01) and in the ABCB6 negative group than that in the positive group (median PFS, 29.6 vs. 12.2 months, p<0.01). UBE2L6 and ABCB6 expression is associated with the prognosis of SOC. UBE2L6 and ABCB6 may be potential biomarkers of platinum-resistant ovarian cancer.

Real-world Efficacy and Safety of Bevacizumab for Advanced or Recurrent Müllerian Cancer: A Single-institutional Experience

The efficacy and safety of bevacizumab for ovarian cancer have been reported in randomized phase III clinical trials. It is important to gather experience and data in a real-world setting. The objective of the present study was to evaluate the efficacy and safety of bevacizumab for patients with ovarian cancer in a real-world setting. For front-line settings, patients with FIGO stage III-IV ovarian cancer treated using bevacizumab and chemotherapy after debulking surgery (Chemo + Bev group, n=79), in addition to those treated with only chemotherapy after debulking surgery (Chemo group; n=66), at our institute were reviewed retrospectively. For recurrent settings, patients with recurrent ovarian cancers treated with bevacizumab and any chemotherapy were reviewed retrospectively (n=65). In the front-line setting, the disease-free survival was significantly longer in the Chemo + Bev group compared with that in the Chemo group (p=0.021). Hypertension and proteinuria were found to be statistically more frequent in the Chemo + Bev group compared with that in the Chemo group (p=0.002 and p=0.004). In the recurrent setting, in platinum-sensitive patients, the response rate (RR) and the disease control ratio (DCR) were 78.4 and 94.1%, respectively. In platinum-resistant patients, the RR and the DCR were 28.6 and 57.1% respectively. The median progression-free survival was 18.3 and 7.1 months for platinum-sensitive recurrence and platinum-resistant recurrence, respectively. The major ≥ grade 3 adverse event was neutropenia. The present study provided encouraging real-world evidence of the efficacy and safety of bevacizumab for ovarian cancer in real-world.

Somatic Variants in DNA Damage Response Genes in Ovarian Cancer Patients Using Whole-exome Sequencing

Several clinical trials have investigated homologous recombination deficiency and BRCA1/2 status to select ovarian cancer patients for treatment with poly(ADP-ribose) polymerase-inhibitors (PARPi), but less attention has been given to other DNA-damage response (DDR) pathways. Therefore, we investigated somatic single/multiple nucleotide variants and small insertions/deletions in exonic and splice-site regions of 356 DDR genes to examine whether genes other than BRCA1/2 are altered. Whole-exome sequencing data from eight high-grade serous adenocarcinoma (HGSC) and four clear cell carcinoma (oCCC) patients were analyzed. Forty-two variants (pathogenic, likely pathogenic or variants of uncertain significance) in 28 genes from DDR pathways were identified. Seven out of nine TP53 variants were previously described in The Cancer Genome Atlas Ovarian Cancer; other variants were found in 23 out of 28 unique genes, whereas no variants were reported in FAAP24, GTF2H4, POLE4, RPA3, and XRCC4. As the identified variants were not only limited to well-known TP53, BRCA1/2, and HR-associated genes, our study might contribute to the better understanding of which DDR pathways potentially influence disease progression. Moreover, they may display a potential role as biomarkers to predict platinum-based chemotherapy or PARPi treatment response or disease progression, as differences in disrupted DDR pathways were observed between patients with long and short overall survival in HGSC and oCCC groups.

Opioid Use in Patients With Cervical Cancer at a Tertiary Academic Medical Center

Opioids are a common treatment for cancer-related pain and information is limited on the rates of opioid use for cervical cancer patients. This study aimed to analyze outpatient opioid use and various predictors among patients with cervical cancer at a tertiary academic medical center. Data from patients with cervical cancer receiving treatment at a single institution, from August 2019 to July 2022, were retrospectively collected. Women with unrelated chronic opioid use or opioid use associated with acute inpatient stays were excluded. Charts were reviewed for patient demographics, disease characteristics, treatment characteristics, disease outcomes, and opioid prescriptions. The primary endpoint was duration of opioid use ≥6 months. Pearson's chi-squared testing, Welch's two-sample t-testing and Fisher's exact testing were used to determine predictors of opioid use ≥6 months. In total, 108 patients with cervical cancer (76.1%) of the 142 that received treatment were prescribed opioids. In women who were prescribed outpatient opioids, the median duration of opioid use was 69 days (interquartile range=5-359 days). In total, 40 (37.0%) had prescriptions for ≥180 days and 27 (25.0%) had prescriptions ≥365 days. On bivariate analysis, lower stage and receipt of surgery were associated with opioid use duration <6 months. Age, race, histology, substance/tobacco/alcohol use, depression/anxiety, and the receipt of brachytherapy/radiation were not associated with length of opioid prescriptions. This study demonstrated that 37% of patients with cervical cancer were using opioids for cancer-related pain longer than 6 months. Higher stage was associated with opioid use duration ≥6 months.

Immunological Markers ofChlamydia trachomatisInfection in Epithelial Ovarian Cancer

Pelvic inflammatory disease (PID) is a risk factor for epithelial ovarian cancer (EOC). Chlamydia trachomatis infection, a major cause of PID, may persist in some women. Serum IgG antibodies to chlamydial TroA and HtrA are more common in ascending or repeat chlamydial infection than in uncomplicated infection. The aim of this study was to explore the role of C. trachomatis infection in EOC by analyzing chlamydial TroA, HtrA and major outer membrane protein (MOMP) IgG serum antibody responses. The study is based on the review of Oulu University Hospital medical records of 162 women diagnosed with EOC between March 2008 and May 2018. Serum IgG antibody responses to recombinant C. trachomatis TroA, HtrA and MOMP were analyzed using enzyme-linked immunoassay. Complete response to the first line therapy and the three-year survival were the study endpoints. Altogether, 16.7%, 11.1% and 12.3% women were C. trachomatis TroA, HtrA and MOMP IgG positive, respectively. Women with these antibodies were more likely to have a complete response to the first-line treatment, compared to women without these antibodies (63.0% vs. 34.1% for TroA IgG, 50.0% vs. 37.5% for HtrA IgG and 50% vs. 37.3% for MOMP IgG, respectively). The presence of these antibodies predicted better three-year survival. Women with EOC and positive markers of persistent C. trachomatis infection have better response to the first-line treatment and seem to have better three-year survival.

