Intracardiac metastasis of gestational choriocarcinoma: a case report and literature review.

INTRODUCTION: Gestational trophoblastic neoplasia (GTN) with intracardiac metastasis is rare, and here we reported a patient with intracardiac metastasis of high-risk and refractory gestational choriocarcinoma and reviewed relevant literatures. CASE PRESENTATION: A 37-year-old woman presented with vaginal bleeding and high level of ß-human chorionic gonadotropin (ß-hCG) at 199,060 (mIU/mL). It was clinically diagnosed with gestational choriocarcinoma. The patient initially received eight cycles of chemotherapy but unsatisfactory response was observed, and the level of ß-hCG still ranged between 5000 and 10,000. Then there was found intracardiac masses in the right atrium (2.6*1.7 cm), anterior chordae tendineae of the tricuspid valve (1.4*0.7 cm) and the right ventricle (4.1*2.9 cm) by ultrasonic cardiogram (UCG). PET/CT highly suspected the intracardiac metastasis of choriocarcinoma (SUVmax = 9.3) and no disease was found in the lung and pelvis. The patient undertook complete intracardiac masses resection. The pathology confirmed the intracardiac metastasis of disease. After a week of operation, the UCG found a 5.4*4.2 cm mass in the right atrium again. Considering the poor prognosis, the patient received palliative care and eventually died of disease progression. CONCLUSION: Intracardiac metastasis of GTN is an aggressive sign of disease. Patients can benefit from chemotherapy and surgery. Future investigation of PD-1 immunotherapy combines with chemotherapy are expected to improve the prognosis in this group of patients.

Clinicopathological analysis of patients with molecularly confirmed stage I adult granulosa cell tumors and prediction of recurrence.

OBJECTIVE: Adult granulosa cell tumors (AGCTs) are rare malignancies that accounts for approximately 1% of ovarian neoplasms. As there are currently no well-recognized models for predicting relapse-free survival (RFS), we performed a clinicopathological analysis to identify risk factors for AGCT recurrence. METHODS: We investigated 130 patients with pathologically diagnosed AGCT as confirmed by the presence of the characteristic FOXL2 C402G mutation. RESULTS: Most patients had International Federation of Gynecology and Obstetrics stage I disease (n = 122, 95.3%). The 10-year RFS rate was 31.4% (22/70) and mean 10-year RFS was 74.4 (95% CI, 65.2-83.7) months. Ten patients experienced recurrence beyond the 10-year follow-up period. Undergoing fertility sparing surgery, an estrogen receptor-α (ERα) score (>0.25), and a Ki-67 index >15% were independent risk factors for recurrence in patients with stage I disease (bias-corrected C-index: 0.776). We constructed a nomogram with well-fitting calibration plots; the areas under the curve (AUCs) for 5-, and 10-year RFS prediction were 0.883 and 0.906 respectively. A simplified model with 3 predictive factors (ERα score, Ki-67 index, and primary surgical procedure) and 2 risk stratification subgroups (low- and high-risk) was constructed; its AUCs for 5-, and 10-year RFS prediction were 0.825 and 0.850 respectively. Kaplan-Meier survival curves showed significant differences in 10-year RFS between the low- and high-risk groups (p < 0.001). CONCLUSIONS: The type of primary surgical procedure, ERα score, and Ki-67 index are independent predictors of recurrence for patients with stage I AGCT. Our predictive model based on these factors showed good performance.

Expression of the immune targets in tumor-infiltrating immunocytes of gestational trophoblastic neoplasia.

