IgG4-related disease mimicking gynecologic malignancy.

Immunoglobulin G4 (IgG4) related disease is a systemic disease that causes fibrosis, tumor-like nodules, and lymphoid hyperplasia with infiltration of IgG4 positive plasma cells. It can manifest in many organ systems; however, there are few cases that report gynecologic organ involvement. It is crucial to correctly diagnose IgG4-related disease versus malignancy because the former is treated with glucocorticoids or rituximab. In this case report, we describe two patients in which IgG4-related disease mimics gynecologic cancer. In the first case, an 85 year old woman presented with diffuse lymphadenopathy and a uterine mass concerning for malignancy. Biopsies were negative for carcinoma. Inguinal lymph node biopsy demonstrated IgG4 positive plasma cells and the patient was treated with rituximab therapy given concurrent severe rheumatoid arthritis. In the second case, a 35 year old woman under surveillance for Stage IB2 squamous cell carcinoma of the cervix (status post definitive chemoradiation therapy) presented with fluorodeoxyglucose (FDG) avid paraaortic lymph nodes on positron emission tomography (PET) imaging with subsequent negative paraaortic lymph node biopsies. Serial imaging and biopsies remained inconclusive despite ongoing diffuse lymphadenopathy and clinical concern for recurrence. Supraclavicular lymph node excision was performed which demonstrated lymphoid hyperplasia with increased IgG4 plasma cells and no evidence of carcinoma, supporting the diagnosis of IgG4-related disease. The patient was treated with high dose steroids with clinical improvement and resolution of abnormal imaging findings. We demonstrate that IgG4-related disease can present with FDG-avid lesions on PET imaging and lymphadenopathy that mimics primary or recurrent gynecologic malignancy. While rare, we conclude the IgG4-related disease is an important differential diagnosis to consider in the workup of primary or recurrent gynecologic malignancy and highlights the value of PET imaging to identify unusual patterns of lymphadenopathy and guide histologic confirmation of disease.

Lessons learned: Telemedicine patterns and clinical application in patients with gynecologic cancers during COVID-19.

Objective: To describe the use of telemedicine in gynecologic oncology and identify patient characteristics associated with telemedicine use during COVID-19. Methods: Single-institution retrospective chart review of patients with gynecologic cancer who participated in in-person and telemedicine visits (video and telephone) from January 2019 to November 2020. Patient characteristics, visit and treatment characteristics were collected. Comparisons between 2019 and 2020 and between in-person and telemedicine visits were performed. Cancer-specific visit details were described. Results: From January to November 2020, 2,039 patients attended 5240 ambulatory visits in our gynecologic oncology outpatient clinics with 4,304 (82.1%) in-person visits, 512 (9.8%) video telemedicine visits, and 424 (8.1%) telephone visits. In 2020, 936 (45.9%) patients participated in a telemedicine visit. Demographic characteristics did not differ between those who participated in any telemedicine versus in-person visits (p > 0.05). Black patients represented a larger share of telephone visits but this was not significant. Patients aged > 65 years were more likely to use the telephone for a visit and less likely to use video visits compared to their younger counterparts. The majority of patients who attended a telemedicine visit also attended a visit in-person (88.0%). The most common purpose of the telemedicine visits was to discuss results and/or treatment plans (46%) with other appointments occurring for treatment check-ins and clinical trials. Conclusions: The use of telemedicine drastically increased in 2020. Patient demographics were not different between in-person and telemedicine visits except that older patients were more likely to use telephone visits over video visits. Telemedicine can be used for a variety of care needs in gynecologic oncology but further work needs to be done to optimize implementation, assess cost-effectiveness and patient outcomes.

Differences in Sociodemographic Disparities Between Patients Undergoing Surgery for Advanced Colorectal or Ovarian Cancer.

