Faculty Bibliography

Background and Aims of the study : We have achieved >6 months survival of a life-supporting kidney with a vascularized thymus (VT) in a pig-to-baboon model. While improved survival has been achieved with GalT KO pig xenografts in primates, non-Gal natural antibody determinants, including beta1,4 N-acetylgalactosaminyl transferase (B4) and N-glycolylneuraminic acid (NeuGc) are recognized by human sera on GalT KO pig cells. In this study, we compared preformed anti-pig natural antibodies (nAb) against GalTKO alone (GalTKO) and triple knockout (TKO) pigs that were GalT, B4, and CMAH (NeuGc) KO, in baboons to test: (1) if TKO induced new antigens that are recognized by baboon preformed nAb; and then (2) assessed if these new antigens were immunogenic in vivo. Methods : Preformed nAb against GalTKO or TKO PBMC in 10 naive baboon sera were assessed by FCM Ab binding assays using anti-human IgM or IgG ab. Among these baboons, five received pig kidneys and VT grafts from porcine CMV negative TKO pigs. All baboons received anti-CD40 mAb, ATG and Rituximab. Graft renal function (sCre and histology), thymic emigrants from pig thymus (chimerism) as well as immunologic assays (anti-pig ab and cellular assays) were performed. Results : Among 10 naive baboon sera, two had less Ab binding against TKO than GalTKO cells. Four baboon sera had similar binding to TKO and GalTKO cells. Notably, 4 baboon sera had higher ab binding to TKO than GalTKO cells, suggesting that new antigens were revealed in association with the additional KO. Although all baboons (n = 5) had stable renal function in the first 11 days (Cre < 1.5 mg/dl), two baboons with higher non-Gal preformed IgG against TKO than GalTKO (high preformed nAb against TKO) rejected their kidney plus VT grafts at POD 20. Immunohistology showed predominant IgG binding in the excised rejected kidneys. In contrast, three baboons, including one that had similarly high preformed non-Gal IgG binding against both GalTKO and TKO equally, did not reject kidneys in the early period. One that had high IgG binding against both GalTKO and TKO maintained renal function but was euthanized due to tracheal edema at POD 53 (Cre 1.2 mg/dl). Others that had low IgG binding against TKO also maintained renal function without evidence of rejection. One was euthanized at POD 154 due to graft growth and the other at POD 43 due to an anesthetic complication. Conclusions : These data indicate that TKO pigs may express new antigenic specificities that led to delayed vascular xenograft rejection in a pig-to-baboon kidney plus VT model. Prescreening for preformed IgM and IgG nAb using both GalTKO and TKO PBMC is essential to avoid early loss of pig xenografts

Introduction : We have recently reported that both CD80 upregulation and the degradation of SMPDL-3b on glomerular podocytes are involved in the development of post kidney xenotransplant (XKTx) proteinuria in a pig-to-baboon model. In this study, we assessed (1) if the incompatibility of porcine CD47 and baboon macrophages (CD47/SIRPalpha pathway) was involved in the development of post XKTx proteinuria, and (2) if transgenic (Tg) expression of human CD47 (hCD47) caused negative effects via a CD47/TSP-1 pathway following pig-to-baboon K+VT Tx. Methods : Study 1 : Phagocytosis of porcine endothelial cells (EC) as well as podocytes with/without hCD47 was assessed in co-culture assays with baboon macrophages. Study 2 (to assess the effect of hCD47 Tg in vivo) : Five baboons received porcine Kidney plus vascularized thymus (K+VT) in which hCD47 was expressed at high levels. All 5 received ATG and rituximab followed by anti-CD40 or CD40L mab +MMF. One of the 5 additionally received anti-IL6 receptor ab weekly from the 3rd week. Graft renal function, immunologic assays as well as graft expression of hCD47 and TSP-1 were assessed. Results : Co-culture phagocytosis assays : Statistically significant reductions of phagocytosis of both porcine EC and podocytes were observed when hCD47 was expressed on porcine ECs or podocytes. Expression of hCD47 and TSP-1 : One animal expressed hCD47 only on glomerular cells while the others (n = 4) expressed hCD47 on glomerular cells as well as vascular ECs and arterial median layers (widespread hCD47). Widespread hCD47-expressing kidneys also expressed TSP1, although weakly, in vascular median layers while no TSP1-expression was observed on kidneys with glomerular hCD47 or naive pig or baboon kidneys. Following XK+VT Tx : Historic controls of GalTKO K+VT without hCD47Tg uniformly developed proteinuria 2+ within 14 days (n > 10), while all recipients of hCD47Tg GalTKO K+VT displayed minimal (1+ or 0) Uprot. However, although the recipient of a kidney graft in which hCD47 was expressed only