Cesarean hysterectomy for placenta accreta spectrum: 3-2-1 approach.

Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are (i) posterior lower uterine segment peritoneum de-serosalization, (ii) identification of the ureters laterally, and (iii) anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.

Lymph Node Isolated Tumor Cells in Patients With Endometrial Cancer.

Importance: Isolated tumor cells (ITCs) are the histopathological finding of small clusters of cancer cells no greater than 0.2 mm in diameter in the regional lymph nodes. For endometrial cancer, the prognostic significance of ITCs is uncertain. Objective: To assess clinico-pathological characteristics and oncologic outcomes associated with ITCs in endometrial cancer. Design, Setting, and Participants: This retrospective cohort study using the National Cancer Database included patients with endometrial cancer who had primary hysterectomy and nodal evaluation from 2018 to 2020. Patients with microscopic and macroscopic nodal metastases and distant metastases were excluded. Data were analyzed from June to September 2023. Exposure: Regional nodal status with ITCs (N0[i+] classification) or no nodal metastasis (N0 classification). Main Outcomes and Measures: (1) Clinical and tumor characteristics associated with ITCs, assessed with multivariable binary logistic regression model, and (2) overall survival (OS) associated with ITCs, evaluated by nonproportional hazard analysis with restricted mean survival time at 36 months. Results: A total of 56 527 patients were included, with a median (IQR) age of 64 (57-70) years. The majority had T1a lesion (37 836 [66.9%]) and grade 1 or 2 endometrioid tumors (40 589 [71.8%]). ITCs were seen in 1462 cases (2.6%). In a multivariable analysis, ITCs were associated with higher T classification, larger tumor size, lymphovascular space invasion (LVSI), and malignant peritoneal cytology. Of those tumor factors, LVSI had the largest association with ITCs (7.9% vs 1.4%; adjusted odds ratio [aOR], 4.37; 95% CI, 3.87-4.93), followed by T1b classification (5.3% vs 1.3%; aOR, 2.62; 95% CI, 2.30-2.99). At the cohort level, 24-month OS rates were 94.3% (95% CI, 92.4%-95.7%) for the ITC group and 96.1% (95% CI, 95.9%-96.3%) for the node-negative group, and the between-group difference in expected mean OS time at 36 months was 0.35 (SE, 0.19) months, but it was not statistically significant (P = .06). There was a statistically significant difference in OS when the low-risk group (stage IA, grade 1-2 endometrioid tumors with no LVSI) was assessed per nodal status and adjuvant therapy use (P < .001): (1) among the cases treated with surgical therapy alone, 24-month OS rates were 95.9% (95% CI, 89.5%-98.5%) for the ITC group and 98.8% (95% CI, 98.6%-99.0%) for the node-negative group, and the between-group mean OS time difference at 36 months was 0.61 (SE, 0.43) months (P = .16); and (2) among the cases with ITCs, adjuvant therapy (radiotherapy alone, systemic chemotherapy alone, or both) was associated with improved survival compared with no adjuvant therapy (24-month OS rates, 100% vs 95.9%; between-group mean OS time difference at 36 months, 0.95 [SE, 0.43] months; P = .03). Conclusions and Relevance: In this cohort study of patients with surgically staged endometrial cancer, the results of exploratory analysis suggested that presence of ITCs in the regional lymph node may be associated with OS in the low-risk group. While adjuvant therapy was associated with improved OS in the low-risk group with ITCs, careful interpretation is necessary given the favorable outcomes regardless of adjuvant therapy use. This hypothesis-generating observation in patients with low-risk endometrial cancer warrants further investigation, especially with prospective setting.

Low-grade endometrioid endometrial cancer with adnexal only metastasis: Evaluation of de-escalation of adjuvant therapy.