Objectives: To evaluate the expression of emerging immune targets in the tumor-infiltrating immunocytes (TIIs) of human gestational trophoblastic neoplasia (GTN) specimens, and to analyze the correlation between the expression patterns and prognosis of GTN patients. Methods: Between January 2008 and December 2017, patients who were diagnosed histologically with GTN were included in this study. The expression densities of LAG-3, TIM-3, GAL-9, PD-1, CD68, CD8, and FOXP3 in the TIIs were assessed independently by two pathologists blinded to clinical outcomes. The expression patterns and correlation with patient outcomes were analyzed to identify prognostic factors. Results: We identified 108 patients with GTN, including 67 with choriocarcinoma, 32 with placental site trophoblastic tumor (PSTT), and 9 with epithelioid trophoblastic tumor (ETT). Almost all GTN patients showed expression of GAL-9, TIM-3, and PD-1 in TIIs (100%, 92.6%, and 90.7%, respectively); LAG-3 was expressed in 77.8% of the samples. The expression densities of CD68 and GAL-9 were significantly higher in choriocarcinoma than that in PSTT and ETT. The TIM-3 expression density in choriocarcinoma was higher than that in PSTT. In addition, the expression density of LAG-3 in the TIIs of choriocarcinoma and PSTT was higher than that in ETT. There was no statistical difference in the expression pattern of PD-1 among different pathological subtypes. The positive expression of LAG-3 in tumor TIIs was a prognostic factor for disease recurrence, and patients with positive expression of LAG-3 in the TIIs had poorer disease-free survival (p = 0.026). Conclusion: Our study evaluated the expression of immune targets PD-1, TIM-3, LAG-3, and GAL-9 in the TIIs of GTN patients and found that they were widely expressed but not associated with patients' prognoses, excepting the positive expression of LAG-3 was a prognostic factor for disease recurrence.

Solid Pseudopapillary Neoplasms of the Pancreas: Clinicopathologic Analysis and a Predictive Model.

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare. They are considered low-grade malignancies, and a small percentage of patients experience recurrence or metastasis. It is critical to investigate associated biological behavior and identify patients at a risk of relapse. This was a retrospective study of 486 patients with SPNs who were diagnosed between 2000 and 2021. Their clinicopathologic features, including 23 parameters and prognoses were analyzed. Six patients (1.2%) presented with synchronous liver metastasis. A total of 21 patients experienced recurrence or metastasis postoperatively. The overall and disease-specific survival rates were 99.8% and 100%, respectively. The 5- and 10-year relapse-free survival (RFS) rates were 97.4% and 90.2%, respectively. Tumor size, lymphovascular invasion, and the Ki-67 index were independent predictors of relapse. Furthermore, a Peking Union Medical College Hospital-SPN risk model was built to evaluate the risk of relapse and compared it with the American Joint Committee on Cancer tumor staging system (eighth edition, 2017). Risk factors included 3 parameters: tumor size (>9 cm), lymphovascular invasion status (presence), and Ki-67 index (>1%). Risk grades were available for 345 patients, who were divided into 2 groups: (1) low risk (n = 124) and (2) high risk (n = 221). The group with no risk factors was designated as low risk and had a 10-year RFS of 100%. The group associated with 1 to 3 factors was designated as high risk, with a 10-year RFS of 75.3%. Receiver operating characteristic curves were generated, and the area under the curve was 0.791 for our model and 0.630 for the American Joint Committee on Cancer with respect to the cancer staging system. We validated our model in independent cohorts and demonstrated a sensitivity of 98.3%. In conclusion, SPNs are low-grade malignant neoplasms that rarely metastasize, and the 3 selected pathologic parameters can be used to predict their behavior. A novel Peking Union Medical College Hospital-SPN risk model was proposed for routine application to guide the patient counseling in clinical practice.

B7-H4 Further Stratifies Patients With Endometrial Cancer Exhibiting a Nonspecific Molecular Profile.

CONTEXT.­: Endometrial cancer is classified into 4 molecular subtypes: DNA polymerase epsilon ultramutated, mismatch repair deficient, p53 mutant, and nonspecific molecular profile (NSMP). Additional biomarkers are urgently needed to better characterize the NSMP subtype, the largest group with heterogeneous pathologic features and prognoses. OBJECTIVE.­: To investigate the expression of B7 homolog 3 (B7-H3), B7 homolog 4 (B7-H4), and V-set and immunoglobulin domain containing 3 (VSIG-3, a ligand for B7-H5) in 833 patients with endometrial cancer and determine their associations with clinicopathologic and molecular features as well as survival outcomes. DESIGN.­: Molecular classification was determined by polymerase epsilon sequencing and immunohistochemical staining for p53 and mismatch repair proteins. B7-H3, B7-H4, VSIG-3, and programmed death ligand-1 (PD-L1) were detected via immunohistochemistry. RESULTS.­: The positivity rates for B7-H3 in each of the tumor and immune cells, B7-H4 (exclusively in tumor cells), and VSIG-3 (exclusively in tumor cells) were 89.0%, 42.3%, 71.5%, and 99.8%, respectively. B7-H3 and B7-H4 positivity in tumor cells was associated with favorable pathologic features and prognosis. In contrast, B7-H3 expression in immune cells was frequent in samples with unfavorable pathologic features; those with p53-mutant subtype, PD-L1 positivity, and a high density of CD8+ T cells; and in patients with poor prognoses. Positive B7-H4 expression was a predictor of improved survival in patients with the NSMP subtype independent of tumor stage or pathologic features. CONCLUSIONS.­: The NSMP subgroup of endometrial cancer can be further stratified by B7-H4 status. Incorporating B7-H4 status into the molecular classification of NSMP could improve the ability to predict disease relapse.

