Avelumab Plus Talazoparib in Patients With BRCA1/2- or ATM-Altered Advanced Solid Tumors: Results From JAVELIN BRCA/ATM, an Open-Label, Multicenter, Phase 2b, Tumor-Agnostic Trial.

Importance: Nonclinical studies suggest that the combination of poly(ADP-ribose) polymerase and programmed cell death 1/programmed cell death-ligand 1 inhibitors has enhanced antitumor activity; however, the patient populations that may benefit from this combination have not been identified. Objective: To evaluate whether the combination of avelumab and talazoparib is effective in patients with pathogenic BRCA1/2 or ATM alterations, regardless of tumor type. Design, Setting, and Participants: In this pan-cancer tumor-agnostic phase 2b nonrandomized controlled trial, patients with advanced BRCA1/2-altered or ATM-altered solid tumors were enrolled into 2 respective parallel cohorts. The study was conducted from July 2, 2018, to April 12, 2020, at 42 institutions in 9 countries. Interventions: Patients received 800 mg of avelumab every 2 weeks and 1 mg of talazoparib once daily. Main Outcomes and Measures: The primary end point was confirmed objective response (OR) per RECIST 1.1 by blinded independent central review. Results: A total of 200 patients (median [range] age, 59.0 [26.0-89.0] years; 132 [66.0%] women; 15 [7.5%] Asian, 11 [5.5%] African American, and 154 [77.0%] White participants) were enrolled: 159 (79.5%) in the BRCA1/2 cohort and 41 (20.5%) in the ATM cohort. The confirmed OR rate was 26.4% (42 patients, including 9 complete responses [5.7%]) in the BRCA1/2 cohort and 4.9% (2 patients) in the ATM cohort. In the BRCA1/2 cohort, responses were more frequent (OR rate, 30.3%; 95% CI, 22.2%-39.3%, including 8 complete responses [6.7%]) and more durable (median duration of response: 10.9 months [95% CI, 6.2 months to not estimable]) in tumor types associated with increased heritable cancer risk (ie, BRCA1/2-associated cancer types, such as ovarian, breast, prostate, and pancreatic cancers) and in uterine leiomyosarcoma (objective response in 3 of 3 patients and with ongoing responses greater than 24 months) compared with non-BRCA-associated cancer types. Responses in the BRCA1/2 cohort were numerically higher for patients with tumor mutational burden of 10 or more mutations per megabase (mut/Mb) vs less than 10 mut/Mb. The combination was well tolerated, with no new safety signals identified. Conclusions and Relevance: In this phase 2b nonrandomized controlled trial, neither the BRCA1/2 nor ATM cohort met the prespecified OR rate of 40%. Antitumor activity for the combination of avelumab and talazoparib in patients with BRCA1/2 alterations was observed in some patients with BRCA1/2-associated tumor types and uterine leiomyosarcoma; benefit was minimal in non-BRCA-associated cancer types. Trial Registration: ClinicalTrials.gov Identifier: NCT03565991.

Development of Leiomyosarcoma in a Patient Treated with Azathioprine.

Cirrhosis resulting from autoimmune hepatitis is associated with an increased risk of hepatocellular carcinoma. A common treatment for autoimmune hepatitis, azathioprine, is also associated with the development of many other cancers, predominantly lymphomas. The strongest association is seen for post-transplant lymphoma and hepatosplenic T-cell lymphoma in Crohn's disease and ulcerative colitis patients; there is also an association with a variety of cutaneous malignancies. A relationship between azathioprine and sarcoma has not been demonstrated, though there have been sporadic case reports. We report here the development of leiomyosarcoma in a patient who was treated with azathioprine for autoimmune hepatitis without cirrhosis.

Uterine sarcoma after tamoxifen therapy for breast cancer.

Tamoxifen has been shown to significantly reduce the risk of tumour recurrence in women with receptor positive breast cancer and has been used for chemoprevention in women with both non-invasive cancer and those with a high risk of developing breast cancer. An established and accepted risk with this treatment is the increased incidence of adenocarcinoma of the endometrium. Less well recognised is uterine sarcoma, a rare and aggressive tumour accounting for under five percent of uterine malignancies, with five year survival rates in the order of 50%.

Use of estradiol-progestin therapy associates with increased risk for uterine sarcomas.

