Perioperative Myomectomy Outcomes Based on the Current Coding Rules: Comparing Leiomyoma Burden and Surgical Approach.

OBJECTIVE: To assess postoperative outcomes based on surgical approach for myomectomies with increasing leiomyoma burden. METHODS: We conducted a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019 of benign myomectomy procedures. These cases were categorized into "smaller" and "larger" procedures based on leiomyoma burden. Smaller myomectomies included leiomyomas weighing less than 250 g or with one-four leiomyomas (Current Procedural Terminology [CPT] codes 58545 and 58140); larger myomectomies included leiomyomas weighing 250 g or more or with five or more leiomyomas (CPT codes 58546 and 58146). Postoperative complications estimated using the Clavien-Dindo classification system were compared based on surgical approach. RESULTS: Of 8,363 total myomectomy procedures, 3,117 (37.3%) were performed using minimally invasive surgery (MIS) and 5,246 (62.7%) were performed using laparotomy. Among MIS cases, 2,080 (66.7%) were categorized as smaller myomectomies and 1,037 (33.3%) cases as larger myomectomies. Among laparotomy cases, 2,587 (49.3%) were smaller myomectomies, and 2,659 (50.7%) were larger myomectomies. Regardless of myomectomy size, MIS was associated with a lower perioperative blood transfusion rate than laparotomy (1.63% vs 8.93%, respectively, P<.01). Laparotomy was associated with an increased rate of minor complications (adjusted odds ratio [aOR] 2.86 (95% CI 2.24-3.67) for smaller leiomyoma burden (11.91% vs 4.28%) and for larger leiomyoma burden (21.59% vs 6.75%, aOR 3.43, 95% CI 2.64-4.47) cases. Laparotomy demonstrated an increased cumulative major complication rate (3.31% vs 1.25%) (aOR 2.45, 95% CI 1.35-4.45) for larger myomectomies. CONCLUSION: A minimally invasive surgical approach for both smaller and larger myomectomies was associated with fewer minor complications compared with laparotomy. Minimally invasive surgery for larger myomectomies was associated with fewer cumulative major complications compared with laparotomy.

Perspectives on Triple-Negative Breast Cancer: Current Treatment Strategies, Unmet Needs, and Potential Targets for Future Therapies.

Triple-negative breast cancer (TNBC), characterized by the absence or low expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor (HER2), is the most aggressive subtype of breast cancer. TNBC accounts for about 15% of breast cancer cases in the U.S., and is known for high relapse rates and poor overall survival (OS). Chemo-resistant TNBC is a genetically diverse, highly heterogeneous, and rapidly evolving disease that challenges our ability to individualize treatment for incomplete responders and relapsed patients. Currently, the frontline standard chemotherapy, composed of anthracyclines, alkylating agents, and taxanes, is commonly used to treat high-risk and locally advanced TNBC. Several FDA-approved drugs that target programmed cell death protein-1 (Keytruda) and programmed death ligand-1 (Tecentriq), poly ADP-ribose polymerase (PARP), and/or antibody drug conjugates (Trodelvy) have shown promise in improving clinical outcomes for a subset of TNBC. These inhibitors that target key genetic mutations and specific molecular signaling pathways that drive malignant tumor growth have been used as single agents and/or in combination with standard chemotherapy regimens. Here, we review the current TNBC treatment options, unmet clinical needs, and actionable drug targets, including epidermal growth factor (EGFR), vascular endothelial growth factor (VEGF), androgen receptor (AR), estrogen receptor beta (ERß), phosphoinositide-3 kinase (PI3K), mammalian target of rapamycin (mTOR), and protein kinase B (PKB or AKT) activation in TNBC. Supported by strong evidence in developmental, evolutionary, and cancer biology, we propose that the K-RAS/SIAH pathway activation is a major tumor driver, and SIAH is a new drug target, a therapy-responsive prognostic biomarker, and a major tumor vulnerability in TNBC. Since persistent K-RAS/SIAH/EGFR pathway activation endows TNBC tumor cells with chemo-resistance, aggressive dissemination, and early relapse, we hope to design an anti-SIAH-centered anti-K-RAS/EGFR targeted therapy as a novel therapeutic strategy to control and eradicate incurable TNBC in the future.

A New Strategy to Control and Eradicate "Undruggable" Oncogenic K-RAS-Driven Pancreatic Cancer: Molecular Insights and Core Principles Learned from Developmental and Evolutionary Biology.

Oncogenic K-RAS mutations are found in virtually all pancreatic cancers, making K-RAS one of the most targeted oncoproteins for drug development in cancer therapies. Despite intense research efforts over the past three decades, oncogenic K-RAS has remained largely "undruggable". Rather than targeting an upstream component of the RAS signaling pathway (i.e., EGFR/HER2) and/or the midstream effector kinases (i.e., RAF/MEK/ERK/PI3K/mTOR), we propose an alternative strategy to control oncogenic K-RAS signal by targeting its most downstream signaling module, Seven-In-Absentia Homolog (SIAH). SIAH E3 ligase controls the signal output of oncogenic K-RAS hyperactivation that drives unchecked cell proliferation, uncontrolled tumor growth, and rapid cancer cell dissemination in human pancreatic cancer. Therefore, SIAH is an ideal therapeutic target as it is an extraordinarily conserved downstream signaling gatekeeper indispensable for proper RAS signaling. Guided by molecular insights and core principles obtained from developmental and evolutionary biology, we propose an anti-SIAH-centered anti-K-RAS strategy as a logical and alternative anticancer strategy to dampen uncontrolled K-RAS hyperactivation and halt tumor growth and metastasis in pancreatic cancer. The clinical utility of developing SIAH as both a tumor-specific and therapy-responsive biomarker, as well as a viable anti-K-RAS drug target, is logically simple and conceptually innovative. SIAH clearly constitutes a major tumor vulnerability and K-RAS signaling bottleneck in pancreatic ductal adenocarcinoma (PDAC). Given the high degree of evolutionary conservation in the K-RAS/SIAH signaling pathway, an anti-SIAH-based anti-PDAC therapy will synergize with covalent K-RAS inhibitors and direct K-RAS targeted initiatives to control and eradicate pancreatic cancer in the future.

RAS pathway biomarkers for breast cancer prognosis.

Metastatic breast cancer is a highly heterogeneous, rapidly evolving and devastating disease that challenges our ability to find curative therapies. RAS pathway activation is an understudied research area in breast cancer. EGFR/RAS pathway activation is prevalent in breast cancer with poor prognosis. The prognostic RAS pathway biomarkers can be used to identify resistant tumour clones, stratify patients and guide therapies.