Non-thermal Acoustic Enhancement of Chemotherapeutic Effects of Cisplatin on Xenografted Cervical Cancer in Mice

We examined the effect of low-intensity focused ultrasound (FUS) on unbinding cisplatin from plasma proteins and enhancing its chemotherapeutic efficacy using a mouse model of xenograft human cervical cancer. FUS, operating in a pulsed mode, was applied to a dialysis cassette immersed in a normal saline bath containing both bovine serum albumin (BSA) and cisplatin, and the unbound level of cisplatin diffused into the cassette was measured. To assess the in vivo efficacy of the technique, athymic nu/nu mice were inoculated with human cervical cancer cells under four different combinatory conditions, with and without the administration of cisplatin and FUS. FUS was delivered to the tumor mass for 1 h across four separate sessions spanning a period of 10 days, following the intraperitoneal injection of cisplatin. In vitro equilibrium dialysis revealed that non-thermal application of FUS increased the concentration of unbound cisplatin compared to cassettes that were not exposed to sonication, suggesting successful unbinding. Assessment of tumor growth in vivo showed that FUS following cisplatin administration resulted in a significant reduction in tumor growth, whereas the administration of cisplatin alone exhibited plateau growth. Without administration of cisplatin, equivalent rates of aggressive tumor growth were observed regardless of the application of FUS. Pulsed application of FUS can unbind cisplatin from albumin and enhance its tumoricidal effects in cervical cancer. Further assessment of intratumoral/systemic cisplatin concentration is required to quantify its selective delivery to the tumor.

WNT Signaling Driven by R-spondin 1 and LGR6 in High-grade Serous Ovarian Cancer

R-spondins control WNT signaling and RSPO1 and LGR6, two of its receptors, are uniquely expressed at high levels in high-grade serous ovarian cancer (HGSOC). The aim of this study was to assess the interrelations between the expression of the RSPOs and LGRs in HGSOC and in the ovarian surface (OSE) and fallopian tube surface epithelium (FTSE) from which HGSOC arises. Analysis of TCGA (HGSOC), CCLE (ovary), and other publicly accessed RNA-Seq data using UC San Diego Computational Cancer Analysis Library (CCAL) to perform differential expression analysis, association studies, and gene set inspection using the single-sample GSEA method. Additionally, we employed multiple publicly available databases including StringDB, Human Protein Atlas, and cBioPortal to aid the investigation. Among normal tissues, expression of RSPO1, LGR5 and LGR6 was highest in the fallopian tube. The relative levels of expression of the RSPOs and LGRs in the OSE and FTSE matched those in HGSOC. RSPO1 and LGR6 were highly co-expressed in all three tissues. Gene set enrichment analysis (GSEA) showed that expression of RSPO1 was strongly linked to the enrichment of three separate WNT-driven GO pathways. Analysis of genes that impacted overall survival identified two other immediately adjacent genes that control WNT signaling, KREMEN1 and ZNRF3 whose expression and copy number were coordinately linked. RSPO1 and LGR6 are coordinately expressed in HGSOC and the two normal tissues from which this tumor arises, and their expression is linked to WNT signaling pathways known the control cell fate and proliferation.

Assessment of Breakthrough Cancer Pain Among Female Patients With Cancer: Knowledge, Management and Characterization in the IOPS-MS Study

Chronic secondary pain from cancer may flare into unexpected acute phases, called breakthrough cancer pain (BTcP). This phenomenon has a moderate-to-severe intensity and short latency between onset and peak of intensity, so clinical and therapeutic implications may be necessary. The Italian Oncologic Pain Multisetting-Multicentric Survey (IOPS-MS) aimed to characterize BTcP in a large number of patients from different settings and assess possible factors influencing its development. Previously, we observed differences according to sex in site, onset and level of BTcP. In this analysis, we assessed differences in non-predictable BTcP between female patients with female-specific cancer (FSC) (including breast and gynecological cancer) and those with non-FSC. A univariate analysis compared patients with FSC (overall and separately for breast and gynecological cancer) and non-FSC. A multivariate analysis stratified by BTcP phenotype was performed to estimate the main determinants of the risk groups in patients with FSC (overall and separately for breast and gynecological cancer) and non-FSC. Odds ratios and 95% confidence intervals were reported. The FSC group was younger, more often treated in clinics or day hospitals, and had an increased risk of locoregional/metastatic disease than the non-FSC group. Patients with breast cancer were at higher risk of locoregional/metastatic disease, less frequently treated by a palliative specialist and had later BTcP onset compared to the non-FSC group. Significant differences concerning age, care setting and BTcP onset were also found in the group of patients with FSC (overall and separately for breast and gynecological cancer) according to tumor extension. Non-predictable BTcP in patients with FSC presents unique characteristics, particularly regarding pain onset, care settings, and metastasis. Differences between breast and gynecological cancer emphasize the need for tailored pain-management approaches.

Ovarian Adult Granulosa Cell Tumors: A Scoping Review of DNA Alterations and Their Known Significance

Adult granulosa cell tumor (aGCT) is a rare and challenging ovarian tumor due to its unpredictable recurrence and its associated increased risk of breast and endometrial cancer. Identifying and describing molecular alterations in tumors has become common with the advent of high-throughput sequencing. However, DNA sequencing in rare tumors, such as aGCT, often lacks statistical power due to the limited number of cases in each study, thereby clinical implications of DNA alterations are difficult to interpretate. This scoping review aims to systematically describe somatic and germline DNA alterations identified in women with aGCT. Search terms (granulosa cell tumour AND molecular alterations) were searched in May 2024 in the following databases: MEDLINE (Ovid), Embase (Ovid), Web of Science Core Collection and Google Scholar. Screening, full-text review and data extraction were performed by two independent reviewers. Twenty-four publications were identified. Eighteen reported on somatic DNA alterations of patholgenic mutations identified in total 1,226 tissues being sequenced. FOXL2 (c.402C>G; p.C134W) was present in 97% of aGCTs. Other pathogenic mutations in the tissues investigated were TERT promoter mutation (41%), truncating KMT2D mutations (14%) and TP53 pathogenic variant (4%). TERT promoter mutation was reported more frequently in recurrent tumors (p<0.01), whereas comparing truncating KMT2D and TP53 mutations reported in primary and recurrent tumors revealed no difference (p=0.15 and p=0.26 respectively). Tumor mutational burden (TMB) was reported in five studies and all showed a low TMB. None of the somatic mutations were candidate targets for biological treatment. Six publications reported germline variants and no shared germline pathogenic variants were described in the published literature. The FOXL2 missense mutation was the only common somatic DNA alteration in aGCT. TERT promoter mutations were reported more frequently in recurrent aGCT but their clinical relevance remains uncertain. In contrast to previous reports, truncating KMT2D mutations were not found to be associated with recurrent aGCT. Evidence on common germline variants in aGCT is sparse. The role of somatic and germline DNA alterations in the development of other malignancies in women with aGCT remains uncertain. Further research involving matched primary and recurrent tumors, as well as other primary malignancies, is essential to better understand the mutations that drive tumor development.

