Predicting Factors for Pelvic Lymph Node Metastasis in Patients with Apparently Early-Stage Endometrial Cancer

Background:

Performing lymphadenectomy in all patients with early-stage endometrial cancer (EC) is debatable because the procedure may expose patients to unnecessary risks of postoperative complications. Aim of this study was to evaluate the prevalence and risk factors of pelvic lymph node metastasis (PLNM) in patients with apparently early-stage EC.

Materials and methods:

Two hundred and two patients with apparently early-stage EC who underwent surgical staging at Thammasat University Hospital between the years 2013 and 2020 were included in this retrospective study. Clinicopathological data and preoperative laboratory results were obtained from computer-based medical records. All data were statistically analyzed to determine the prevalence of PLNM and risk factors for developing PLNM.

Results:

PLNM was detected in 22 (10.9%) patients. Univariate analysis demonstrated that having grade 3 tumor, myometrial invasion of 50% or greater, vaginal involvement, cervical involvement, adnexal involvement, lower uterine segment involvement, lymphovascular space invasion (LVSI), and positive peritoneal cytology were associated with higher risk for developing PLNM. In addition, lower preoperative hemoglobin level and higher preoperative white blood cell count were significantly associated with PLNM. Multivariate analysis demonstrated that myometrial invasion of 50% or greater and LVSI were independent risk factors for developing PLNM (odds ratio (OR) 9.31, 95% confidence interval (CI) 2.58-33.55, p = 0.001, and OR 3.73, 95%CI 1.39-10.02, p = 0.009, respectively).

Conclusions:

Myometrial invasion of 50% or greater and LVSI were independent risk factors for developing PLNM in patients with apparently early-stage EC and thus lymphadenectomy in these patients should be provided.

Multi-Parametric Magnetic Resonance Imaging-Based Radiomics Analysis of Cervical Cancer for Preoperative Prediction of Lymphovascular Space Invasion

Background

Detection of lymphovascular space invasion (LVSI) in early cervical cancer (CC) is challenging. To date, no standard clinical markers or screening tests have been used to detect LVSI preoperatively. Therefore, non-invasive risk stratification tools are highly desirable.

Objective

To train and validate a multi-parametric magnetic resonance imaging (mpMRI)-based radiomics model to detect LVSI in patients with CC and investigate its potential as a complementary tool to enhance the efficiency of risk assessment strategies.

Materials and Methods

The model was developed from the tumor volume of interest (VOI) of 125 patients with CC. A total of 1037 radiomics features obtained from conventional magnetic resonance imaging (MRI), including a small field-of-view (sFOV) high-resolution (HR)-T2-weighted MRI (T2WI), apparent diffusion coefficient (ADC), T2WI, fat-suppressed (FS)-T2WI, as well as axial and sagittal contrast-enhanced T1-weighted MRI (T1c). We conducted a radiomics-based characterization of each tumor region using pretreatment image data. Feature selection was performed using the least absolute shrinkage and selection operator method on the training set. The predictive performance was compared with single variates (clinical data and single-layer radiomics signatures) analyzed using a receiver operating characteristic (ROC) curve. Three-fold cross-validation performed 20 times was used to evaluate the accuracy of the trained classifiers and the stability of the selected features. The models were validated by using a validation set.

Results

Feature selection extracted the six most important features (3 from sFOV HR-T2WI, 1 T2WI, 1 FS-T2WI, and 1 T1c) for model construction. The mpMRI-combined radiomics model (area under the curve [AUC]: 0.940) reached a significantly higher performance (better than the clinical parameters [AUC: 0.730]), including any single-layer model using sFOV HR-T2WI (AUC: 0.840), T2WI (AUC: 0.770), FS-T2WI (AUC: 0.710), ADC maps (AUC: 0.650), sagittal, and axial T1c values (AUC: 0.710, 0.680) in the validation set.

Conclusion

Biomarkers using multi-parametric radiomics features derived from preoperative MR images could predict LVSI in patients with CC.

Is Adjuvant Chemotherapy Necessary in Patients with Early Endometrial Cancer?

BACKGROUND

We investigated whether there was a difference in prognosis between patients with stage IA endometrial cancer with and without lymphovascular space invasion.

METHODS

We enrolled patients with stage IA (pT1aN0M0) endometrial cancer admitted to our hospital from 2009 to 2018. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and systematic pelvic lymphadenectomy. We immunopathologically evaluated the presence or absence of lymphovascular space invasion in the tumor tissue using hematoxylin and eosin, Elastica-van Gieson, and podoplanin staining. We analyzed disease-free and overall survival and calculated patients' survival distribution using the Kaplan-Meier method and log-rank test. The multivariate analysis was performed to determine the prognostic factors.

RESULTS

A total of 116 patients were included. The median age of the patients was 57 (range, 30-78) years, and the histological subtype revealed 98 and 18 cases of types 1 and 2, respectively. The median follow-up period was 71.9 (range, 10.8-149) months, and the 3-year disease-free and 3-year overall survival rates were 94% and 99%, respectively. The disease-free and overall survival rates were significantly shorter in type 2 patients than in type 1 patients (type 2 vs. type 1; 77% vs. 97%, P < 0.01, 94% vs. 100%, P = 0.014, respectively). The univariate and multivariate analyses showed that there were no significant differences in disease-free survival between the lymphovascular space invasion-positive and -negative groups among type 1 cases.

