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Abdominal pregnancy represents a rare subset of ectopic pregnancy with a reported incidence around one per 10,000 live births. It is associated with high fetal and maternal morbidity and mortality. In this case, we describe a 25-year-old primigravida female who presented as a trauma activation with acute hypotension following blunt trauma to the abdomen and who was found to have a viable abdominal pregnancy with placental abruption. Given hypotension and non-reassuring fetal heart tones, the decision was made to take the patient to the operating room for emergent exploratory laparotomy and cesarean section. The placenta was severely adhered to a portion of small bowel, the appendix, and the right adnexa with an approximate 20% abruption. The placenta and adhered structures were removed. In pregnant patients presenting after blunt trauma with free intraabdominal fluid and hypotension, abdominal pregnancy with abruption should be considered as an unlikely differential.

Introduction The International Federation of Gynecology and Obstetrics (FIGO) changed the staging system for cervical cancer in 2018 and formally allowed cross-sectional imaging for staging purposes. Stage IB is now divided into three substages based on tumor size (IB1 < 2 cm, IB2 2-4 cm and IB3 > 4 cm). The presence of lymph nodes in the pelvis or para-aortic region will upstage the patient to stage IIIC. The purpose of this study was to evaluate the extent of stage migration using the FIGO 2018 staging system for cervical cancer and validate the new staging system by assessing the survival outcomes. Methods An Institutional Review Board-approved and Health Insurance Portability and Accountability Act-compliant retrospective analysis was performed on 158 patients from the cervical cancer database at the University of Mississippi Medical Center, USA. Patients had been treated between January 2010 and December 2018, and they were all staged according to the FIGO 2009 staging system previously. We collected data regarding tumor size, lymph node presence, and extent of metastatic disease in the pretreatment CT, positron emission tomography (PET), or MRI scans and restaged the patients using the FIGO 2018 system. The extent of stage migration was evaluated using the new staging system. We analyzed the three-year overall survival (OS) using both FIGO 2009 and 2018 staging systems for validation purposes. Kaplan-Meier analyses were performed using SPSS version 24. Results Fifty-nine percent of the patients were upstaged when they were restaged using the FIGO 2018 staging system. In the current 2018 staging system, Stage IB3 accounted for 4%, and Stage IIIC accounted for 48% of the patient cohort, while other stages accounted for the rest. The median overall survival of the entire cohort was 20.5 months. There was a change in the survival curves using FIGO 2018 stages compared to those of FIGO 2009. There was a numerical improvement in three-year OS in stages IB and III among the two staging systems; however, it was not statistically significant. Interestingly, the three-year overall survival of Stage IIIC patients was better when compared to Stages III A& B combined (61% vs. 25%, p=0.017). Conclusion The increased availability of cross-sectional imaging across the world has led to recent changes in the FIGO staging system for cervical cancer, which allowed imaging in staging. We identified a significant stage migration in our patient cohort with the FIGO 2018 staging system, but no difference in the three-year overall survival was observed. Local tumor extent may be a worse prognostic indicator than nodal metastasis among stage III patients.

Objective The purpose of this study was to identify racial disparities in treatment outcomes, if any, among patients with carcinoma of the cervix treated at a tertiary care institution in the state of Mississippi. Methods A retrospective review of patients with carcinoma of the cervix treated in the Department of Radiation Oncology at our institution between 2010 and 2018 was performed. Data regarding demographics, disease stage, treatments administered, and follow-up were collected. Patient outcomes, including median survival and overall survival, were analyzed using the Kaplan-Meier method. All analyses were performed using SPSS Statistics version 24 (IBM, Armonk, NY). Results Between January 2010 and December 2018, a total of 165 patients with carcinoma of the cervix were treated at our institution. We had a significantly higher proportion of African American (AA) compared to Caucasian American (CA) patients (59.4 vs. 36.4%; p=0.03). There was a significant difference in the disease stage at the time of presentation between AA and CA in that compared to AA women, a higher number of CA patients presented with locally advanced disease [Federation of Gynecology and Obstetrics (FIGO) stages IB2 to IVA] (78.6 vs. 86.7%; p

Exposure to radiation oncology (RO) is limited among medical students, excluding those who wish to pursue a radiation oncology career. Consequently, RO knowledge in gynecological malignancies may differ among obstetricians and gynecologists (OB&G), depending on their experience and training level. Establishing a program to educate OB&G residents about basic radiation oncology principles may improve patients' coordination and treatment with gynecological malignancies. At our institution, radiation oncology residents conducted a 2-part training session for OB&G colleagues, which included a lecture and hands-on training. Educational sessions targeting OB&G residents are needed to enhance knowledge about radiation treatments and improve patient care.