Incorporating Molecular Classification When Stratifying the Survival Risk of Patients with High-Grade Endometrial Carcinomas.

Assessing survival risk in patients with high-grade endometrial carcinomas has remained challenging. We aimed to investigate the distribution of molecular subtypes and assess their prognostic role in a large cohort of 355 patients with high-grade endometrial carcinoma. Molecular classification was determined using DNA polymerase epsilon (POLE) sequencing as well as immunohistochemical staining for p53 and mismatch repair (MMR) proteins. Endometrial carcinomas were stratified into four subtypes: POLE ultramutated, MMR-deficient, non-specific molecular profile (NSMP), and p53-mutant. This study included 177 and 178 patients with endometrioid and non-endometrioid carcinomas, respectively. Forty-two patients (11.8%) were categorized as POLE ultramutated, 106 (29.9%) as MMR-deficient, 128 (36.1%) as p53-mutant, and 79 (22.2%) as NSMP. Patients of different molecular subtypes had distinct survival times; molecular classification, but not histotype, was significantly associated with survival outcomes. When incorporating molecular classification into the stratification model, 52 patients (15.5%) switched risk groups, with 40 (11.9%) shifting to a lower risk for having a POLE mutation and 12 (3.6%) shifting to a higher risk owing to p53-mutant status. Molecular classification may provide more accurate prognostic information among patients with high-grade endometrial carcinomas and improve their stratification for purposes of clinical management.

Expression and Prognostic Value of B7 Family Immune Checkpoints in Pancreatic Neuroendocrine Tumors.

CONTEXT.­: Pancreatic neuroendocrine tumors (PanNETs) are rare malignancies with heterogeneous clinical courses requiring novel prognosticators and therapies. B7 family molecules have an important role in various cancers; however, these have not been distinguished in PanNETs. OBJECTIVE.­: To investigate the expression and clinical significance of programmed death ligand-1 (PD-L1), programmed death ligand-2 (PD-L2), B7 homolog 3 (B7-H3), B7 homolog 4 (B7-H4), and V-domain immunoglobulin suppressor of T-cell activation (VISTA) in 182 PanNETs (with a high proportion of functioning versus nonfunctioning PanNETs: 51% versus 49%). DESIGN.­: Molecules were immunostained by using tissue microarrays from 182 patients with grade 1/2 PanNETs. VISTA-positive microvessel density (VISTA+ MVD) was evaluated in 4 high-power fields (HPFs) (×200) and mean count was calculated; immune cells with 1% or greater VISTA staining were considered positive. PD-L1 tumoral expression was considered positive in samples with 5% or more membranous staining. Tumoral VISTA, stromal PD-L1, PD-L2, B7-H3, and B7-H4 expression were deemed positive if any staining was observed. RESULTS.­: VISTA+ MVD was high (≥10.8/HPF) in 45 patients (25%), while VISTA stained positively on immune and tumor cells in 121 (66%) and 0 patients, respectively. Positive PD-L1 tumoral and stromal expression was observed in 23 (13%) and 0 patients, with positive B7-H3 expression in 76 (42%) and 98 (54%) patients, respectively, in these cells; PD-L2 and B7-H4 were not detected. PD-L1 positivity rate was high in functioning PanNETs. Stromal B7-H3 and high VISTA+ MVD correlated with unfavorable clinicopathologic features. Moreover, high VISTA+ MVD was an independent predictor of shorter progression-free survival. CONCLUSIONS.­: VISTA may serve as a prognosticator and immunotherapeutic target for patients with pancreatic neuroendocrine tumor (PanNET).

A Novel Signature Based on m6A RNA Methylation Regulators Reveals Distinct Prognostic Subgroups and Associates with Tumor Immunity of Patients with Pancreatic Neuroendocrine Neoplasms.

