Germline and somatic mutations in homologous recombination genes predict platinum response in ovarian, fallopian tube, and peritoneal carcinomas

Abstracts / Gynecologic Oncology 125 (2012) S3–S167

5 Thirty-four successful cases of pregnancy following fertility-preserving hormonal therapy for endometrial cancer W. Yamagami1, N. Susumu1, Y. Ichikawa2, F. Kataoka1, A. Hirasawa1, A. Suzuki1, K. Banno1, H. Tsuda1, D. Aoki1. 1School of Medicine, Keio University, Tokyo, Japan, 2Shizuoka Red Cross Hospital, Shizuoka, Japan. Objective: In Japan, there has been an increase in relatively younger patients of reproductive age who desire fertility preservation in the treatment of endometrial cancer. Hormonal therapy using high-dose medroxyprogesterone acetate (MPA) for younger patients with endometrial cancer is currently offered to such patients. However, there have been few reports about the course and prognosis of successful pregnant cases following hormonal therapy. We aimed to clarify the outcomes of pregnancies following hormonal therapy in our hospital. Methods: We reviewed 155 patients with atypical endometrial hyperplasia (55 patients), endometrioid adenocarcinoma G1 (96 patients), and G2 (4 patients) who were presumed to have neither myometrial invasion nor metastases and who were treated with high-dose MPA therapy at Keio University Hospital and Shizuoka Red Cross Hospital. After 4 months oral administration of MPA 600 mg/ day, D&C was performed. When residual disease existed with no evidence of myometrial invasion or metastases, an additional 2 months of oral administration and D&C were repeated. After tumor disappearance, patients were allowed to attempt pregnancy. We evaluated 34 patients who experienced pregnancy following tumor disappearance with hormonal therapy. Results: The median age of patients at initial treatment was 34 years old (range 19–39) and at initial pregnancy was 35 years old (range 22–41), respectively. The median period needed for tumor disappearance was 91 days (range 23–453). High-dose MPA therapy was performed once, twice, 3 times, and 4 times before pregnancy in 21 cases, 10 cases, 2 cases, and 1 case, respectively. The total number of pregnancies was 42 times; delivery outcomes were 19 normal deliveries, 11 caesarean sections, 2 premature deliveries, 5 spontaneous abortions, 2 induced abortions, 1 unknown, and 2 during pregnancies. We experienced 3 cases (7%) of placenta accreta among serious delivery complications. 8 patients (24%) have relapsed following delivery. The relapse free rate was 27% at 5 years in adenocarcinoma cases after delivery (Kaplan–Meier method). Conclusions: Our study found that placenta accreta occurs with higher incidence at delivery following hormonal therapy and, thus, requires careful clinical observation. Our results also found a high relapse rate following delivery; we. thus, recommend hysterectomy for patients if there is no strong desire for fertility preservation following a successful pregnancy. doi:10.1016/j.ygyno.2011.12.006

6 The impact of chemotherapy and fertility-sparing surgery on recurrence of serous borderline ovarian tumors: A multi-institutional study of 491 patients R. Brooks1, T. Ghezelayagh2, T. Kiet1, K. Fuh1, S. Ueda1, T. Longacre3, N. Teng3, L. Chen1, J. Chan1. 1UCSF Comprehensive Cancer Center, San Francisco, CA, 2University of California San Francisco, San Francisco, CA, 3Stanford University Medical Center, Stanford, CA. Objective: The benefit of chemotherapy in advanced disease and risk of fertility-sparing surgery (FSS) in younger women with borderline ovarian cancer remains controversial. We proposed to examine the role of chemotherapy and FSS in this multi-institutional study.

S5

Methods: Data was extracted and analyzed for patients treated for serous ovarian borderline tumors at 2 large academic medical centers from 1992 to 2011. Kaplan Meier and Cox regression methods were used for statistical analyses. Results: Follow-up patients were included, and median follow-up was 4.5 years (range 0.2–21.4). Median patient age was 41 (12–89). Early stage (I–II) disease was found in 339 (72%), while 131 (28%) had late stage (III-IV) disease. Desmoplastic implants were identified in 179 cases and were invasive in 18. Of 220 patients who underwent lymphadenectomy, nodal involvement was identified in 136 patients and was not associated with recurrence (p = 0.38). Adjuvant chemotherapy was administered to 71 patients (15%), was more commonly given to patients with advanced stage, implants, and micropapillary features (p b 0.02), but was not associated with improved survival. Only 2 patients received adjuvant hormonal therapy. The overall median 5-year survival rate was 96%, and 78 patients (16%) developed recurrence. Younger age, later stage, and micropapillary features were significantly associated with recurrence in univariate analysis only. Additionally, on multivariate analysis, the presence of implants (HR 2.1, p = 0.009) and FSS (HR 3.4, p b 0.001) were independent predictors for recurrence. In a subset analysis of 106 younger patients (22%) who underwent FSS, there was a higher risk of recurrence (35% vs 15%, p b 0.001) though without any difference in overall survival (p = 0.40), and at least 7 healthy infants were delivered. Conclusions: In this large detailed series of serous borderline tumors with long median follow-up, we identified increased recurrence in patients who underwent fertility-sparing surgery, but interestingly, not in patients with lymph node involvement. Further work is needed to clarify the ideal management of the often young women who suffer from this disease.

