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Despite recent therapeutic breakthroughs, advanced and/or recurrent endometrial cancer still poses a significant health burden globally. While immunotherapy can theoretically lead to durable responses, the benefits to patients remain limited. In an effort to identify novel immunotherapeutic targets, we specifically focused on the potential role of nucleophosmin (NPM, also known as B23) - a nucleolar phosphoprotein involved in tumorigenesis - in cancer immune evasion. Expression profiling with oligonucleotide microarrays was conducted to identify differentially expressed genes in NPM/B23-silenced endometrial cancer cells. CD24 - a heat-stable antigen commonly overexpressed in solid tumors and a target for cancer immunotherapy - was identified as one of the key NPM/B23-regulated molecules. We found that NPM/B23 was capable of inducing CD24 expression, with the Sp1 binding site in the CD24 promoter being essential for NPM/B23-mediated transcriptional activation. Interestingly, NPM/B23 silencing in endometrial cancer cells enhanced phagocytic removal by macrophages through a decreased exposure of CD24 on the cell surface. Conversely, restoration of CD24 expression in NPM/B23-silenced endometrial cancer cells inhibited macrophage-mediated phagocytosis. These results indicate that NPM/B23-driven CD24 overexpression enables endometrial cancer cells to evade from phagocytosis. We further suggest that CD24 may serve as a novel target for endometrial cancer immunotherapy. KEY MESSAGES: NPM/B23 induced CD24 expression in endometrial tumorigenesis. Sp1 binding site in the CD24 promoter is essential for the activation. NPM/B23 silencing enhanced phagocytosis by macrophages through decrease of CD24 on cancer cells. Restoration of CD24 expression in NPM/B23-silenced cancer cells inhibited macrophage-mediated phagocytosis.

Background Extracellular and cell-surface molecules remain the most common druggable cancer targets. However, intracellular therapeutic modalities are gaining momentum. The overexpression of stress-induced phosphoprotein 1 (STIP1), an adaptor protein that coordinates the functions of different chaperones in protein folding, has been reported in several solid malignancies. Here, we investigated the effects of intracellular STIP1 inhibition, attained either through the HEPES-mediated cytosolic delivery of anti-STIP1 antibodies or the use of a cell-penetrating signal-tagged peptide 520, in different human cancer cell lines and luciferase-expressing murine ovarian cancer cells (MOSEC/Luc) tumor-bearing C57BL/6 mice. Methods The effects of STIP1 in different human cell lines were determined by cell viability, cell cytotoxicity and cell apoptosis assays. Immunoblotting was used to assess the relevant proteins found in this study and tumor xenograft mice models were also employed. Results Intracellular targeting of STIP1 inhibited cancer cell line growth and promoted caspase 3-dependent apoptotic cell death. Moreover, the intracellular delivery of anti-STIP1 antibodies facilitated the degradation of STIP1 and two of its client proteins, lysine-specific demethylase 1 and Janus kinase 2. In vivo studies demonstrated that survival of mice bearing experimental tumors was improved by administration of anti-STIP1 antibodies. Conclusions Our findings demonstrate that the cytosolic inhibition of STIP1 in tumor cells is feasible and provides a solid basis for further investigation of STIP1 as an intracellular cancer target. Our findings demonstrate that cytosolic inhibition of STIP1 in tumor cells is feasible and provide a solid basis for further exploration of STIP1 as an intracellular cancer target.

Monoclonal antibodies against programmed cell death protein-1 (PD-1) and its ligand PD-L1 are immune checkpoint inhibitors (ICIs) that have been approved for the treatment of many human cancers. However, the response to these ICIs was limited in patients with ovarian cancer. Studies have indicated that the response to PD-1–PD-L1 blockade might be correlated with the PD-L1 expression level in cancer cells. Mechanistic pathways that control PD-L1 expression are yet to be elucidated and targeting these pathways can improve the efficacy of PD-1–PD-L1 blockade in patients with ovarian cancer. Our results revealed that NPM/B23 regulated PD-L1 expression in ovarian cancer cells. Mechanistically, NPM/B23 negatively regulates PD-L1 expression through NF-κB/p65. Moreover, in the immunocompetent mouse model, the NPM/B23 inhibitor/modulator sensitized the cancer cells to the anti-PD-1 antibody by regulating PD-L1 expression. Compared with treatment with the NPM/B23 inhibitor/modulator or the anti-PD-1 antibody alone, their combined use reduced tumorigenesis and increased CD8+ T-cell expansion, thus contributing to prolong the survival of MOSEC/Luc-bearing mice in vivo. In conclusion, targeting NPM/B23 is a novel therapeutic approach to sensitize cancer cells to immune therapy and reduce tumorigenesis.