INTRODUCTION: The RNA N6-methyladenosine (m6A) regulators play a crucial role in tumorigenesis and could be indicators of prognosis and therapeutic targets in various cancers. However, the expression status and prognostic value of m6A regulators have not been studied in pancreatic neuroendocrine neoplasms (PanNENs). We aimed to investigate the expression patterns and prognostic value of m6A regulators and assess their correlations with immune checkpoints and infiltrates in PanNENs. METHODS: Immunohistochemistry was performed for 15 m6A regulators and immune markers using tissue microarrays obtained from 183 patients with PanNENs. The correlation between m6A protein expression and clinicopathological parameters with recurrence-free survival (RFS) was examined using a random survival forest, Cox regression model, and survival tree analysis. RESULTS: Among the 15 m6A proteins, high expression of YTHDF2 (p < 0.001) and HNRNPC (p = 0.006) was found to be significantly associated with recurrence and served as independent risk factors in multivariate analysis. High YTHDF2 expression was associated with higher number of CD3+ T cells (p = 0.003), whereas high HNRNPC expression was significantly correlated with the expression of PD-L1 (p = 0.039). A YTHDF2-based signature was determined, including five patterns from survival tree analysis: patients with the LNnegYTHDF2high signature had a 5-year RFS rate of 92.1%, whereas patients with LNposTumorSize＜2.5 cm signature had the worst 5-year RFS rate of 0% (p < 0.001). The area under receiver operating characteristic curve was 0.870 (95% confidence interval: 0.762-0.915) for the YTHDF2-based signature. The C-index was 0.978, suggesting good discrimination ability; moreover, the risk score of recurrence served as an independent prognostic factor indicating shorter RFS. CONCLUSIONS: YTHDF2 appears to serve as a promising prognostic biomarker and therapeutic target. A YTHDF2-based signature can identify distinct subgroups, which may be helpful to strategize personalized postoperative monitoring.

Clinicopathological and molecular characterization of high-grade endometrial carcinoma with POLE mutation: a single center study.

OBJECTIVE: The molecular classification system of endometrial carcinoma (EC) in 'The Cancer Genome Atlas' is widely acknowledged for its prognostic utility. Subsequently, more simplified classification system that incorporate DNA polymerase epsilon (POLE) exonuclease domain mutations, mismatch repair deficiencies (MMRd), and abnormal p53 (P53abn) has also demonstrated its clinical utility. These classifications helped identifying a 'POLE ultramutated' (POLEmut) category of patients, most of whom show excellent prognoses despite having high-grade ECs. We aimed to investigate the clinicopathological and molecular characteristics of high-grade ECs with POLEmut. METHODS: We investigated 414 patients with high-grade ECs (including endometrioid carcinomas grade 3, serous carcinomas, clear cell carcinomas, mixed carcinomas, undifferentiated and dedifferentiated carcinomas, and carcinosarcomas) by sequencing and immunohistochemical staining. RESULTS: Forty-three tumors (10.4%) were classified as POLEmut, including 2 with new, possibly pathogenic POLE mutations at P286C and L424V. These patients had very good prognoses except for 1 with stage IV disease and residual tumor. Eleven patients in this group also had P53abn and 4 had MMRd; molecular analysis revealed that patients with synchronous POLE pathogenic mutation and other mutations had a POLEmut or MMRd phenotype; survival analysis found no difference in prognosis between these patient categories. The prognoses of patients in the POLEmut EC group were not significantly influenced by treatment or risk category. CONCLUSIONS: Patients with high-grade EC exhibiting POLEmut have very good clinical outcomes, and should be identified urgently in daily work owing to their conflicting morphology. Our findings also provide guidance on subclassifying ECs with poor histological appearance.

Analysis of the immune checkpoint V-domain Ig-containing suppressor of T-cell activation (VISTA) in endometrial cancer.