doi:10.1016/j.ygyno.2011.12.007

Education Forum III: Critical Pathways in Gynecologic Cancers Saturday, March, 24, 2012, 4:00 p.m.–5:23 p.m. Ballroom D (Austin Convention Center) Moderator, Abstracts: 7–13: Leslie M. Randall, MD, UC Irvine Medical Center, Orange, CA 7 Germline and somatic mutations in homologous recombination genes predict platinum response in ovarian, fallopian tube, and peritoneal carcinomas K. Pennington, T. Walsh, S. Casadei, M. Lee, C. Pennil, A. Thornton, K. Agnew, R. Garcia, M. King, E. Swisher. University of Washington Medical Center, Seattle, WA. Objective: Homologous recombination (HR) DNA repair impacts response to chemotherapy, and cells that are defective in HR demonstrate increased sensitivity to platinum agents and to polyADP-ribose polymerase inhibitors (PARPi). Germline mutations in BRCA1 and BRCA2 and other genes in the HR pathway can increase the risk of breast and ovarian cancer and influence response to therapy. Somatic mutations also occur in HR genes in ovarian cancers, and their influence on therapeutic response has not been characterized. We sought to determine the rate of both germline and somatic mutations in multiple HR genes and correlate the presence of loss-offunction mutations with response to platinum-based chemotherapy. Methods: Neoplastic and germline DNA from 210 cases of ovarian, fallopian tube, or peritoneal carcinoma was evaluated by targeted

S6

Abstracts / Gynecologic Oncology 125 (2012) S3–S167

capture and massively parallel genomic sequencing for germline and somatic mutations in 30 tumor suppressor genes. Cases referred for genetic risk were excluded. All suspected deleterious mutations were verified with Sanger sequencing and only clear loss-of-function mutations were included. Statistical analysis was performed using the Fisher's exact test and the methods of Kaplan and Meier. Results: Twenty-seven percent of cases were found to have a deleterious germline (13.3%) or somatic (13.8%) mutation in 1 of the following genes involved in the HR DNA repair pathway: BRCA1, BRCA2, BARD1, BRIP1, PTEN, MRE11A, PALB2, RAD50, RAD51C, CHEK2, and NBN. Having a germline or somatic mutation was predictive of primary platinum sensitivity (p = 0.02), with 86% of mutant but only 46% of wild-type cases showing platinum sensitivity. Somatic and germline mutations predicted initial platinum response equally well, though germline mutation carriers had longer overall survival (median overall survival 66 months in germline carriers, 54 months in cases with somatic mutations, and 47 months in wild-type cases). Conclusions: Either a somatic or germline mutation in a HR gene was predictive of primary platinum sensitivity, but germline mutations appear to have a more profound effect on overall survival than somatic mutations. Massively parallel sequencing allows sensitive mutation detection at low cost in many target genes. Targeting HR genes for mutation detection might predict who would be more likely to benefit from combining a PARPi with primary chemotherapy. We will present an expanded set of cases at the annual meeting. doi:10.1016/j.ygyno.2011.12.008