in the glomeruli maintained function >4 months, three of 4 animals that received widespread hCD47 K+V were euthanized due to systemic edema with evidence of up-regulation of TSP-1 in grafts, without evidence of immunologic rejection within 8 weeks. These had circulating pig CD3+ T thymic emigrants >5% following Tx with increased serum levels of IL6. One animal that received weekly anti-IL6r ab maintains stable renal function without systemic edema (Cr <1 mg/dl currently on POD 86). Conclusions : These results demonstrate that (1) high expression of hCD47 on porcine glomerular cells prevented the development of proteinuria; however, (2) widespread expression of hCD47 upregulates TSP-1 which might play a role in increased vascular permeability leading to systemic edema. These effects may be inhibited by anti-IL6r treatment

OBJECTIVES/OBJECTIVE:Neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) is a treatment strategy for ovarian cancer patients with unresectable disease or poor performance status (PS). This strategy has been used in the treatment of advanced endometrial cancer and a survival benefit has been shown in patients who are subsequently able to undergo interval cytoreduction. This study sought to review our single institution experience with NACT for advanced endometrial cancer. METHODS:We conducted a retrospective review of all patients who received NACT for advanced endometrial cancer at two institutions in New York City between 2002 and 2016. RESULTS:We identified 39 patients (median age 61, range 35-89). The histologic subtype distribution was: serous (44%), endometrioid (28%), carcinosarcoma (10%), clear cell (8%), mixed (8%), neuroendocrine (3%). Contraindications to primary surgery included: unresectable disease (72%), poor PS (15%), unresectable disease and poor PS (13%). Twenty-three patients (59%) did not undergo IDS due to: progression of disease (70%), medical ineligibility (4%), unresectable disease (17%), lost to follow-up (4%), death (4%). Sixteen patients (41%) underwent IDS, 81% had an optimal cytoreduction. Disease status at NACT completion was: partial response (56%), stable disease (3%) and progression of disease (41%). There were no complete responses. Patients who responded to NACT had a significantly longer overall survival than those who did not (15 vs. 5 months. P = 0.015). IDS was also associated with an improvement in overall survival versus no surgery (16 vs. 6 months, P = 0.04). CONCLUSIONS:Unlike ovarian cancer, less than half of the patients undergoing NACT for endometrial cancer underwent IDS, none had a complete response, and 41% had disease progression during NACT. However, endometrial cancer patients who underwent IDS had a high rate of optimal cytoreduction. Both response to NACT and IDS were associated with improved survival.

Objective: Obesity is a significant risk factor for perioperative morbidity and mortality. Outcomes can be improved with standardized protocols including preventive measures and specialized surgical equipment and personnel. We sought to evaluate the outcomes of a surgical safety protocol for all patients with a body mass index (BMI) of >=40 undergoing planned gynecologic surgery.
Method(s): The high BMI pathway (HBP) was developed by a multidisciplinary team of gynecologic oncologists (GO), anesthesiologists, and ancillary surgical and nursing staff based on the most current recommendations from the literature and instituted as a quality improvement project. It was implemented for all morbidly obese patients undergoing planned surgery by a GO. Patients who underwent robotic hysterectomies (RH) on the HBP from 2016 to 2018 were compared with consecutive historical controls who had RHs from 2014 to 2015 prior to HBP implementation. Standard two-sided statistical analyses were performed.
Result(s): Of the 80 patients who successfully completed surgery on the HBP, 55 patients (68.8%) underwent RH and were included in this analysis. These patients were compared to 48 historical controls prior to HBP initiation. There were no significant differences in patient factors or perioperative times between pre- and post-HBP groups (Table 1). Since implementing HBP, there were fewer anesthesia-related complications (ARC) in HBP patients after RH compared to pre-HBP patients (0.0% vs 12.5%, P = 0.02). Among the control patients with ARC, two had respiratory distress requiring pharmacologic intervention, two had increased postoperative nausea and vomiting, and two had intractable postoperative pain. There was also an increase in same-day discharges among patients who underwent RH (65.5% vs 41.7%, P = 0.03), but no difference in hospital readmission rates. There were no differences in intraoperative and 30-day postoperative complications.