OBJECTIVE: To assess survival outcomes of stage IA3 endometrial cancer and the association of adjuvant therapy and survival. METHODS: The National Cancer Database was retrospectively queried to examine 594 and 1455 patients with stage IA3 and IIIA1 endometrial cancer, respectively, from 2010-2015. Overall survival (OS) was examined based on adjuvant therapy: multimodal combination chemotherapy and external beam radiotherapy, chemotherapy alone, external beam radiotherapy alone, and none. RESULTS: For stage IA3 disease, 109 (18.4%) patients did not receive adjuvant therapy. The 5-year OS rates for the no adjuvant therapy group and the combination group were 86.3% and 91.4%, respectively (adjusted-hazard ratio [aHR] 1.23, 95% confidence interval [CI] 0.70-2.18). This survival association was consistent when compared to chemotherapy alone (5-year OS rates 86.3% vs 86.3%, aHR 1.11, 95%CI 0.67-1.83). The results were similar among those who underwent nodal evaluation (5-year OS rates, 92.6%, 86.6%, and 89.4% for combination therapy, chemotherapy alone, and no adjuvant therapy), including grade 1 lesions (96.2%, 89.4%, and 100%, respectively). In grade 2 lesions, 5-year OR rates was modestly lower for no adjuvant therapy than combination therapy (89.4%, 84.0%, and 82.7% for combination, chemotherapy alone, and no adjuvant therapy, P = 0.03). For stage IIIA1 disease, omission of adjuvant therapy was associated with decreased OS compared to combination therapy (43.2% vs 73.1%, aHR 1.65, 95%CI 1.30-2.11) or chemotherapy alone (43.2% vs 67.1%, aHR 1.62, 95%CI 1.32-1.99). CONCLUSION: The results of this investigation suggest that survival effects of adjuvant therapy differ for stage IA3 and IIIA1 diseases. Patients with stage IA3 disease have overall good prognosis regardless of adjuvant therapy particularly grade 1 lesions, partly supporting the FIGO committee suggestion for adjuvant therapy de-escalation in stage IA3 endometrial cancer.

An absence of translated consent forms limits oncologic clinical trial enrollment for limited English proficiency participants.

OBJECTIVES: A lack of diversity amongst participants in cancer clinical trials has raised scrutiny over the past decade. Patients with limited English proficiency (LEP) are further excluded. One modifiable reason for low LEP participation is a lack of non-English consent forms. METHODS: We queried the clinical trials registry database at an academic hospital serving a predominantly Spanish-speaking patient population. Clinical trials related to gynecology oncology were evaluated for the availability of fully translated Spanish consent forms, the racial and ethnic identification of enrolled patients, and the number of signed Spanish consents. Enrolment data was compared before and after 2019, when institutional financial support for document translation was withdrawn. RESULTS: Sixteen gynecologic oncology clinical trials were opened between 2014 and 2022, with 10 trials enrolling 128 patients. Eight trials opened prior to 2019, all with fully translated consent forms. Seven of these trials enrolled 99 participants, 70% of whom identified as Hispanic and 60% who signed a Spanish consent. Eight trials opened after 2019 and one had a fully translated consent form. Three of the trials enrolled 29 participants, with 10% of subjects identifying as Hispanic and none signing a Spanish consent form. CONCLUSIONS: There was a decrease in fully translated clinical trial consent forms for gynecologic oncology studies following the loss of subsidized translation services in our single institution with a predominantly LEP population. This correlated with a decrease in enrollment of Hispanic subjects. To increase enrollment of diverse participants, including those with LEP, simple actions such as fully translating consent forms would help maintain equity in research conduct and improve clinical outcomes through trial involvement.

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

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

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination.

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Evaluation of the Anti-Tumor Activity of the Humanized Monoclonal Antibody NEO-201 in Preclinical Models of Ovarian Cancer.