OBJECTIVE: Insufficient data exist on the effect of postmenopausal hormone therapy as the risk factor for uterine sarcomas. We therefore evaluated the association of estradiol-progestin therapy (EPT) with the risk of uterine sarcoma in nation-wide cohort study. METHODS: All Finnish women (>50 years of age) who had used EPT during the years 1994-2008 for at least 6 months (n=243,857) were identified from the national Medical Reimbursement Registry. Their incidence of uterine stromal and leiomyosarcoma among the EPT users was compared to that in the background population with the aid of the Finnish Cancer Registry. RESULTS: A total of 76 uterine sarcomas were encountered in the EPT cohort; 45 (59%) were leiomyosarcomas, 24 (32%) stromal sarcomas and 7 (9%) other sarcomas. The exposure to EPT for less than 5 years did not associate with significant rises in the sarcoma risk but longer exposure was accompanied with significant risk elevations for all uterine sarcomas: the standardized incidence ratio (SIR) for 5-10 years of use was 2.0, 95% confidence interval (CI) 1.4-2.9 and for ≥10 years of use 3.0 (1.3-5.9): the SIRs were highest for leiomyosarcoma. The sequential and continuous uses of progestin were associated with similar increased SIRs for uterine sarcoma. CONCLUSIONS: The use of EPT for 5 years or more is associated with an increased risk for uterine sarcomas. This turns to an absolute excess risk of 2-3 extra uterine sarcoma cases per 10,000 long-time EPT users followed for 10 years.

Quinacrine sterilization and gynecologic cancers: a case-control study in northern Vietnam.

BACKGROUND: Over 100,000 women worldwide have been sterilized by insertion of quinacrine into the uterus to induce tubal scarring. Concern has been expressed about possible carcinogenicity, and specifically the risk of uterine cancer. METHODS: From 2001 through 2006, we conducted a population-based, case-control study of gynecologic cancers in 12 provinces in northern Vietnam, where relatively large numbers of women had received quinacrine. Cases of incident cervical, ovarian, and uterine cancer were identified at provincial hospitals or at referral hospitals in Hanoi. For each case, 3 age- and residence-matched controls were randomly selected from the population registries of the case's home community. RESULTS: The prevalence of quinacrine exposure was 1.2% among cases and 1.1% among controls. For cervical cancer, analysis of 606 cases (9 exposed) and their 1774 matched controls (18 exposed) produced an odds ratio of 1.44 (95% confidence interval = 0.59-3.48) (adjusted for several covariates including human papillomavirus risk score). For ovarian cancer, based on 262 cases (3 exposed) and 755 controls (8 exposed) and adjusted for age and number of years of ovulation, the odds ratio was 1.26 (0.21-5.45). For uterine cancer, none of the cases-including 23 cases of leiomyosarcoma-was exposed to quinacrine. The 95% confidence interval, based on 161 cases (none exposed) and 470 controls (7 exposed) and adjusted only for age, was 0-1.85. CONCLUSION: We found no evidence of a relationship between quinacrine sterilization and gynecologic cancer.

Anticarcinogenic and antiplatelet effects of carvacrol.

AIM: To investigate the effect of carvacrol on chemical carcinogenesis, cancer cell proliferation and platelet aggregation, and to find possible correlation between all these processes and the antioxidant properties of carvacrol. MATERIALS AND METHODS: 3,4-benzopyrene-induced carcinogenesis model using Wistar rats was used. Leiomyosarcoma cells from Wistar rats were used to study carvacrol antiproliferative activity in vitro. The carvacrol antiplatelet properties were investigated with platelet aggregation assay and flow cytometry technique. The production of thromboxane B2, final metabolite of platelet aggregation, was evaluated by radioimmunoassay. RESULTS: Our study revealed significant anticarcinogenic properties of carvacrol. We observed 30% decrease of 3,4 benzopyrene carcinogenic activity in vivo. Antiproliferative activity of carvacrol (IC(50)) was 90 microM and 67 microM for 24 h and 48 h of incubation of cells, respectively. Carvacrol possessed also mild antiplatelet effect, inducing the decrease of thromboxane A2 production in platelets and as a result - restrictive expression of the GPIIb/IIIa platelet receptor. CONCLUSION: Our data demonstrated that carvacrol possesses anticarcinogenic, antiproliferative and antiplatelet properties.

Myxoid leiomyosarcoma of the uterus in a patient receiving tamoxifen therapy: a case report.