CONCLUSION

There was no difference in prognosis between patients with stage IA and type 1 endometrial cancer with and without lymphovascular space invasion.

Association of Myometrial Invasion With Lymphovascular Space Invasion, Lymph Node Metastasis, Recurrence, and Overall Survival in Endometrial Cancer: A Meta-Analysis of 79 Studies With 68,870 Patients

Background

Myometrial invasion has been demonstrated to correlate to clinicopathological characteristics and prognosis in endometrial cancer. However, not all the studies have the consistent results and no meta-analysis has investigated the association of myometrial invasion with lymphovascular space invasion (LVSI), lymph node metastasis (LNM), recurrence, and overall survival (OS). Therefore, a meta-analysis was performed to evaluate the relationship between myometrial invasion and clinicopathological characteristics or overall survival in endometrial cancer.

Materials and Methods

A search of Pubmed, Embase, and Web of Science was carried out to collect relevant studies from their inception until June 30, 2021. The quality of each included study was evaluated using Newcastle–Ottawa scale (NOS) scale. Review Manager version 5.4 was employed to conduct the meta-analysis.

Results

A total of 79 articles with 68,870 endometrial cancer patients were eligible including 9 articles for LVSI, 29 articles for LNM, 8 for recurrence, and 37 for OS in this meta-analysis. Myometrial invasion was associated with LVSI (RR 3.07; 95% CI 2.17–4.35; p < 0.00001), lymph node metastasis (LNM) (RR 4.45; 95% CI 3.29–6.01; p < 0.00001), and recurrence (RR 2.06; 95% CI 1.58–2.69; p < 0.00001). Deep myometrial invasion was also significantly related with poor OS via meta-synthesis of HRs in both univariate survival (HR 3.36, 95% CI 2.35–4.79, p < 0.00001) and multivariate survival (HR 2.00, 95% CI 1.59–2.53, p < 0.00001). Funnel plot suggested that there was no significant publication bias in this study.

Conclusion

Deep myometrial invasion correlated to positive LVSI, positive LNM, cancer recurrence, and poor OS for endometrial cancer patients, indicating that myometrial invasion was a useful evaluation criterion to associate with clinical outcomes and prognosis of endometrial cancer since depth of myometrial invasion can be assessed before surgery. The large scale and comprehensive meta-analysis suggested that we should pay more attention to myometrial invasion in clinical practice, and its underlying mechanism also deserves further investigation.

Can Conization Specimens Predict Sentinel Lymph Node Status in Early-Stage Cervical Cancer? A SENTICOL Group Study

Simple Summary

Lymph node involvement is one of the major prognosis factors for early-stage cervical cancer. Improvement in preoperative identification of node-positive patients may lead to a more accurate triage to primary chemoradiation for these patients instead of radical surgery followed by adjuvant radiotherapy, given the increased morbidity of combined treatment. Several studies have well established risk factors for node involvement, but they are based on final pathologic examination of radical hysterectomy specimens and are usually extrapolated for preoperative risk assessment. Among these risk factors, tumor size, lymphovascular space invasion (LVSI) and depth of stromal invasion might be assessed in conization specimens. Our findings suggest that patients with depth of stromal invasion lower than 10 mm and no LVSI in conization specimens had lower risk of micro- and macrometastatic SLN. In this subpopulation, full node dissection may be questionable in case of SLN unilateral detection.

Abstract

Background: The prognosis of patients with cervical cancer is significantly worsened in case of lymph node involvement. The goal of this study was to determine whether pathologic features in conization specimens can predict the sentinel lymph node (SLN) status in early-stage cervical cancer. Methods: An ancillary analysis of two prospective multicentric database on SLN biopsy for cervical cancer (SENTICOL I and II) was carried out. Patients with IA to IB2 2018 FIGO stage, who underwent preoperative conization before SLN biopsy were included. Results: Between January 2005 and July 2012, 161 patients from 25 French centers fulfilled the inclusion criteria. Macrometastases, micrometastases and Isolated tumor cells (ITCs) were found in 4 (2.5%), 6 (3.7%) and 5 (3.1%) patients respectively. Compared to negative SLN patients, patients with micrometastatic and macrometastatic SLN were more likely to have lymphovascular space invasion (LVSI) (60% vs. 29.5%, p = 0.04) and deep stromal invasion (DSI) ≥ 10 mm (50% vs. 17.8%, p = 0.04). Among the 93 patients with DSI < 10 mm and absence of LVSI on conization specimens, three patients (3.2%) had ITCs and only one (1.1%) had micrometastases. Conclusions: Patients with DSI < 10 mm and no LVSI in conization specimens had lower risk of micro- and macrometastatic SLN. In this subpopulation, full node dissection may be questionable in case of SLN unilateral detection.

Impact of cytoreductive surgery on survival of patients with low-grade serous ovarian carcinoma: A multicentric study of Turkish Society of Gynecologic Oncology (TRSGO-OvCa-001)

BACKGROUND AND OBJECTIVES

The aim of this study was to analyze the factors affecting recurrence-free (RFS) and overall survival (OS) rates of women diagnosed with low-grade serous ovarian cancer (LGSOC).