Human papillomavirus (HPV) is the well‐established etiologic factor for cervical neoplasia. Cervical conization constitutes an effective treatment for high‐grade cervical intraepithelial neoplasia (HG‐CIN). We conducted an observational study for long‐term outcomes and HPV genotype changes after conization for HG‐CIN. Between 2008 and 2014, patients with newly diagnosed HG‐CIN before conization (surveillance new [SN] group) and those who had undergone conization without hysterectomy (surveillance previous [SP] group) were enrolled. HPV testing and Pap smear were performed periodically for the SN and SP (collectively S) groups. All other patients receiving conization for HG‐CIN during the study period were identified from our hospital database. Those eligible but not enrolled into our study were assigned to the non‐surveillance (non‐S) group. For the S group (n = 493), the median follow‐up period was 74.3 months. Eighty‐four cases had recurrent CIN Grade 2 or worse (CIN2+) (5‐year cumulative rate: 14.8%), of which six had invasive cancer. Among the 84 patients, 65 (77.4%) exhibited type‐specific persistence in the paired HPV results, whereas only 7 (8.3%) harbored new HPV types that belonged to the 9‐valent vaccine types. Among the 7397 non‐S patients, 789 demonstrated recurrent CIN2+, of which 57 had invasive cancer. The stages distribution of those progressed to invasive cancer in the non‐S group were more advanced than the S group (P = .033). Active surveillance might reduce the severity of those progressed to cancer. Because a majority of the patients with recurrent CIN2+ had persistent type‐specific HPV infections, effective therapeutic vaccines are an unmet medical need., What's new? High‐grade cervical intraepithelial neoplasia (HG‐CIN), a cervical carcinoma precursor, frequently is caused by high‐risk human papillomavirus (hr‐HPV) infection. HG‐CIN can be treated by cervical conization, though the procedure does not eradicate hr‐HPV, potentially enabling CIN recurrence. Here, in Taiwanese patients, investigation of HPV genotype changes in relation to HG‐CIN status after conization shows that 77.4 percent of patients with recurrent CIN 2 grade or worse (CIN2+) after conization had persistent type‐specific HPV infections. Vaccination against the remaining high‐risk HPVs prevented recurrent CIN2+ in only 8.3 percent of patients, revealing an unmet need for effective therapeutic vaccines.

Background/purpose: Ovarian clear cell carcinoma (OCCC) with recurrence/progression after treatment has dismal prognosis. We aimed to investigate the management and outcomes of such patients. Methods: OCCC patients who were treated between 2000 and 2013 with cancer recurrence or progression after primary treatment were analyzed. Univariate and multivariate analyses were used to identify the independent predictors of survival after recurrence (SAR) and cancer-specific survival (CSS). Results: A total of 64 patients experienced treatment failure (49 recurred after remission and 15 progressed without remission). The 5-year CSS rates of recurrent/progressive OCCC patients were 22.9% (progression group: median CSS 5.9 months [range, 0.8–25.2] vs recurrence group: 43.6 months [range, 7.1–217.8]; p 12 months (HR: 0.22–0.40, p = 0.001 and p = 0.023), CA125

We aimed to detect endometrial cancer (EC)-associated mutations in endometrial lavage specimens collected in an office setting and to compare the detected mutations with those identified in tissue samples. Participants included 16 women attending for an office hysteroscopy because of suspected EC between July 2020 and October 2021. Massively parallel sequencing was conducted using the targeted 72 cancer-associated genes. Endometrial lavage specimens, endometrial tissue samples, and blood samples were simultaneously sequenced to establish the concordance of genetic alterations. In this study, the vast majority of EC-associated mutations identified in lavage samples (Rsup2/sup = 0.948) were identical to those detected in endometrial tissues. Of the 13 patients with EC, 12 (92.3%) had at least one mutation identified in endometrial lavage samples. Notably, no mutations in lavage samples were identified in the two patients with a previous history of EC but no actual endometrial lesions, supporting a high negative predictive value of the test. A patient previously diagnosed with EC and with current evidence of atypical hyperplasia showed persisting PTEN, PIK3R1, and KRAS mutations in her endometrial lavage specimen. PTEN was the most commonly mutated gene, followed by PIK3R1, ARID1A, PIK3CA, CTNNB1, and KRAS. In conclusions, our study provides pilot evidence on the actionability of uterine lavage samples sequencing to detect EC-associated mutations in women with suspected endometrial lesions. In a precision medicine framework, the high mutational concordance between uterine lavage samples and tissue specimens may help inform less invasive diagnostic protocols and the need for ongoing surveillance in patients with EC who wished for fertility-preserving treatment. KEY MESSAGES: • Sequencing of uterine lavage samples collected by office hysteroscopy is feasible. • Most EC mutations identified in lavage were identical to endometrial tissues. • Sequencing of uterine lavage samples may help inform diagnostic protocols for EC. • This approach can be used for recurrence surveillance in patients with EC.