In this paper, we present a case of myxoid leiomyosarcoma development in a patient receiving tamoxifen for 3 years because of breast cancer. The myxoid leiomyosarcoma should be included in the differential diagnosis of any uterine tumor with a predominantly myxomatous composition. A review of the literature indicates that tamoxifen may increase not only the risk for endometrial cancer but also for uterine sarcoma, suggesting vigilance for uterine cancer in women who are being treated with this drug.

Leiomyosarcoma of the bladder in a 16-year-old girl with a history of cyclophosphamide therapy for bilateral retinoblastoma during infancy.

A 16-year-old female with bladder leiomyosarcoma had a history of bilateral retinoblastoma at 6 months of life. She received cyclophosphamide chemotherapy after surgical enucleation. In this report, we discussed the possible role of retinoblastoma or cyclophosphamide as a target for the development of bladder leiomyosarcoma.

Development of uterine sarcoma after tamoxifen treatment for breast cancer: report of four cases.

Tamoxifen (TAM) is widely used in the treatment of breast cancer, and its paradoxical effects on female genital system are well known. During the past 10 years, many descriptions of nonepithelial uterine malignancies related to long-term TAM usage have been reported in the literature. Four uterine sarcoma patients who had history of TAM usage for previous breast cancer are presented in this study. The mean time of exposure to TAM was 6 (range 3-11) years, and the mean cumulative dose of drug was 43.82 g. All patients were postmenopausal, and the mean age was 66 (range 61-73) years at the time of the diagnosis of the uterine malignancy. Two (50%) patients had uterine malignant mixed müllerian tumor, and two (50%) had leiomyosarcoma. In one (25%) patient was diagnosed with endometrial biopsy made for a postmenopausal vaginal bleeding; the others (75%) were asymptomatic and their diseases were diagnosed during the pelvic examination and transvaginal ultrasonography. All patients underwent surgery +/- adjuvant therapy (chemotherapy and/or radiation therapy), and two (50%) patients died because of the sarcoma. In consequence, early detection of TAM-related uterine sarcoma is required for orderly gynecological examination in patients having history of TAM usage for previous breast cancer.

Leiomyosarcoma of urinary bladder following cyclophosphamide therapy: report of two cases.

Leiomyosarcoma of urinary bladder is rare, although it is the most common mesenchymal tumor in adults. We report two cases of this tumor following cyclophosphamide therapy. The first case is from a 53-year-old man with Wegener's granulomatosis treated for 6 years with cyclophosphamide. He presented with painless hematuria, and the initial biopsy of the bladder tumor revealed a malignant spindle cell neoplasm. A final diagnosis of leiomyosarcoma was made on radical cystoprostatectomy. The second example is from a 21-year-old man who had received cyclophosphamide in early infancy for a bilateral retinoblastoma. He also presented with painless hematuria, and a bladder tumor was resected transurethrally and diagnosed as leiomyosarcoma. He underwent partial cystectomy two months later. Cyclophosphamide, when used for a neoplastic or non-neoplastic condition, is associated with an increased risk of developing bladder cancer. The distribution of histologic subtypes differs from that seen in spontaneous bladder tumors. A review of the literature shows an increased proportion of squamous cell carcinomas and sarcomas, especially leiomyosarcomas in cyclophosphamide exposed patients. Acrolein, a cytotoxic metabolite of cyclophosphamide excreted in urine, is regarded as the most likely causative agent.

Genital tract smooth muscle tumors are common in zoo felids but are not associated with melengestrol acetate contraceptive treatment.

In a survey of gynecologic lesions in female zoo felids conducted to determine if the widely used progestin contraceptive melengestrol acetate (MGA) had adverse effects, numerous leiomyomas and leiomyosarcomas were detected. This current study aimed to characterize the morphologic features of these tumors, determine their prevalence, and assess if MGA was a risk factor for their genesis. Genital tracts from 219 zoo felids representing 23 species were evaluated, and leiomyomas were detected in 24% of the felids. Leiomyomas were often multiple and occurred in the myometrium, ovary, or adjacent broad ligament. The risk of developing leiomyomas increased with age, but MGA treatment or parity had no effect. Five other felids had leiomyosarcomas. Leiomyosarcomas were distinguished from poorly demarcated leiomyomas by the presence of local invasion, metastasis, and cellular atypia, but necrosis and mitotic rate were not distinguishing criteria. Four of five felids with leiomyosarcomas had been treated with MGA. These results indicate that leiomyomas are common spontaneous lesions in the genital tracts of zoo felids and their genesis is not linked to MGA exposure. Whether progression to malignancy is promoted by MGA warrants further investigation.