Purpose: Despite high initial response rates with cytoreductive surgery, conventional chemotherapy and the incorporation of biologic agents, ovarian cancer patients often relapse and die from their disease. New approaches are needed to improve patient outcomes. This study was designed to evaluate the antitumor activity of NEO-201 monoclonal antibody (mAb) in preclinical models of ovarian cancer where the NEO-201 target is highly expressed. Experimental Design: Functional analysis of NEO-201 against tumor cell lines was performed by antibody-dependent cellular cytotoxicity (ADCC) assays. Binding of NEO-201 to tumor tissues and cell lines were determined by immunohistochemistry (IHC) and flow cytometry, respectively. Further characterization of the antigen recognized by NEO-201 was performed by mass spectrometry. Ovarian cancer models were used to evaluate the anti-tumor activity of NEO-201 in vivo. NEO-201 at a concentration of 250 g/mouse was injected intraperitoneally (IP) on days 1, 4, and 8. Human PBMCs were injected IP simultaneously as effector cells. Results: Both IHC and flow cytometry revealed that NEO-201 binds prominently to the colon, pancreatic, and mucinous ovarian cancer tissues and cell lines. Immunoprecipitation of the antigen recognized by NEO-201 was performed in human ovarian, colon, and pancreatic cancer cell lines. From these screening, carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) and CEACAM6 were identified as the most likely targets of NEO-201. Our results confirmed that NEO-201 binds different types of cancers; the binding is highly selective for the tumor cells without cross reactivity with the surrounding healthy tissue. Functional analysis revealed that NEO-201 mediates ADCC killing against human ovarian and colorectal carcinoma cell lines in vitro. In addition, NEO-201 inhibited tumor growth in the presence of activated human PBMCs in orthotopic mouse models of both primary and metastatic ovarian cancer. Importantly, NEO-201 prolonged survival of tumor-bearing mice. Conclusions: These data suggested that NEO-201 has an antitumor activity against tumor cells expressing its antigen. Targeting an antigen expressed in tumors, but not in normal tissues, allows patient selection for optimal treatment. These findings strongly indicate that NEO-201 warrants clinical testing as both a novel therapeutic and diagnostic agent for treatment of ovarian carcinomas. A first in human clinical trial evaluating NEO-201 in adults with chemo-resistant solid tumors is ongoing at the NIH clinical Center.

Phosphorylation-Dependent Targeting of Tetrahymena HP1 to Condensed Chromatin.

The evolutionarily conserved proteins related to heterochromatin protein 1 (HP1), originally described in Drosophila, are well known for their roles in heterochromatin assembly and gene silencing. Targeting of HP1 proteins to specific chromatin locales is mediated, at least in part, by the HP1 chromodomain, which binds to histone H3 methylated at lysine 9 that marks condensed regions of the genome. Mechanisms that regulate HP1 targeting are emerging from studies with yeast and metazoans and point to roles for posttranslational modifications. Here, we report that modifications of an HP1 homolog (Hhp1) in the ciliate model Tetrahymena thermophila correlated with the physiological state and with nuclear differentiation events involving the restructuring of chromatin. Results support the model in which Hhp1 chromodomain binds lysine 27-methylated histone H3, and we show that colocalization with this histone mark depends on phosphorylation at a single Cdc2/Cdk1 kinase site in the "hinge region" adjacent to the chromodomain. These findings help elucidate important functional roles of reversible posttranslational modifications of proteins in the HP1 family, in this case, regulating the targeting of a ciliate HP1 to chromatin regions marked with methylated H3 lysine 27. IMPORTANCE Compacting the genome to various degrees influences processes that use DNA as a template, such as gene transcription and replication. This project was aimed at learning more about the cellular mechanisms that control genome compaction. Posttranslational modifications of proteins involved in genome condensation are emerging as potentially important points of regulation. To help elucidate protein modifications and how they affect the function of condensation proteins, we investigated the phosphorylation of the chromatin protein called Hhp1 in the ciliated protozoan Tetrahymena thermophila. This is one of the first functional investigations of these modifications of a nonhistone chromatin condensation protein that acts on the ciliate genome, and discoveries will aid in identifying common, evolutionarily conserved strategies that control the dynamic compaction of genomes.

Molecular Pathways: The Balance between Cancer and the Immune System Challenges the Therapeutic Specificity of Targeting Nuclear Factor-κB Signaling for Cancer Treatment.

