BackgroundDeep angiomyxoma (formerly known as aggressive angiomyxoma) is a rare, benign, but locally infiltrative mesenchymal tumor that most commonly arises in the pelvis and perineum of reproductive-age women but may also occur in postmenopausal patients. Its indolent growth, nonspecific presentation, and resemblance to common vulvoperineal lesions often delay diagnosis. Despite benign histology, recurrence rates are high, particularly when complete surgical excision with negative margins is not achieved.Case SeriesThe first case involved a 31-year-old post-partum patient with an enlarging, painful vulvar mass presumed to be a Bartholin cyst. Imaging revealed a large mass extending from the rectouterine space into the left labia. MRI demonstrated a multilobulated, T2-hyperintense mass consistent with a myxoid neoplasm. Partial resection and histopathology confirmed an estrogen and progesterone receptor positive deep angiomyxoma. Given extensive pelvic involvement, and the patient’s desire to preserve fertility, multidisciplinary consensus favored medical management with leuprolide acetate and close surveillance.The second case involved a 63-year-old postmenopausal woman presenting with a multilobulated vulvar mass. Surgical excision and histopathology confirmed deep angiomyxoma with positive margins. Re-excision was not feasible due to the inability to localize residual disease. Given hormone receptor positivity, the patient was started on letrozole with ongoing clinical and radiologic surveillance.ConclusionDeep angiomyxoma should be considered in the differential diagnosis of slow-growing vulvoperineal masses. MRI aids diagnosis and surgical planning. While complete surgical excision is preferred, hormone therapy may be an important adjunct or alternative for residual or unresectable disease, with long-term surveillance recommended due to recurrence risk.

OBJECTIVE:KEYNOTE-775 defined lenvatinib/pembrolizumab as the new standard-of-care for patients with proficient mismatch repair (pMMR) recurrent EC. However, the regimen required dose reductions in 66.5 % of participants and the generalizability of these results was uncertain. We conducted an observational study to determine the prescribing patterns, outcomes and side effects in a real-world setting. METHODS:A national multidisciplinary consortium was utilized to study treatment patterns of patients with advanced/recurrent EC treated with lenvatinib/pembrolizumab from 2019 through 2022. Treatment decisions were based on the physician's recommendation. RESULTS:188 patients across 14 institutions were included. Histologic subtypes were 33 % endometrioid, 41 % serous, 9.6 % mixed, 10.1 % carcinosarcoma, and 2.1 % clear cell. 85.6 % were pMMR and 5.3 % were dMMR. Lenvatinib starting dose was 20 mg in 19.7 %, 18 mg in 14.9 %, 14 mg in 47.3 %, and 10 mg in 18.1 %. Median dose intensity of lenvatinib was 14 mg. Pembrolizumab dosing was 200 mg Q3W in 94.1 %. Grade ≥ 3 adverse events (AE) rates related to lenvatinib were similar across starting doses: 20 mg (13.5 %), 18 mg (17.9 %), 14 mg (7.9 %), 10 mg (17.6 %) (p = 0.31). Response rates in relation to lenvatinib starting dose were 20 mg (27 %), 18 mg (35.7 %), 14 mg (39.3 %), 10 mg (44.1 %) (p = 0.50). In relation to lenvatinib starting dose, PFS, OS and duration of therapy were not statistically different. Response rates (p = 0.24), PFS (p = 0.66) & OS (p = 0.22) were similar in White and Black patients. CONCLUSIONS:In a real-world analysis, the predominant starting dose was 14 mg lenvatinib and 200 mg pembrolizumab. Starting at varying doses does not appear to compromise response rates or survival and no new severe adverse events emerged.