Objective This two-stage Phase II study assessed the activity of single agent alisertib in patients with recurrent/persistent uterine leiomyosarcoma (uLMS). Methods Eligibility criteria included histologically-confirmed, recurrent or persistent uLMS, age≥18, 1–2 prior cytotoxic regimens, and RECIST version 1.1 measurable disease. The primary objective of the study was to evaluate the efficacy of alisertib through the frequency of patients with objective tumor responses and the frequency who survived event-free for at least 6months (EFS6). The endpoints for EFS were RECIST progression, death, or beginning a subsequent therapy. The null hypothesis jointly specified the probability of a patient experiencing a tumor response to less than or equal to 5% and the probability of a patient surviving event-free for at least 6months to less than or equal to 20%. A two-stage design was used with a target accrual of 23 patients for stage 1 and 47 pts. cumulative for stage 2. Confidence intervals do not correct for multiplicity. Results Twenty-three patients were enrolled with two patients excluded on central histology review, yielding 21 eligible patients. Median age was 61years. Prior treatment was either 1 cytotoxic regimen (71.4%) or 2 (28.6%). The most common treatment related AEs (grade 3 or worse) were anemia Hensley et al. (2008a) , leukopenia Hensley et al. (2008b) , neutropenia Maki et al. (2007) , thrombocytopenia Huang et al. (2012) , mucositis Hensley et al. (2008a) , diarrhea Huang et al. (2012) , and palmer-planter syndrome Zivanovic et al. (2012) . There were no objective responses (0%; 90% CI: 0–10.4%). Best response was stable disease (38.1%); 12 patients had progressive disease (57.1%). EFS6 was 0% (90% CI: 0–10.4%). Median PFS and OS were 1.7 (90% CI: 1.4–3.2) and 14.5months (90% CI: 7.6 - NA), respectively. Conclusion Alisertib did not demonstrate clinically meaningful single agent activity in previously treated uLMS.

Purpose: To assess if the time interval between concurrent chemo radiotherapy [conc ChemoRT] followed by brachytherapy [B] determines the clinical outcomes in cervical cancer patients (FIGO stage IB2 – IVA) among a predominantly African- American population in a state university medical center. Methods: A retrospective analysis of 147 cervical cancer patients diagnosed with stage IB2- IVA treated with conc ChemoRT followed by B at various time intervals between 2005 and 2018 was performed. Survival analysis with several treatment [TX] duration interval parameters (pre 2010 and post 2010 to evaluate the significant organizational advancements); conc ChemoRT and B completed ≤ 60 days and > 60 days per American College of Surgeons cervical cancer surveillance measure; and TX intervals 6 to 10 weeks were evaluated. The overall survival [OS], local control [LC] and distant control [DC] were estimated by using Kaplan- Meier method. Uni, bi and multi- variable Cox hazard regression analyses were used to compare the risk of death among cervical cancer patients with different TX intervals. The SPSS v.24.0 was used for statistical analyses. Results: The 147 cervical cancer patients (median age, 55 y; range 28-83 y) had a median follow-up of 32 months (range 0 to 164 months). Our patient cohort included 34% patients treated pre 2010 and 66% post 2010; 42.2% ≤60 days and 57.8% > 60 days; 53.1% ≤ 6 to 8 weeks, 12.2% ≤ 8 to 10 weeks and 34.7% d>10 weeks. The patients diagnosed and treated post 2010 had better 5-year OS rates (65% vs. 32%) compared to pre 2010; p=0.000; patients treated ≤ 60 days had better 5-year OS rates (59.3% vs. 40.3%) to > 60 days; p=0.094; patients treated ≤ 6 to 8 weeks had better 5-year OS rates (56.1% vs. 53.1% and 34.3%) compared to ≤ 8 to 10 weeks and > 10 weeks; p=0.188 respectively. The 5-y OS rates for FIGO stages were IB2 (65.8%); IIA (62.5%); IIB (40.4%); IIIA (50%); IIIB (42.4%); and IVA (25.2%); p=0.508. There was no trend for improved LC (p=0.331; p=0.962; p=0.616) and DC (p= 0.284; p=0.596; p=0.606) observed among patients with different TX intervals. In the bi-variate analysis for TX year group, after adjusting for age, race, insurance, income level, distance travelled, tobacco exposure, alcohol history, and tumor stage, BMI-lower had twice the risk of death (hazard ratio [HR], 2.74; 95% CI, 1.34-5.59; p= 0.005). For patients treated ≤ 60 days, their insurance-private had a 63% reduction (HR, 0.37; 95% CI, 0.15-0.90; p=0.029), and for the weekly TX group by the multivariate analysis, insurance-private showed a 76% reduction in the risk of death (HR, 0.35; 95% CI, 0.14-0.87; p=0.024). Conclusion: Our analysis suggests better OS among patients diagnosed and treated post 2010; ≤ 60 days duration; and ≤ 6 to 8 weeks with a shorter interval between conc ChemoRT and B to be superior to that of the patients undergoing longer TX’s. Citation Format: Mary R. Nittala, Satyaseelan Packianathan, Eswar K. Mundra, Maurice L. King, Shivanthidevi Gandhi, Robert M. Albright, Maria L. Smith, William C. Woods, Toms V. Thomas, Mildred Ridgway, Srinivasan Vijayakumar. Improved clinical outcomes with shorter intervals between concurrent chemoradiation and brachytherapy in FIGO IB2-IVA cervical cancer patients among a predominantly African-American population [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-230.