Conclusion(s): A HBP to improve perioperative safety for morbidly obese patients undergoing RH resulted in fewer ARCs and increased rates of same-day discharge without increasing perioperative times or intraoperative and postoperative complications. [Figure presented]
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Objective: Few effective treatment options exist for women with advanced or recurrent endometrial cancer (EC). To explore a modification of the standard systemic treatment for advanced or recurrent EC, we sought to determine the feasibility of completing 6 cycles of nab-paclitaxel (Nab-P) and carboplatin. Unlike paclitaxel, Nab-P does not require any steroid or other premedication, an important consideration for patients with diabetes mellitus and in the investigation of combinations with immunotherapy. We prospectively evaluated safety and efficacy of a day 1, 8-dose schedule of Nab-P in combination with carboplatin day 1 q3weeks in patients with chemotherapy naive EC.
Method(s): Patients with early-stage and high-risk, advanced primary, or recurrent EC with no prior platinum and taxane exposure were enrolled at a single institution. Patients received 6 cycles of day 1 Nab-P 100 mg/m² IV with carboplatin AUC 6 IV and day 8 Nab-P 100 mg/m² IV q21days. We evaluated percentage completion of 6 cycles with standard dose reductions, as well as toxicity per CTCAE v.4. Measurable disease was not required, and efficacy was assessed by PFS rate at 6 months.
Result(s): From 2016 to 2018, 23 subjects were enrolled; median age was 65 (43-73) years. Nineteen (82%) completed 6 cycles of the doublet therapy. Eight subjects (35%) were dose-reduced 1 level, and 5 (22%) were reduced 2 levels; only 1 subject withdrew due to toxicity. Twelve subjects (52%) had at least 1 grade 3/4 treatment-related adverse event, the most common being anemia, 6 (26%); neutropenia, 4 (17%); and diarrhea, 2 (9%). Pre-existing neuropathy was an exclusion criteria, and 13 (57%) reported at least grade 1 neuropathy with treatment. After treatment, 3 (13%) deaths occurred with 2 due to disease progression and 1 to pulmonary embolism. At 6 months after treatment initiation, 19 (83%) had no evidence of disease or its progression; 4 (17%) had progressed. Kaplan-Meier analysis revealed a 6-month PFS rate of 80.5% (95% CI 65.1%-99.7%) (Figure 1).
Conclusion(s): The Nab-P/carboplatin day 1, 8 regimen met the prespecified criteria of feasibility with acceptable toxicity and efficacy. Use of Nab-P obviates steroid premedications, ideal for immune checkpoint inhibitors that target mismatch repair deficient advanced EC. A future phase II feasibility trial combining an anti-PD-1 agent with Nab-P and carboplatin is planned. [Figure presented]
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Objective: The Gynecologic Oncology Group (GOG) study 240 demonstrated a 3.5-month improvement in overall survival when bevacizumab (bev) was added to a combination chemotherapy regimen. This study established a bev-containing regimen as standard therapy for women with recurrent, persistent, or metastatic cervical cancer (CC). Gastrointestinal fistula (GIF) formation is a known complication of bev, and the long-term data of GOG 240 reported that a GIF rate of 15% in women who were treated with bev compared to 1% in the control group women. We sought to evaluate our experience with women treated with bev for CC and to identify associated risk factors for GIF formation.
Method(s): All patients who have received bev for CC from 2012 to 2018 at two academic institutions were identified, and their records were reviewed. Standard two-sided statistical analyses were performed.
Result(s): A total of 43 women were treated with a bev-containing chemotherapy regimen; among them, 34 (79.1%) were treated for CC recurrence, and the remaining were treated for metastatic disease at initial presentation or persistent disease following primary treatment. Thirty-three women (76.6%) received prior radiation therapy (RT); of these, 10 (32.3%) received external beam radiation therapy (EBRT), and 21 (67.7%) had prior EBRT and brachytherapy (BT). The median dose of bev was 15 mg/kg for both EBRT only and EBRT and BT groups. Eleven women developed GIF after bev treatment (11/43, 25.6%). All 11 (100%) had been previously treated with RT, and six (54.5%) had received EBRT plus BT. This resulted in rates of 33.3% (11/33) for GIF formation among women who received EBRT, and 28.6% (6/21) for GIF formation among women who received EBRT plus BT. The median number of bev cycles prior to GIF development was 8 (1-29), and 7 (7/11, 63.6%) received the dose of bev (15 mg/kg) as prescribed in GOG 240. See Table 1.