METHODS

Databases from 13 participating centers in Turkey were searched retrospectively for women who had been treated for stage I-IV LGSOC between 1997 and 2018.

RESULTS

Overall 191 eligible women were included. The median age at diagnosis was 49 years (range, 21-84 years). One hundred seventy-five (92%) patients underwent primary cytoreductive surgery. Complete and optimal cytoreduction was achieved in 148 (77.5%) and 33 (17.3%) patients, respectively. The median follow-up period was 44 months (range, 2-208 months). Multivariate analysis showed the presence of endometriosis (p = .012), lymphovascular space invasion (LVSI) (p = .022), any residual disease (p = .023), and the International Federation of Gynecology and Obstetrics (FIGO) stage II-IV disease (p = .045) were negatively correlated with RFS while the only presence of residual disease (p = .002) and FIGO stage II-IV disease (p = .003) significantly decreased OS.

CONCLUSIONS

The maximal surgical effort is warranted for complete cytoreduction as achieving no residual disease is the single most important variable affecting the survival of patients with LGSOC. The prognostic role of LVSI and endometriosis should be evaluated by further studies as both of these parameters significantly affected RFS.

Validation of the FIGO 2018 staging system of cervical cancer: Retrospective analysis of FIGO 2009 stage IB1 cervical cancer with tumor under 2 cm

AIM

The International Federation of Gynecology and Obstetrics (FIGO) revised the cervical cancer staging system in 2018. This study aims to validate the revised staging system in patients with tumors <2 cm in size who were classified as FIGO 2009 stage IB1.

METHODS

We evaluated 62 women with stage IB1 cervical cancer (FIGO 2009) who underwent radical hysterectomy as the initial treatment between November 2004 and August 2018 in our institution. The patients with FIGO 2009 stage IB1 and tumors <2 cm in size were enrolled. We reclassified their stage according to the FIGO 2018 staging system and analyzed their clinicopathological data retrospectively.

RESULTS

Twenty-five patients met the inclusion criteria. According to the FIGO 2018 classification, 9 (36.0%) patients were classified as stage IA, 13 (52.0%) as stage IB1, and 3 (12.0%) as stage IIIC, respectively. One (11.1%), six (46.2%), and three (100%) patients with lymphovascular space invasion were classified as stage IA, IB1, and IIIC, respectively. No significant differences were found in the 5-year overall survival or progression-free survival among the three stages.

CONCLUSIONS

As many as 36.0% of patients classified as FIGO 2009 stage IB1 with a tumor <2 cm in size were classified as stage IA in the FIGO 2018 classification. For these cases, a treatment less invasive than radical hysterectomy or radiotherapy might be sufficient. Our results suggest that cervical cancer patients with tumors <2 cm should be carefully diagnosed by performing cervical conization and assessed the pathological findings before hysterectomy.

Is the extent of lymphadenectomy a prognostic factor in International Federation of Gynecology and Obstetrics stage II endometrioid endometrial cancer?

AIM

This study aimed to evaluate the prognostic significance of adequate lymph node dissection (LND) (≥10 pelvic lymph nodes (LNs) and ≥ 5 paraaortic LNs removed) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrioid endometrial cancer (EEC).

METHODS

A multicenter department database review was performed to identify patients who had been operated and diagnosed with stage II EEC at seven centers in Turkey retrospectively. Demographic, clinicopathological, and survival data were collected and analyzed.

RESULTS

We identified 284 women with stage II EEC. There were 170 (59.9%) patients in the adequate lymph node dissection (LND) group and 114 (40.1%) in the inadequate LND group. The 5-year overall survival (OS) rate of the inadequate LND group was significantly lower than that of the adequate LND group (84.1% vs. 89.1%, respectively; p = 0.028). In multivariate analysis, presence of lymphovascular space invasion (LVSI) (hazard ratio [HR]: 2.39, 95% confidence interval [CI]: 1.23-4.63; p = 0.009), age ≥ 60 (HR: 3.30, 95% CI: 1.65-6.57; p = 0.001], and absence of adjuvant therapy (HR: 2.74, 95% CI: 1.40-5.35; p = 0.003) remained as independent risk factors for decreased 5-year disease-free survival (DFS). Inadequate LND (HR: 2.34, 95% CI: 1.18-4.63; p < 0.001), age ≥ 60 (HR: 2.67, 95% CI: 1.25-5.72; p = 0.011), and absence of adjuvant therapy (HR: 4.95, 95% CI: 2.28-10.73; p < 0.001) were independent prognostic factors for decreased 5-year OS in multivariate analysis.

CONCLUSION

Adequate LND and adjuvant therapy were significant for the improvement of outcomes in FIGO stage II EEC patients. Furthermore, LVSI was associated with worse 5-year DFS rate in stage II EEC.

Risk factors for cervical stromal involvement in endometrioid-type endometrial cancer

OBJECTIVE

The aim of this study was to identify predictors of cervical stromal involvement in women with endometrioid-type endometrial cancer (EEC).

