Gynecologic Oncology Reports最新文献

There is limited data regarding the use of immunotherapy for patients with vulvar squamous cell carcinoma and coexisting autoimmune disease. Cemiplimab is a PD-1 inhibitor approved for use in patients with locally advanced and metastatic cutaneous squamous cell carcinoma. However, little is known about its efficacy in the setting of vulvar cancer. We present a case of advanced vulvar squamous cell carcinoma treated with induction chemotherapy and immunotherapy with cemiplimab followed by definitive chemoradiation in the setting of multiple autoimmune diseases. She achieved a complete clinical response and experienced no worsening of her autoimmune conditions despite cessation of her immunosuppressants and initiating an immune checkpoint inhibitor. We review existing data on neoadjuvant treatment of vulvar cancer and the use of cemiplimab in genital and inguinal squamous cell carcinomas. Ongoing exploration of cemiplimab’s efficacy in vulvar cancer and safety in immunosuppressed patients is critical.

Cameroon is a low-and-middle income country (LMIC) with one of the highest incidence and mortality from cervical cancer in Africa. In this Central African country where the prevalence of human immunodeficiency virus (HIV) is high and the screening coverage is low, cervical cancer is the most deadly and the second most common cancer among women. Notwithstanding the growing burden of cervical cancer in Cameroon, most patients - often of lower socioeconomic status - continue to encounter multi-level barriers to timely and adequate care. These include the lack of physical and financial access to healthcare facilities, limited quality pathology, imaging and treatment services, ignorance of disease by the population, shortage of a well-trained oncology workfroce, which result in significant delays in gaining access to screening, diagnosis, treatment and care. This paper presents 3 cases of patients with advanced cervical cancer who had surgery (hysterectomy) as primary treatment, without appropriate post-surgical investigation to further specify disease stage, persistence of residual disease, and need for adjuvant chemoradiation. Pathology services and diagnostic imaging procedures remain scarce and underused in LMIC countries like Cameroon. Healthcare professionals involved in patient care lack adequate knowledge, skills and collaborative strategy to properly navigate these patients. To address these challenges, the health system should be reinforced with adequate infrastructures, sustainable funding should be secured to enhance universal health coverage and promote cancer prevention and control programs, multidisciplinary teams and coordination of care among providers should be improved, and relevant health indicators should be put in place to better monitor the quality of care delivered to patients who are mostly vulnerable and uninformed.

Objective

Platinum-free interval (PFI) is the period from the end of platinum-based chemotherapy to the date of recurrence. If the PFI is > 6 months, a platinum-based chemotherapy rechallenge is considered; however, its efficacy after poly adenosine 5′-diphosphate-ribose polymerase (PARP) inhibitor maintenance therapy is unknown. This study aimed to examine the efficacy of a platinum-based chemotherapy rechallenge after PARP inhibitor therapy.

Methods

We retrospectively evaluated patients with ovarian cancer with a PFI≥6 months with PARP inhibitor maintenance therapy, receiving platinum-based chemotherapy. Duration of PARP inhibitor therapy, best response to subsequent platinum chemotherapy rechallenge, and clinical characteristics were collected from medical records. Tumor response was assessed according to RECIST 1.1. Correlations were calculated using Spearman’s correlation coefficients.

Results

Among the 10 included patients, seven (70 %) received PARP inhibitors after primary chemotherapy, and three (30 %) received chemotherapy for platinum-sensitive relapse. One and five patients harbored a germline BRCA1 and BRCA wild-type mutations, respectively, and two had homologous recombination proficiency. The median PFI was 303.5 (182–602) days, and PARP inhibitor therapy duration was 249 (147–570) days. Platinum chemotherapy rechallenge efficacy was complete and partial response and stable disease in one (10 %), six (60 %), and three (30 %) patients, respectively. The longer the duration of PARP inhibitor treatment, better the response to platinum agents (Spearman correlation coefficient 0.284, p = 0.0288).

Conclusion

Platinum-based chemotherapy rechallenge is reasonable for patients with platinum-sensitive disease, using the traditional PFI cutoff of 6 months, even when the PFI is obtained with a maintenance PARP inhibitor.