BACKGROUND: Cytoreductive surgery (CRS) for ovarian cancer with peritoneal metastases (OPM) is an established treatment, yet access-related racial and socioeconomic disparities are well documented. CRS for colorectal cancer with peritoneal metastases (CRPM) is garnering more widespread acceptance, and it is unknown what disparities exist with regards to access. METHODS: This retrospective cross-sectional multicenter study analyzed medical records from the National Cancer Database from 2010 to 2015. Patients diagnosed with CRPM or ORP only and either no or confirmed resection were included. Patient- and facility-level characteristics were analyzed using uni- and multivariable logistic regressions to identify associations with receipt of CRS. RESULTS: A total of 6634 patients diagnosed with CRPM and 14,474 diagnosed with OPM were included in this study. Among patients with CRPM, 18.1% underwent CRS. On multivariable analysis, female gender (odds ratio [95% CI] 2.04 [1.77-2.35]; P < 0.001) and treatment at an academic or research facility (OR 1.55 [1.17-2.05]; P = 0.002) were associated with CRS. Among patients with OPM, 87.1% underwent CRS. On multivariable analysis, treatment at facilities with higher-income patient populations was positively associated with CRS, while age (OR 0.97 [0.96-0.98]; P < .0001), use of nonprivate insurance (OR 0.69 [0.56-0.85]; P = 0.001), and listed as Black (OR 0.62 [0.45-0.86]; P = 0.004) were negatively associated with CRS. CONCLUSION: There were more systemic barriers to CRS for patients with OPM than for patients with CRPM. As CRS becomes more widely practiced for CRPM, it is likely that more socioeconomic and demographic barriers will be elucidated.

Clinical outcomes in ovarian cancer patients receiving three versus more cycles of chemotherapy after neoadjuvant treatment and interval cytoreductive surgery.

OBJECTIVES: To compare clinical outcomes for stage IIIC and IV ovarian cancer patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery followed by up to three versus more cycles of post-operative chemotherapy. METHODS: We conducted a multi-institution retrospective cohort study of patients treated from January 2005 to February 2016 with neoadjuvant platinum-based therapy followed by interval surgery and post-operative chemotherapy. The following were exclusion criteria: more than four cycles of neoadjuvant chemotherapy, bevacizumab with neoadjuvant chemotherapy, non-platinum therapy, prior chemotherapy, and elevated CA125 values after three post-operative chemotherapy cycles. Progression-free and overall survival and toxicity profiles were compared between groups receiving up to three cycles versus more that three cycles post-operatively. RESULTS: A total of 100 patients met inclusion criteria: 41 received up to three cycles and 59 received more than three cycles. The groups were similar in terms of age, body mass index, performance status, tumor histology, optimal cytoreduction rates, and median number of neoadjuvant chemotherapy cycles. Median progression-free survival was 14 vs 16.6 months in those receiving up to three cycles versus more than three cycles, respectively (HR 0.99, 95% CI 0.58 to 1.68, p=0.97). Similarly, median overall survival was not different at 47.1 vs 69.4 months, respectively (HR 1.96, 95% CI 0.87 to 4.42, p=0.10). There were no differences in grade 2 or higher chemotherapy-related toxicities. CONCLUSIONS: Extending post-operative chemotherapy beyond three cycles in patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery with normalization of CA125 levels was not associated with improved survival or greater toxicity. Future study in a larger cohort is warranted to define optimal length of cytotoxic treatment.

Combination simvastatin and metformin synergistically inhibits endometrial cancer cell growth.

OBJECTIVE: Recent data show that simvastatin (SIM) and metformin (MET) have anti-proliferative effects in endometrial cancer cells. The combination (MET+SIM) inhibits tumor growth and metastasis in prostate cancer cells which possess similar molecular alterations to many early endometrial cancers. We tested the hypothesis that the anti-proliferative effects of MET+SIM in endometrial cancer cells would be greater than the effects of each agent alone. METHODS: RL95-2, HEC1B, and Ishikawa endometrial cancer cell lines were treated with MET and/or SIM. Growth inhibition was measured by MTS cell proliferation assays. Apoptosis was evaluated by caspase-3, Annexin V, and TUNEL assays and by apoptosis markers (BAX, Bcl-2, Bim) using western blot. Bim was silenced using Bim siRNA to confirm this apoptotic pathway. Treatment effects on the mTOR pathway were investigated by western blot using antibodies to phosphorylated (phospho)-AMPK and phospho-S6. RESULTS: MET+SIM synergistically inhibited growth in all three cell lines. The combination induced apoptosis as measured by TUNEL, Annexin V, and caspase-3 assays. Bim siRNA transfection abrogated this effect-silencing Bim in MET+SIM-treated RL95-2 cells rescued cell viability in MTS assays and reduced caspase-3 activity compared with control siRNA-transfected cells. Combination treatment upregulated phosphorylated AMPK and downregulated downstream phosphorylated S6, suggesting mTOR inhibition as a mechanism for these anti-proliferative effects. CONCLUSIONS: MET+SIM treatment synergistically inhibits endometrial cancer cell viability. This may be mediated by apoptosis and mTOR pathway inhibition. Our results provide preclinical evidence that the combination of these well-tolerated drugs may warrant further clinical investigation for endometrial cancer treatment.