TPS5633 Background: Patients with advanced/recurrent endometrial cancer have limited 2L+ treatment options. The PI3K/mTOR pathway regulates glucose homeostasis downstream of insulin/insulin receptor signaling and is mutated in >80% of endometrial cancer. Multi-node inhibition of this pathway with the combination of sapanisertib, an mTORC1/2 inhibitor, and serabelisib, a PI3Kα inhibitor, (PIKTOR) achieves more complete PI3K pathway blockade compared to single node inhibition in preclinical models. In a Phase 1b trial (NCT03154294) of triplet combination paclitaxel, serabelisib, and sapanisertib, the combination led to an overall response rate of 80% with 3 CR and 1 PR in 5 patients with advanced, treatment refractory endometrial cancer. This study evaluates whether PIKTOR with paclitaxel improves efficacy outcomes in participants with advanced/recurrent endometrial cancer with mutation(s) in the PI3K/AKT/mTOR pathway and who have failed prior systemic therapies. Methods: GOG-3111 is a Phase 2 (ClinicalTrials.gov ID NCT06463028), multi-center, open-label, single-arm trial evaluating the efficacy and safety of PIKTOR plus paclitaxel in participants with advanced/recurrent endometrial cancer. Approximately 40 participants will be enrolled in the main study and up to 50% of participants will have the option to receive triplet combination therapy with a diet. Eligible participants will have histologically confirmed diagnosis of advanced/recurrent endometrioid endometrial carcinoma and documented genetic mutation(s) in the PI3K/AKT/mTOR pathway by next generation tumor testing. Participants must have received >1 but no more than 3 prior systemic therapies for advanced/recurrent disease (ie, including platinum-based therapy and an immune checkpoint inhibitor either together or separately). Study interventions are 28-day cycles with: Paclitaxel: 80 mg/m2 IV weekly on Days 1, 8, and 15; PIKTOR (sapanisertib [1] 3mg and serabelisib [2] 100 mg) oral with food on Days 2-4, 9-11, 16-18, and 23-25. Radiographic imaging and RECIST v1.1 response assessment will be performed every 8 weeks starting at C1D1. The primary objective is to evaluate the objective response rate (ORR) and secondary objective is to evaluate efficacy via progression-free survival (PFS), PFS at 6 months, overall survival, clinical benefit rate, duration of response; and safety/tolerability of PIKTOR + paclitaxel. The substudy rationale is to evaluate the impact of diet on treatment tolerability and efficacy. Clinical trial information: NCT06463028 .

INTRODUCTION:Pelvic and peritoneal washings (PW) are often taken during gynecologic resections when the presence of a neoplastic process is known or suspected. A positive PW may upstage a patient and/or impact a patient's prognosis and treatment. Two surveys were created to inform The International System for Serous Fluid Cytology, a standardized reporting system, regarding the practice and utilization of PW cytology. MATERIALS AND METHODS:Pathologists and cytotechnologists (n = 475) responded to a survey which examined their reporting preferences. Gynecologic oncologists (GONC) (n = 168) answered a separate survey which examined how they utilized PW specimens. RESULTS:Most pathologists/cytotechnologists felt that bland-appearing epithelial cells of unknown origin should be classified as benign. Most favored reporting psammomatous calcification without associated epithelial cells as benign (64.1%), whereas 8.6% did not report this finding at all, 20.5% would report as atypical, and 6.8% would report as suspicious of a neoplasm. Most GONCs (63.9%) routinely obtained PW specimens during endometrial cancer staging; of those, 53% reported that a positive cytology result could change their management. Sixty-six percent of GONCs indicated that they treat indeterminate PW results as negative. Others indicated that an indeterminate PW may result in review of slides with the pathologist, counseling the patient, and/or closer observation. Most GONCs did not find utility in the reporting of psammomatous calcifications, presence of mucin, atypical cells favored to be benign, endometrial cells, or iatrogenic material. CONCLUSIONS:Substantial variability exists among pathologists in how PW specimens are reported, as well as how gynecologic oncologists utilize these specimens.