METHODS

A total of 795 patients with EEC who underwent comprehensive surgical staging including pelvic and para-aortic lymph node dissection between January 2007 and December 2018 were retrospectively analyzed. Data including age, menopausal status, serum CA-125 levels, tumor size, lymphovascular space invasion (LVSI), depth of myometrial invasion, positive peritoneal cytology, cervical stromal involvement, histologic grade, recurrence, and follow-up duration were recorded.

RESULTS

Median follow up was 49 months. Cervical stromal invasion was found in 88 patients. Multivariate analysis revealed that presence of LVSI (hazard ratio [HR] 2, 95% confidence interval [CI] 1.02-4.25, P = 0.045), a primary tumor diameter of at least 3 cm (HR 3, 95% CI 1.31-7.25, P = 0.010), and at least 50% deep myometrial invasion (HR 2.7, 95% CI 1.37-5.41, P = 0.004) were independent risk factors for cervical stromal involvement in patients with EEC.

CONCLUSION

Our study results suggest that presence of LVSI, a primary tumor diameter of at least 3 cm, and LVSI of at least 50% seem to be independent predictors of cervical involvement in women with EEC.

Prediction of lymphovascular space invasion in patients with endometrial cancer

Objective: Predict the presence of lymphovascular space invasion (LVSI), using uterine factors such as tumor diameter (TD), grade, and depth of myometrial invasion (MMI). Develop a predictive model that could serve as a marker of LVSI in women with endometrial cancer (EC). Methods: Data from 888 patients with endometrioid EC who were treated between January 2009 and December 2018 were reviewed. The patients' data were retrieved from six institutions. We assessed the differences in the clinicopathological characteristics between patients with and without LVSI. We performed logistic regression analysis to determine which clinicopathological characteristics were the risk factors for positive LVSI status and to estimate the odds ratio (OR) for each covariate. Using the risk factors and OR identified through this process, we created a model that could predict LVSI and analyzed it further using receiver operating characteristic curve analysis. Results: In multivariate logistic regression analysis, tumor size (P = 0.027), percentage of MMI (P < 0.001), and presence of cervical stromal invasion (P = 0.002) were identified as the risk factors for LVSI. Based on the results of multivariate logistic regression analysis, we developed a simplified LVSI prediction model for clinical use. We defined the "LVSI index" as "TD×%MMI×tumor grade×cervical stromal involvement." The area under curve was 0.839 (95% CI= 0.809-0.869; sensitivity, 74.1%; specificity, 80.5%; negative predictive value, 47.3%; positive predictive value, 8.6%; P < 0.001), and the optimal cut-off value was 200. Conclusion: Using the modified risk index of LVSI, it is possible to predict the presence of LVSI in women with endometrioid endometrial cancer. Our prediction model may be an appropriate tool for integration into the clinical decision-making process when assessed either preoperatively or intraoperatively.

Novel T2 Mapping for Evaluating Cervical Cancer Features by Providing Quantitative T2 Maps and Synthetic Morphologic Images: A Preliminary Study

BACKGROUND

The application value of T₂ mapping in evaluating cervical cancer (CC) features remains unclear.

PURPOSE

To investigate the role of T₂ values in evaluating CC classification, grade, and lymphovascular space invasion (LVSI) in comparison to apparent diffusion coefficient (ADC), and to compare synthetic T₂ -weighted (T₂ W) images calculated from T₂ values to conventional T₂ W images for CC staging.

STUDY TYPE

Retrospective.

POPULATION

Sixty-three patients with histopathologically confirmed CC.

FIELD STRENGTH/SEQUENCE

3T, conventional T₂ W turbo spin-echo, diffusion-weighted echo-planar, and accelerated T₂ mapping sequence.

ASSESSMENT

T₂ and ADC values between different pathological features of CC were compared. The diagnostic accuracies of conventional and synthetic T₂ W images in staging were also compared.

STATISTICAL TESTS

Parameters were compared using an independent t-test, Wilcoxon signed-rank test, and the chi-square test. Receiver operating characteristic analysis was performed.

RESULTS

The T₂ values varied significantly between well/moderately differentiated and poorly differentiated tumors ([92.8 ± 9.5 msec] vs. [83.8 ± 9.5 msec], P < 0.05) and between LVSI-positive and LVSI-negative CC ([82.2 ± 8.2 msec] vs. [93.9 ± 9.1 msec], P < 0.05). The ADC values showed a significant difference for grade ([0.76 ± 0.10 × 10^-3 mm² /s] vs. [0.65 ± 0.11 × 10^-3 mm² /s], P < 0.05) and no difference for LVSI status ([0.71 ± 0.11× 10^-3 mm² /s] vs. [0.73 ± 0.12× 10^-3 mm² /s], P = 0.472). There was no significant difference in T₂ and ADC values between squamous cell carcinoma and adenocarcinoma (P = 0.378 and P = 0.661, respectively). In MRI staging, the conventional and synthetic T₂ W images resulted in a similar accuracy (71% vs. 68%, P = 0.698).

DATA CONCLUSION

The accelerated T₂ mapping sequence may facilitate grading and staging of CC by providing quantitative T₂ maps and synthetic T₂ W images in one acquisition. T₂ values may be superior to ADC in predicting LVSI.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 2 J. MAGN. RESON. IMAGING 2020;52:1859-1869.