Gene Expression Profiles in Ovarian Cancer Tissues as a Potential Tool to Predict Platinum-based Chemotherapy Resistance

Ovarian cancer (OC) is one of the leading gynecological causes of death among women. The current standard treatment for OC is debulking surgery followed by platinum-based chemotherapy treatments; however, despite initial success to treatment many patients experience relapses. Currently, there are no available tests to predict sensitivity or resistance to chemotherapy. The aim of this review is to investigate the literature regarding prediction of chemotherapy resistance in patients with OC using gene expression patterns. The literature research on PubMed resulted in a total of 490 articles published from November 20 Forty-four articles were included covering data from discovery cohorts obtained from hospitals and universities, as well as additional data obtained from online datasets from Gene Expression Omnibus and The Cancer Genome Atlas Program that provided either single- or multiple mRNA signatures that could discriminate between chemotherapy-sensitive and chemotherapy-resistant OC patients. OCs at all stages and histological subtypes were used but most articles included exclusively high-grade serous OC patients. mRNA-based biomarkers to predict chemotherapy resistance in patients have not yet been clinically implemented, but many differentially expressed genes between chemotherapy-resistant and -sensitive patients have been reported, such as ABCG2, DOCK4, DUSP1, DUSP4, DUSP5, GADD45B, HELQ, HOXA9, KLF4, and NR4A1, which could be compelling biomarker candidates for further studies.

Effect of MYC and PARP Inhibitors in Ovarian Cancer Using anIn VitroModel

The 8q24 chromosomal region, which contains the MYC and PVT1 candidate oncogenes, is amplified in carcinomas. Both genes have been involved in the etiopathogenesis of ovarian cancer (OC). In this study, we used an in vitro OC model with a known 8q24 copy number increase and in silico tools to investigate the expression of MYC/PVT1 loci and copy number variation in OC. We also assessed the effects of rucaparib (a PARP inhibitor) in the presence or absence of 10058F4 (a MYC inhibitor) on the expression of MYC/linear PVT1/circular PVT1. Tissue culture, chromosome preparation, RNA extraction, RT-qPCR, FISH, and wound healing assays were employed. OncoDB, cBioportal, UALKAN, and ROC Plotter in silico tools were also utilized. Although PVT1 and MYC expression levels remained unaltered in OC, putative copy number alterations across all cancers showed a marked difference between the two genes, particularly in gain and amplification for MYC. PVT1 expression demonstrated prognostic value for the treatment of patients with serous and endometrioid OC. Both genes correlated with PARP10, FAM83H, and DEPTOR. The use of rucaparib in the presence or absence of the MYC inhibitor (10058F4) in vitro, led to a significant down-regulation in the expression of MYC, linear, and circular PVT1. Our data provide a novel insight into the potential interactions of MYC and PVT1 with other genes. Moreover, we identified a new PARP inhibition mechanism down-regulating MYC, as well as the linear and circular PVT1 transcripts. Future work should expand on clinical studies to better understand the prognostic role of PVT1 in OC.

Therapeutic Efficacy of Prodrug Activator Gene Therapy Using Retroviral Replicating Vectors for Human Ovarian Cancer

Retroviral replicating vectors (RRV) have exhibited efficient tumor transduction and improved therapeutic benefits in a variety of cancer models. In this study, we validated two RRV created from amphotropic murine leukemia virus (AMLV) and gibbon ape leukemia virus (GALV), which use different cell receptors for virus entry, in human ovarian cancer (OC) cells. Expression levels of the receptors for AMLV (PiT-2) and GALV (PiT-1) in human OC cell lines (A2780, Caov3, RMG-1, SKOV-3), fibroblasts and HEK293 cells were evaluated using quantitative RT-PCR. In vitro RRV-GFP replication was monitored using flow cytometry, and cytotoxicity quantitated using AlamarBlue assay after 5-fluorocytosine treatment of OC cells transduced with RRV expressing the yeast cytosine deaminase prodrug activator gene. In vivo antitumor effect of RRV-mediated prodrug activator gene therapy was investigated in a SKOV-3 subcutaneous tumor model. Quantitative RT-PCR analysis revealed high expression levels of PiT-2 (AMLV receptor) and PiT-1 (GALV receptor) in the RMG-1 and SKOV3 OC cell lines, compared with their levels in non-malignant cells. In RMG-1 and SKOV3 cells, both RRV showed highly efficient RRV replication and spread leading to over 90% transduction by Days 10-13. Additionally, both RRV that express the yeast cytosine deaminase gene demonstrated effective cell killing of RMG-1 and SKOV-3 cells upon treatment with the prodrug 5-fluorocytosine. Notably, RRV-mediated prodrug activator gene therapy showed significant inhibition of subcutaneous SKOV-3 tumor growth in nude mice. RRV-mediated prodrug activator gene therapy may be used for treating PiT-expressing human OC.

Tumor Load Matters – the Peritoneal Cancer Index in Patients With High-grade Serous Ovarian Cancer

The aim of this study was to analyze the predictive and prognostic value of the peritoneal cancer index (PCI) with regard to complete cytoreduction and clinical outcomes in patients with high-grade serous ovarian cancer. In a cohort comprising 188 patients with high-grade serous ovarian cancer, the PCI was retrospectively assessed. Clinical factors and perioperative complications were analyzed according to different PCI groups. Five-year disease-free survival (DFS) and overall survival (OS) were calculated based on the Kaplan-Meier Log rank analysis. Receiver operating characteristic (ROC) analysis was applied to detect associations of PCI and complete cytoreduction. Multivariate survival analysis was performed by Cox proportional hazards model. In our study, the PCI was predictive of complete cytoreduction (ROC analysis; AUC 0.8227). In patients with optimal cytoreduction, higher PCI scores were associated with poorer 5-year OS (p9 (p=0.0023). Five-year OS was reduced in patients with severe complications compared to patients with none or mild complications (30.88% versus 51.01%; p=0.001). There were significant OS (p18). The PCI score showed high predictability for complete cytoreduction and was associated with clinical outcomes. In presence of severe complications, higher PCI scores were associated with poorer survival. Hence, in patients with high tumor load, the prevention of severe perioperative complications is of utmost importance in all cases where complete cytoreduction is deemed to be feasible.