OBJECTIVE:We sought to determine the association between platinum-free interval (PFI) and response to retreatment with platinum-based chemotherapy vs lenvatinib/pembrolizumab in patients with recurrent endometrial cancer. METHODS:Endometrial Cancer Molecularly Targeted Therapy (ECMT2) Consortium patients with recurrent disease were included in this retrospective analysis if they received first-line treatment with platinum-based chemotherapy (adjuvant or first recurrence), followed by second-line re-treatment with platinum or lenvatinib/pembrolizumab. PFI was defined as time between date of last platinum to start date of second-line therapy. Patients were stratified according to PFI ≤12 months or > 12 months. Overall response rate (ORR) to second-line treatment was estimated after stratification by PFI. RESULTS:Of 217 patients, 146 (67 %) underwent retreatment with platinum and 71 (33 %) were treated with lenvatinib/pembrolizumab. 127 (59 %) had PFI ≤12 months, and 84 (39 %) patients had PFI >12 months. Patients treated with platinum had longer PFI than those treated with lenvatinib/pembrolizumab (median PFI 12.9 vs 4.6 months; p < 0.001). ORR was 58 % vs 49 % for platinum vs lenvatinib/pembrolizumab (p = 0.27). For all patients, ORR was 68 % vs 47 % with PFI >12 months and ≤ 12 months, respectively (p = 0.002). At each PFI, ORR was similar regardless of treatment with platinum or lenvatinib/pembrolizumab (PFI ≤12 months ORR 49 % vs 44 % respectively, p = 0.75; PFI >12 months ORR 67 % vs 75 % respectively, p = 0.74). CONCLUSION:Longer PFI is associated with improved response to second-line treatment in patients with recurrent endometrial cancer. Despite utilization of PFI for real-world treatment decisions, it was not found to predict response between regimens at any given PFI.

OBJECTIVE:Next-generation sequencing and tumor testing to direct therapy in advanced/recurrent endometrial cancer are frequently used, but the impact of this approach is unclear. We sought to confirm the proportion of patients with at least 1 actionable alteration and whether the use of molecularly targeted therapy was associated with improved survival in metastatic endometrial cancer. METHODS:A multidisciplinary consortium was formed to study tumor testing and treatment with targeted therapies in advanced/recurrent endometrial cancer. Tumor testing and therapeutic decisions were physician's recommendations. The abstracted data included age, stage, grade, histology, race, ethnicity, treatment, genomic alterations, protein expression for Her2, p53, mismatch repair, estrogen and progesterone receptors, and survival. Statistical analyses were performed using SAS v9.4. RESULTS:A total of 967 patients from 12 centers were included. The median age was 64 years (range; 22-93 years). Of the participants, 68.5% were White, 24.0% were Black, 2.0% were Asian, and 92.7% were non-Hispanic. A total of 656 (67.8%) patients had recurrent/persistent disease and received a median of two (range; 0-9) therapies. 902 (93.3%) underwent tumor testing. Overall, 576 (94.0%) patients with next-generation sequencing testing had at least 1 genomic alteration in 11 pre-specified genes. The most frequent alterations were PI3K (35.8%), TP53 (34.7%), and PTEN (26.5%) mutations, respectively. A subset of 233 patients received 292 matched biologic therapies, and the median follow-up was 29.7 months, while the median progression-free survival and overall survival were 6.9 and 20.5 months, respectively. CONCLUSIONS:The consortium facilitated the development of real-world data on the patterns of genomic testing and molecularly targeted therapy used in a racially and geographically diverse patient cohort with advanced/recurrent endometrial cancer. Survival improved for those receiving matched biologic therapies compared to chemotherapy.