V-domain Ig-containing suppressor of T-cell activation (VISTA) is a novel immune checkpoint protein and a potential immunotherapeutic target. However, its expression in endometrial cancer has not been clearly defined. This study aimed to investigate VISTA expression and determine its associations with clinicopathological features, molecular subtypes, programmed cell death-ligand 1 (PD-L1) expression, CD8+ T-cell count, and survival in a cohort of 839 patients with endometrial cancer. Using direct sequencing of the polymerase epsilon (POLE) exonuclease domain and immunohistochemistry for mismatch repair (MMR) proteins and p53, we stratified endometrial cancers into four molecular subtypes: POLE ultramutated, MMR-deficient, p53-mutant, and nonspecific molecular profile (NSMP). PD-L1, CD8, and VISTA were detected via immunohistochemistry. VISTA was expressed in the immune cells of 76.6% (643/839) of the samples and in the tumor cells of 6.8% (57/839). VISTA positivity in the immune cells was frequent in tumors staged I-III, those with positive PD-L1 or high CD8+ T-cell density, and those representing POLE ultramutated and MMR-deficient subtypes. Furthermore, VISTA positivity in tumor cells was more frequent in clear cell carcinoma samples. VISTA in immune cells was associated with improved survival in the entire cohort as well as in the endometrioid histology, stage I, PD-L1-negative, MMR-deficient, MMR-proficient, and high and low number of CD8+ T-cell-infiltrated tumor subgroups. VISTA in immune cells was a prognostic factor overall, as well as in patients with endometrioid histology, independent of molecular subtype or CD8+ T-cell density. The data produced by this study, which was the largest to focus on VISTA expression in patients with endometrial cancer to date, suggest that VISTA is a predictor of improved survival.

High Mast Cell Density Predicts a Favorable Prognosis in Patients with Pancreatic Neuroendocrine Neoplasms.

INTRODUCTION: Mast cells are involved in allergic diseases, immune regulation, and tumor microenvironment modulation, with both pro- and anti-tumorigenic functions, and could serve as a prognostic factor in various cancers. However, their potential role in pancreatic neuroendocrine neoplasms (PanNENs) is largely unknown. Here, our aim was to investigate the presence of mast cells in PanNENs and evaluate their association with clinicopathological parameters and other common tumor-infiltrating immune cells. METHODS: Tissue microarrays containing PanNEN samples from 187 patients were constructed and stained immunohistochemically for CD117, CD15, CD68, CD3, CD4, and CD8. Immune cells were counted from four high-power fields (HPFs; ×400) at maximal concentrations, and the mean counts were calculated per HPF. The cutoff values were set by X-tile. RESULTS: The median (interquartile range) counts of CD117+ mast cells, CD15+ neutrophils, CD68+ macrophages, CD3+ T cells, and CD4+ T cells were 3.5 (2.0-6.0), 3.0 (1.3-6), 3.8 (2.5-5.8), 13 (8.0-24.0), and 2.0 (1.0-4.0)/HPF, respectively. CD8+ T cells were not detected. The cutoff values for these immune cells were 1.5/HPF, 6/HPF, 4.8/HPF, 32.5/HPF, and 2/HPF, respectively. Low mast cell density was correlated with higher grades, noninsulinoma, and advanced stages. Moreover, high mast cell infiltration was associated with elevated CD4+ T cell and CD15+ neutrophil counts. Multivariate analysis revealed that high mast cell density was an independent predictor of prolonged progression-free survival in the entire cohort; in pancreatic neuroendocrine tumors; and in intermediate-grade, noninsulinoma, and advanced stage subgroups. CONCLUSIONS: These findings suggest a protective role of mast cells in PanNENs.

Expression of B7 family checkpoint proteins in cervical cancer.

The role of programmed cell death-ligand 1 (PD-L1) in cervical cancer has been widely investigated; however, the influences of other inhibitory B7 family members are poorly understood. We investigated the expression of PD-L1, B7 homolog 3 (B7-H3), B7-H4, and V-domain Ig suppressor of T-cell activation (VISTA) and their association with the clinicopathological features and outcomes of a large cohort of 673 patients with squamous cell carcinoma or adenocarcinoma of the uterine cervix. The positivity rates for PD-L1 (combined positive score ≥1), B7-H3 in tumor cells (TCs), B7-H4 (exclusively in TCs), VISTA in immune cells (ICs), and VISTA in TCs were 57.9%, 62.8%, 44.8%, 92.6%, and 4.8%, respectively, in 606 primary cervical cancer samples. Co-expression of PD-L1 with B7-H3 in TCs and with B7-H4 and VISTA in ICs was observed in 38.8%, 25.4%, and 57.9% of samples, respectively. B7-H3 in TCs and B7-H4 and VISTA in ICs were observed in 58.1%, 46.6%, and 83.1% of PD-L1-negative samples, respectively. These proteins were observed more frequently in squamous cell carcinomas and in moderately to poorly differentiated carcinomas. VISTA (in ICs) and B7-H4 were more frequent in primary tumors than in recurrent counterparts and correlated with improved survival; in contrast, B7-H3 positivity in TCs was less frequent in primary tumors and correlated with short disease-specific survival. Co-expression of B7-H4 and VISTA in ICs was an independent predictor of favorable outcomes overall and among patients with PD-L1-negative tumors. These data indicate that B7 family proteins exhibit differing expression patterns, distributions, and prognostic implications in cervical cancer. Furthermore, the co-expression of PD-L1 with other checkpoint proteins suggests that PD-1/PD-L1 blockade combined with modulating other immune checkpoints may present a novel therapeutic approach for cervical cancer. Future studies are needed to validate prognostic values of B7 family proteins and explore their biological roles in this malignancy.