Rare Histologies and Infrequent Indications for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

This single-centre study evaluated cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with rare histologies and uncommon tumour origins. Prospectively collected data from the data registry of a single institution was retrospectively investigated. We present a series of selected patients who underwent CRS and HIPEC between 2011 and 2021 for peritoneal metastases arising from infrequent tumour entities. The study included 76 patients. From the wide range of histologies, seven groups were formed: Cancer of unknown primary, uncommon ovarian cancer types, other gynaecological tumours (endosalpingiosis, endometrial and cervical cancer), small bowel carcinoma, recurrent peritoneal mesothelioma, desmoplastic small round-cell tumour, and other rare malignancies. The median peritoneal cancer index was 8. Fifty-five patients with primary and 22 patients with recurrent disease were examined. Complete macroscopic tumour resection was achieved in 84% of cases. The median survival was 68.53 months considering the entire cohort, whilst the longest survival rate was registered in the group with rare ovarian cancer, and the shortest in the group of patients with small round-cell tumour, at 112.3 and 11.4 months, respectively (small round-cell tumour versus rare ovarian cancer, hazard ratio=15.6817; 95% confidence interval=2.6585-92.5030; p=0.0024). Based on the encouraging results in some test groups, especially in rare ovarian cancer, CUP, small bowel cancer and recurrent mesothelioma, multicenter prospective studies examining such rare tumour histologies are needed to reach a higher number of cases and, thus, explore the impact of multimodal therapy on these patients.

Screening for Ovarian Cancer in the General Population: State of Art and Perspectives of Clinical Research

Screening for ovarian cancer in the general population is a challenging issue. The aim of this review was to analyze both the studies based on serum CA125 assay and ultrasound (US) and the novel perspectives of clinical and biological research on this issue. The trials on the combination of serum CA125 and vaginal/pelvic US as well as the investigations on microRNA (miRNA)s, circulating tumor DNA and tumor protein 53 (TP53) variants in DNA purified from Pap smears have been critically analyzed. Two large randomized trials failed to detect a reduction in ovarian cancer-related deaths in women who underwent serum CA125- and US-based screening compared to those who had no screening. The United Kingdom Collaborative Trial of Ovarian Cancer Screening reported a 39.2% higher incidence of stage I-II and 10.2% lower incidence of stage III-IV disease in women who underwent annual multimodal screening with serum CA125 and vaginal US compared to women who had no screening, but this stage shifting did not translate into a survival benefit. A longitudinal, multiple biomarker algorithm-based strategy might improve ovarian cancer detection compared with serial CA125 alone. The use of serum tumor-associated autoantibodies, circulating tumor DNA and microRNA is still investigational. The identification of TP53 clonal variants in DNA purified from Pap smears can detect early steps of serous ovarian carcinogenesis. The availability of sensitive next-generation sequencing-based approaches for TP53 assessment in PAP smears may allow the reliability of this genetic marker for early detection of ovarian cancer to be verified.

Adverse Events Associated With Long-term Treatment of Epithelial Ovarian Cancer With Bevacizumab and Chemotherapy

Adverse events associated with long-term bevacizumab administration for ovarian cancer have been poorly documented in Japan. This study aimed to evaluate the adverse events of bevacizumab combined with chemotherapy for treating primary and recurrent epithelial ovarian cancer in Japan. In this single-center retrospective study, we analyzed data of patients with advanced and recurrent epithelial ovarian cancer treated with bevacizumab and chemotherapy between January 2013 and November 2019. Statistical analyses were performed using the Fisher's exact test and Kaplan-Meier method. A total of 46 patients were included and the follow-up time was 30 months. The median duration of bevacizumab treatment was 14 months, and the median total dose of bevacizumab was 247.5 mg/kg. The most common adverse events were hypertension (n=30; 65.2%) and proteinuria (n=24; 49%) in all grades. The onset of hypertension and proteinuria occurred at a median of 2 months and 14 months after treatment initiation in all grades, respectively. Gastrointestinal perforation occurred significantly more frequently in patients with a history of radiation therapy. This study included cases of primary advanced and recurrent epithelial ovarian cancer, and had a longer observation period and reported more adverse events of bevacizumab with chemotherapy than previous reports. The administration of bevacizumab therapy in patients with a history of radiation should be carefully considered due to increased chances of gastrointestinal perforation.

Highly Aggressive Surgery Benefits in Patients With Advanced Ovarian Cancer

We investigated whether highly aggressive surgery has survival and perioperative complication benefit in patients with advanced ovarian cancer. This retrospective study included 209 patients with stage III/IV ovarian cancer who underwent aggressive surgery [surgical complexity score (SCS) ≥8] between January 2008 and December 2018. Patients were categorized into the SCS 8-12 (less aggressive surgery, 83 patients) and SCS ≥13 (highly aggressive surgery, 126 patients) groups. Survival outcomes and perioperative complications between the groups were compared. Patient suitability for primary debulking surgery or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) was based on the evaluation of performance status, tumor load, and ascites. If patients were suitable for NACT/IDS, the residual tumor margins were marked at the initial laparotomy. The previously marked lesions were removed during IDS, even in patients with macroscopic tumor resolution. Prevalence rates of stage IV disease, poor performance status, presence of omental cake, peritoneal cancer index ≥15, and IDS performed were significantly higher in the highly aggressive surgery group than in the less aggressive surgery group. The median progression-free survival (PFS) and overall survival (OS) were not significantly different between the groups (PFS, 32 and 31 months, respectively; p=0.622; OS, 99 and 75 months, respectively; p=0.390). The incidence of severe perioperative complications was not significantly different between the less aggressive group (4.8%) and the highly aggressive surgery group (6.4%) (p=0.767). Highly aggressive surgery with appropriate selection regardless of the timing of cytoreduction benefits patients with advanced ovarian cancer.