Introduction: The purpose of this study was to evaluate the racial disparities among patients with carcinoma of cervix treated at a tertiary care institution. Methods: An IRB-approved and HIPPA-compliant retrospective analysis of patients with carcinoma of cervix was performed. All patients were treated in the department of Radiation Oncology at our institution between 2010 and 2018. Data regarding demographics, stage, treatment administered, and follow up were collected. Patient outcomes including median survival and overall survival were evaluated using the Kaplan Meier method. All analyses were performed using SPSS v. 24. Results: One hundred sixty-five patients with carcinoma of the cervix were treated between January 2010 and December 2018. We had significantly higher proportion of African American (AA) as compared to Caucasian Americans (CA) patients (59.4 % vs 36.4 %; p=0.03). There was a significant difference in stage at the time of presentation between African Americans and Caucasian Americans in that a higher number of CA patients presented with locally advanced disease, (FIGO Stages IB2 to IVA) as compared to AA (86.7 vs 78.6 %; p=0.000). Unfortunately, a higher number of African Americans presented with metastatic disease at diagnosis 13.3 % vs 8.3 % (p=0.000), as compared to Caucasian Americans. In regard to treatment, 157 (95.2 %) underwent definitive chemoradiotherapy while 3 (1.8 %) had definitive surgery, followed by adjuvant radiation or chemoradiation depending on the risk factors. The treatment details of 5 patients were not available. The median follow up and the median survival of the entire cohort was 16 months and 79 months, respectively. In our cohort, there was no significant difference in overall survival between AA and CA patients at 3 years (80 % vs 68 %; p=0.883) or at 5 years (77 % vs 68 %; p=0.883). As expected, patients with locally advanced disease showed a significantly improved median survival of 79 months as compared to 11 months for those with metastatic disease at their presentation (p=0.000). Conclusions: Retrospective review of the patients with carcinoma of the cervix treated at our institution over the last 8 years revealed a significant racial disparity in that more AA women presented with metastatic disease. However, our analysis did not identify any racial disparity in the prognosis of the whole cohort. Citation Format: Toms Vengaloor Thomas, Eldrin Bhanat, Shivanthidevi Gandhi, Teessa Perekattu Kuruvilla, Anu Abraham, Mildred Ridgway, Satyaseelan Packianathan, Srinivasan Vijayakumar. Racial disparities among patients with carcinoma of the cervix [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D126.