Incorporation of molecular characteristics into endometrial cancer management

Histopathological evaluation including subtyping and grading is the current cornerstone for endometrial cancer (EC) classification. This provides clinicians with prognostic information and input for further treatment recommendations. Nonetheless, patients with histologically similar ECs may have very different outcomes, notably in patients with high‐grade endometrial carcinomas. For endometrial cancer, four molecular subgroups have undergone extensive studies in recent years: POLE ultramutated (POLEmut), mismatch repair‐deficient (MMRd), p53 mutant (p53abn) and those EC lacking any of these alterations, referred to as NSMP (non‐specific molecular profile). Several large studies confirm the prognostic relevance of these molecular subgroups. However, this ‘histomolecular’ approach has so far not been implemented in clinical routine. The ongoing PORTEC4a trial is the first clinical setting in which the added value of integrating molecular parameters in adjuvant treatment decisions will be determined. For diagnostics, the incorporation of the molecular parameters in EC classification will add a level of objectivity which will yield biologically more homogeneous subclasses. Here we illustrate how the management of individual EC patients may be impacted when applying the molecular EC classification. We describe our current approach to the integrated diagnoses of EC with a focus on scenarios with conflicting morphological and molecular findings. We also address several pitfalls accompanying the diagnostic implementation of molecular EC classification and give practical suggestions for diagnostic scenarios.

Preoperative predictors of pelvic and para-aortic lymph node metastases in cervical cancer

Aim

This study investigated potential preoperative predictors of pelvic lymph node (PLN) and para-aortic LN (PaLN) involvement in cervical cancer (CC).

Materials and Methods

This study retrospectively analyzed 283 patients diagnosed with early (stage IA1-IIA) CC who underwent retroperitoneal LN dissection between January 1992 and February 2015. Several risk factors that are believed to influence PLN and PaLN involvement in CC were analyzed as follows: age >50 years, lymphovascular space invasion (LVSI), tumor size ≥2 cm, hemoglobin <12 g/dL, and nonsquamous cell histologic type.

Results

LVSI (odds ratio [OR] = 11.3, 95% confidence interval [CI] = 5.2-24.3) and tumor size (OR = 3.2, 95% CI = 1.4-7.2) were independent predictors of PLN involvement. None of the factors predicted PaLN involvement in a regression analysis. However, all nine patients who had PaLN involvement also had PLN involvement.

Conclusion

LVSI and tumor size independently increase the risk of PLN involvement.

Lower uterine segment involvement in lymphovascular space invasion and lymph node metastasis in endometrioid endometrial cancer

OBJECTIVES

To evaluate the correlation between lymphovascular space invasion (LVSI) indicating lower uterine segment involvement (LUSI) in endometrioid endometrial cancer and lymph node metastasis based on the lymphatic drainage difference between the uterine corpus and the lower segment.

MATERIAL AND METHODS

Patients who underwent staging surgery for endometrioid endometrial cancer between January 2010 and January 2019 at our institution were reviewed. The clinicopathologic findings and LUSI status of the patients were compared with their LVSI and lymph node metastasis status.

RESULTS

Of the 253 patients included in this study, 49 (19.4%) had LUSI. Among these patients, none of the 31 LVSI-negative patients had metastatic lymph node involvement. However, of the 18 LVSI-positive patients, half had metastatic lymph node involvement; this difference was significant (p < 0.05).

CONCLUSIONS

The significant correlation between LVSI and lymph node metastasis in LUSI-positive cases indicates that pathologists should also focus on LVSI findings in the frozen examination required for the decision of staging surgery in patients with endometrioid endometrial cancer limited to the uterus. This is especially important in patients with a lower uterine segment involvement.

Early-stage endometrial cancer, CTNNB1 mutations, and the relation between lymphovascular space invasion and recurrence

INTRODUCTION

Women diagnosed with early-stage (FIGO 1) endometrial cancer, grade 1 and 2 can have a good prognosis. Most of these women can be treated successfully with a hysterectomy and bilateral salpingo-oophorectomy and without the additional adjuvant treatment that is accompanied by more risks for complications. However, when recurrence does occur, the consequences can be dire. Accurate decisions must therefore be made by surgeons to avoid either under- or over-treatment. Risk and patient stratification for tailoring treatment still need further improvement. Both histopathology and genetic variants could be integrated into the decision process if relevant factors were identified.

MATERIAL AND METHODS

Morphological features and the presence of selected genetic mutations in isolated malignant endometrial epithelial cells from these tumors were analyzed in a strictly defined cohort of FIGO 1, grade 1 and 2 low-risk endometrial cancer. Their presence in this cohort, their relation to recurrence, and the association between histopathological features and mutations were determined. This analysis was performed using archival formalin-fixed paraffin-embedded tissue, complete re-evaluation of histopathological features, laser capture microdissection of epithelial cells, and a polymerase chain reaction-based mutational screening assay.

RESULTS

Twenty-one women with recurrence, after initial identification as low-risk endometrial cancer, were compared with 20 matched control women. The histological marker of lymphovascular invasion was significantly associated with recurrence. There was also a very high prevalence of mutations in CTNNB1 gene, occurring in 50% of this cohort. PTEN mutations were also observed in 27.8% of cases and PIK3CA mutations in 22.2%; none of these mutations were significantly related to recurrence.