Nestin as a Prognostic Biomarker in High-grade Epithelial Ovarian Cancer Treated by Neoadjuvant Chemotherapy

High-grade epithelial ovarian cancer (HGEOC) is a heterogeneous disease and among the deadliest types of cancer. It often acquires resistance to conventional chemotherapy and its prognosis remains highly poor. The tissue protein nestin, implicated in the assembly and disassembly of intermediate filaments, has been reported to be an unfavourable prognostic factor in several cancer types. We hypothesized that HGEOC progression is regulated by the proliferation of chemoresistant cancer stem cells, in which nestin might be implicated. This preliminary study aimed to evaluate nestin as a prognostic biomarker in HGEOC treated by neoadjuvant chemotherapy (NACT) followed by cytoreductive surgery. A retrospective study (2009-2019) was conducted on 92 patients with primary ovarian, fallopian tube or peritoneal HGEOC who underwent NACT followed by cytoreductive surgery. Nestin expression in tissue samples was semi-quantitatively evaluated defining nestin positivity for those with histochemical score ≥30. We then evaluated the prognostic value of nestin expression. The median progression-free survival was similar between nestin-positive (22 months) and nestin-negative (19 months) groups (p=0.57). Interestingly, the median overall survival was shorter for the nestin-positive group (48 vs. 67 months, respectively), however the difference did not reach statistical significance (p=0.43). Tissue nestin expression does not appear to be a relevant prognostic biomarker in HGEOC treated by NACT. However, we believe that prospective studies in larger cohorts should be conducted and evaluation of nestin in pre-NACT HGEOC samples needs to be explored.

Bevacizumab-based Salvage Chemotherapy Improves Survival Outcomes for Patients With Brain Metastasis from Ovarian Cancer

Brain metastases from ovarian cancer remain rare and the appropriate treatment is unknown. We investigated survival outcomes following salvage chemotherapy before and after bevacizumab approval to evaluate the efficacy of bevacizumab in patients with brain metastasis from ovarian cancer. We investigated 23 consecutive patients with brain metastasis from ovarian cancer at our hospital between 2001 and 2020. Bevacizumab was administered for treating ovarian cancer after approval in Japan in November 2013. Survival after brain metastasis was compared between 9 patients treated before bevacizumab approval (2000-2013) and 14 patients treated after approval (2014-2020). Seven patients treated in the latter period received bevacizumab-salvage chemotherapy for brain metastasis. Median survival in all patients was 9.1 months [95% confidence interval (CI)=4.2-33.5]. In addition, patients treated during the latter period presented better survival outcomes than those treated in the former period (former, 2.9 months vs latter, 33.5 months, log-rank test, p=0.015; Wilcoxon test, p=0.009). Multivariate analysis revealed that bevacizumab addition (p=0.020), interval to brain metastasis (p=0.005), number of brain lesions (p=0.001), number of recurrences (p=0.001), and platinum sensitivity (p=0.028) were independently associated with survival in all cohorts. Bevacizumab-based salvage chemotherapy may improve survival outcomes in patients with brain metastasis.

Prognostic Value of Peritoneal Cancer Index After Complete Cytoreductive Surgery in Advanced Ovarian Cancer

Residual disease (RD) after primary debulking surgery (PDS) is a prognostic factor for survival in advanced ovarian cancer (AOC). This study aimed to examine whether the tumor extent affects overall survival (OS) and progression-free survival (PFS) in AOC patients treated with PDS. A total of 118 patients treated with PDS were included. Age, ECOG score, AOC International Federation of Gynecology and Obstetrics (FIGO) stage, CA-125, RD, peritoneal cancer index (PCI), preoperative imaging (CT-PCI) and macroscopic visualization at the surgery start (S-PCI) were analyzed. Tumor extent was quantified using the PCI, and by CT-PCI and S-PCI. Cox regression, Kaplan-Meier and receiver operating curves (ROC) were performed for survival analyses. S-PCI correlated with both OS (1.067, 95%CI=1.018-1.119, p<0.007) and PFS. Patients exhibiting S-PCI≥18.5, adjusted to age, performance status, and RD, had a two-fold risk of dying (HR=2.070, 95%CI=1.061-4.038, p=0.033) compared those with PCI<18.5. CT-PCI correlated with OS in crude data (1.037, 95%CI=1.005-1.071, p=0.025), but this was not sustained in multivariate analyses. RD of any size doubled the risk of dying (2.177, 95%CI=1.235-3.838, p=0.007). The tumor extent at the beginning of surgery seemed to affect OS in patients with AOC, regardless of the extent of RD at the end of the surgery. PCI above 18.5 doubled the risk of dying of the disease. No difference in major complications was noted in the two groups of patients. CT-PCI seemed to play a prognostic role for PFS; however, it is still to be investigated as a prognostic factor for OS.

Response to Chemotherapy and Clinical Outcome of Patients With Recurrent Epithelial Ovarian Cancer After PARP Inhibitor Maintenance Treatment: A Multicenter Retrospective Italian Study

To assess response rates and survival in patients with recurrent platinum-sensitive epithelial ovarian cancer (EOC) who received PARP inhibitor (PARP-i) maintenance and who subsequently underwent salvage chemotherapy for disease progression after PARPi. This retrospective investigation analyzed 103 patients who were treated in five Italian Gynecologic centers. The PARPi used was olaparib in 46 patients, niraparib in 55, and rucaparib in 2. The interval time between the last cycle of pre- PARPi platinum-based chemotherapy and the diagnosis of progression during PARPi maintenance was defined as platinum-free interval (PFI). Of the 28 patients with PFI 12 months received chemotherapy (platinum-based chemotherapy, 23; trabectedin + PLD, 3; non platinum - single agent, 5). An objective response was found in 13.0%, 26.2% and 41.9 % of the patients with PFI 12 months (p= 0.03), respectively, and the corresponding median survivals after PARPi were 8.9 months, 17.5 months and 24.1 months (p= 0.002), respectively. Before the PARPi era, some randomized trials on platinum rechallenge in patients with recurrent EOC after more than 6 months from the last platinum cycle have shown response rates ranging from 47.2% to 66%. Response rates to chemotherapy for progression after PARPi appear to be lower than those expected according to PFI.