Background Risk-reducing salpingo-oophorectomy (RRSO) has been associated with approximately 50% breast cancer risk reduction among women with a pathogenic variant in BRCA1 or BRCA2 (BRCA1/2), a finding that has recently been questioned. Methods We estimated incidence rates of breast cancer and all cancers combined during 5 years of follow-up among participants selecting RRSO or ovarian cancer screening (OCS) among women with a BRCA1/2 pathogenic variant or strong breast and/or ovarian cancer family history. Ovarian or fallopian tube or peritoneal cancer incidence rates were estimated for the OCS group. Breast cancer hazard ratios (HRs) for time-dependent RRSO were estimated using Cox regression with age time-scale (4943 and 4990 women-years in RRSO and OCS cohorts, respectively). All statistical tests were two-sided. Results The RRSO cohort included 925 participants, and 1453 participants were in the OCS cohort (381 underwent RRSO during follow-up), with 88 incident breast cancers diagnosed. Among BRCA1/2 pathogenic variant carriers, a non-statistically significant lower breast cancer incidence was observed in the RRSO compared with the OCS cohort (HR = 0.86, 95% confidence interval = 0.45 to 1.67; P = .67). No difference was observed in the overall population or among subgroups stratified by prior breast cancer history or menopausal status. Seven fallopian tube and four ovarian cancers were prospectively diagnosed in the OCS cohort, and one primary peritoneal carcinoma occurred in the RRSO cohort. Conclusions These data suggest that RRSO might be associated with reduced breast cancer incidence among women with a BRCA1/2 pathogenic variant, although the effect, if present, is small. This evolving evidence warrants a thorough discussion regarding the impact of RRSO on breast cancer risk with women considering this intervention.

Ovarian cancer is the first in mortalities among gynecologic cancers in the United States, often due to late diagnosis and/or acquired platinum-resistant recurrences. This study investigates whether BRCA1-IRIS is a novel treatment target for ovarian cancers and in platinum-resistant recurrences. Here we show that more than half of the ovarian cancer samples analyzed showed BRCA1-IRIS and survivin overexpression and lacked nuclear FOXO3a expression. Normal ovarian epithelial cells overexpressing BRCA1-IRIS formed metastasis in mice when injected in the peritoneal cavity, whereas aggressive ovarian cancer cell lines failed to form tumors or metastases in mice when BRCA1-IRIS was silenced in them. We show that BRCA1-IRIS activates two autocrine signaling loops, brain-derived neurotrophic factor/tyrosine kinase B receptor (BDNF/TrkB) and neuregulin 1 (NRG1)/ErbB2. These loops are involved in anoikis resistance and metastasis promotion. These loops operate in several ovarian cancer cell lines, and BRCA1-IRIS silencing or inactivation using a novel inhibitory peptide renders both non-functional and promoted cell death. In a mouse xenograft model, BRCA1-IRIS inactivation using this novel inhibitory peptide resulted in significant reduction in ovarian tumor growth. More importantly, this treatment sensitized ovarian tumors to low cisplatin concentrations. Taken together, these data strongly suggest that BRCA1-IRIS and/or BDNF/TrkB and NRG1/ErbB2 could serve as rational therapeutic targets for advanced ovarian cancers.

Choriocarcinoma in the second trimester with a normal appearing live fetus is rare. A primigravida presented at 24 weeks' gestation with 5 days of worsening dyspnea and multiple widespread small lung nodules. Pelvic ultrasound revealed a normal intrauterine live singleton fetus with an extrauterine mass. Gestational hypertension progressed to preeclampsia with severe features and onset of vaginal bleeding. Cesarean delivery was undertaken with liveborn delivery and removal of an intrauterine mass confirmed to be choriocarcinoma. Postpartum treatment with multi-agent chemotherapy was initiated. The newborn thrived; the mother has no evidence of residual disease.