CONCLUSIONS

This study supports the importance of lymphovascular space invasion to identify women with significant risk for recurrence in initially low-risk, early-stage endometrial cancer. It also identifies CTNNB1 as a significant mutation in early-stage disease, and although it may not represent a marker for recurrence its high prevalence in early stage disease could have relevance for both pathogenesis and early treatment.

Prognostic value of lymphovascular space invasion in patients with early stage cervical cancer in Jilin, China: A retrospective study

The metastasis of cervical carcinoma is associated with the lymphovascular spread. The primary objective of the present study was to determine the prognostic value of lymphovascular space invasion (LVSI) in patients with early-stage cervical cancer in Jilin, China.In this retrospective cohort study, patients with early-stage cervical cancer (stage IB-IIA) at the Second Hospital of Jilin University from February 2014 to December 2016 were included in the analysis. All included participants underwent radical hysterectomy with pelvic lymphadenectomy. LVSI was identified by hematoxylin and eosin (H&E) staining. The primary outcomes are overall survival (OS) and progression-free survival (PFS). Kaplan-Meier curves were used to calculate the patient's survival. Survival was compared using the log-rank test, while risk factors for the prognosis were assessed by Cox regression analysis.The incidence of LVSI was positively associated with the depth of stromal invasion (P = .009) and lymph node metastasis (LNM, P < .001). LVSI is an independent factor that affects OS (P = .009) and PFS (P = .006) in patients with early stage cervical cancer. LNM status is an independent factor that affects postoperative OS (P = .005).The incidence of lymphatic vessel infiltration is positively associated with the depth of stromal invasion and LNM. LVSI is an independent risk factor for the prognosis of early cervical cancer. The results suggest that further large-scale studies are needed to improve the treatment for patients with LVSI.

Expanded study on the risk of lymphovascular space invasion and lymph node metastasis of endocervical adenocarcinoma using Pattern Classification: a single-centre analysis of 213 cases

A new three-tiered Pattern Classification system for usual-type endocervical adenocarcinomas (U-EACs) recommends using tumour invasive patterns rather than depth of invasion (DOI) and horizontal spread to categorise tumours. Tumours categorised by Pattern Classification are associated with lymph node (LN) metastasis and adverse outcomes. The aim of this study is to further explore the potential of Pattern Classification in surgical pathology practice. A total of 213 consecutive cases [201 U-EACs and 12 gastric-type adenocarcinomas (GACs)] diagnosed between 2006 and 2017 was retrospectively analysed. Clinicopathological data included age at diagnosis, DOI measurement, the status of lymphovascular space invasion (LVSI) and LN metastasis, and the number of LVSI foci, dissected and metastatic LNs. Immunostaining for CD34 and D2-40 was performed to identify LVSI in 14 challenging cases. Overall, mean age at diagnosis was 51 years (range 23-75). LVSI and LN metastasis occurred in 128 (60.1%, 128/213) and 42 (20.5%, 42/205) cases, respectively. Also, 28 (13.1%), 21 (9.9%), and 164 (77.0%) patients had pattern A, B, and C tumours, respectively. Patients with pattern C tumours had the oldest age at diagnosis (p=0.007), the highest incidence of LVSI and LN metastasis, and the highest DOI (p<0.001). Due to a highly heterogeneous growth pattern, pattern C U-EACs were stratified into four subgroups: C1, C2 and C3 corresponded to solid, extensive linear destructive, and band-like lymphocytic infiltrate growth patterns, respectively, and C4 included diffuse destructive, confluent, micropapillary and mixed growth pattern. C2 and C3 subgroup tumours had lower incidence of LVSI (20% and 40%, respectively) than the other two subgroups (p<0.001). None of the patients with C2 and C3 subgroup had LN metastasis and ≥3 LVSI foci. All GACs belonged to pattern C and had deeper stromal invasion (p=0.008), higher incidence of LN metastasis (p=0.001), and larger quantity of LVSI foci (p=0.008) and metastatic LNs (p=0.004) than those of pattern C U-ECAs. Number of LVSI foci were moderately positively correlated with LN metastasis status (p<0.001, γ=0.489) or number of metastatic LNs (p<0.001, γ=0.409). Our study further supports that Pattern Classification is a system easy to follow, which has a strong correlation to LVSI and an effective predictability for LN metastasis. Extensive linear destructive and band-like lymphocytic infiltrate growth patterns in pattern C U-EACs need to be recognised, as they behave less aggressively than that for the other growth pattern subgroups. Our study supports that Pattern Classification can be routinely applied to guide therapies for patients with U-EACs.

Corrigendum: Uterine Adenosarcoma: A Retrospective 12-Year Single-Center Study

[This corrects the article DOI: 10.3389/fonc.2019.00237.].