[Uterine sarcoma in patients receiving tamoxifen therapy. Apropos of 2 cases]. / Sarcome utérin survenant au cours d'une hormonothérapie par tamoxifène. A propos de deux cas.

INTRODUCTION: Tamoxifen--a non steroidal triphenylethyl compound--in addition to having antiestrogenic properties may provoke weak estrogenic effects, the well known "paradoxical effects" on the female genital tractus. Concern has been raised about prolonged tamoxifen treatment and subsequent occurrence of endometrial adenocarcinoma; subsequent attention has been drawn through high risk histologic subtypes including poorly differentiated patterns and uterine sarcomas. EXEGESIS: We report two cases of uterine sarcoma arising in postmenopausal women taking tamoxifen, 20 mg daily during 38 and 42 months, for breast carcinoma: one leiomyosarcoma and one endometrial stromal sarcoma; both cases were asymptomatic and detected by pelvic sonography. CONCLUSION: Further studies will be required to establish if there is a relationship between long term tamoxifen exposure and highly aggressive types of cancer of the uterine corpus exhibiting adverse histologic features such as uterine sarcomas. There is no consensus regarding uterine surveillance of women receiving tamoxifen. We advocate an annual gynecologic examination plus imaging by means of transvaginal ultrasonography.

Leiomyosarcoma of the bladder fourteen years after cyclophosphamide therapy for retinoblastoma.

We report a case of bladder leiomyosarcoma which occurred in a 22-year-old female who had been treated with cyclophosphamide for a period of 68 months for retinoblastoma diagnosed at 18 months postpartum. Partial cystectomy was performed. Forty-two months after the operation she is tumor-free.

Intratesticular leiomyosarcoma in a young man after high dose doping with Oral-Turinabol: a case report.

BACKGROUND: Androgenic anabolic steroids have been suspected of activity as carcinogens in the development of carcinoma and angiosarcoma of the liver and adenocarcinoma of the prostate. Although the proliferation of smooth muscle cells is stimulated by sexual steroids, to the authors' knowledge a possible relation between androgenic anabolic steroids and the development of leiomyosarcoma has not previously been reported in humans. METHODS: A 32-year-old man underwent right radical orchiectomy for a tumor of the upper pole of the right testicle. Routine histopathologic examination and immunohistochemical staining were performed. RESULTS: The tumor was identified as an intratesticular leiomyosarcoma based on its typical growth pattern and the characteristic immunohistochemical staining profile. The patient reported a 5-year history of systematic use of high dose Oral-Turinabol (4-chloro-1-dehydro-17alpha-methylteststerone) that began at age 18 years and stopped approximately 9 years before presentation. CONCLUSIONS: The rarity of intratesticular leiomyosarcoma, the experimental induction of similar tumors in animals by androgens and estrogens, and the unusually young age at presentation of the patient in the current study support the hypothesis that high dose doping with androgenic anabolic steroids could have played a cocarcinogenic role in the development of the tumor in this case.

[Rat submandibular gland tumor induced by 3-methylcholanthrene].

OBJECTIVE: To study the genesis and the development of salivary gland tumor (SGT). METHODS: SGT animal models were established by injection of 3-methylcholanthrene (3-MCA) oil solution into 40 submandibular glands of Sprague-Dawley (SD) rats, then histopathology and ultrastructure of induced tumors were observed under microscope, and immunohistochemical detection of keratin and actin was carried out. RESULTS: 32 models of submandibular gland tumors were induced successfully, with 4 rats of squamous cell carcinoma and 28 leiomyosarcoma, and the carcinogenesis of 3-MCA and tissue genesis of induced tumors were discussed. CONCLUSION: Submandibular gland tumor can be induced by 3-MCA, and sarcoma was of high incidence.

Beneficial effects of a vanadium complex with cysteine, administered at low doses on benzo(alpha)pyrene-induced leiomyosarcomas in Wistar rats.