BACKGROUND:Black women are at an increased risk of developing uterine leiomyomas and experiencing worse disease prognosis than White women. Epidemiologic and molecular factors have been identified as underlying these disparities, but there remains a paucity of deep, multiomic analysis investigating molecular differences in uterine leiomyomas from Black and White patients. OBJECTIVE:To identify molecular alterations within uterine leiomyoma tissues correlating with patient race by multiomic analyses of uterine leiomyomas collected from cohorts of Black and White women. STUDY DESIGN:We performed multiomic analysis of uterine leiomyomas from Black (42) and White (47) women undergoing hysterectomy for symptomatic uterine leiomyomata. In addition, our analysis included the application of orthogonal methods to evaluate fibroid biomechanical properties, such as second harmonic generation microscopy, uniaxial compression testing, and shear-wave ultrasonography analyses. RESULTS:We found a greater proportion of MED12 mutant uterine leiomyomas from Black women (>35% increase; Mann-Whitney U, P<.001). MED12 mutant tumors exhibited an elevated abundance of extracellular matrix proteins, including several collagen isoforms, involved in the regulation of the core matrisome. Histologic analysis of tissue fibrosis using trichrome staining and secondary harmonic generation microscopy confirmed that MED12 mutant tumors are more fibrotic than MED12 wild-type tumors. Using shear-wave ultrasonography in a prospectively collected cohort, Black patients had fibroids that were firmer than White patients, even when similar in size. In addition, these analyses uncovered ancestry-linked expression quantitative trait loci with altered allele frequencies in African and European populations correlating with differential abundance of several proteins in uterine leiomyomas independently of MED12 mutation status, including tetratricopeptide repeat protein 38. CONCLUSION:Our study shows that Black women have a higher prevalence of uterine leiomyomas harboring mutations in MED12 and that this mutational status correlates with increased tissue fibrosis compared with wild-type uterine leiomyomas. Our study provides insights into molecular alterations correlating with racial disparities in uterine leiomyomas and improves our understanding of the molecular etiology underlying uterine leiomyoma development within these populations.

BACKGROUND:HIV-associated tuberculosis (TB) contributes disproportionately to global tuberculosis mortality. Patients hospitalised at the time of the diagnosis of HIV-associated disseminated TB are typically severely ill and have a high mortality risk despite initiation of tuberculosis treatment. The objective of the study is to assess the safety and efficacy of both intensified TB treatment (high dose rifampicin plus levofloxacin) and immunomodulation with corticosteroids as interventions to reduce early mortality in hospitalised patients with HIV-associated disseminated TB.METHODS:This is a phase III randomised controlled superiority trial, evaluating two interventions in a 2 × 2 factorial design: (1) high dose rifampicin (35 mg/kg/day) plus levofloxacin added to standard TB treatment for the first 14 days versus standard tuberculosis treatment and (2) adjunctive corticosteroids (prednisone 1.5 mg/kg/day) versus identical placebo for the first 14 days of TB treatment. The study population is HIV-positive patients diagnosed with disseminated TB (defined as being positive by at least one of the following assays: urine Alere LAM, urine Xpert MTB/RIF Ultra or blood Xpert MTB/RIF Ultra) during a hospital admission. The primary endpoint is all-cause mortality at 12 weeks comparing, first, patients receiving intensified TB treatment to standard of care and, second, patients receiving corticosteroids to those receiving placebo. Analysis of the primary endpoint will be by intention to treat. Secondary endpoints include all-cause mortality at 2 and 24 weeks. Safety and tolerability endpoints include hepatoxicity evaluations and corticosteroid-related adverse events.DISCUSSION:Disseminated TB is characterised by a high mycobacterial load and patients are often critically ill at presentation, with features of sepsis, which carries a high mortality risk. Interventions that reduce this high mycobacterial load or modulate associated immune activation could potentially reduce mortality. If found to be safe and effective, the interventions being evaluated in this trial could be easily implemented in clinical practice.TRIAL REGISTRATION:ClinicalTrials.gov NCT04951986. Registered on 7 July 2021 https://clinicaltrials.gov/study/NCT04951986.