Reproducibility of lymphovascular space invasion (LVSI) assessment in endometrial cancer

Aims

Lymphovascular space invasion (LVSI) in endometrial cancer (EC) is an important prognostic variable impacting on a patient's individual recurrence risk and adjuvant treatment recommendations. Recent work has shown that grading the extent of LVSI further improves its prognostic strength in patients with stage I endometrioid EC. Despite this, there is little information on the reproducibility of LVSI assessment in EC. Therefore, we designed a study to evaluate interobserver agreement in discriminating true LVSI from LVSI mimics (Phase I) and reproducibility of grading extent of LVSI (Phase II).

Methods and results

Scanned haematoxylin and eosin (H&E) slides of endometrioid EC (EEC) with a predefined possible LVSI focus were hosted on a website and assessed by a panel of six European gynaecological pathologists. In Phase I, 48 H&E slides were included for LVSI assessment and in Phase II, 42 H&E slides for LVSI grading. Each observer was instructed to apply the criteria for LVSI used in daily practice. The degree of agreement was measured using the two‐way absolute agreement average‐measures intraclass correlation coefficient (ICC). Reproducibility of LVSI assessment (ICC = 0.64, P < 0.001) and LVSI grading (ICC = 0.62, P < 0.001) in EEC was substantial among the observers.

Conclusions

Given the good reproducibility of LVSI, this study further supports the important role of LVSI in decision algorithms for adjuvant treatment.

Uterine Adenosarcoma: A Retrospective 12-Year Single-Center Study

Synopsis: Lymphovascular space invasion is an independent risk factor for disease progression and presence of tumor stalk an independent protective factor. Fertility sparing surgery may be acceptable in cases whose tumors present with stalks and without high risk factors.

Objectives: The aim of the present study was to investigate the potential prognostic factors of uterine adenosarcoma.

Methods: A total of 49 cases of uterine adenosarcoma were retrospectively reviewed at our institution between April 2006 and October 2018.

Results: Median follow-up time was 34 months (range: 1–148). Median age was 47.50 years (19–75). Nineteen (38.9%) patients were uterine cervical adenosarcoma and 30 (61.22%) patients were uterine corpus adenosarcoma. Twenty-nine (59.2%) patients were polypoid with a stalk to the uterine cervix or corpus. Twenty-six (38.8%) patients were stage IA. Fifteen (30.6%) patients showed sarcomatous overgrowth. Six (12.2%) patients displayed lymphovascular space invasion (LVSI). Four (8.16%) patients had heterologous elements. In univariate analysis, Disease-free-survival (DFS) was associated with tumor location, presence of tumor stalk, heterologous elements, LVSI. In multivariate analysis, presence of tumor stalk remained an independently protective factor for recurrence (HR = 0.088, P = 0.005), and LVSI a risk factor for recurrence (HR = 11.953, P = 0.002). Fertility-sparing surgery (FSS) was performed in seven stage IA patients. When patients of stage IA analyzed separately, FSS was not significant with the DFS or OS.

Conclusions: Presence of tumor stalk remained an independently protective factor for recurrence. Along with adequate counseling, FSS may be acceptable in cases whose tumors present with stalks and without high risk factors.

The diagnostic performance of ADC value for tumor grade, deep myometrial invasion and lymphovascular space invasion in endometrial cancer: a meta-analysis

BACKGROUND

Disputes exist regarding whether the apparent diffusion coefficient (ADC) can differentiate the tumor grade, deep myometrial invasion and lymphovascular space invasion (LVSI) in endometrial cancer. The aim of this review was to assess the diagnostic performance of the ADC value in endometrial cancer.

MATERIAL AND METHODS

The PubMed, Web of Science, Embase and Cochrane Library databases were searched for studies that used the ADC value to assess tumor grade, deep myometrial invasion and LVSI in endometrial cancer. We used forest plots to analyze the heterogeneity and generate the pooled sensitivity (SEN) and specificity (SPE). We used summary receiver operating characteristic (SROC) curves to work out the area under the SROC curve (AUC). Likelihood ratios (LRs) were also obtained.

RESULTS

Of the 460 identified studies, 11 studies met our inclusion criteria and were included. Overall, nine studies (491 patients) aimed at differentiating high tumor grade had a pooled SEN, SPE and AUC of 77%, 73% and 81%, respectively; three studies (181 patients) for differentiating deep myometrial invasion had a pooled SEN, SPE and AUC of 71%, 67% and 77%, respectively; and two studies (106 patients) for differentiating LVSI had a pooled SEN and SPE of 66% and 74%, respectively. The positive and negative LRs were 2.77 and 0.35 for the tumor grade, 2.08 and 0.45 for deep myometrial invasion, and 2.48 and 0.45 for LVSI.

CONCLUSION

This meta-analysis showed that the ADC value had a moderate diagnostic performance for the tumor grade, deep myometrial invasion and LVSI in endometrial cancer.