The histological criteria for classifying endometrial hyperplasia (EH) are based on architectural crowding and nuclear atypia; however, diagnostic agreement among pathologists is poor. We investigated molecular biomarkers of endometrial cancer (EC) risk in women with simple hyperplasia or complex hyperplasia without atypia (SH/CH-nonA). Forty-nine patients with EC preceded by SH/CH-nonA were identified, of which 23 were excluded (15 with complex atypical hyperplasia (CAH), six not consenting, one with a diagnosis 4) between the control (n = 12) and case (n = 6) patients. Multiplex RT-qPCR for the 20 miRNAs in the expanded cohort (94 control and 25 case patients) led to the validation of miR-30a-3p (p = 0.0009), miR-141 (p < 0.0001), miR-200a (p < 0.0001), and miR-200b (p < 0.0001) as relevant biomarkers, among which miR-141, miR-200a, and miR-200b regulate the expression of phosphatase and tensin homolog (PTEN). For the prediction of EC, the area under the curve for miR-30a-3p, miR-141, miR-200a, and miR-200b was 0.623, 0.754, 0.783, and 0.704, respectively. The percentage of complete PTEN loss was significantly higher in the case group than in the control group (24% vs. 0%, p < 0.001, Fisher’s exact test). A combination of complete PTEN loss and miR-200a provided optimal prediction performance (sensitivity = 0.760; specificity = 1.000; positive predictive value = 1.000; negative predictive value = 0.937; accuracy = 0.947). MiR-30a-3p, miR-141, miR-200a, miR-200b, and complete PTEN loss may be useful tissue biomarkers for predicting EC risk among patients with SH/CH-nonA.

To investigate outcomes and morbidity of patients undergoing secondary cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in recurrent ovarian cancer.Between April 2014 and January 2019, a total of 51 recurrent ovarian cancer patients receiving secondary CRS and HIPEC were retrospectively reviewed.Among the 51 patients, median peritoneal cancer index score was 13 (range 3-34), and completeness of cytoreduction (CC) score of 0/1 was achieved in 41 patients (78.8%). Regimen of HIPEC included cisplatin and paclitaxel in 39 (75%) cases. The median follow-up duration of survivors was 20.2 months. Sixteen (30.8%) patients remained free of recurrence after HIPEC. The median progression-free survival (PFS) and overall survival (OS) were 11.8 months and 34.5 months respectively. Multivariate analysis showed previous chemotherapylt;2 lines (HR 0.24, 0.11-0.52; p = 0.001), chemotherapy-free interval ≥6 months (HR 0.19, 0.09-0.37; p lt; 0.001) and CA125 lt; 35 U/mL before HIPEC (HR 0.133, 0.021-0.0832; p = 0.031) were good prognostic factors for PFS. CC0/1 was not significant in multivariate analysis. The most common grade 3/4 toxicity was anemia (17.3%), pleural effusion (11.5%) and renal insufficiency (5.7%). Patients with age ≥50, peritoneal carcinomatosis index (PCI) ≥ 11, operation time ≥10 h and diaphragm surgery had significantly higher incidence of pleural effusion.The current study showed adding HIPEC to secondary CRS might prolong PFS especially in patients with previous chemotherapylt;2 lines, chemotherapy-free interval ≥6 months and CA125 lt; 35 U/mL before HIPEC.