Venous Thromboembolism in Patients Receiving Extended Pharmacologic Prophylaxis After Robotic Surgery for Endometrial Cancer.

OBJECTIVE: This study aims to determine the rate of postoperative venous thromboembolism (VTE) in endometrial cancer patients undergoing robotic hysterectomy with or without extended pharmacologic VTE prophylaxis. METHODS/MATERIALS: A retrospective chart review of women undergoing robotic hysterectomy with or without other procedures for endometrial cancer from January 2010 to February 2015 was conducted at 2 institutions. Charts were manually abstracted, and rates of VTE within 30 and 60 days after surgery were determined. Patients were then stratified by those who did and did not receive extended VTE prophylaxis. RESULTS: A total of 403 patients were included, of which 367 patients (91%) received extended pharmacologic prophylaxis and 36 patients (9%) did not. Low molecular weight heparin prescriptions ranged from 7 to 30 days. Patients receiving extended prophylaxis (EP) were older (63 ± 11 vs 57 ± 12; P = 0.004), more frequently underwent lymphadenectomy (67% vs 34%; P < 0.001), and had higher-grade tumors compared with patients not receiving EP. Overall 30-day and 60-day VTE rates were 0.7% and 1.2%, respectively. There were no significant differences in 30-day and 60-day VTE rates among patients that did and did not receive EP, although a trend toward lower VTE rates in the EP group was observed (30-day rates 0.5% vs 2.8% respectively, P = 0.25; 60-day rates 0.8% vs 5.6%, P = 0.07). CONCLUSIONS: In this study, 30-day and 60-day VTE rates after minimally invasive surgery for endometrial cancer were low. Rates were also similar to those of previous reports in this setting in which the majority of patients did not receive extended VTE prophylaxis. Given the consistent finding that postoperative VTE in this population is rare regardless of prophylaxis use and the variability in practice patterns for VTE prophylaxis, the development of best practice guidelines for EP use specific to this setting is warranted.

Recurrent cervical cancer isolated to the sigmoid colon: A case report.

Fused positron emission tomography and computed tomography scan showed a hypermetabolic lesion in the sigmoid colon, with no evidence of metastatic disease elsewhere.

Excess risk of Clostridium difficile infection in ovarian cancer is related to exposure to broad-spectrum antibiotics.

PURPOSE: The purpose of the study was to determine if a diagnosis of ovarian cancer is independently associated with an increased risk of Clostridium difficile infection (CDI). METHODS: The University HealthSystem Consortium database was queried to perform a retrospective cohort study of women with and without ovarian cancer who were diagnosed with CDI. Inpatients undergoing total hysterectomy from 2008 to 2012 were studied. Ovarian cancer patients were compared to non-ovarian cancer patients to evaluate relative risk (RR) of CDI. Adjustment was made for known or suspected CDI risk factors to determine RR of CDI independent of these variables. RESULTS: In this study, 115,203 patients were included. CDI was reported in 0.80 % of ovarian cancer patients and in 0.31 % of non-ovarian cancer patients (RR = 2.50; 95 % confidence interval (CI) = 2.02 to 3.35). Stratification by age, presence of other comorbidities, or administration of antineoplastic drugs did not significantly modify the elevated risk associated with ovarian cancer. Significantly increased risk in ovarian cancer patients was no longer observed after controlling for broad-spectrum antibiotic administration (RR = 1.28, 95 % CI = 0.39 to 4.13). Compared to non-ovarian cancer patients, ovarian cancer patients were more frequently treated with broad-spectrum antibiotics, had a 39 % longer mean duration of therapy, and had 2.5-fold greater mean total exposure to broad-spectrum antibiotics. CONCLUSIONS: After adjustment for antibiotic use, ovarian cancer patients are not at excess risk of CDI. Additional studies are needed to understand the patterns of broad-spectrum antibiotic prescription for ovarian cancer patients leading to increased exposure. If feasible, reduction of this exposure may decrease morbidity in this population.