BACKGROUND: Vanadium is a potent environmental and body metal, possessing remarkable antitumor and antidiabetic properties. Vanadium salts and complexes have been widely investigated for their anticarcinogenic properties in experimental carcinogenesis. In the present study the antitumor effects of a new vanadium complex with cysteine in relation to identical doses of vanadyl sulfate and cysteine, in tumor bearing rats are investigated. MATERIALS AND METHODS: Male wistar rats were injected with benzo(alpha)pyrene and divided into four groups of 21 rats each. Control group was treated only with BaP. The first group(TR-1) was treated by vanadyl sulfate per os at daily doses of 0.5 mg of V/kg b.w per day. The second (TR-2) by cysteine at doses of 4.5 mg/kg b.w per day and the third group (TR-3), by the complex V(III)-cysteine at daily doses of V 0.5 mg/kg b.w (containing cysteine at concentrations of 4.5 mg/b.w). Treatment was started when tumors were developed (evidenced from a palbable mass at the site of Bap injection) and went on till death. Toxicological tests were performed in 27 rats divided into a control group and two test groups; T-1 administered with vanadyl sulfate at daily doses of 18.5 mg V/kg b.w and T-2 group with V(III)-cysteine complex at daily doses of 18.5 V/kg b.w, for 9 weeks. Mean survival time, death rate, tumor growth rate, the carcinogenic potency of BaP, and the anticarcinogenic potency in relation to histological findings in each treatment group were calculated in each group in order to evaluate the antitumor effects of the substances used. RESULTS: Vanadyl sulfate, cysteine and V(III)-cysteine exerted antitumor effects on leiomyosarcoma bearing Wistar rats. However, V(III)-complex exerted much more potent effects than the other treatments, significantly prolonging mean survival time, retarding tumor growth rate and decreasing the carcinogenic potency of BaP in the TR-3 group, in comparison to the control and the TR-1 and TR-2 groups. Moreover V(III)-cysteine complex resulted in complete remission of 4 (19.7%) of the tumor bearing rats. Blood, urine, biochemical routine tests as well as autopsy did not reveal any toxic effects either of vanadyl sulafate or V(III)-cysteine complex. CONCLUSIONS: Vanadyl sulfate, cysteine and V(III)-cysteine complex exerted antitumor effects in tumor bearing rats. The V(III)-cysteine complex, however, exerts much more potent effects, as evident from the results of the present study. These beneficial effects of the above complex, in combination with its low toxicity provide evidence suggest its possible application in the treatment of human malignant diseases.

Immunophenotype, ras oncogenes and p53 onco-suppressor gene in benzo(a)pyrene induced malignant soft tissue tumours in Wistar rats.

This study was designed to identify the immunophenotypic characteristics of malignant soft tissue tumours, induced experimentally with benzo(a)pyrene (BaP), and to evaluate the immunohistochemical expression of the ras oncogene family and p53 onco-suppressor gene in these tumours, in association with prognostic factors. Seventy-five male Wistar rats were subcutaneous injected, dorsally, with a single dose of 10.08 mgr BaP. A solid, well-circumscribed tumour was formed at the injection site, in 70 of the animals, 80-100 days after the carcinogen's administration. The tumour as well as selected main organs were excised and studied after the animals' death. All the specimens were fixed in formalin 10%, embedded in paraffin and stained with H + E. The immunohistochemical avidin-biotin method was performed in the tumour sections, using the following monoclonal or polyclonal antibodies: vimentin, desmin, muscle specific actin (MSA), a-smooth muscle actin (SMA), myoglobin, smooth muscle myosin, a-1-antitrypsin, a-1-antichymotrypsin, S-100 protein, epithelial membrane antigen (EMA), K-ras, H-ras, Pan-ras and p53. The induced tumours of the animals were almost well-circumscribed, with a partly storiform cut surface. Histologically, their appearance was more conventional with high grade leiomyosarcomas; about half of them showed highly anaplastic areas, resembling other pleomorphic undifferentiated sarcomas. Pulmonary metastatic foci were detected in 37 animals. Immunohistochemically, all the tumours displayed positive expression of vimentin, MSA and SMA. Desmin was positively expressed in 40 tumours, smooth muscle myosin in 57 tumours and EMA in 12 tumours. All the tumours were negative for myoglobin, a-1-antitrypsin, a-1-antichymotrypsin and S-100 protein. In addition, five tumours showed a positive reaction for K-ras p21, 37 for H-ras p21, 41 for Pan-ras p21 and 14 for p53 protein. The overexpression of the oncoproteins H-ras p21 and Pan-ras p21 in these tumours was significantly associated with a non-advanced tumour stage (absence of metastatic focus). In conclusion, the histological as well as the immunophenotypic features of the induced tumours are more conventional with leiomyosarcomas mostly of high grade; many of them are "dedifferentiated". The identification of both ras and p53 gene products in these tumours indicates that alterations of these genes are common but not specific events, implicated in the tumourigenesis, which may become prognostic markers for this subtype of soft tissue sarcomas.