Despite recent therapeutic breakthroughs, advanced and/or recurrent endometrial cancer still poses a significant health burden globally. While immunotherapy can theoretically lead to durable responses, the benefits to patients remain limited. In an effort to identify novel immunotherapeutic targets, we specifically focused on the potential role of nucleophosmin (NPM, also known as B23) - a nucleolar phosphoprotein involved in tumorigenesis - in cancer immune evasion. Expression profiling with oligonucleotide microarrays was conducted to identify differentially expressed genes in NPM/B23-silenced endometrial cancer cells. CD24 - a heat-stable antigen commonly overexpressed in solid tumors and a target for cancer immunotherapy - was identified as one of the key NPM/B23-regulated molecules. We found that NPM/B23 was capable of inducing CD24 expression, with the Sp1 binding site in the CD24 promoter being essential for NPM/B23-mediated transcriptional activation. Interestingly, NPM/B23 silencing in endometrial cancer cells enhanced phagocytic removal by macrophages through a decreased exposure of CD24 on the cell surface. Conversely, restoration of CD24 expression in NPM/B23-silenced endometrial cancer cells inhibited macrophage-mediated phagocytosis. These results indicate that NPM/B23-driven CD24 overexpression enables endometrial cancer cells to evade from phagocytosis. We further suggest that CD24 may serve as a novel target for endometrial cancer immunotherapy. KEY MESSAGES: NPM/B23 induced CD24 expression in endometrial tumorigenesis. Sp1 binding site in the CD24 promoter is essential for the activation. NPM/B23 silencing enhanced phagocytosis by macrophages through decrease of CD24 on cancer cells. Restoration of CD24 expression in NPM/B23-silenced cancer cells inhibited macrophage-mediated phagocytosis.

Objectives To analyze prevalence of HPV DNA, HPV genotype distribution, prognostic factors and long-term outcomes of vulvar carcinoma. Methods We retrospectively reviewed medical records of patients with vulvar carcinoma who received primary surgeries between 1985 and 2014 in a single institution. General polymerase chain reaction (PCR) SPF1/GP6+ followed by revert-blot detection was performed for human papillomavirus (HPV) genotyping. E6 type-specific PCR of the top-5 prevalent types was performed to reconfirm HPV-negative status. P16INK4a immunohistochemistry staining was performed. Univariate and multivariate analyses were performed to identify predictors of clinical outcomes of squamous cell carcinomas (SCCs). Results A total of 150 vulvar carcinoma patients eligible for analysis were retrieved. Medial follow up time was 71.4 months (0.2–341.8 months). One hundred and twenty-nine patients (86.0%) were diagnosed as SCC. In SCC specimens, HPV DNA sequences were detected in 56.6%, and 14.3% of non-SCC vulvar cancer (n = 21) were HPV positive. The leading 4 types were HPV16 (54.0%), HPV58 (15.8%), HPV52 (6.6%), and HPV18 (5.3%). HPV-positivity was associated with better 5-year cancer-specific survival (CSS) (P = 0.037). In multivariable analysis, older age (continuous, hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.03–1.08, P Conclusion Advanced FIGO stage and older age were significant adverse predictors, while p16-positivity was a significant factor of better prognosis.

Background/purpose To compare the clinical outcomes of Taiwanese patients with ovarian clear cell carcinomas (CCCs) and serous carcinomas (SCs). Methods We retrieved the clinical records of women with epithelial ovarian cancer (Stage I–IV) who received primary surgeries between 2000 and 2013. Cancer-specific survival (CSS), progression-free survival, and survival after recurrence (SAR) of CCC and SC patients were retrospectively compared. Multivariate analysis was used to identify the independent predictors of survival. Results Of 891 women diagnosed with epithelial ovarian cancer, 169 CCCs and 351 high-grade SCs were analyzed. The 5-year CSS rates of CCC patients were significantly lower than those of SC for both Stage III (22.3% vs. 47.3%, p = 0.001) and Stage IV (0% vs. 24.4%, p = 0.001) disease. In the absence of gross residual malignancies, the 5-year CSS rate was better for CCC (82.3%) than SC (75.2%, p = 0.010). The 5-year SAR rate was significantly lower for CCC than SC (14.3% vs. 24.4%, p = 0.002). Old age and residual malignancies were independent prognostic factors for CSS in the entire cohort of CCC patients. In the subgroup of Stage I CCC, positive cytology was identified as the only adverse prognostic factor for CSS. Conclusion The clinical outcomes of CCC are generally poorer than SC. Complete cytoreduction to no gross residual disease should be ideally achieved in CCC patients. A greater understanding of the molecular pathogenesis of CCC may lead to tailored therapies, ultimately optimizing outcomes.

