Uterine papillary serous and clear cell carcinomas predict for poorer survival compared to grade 3 endometrioid corpus cancers

Factors associated with Type I and Type II endometrial cancer

OBJECTIVE

We investigated risk factors for Type II (n = 176) vs. Type I (n = 1,576) endometrial cancer (EC) in cases treated at Magee-Womens Hospital between 1996 and 2008.

METHODS

Clinical data were available from the University of Pittsburgh Medical Center (UPMC) Network Cancer Registry. Logistic regression was used to estimate the adjusted odds of having Type II EC vs. Type I EC. Risk factors of interest in this analysis were age, race, body mass index (BMI), year of diagnosis, parity, menopausal status, and history of additional primary tumors.

RESULTS

Relative to women with Type I EC, women with Type II EC were more likely to be older at diagnosis (OR: 1.03 per 1 year increase in age, 95% CI 1.01-1.05), of non-white race (OR: 2.95, 95% CI 1.66-5.27), have a history of additional primary tumors (OR: 1.56, 95% CI 1.05-2.32), and less likely to be obese (OR: 0.45, 95% CI 0.29-0.70).

CONCLUSION

In this large retrospective cohort of patients with EC, the striking difference in risk factors associated with Type II vs. Type I tumors suggests that these subtypes represent different disease entities that require different treatment modalities. Currently, Type II cases have a significantly worse prognosis compared to Type I. Further characterization of risk factors associated with developing Type II tumors is needed to prevent this aggressive malignancy.

Uterine papillary serous carcinoma: epidemiology, pathogenesis and management

PURPOSE OF REVIEW

Uterine papillary serous carcinoma (UPSC) is a rare but aggressive subtype of endometrial cancer. Although it represents only 10% of all endometrial cancer cases, UPSC accounts for up to 40% of all endometrial cancer-related recurrences and subsequent deaths. The present article reviews the literature concerning the epidemiology, molecular pathogenesis and recent updates on management of UPSC.

RECENT FINDINGS

Women most often present with postmenopausal vaginal bleeding but may also be diagnosed by vaginal cytology. In women diagnosed with metastatic disease, ascites, omental implants or a pelvic mass may be present. Pelvic and extrapelvic recurrences occur frequently, with extrapelvic relapses being observed most commonly. Although few prospective trials exist, several retrospective series have demonstrated that optimal cytoreduction and adjuvant platinum/taxane-based chemotherapy with or without radiotherapy appears to improve survival. In addition, another approach to UPSC management may lie in targeted therapy.

SUMMARY

Women diagnosed with UPSC should undergo comprehensive surgical staging and an attempt at optimal cytoreduction. Platinum/taxane-based adjuvant chemotherapy should be considered in the treatment of both early and advanced-stage patients. Careful long-term surveillance is indicated as many of these women will recur. Prospective studies are needed to define the optimal treatment regimens and to study the role of targeted therapies in UPSC.

Pure papillary serous tumors of the endometrium: a clinicopathological analysis of 61 cases from a single institution

OBJECTIVE

The aim of this study was to evaluate the clinicopathological data and prognosis factors corresponding to patients with papillary serous carcinoma of the endometrium treated at a single institution.

METHODS

Medical and anatomopathological records were reviewed in the Department of Gynecological Oncology of the Canarian University Hospital between 1989 and 2006. Only pure cases of papillary serous carcinoma of the endometrium were included. Survival rates were analyzed using the Kaplan-Meier technique.

RESULTS

The study included 61 patients. Stages I, II, III, and IV were identified in 32.8%, 19.7%, 31.1%, and 8.2% of patients, respectively. Event-free survival rates after 5 and 10 years were 59% and 40%, respectively, with a median time of 83 months (95% confidence interval, 63-110). Relapse occurred in 40.5% of the patients. Overall survival rates after 5 and 10 years were 37.7% and 29%, respectively, with a median time of 55 months (95% confidence interval, 40-70). A univariate analysis showed that prognosis factors were tumor markers, stage, myometrial infiltration, lymphovascular invasion, and ganglia involvement. A multivariate analysis showed that tumor markers, stage, and myometrial infiltration had an independent influence on overall survival.

CONCLUSIONS

Papillary serous carcinoma of the endometrium is a very aggressive type of endometrial carcinoma that behaves more similar to ovarian carcinoma than to endometrial carcinoma. Tumor markers at diagnosis, stage, and myometrial infiltration mainly determine prognosis at our institution.