The NF-κB signaling pathway is a complex network linking extracellular stimuli to cell survival and proliferation. Cytoplasmic signaling to activate NF-κB can occur as part of the DNA damage response or in response to a large variety of activators, including viruses, inflammation, and cell death. NF-κB transcription factors play a fundamental role in tumorigenesis and are implicated in the origination and propagation of both hematologic and solid tumor types, including melanoma, breast, prostate, ovarian, pancreatic, colon, lung, and thyroid cancers. On the other hand, NF-κB signaling is key to immune function and is likely necessary for antitumor immunity. This presents a dilemma when designing therapeutic approaches to target NF-κB. There is growing interest in identifying novel modulators to inhibit NF-κB activity as impeding different steps of the NF-κB pathway has potential to slow tumor growth, progression, and resistance to chemotherapy. Despite significant advances in our understanding of this pathway, our ability to effectively clinically block key targets for cancer therapy remains limited due to on-target effects in normal tissues. Tumor specificity is critical to developing therapeutic strategies targeting this antiapoptotic signaling pathway to maintain antitumor immune surveillance when applying such therapy to patients. Clin Cancer Res; 22(17); 4302-8. ©2016 AACR.

Evaluation of Autogenous Engineered Septal Cartilage Grafts in Rabbits- A Minimally Invasive Preclinical Model.

OBJECTIVES: Evaluate safety of autogenous engineered septal neocartilage grafts.Compare properties of implanted grafts versus in vitro controls. STUDY DESIGN: Prospective, basic science. SETTING: Research laboratory. METHODS: Constructs were fabricated from septal cartilage and serum harvested from adult rabbits and then cultured in vitro or implanted on the nasal dorsum as autogenous grafts for 30 or 60 days. Rabbits were monitored for local and systemic complications. Histological, biochemical and biomechanical properties of implanted and in vitro constructs were evaluated and compared. RESULTS: No systemic or serious local complications were observed. After 30 and 60 days, implanted constructs contained more DNA (p<0.01) and less sGAG per DNA (p<0.05) when compared with in vitro controls. Confined compressive aggregate moduli were also higher in implanted constructs when compared with in vitro controls (p<0.05) and increased with longer in vivo incubation time (p<0.01). Implanted constructs displayed resorption rates of 20-45 percent. Calcium deposition in implanted constructs was observed using alizarin red histochemistry and microtomographic analyses. CONCLUSION: Autogenous engineered septal cartilage grafts were well tolerated. As seen in experiments with athymic mice, implanted constructs accumulated more DNA and less sGAG when compared with in vitro controls. Confined compressive aggregate moduli were also higher in implanted constructs. Implanted constructs displayed resorption rates similar to previously published studies using autogenous implants of native cartilage. The basis for observed calcification in implanted constructs and its effect on long-term graft efficacy is unknown at this time and will be a focus of future studies.

Volume Expansion of Tissue Engineered Human Nasal Septal Cartilage.

IMPORTANCE: Cartilaginous craniofacial defects range in size and autologous cartilaginous tissue is preferred for repair of these defects. Therefore, it is important to have the ability to produce large size cartilaginous constructs for repair of cartilaginous abnormalities. OBJECTIVES: To produce autologous human septal neocartilage constructs substantially larger in size than previously produced constructsTo demonstrate that volume expanded neocartilage constructs possess comparable histological and biochemical properties to standard size constructsTo show that volume expanded neocartilage constructs retain similar biomechanical properties to standard size constructs. DESIGN: Prospective, basic science. SETTING: Laboratory. PARTICIPANTS: The study used remnant human septal specimens removed during routine surgery at the University of California, San Diego Medical Center or San Diego Veterans Affairs Medical Center. Cartilage from a total of 8 donors was collected. MAIN OUTCOMES MEASURED: Human septal chondrocytes from 8 donors were used to create 12mm and 24mm neocartilage constructs. These were cultured for a total of 10 weeks. Photo documentation, histological, biochemical, and biomechanical properties were measured and compared. RESULTS: The 24mm diameter constructs were qualitatively similar to the 12mm constructs. They possessed adequate strength and durability to be manually manipulated. Histological analysis of the constructs demonstrated similar staining patterns in standard and volume expanded constructs. Proliferation, as measured by DNA content, was similar in 24mm and 12mm constructs. Additionally, glycosaminoglycan (GAG) and total collagen content did not significantly differ between the two construct sizes. Biomechanical analysis of the 24mm and 12mm constructs demonstrated comparable compressive and tensile properties. CONCLUSION AND RELEVANCE: Volume expanded human septal neocartilage constructs are qualitatively and histologically similar to standard 12mm constructs. Biochemical and biomechanical analysis of the constructs demonstrated equivalent properties. This study shows that modification of existing protocols is not required to successfully produce neocartilage constructs in larger sizes for reconstruction of more substantial craniofacial defects. LEVEL OF EVIDENCE: NA.