With the advent of next-generation sequencing (NGS), The Cancer Genome Atlas (TCGA) research network has given gynecologic cancers molecular classifications, which impacts clinical practice more and more. New cancer treatments that identify and target pathogenic abnormalities of genes have been in rapid development. The most prominent progress in gynecologic cancers is the clinical efficacy of poly(ADP-ribose) polymerase (PARP) inhibitors, which have shown breakthrough benefits in reducing hazard ratios (HRs) (HRs between 0.2 and 0.4) of progression or death from BRCA1/2 mutated ovarian cancer. Immune checkpoint inhibition is also promising in cancers that harbor mismatch repair deficiency (dMMR)/microsatellite instability (MSI). In this review, we focus on the druggable genetic alterations in gynecologic cancers by summarizing literature findings and completed and ongoing clinical trials.

Objectives: This multi-center international study (Asian Gynecologic Oncology Group [AGOG]13-001/Taiwanese Gynecologic Oncology Group [TGOG]1006) was to validate human papillomavirus (HPV)16 as an independent prognostic factor of cervical adenocarcinoma and adenosquamous carcinoma (AD/ASC). Methods: Retrospective and prospective collection of patients receiving primary treatment at AGOG and TGOG member hospitals for cervical AD/ASC were enrolled. The cases treated between 1993 and 2014 were retrospectively collected, and the prospective enrollment was started since 2014. Those endometrial origin (by immunohistochemistry and imaging studies) cannot rule out were excluded for analysis. Results: A total of 354 patients were enrolled, 287 (81.1%) of which had HPV-positive tumors. The top-3 types among HPV-positive cases was HPV 18 (50.8%), HPV16 (22.9%) and HPV45 (4.0%). A total of 322 patients were eligible for prognostic analyses. Patient with HPV16-positivity had significantly longer progression-free survival (PFS) and overall survivals (OS) than those without HPV16 (p=0.001 and 0.026, respectively). By multivariate analysis, advanced FIGO stage (HR5.7, 2.4-13.5), lymph node metastasis (HR4.6, 2.7-7.9), tumor size (>4 cm HR3.3), and HPV16-positivity (HR0.3, 0.1-0.7) were independent prognostic factors for PFS. Only the former 2 variables remained significant, while HPV16-positivity was marginally significant (p=0.064) for OS. HPV-negativity rates varied across hospitals, yet it seemed to be increasing over time (4.4% versus 12.5%, p Conclusions: This study confirmed that HPV16-positivity was a good prognostic factor for PFS, yet the increasing HPV-negative AD/ASCs seemed to be a trend that needs attention.

e17563 Background: The histological criteria of predicting risk of progression of endometrial hyperplasia (EH) to endometrial cancer (EC) is based on the degree of architectural crowding and nuclear atypia. We aim to investigate the cumulative rate of progression to EC in simple or complex hyperplasia without atypia (SH/CH-nonA) and the molecular biomarkers for risk of developing EC in women with SH/CH-nonA. Methods: EH tissues of EC patients with preceding SH/CH-nonA (case) were compared to SH/CH-nonA patients without progression to EC (control) using miRNA array, followed by reverse transcription and quantitative real-time polymerase chain reaction (RT-qPCR), and verified in an independent cohort. Results: The 10-year and 15-year cumulative rates were 8% and 10%, respectively by the hospital medical records. The median time from EH to EC was 8.71 years (range, 0.55-19.84). Twenty miRNAs (p < 0.05, fold change > 4) were significantly different in SH/CH-nonA cases (n = 6) compared to SH/CH-nonA controls (n = 12) by miRNA array. Multiplex RT-qPCR validation (51 SH/CH-nonA controls and 19 SH/CH-nonA cases) selected miR30a-3p, miR141, miR200a, and miR200b. Area under the curve values for tissue miR30a-3p (p = 0.043), miR141(p = 0.003), miR-200a (p < 0.001), and miR200b (p = 0.004) in discriminating cases from controls were 0.658, 0.734, 0.811, and 0.710, and the sensitivity and specificity rates were 56.9% and 76.5%, 73.7% and 74.5%, and 68.4% and 100%, 47.4% and 100%, respectively. Conclusions: MiR30a-3p, miR141, miR-200a, and miR200b are useful tissue biomarkers for predicting future risk of developing EC for patients with SH/CH-nonA.

