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Objective: The objective of this study is to evaluate the patterns and outcomes of maintenance bevacizumab for patients with advanced or recurrent cervical cancer. Methods: This is a single-institution retrospective cohort study of patients who received clinical benefit from systemic therapy with bevacizumab from 2010 to 2022. Patients were divided into two cohorts: Cohort A received maintenance bevacizumab following therapy while Cohort B did not. Univariate Cox proportional hazards regression was performed to evaluate factors associated with progression free survival (PFS) and overall survival (OS) including age, stage, histology, hysterectomy, radiation, maintenance bevacizumab, and treatment line. Results: Of 53 patients, 15 patients were in Cohort A while 38 patients were in Cohort B. In Cohort A, 60 % had complete response to initial treatment, while only 34.2 % of Cohort B had complete response (p = 0.22). Of the ten (26.3 %) patients in Cohort B who developed a fistula, all had prior radiation. On univariate analysis, maintenance bevacizumab was associated with improved PFS (p = 0.002), and OS (p = 0.007), and up front treatment (rather than treatment for recurrence) and receipt of prior brachytherapy were associated with OS (p = 0.016 and p = 0.039, respectively). Median PFS with maintenance bevacizumab was 18.7 months vs 9.6 months, (HR 0.32, p = 0.002). Median OS for those receiving maintenance bevacizumab was 39.9 months vs 15.5 months, (HR 0.34, p = 0.007). Conclusions: Maintenance bevacizumab was associated with significantly prolonged PFS and OS in patients with advanced or recurrent cervical cancer who tolerated bevacizumab, but toxicity may preclude the use of maintenance therapy.

To evaluate the efficacy of the combination of pembrolizumab and lenvatinib in MMR deficient (dMMR) endometrial cancer (EC) patients who previously failed to respond to single-agent pembrolizumab. A retrospective review of MMR deficient endometrial cancer patients was performed. Patients who failed to respond to pembrolizumab as a single-agent and subsequently received a combination of pembrolizumab and lenvatinib were analyzed. RECIST 1.1 criteria was used to establish clinical response (complete response, partial response, stable disease, and progression) based on CT and/or PET, comparing imaging before and after the addition of lenvatinib. Radiologic review was conducted by an independent radiologist. Eight patients with dMMR EC meeting treatment criteria were identified. The patients’ ages ranged from 54 to 80 and all tumors identified were of endometrioid histology. Initial pathologic stage ranged from FIGO stage IB to IVB and recurrence confirmed via imaging or tissue biopsy. Patients received a median of 14 cycles of therapy with pembrolizumab and lenvatinib (range 1–39). All patients had decrease in measurable disease with an objective response of 75 % (PR 62.5 %, CR 12.5 %). Both patients who received the initial recommended dose of 20 mg daily required a dose reduction. Based on this retrospective study, patients with dMMR EC without significant benefit from pembrolizumab monotherapy have a significant clinical response after the addition of lenvatinib. Combination therapy should be considered for dMMR EC patients who fail pembrolizumab monotherapy.

Objective(s): To investigate the efficacy and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of iterval debulking surgery (IDS) in women with advanced uterine serous carcinoma (USC) following neoadjuvant chemotherapy (NACT). Methods: An IRB-approved single-institution prospective registry was queried to identify women with incidentally identified USC at the time of IDS + HIPEC for high-grade serous carcinoma. Patient demographic, oncologic, and surgical outcomes data were recorded. Univariate analysis determined progression-free survival (PFS) and overall survival (OS). Results: In total, seven patients were found to have advanced USC after undergoing IDS + HIPEC, with a median age of 64.5 years. The majority had stage IV, (n = 6, 85.7%), MMR proficient (n = 5, 71.4%), p53 mutant (n = 6, 85.1%) USC. The median pre-operative CA125 was 24.0U/mL. HIPEC regimen was cisplatin (n = 3, 42.9%) or cisplatin with paclitaxel (n = 4, 57.1%). All patients underwent optimal cytoreduction, with 71.4% (n = 5) having no gross residual disease. Accordion post-operative complications were mild in 14.3% (n = 1), moderate in 57.1% (n = 4) and severe in 14.3% (n = 1); 14.3% (n = 1) had no complications. The median length of stay was 6.5 days (IQR 4–8 days) with a median time to chemotherapy of 33.0 days. The median PFS was 14.0 months (95% CI 3.5–20.8 months), and the median OS was 27.0 months (95% CI 5.1- not reached). Conclusions: In this small, prospective series, we demonstrate that IDS + HIPEC is well tolerated in patients with USC and is associated with favorable PFS and OS following NACT. Further prospective investigation is needed to validate these promising findings in larger, heterogeneous cohorts of women with advanced USC who are not candidates for primary surgical management.