Lactate Is a Reliable Predictor of ICU Length of Stay Following Ultra-radical Ovarian Cancer Surgery

With a greater proportion of women with advanced ovarian cancer (AOC) successfully undergoing radical cytoreductive surgery, the demand on peri-operative resources - including intensive care (ICU) beds - is also on the rise. Extended post-operative ICU length of stay (LOS) confers increased patient morbidity and mortality. Several variables associated with prolonged ICU LOS following AOC surgery have been identified. We aimed to evaluate the predictive value of serum lactate levels. All patients undergoing ultra-radical surgery for AOC in a large cancer centre over a 34-month period between 2018-2021 were identified via the institution tumour registry. Data were collected retrospectively via electronic care and operating records; biochemistry, radiology, and histopathology databases. In total, 63 patients were identified. Elevated intra-operative serum lactate levels were associated with significantly longer length of ICU post-operative stay. Longer time for hyperlactaemia to normalise following surgery also conferred significantly longer ICU, high dependency and total hospital LOS. Greater blood loss, higher surgical complexity and peritoneal carcinomatosis score, and longer operating time were associated with higher - and persistently elevated - peri-operative lactate levels. Serum lactate in the context of ultra-radical surgery for AOC represents an accessible and inexpensive marker with potential to not only reliably predict LOS, but also to serve as a dynamic prompt for early targeted intervention. Early recognition and correction of hyperlactaemia following AOC may reduce ICU LOS limiting both the resource pressure and patient morbidity/mortality sequelae.

Minimizing Fertility-sparing Treatment for Low Volume Early Stage Cervical Cancer; Is Less the (R)Evolution?

The aim of this study was to conduct a review on less radical fertility-sparing surgical treatment for early-stage cervical cancer. We conducted a Medline search from 2014 to 2018 regarding less radical fertility-sparing techniques, such as simple trachelectomy or cervical conization, with pelvic lymphadenectomy. We also assessed the impact of the removal of the parametrium on the obstetric and oncologic outcome, in women who desire to preserve their fertility. We analyzed studies about cervical conization and simple trachelectomy, together with pelvic lymphadenectomy in early-stage cervical cancer. We also assessed the importance of parametrial involvement in reducing morbidity, without jeopardizing the oncologic outcome of these patients. Studies demonstrate that in tumors ≤2 cm, without lymphovascular Space Invasion and without evidence of parametrial involvement, a less radical fertility-sparing surgical approach could increase pregnancy rates and have a positive effect on the quality of life of these patients. Standard fertility-sparing treatment for early-stage cervical cancer is still radical trachelectomy with pelvic lymphadenectomy. However, studies suggest that the omission of parametrectomy is a feasible and safe option. Simple trachelectomy or cervical conization, both combined with pelvic lymphadenectomy are acceptable approaches in a selected group of patients with early-stage cervical cancer.

Continuity Unveiled: Evaluating Cytoreduction Outcomes for Advanced Ovarian Cancer Amidst the COVID-19 Era at an ESGO Designated Centre of Excellence

The COVID-19 pandemic brought unprecedented global changes, necessitating adjustments to address public health challenges. The impact on advanced epithelial ovarian cancer (EOC) surgery, marked by increased perioperative risks, and changes in management plans was explored in this study based on promptly published British Gynaecologic Cancer Society (BGCS) and European Society of Gynaecologic Oncology (ESGO) guidelines. Retrospective data from 332 patients with advanced EOC who underwent cytoreductive surgery at a UK tertiary center were analyzed, and the outcomes were compared between pre-COVID-19 (2018-2019) (n=189) and COVID-19 era (2020-2021) (n=143) cohorts, covering the same timeframe (March to December). Primary outcomes included residual disease (RD) and progression-free survival (PFS), while secondary outcomes were the ESGO quality indicators (QIs) for advanced EOC surgery. Kaplan-Meier curves were produced to illustrate PFS. Complete cytoreduction rates remained comparable at 74.07% and 72.03% for pre-COVID-19 and COVID-19 groups, respectively. Differences were observed in ECOG performance status (p=0.015), Intensive Care Unit (ICU) admissions (p=0.039) with less interval debulking surgeries (p=0.03), lower surgical complexity scores (p=0.02), and longer operative times in the COVID-19 group (p=0.01) compared to the pre-COVID-19 group. The median PFS rates were 37 months and 34 months in the pre-COVID-19 and COVID-19 groups, respectively (p=0.08). The surgical QIs 1-3 remained uncompromised during the COVID-19 era. Management modifications prompted by the COVID-19 pandemic did not adversely impact cytoreduction rates or PFS.

EZH2 Expression Is Associated With Sensitivity to Inhibitors and Promotes Malignancy in Endometrial Cancer Cells

Endometrial cancer (EC) incidence is increasing globally, highlighting the need for novel therapies targeting molecular drivers of malignancy. Enhancer of zeste homolog 2 (EZH2), a histone methyltransferase implicated in tumor progression, is overexpressed in EC; however, its precise role and therapeutic potential remain unclear. In this study, we aimed to investigate EZH2 expression, its functional role, and the efficacy of EZH2 inhibitors in EC cell lines. EZH2 expression was analyzed in eight EC cell lines using western blotting and immunocytochemistry. The efficacy of five EZH2 inhibitors (CPI-1205, EI1, EPZ005687, EPZ-6438, and GSK126) was evaluated using drug sensitivity assays. Furthermore, functional analyses, including cell proliferation, colony formation, migration, and invasion assays, were performed following siRNA-mediated EZH2 knockdown in HEC-50B cells. Variable EZH2 expression was observed across EC cell lines, with high levels in HEC-50B and Ishikawa 3-H-12 cells. EZH2-high expressing cell lines were markedly more sensitive to EZH2 inhibitors, particularly GSK126, compared to EZH2-low expressing lines. EZH2 knockdown in HEC-50B cells reduced EZH2 expression and decreased sensitivity to EZH2 inhibitors, confirming target specificity, while also attenuating cell proliferation, colony formation, migration, and invasion. EZH2 plays a crucial role in promoting malignant phenotypes in EC, and its expression level correlates with cellular sensitivity to EZH2 inhibitors. These findings suggest that EZH2 could serve as a valuable therapeutic target and predictive biomarker for personalized medicine in EC.

Lymph-vascular Space Involvement and/or p53 Overexpression Correlated With the Clinical Outcome of Early-stage Endometrial Cancer Patients Treated With Adjuvant Vaginal Brachytherapy

The majority of patients with endometrial cancer (EC) are diagnosed at an early stage and undergo primary surgery, followed by observation or adjuvant therapy according to risk factors on surgical samples. The objective of this study was to assess the correlation between a risk profile represented by the presence of substantial lymph-vascular space involvement (LVSI) and/or p53 overexpression and the clinical outcome of patients with early-stage endometrial cancer (EC) who received adjuvant vaginal brachytherapy (BT). This investigation assessed 79 patients who underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic and/o aortic lymphadenectomy or sentinel lymph node biopsy followed by hypofractionated (HDR)-vaginal BT, using 192Ir source, for stage I-II endometrioid (n=70) or non-endometrioid (n=9) EC. Thirty-four patients (43.0%) were considered to have an unfavorable risk profile defined by the presence of substantial LVSI and /or p53 overexpression. Five-year disease-free survival (DFS) and five-year overall survival (OS) were 93.7% and 95%, respectively. There was a significant correlation between unfavorable risk-profile and pelvic recurrence rate (p=0.002) and distant recurrence rate (p=0.017). Patients with abnormal p53 had a higher risk of local relapse (p=0.041). Substantial LVSI was strongly associated with pelvic recurrence (p=0.001) and distant metastasis (p<0.001). The presence of substantial LVSI and/or p53 overexpression strictly correlated with poor outcome of patients with early-stage EC and should be taken into consideration for better planning adjuvant treatment in this clinical setting.