Conclusion(s): In our cohort of women with CC who were treated with bev, over 25% developed GIF. This is more than expected based on the 15% seen in GOG 240. Notably almost all who developed GIF had recurrent disease and were treated with prior RT. A third of women treated with RT followed by bev formed GIF, representing a considerable proportion of the cohort. GIF development and the possibility of requiring a colostomy should be a part of counseling prior to bev initiation especially in those who have had prior RT. [Figure presented]
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Objective: Enhanced Recovery Protocols (ERPs) minimize the stress response associated with surgery, decrease postoperative opioid consumption, and reduce length of stay (LOS). However, several of the medications on standard ERPs are expensive, which may limit their availability in low-resource settings. Our gynecologic oncology service takes care of patients at both an academic tertiary care center and a safety net hospital. We sought to examine whether a modified ERP at the safety net hospital led to comparable patient outcomes when compared to a standard protocol.
Method(s): From January 2016 to June 2017, patients undergoing scheduled laparotomy by 1 team of gynecologic oncologists who cover 2 hospital networks were placed on a perioperative ERP. Hospital A is an academic medical center; hospital B is a safety net public hospital. ERP was modified at hospital B because of the high cost of several medications (Figure 1). Demographics and perioperative outcomes including LOS, complication, and readmission rates were compared.
Result(s): One hundred and four patients at hospital A and 45 patients at hospital B were included. Patients at hospital B were younger on average (49.0 +/- 13.2 years vs 55.7 +/- 14.4 years, P < 0.001), more likely to be nonwhite (93.3% vs 40.4%, P < 0.001), utilize public insurance (48.9% vs 26.0%, P < 0.001), and be unmarried (55.7% vs 33.7%, P < 0.001). There were no statistically significant differences in LOS, postoperative complications, final pathology, estimated blood loss, 30-day readmission, or 30-day complication rates. Compared to patients at hospital A, patients at hospital B were less likely to receive intraoperative transfusions (0% vs 11.5%, P = 0.018) and had fewer inpatient complications (6.7% vs 21.2%, P = 0.032)
Conclusion(s): Despite the lack of several medications, patients on a modified ERP had similar outcomes to patients on a standard ERP protocol. A lower cost ERP is feasible, effective, and may represent an opportunity for cost reduction. [Figure presented]
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Objective: Cost-effective postoperative care for endometrial cancer relies on addressing complications and lowering emergency department visits and readmissions. Patients seen in the emergency department but subsequently released without hospital admission present an opportunity for cost savings. Patients seen in safety net hospitals may have less social support, leading to higher emergency department visits and readmissions. We sought to evaluate factors associated with postoperative emergency department visits following surgery for endometrial cancer.
Method(s): All patients undergoing hysterectomy for endometrial cancer by gynecologic oncologists between 2013 and 2016 at both a private and a public hospital were included in the study. Outcomes clinically associated with emergency department visits during the 30- and 60-day postoperative periods were analyzed using comparative and multivariate analyses.
Result(s): Four hundred and twelve patients were included. During the 30-day postoperative period, 38 patients were seen in the emergency department: 19 (4.6%) were readmitted to the hospital (RAH) and 19 (4.6%) patients were treated and released (TAR). During the 60-day postoperative period, 49 patients were seen in the emergency department: 26 (6.3%) were RAH and 23 (5.6%) were TAR. RAH patients had the highest number of phone calls and outpatient visits both 30 and 60 days postoperatively (Table 1). In the 30-day postoperative period, compared to patients who did not present to the emergency department, TAR patients had fewer clinic visits than RAH patients (1.33 +/- 0.03 vs 1.16 +/- 0.12, respectively). Receiving care at a private hospital was associated with decreased rates of TAR visits within 30 days (OR = 0.351, 95% CI 0.129-0.956), adjusting for number of clinic visits, home nursing services at time of discharge, and American Society of Anesthesiologists' classification system.
Conclusion(s): Readmitted patients have the highest number of phone calls and outpatient visits, which may reflect the true acuity of these patients. Patients who were TAR had a lower number of clinic visits within 30 days. These data can aid in care planning as well as cost modeling for payment models in endometrial cancer.
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