Background

Vulvar melanoma and vaginal melanoma are rare and difficult to treat. We describe the last three decades in a cohort predominantly treated surgically with adjuvant therapy.

Methods

All new patients between 1993 and 2021 followed until 2024. Collection of demographic and oncologic data allowed comparisons and Kaplan-Meier method was used to evaluate overall survival (OS) and progression free survival (PFS) stratified by adjuvant therapy type, diagnosis before and after 2011, and between vulvar and vaginal melanomas.

Results

Consultation for 63/72 patients (87.5 %) were for primary treatment. Most patients had vulvar melanoma (50/72, 69.4 %), received surgery (65/72, 90.3 %), and adjuvant treatment (40/72, 55.6 %) with immunotherapy, chemotherapy, and/or targeted therapy. Median survival for 63 patients presenting for primary treatment was 54.2 months, and 9/13 patients who were disease free after five years later received adjuvant immunotherapy. Survival did not vary by adjuvant therapy type or diagnosis after 2011 but was significantly less for vaginal melanoma. Following recurrence seven patients experienced complete response including three patients receiving combined nivolumab with ipilimumab and two nivolumab alone experienced.

Conclusions

Survival was not significantly different by adjuvant therapy type or after 2011. Most patients who were disease-free five years after surgery had received adjuvant therapy. Seven patients experienced complete responses to therapy after recurrence of whom five received immune checkpoint inhibitors. Although survival is not improved as in cutaneous melanomas by immune checkpoint inhibitors, signal continues for the use of immune checkpoint inhibitors in gynecologic melanomas.

Introduction

Pembrolizumab is an immunotherapy approved for use in patients with a combined positive score (CPS) greater than one with recurrent cervical cancer. In clinical practice, the CPS score is not typically analyzed in both primary and metastatic specimens.

Case descriptions

Case 1

A 42-year-old woman with history of an abnormal pap smears who presented with a large pelvic mass with initial biopsy of cervix demonstrating squamous cell carcinoma with negative PDL1 expression and a CPS score of 0. She underwent chemoradiation and presented three months after primary treatment completion with recurrence of squamous cell carcinoma and positive PD-L1 expression with a CPS score of 20. Pembrolizumab was added to cycle three of her systemic chemotherapy regimen of carboplatin/paclitaxel/bevacizumab. She had progression on this regimen and was transitioned to tisotumab vedotin; however, ultimately opted to proceed with hospice secondary to failure to thrive.

Case 2

A 36-year-old woman with history of an abnormal pap smear in pregnancy and initial biopsy demonstrating endocervical adenocarcinoma, mucinous type. She underwent open radical hysterectomy, bilateral salpingectomy, bilateral oophorepexy, and bilateral pelvic lymph node dissection with subsequent adjuvant chemoradiation. Her initial pathology demonstrated positive PDL1 expression with CPS score of 15. She presented six months after completion of primary treatment with recurrence of endocervical adenocarcinoma, mucinous type and negative PD-L1 expression with a CPS score of < 1. Regardless of this discrepancy, pembrolizumab was added to cycle five of her systemic chemotherapy regimen of carboplatin/paclitaxel/bevacizumab. She initially demonstrated a mixed response; however, ultimately progressed after eight cycles and was transitioned to tisotumab vedotin.

Discussion

To our knowledge, discrepancies in PD-L1 expression in a matched setting between primary and metastatic tumors has only been reported once. This is the first case report describing these inconsistencies. Etiologies of and outcomes related to the discrepant expression of PD-L1 should be further studied.

No prospective data have been described to inform guidelines on antibiotic prophylaxis for partial vulvectomies. Thus, we conducted a single-center, pilot, double-blind randomized controlled trial to assess the effectiveness of prophylactic antibiotics to prevent wound complications after partial vulvectomies. Patients were randomly assigned 1:1 to preoperative antibiotics or no preoperative antibiotics. The primary outcome of 30-day postoperative wound complications occurred in 31 (62 %) of all patients, with no differences between groups. The most common wound complications were superficial separation (54.2 % antibiotic prophylaxis vs. 65.3 % no prophylaxis, p = 0.37) and surgical site infection (0 % antibiotic prophylaxis vs 7.7 % no prophylaxis, p = 0.49). However, this study was limited by differences in patient characteristics between the groups. This study provides data to perform power calculations for a trial examining the effect of preoperative antibiotics on surgical site infection.