Objective(s): To investigate the efficacy of pembrolizumab plus lenvatinib as a second-line or later-line therapy in women with advanced or recurrent uterine carcinosarcoma (UCS). Methods: A single-institution pharmacy database was queried for women with advanced or recurrent UCS who were prescribed concurrent pembrolizumab and lenvatinib. Patient demographic, oncologic, and immunotherapy outcomes data were recorded. Univariate analysis summarized progression-free survival (PFS) and overall survival (OS). Results: Seven patients with advanced or recurrent UCS were treated with combination pembrolizumab and lenvatinib, with a median age of 63.0 years. The majority had stage III or IV disease (n = 6, 85.7%) and had failed two or more lines of therapy (n = 7, 100.0%), and a minority were MMR deficient (n = 1, 14.3%) or PD-L1+ (n = 1, 14.3%). No partial or complete responses were observed. The median PFS was 2.6 months (95% CI, 0.9–11.2 months), and the median OS was 2.8 months (95% CI, 2.4-NE). Conclusions: In this small, retrospective series, we demonstrate that pembrolizumab and lenvatinib combination therapy may not be highly active in UCS and may be associated with similar PFS and OS as traditional cytotoxic regimens. Further study is warranted to assess the efficacy of this regimen in more targeted cohorts of women with advanced or recurrent UCS.

Rates of blood transfusion are reported as high as 32% in women undergoing major gynecologic cancer surgery. Therefore, care of the gynecologic oncology patient who refuses blood products, such as Jehovah's witnesses, can pose a unique challenge. The objective of this study was to determine rate of adverse post-operative outcomes within 30 days of surgery in Jehovah's witnesses with gynecologic cancer. This was a retrospective cohort study of Jehovah's witnesses undergoing laparotomy or minimally invasive surgery (MIS) for gynecologic cancer at a single institution. Data for post-adverse complications within 30 days of surgery were recorded. In total, 36 patients were included with a median age of 58.5 years (32–85 years). The majority had endometrial adenocarcinoma (n = 23; 63.9%) or epithelial ovarian, fallopian tube or peritoneal cancer (EOC) (n = 8; 22.2%). 61.1% (n = 22) of patients underwent laparotomy and 38.9% (n = 14) had MIS procedures. 31.8% of laparotomies (n = 7) were terminated prematurely due to surgeon concern for ongoing blood loss. In patients with advanced stage EOC, the rate of suboptimal cytoreduction (>1 cm) was 50%. In the laparotomy cohort, there were four (18.2%) ICU admissions and two (9.1%) mortalities. The time to adjuvant chemotherapy or radiation was 45.5 days (31–64) for laparotomy compared to 35.0 days (12–64) for MIS. While the majority of patients (97.2%) were unwilling to accept packed red blood cells, over one third (38.9%) were agreeable to autologous blood transfusion. Additionally, five (13.9%) patients were accepting of fresh frozen plasma, six (16.7%) patients were agreeable to cryoprecipitate and seven (19.4%) patients were willing to accept platelet transfusions. There is a high rate of postoperative adverse outcomes among Jehovah's witnesses undergoing laparotomy for gynecologic malignancy compared. Acceptance of blood products is low among Jehovah's witnesses, even in the setting of major oncologic surgery.