A compositional analysis of cadaveric human nasal septal cartilage.

OBJECTIVES/HYPOTHESIS: To localize quantitatively the major biochemical constituents of native adult human septal cartilage across whole septa. STUDY DESIGN: Prospective, basic science. METHODS: The nasal septa from seven cadavers were partitioned into 24 separate regions: six from caudal to cephalic and four from dorsal to ventral. Biochemical assays were used to determine the quantities, relative to wet weight, of the major constituents of cartilage: chondrocytes, collagen, and sulfated glycosaminoglycan. RESULTS: On average, each milligram of wet cartilage contained 24,900 cells, 73.9 µg collagen, and 17.1 µg sulfated glycosaminoglycan. Cell number showed no significant variation across the septa. In contrast, the caudal regions of the septa were associated with higher levels of collagen, the ventral regions correlated with higher levels of sulfated glycosaminoglycan, and the dorsal regions were associated with an elevated ratio of collagen to sulfated glycosaminoglycan. CONCLUSIONS: This study represents the first characterization of the biochemical composition of native human septal cartilage across whole septa. Quantities of collagen and sulfated glycosaminoglycan showed region-specific variation across the septum. The localized pattern of collagen and sulfated glycosaminoglycan deposition are consistent with the significance of preserving the L-strut during rhinoplasty and other nasal reconstructive procedures. In addition, it may assist in defining design goals for tissue-engineered septal neocartilage constructs to meet specific reconstructive needs in the future.

Shape fidelity of native and engineered human nasal septal cartilage.

OBJECTIVE: To test engineered and native septal cartilage for resistance to deformation and remodeling under sustained bending loads and to determine the effect of bending loads on the biochemical properties of constructs. STUDY DESIGN: Prospective, basic science. SETTING: Laboratory. SUBJECTS AND METHODS: Human septal chondrocytes from 6 donors were used to create 12-mm constructs. These were cultured for 10 weeks and subjected to bending for 6 days. Free-swelling controls and native tissue from 6 donors were used for comparison. Shape retention, photo documentation, live-dead staining, and biochemical properties were measured. RESULTS: Live-dead staining showed no difference in cell survival between loaded constructs and free-swelling controls. The immediate shape retention of the constructs was 39.0% versus 24.4% for native tissue (P = .13). After 2 and 24 hours of relaxation, the constructs possessed similar shape retention to native tissue (26.9% and 16.4%; P = .126; 21.7% and 14.4%; P = .153). There was no significant change in construct shape retention from immediately after release to 2 hours of relaxation (39.0% and 26.9%, respectively; P = .238). In addition, the retention did not change significantly between 2 and 24 hours of relaxation (26.9% and 21.7%; P = .48). There was no significant difference in biochemical properties between loaded constructs and controls. CONCLUSION: The shape retention properties of human septal neocartilage constructs are comparable to human native septal cartilage. In addition, mechanical loading of neocartilage constructs does not adversely affect cell viability or biochemical properties. This study demonstrates that neocartilage constructs possess adequate shape fidelity for use as septal cartilage graft material.