The development of noninvasive methods to detect and monitor tumors continues to be a major challenge in oncology. We used digital polymerase chain reaction–based technologies to evaluate the ability of circulating tumor DNA (ctDNA) to detect tumors in 640 patients with various cancer types. We found that ctDNA was detectable in >75% of patients with advanced pancreatic, ovarian, colorectal, bladder, gastroesophageal, breast, melanoma, hepatocellular, and head and neck cancers, but in less than 50% of primary brain, renal, prostate, or thyroid cancers. In patients with localized tumors, ctDNA was detected in 73, 57, 48, and 50% of patients with colorectal cancer, gastroesophageal cancer, pancreatic cancer, and breast adenocarcinoma, respectively. ctDNA was often present in patients without detectable circulating tumor cells, suggesting that these two biomarkers are distinct entities. In a separate panel of 206 patients with metastatic colorectal cancers, we showed that the sensitivity of ctDNA for detection of clinically relevant KRAS gene mutations was 87.2% and its specificity was 99.2%. Finally, we assessed whether ctDNA could provide clues into the mechanisms underlying resistance to epidermal growth factor receptor blockade in 24 patients who objectively responded to therapy but subsequently relapsed. Twenty-three (96%) of these patients developed one or more mutations in genes involved in the mitogen-activated protein kinase pathway. Together, these data suggest that ctDNA is a broadly applicable, sensitive, and specific biomarker that can be used for a variety of clinical and research purposes in patients with multiple different types of cancer.

Papanicolaou (Pap) smears have revolutionized the management of patients with cervical cancers by permitting the detection of early, surgically curable tumors and their precursors. In recent years, the traditional Pap smear has been replaced by a liquid-based method, which allows not only cytologic evaluation but also collection of DNA for detection of human papillomavirus, the causative agent of cervical cancer. We reasoned that this routinely collected DNA could be exploited to detect somatic mutations present in rare tumor cells that accumulate in the cervix once shed from endometrial or ovarian cancers. A panel of genes that are commonly mutated in endometrial and ovarian cancers was assembled with new whole-exome sequencing data from 22 endometrial cancers and previously published data on other tumor types. We used this panel to search for mutations in 24 endometrial and 22 ovarian cancers and identified mutations in all 46 samples. With a sensitive massively parallel sequencing method, we were able to identify the same mutations in the DNA from liquid Pap smear specimens in 100% of endometrial cancers (24 of 24) and in 41% of ovarian cancers (9 of 22). Prompted by these findings, we developed a sequence-based method to query mutations in 12 genes in a single liquid Pap smear specimen without previous knowledge of the tumor’s genotype. When applied to 14 samples selected from the positive cases described above, the expected tumor-specific mutations were identified. These results demonstrate that DNA from most endometrial and a fraction of ovarian cancers can be detected in a standard liquid-based Pap smear specimen obtained during routine pelvic examination. Although improvements need to be made before applying this test in a routine clinical manner, it represents a promising step toward a broadly applicable screening methodology for the early detection of gynecologic malignancies.

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The NCCN Guidelines for Cervical Cancer provide recommendations for diagnostic workup, staging, and treatment of patients with the disease. These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to first- and second-line systemic therapy recommendations for patients with recurrent or metastatic disease, and emerging evidence on a new histopathologic classification system for HPV-related endocervical adenocarcinoma.