Overexpression of EpCAM in uterine serous papillary carcinoma: implications for EpCAM-specific immunotherapy with human monoclonal antibody adecatumumab (MT201)

We evaluated the expression of epithelial cell adhesion molecule (EpCAM) and the potential of MT201 (adecatumumab), a human monoclonal antibody against EpCAM, in uterine serous papillary carcinoma (USPC). EpCAM expression was evaluated by real-time PCR and immunohistochemistry in a total of 56 USPC fresh-frozen biopsies and paraffin-embedded tissues. EpCAM surface expression was also evaluated by flow cytometry and immunohistochemistry in six USPC cell lines. Sensitivity to MT201 antibody-dependent cellular cytotoxicity and complement-dependent cytotoxicity was tested against a panel of primary USPC cell lines expressing different levels of EpCAM in standard 5-h (51)Cr release assays. EpCAM transcript was significantly overexpressed in fresh-frozen USPC when compared with normal endometrial cells (NEC). Median (minimum-maximum) copy number was 943.8 (31.5-1568.3) in tumor samples versus 12.9 (1.0-37.0) in NEC (P < 0.001). By immunohistochemistry, EpCAM expression was found in 96% (26 out of 27) of USPC samples with significantly higher expression compared with NECs (P < 0.001). High surface expression of EpCAM was found in 83% (five out of six) of the USPC cell lines tested by flow cytometry. EpCAM-positive cell lines were found highly sensitive to MT201-mediated antibody-dependent cellular cytotoxicity in vitro, whereas primary USPC cell lines were resistant to natural killer cell-dependent cytotoxicity. Human plasma IgG did not significantly inhibit MT201-mediated cytotoxicity against USPC. EpCAM is highly expressed in uterine serous carcinoma at mRNA and protein levels, and primary USPC are highly sensitivity to MT201-mediated cytotoxicity. MT201 might represent a novel therapeutic strategy in patients harboring advanced/recurrent or metastatic USPC refractory to standard treatment modalities.

Changes in microRNA expression levels correlate with clinicopathological features and prognoses in endometrial serous adenocarcinomas

This study aimed to determine the expression profiles of microRNAs (miRNAs) in endometrial serous adenocarcinoma and to examine the association between miRNA expression and clinical outcomes. Twenty-one patients diagnosed with endometrial serous adenocarcinoma between January 2001 and December 2006 were enrolled. miRNA expression profiles were examined using miRNA microarray and qRT-PCR. miRNA expression levels were correlated with clinicopathological variables and survival rates. A total of 120 miRNAs were differentially expressed in endometrial serous adenocarcinoma compared to normal endometria. Of these, 54 miRNAs were down-regulated (>2-fold), including miR-101, miR-10b*, miR-152, and miR-29b, and the remainder were up-regulated (>2-fold), including miR-200a, miR-200b, and miR-205. Decreased expression of miR-10b*, miR-29b, and miR-455-5p was correlated with vascular invasion (P = 0.048, P = 0.013, and P = 0.032, respectively). Univariate analysis revealed that lower expression of miR-101, miR-10b*, miR-139-5p, miR-152, miR-29b, and miR-455-5p was significantly correlated with poor overall survival (P < 0.05), and reduced expression of miR-152, miR-29b, and miR-455-5p was significantly correlated with poor disease-free survival (P < 0.05). Multivariate analysis demonstrated that decreased expression of miR-152 (P = 0.021) was a statistically independent risk factor for overall survival, and decreased expression levels of miR-101 (P = 0.016) and miR-152 (P = 0.010) were statistically independent risk factors for disease-free survival. In addition, transfection of miR-101 or miR-152 precursors into an endometrial serous carcinoma cell line inhibited cell growth (P < 0.0001 and P = 0.01, respectively). Moreover, strong positive immunoreactivity of cyclooxygenase-2 (COX-2) was significantly correlated with down-regulation of miR-101 (P = 0.035). These findings suggest that the dysregulation of miRNAs is associated with the poor prognosis in endometrial serous adenocarcinoma patients.