Impact of the Introduction of the S3 Guideline on the Management of Primary Endometrial Cancer: A Comparative Analysis of Cancer Registry Data from Hamburg (2014-2022)

This study evaluated the impact of the 2018 S3 guideline for endometrial cancer on clinical management using cancer registry data from Hamburg. This retrospective cohort study included 2,249 patients with primary endometrial cancer (2014-2022), divided into a pre-guideline group (2014-2017) and a post-guideline (2019-2022) group. Quality indicators included parametrial resection rates, lymphadenectomy utilization, and radiation therapy application. Poisson regression models assessed changes with adjustment for age, treatment center, and tumor grading. Patients without parametrial resection increased from 88% to 93% [adjusted effect estimate: 1.06, 95% confidence interval (CI)=0.94-1.19]. Patients without lymphadenectomy increased from 76% to 88% [adjusted effect estimate: 1.13, 95%CI=0.93-1.37]. Radiation therapy use increased from 95% to 100%. Changes aligned with guideline recommendations but were not statistically significant. Poorly differentiated tumors showed significantly different treatment patterns. Practice patterns in Hamburg moved closer to S3 Guideline on the Management of Primary Endometrial Cancer after 2018, although statistical significance was not achieved. Improved registry documentation likely contributed to observed trends. Larger studies with longer follow-up are required to clarify the clinical impact of guideline implementation.

Endometrial Cancer Metastatic to the Sigmoid Colon and Pelvic Retroperitoneal Space: A Case Report

The majority of colorectal tumors are primary colorectal cancers (CRCs), which commonly develop distant metastases in advanced stages. In contrast, secondary involvement of the colon by tumors originating from other organs is rare. Endometrial cancer (EC) typically metastasizes to the vagina, lungs, and peritoneum, with colonic metastasis being exceedingly uncommon. A 76-year-old female patient presented with abdominal pain. Her medical history was notable for multiple malignancies, including Stage I left breast cancer, Stage IA endometrial cancer, and Stage IIA right breast cancer. Laboratory tests showed elevated levels of cancer antigen (CA)125 (234.5 U/ml) and CA19-9 (110.0 U/ml) were elevated. Contrast-enhanced computed tomography revealed large pelvic cystic tumor and irregular wall thickening of the sigmoid colon. Intraoperative findings showed that the small intestine and sigmoid colon were adherent to the pelvic tumor, forming a large single mass. To achieve en bloc and R0 resection, pelvic tumor resection, high anterior resection, enterectomy, and temporary ileostomy were performed. The histopathological diagnosis confirmed metastasis of EC to the sigmoid colon and pelvic retroperitoneal space, with 2 of 12 lymph nodes positive for metastasis. All surgical margins were negative, and no recurrences were observed nine months post-discharge. We present a rare case of EC metastasis to the colon and pelvic retroperitoneal space with lymph node metastases, successfully treated with en bloc surgical resection. Because EC and CRC exhibit morphological and pathological similarities, laboratory testing for tumor markers, including CA125, may be useful for the preoperative diagnosis of colonic tumors in patients with a history of EC.

Oxidative Stress-regulating Enzymes and Endometrial Cancer Survival in Relation to Metformin Intake in Diabetic Patients

Metformin inhibits tumorigenesis in endometrial carcinoma and interferes with the expression of oxidative stress-regulating proteins, such as nuclear factor erythroid 2-related factor 2 (Nrf2) and Kelch-like ECH-associated protein 1 (Keap1). Although manganese superoxide dismutase (MnSOD) is vital for withstanding mitochondrial oxidative stress, it has also been linked with chemoresistance and poorer outcomes in several cancer types. However, data on endometrial cancers are limited. This study aimed to highlight the relationship between mitochondrial redox regulation and endometrial cancer survival in relation to metformin consumption in women with type 2 diabetes mellitus (T2DM). Our retrospective hospital-based cohort study included 121 patients diagnosed with endometrial carcinoma and T2DM between 2007 and 2014. Fifty-eight patients were using metformin at the time of diagnosis. Nrf2 and Keap1 expression levels in the tumor samples were assessed immunohistochemically, and MnSOD levels were measured both immunohistochemically and from the serum samples. High MnSOD tissue expression was associated with better overall survival among metformin users in the univariate analysis (p=0.03). When adjusted for histology and stage, high serum MnSOD was associated with better overall survival (HR=0.22, 95%CI=0.07-0.71, p=0.01). No association was found between MnSOD, Nrf2, or Keap1 and overall survival among metformin non-users. Higher expression of MnSOD in patients with endometrial cancer and T2DM is associated with better overall survival if the patient is consuming metformin.

HPV16 E6 Gene Transcripts in Primary Type II Endometrial Carcinomas

Data on the prevalence of human papilloma virus (HPV) DNA in different subtypes of endometrial carcinomas (EC) are limited. We investigated the incidence of HPV16 DNA E6/E7 transcripts in 47 type I (endometrioid-type) tumors and eight type II (non-endometrioid-type) uterine neoplasms applying PCR-based technology. Immunohistochemical staining in HPV16 positive cases was also performed, and seven lymph node metastases were examined for the presence of HPV16 DNA E6/E7. None of the type I ECs was positive for HPV16 E6 gene transcripts; however, four out of 8 (50%) type II ECs (two out of four papillary-serous and two out of four clear-cell carcinomas) were positive for HPV16 E6 transcripts. The difference in HPV16 E6 transcripts between endometrioid and non-endometrioid neoplasms was statistically significant (p=0.0011). Apart from the cancer subtype, none of the EC clinicopathological features were related to HPV16 E6 positivity. None of 55 ECs contained an HPV16 E7 gene transcripts. All slides from gene-positive samples revealed intense immunostaining reactions. Interestingly, the virus was not detected in any of seven lymph node metastases, including four from HPV16-positive primary tumors. HPV16 E6 gene transcripts may be present in ECs, primarily in the non-endometrioid (type II) uterine cancer subtypes. HPV E6/E7 DNA transcripts were not found in lymph node metastases, even when the primary tumors harboured HPV DNA.