Objectives Synchronous endometrial and ovarian carcinomas (SEOCs) present gynecologic oncologists with a challenging diagnostic puzzle: discriminating between double primary cancers and single primary cancer with metastasis. We aimed to determine the clonal relationship between simultaneously diagnosed endometrial and ovarian carcinomas. Methods Fourteen pairs of SEOCs of endometrioid type and two pairs of SEOCs with disparate histologic types (control for dual primary tumors) were subjected to massively parallel sequencing (MPS) and molecular inversion probe microarrays. Results Thirteen of the 14 pairs of SEOCs harbored somatic mutations shared by both uterine and ovarian lesions, indicative of clonality. High degree of chromosomal instability in the tumors from 10 patients who received adjuvant chemotherapy, of whom 9 had synchronous carcinomas with significantly overlapping copy number alterations (CNAs), suggestive of single primary tumors with metastasis. The clonal relationship determined by genomic analyses did not agree with clinicopathological criteria in 11 of 14 cases. Minimal CNAs were identified in both ovarian and endometrial carcinomas in 4 patients, who did not receive adjuvant chemotherapy and experienced no recurrent diseases. In contrast, two of the 10 patients with chromosomally unstable cancers developed recurrent tumors. Conclusion Our findings support a recent paradigm-shifting concept that most SEOCs originate from a single tumor. It also casts doubt on the clinicopathological criteria used to distinguish between dual primary tumors and single primary tumor with metastasis. Testing of CNAs on SEOCs may help determining the need of adjuvant therapy.

ObjectiveOur aim was to investigate the outcomes and prognostic factors after treatment failure of endometrial cancer.MethodsA total of 923 endometrial cancer patients were treated between 2000 and 2010, of which 109 experienced treatment failure. Treatment failure was defined as relapse after complete removal of all cancerous lesions or persistent/progressive disease despite treatment. Variables including clinicopathological features at initial treatment, type of primary treatment, failure pattern, salvage treatment, and outcomes were analyzed. Kaplan-Meier survival curves were compared with log-rank test. Cox proportional hazards regression model was used to identify significant prognostic factors.ResultsEighteen cases with persistent/progressive disease died shortly from primary diagnosis (1–23 months). The remaining 91 patients had recurrences in vagina only (8.8%), pelvis (3.3%), distant (63.7%), and combined pelvic-distant sites (24.2%). Median time to recurrence was 13.3 months (3.2–97.2 months). The median follow-up after recurrence of survivors was 60.5 months (10.6–121.7 months). The median survival after recurrence (SAR) was 20.3 months (1.9–121.7 months) with 5-year SAR rate of 32.4%. By multivariate analysis, initial stage II to IV (hazards ratio [HR], 3.41; 1.53–7.60;P= 0.003), type II histology (HR, 2.50; 1.28–4.90;P= 0.008), positive peritoneal cytology (HR, 2.23; 1.07–4.68;P= 0.033), and recurrence at multiple sites (HR, 2.51; 1.30–4.84;P= 0.006) were significantly associated with poor SAR. The 5-year SAR rates in patients with solitary vaginal, nodal/liver, or pulmonary/bony recurrence were 83.3%, 50.5%, and 24.2%, respectively. Ten cases with resectable or irradiatable recurrence at multiple sites or multiple relapses attained SAR greater than 5 years after multimodality salvage therapy.ConclusionsInitial stage II to IV, type 2 histology, positive cytology, and recurrence at multiple sites were significant poor prognostic factors. Curative intent salvage therapy remains a viable option for cases with resectable or irradiatable multiple recurrences and solitary distant metastasis.

Objective To investigate the clinical and pathological characteristics and the management of uterine papillary serous carcinoma (UPSC) in relation to patients' outcomes. Methods Clinicopathological data and the management of patients treated between 1991 and 2010 at 11 member hospitals of the Taiwanese Gynecologic Oncology Group (TGOG) were retrospectively reviewed. The Kaplan–Meier method was used to generate survival curves, and factors predictive of outcome were compared using the log-rank test and Cox regression analysis. Results A total of 119 pure UPSC patients were recruited. Stages I, II, III, and IV were identified in 34.5%, 2.5%, 36.1%, and 26.9% of the patients, respectively. The recurrence rate was 20.5% in FIGO stage I/II disease and 55.2% in FIGO stage III/IV disease. The 5-year overall survival rates for the patients with stage I, II, III, and IV disease were 92.0%, 66.7%, 34.2%, and 17.3%, respectively. Multivariate analysis showed that tumor stage (stage III/IV hazard ratio [HR] 8.65, 95% confidence interval [CI] 3.00–24.9) and optimal cytoreduction (HR 0.40, 95% CI 0.22–0.73) independently influenced the overall survival rate of UPSC patients. In addition, optimal cytoreduction (HR 0.36, 95% CI 0.17–0.78) and the combination of chemotherapy and radiation (HR 0.11, 95% CI 0.04–0.37) improved the overall survival of the advanced stage (FIGO stage III/IV) UPSC patients. Conclusions UPSC represents an aggressive subtype of endometrial cancer commonly accompanied by extra-uterine disease. Comprehensive surgical staging with cytoreductive surgery is mandatory and beneficial for UPSC patients. Systemic chemotherapy combined with radiation should be considered as an adjuvant therapy for advanced stage UPSC patients.