Molecular pathogenesis of endometrial and ovarian cancer

Pregnancy, breastfeeding, and oral contraceptive pill use interrupt menstrual cycles and reduce endometrial and ovarian cancer risk. This suggests the importance of turnover within Mullerian tissues, where the accumulation of mutations in p53 and PTEN has been correlated with number of cycles. The most common type of endometrial cancer (Type I) is endometrioid and molecular abnormalities include mutations in PTEN, KRAS and β-catenin. The Type I precursor is Endometrial Intraepithelial Neoplasia which displays PTEN defects. Type II endometrial cancer (whose precursors are less clear) includes serous and clear cell tumors and the most common alteration is p53 mutation. For ovarian cancer, histopathologic types parallel endometrial cancer and include serous, mucinous, endometrioid, and clear cell; some molecular features are also shared. The most frequent type of ovarian cancer is high grade serous that often displays p53 mutation and its precursor lesions may originate from normal-appearing fallopian tube epithelium that contains a p53 "signature". Mutations in KRAS, BRAF and PTEN are described in mucinous, endometrioid and low grade serous cancers and these may originate from ovarian cortical inclusion cysts. A consideration of molecular and other pathogenetic features, like epidemiology and histopathology, may provide a better understanding of endometrial and ovarian cancer.

Racial and ethnic variations in the incidence of cancers of the uterine corpus, United States, 2001-2003

OBJECTIVE

We examined racial/ethnic variations in uterine corpus cancer incidence.

METHODS

Data are from state cancer registries meeting quality criteria in the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) programs, 2001-2003. We included females with microscopically confirmed invasive uterine corpus cancer (n = 97,098). We calculated age-adjusted incidence rates per 100,000, stratified by race and ethnicity.

RESULTS

Cancers were most common among women who were 50-64 years old, white and non-Hispanic. Epithelial cancer rates were lower for Asian/Pacific Islanders (API) than whites (12.8 vs. 21.7, p < 0.0001), including serous adenocarcinoma (0.5 vs. 0.9, p < 0.0001). Epithelial cancer rates were also lower for American Indian/Alaska Natives (AIAN) vs. whites (11.5 vs. 21.7, p < 0.0001) and Hispanics vs. non-Hispanics (16.0 vs. 21.3, p < 0.0001). Among all race groups, blacks had the highest rates of mesenchymal (0.9) and mixed cancers (2.0) and of serous adenocarcinoma (2.0), clear cell adenocarcinoma (0.5), and carcinosarcoma (1.9). Blacks also had the lowest rates of low-grade and localized stage epithelial cancer and the highest rates of high-grade and distant stage disease.

CONCLUSIONS

Uterine corpus cancer rates are generally lower for API and AIAN than for whites or blacks and for Hispanics vs. non-Hispanics. Further research is needed to understand reasons for the differences in incidence.

Synuclein-gamma (SNCG) may be a novel prognostic biomarker in uterine papillary serous carcinoma

OBJECTIVES

SNCG in breast cancer is a marker for advanced and aggressive disease thereby correlating with a poor prognosis in patients. We set out to determine if SNCG expression in UPSC correlates with aggressive cellular properties, poor prognosis, and chemoresistance, and if silencing SNCG can reverse these attributes in vitro.

METHODS

A focused, real time PCR array was performed comparing a papillary serous (SPEC2) and an endometrioid (Ishikawa) endometrial cancer cell line. SNCG was the most differentially expressed gene. SNCG expression was confirmed by real time PCR, Western blot, and immunohistochemistry (IHC) and correlated with outcomes in a pilot set of 20 UPSC patients. A stably transfected SPEC2 cell line was created using shSNCG oligonucleotides. The effect of SNCG knockdown in SPEC2 cells on cell proliferation and sensitivity to paclitaxel-induced apoptosis was measured using a cell viability assay, BrdU incorporation assay, as well as cleaved PARP analyses.

RESULTS

SNCG mRNA as well as protein was highly expressed in SPEC2 cells while minimally to undetectable in several endometrioid endometrial cancer and normal endometrial cell lines. IHC also confirmed unique SNCG expression in UPSC tumors compared to low grade endometrial cancers. In UPSC patients, SNCG expression by IHC correlated with advanced stage and decreased progression-free survival. Knockdown of SNCG in SPEC2 cells caused a significant decrease in cell proliferation and increased sensitivity to paclitaxel-induced apoptosis.

CONCLUSIONS

SNCG is a novel biomarker for aggressive disease and chemoresistance in UPSC and merits further investigation both as a prognostic tool and as a therapeutic target.