Tissue Expression and Plasma Soluble PD-L1 Levels in Patients With Endometrial Cancer

The prognostic role of tissue PD-L1 expression in endometrial cancer (EC) remains controversial. Moreover, its value in guiding anti-PD1/PD-L1 immunotherapy is questionable. The eventual role of soluble PD-L1 (sPD-L1), released by cancer tissue and circulating immune cells, is largely unexplored. In this pilot study, we investigated the expression of PD-L1 in cancer cells and tumor stroma infiltrating inflammatory cells (TIICs), in parallel with sPD-L1 levels in the plasma of 19 patients with early-stage endometrioid EC, before and after hysterectomy. Cancer cell membrane staining was noted in 5/19 (26.3%) cases (range=1-5%; median 1% of the cancer cell population). IICs showed positive reactivity in 14/19 (73.7%) cases. sPD-L1 plasma levels ranged from 53-408 pg/ml and 113-557 pg/ml, respectively, in the plasma of patients before and after hysterectomy (p=0.01). High PD-L1 expression by IIC was marginally associated with a high histology grade (p=0.08). High sPD-L1 levels before surgery were significantly associated with ICC PD-L1 expression (p=0.0007), high histology grade (p=0.04), and marginally with T2-stage (p=0.08). sPD-L1 is easily detectable in the plasma of EC patients and may be associated with aggressive clinical features and PD-L1-expressing immune cells infiltrating the tumor stroma. sPD-L1 plasma levels in EC patients undergoing immunotherapy can be further tested as a biomarker for therapeutic stratification.

Treatment of Mediastinal Endometrial Carcinoma Developed from Extragenital Endometriosis and Simultaneous Rectal Adenocarcinoma in a 55-year-old Woman

Endometriosis is a common disorder in reproductive-age women leading to a broad range of symptoms and is associated with a higher risk for endometrioid ovarian carcinoma. We report the case of a 55 year-old woman with previously undiagnosed endometriosis presenting with a large mediastinal cancer of unknown primary (CUP) and synchronous Union Internationale Contre le Cancer (UICC) stage II rectal adenocarcinoma. Histopathologically the mediastinal tumor resembled endometrial carcinoma and laparoscopically endometriotic lesions on the patient's peritoneum were detected. The patient was treated with neoadjuvant carboplatin and paclitaxel, followed by resection of the mediastinal tumor. After recovery, the patient received neoadjuvant short-course radiation to the rectal adenocarcinoma, which was resected afterwards. No primary endometrial carcinoma was found in the uterus, leading to the most likely conclusion that the mediastinal tumor derived from an extragenital endometriotic lesion. Although rare, cases of degeneration of endometriosis have been described. In this case not only the localization of endometriosis was uncommon, but also its malignant transformation and synchronous diagnosis of a rectal adenocarcinoma, complicating diagnosis, and treatment of the patient. This rare case highlights the importance of diagnosing and treating patients with CUP or multiple malignancies at large interdisciplinary centers to reach the best possible outcome.

Molecular Characteristics of Metastatic Lesions Have Superior Prognostic Impact on Endometrial Cancer

In endometrial cancer (EC), lymph node (LN) metastasis significantly impacts prognosis. Thus far, no studies have reported the molecular genetics of each metastatic lesion. This study aimed to investigate the molecular characteristics of primary and metastatic LNs and their association with clinical outcomes. The clinicopathological and molecular characteristics of 33 patients with EC with regional LN metastasis (FIGO stage IIIC) were investigated; we evaluated the mutational status of p53 and DNA mismatch repair (MMR) proteins in the primary lesion, all the positive LNs (102 lesions), mutational variation between primary and paired metastatic lesions, inter-lesion heterogeneity, and their association with clinical outcomes. Immunohistochemically, 12 patients (36.4%) displayed aberrant p53 expression in metastatic lesions, and a concordant rate of 93.4% was observed between primary and metastatic lesions. Inter-lesion heterogeneity was observed in 20 cases (60.6%). In Kaplan-Meier analysis, patients with aberrant p53 expression in metastatic LNs exhibited worse progression-free survival (PFS) than those with wild-type p53 expression (p=0.008). Wild-type p53 expression in primary lesion with inter-lesion heterogeneity had a significantly worse PFS (p=0.049) than those without heterogeneity. In the Cox univariate analysis, p53 expression in metastatic LNs was significantly associated with recurrence (p=0.013). Genetic diversity between primary and metastatic lesions and among metastases was validated by evaluating the p53 and MMR proteins using immunohistochemistry analysis. The molecular characteristics of metastatic lesions in addition to those of primary lesions could provide beneficial prognostic information in patients with EC with regional LN metastasis.

Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer

Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Mesonephric-like Differentiation of Ovarian Endometrioid and High-grade Serous Carcinomas: Clinicopathological and Molecular Characteristics Distinct from Those of Mesonephric-like Adenocarcinoma

Ovarian endometrioid carcinoma (EC) and high-grade serous carcinoma (HGSC) may exhibit various growth patterns and mimic mesonephric-like adenocarcinoma (MLA). We investigated the clinicopathological and molecular features of ovarian carcinomas with mesonephric-like differentiation (MLD). We analyzed the electronic medical records and pathology slides of two EC-MLD and three HGSC-MLD patients, and conducted immunostaining and targeted sequencing of their samples. All cases showed architectural diversity, compactly aggregated small tubules and ducts, and eosinophilic intraluminal secretions, indicating the possibility of an ovarian MLA. However, the following histological and immunophenotypical features confirmed the diagnoses of EC-MLD and HGSC-MLD: squamous, tubal, and sertoliform differentiation; serous tubal intraepithelial carcinoma; solid, endometrioid, transitional (SET) feature; solid, transitional, endometrioid, mucinous-like (STEM) feature; diffuse expression of hormone receptors and Wilms tumor 1; mutant p53 immunostaining pattern; and wild-type v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog gene. A subset of ovarian ECs and HGSCs can display MLD and mimic an MLA. A thorough histological examination combined with ancillary tests is crucial to differentiate between these ovarian neoplastic entities.

Publisher

International Institute of Anticancer Research

ISSN

0250-7005