Human papillomavirus (HPV) is the causative agent of cervical intraepithelial neoplasia and cervical cancer. HPV and cytology co-tests in women aged 30 years or older every 5 years as primary cervical screening is recommended for developed countries. In HPV-positive and cytology-negative women, follow-up with co-tests at 12 months is recommended. Nevertheless, if HPV-16 or HPV-18 is positive, direct colposcopy is recommended. In mild cytological abnormality and HPV-negative women, routine screening should be continued as per age-specific guidelines. Women with history of cervical intraepithelial neoplasia grade 2 or more should be followed at least 20 years even after age 65 years. In area with very limited resource, a single visit “screen-and-treat” visual inspection with acetic acid might be reasonable. Although the policies of cervical screening vary in different regions, the future screening strategies when the young HPV vaccinated population reaches the screening age will need to be renovated.

Objective It is not clear whether the prognostic value of pretreatment serum CA125 levels is independent or through association with other clinicopathological features in endometrial cancer. Methods All patients with endometrial cancer treated between 2000 and 2010 were retrospectively reviewed. The correlation of clinicopathological characteristics, CA125 and treatment outcomes was analyzed. Receiver operating characteristics (ROC) curves were used to determine the CA125 cut-off values. Cox proportional hazard regression was used for multivariate analysis. Results Of the 923 eligible patients, 757 had serum CA125 levels measured before treatment. We identified 264 (34.9%) patients with pretreatment serum CA125>35U/mL. By multivariate analysis, advanced stage ( P =0.001), serous or clear cell carcinoma ( P =0.008), positive peritoneal cytology ( P =0.042), and lymph node metastases ( P =0.004) were significant risk factors for cancer-specific survival (CSS), while serum CA125>35U/mL ( P =0.067) was of borderline statistical significance. Using ROC curve stratified by age, we found that a serum CA125>35U/mL was significant for CSS (HR=2.34, 95% CI=1.04–5.29) among patients >49years old. After adjustment for confounding factors, serum CA125>105U/mL was significant (HR=6.03, 95% CI=1.19–30.63) in patients ≤49years old. Conclusions These results suggest that an age-stratified cut-off level for CA125 (35U/mL in patients >49years old and 105U/mL in patients ≤49years old) can improve the prognostic stratification of patients with endometrial cancer.

Measurement of intratumoral heterogeneity by 18F-fluorodeoxyglucose (18F-FDG) Positron Emission Tomography (PET) is a valuable modality, which showed correlation to response of treatment and prognosis in various malignancies. PET-based texture analysis for tumor heterogeneity is a potential predictive factor for cervical cancer and related to lymph node metastasis, tumor volume, response of treatment, and pelvic recurrence. Although seemed promising in utility in oncology, a plenty of methods have been used for analysis of heterogeneity which led to confusion of definitions and comparing results challenging. Further larger sized prospective studies are needed for standardized heterogeneity descriptors and clinical applications.