Meningeal carcinomatosis and uterine carcinoma: three different clinical settings and review of the literature

INTRODUCTION

Leptomeningeal carcinomatosis is a rare metastatic event in gynecological neoplasias, and most cases occur in ovarian cancer. It is extremely infrequent in cervical cancer, and so far, there are not any reports of this complication in association with endometrial cancer.

PATIENTS AND METHODS

We report a case of leptomeningeal carcinomatosis secondary to endometrial carcinoma and 2 complex cervix cancer cases. A MEDLINE search was done to review all published cases of this complication in gynecological cancer to identify predictive factors for this diagnosis.

RESULTS AND DISCUSSION

Leptomeningeal carcinomatosis is usually diagnosed late in the course of the disease, and most reports concern ovarian cancer patients. The number of cases describing this neurologic complication in cervix cancer is increasing. Gadolinium-enhanced magnetic resonance imaging may be necessary for this diagnosis, because cerebrospinal fluid analysis results may be negative. Most cervix cases had squamous cell (8/14) or neuroendocrine histologic subtype (3/14), and when reported, differentiation was usually poor. The case we report of endometrial carcinoma, unique in the literature, is a serous adenocarcinoma.

CONCLUSIONS

A high index of suspicion is necessary, and leptomeningeal carcinomatosis should be considered in patients with unexplained neurologic symptoms whose gynecologic tumors are poorly undifferentiated or have a serous component.

Management of early-stage endometrial cancer

Endometrial cancer is the most common gynecologic malignancy in the United States. The majority of women are diagnosed with early-stage disease. Surgical therapy of early-stage endometrial cancer includes full staging, including pelvic and para-aortic lymphadenectomy. While most women with early-stage endometrial cancer can anticipate cure with surgery alone, a significant minority of women with deeply invasive or high-grade tumors will experience local, regional, or distant recurrences of their disease. Therefore, adjuvant therapies have been proposed for these women. While radiotherapy is effective at reducing the risk of local and regional tumor recurrence, studies have demonstrated no improvement on survival. The role of systemic adjuvant chemotherapies in this high-risk, early-stage patient population is currently the focus of several randomized trials. In addition, for women with early-stage tumors with atypical histology, such as papillary serous and clear cell malignancies, the role of adjuvant therapy remains uncertain. Optimizing management of women with early-stage disease requires a careful assessment of the risk of recurrent disease, the potential benefit of various adjuvant strategies, and the risk associated with adjuvant therapy. New molecular markers may be helpful in the future to refine our ability to identify high-risk, early-stage patients.

FGFR2 as a molecular target in endometrial cancer

Although molecularly targeted therapies have been effective in some cancer types, no targeted therapy is approved for use in endometrial cancer. The recent identification of activating mutations in fibroblast growth factor receptor 2 (FGFR2) in endometrial tumors has generated a new avenue for the development of targeted therapeutic agents. The majority of the mutations identified are identical to germline mutations in FGFR2 and FGFR3 that cause craniosynostosis and hypochondroplasia syndromes and result in both ligand-independent and ligand-dependent receptor activation. Mutations that predominantly occur in the endometrioid subtype of endometrial cancer, are mutually exclusive with KRAS mutation, but occur in the presence of PTEN abrogation. In vitro studies have shown that endometrial cancer cell lines with activating FGFR2 mutations are selectively sensitive to a pan-FGFR inhibitor, PD173074. Several agents with activity against FGFRs are currently in clinical trials. Investigation of these agents in endometrial cancer patients with activating FGFR2 mutations is warranted.

Uterine papillary serous carcinoma: state of the state

Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer that is likely to present with deep myometrial invasion and lymph vascular involvement. By the time most affected women are diagnosed, the UPSC has spread outside the uterus. Because many reports include patients who are not completely staged, the risk of recurrence in stage I patients has likely been overestimated. Recently, several large series of well-staged patients have demonstrated that survival in stage I patients is similar to that of poorly differentiated endometrioid tumors. Because of the high risk of extrauterine spread, all patients with UPSC should have an extended surgical staging procedure, including lymphadenectomy and omentectomy. Chemotherapy with or without local or regional radiation is probably the most effective adjuvant therapy in both early and advanced disease. Because patients with stage I UPSC are still at significant risk of recurrence, adjuvant therapy is often recommended for all patients. It has been difficult to conduct prospective randomized trials for patients with UPSC because of the rare nature of these cancers.