B7-H4 Expression in Precancerous Lesions of the Uterine Cervix.

Over 10% of patients diagnosed with cervical intraepithelial neoplasia (CIN) have no lesions detected in their cervical conization specimens. The purpose of this study was to determine the factors related to the absence of such lesions. We particularly sought to investigate whether the expression of B7-H4 in precancerous lesions and cancer of the uterine cervix plays a role in the presence or absence of residual lesions in conization specimens and whether this protein is associated with T cells (i.e., Foxp3+ regulatory T cells, CD4+, and CD8+) and interferon-γ production. Of the 807 patients with CIN treated by conization, 104 (12.9%) had no lesions in their conization specimens. Seventy-five of these patients were deemed the study group and were matched with 75 patients who did have CIN detected in their conization specimens (the control group). Immunohistochemistry and immunofluorescence staining were used to detect B7-H4, Foxp3, CD4, CD8, and interferon-γ in the 75 pairs of specimens obtained via biopsy; 20 samples were found to have chronic cervicitis, and another 20 had squamous cell carcinoma of the cervix. Menopause, the absence of human papillomavirus, low-grade histological findings, and a diagnosis of CIN1 and CIN2 on biopsy correlated with a low probability of lesions on conization specimens. B7-H4 expression was detected in 11.1% of CIN2, 46.6% of CIN3, and 70% of cervical cancer samples, but not in tissues representing chronic cervicitis or CIN1. B7-H4 expression was associated with the presence of lesions on conization specimens, increased regulatory T cells, decreased CD8+ T cells, and lower interferon-γ production. These data suggest that close follow-up and thorough reevaluation should be considered for patients diagnosed with CIN2 who are negative for B7-H4 expression on biopsy before proceeding with cervical conization.

Camrelizumab plus apatinib in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia (CAP 01): a single-arm, open-label, phase 2 trial.

BACKGROUND: Treatment options for patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia are scarce. The synergistic antitumour effect of immunotherapy and antiangiogenic drugs has been shown in many solid tumours. This phase 2 trial evaluated the activity and safety of camrelizumab (PD-1 inhibitor) plus apatinib (VEGF receptor inhibitor) in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. METHODS: This was a single-arm, open-label, phase 2 trial, done at a single tertiary health-care centre in Beijing, China. Women (18-70 years) with high-risk (International Federation of Gynecology and Obstetrics score ≥7) chemorefractory or relapsed gestational trophoblastic neoplasia who had received at least two lines of previously unsuccessful multidrug chemotherapy regimens and had an Eastern Cooperative Oncology Group performance status of 0-2 were eligible for inclusion. Patients received 4-week cycles of intravenous camrelizumab 200 mg every 2 weeks plus oral apatinib 250 mg once per day until disease progression or unacceptable toxicity. The primary endpoint was objective response rate assessed according to serum human chorionic gonadotrophin concentration. Activity and safety were analysed in all patients who received at least one dose of study drug. The study is ongoing, but recruitment is complete. The study is registered with ClinicalTrials.gov, NCT04047017. FINDINGS: Between Aug 7, 2019, and March 18, 2020, 20 patients enrolled; 19 (95%) were diagnosed with choriocarcinoma and one (5%) had placental site trophoblastic tumour. The median follow-up duration was 18·5 months (IQR 14·6-20·9). The objective response rate was 55% (95% CI 32-77); ten (50%; 95% CI 27-73) patients had complete response. The most common grade 3 treatment-related adverse events were hypertension (five [25%] patients), rash (four [20%] patients), neutropenia (two [10%]), leukocytopenia (two [10%]), and aspartate aminotransferase increase (two [10%]). One patient had a treatment-related serious adverse event (aspartate aminotransferase 19-times higher than the upper limit of normal). No grade 4 or 5 treatment-related adverse events were reported. INTERPRETATION: Camrelizumab plus apatinib showed promising antitumour activity and acceptable toxicity and could be a salvage therapy option for the treatment of high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. Immune checkpoint inhibitors combined with chemotherapy for heavily-treated patients and upfront use of camrelizumab plus apatinib for patients with high-risk gestational trophoblastic neoplasia are under investigation in phase 2 trials. FUNDING: National Natural Science Foundation of China, Jiangsu Hengrui Pharmaceuticals.