There are limited data on the prevalence and distribution of human papillomavirus (HPV) genotypes in vaginal intraepithelial neoplasia (VAIN). We sought to clarify this issue in a series of 450 VAIN cases with a confirmed diagnosis between 1990 and 2006. HPV genotyping was performed using paraffin-embedded specimens and polymerase chain reaction (PCR)-based methods. Multiple HPV types were validated by E6 type-specific PCR and direct sequencing. The HPV genotypes of the vaginal and cervical neoplasms were compared for those with incident VAIN and a history of previous/concomitant cervical neoplasms. Ki-67 was performed for supporting diagnosis of VAIN. Of these 450 VAIN cases (median age, 59 years; range, 19-93), two with missing paraffin blocks and 54 with poor DNA quality were excluded. HPV was detected in 273/394 (69.3%) VAIN, and multiple infections were found in 17.9% of HPV-positive samples. The leading types were HPV16 (35.5%), HPV58 (9.9%), HPV52 (9.9%), HPV39 (8.4%), HPV33 (7.3%) and HPV53 (7.0%). Among the 156 cases with a history of previous cervical neoplasia, 29.0% had concordant HPV genotypes, while synchronous VAIN samples (n = 49) were more likely to harbor concordant genotypes (58.7%) with the concomitant cervical neoplasm (p = 0.0003). Whether those HPV types in the incident VAIN lesions had existed in the vaginal epithelium at the time of the previous cervical neoplasia or a new acquisition needs to be clarified in prospective follow-up studies.

Background/Purpose Under-utilization of Papanicolaou (Pap) smear causes a gap in the prevention of cervical neoplasms. A prospective population-based study was conducted investigating whether a self-sampling human papillomavirus (HPV) test was feasible for under-users of Pap smear and factors associated with under-screening in Taiwan. Methods Women not having Pap smear screening for > 5 years were invited to participate in this study. Invitation letters and educational brochures were mailed to 4% of randomly selected eligible women from Taoyuan City, Taiwan, and responders received an HPV self-sampling kit. Those with HPV-positive results were recalled for a Pap smear and colposcopy. Results Between March 2010 and June 2012, 10,693 women were invited, 354 responded (3.3%), and 282 (2.6%) gave valid informed consent, answered the questionnaire, and submitted HPV samples. The median age of enrolled women was 48.1 years. Forty-seven women (16.7%) had a positive HPV test, and 14 women accepted further survey to find two CIN2+. Another two cases of CIN2+ were identified from a national registry database. The cost of direct mailing self-samplers was less than that done on request (from NT$434,866 to NT$164,229, response rate of 5% to 15%, respectively, versus NT$683,957 for detecting 1 CIN2+). Reasons for not attending screening included lack of time, embarrassment, assumed low risk, fear of positive results, and perceived potential pain. Among the responders, 90.8% found the method acceptable. Conclusion Our study indicated that different approaches (e.g., direct mailing self-samplers to under-users and/or various educational interventions) must be explored to improve coverage in populations with culture characteristics similar to Taiwan.

Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan Department of Nuclear Medicine, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Shin St., Kueishan, Taoyuan, Taiwan Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Shin St., Kueishan, Taoyuan, Taiwan Department of Clinical Pathology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan Department of Radiology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan

e16537 Background: To evaluate the clinical features and the outcomes of endometrial cancer with treatment failure after primary definitive surgery. Methods: A total of 89 patients who received primary definitive surgery between 2000 and 2010 with treatment failure were retrospectively reviewed. The correlation of clinicopathological features, primary treatment, failure pattern, and salvage treatment with outcomes were analyzed. Results: Twenty of the 89 patients with persistent or progressive diseases died at a median of 7.6 months (range, 1.9-14.0 months). The remaining 69 patients with initial disease controlled but subsequent relapse had a median time to recurrence of 13.9 months (range, 3.2 – 97.1). Assessable failure patterns included vaginal only in 14.5%, pelvic in 2.9%, distant in 59.4%, distant and loco-regional in 23.2%. The median survival after recurrence (SAR) was 25.5 months (range 1.5-121.7 months). The 5-year SAR rate was 52.7%. By univariate analysis, FIGO stage, grade of differentiation, histologic cell type, cervical invasion, adnexal metastasis, and status of lymph node metastasis when initial diagnosis, and bone or/and lung metastasis, radiotherapy after recurrence, and CA-125 ≥ 35 U/mL at recurrence were significant factors of 5-year survival after recurrence. By multivariate analysis, high-grade cancer (HR 3.05, 1.17-8.01; p = 0.023), bone and/or lung metastasis at recurrence (HR2.81, 1.15-6.85; p = 0.023), and CA-125 ≥ 35 U/mL (HR 2.85, 1.18-6.87; p = 0.013) were significantly poor prognostic factors for SAR. Six patients achieved long-term survival with more than one recurrence after aggressive multimodal salvage therapy along with deliberate restaging and post-therapy surveillance. Conclusions: High-grade, bone and/or lung metastasis and CA-125 ≥ 35 U/mL at recurrence were significantly poor prognostic factors for SAR. After intensive treatment, patients with recurrent endometrial cancer may have long-term survival.