Insights into endometrial serous carcinogenesis and progression

Endometrial serous carcinomas (ESC) constitute only approximately 10% of endometrial cancers, but have a substantially higher case-fatality rate than their more common endometrioid counterparts. The precise composite of factors driving endometrial serous carcinogenesis and progression remain largely unknown, but we attempt to review the current state of knowledge in this report. ESC probably do not evolve through a single pathway, and their underlying molecular events probably occur early in their evolution. TP53 gene mutations occur in 22.7 to 96% of cases, and p53 protein overexpression is seen in approximately 76%. By gene expression profiling, p16 is upregulated in ESC significantly above both normal endometrial cells and endometrioid carcinomas, and 92-100% of cases display diffuse expression of the p16 protein by immunohistochemistry (IHC). Together, these findings suggest dysregulation of both the p16(INKA)/Cyclin D-CDK/pRb-E2F and the ARF-MDM2-p53 cell cycle pathways in ESC. By IHC, HER2/neu is overexpressed (2+ or 3+) in approximately 32.1% of ESC, and approximately 54.5% of cases scored as 2+ or 3+ by IHC display c-erbB2 gene amplification as assessed by fluorescent in situ hybridization. Genetic instability, typically manifested as loss of heterozygosity in multiple chromosomes, is a common feature of ESC, and one study found loss of heterozygosity at 1p32-33 in 63% of cases. A subset of ESC display protein expression patterns that are characteristic of high grade endometrial carcinomas, including loss of the metastasis suppressor CD82 (KAI-1) and epithelial-to-mesenchymal transformation, the latter manifested as E-cadherin downregulation, P-cadherin upregulation, and expression of epithelial-to-mesenchymal transformation-related molecules such as zinc-finger E-box-binding homeobox 1 (ZEB1) and focal adhesion kinase. Preliminary data suggests differential patterns of expression in ESC of some isoforms of claudins, proteases, the tumor invasiveness and progression-associated oncofetal protein insulin-like growth factor II mRNA-binding protein 3 (IMP3), as well as a variety of other molecules. At the morphologic level, evidence that indicates that endometrial glandular dysplasia (EmGD) is the most likely morphologically recognizable precursor lesion to ESC is presented. We advocate use of the term endometrial intraepithelial carcinoma (EIC, or its other appellations) only as a morphologic descriptor and never as a diagnostic/pathologic statement of biologic potential. Given its potential for extrauterine extension, we consider the lesions described as EIC, when present in isolation, as examples of localized ESC, and patients should be managed as such. Morphologically normal, p53 immunoreactive endometrial cells (the so-called "p53 signatures"), show a statistically significant association with ESC, display p53 mutations in a significant subset, and form the start of a progression model, outlined herein, from p53 signatures to EmGD to localized ESC to the more conventionally invasive neoplasm. The identification of a morphologically-recognizable precursor holds the promise of early detection of ESC, with the attendant reduction in its overall associated mortality rate. Deciphering the molecular basis for endometrial serous carcinogenesis should uncover potential targets for diagnosis, therapy, and/or disease surveillance.

Stage II uterine papillary serous carcinoma: Carboplatin/paclitaxel chemotherapy improves recurrence and survival outcomes

OBJECTIVES

To determine recurrence patterns and survival outcomes of stage II uterine papillary serous carcinoma (UPSC) patients treated by various modalities with an emphasis on carboplatin/paclitaxel-based chemotherapy (CT)+/-radiotherapy (RT).

METHODS

A retrospective, multi-institution study of women with stage II UPSC diagnosed from 1992 to 2006 was performed. All patients underwent comprehensive surgical staging. Treatment included observation (OBS), RT (vaginal brachytherapy, whole pelvic and/or whole abdominal therapy), or >or=3 cycles carboplatin/paclitaxel alone or with RT. Recurrence and survival outcomes were determined.