This study was conducted to identify clinical factors that are predictive of treatment choice for pelvic organ prolapse. One hundred forty-six women diagnosed with pelvic organ prolapse were educated about their condition and possible treatments before being offered one of three different treatment choices: expectant management (any choice other than pessary or surgery, including pelvic muscle exercises), pessary, or surgery. Data were recorded for all factors that might be predictors of treatment choice, including age (mean, 62 years); weight (mean body mass index, 26.5); vaginal parity (mean, 3.23); history of incontinence and prolapse surgery; pelvic and lower back pain scores; pelvic organ prolapse severity; pain medication use; prior hysterectomy; presence of cystocele, rectocele, enterocele, or uterovaginal-vaginal vault prolapse on examination; and presence of ovaries. Prior surgery included hysterectomy 68.5%, prolapse surgery 32.9%, and incontinence procedures 43.2%. The ovaries were intact in 71% of patients. Approximately 40% of participants reported no lower back or pelvic pain. Lower back and pelvic pain scores, as measured on a scale of 1 to 5 based on facial expressions, were at level 1 for 15% and 18% of participants, and at level 2 for 30% and 21% of participants, respectively. Ten percent of patients reported level 3 pain in both lower back and pelvic area, and lower back and pelvic pain were reported by approximately 5% each in both level 4 and level 5. Cystoceles were diagnosed in 65% of the women, rectoceles in 41%, enteroceles in 55%, and uterovaginal-vaginal vault in 88% of women. Nearly two thirds of the women (65%) were diagnosed with cystocele, 41% and 55% had rectocele and enterocele, respectively, and most (88%) had uterovaginal-vaginal vault prolapse with the leading edge descending a mean 2.2 cm beyond the introitus. Pelvic organ prolapse quantification (POP-Q) system scores were stage I in 4.8% of patients, stage II in 29.7%, stage III in 53%, and stage IV in 2.1% of patients. Overall, expectant management was the treatment choice for 11% of the participants, 19.4% chose pessary, and 69.4% elected to be treated with surgery. Factors that attained a significant influence in the choice of treatment were age (P Ͻ0.001), enterocele (P ϭ 0.004), lower back pain (P ϭ 0.040), pelvic pain (P ϭ 0.022), descent of leading edge of prolapse (P ϭ 0.002), and POP-Q stage (P Ͻ0.001). These factors were used for logistic regression analysis comparing expectant management and pessary with surgery. The chance of a patient choosing expectant management over surgery improved as the pelvic pain score increased (odds ratio [OR], 1.6; P ϭ 0.024), but decreased with greater descension of the leading edge of prolapse (OR, 0.46; P ϭ 0.001). The likelihood of choosing pessary over surgery increased with age (OR, 1.1; P Ͻ0.001) but decreased with increased length of prolapse descension (OR, 0.77; P ϭ 0.0420), and decreased with prior prolapse surgery (OR, 0.23; P ϭ 0.017). A regression model was developed for ...

• Plerixafor can be given safely to WHIM syndrome patients twice daily for a 6-month period and appears promising as a treatment.Warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome is a rare immunodeficiency disorder caused by gain-of-function mutations in the G proteincoupled chemokine receptor CXCR4. The CXCR4 antagonist plerixafor, which is approved by the US Food and Drug Administration (FDA) for stem cell mobilization in cancer and administered for that indication at 0.24 mg/kg, has been shown in short-term (1-to 2-week) phase 1 dose-escalation studies to correct neutropenia and other cytopenias in WHIM syndrome. However, long-term safety and long-term hematologic and clinical efficacy data are lacking. Here we report results from the first long-term clinical trial of plerixafor in any disease, in which 3 adults with WHIM syndrome self-injected 0.01 to 0.02 mg/kg (4% to 8% of the FDA-approved dose) subcutaneously twice daily for 6 months. Circulating leukocytes were durably increased throughout the trial in all patients, and this was associated with fewer infections and improvement in warts in combination with imiquimod; however, immunoglobulin levels and specific vaccine responses were not fully restored. No drug-associated side effects were observed. These results provide preliminary evidence for the safety and clinical efficacy of long-term, low-dose plerixafor in WHIM syndrome and support its continued study as mechanism-based therapy in this disease. The ClinicalTrials.gov identifier for this study is NCT00967785. (Blood. 2014;123(15):2308-2316

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The NCCN Guidelines for Uterine Neoplasms provide recommendations for diagnostic workup, clinical staging, and treatment options for patients with endometrial cancer or uterine sarcoma. These NCCN Guidelines Insights focus on the recent addition of molecular profiling information to aid in accurate diagnosis, classification, and treatment of uterine sarcomas.