Increased risk of poor survival in ovarian cancer patients with high expression of SNAI2 and lymphovascular space invasion

This study is aimed to conduct a meta-analysis to evaluate the prognostic value of lymphovascular space invasion(LVSI) and to explore the potential association of SNAI1 and SNAI2 with LVSI in ovarian cancer. A systematic literature search in PubMed, ISI Web of Science, and Medline was conducted to identify relevant studies assessing the prognostic value of LVSI in ovarian cancer. The main outcomes analyzed were progression free survival/disease free survival and overall survival. TCGA database was used to explore the potential link of SNAI1 and SNAI2 with LVSI status. A total of 11 eligible studies enrolling 1817 patients were included for the meta-analysis. The overall analysis indicated that LVSI presence was associated with shorter duration of survival in ovarian cancer patients. Multivariate analysis indicated that both advanced stage and SNAI2 expression were associated with increased risk of LVSI presence. Survival analysis indicated that tumors with LVSI presence and high SNAI2 expression were significantly correlated with poorer survival when compared to tumors with both LVSI absence and low SNAI2 expression. In conclusion, LVSI presence was associated with worse clinical outcomes in ovarian cancer. Increased expression of SNAI2 and advanced stage were independent risk factors for LVSI presence. Our findings also emphasizes the potential of SNAI2 in promoting lymphovascular spread of ovarian cancer.

Impact of lympho-vascular space invasion on tumor characteristics and survival outcome of women with low-grade serous ovarian carcinoma

BACKGROUND AND OBJECTIVES

To examine association of lympho-vascular space invasion (LVSI) with clinico-pathological factors and to evaluate survival of women with low-grade serous ovarian carcinoma containing areas of LVSI.

METHODS

This is a multicenter retrospective study examining consecutive cases of surgically treated stage I-IV low-grade serous ovarian carcinoma (n = 178). Archived histopathology slides for the ovarian tumors were reviewed, and LVSI was scored as present or absent. LVSI status was correlated to clinico-pathological findings and survival outcome.

RESULTS

LVSI was seen in 79 cases (44.4%, 95% confidence interval [CI] 37.1-51.7). LVSI was associated with increased risk of omental metastasis (87.0% vs 64.9%, odds ratio [OR] 3.62, P = 0.001), high pelvic lymph node ratio (median 12.9% vs 0%, P = 0.012), and malignant ascites (49.3% vs 32.6%, OR 2.01, P = 0.035). On multivariable analysis, controlling for age, stage, and cytoreductive status, presence of LVSI in the ovarian tumor remained an independent predictor for decreased progression-free survival (5-year rates 21.0% vs 35.7%, adjusted-hazard ratio 1.57, 95%CI 1.06-2.34, P = 0.026). LVSI was significantly associated with increased risk of recurrence in lymph nodes (OR 2.62, 95%CI 1.08-6.35, P = 0.047).

CONCLUSION

LVSI in the ovarian tumor is associated with adverse clinico-pathological characteristics and decreased progression-free survival in women with low-grade serous ovarian carcinoma.

Expression of cyclooxygenase-2 in cervical cancer is associated with lymphovascular invasion

Cyclooxygenase-2 (COX-2) is associated with carcinogenesis and tumor progression. The current study analyzed the effect of COX-2 expression in patients with invasive squamous cervical cancer. Tissue samples from 123 cervical cancer patients were collected for a retrospective analysis using immunohistochemistry (IHC) with an antibody against COX-2. The clinical and survival data of the patients were analyzed. Positive staining for COX-2 (defined as an immunoreactivity score of ≥4) was detected in 28 patients (23%), with significantly higher percentages of staining in tumor cells compared with peritumoral stroma cells (P<0.001). COX-2 expression was significantly associated with lymphovascular space invasion (LVSI; P=0.017). The association of COX-2 expression with LVSI suggests a possible effect of COX-2 on tumor progression in cervical cancer. Further studies including larger patient collectives are required in order to perform analyses of clinical subgroups and patient survival.

Lymphovascular space invasion and cervical stromal invasion are independent risk factors for nodal metastasis in endometrioid endometrial cancer

AIMS

The purpose of this study was to investigate the potential roles of pathological variables in the prediction of nodal metastasis in women with endometrioid endometrial cancer (EC).

MATERIALS AND METHODS

Women who underwent surgery for endometrioid EC between 1995 and 2012 were retrospectively reviewed. Those who underwent prior neoadjuvant chemotherapy or radiotherapy and inadequate lymphadenectomy as well as those with nonendometrioid histology, synchronous cancers, International Federation of Gynecology and Obstetrics stage IV disease, gross uterine serosal and/or gross adnexal involvement were excluded. Lymph node dissemination was defined as occurring in the following circumstances: (i) when nodal metastasis with pelvic and/or para-aortic (P/PA) lymph node dissection (LND) was performed or (ii) when there was recurrence in the P/PA lymph nodes after a negative LND or when LND was not performed. Univariate and multivariate logistic regression models were used to identify the pathological predictors of lymphatic dissemination.

RESULTS

A total of 827 women with endometrioid EC were assessed; 516 (62.4%) of whom underwent P/PA LND and 205 (24.8%) underwent P LND. Sixty-seven (13%) women in the P/PA LND group and 5 (2.4%) in the P LND group had positive lymph nodes. Multivariate analysis confirmed cervical stromal invasion (OR 4.04, 95% CI 2.02-8.07 (P < 0.001)) and lymphovascular space invasion (LVSI) (OR 110.18, 95% CI 38.43-315.87 (P < 0.001)) as independent predictors of lymphatic dissemination.

CONCLUSION

Cervical stromal invasion and LVSI are highly associated with LN metastasis. These markers may serve as a surrogate for nodal metastasis.