RESULTS

We identified 55 subjects: 10 treated with OBS, 26 with RT alone and 19 with CT+/-RT. After a median follow-up of 33 mos (range, 10-119), 20 recurrences (36%) were observed. There was an overall difference in recurrence based upon treatment (p=.013). Specifically, all CT+/-RT treated patients had a lower risk of recurrence (11%) compared to patients treated by RT alone (50%) or OBS (50%). No patients treated with both CT+RT (n=12) experienced a recurrence. Treatment with CT was also associated with a decreased risk of recurrence on multivariate analysis (p=.015). Most recurrences were extra-pelvic (70%), occurred within 2 years (85%) and were not salvageable (84%). Five-year progression-free survival was 86% in chemotherapy-treated patients versus 41% in those not receiving chemotherapy (p=.010); overall survival was 88% in chemotherapy-treated patients versus 64% in those not receiving chemotherapy (p=.115).

CONCLUSIONS

Stage II UPSC patients have a significant risk for unsalvageable, extra-pelvic recurrence. However, treatment with platinum/taxane therapy+/-RT appears to reduce this risk and is associated with improved progression free survival outcomes.

Non-Endometrioid Adenocarcinoma of the Uterine Corpus: A Review of Selected Histological Subtypes

Background

Understanding the etiology, presentation, evaluation, and management of selected non-endometrioid endometrial adenocarcinomas of the uterine corpus is needed to define optimal treatment regimens.

Methods

The pathology and treatment of selected non-endometrioid endometrial adenocarcinomas of the uterus are reviewed and summarized.

Results

The most common non-endometrioid histology is papillary serous (10%), followed by clear cell (2% to 4%), mucinous (0.6% to 5%), and squamous cell (0.1% to 0.5%). Some non-endometrioid endometrial carcinomas behave more aggressively than the endometrioid cancers such that even women with clinical stage I disease often have extrauterine metastasis at the time of surgical evaluation. Therefore, when technically and medically feasible, comprehensive surgical staging is helpful for women with non-endometrioid endometrial cancer histology. Comprehensive surgical staging includes hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and cytological evaluation of the abdominal cavity. While whole abdominal radiotherapy has a limited role in early-stage uterine papillary serous carcinoma (UPSC) and clear cell carcinoma (CC), there may be a role for postoperative chemotherapy and volume-directed radiotherapy in both early-stage UPSC and CC. In the setting of optimally debulked advanced-stage disease, a combination of radiation and chemotherapy may be indicated. In the setting of recurrent disease or in women with residual disease after surgery, a platinum-based regimen or enrollment in a clinical trial is recommended.

Conclusions

UPSC and CC are managed similarly since sufficient data to separate treatment recommendations are lacking. Because both histologies are associated with a high rate of recurrence, adjuvant therapy is recommended even in women with early-stage disease. The remaining cell types should be treated similar to endometrioid or other low-grade histologies.

Clinical aspects of uterine papillary serous carcinoma

PURPOSE OF REVIEW

We review the demographic and clinicopathologic characteristics, and prognosis of women diagnosed with uterine papillary serous carcinoma, with a focus on clinical management.

RECENT FINDINGS

Pathologic evaluation of postmenopausal bleeding is preferred for patients who fit the profile of a high-risk endometrial cancer such as uterine papillary serous carcinoma. Women diagnosed with endometrial cancer who fit this profile and all women with uterine papillary serous carcinoma should undergo comprehensive surgical staging and aggressive cytoreduction of extrauterine disease. Adjuvant therapy remains controversial. Several recent investigations reported on the potential benefit of adjuvant chemotherapy, with many recommending additional loco-regional radiation.

SUMMARY

Despite the lack of randomized trials on uterine papillary serous carcinoma, several recent reports have provided insight into the diagnosis, surgical management, and adjuvant treatment of this high-risk endometrial cancer.

Trends in demographic and clinical characteristics in women diagnosed with corpus cancer and their potential impact on the increasing number of deaths

OBJECTIVE

The purpose of this study was to determine factors responsible for the increasing number of deaths from corpus cancer over three time periods.

STUDY DESIGN

Data were collected from the Surveillance, Epidemiology and End Results database from 1988-2001. Kaplan-Meier and Cox proportional hazards regression analyses were performed.

RESULTS

Of 48,510 women with corpus cancer, there was an increase in the proportion of patients dying from advanced cancers (52.1% to 56.0% to 68.8%; P < .001), grade 3 disease (47.5% to 53.3% to 60.6%; P < .001), serous tumors (14.3% to 18.4% to 16.6%; P < .001), and sarcomas (19.1% to 20.4% to 27.2%; P < .001) over time. On multivariate analysis, older age, African American race, lack of primary staging procedures, advanced-stage, high-grade, and non-endometrioid histology were independent prognostic factors for worse survival.