Persistent HPV16 infection is a major cause of the global cancer burden. The viral life cycle is dependent on the differentiation program of stratified squamous epithelium, but the landscape of keratinocyte subpopulations which support distinct phases of the viral life cycle has yet to be elucidated. Here, single cell RNA sequencing of HPV16 infected compared to uninfected organoids identifies twelve distinct keratinocyte populations, with a subset mapped to reconstruct their respective 3D geography in stratified squamous epithelium. Instead of conventional terminally differentiated cells, an HPV-reprogrammed keratinocyte subpopulation (HIDDEN cells) forms the surface compartment and requires overexpression of the ELF3/ESE-1 transcription factor. HIDDEN cells are detected throughout stages of human carcinogenesis including primary human cervical intraepithelial neoplasias and HPV positive head and neck cancers, and a possible role in promoting viral carcinogenesis is supported by TCGA analyses. Single cell transcriptome information on HPV-infected versus uninfected epithelium will enable broader studies of the role of individual keratinocyte subpopulations in tumor virus infection and cancer evolution.

OBJECTIVE:Detection of lymph node metastases in cervical cancer patients is important for guiding treatment decisions, however accuracies of current detection methods are limited. We evaluated associations of abnormal glycosylation, represented by Tn and STn antigens on mucin (MUC) proteins, in primary tumor specimens with lymph node metastasis or recurrence of cervical cancer patients. METHODS:Surgical specimens were prospectively collected from 139 patients with locally-advanced cervical cancer undergoing lymphadenectomy enrolled in a nation-wide clinical trial (NCT00460356). Of these patients, 133 had primary cervix tumor, 67 had pelvic lymph node (PLN) and 28 had para-aortic lymph node (PALN) specimens. Fixed tissue serial sections were immunohistochemically stained for Tn, STn, MUC1 or MUC4. Neuraminidase was used to validate Tn versus STn antibody specificity. Stain scores were compared with clinical characteristics. RESULTS:Primary tumor STn expression above the median was associated with negative PLN status (p-value: 0.0387; odds ratio 0.439, 95% CI: 0.206 to 0.935). PLN had higher STn compared to primary tumor, while primary tumor had higher MUC1 compared to PALN, and MUC4 compared to PALN or PLN (p = 0.017, p = 0.011, p = 0.016 and p < 0.001, respectively). Tn and STn expression correlated in primary tumor, PALN, and PLN, Tn and MUC1 expression correlated in primary tumors only (Spearman correlation coefficient [r] = 0.301, r = 0.686, r = 0.603 and r = 0.249, respectively). CONCLUSIONS:STn antigen expression in primary cervical tumors is a candidate biomarker for guiding treatment decisions and for mechanistic involvement in PLN metastases.

Few studies from Africa have described the clinical impact of co-infections on SARS-CoV-2 infection. Here, we investigate the presentation and outcome of SARS-CoV-2 infection in an African setting of high HIV-1 and tuberculosis prevalence by an observational case cohort of SARS-CoV-2 patients. A comparator group of non SARS-CoV-2 participants is included. The study includes 104 adults with SARS-CoV-2 infection of whom 29.8% are HIV-1 co-infected. Two or more co-morbidities are present in 57.7% of participants, including HIV-1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS-CoV-2, clinical features can be typical of either SARS-CoV-2 or tuberculosis: lymphopenia is exacerbated, and some markers of inflammation (D-dimer and ferritin) are further elevated (p < 0.05). Amongst HIV-1 co-infected participants those with low CD4 percentage strata exhibit reduced total, but not neutralising, anti-SARS-CoV-2 antibodies. SARS-CoV-2 specific CD8 T cell responses are present in 35.8% participants overall but undetectable in combined HIV-1 and tuberculosis. Death occurred in 30/104 (29%) of all COVID-19 patients and in 6/15 (40%) of patients with coincident SARS-CoV-2 and tuberculosis. This shows that in a high incidence setting, tuberculosis is a common co-morbidity in patients admitted to hospital with COVID-19. The immune response to SARS-CoV-2 is adversely affected by co-existent HIV-1 and tuberculosis.