8 Identification of NBS1 as a novel prognostic biomarker in BRCAness ovarian cancer Y. Lee, N. Park, H. Chung, J. Kim, Y. Song, S. Kang, H. Lee. Seoul National University, Seoul, Republic of Korea. Objective: Epithelial ovarian cancers (EOC) are highly lethal gynecological malignancies that are resistant to chemotherapy. For this reason, prognostic markers for recurrence and tumor progression after standard treatment and new targeted therapy are crucial to overcome the diseases. Since EOC frequently present with genetic instability, BRCAness genes associated with DNA damage repair could play key roles in aggravating EOC. Thus, this study aimed to assess the clinicopathological significance of key factors of BRCAness genes in EOC. Methods: The current study included EOC cell lines and paraffinembedded tissue sections from 140 EOC patients treated with optimal debulking surgery followed by platinum-based chemotherapy. Cancer cell lines and patients' tissues were used to analyze clinicopathological impacts of BRCAness genes, including BRCA1, BRCA2, BARD1, ATM, RAD51, and NBS1, using western blot analysis, immunofluorescence, and quantitative real-time RT PCR. Immunohistochemical expression of selected BRCAness gene, NBS1, was tested for an association with normalized mRNA level and clinicopathological parameters and survival analysis. Results: BRCAness genes, including BRCA1, BRCA2, BARD1, ATM, RAD51, and NBS1, play important roles in the DNA damage repair pathway, and variable expressions of mRNA and protein were found in EOC. Among them, BRCA1, ATM, and NBS1 were related to aggressive parameters in EOC. In addition, only NBS1 was associated with recurrence. In validation, NBS1 IHC scores were correlated with mRNA expression. Increased NBS1 expression was found in 107 among 140 cases (76.0%), and correlated with advanced stage (p = 0.001), high grade (p = 0.001), and serous histology (p = 0.008). The median recurrence-free survival in patients with positive and negative expression of NBS1 was 30 and 78 months, respectively (p = 0.0068).

In multivariate analysis, NBS1 was an independent prognostic factor for recurrence of EOC. Conclusions: NBS1 is the most powerful prognostic marker among BRCAness genes for recurrence-free survival rates in EOC and is associated with aggressive clinicopathological parameters. doi:10.1016/j.ygyno.2011.12.009

9 Loss of function germline mutations in RAD51D are present in 1% of unselected women with ovarian carcinoma A. Wickramanayake, C. Pennil, T. Walsh, S. Casadei, K. Pennington, K. Agnew, R. Garcia, E. Swisher. University of Washington Medical Center, Seattle, WA. Objective: RAD51D is a gene in the Fanconi anemia–BRCA pathway that regulates homologous recombination DNA repair that was recently identified as a gene involved in hereditary ovarian cancer by evaluating families with multiple members with breast and ovarian cancer. The total contribution of RAD51D to unselected ovarian cancer is not known. Methods: Germline DNA from 360 unselected women with ovarian (n = 281), primary peritoneal (n = 48), and fallopian tube (n = 31) carcinomas were sequenced across all 10 coding exons and intronexon boundaries of RAD51D using PCR and standard Sanger sequencing. All women had previously been evaluated for germline mutations in 21 tumor suppressor genes, including BRCA1 and BRCA2, using targeted capture and massively parallel sequencing in a test we call BROCA. Results: Three women (0.8%) had clear loss of function mutations in RAD51D, including 1 nonsense and 2 frameshift mutations. All 3 had grade 3 ovarian carcinomas, and accounted for 1.1% of the ovarian primaries. These women were ages 33, 43, and 75 at diagnosis; 2 had no family history of breast or ovarian cancer, and 1 had a paternal aunt with early-onset ovarian cancer. All 2 were previously wildtype for BRCA1, BRCA2, the Lynch syndrome genes, and the other known breast and ovarian cancer genes included on BROCA. Three additional women had missense mutations that were not present in 2690 European American or 2700 African American control alleles on the exome variant server (http://snp.gs.washington.edu/EVS/). Adding the RAD51D carriers to previously identified loss of function mutations in these cases brings the total number of genes mutated to 13 and the total proportion of women with a deleterious mutation to 23.6%, including 17.5% in BRCA1 or BRCA2 and 6.1% in other genes. Conclusions: RAD51D loss of function mutations account for a small but significant proportion of hereditary ovarian cancer and can be identified in women with no family history of breast or ovarian cancer. Ovarian cancers in women with RAD51D mutations are predicted to be defective in homologous recombination and more susceptible to Poly-ADP-ribose polymerase inhibitors (PARPi). Comprehensive and cost-effective evaluation for hereditary ovarian cancer risk and for identification of women for PARPi therapy can be done using targeted capture and massively parallel sequencing. We have added RAD51D and several other candidate genes to the new version of BROCA. doi:10.1016/j.ygyno.2011.12.010

10 PI3K/AKT pathway alterations in paired primary and recurrent endometrial carcinoma S. Wethington1, K. Garg1, V. Makker1, N. Olvera1, F. Dao2, F. Bogomolniy1, M. Cesari1, R. Soslow1, D. Levine1. 1Memorial Sloan-