CONCLUSION

Our data suggest that the increase in mortality in women with corpus cancer over the last 14 years may be related to an increased rate of advanced-stage cancers and high-risk histologies.

Immunohistochemical detection of hepatocyte nuclear factor 1β in ovarian and endometrial clear-cell adenocarcinomas and nonneoplastic endometrium

Recent studies have noted specific expression of hepatocyte nuclear factor (HNF) 1beta in ovarian clear-cell adenocarcinoma (CCA). In this study, we aimed to determine whether HNF-1beta can be a specific marker of CCA in both the ovary and the endometrium and to assess the pathological significance of HNF-1beta expression in CCAs. We examined HNF-1beta expression immunohistochemically in 186 ovarian carcinomas, including 40 CCAs; 33 endometrial carcinomas, including 5 CCAs; 22 endometria at different stages of the menstrual cycle (5 in the proliferative, 12 in the secretory, and 5 in the menstrual phases); and 7 gestational endometria. The incidence of HNF-1beta immunoreactivity differed significantly between CCAs and other histology in both the ovary (100% in the former versus 2% in the latter) and the endometrium (100% in the former versus 0% in the latter) (P < .0001 each). In nonneoplastic endometrium, 25% or more immunoreactive cells were confined to the mid-to-late secretory phase of the menstrual cycle and gestational endometrium. HNF-1beta would be an excellent marker for distinguishing CCAs from other lesions in both the ovary and the endometrium. HNF-1beta expression seems to be associated with physiopathological cytoplasmic glycogen accumulation in these organs.

Clinicopathologic Analysis of 187 High-grade Endometrial Carcinomas of Different Histologic Subtypes: Similar Outcomes Belie Distinctive Biologic Differences

The clinical and histopathologic features of 187 high-grade endometrial cancers [FIGO grade 3 endometrioid (EC-3), serous (SC), and clear cell (CC)] were studied to determine whether clinicopathologic differences between these various histologic subtypes existed. The study group consisted of 89 EC-3s, 61 SCs, and 37 CCs. Treatment regimens were individualized. SCs and CCs were significantly more likely than EC-3s to occur in patients older than 65 years (P=0.03), and SCs tended to occur more frequently in patients of African descent than EC-3s and CCs (P=0.07), although this was not statistically significant. EC-3s had the highest rate of associated endometrial hyperplasia (P=0.05). SCs were most likely to have high-stage disease at presentation (>or=stage IIB; P=0.01), with peritoneal dissemination at diagnosis being much more common compared with EC-3s and CCs (P=0.004). Median follow-up was 39 months, and median overall survival was 47 months. Five-year survivals were 45% (EC-3), 36% (SC), and 50% (CC)-differences that were not statistically significant. In contrast, the impact of stage on survival was significant (P<0.001). Among all other factors evaluated, only age greater than 65 years was a negative predictor (risk ratio, 2.23; P<0.001), whereas a family history of cancer reduced the risk of death when controlling for stage (risk ratio, 0.54; P=0.005). When controlling for stage, race, reproductive history, personal history of cancer, histologic subtype, depth of myometrial invasion, lymphovascular invasion, presence of an endometrial polyp, presence of hyperplasia, or staging adequacy did not affect prognosis. High-grade endometrial cancers of different histologic subtypes treated in an individualized manner are associated with similar clinical outcomes, but differences in age at presentation, race distribution, association with hyperplasia, stage, and sites of tumor dissemination support the idea that these represent distinct disease entities as defined by traditional histopathologic classification of endometrial cancers.

Accuracy of preoperative endometrial sampling for the detection of high-grade endometrial tumors

OBJECTIVE

This study was undertaken to evaluate the ability of preoperative endometrial sampling to accurately diagnose high-grade endometrial tumors.

STUDY DESIGN

Three hundred sixty endometrial cancer patients had preoperative endometrial sampling and hysterectomy specimens that underwent pathologic review at a single institution from 1995 to 2005. The sensitivity of Pipelle and curettage to diagnose high-grade endometrial tumors (grade 3 endometrioid adenocarcinoma, serous carcinoma, carcinosarcoma, clear cell carcinoma) was determined. Agreement between preoperative and hysterectomy diagnoses was measured by the Kappa statistic.