PD-L1 expression in tumor cells is associated with a favorable prognosis in patients with high-risk endometrial cancer.

OBJECTIVE: To investigate programmed cell death ligand 1 (PD-L1) expression patterns and define the associations among PD-L1, molecular subtypes, pathological features, and survival in a cohort of 833 patients with endometrial cancer, of whom approximately half had high-risk disease. METHODS: Using direct sequencing of the polymerase epsilon (POLE) exonuclease domain as well as immunohistochemistry for mismatch repair (MMR) proteins (MLH1, PMS2, MSH2, and MSH6) and p53, we stratified endometrial cancers into four molecular subtypes: POLE ultramutated, MMR-deficient, p53-mutant, and non-specific molecular profile (NSMP). PD-L1 was detected via immunohistochemistry and evaluated in tumor cells (TCs) and immune cells (ICs) individually and using the combined positive score (CPS). RESULTS: Positive PD-L1 staining in TCs (≥1%), ICs (≥1%), and in combination (CPS ≥1) was detected in 14.0%, 37.3%, and 45.1% of the samples, respectively. PD-L1 positivity in TCs was more frequent in high-grade than in low-grade tumors, while that in ICs was associated with lymphovascular space invasion, non-endometrioid histology, and deep myometrial invasion. PD-L1 expression in both TCs and ICs was more frequent in POLE ultramutated and MMR-deficient subtypes than in p53-mutant and NSMP subtypes. PD-L1 positivity in TCs, but not in ICs or combined (CPS), was associated with a favorable prognosis in patients with high-risk endometrial cancer. CONCLUSIONS: The distribution and prognostic significance of PD-L1 in TCs versus ICs differ in patients with endometrial cancer, indicating that the separate assessment of PD-L1 in these cells (rather than determining the CPS) may be more relevant to selecting patients eligible for endometrial cancer immunotherapy.

Expression of B7-H3 Correlates with PD-L1 and Poor Prognosis in Patients with Cervical Cancer.

PURPOSE: The purpose of this study was to investigate B7 homolog 3 (B7-H3) expression patterns and define its associations with programmed cell-death ligand 1 (PD-L1), pathological features, and survival in patients with cervical cancer. PATIENTS AND METHODS: Immunohistochemical staining was used to investigate B7-H3 and PD-L1 expression in tissue microarrays from 552 patients with stage IB1 and IIA1 cervical cancer, including 406 with squamous cell carcinoma and 146 with endocervical adenocarcinoma. RESULTS: B7-H3 was expressed in the tumor cells (TCs) of 32.1% of the samples as well as in the stromal cells of 92.9% of the specimens. B7-H3 was co-expressed with PD-L1 in 21.0% of the samples, while only one or the other was expressed in 41.7% of the samples. B7-H3 expression in TCs was more frequent in squamous cell carcinoma, PD-L1-positive samples, and tissues from patients with lymph node metastasis; moreover, its expression was an independent predictor of shorter survival. CONCLUSION: B7-H3 positivity in TCs is a promising prognostic biomarker, and targeting B7-H3 alone or in combination with PD-1/PD-L1 may be a potential immunotherapeutic strategy for patients with cervical cancer.

Upregulated MicroRNA-483-3p is an Early Event in Pancreatic Ductal Adenocarcinoma (PDAC) and as a Powerful Liquid Biopsy Biomarker in PDAC.