Introduction

Tertiary syphilis, a late form of the disease with neurologic, cutaneous, and cardiovascular manifestations, is rarely seen in the United States in modern times. Also called the “great imitator,” syphilis tends to mimic other disease processes, which can lead to a delay in proper diagnosis and treatment.

Case

We present the case of a 59-year-old woman who presented for evaluation of possible squamous cell carcinoma of the vulva. After multiple inconclusive biopsies and extensive workup with multiple providers, she was instead found to have cutaneous and neurologic tertiary syphilis. A correct diagnosis was delayed in this patient due to a presentation not consistent with classical teachings and due to a lack of access to care.

Conclusion

Syphilis has characteristic signs and symptoms, but in practice, it can have an indolent presentation that may differ from traditional presentations. To our knowledge, this is the first comprehensive case report of vulvar cutaneous syphilis masquerading as squamous cell carcinoma of the vulva. This case also provides additional evidence for the necessity of comprehensive gynecologic care and sexual history-taking in the post-menopausal populations and in rural communities.

Artificial intelligence (AI) applications to medical care are currently under investigation. We aimed to evaluate and compare the quality and accuracy of physician and chatbot responses to common clinical questions in gynecologic oncology. In this cross-sectional pilot study, ten questions about the knowledge and management of gynecologic cancers were selected. Each question was answered by a recruited gynecologic oncologist, ChatGPT (Generative Pretreated Transformer) AI platform, and Bard by Google AI platform. Five recruited gynecologic oncologists who were blinded to the study design were allowed 15 min to respond to each of two questions. Chatbot responses were generated by inserting the question into a fresh session in September 2023. Qualifiers and language identifying the response source were removed. Three gynecologic oncology providers who were blinded to the response source independently reviewed and rated response quality using a 5-point Likert scale, evaluated each response for accuracy, and selected the best response for each question. Overall, physician responses were judged to be best in 76.7 % of evaluations versus ChatGPT (10.0 %) and Bard (13.3 %; p < 0.001). The average quality of responses was 4.2/5.0 for physicians, 3.0/5.0 for ChatGPT and 2.8/5.0 for Bard (t-test for both and ANOVA p < 0.001). Physicians provided a higher proportion of accurate responses (86.7 %) compared to ChatGPT (60 %) and Bard (43 %; p < 0.001 for both). Physicians provided higher quality responses to gynecologic oncology clinical questions compared to chatbots. Patients should be cautioned against non-validated AI platforms for medical advice; larger studies on the use of AI for medical advice are needed.

Lenvatinib plus pembrolizumab (LP) therapy is currently used in patients with advanced or recurrent endometrial cancer. However, patients with uterine carcinosarcoma (UCS) were not included in the KEYNOTE-775, and the efficacy of LP therapy for patients with UCS in clinical practice remains unclear. We administered LP therapy to five patients with UCS. We aimed to report our clinical experience with LP therapy in these patients and investigate the genomic characteristics of those who responded to LP therapy.

We retrospectively reviewed patients with UCS (n = 5) who underwent LP therapy at our hospital from January 2019 to December 2023. Efficacy was assessed using the response rate according to the Response Evaluation Criteria in Solid Tumors version 1.1. Safety was evaluated in terms of adverse events.

The median age was 65 (55–78) years, and the mismatch repair status was proficient in all of the patients. One patient had stage II disease, and four had stage III. The median number of LP therapy courses was 8 (1–35). The overall response rate was 40%. None of the patients experienced adverse events that were grade 3 or higher. The median follow-up duration was 9 (1–26) months, median progression-free survival was 9.1 (0.16 to NA) months, and median overall survival was 10.2 (1.41 to NA) months.

LP therapy may be effective for patients with UCS. As this report was based on a limited number of patients, more cases are required to investigate the efficacy of LP therapy in patients with UCS.