RESULTS

Sensitivity of Pipelle and curettage was 93.8% and 97% in patients with low-grade cancer and 99.2% and 100% in patients with high-grade cancer. Good agreement was observed between the preoperative and the hysterectomy histologic diagnoses (Kappa = 0.69), and between the preoperative and hysterectomy tumor grade (Kappa=0.78).

CONCLUSION

Preoperative endometrial sampling with Pipelle or curettage is sensitive and accurate for the diagnosis of high-grade endometrial tumors, including tumors with nonendometrioid histology.

Chemotherapy for high-risk early-stage endometrial cancer

PURPOSE OF REVIEW

To discuss the usefulness of chemotherapy in high-risk early-stage endometrial cancer and the best chemotherapy regimen.

RECENT FINDINGS

External radiation therapy has been successfully used to prevent local recurrence; however, it does not improve the overall survival and it increases the incidence of late toxicity. A recent randomized study revealed that adjuvant platinum-based combination chemotherapy might be a suitable alternative to radiotherapy for high-risk early-stage endometrial cancer. The optimal regimen is still in question because combinations of doxorubicin-cisplatin and paclitaxel-doxorubicin-cisplatin cause significant toxicity. The combination of paclitaxel-carboplatin may be better than doxorubicin-cisplatin with regard to toxicities.

SUMMARY

Radiation treatment following surgery has been the standard adjuvant therapy for endometrial cancer for a long time. Radiotherapy decreases the local recurrence rates; however, a significant impact on the overall survival has not been demonstrated. The usefulness of adjuvant chemotherapy has been demonstrated by only a little evidence. Nonetheless, we are encouraged by a recent randomized study. In light of the excellent outcomes associated with early-stage endometrial cancer, it is important to conduct another large randomized trial based on standardization of high-risk criteria to evaluate the efficacy of adjuvant chemotherapy.

Preoperative serum YKL-40 is a marker for detection and prognosis of endometrial cancer

OBJECTIVE

YKL-40 is a secreted glycoprotein of the chitinase family that has been previously described as a diagnostic and prognostic marker for a number of cancers, including epithelial ovarian cancer. In this study, we examined the frequency of serum elevation as well as the diagnostic and prognostic significance of this serum marker in endometrial cancer.

MATERIALS AND METHODS

Preoperative serum levels of YKL-40 and CA125 were evaluated by enzyme-linked immunosorbent assay (ELISA) for all endometrial cancer patient samples (34) available in the Memorial Sloan-Kettering Cancer Center Gynecology Service Tissue Bank between the years 1987 and 2002, and compared to a cohort of normal individuals. A YKL-40 value of 61 ng/mL has previously been determined to represent the upper limit of normal. YKL-40 values were correlated with clinical characteristics, including patient age, tumor grade, histology, clinical stage, and clinical outcome (progression-free survival [PFS] and overall survival [OS]).

RESULTS

YKL-40 was elevated (>61 ng/mL) in 26 (76%) of 34 endometrial cancer patients compared with elevations of CA125 in 21 (62%) of 34 patients (P=0.09). Twenty-eight (82%) of all 34 patients had elevations of either CA125 or YKL-40 or both; 16 (89%) of 18 advanced-stage endometrial cancer patients had elevation of at least one of these two markers. Median preoperative YKL-40 value was 137 ng/mL (range, 22-1738 ng/mL) for endometrial cancer patients compared with 28 ng/mL (range, 15-72 ng/mL) for normal healthy subjects (P<0.0001). There was no statistically significant association of YKL-40 with patient age, tumor grade, histology, or stage. Elevation of YKL-40 (>80 ng/mL) was correlated with poor clinical outcome in univariate analysis, but was not demonstrated in multivariate analysis. At 5 years' follow-up, the PFS rate was 80% for patients with YKL-40<80 ng/mL compared with 43% for patients with YKL-40>80 ng/mL (P=0.004). The 5-year OS rate for patients with YKL-40<80 ng/mL was 79% compared with 48% for patients with YKL-40>80 ng/mL (P=0.047).

CONCLUSION

Preoperative serum YKL-40 is frequently elevated and may represent a novel marker for the detection of endometrial cancer and the identification of high-risk subsets of patients with worse clinical outcome. Further investigation of this promising endometrial cancer marker in larger studies is warranted.