Treatment of synchronous resectable colorectal liver metastases has traditionally involved a staged surgical approach. Specialized centers have demonstrated good results with simultaneous resection. We aim to report our outcomes at the University of Mississippi Medical Center (UMMC) with simultaneous liver metastasectomy at the time of operation for primary colorectal or gynecologic malignancyFrom January 2010- September 2011, 6 patients underwent simultaneous resection of liver metastases and primary colorectal or gynecologic malignancy. Operative, postoperative, and pathologic data were retrospectively reviewed.Four patients with colorectal primaries underwent simultaneous resection. One received abdominoperineal resection with resection of lesions in hepatic segments II and VII. A second received right hemicolectomy with en bloc resection of gallbladder and segments IV and V. The third and fourth patients both underwent left colectomy with resection of segments IV and V, respectively. All resections were non-anatomic, and frozen-sections were confirmed to be negative at the resection base. No patients suffered additional postoperative morbidity or mortality related to liver resection. Two patients had ovarian cancer with metastatic disease to the liver. The first underwent en bloc resection ofgallbladder and segments IV and V along with extensive debulking. The second had recurrent ovarian cancer with metastases with liver segments VI and VII. Both patients underwent simultaneous resection with no added postoperative morbidity or mortality attributed to hepatic resection. For gynecologic malignancy, the objective is to remove bulky disease, and although microscopic margins were positive, the goal of tumor load reduction was achieved.Liver resection at the time of operation for primary colorectal or gynecologic malignancy can safely be performed with the benefit of avoiding morbidity of a second laparotomy without compromising safety.

The purpose of this study was to compare outcomes in women who underwent endometrial cancer staging by different surgical techniques.Three hundred twenty-two women underwent endometrial cancer staging: 138 by laparotomy (TAH); 81 by laparoscopy (TLH) and 103 by robotic technique (TRH).The TRH cohort had a higher body mass index than the TLH cohort (P = .0008). Lymph node yield was highest for TRH (P.0001); hospital stay (P.0001) and estimated blood loss (P.0001) were lowest for this cohort. Operative time was longest for TLH (213.4 minutes) followed by TRH (191.2 minutes) and TAH (146.5 minutes; P.0001. Postoperative complication rates were lower for TRH, compared with TAH (5.9% vs 29.7%; P.0001). Conversion rates for the robotic and laparoscopic groups were similar.TRH with staging is feasible and preferable over TAH and may be preferable over TLH in women with endometrial cancer. Further study is necessary to determine long-term oncologic outcomes.

Ovarian cancer is the first in mortalities among gynecological cancers in the USA, often due to late diagnosis and/or acquired platinum-resistant recurrences. This study investigates whether BRCA1-IRIS is a novel treatment target for ovarian cancers and their platinum-resistant recurrences. Here we show that more than half of ovarian cancer samples analyzed showed BRCA1-IRIS and survivin overexpression and lacked nuclear FOXO3a expression. Normal ovarian epithelial cells overexpressing BRCA1-IRIS formed metastasis in mice when injected in the peritoneal cavity, whereas aggressive ovarian cancer cell lines failed to form tumors or metastases in mice when BRCA1-IRIS was silenced in them. We show that BRCA1-IRIS activates two autocrine signaling loops, BDNF/TrkB and NRG1/ErbB2. These loops are involved in anoikis resistance and metastasis promotion. These loops operate in several ovarian cancer cell lines and BRCA1-IRIS silencing or inactivation using a novel inhibitory peptide renders both non-functional and promoted cell death. In a mouse xenograft model BRCA1-IRIS inactivation using this novel inhibitory peptide resulted in significant reduction in ovarian tumor growth. More importantly, this treatment sensitized ovarian tumors to low Cisplatin concentrations. Taken together, these data strongly suggest that BRCA1-IRIS and/or BDNF/TrkB and NRG1/ErbB2 could serve as rational therapeutic targets for advanced ovarian cancers. Citation Format: Bibbin T. Paul, Zannel Blanchard, Mildred Ridgway, Wael M. ElShamy. BRCA1-IRIS inactivation sensitizes ovarian tumors to cisplatin [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr AS30.

Objective The purpose of this study was to compare robotically assisted hysterectomy (RAH) with open (ORH) type III radical hysterectomy in the treatment of early-stage cervical cancer. Study Design The outcomes of 51 consecutive patients who underwent RAH were compared with the outcomes of 49 patients who underwent ORH. Results There were no differences with regard to patient demographics. There were significant differences between the groups with regard to operative blood loss ( P P = .0002), and lymph node retrieval ( P = .0003), all of which were in favor of the RAH cohort. All patients with RAH were discharged on postoperative day 1, compared with a 3.2-day average hospitalization for the cohort with ORH. The incidence of postoperative complications was 7.8% and 16.3% for the RAH and ORH cohorts, respectively ( P = .35). Conclusion Robotic type III radical hysterectomy with pelvic node dissection is feasible and may be preferable over open radical hysterectomy in patients with early-stage cervical cancer. Further study will determine procedure generalizability and long-term oncologic outcomes.