BACKGROUND: There is an urgent need for the development of effective noninvasive biomarkers for early pancreatic cancer diagnosis. MicroRNAs (miRNAs) are promising candidates that can be identified in peripheral blood and can act as "liquid biopsy" biomarkers. miR-483-3p is overexpressed in the tumor tissue of pancreatic duct adenocarcinoma, but its potential as noninvasive biomarker remains unknown. METHODS: We conducted locked nucleic acid in situ hybridization (LNA-ISH) for miR-483-3p in archival tissues of 107 patients with PDAC. We also used immunohistochemistry to evaluate SMAD4 expression, the putative miR-483-3p target gene. miR-483-3p expression level was also assessed using quantitative real-time PCR (qRT-PCR) in serum and serum exosome samples from 63 patients with PDAC and 22 healthy individuals. RESULTS: LNA-ISH showed that miR-483-3p was overexpressed in PDAC and PanIN tissues compared to normal pancreatic duct cells. miR-483-3p expression levels correlated with increases in PanIN lesion grade. miR-483-3p expression negatively correlated with Smad4 expression (γ=-0.770, p<0.0001) in PDAC and PanIN tissues. Circulating miR-483-3p levels were significantly elevated in the serum and serum exosomes of PDAC patients compared to healthy controls (p<0.0001 and p<0.01, respectively). Specifically, serum miR-483-3p levels were able to distinguish patients with early stage (≤2cm) PDAC from healthy controls with an AUC of 0.83 [95% CI, 0.70-0.96]. Higher serum exosomal miR-483-3p levels predicted worse survival in PDAC patients and serum exosomal miR-483-3p also proved to be an independent prognostic factor for PDAC (hazard ratio = 3.307; 95% CI=1.104 to 9.903; p=0.033). In vitro studies also showed that miR-483-3p promoted pancreatic cancer cell migration and invasion. CONCLUSION: miR-483-3p overexpression occurs early in PDAC development and is present in premalignant PanIN lesions. Serum miR-483-3p may act as an early PDAC diagnostic biomarker and serum exosomal miR-483-3p may be a PDAC prognostic biomarker.

High VISTA Expression Correlates With a Favorable Prognosis in Patients With Colorectal Cancer.

Colorectal cancer (CRC) is the third most common malignancy worldwide. The novel immune checkpoint V-domain Ig suppressor of T-cell activation (VISTA) has emerged as a promising target for cancer treatment; however, the prognostic significance of its expression in CRC remains unknown. In this study, immunohistochemical staining was used to investigate VISTA expression in tissue microarrays from 1434 patients with stage I-III CRC (816 in the exploratory cohort and 618 in the validation cohort). VISTA protein was evaluated separately in tumor cells and tumor-infiltrating immune cells (ICs). The associations between VISTA expression, mismatch repair (MMR) status, and clinicopathologic parameters were analyzed, as was the effect of VISTA on survival. High VISTA expression on ICs (ie, ≥5% staining) was more frequent in patients with N0 stage, T1-2 stage, low tumor grade, high CD8 density, and MMR-deficient tumors, and was positively associated with prolonged survival in patients with CRC. High VISTA expression was a significant predictor of prolonged survival independent of clinicopathologic parameters and MMR status. Overall, our results indicate that high VISTA expression on tumor-infiltrating ICs correlates with early tumor stage, MMR deficiency, and a favorable prognosis in patients with CRC. This ought to be considered in future trials of VISTA-modulating immunotherapy for patients with CRC.

Emerging Targets of Immunotherapy in Gynecologic Cancer.

Although programmed cell death protein 1/programmed death-ligand 1 (PD-1/PD-L1) and cytotoxic T lymphocyte antigen-4 (CTLA-4) have been successfully applied in the treatment of tumors, their efficiency is still not high enough. New immune targets need to be identified in order to seek alternative treatment strategies for patients with refractory tumors. Immune targets can be divided into stimulating and inhibiting molecules according to their function after receptor-ligand binding. We herein present a compendious summary of emerging immune targets in gynecologic tumors. These targets included coinhibitory molecules, such as T cell immunoglobulin-3 (TIM-3), T cell immunoglobulin and ITIM domain (TIGIT), lymphocyte activation gene-3 (LAG-3), V-type immunoglobulin domain-containing suppressor of T cell activation (VISTA), and B7-H3 and B7-H4, and co-stimulatory molecules, such as CD27, OX40, 4-1BB, CD40, glucocorticoid-induced tumor necrosis factor receptor (GITR) and inducible co-stimulator (ICOS). In this review, the characteristics and preclinical/clinical progress of gynecological malignancies are briefly discussed. However, the potential mechanisms and interactions of immune targets need to be elucidated in further studies.

Correction to: Expression of the immune checkpoint VISTA in breast cancer.

The original version of this article unfortunately contained a mistake. The correct information is given below.