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Xing Y, Sun X, Li F, Jiang X, Jiang A, Li X, Lv R, Shao L. Long non-coding RNA (lncRNA) HOXB-AS3 promotes cell proliferation and inhibits apoptosis by regulating ADAM9 expression through targeting miR-498-5p in endometrial carcinoma. J Int Med Res 2021; 49:3000605211013548. [PMID: 34187214 PMCID: PMC8258772 DOI: 10.1177/03000605211013548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective Long non-coding RNA (lncRNA) expression is closely related to the pathogenesis and progression of various tumors. In this study, we investigated the mechanisms of lncRNA HOXB cluster antisense RNA 3 (HOXB-AS3), miRNA(miR)-498-5p, and disintegrin and metalloproteinase domain-containing protein 9 (ADAM9) in endometrial carcinoma (EC) cells. Methods The expression levels of lncRNA HOXB-AS3 in EC tissues and cells were detected using RT-qPCR assays. The effects of HOXB-AS3 knockdown on EC cell proliferation and apoptosis were measured using CCK-8 assays, colony formation assays, and flow cytometry. In addition, putative miR-498-5p binding sites were identified in HOXB-AS3 and ADAM9. The targeted relationships were further verified using dual-luciferase reporter and RNA pull-down assays. Results HOXB-AS3 expression was upregulated in EC tissues and cells. EC cell proliferation and viability decreased significantly in HOXB-AS3 knockdown groups. A putative miR-498-5p binding site in HOXB-AS3 was verified. Inhibition of miR-498-5p rescued the effects of HOXB-AS3 knockdown on cell proliferation and apoptosis. Finally, ADAM9 was verified as a direct target gene of miR-498-5p. Conclusions Our results suggest that lncRNA HOXB-AS3 is highly expressed in EC tissues and cells. Downregulation of HOXB-AS3 inhibits cell proliferation and promotes apoptosis in EC cells. HOXB-AS3 can upregulate ADAM9 expression by sponging miR-498-5p.
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Affiliation(s)
- Ying Xing
- Department of General Medicine, Wulidun Neighborhood Community Health Service Center Affiliated with the Fifth Hospital of Wuhan, Wuhan, Hubei, China
| | - Xianhua Sun
- Department of General Medicine, Wulidun Neighborhood Community Health Service Center Affiliated with the Fifth Hospital of Wuhan, Wuhan, Hubei, China
| | - Feng Li
- Department of Infectious Disease, Red Cross Society Hospital of Wuhan (Wuhan No.11 Hospital), Wuhan, Hubei, China
| | - Xuan Jiang
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, Qingdao women and children's Hospital, Qingdao, Shandong, China
| | - Afang Jiang
- Department of Hematology-oncology and Nephrology, Changyi People's Hospital, Shandong, China
| | - Xiaofan Li
- Department of Infectious Disease, Red Cross Society Hospital of Wuhan (Wuhan No.11 Hospital), Wuhan, Hubei, China
| | - Ruiting Lv
- Department of Ophthalmology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liwei Shao
- Department of Ophthalmology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Åkesson Å, Wolmesjö N, Adok C, Milsom I, Dahm-Kähler P. Lymphadenectomy, obesity and open surgery are associated with surgical complications in endometrial cancer. Eur J Surg Oncol 2021; 47:2907-2914. [PMID: 34238643 DOI: 10.1016/j.ejso.2021.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/08/2021] [Accepted: 06/29/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To investigate surgical complications related to the staging procedure for endometrial cancer (EC) and to explore complication associations towards patient characteristics and survival. METHODS A population-based cohort study of women diagnosed with EC where primary surgery was performed at a tertiary centre between 2012 and 2016. The Swedish Quality Registry for Gynecological Cancer was used for identification, medical records reviewed and surgical outcomes, including complications according to Clavien-Dindo (CD), and comorbidity (Charlson's index) registered. Uni- and multivariable logistic regression analyses were performed with complications as outcome and multivariable Cox regression analysis with overall survival (OS) as endpoint. RESULTS In total 549 women were identified where 108 (19.7%) had CD grade II-V complications. In the multivariable regression analysis; surgical technique, BMI and lymph node dissection, but not comorbidity or age, were found to be risk factors for complications CD grade II-V, with OR of 0.32 (95%CI:0.18-0.56) for minimalinvasive surgery (MIS) compared to open, OR 2.18 (95%CI:1.37-3.49) for BMI ≥30 and OR 2.63 (95%CI:1.32-5.31) for pelvic and paraaortic lymphnode dissection. In Cox regression analysis, a significant lower OS was found within the first 1.5 years for the cohort of complications (CD II-V) compared to no complications. CONCLUSION Surgical staging with lymphadenectomy was found a risk factor for complications together with high BMI in EC. Using MIS was significantly associated with less complications. Overall survival was found to be negatively affected within the first years after complications. Our results may be taken into consideration when performing updated treatment guidelines including surgical staging.
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Affiliation(s)
- Åsa Åkesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Nina Wolmesjö
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Claudia Adok
- Regional Cancer Center Western Sweden, Gothenburg, Sweden.
| | - Ian Milsom
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
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Yi T, Song Y, Zuo L, Wang S, Miao J. LINC00470 Stimulates Methylation of PTEN to Facilitate the Progression of Endometrial Cancer by Recruiting DNMT3a Through MYC. Front Oncol 2021; 11:646217. [PMID: 34249684 PMCID: PMC8267821 DOI: 10.3389/fonc.2021.646217] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Increasing researches emphasize the importance of long non-coding RNAs (lncRNAs) in the development of endometrial cancer (EC). There is wide recognition that LINC00470 is a critical participant in the tumorigenesis of cancers such as gastric cancer and glioblastoma, but its possible effects on EC progression remain to be explored. METHODS We collected EC tissues and cells, where the expression of LINC00470 was determined, and followed by the Kaplan-Meier analysis of EC patient survival. We next examined the effect of LINC00470 and phosphatase and tensin homolog (PTEN) on EC cell migration, invasion, tube formation in vitro, and angiogenesis in mice xenografted with tumor after gain- or loss-of-function treatments. RNA pull-down, Co-IP, and ChIP experiments were performed to analyze the targeting relationships among LINC00470, MYC and DNMT3a. RESULTS LINC00470 was aberrantly upregulated in EC and its high expression correlated to prognosis of EC patients. LINC00470 promoted invasiveness, migration, and angiogenesis of EC cells, and facilitated tumorigenesis and metastasis in vivo, but those effects were reversed by up-regulating PTEN. Functionally, LINC00470 bound to MYC in EC and that LINC00470 stimulated the binding of MYC to DNMT3a, and thus recruited DNMT3a through MYC to promote PTEN methylation. CONCLUSIONS Our findings revealed that LINC00470 stimulated PTEN methylation to inhibit its expression by MYC-induced recruitment of DNMT3a, thus aggravating EC.
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Affiliation(s)
- Tiezhong Yi
- Department of Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yicun Song
- Department of Pathology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lingling Zuo
- Department of Obstetrics and Gynecology, Heilongjiang Provincial Hospital, Harbin, China
| | - Siyun Wang
- Department of Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jintian Miao
- Department of Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Bednarikova M, Vinklerova P, Gottwaldova J, Ovesna P, Hausnerova J, Minar L, Felsinger M, Valik D, Cermakova Z, Weinberger V. The Clinical Significance of DJ1 and L1CAM Serum Level Monitoring in Patients with Endometrial Cancer. J Clin Med 2021; 10:jcm10122640. [PMID: 34203959 PMCID: PMC8232635 DOI: 10.3390/jcm10122640] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022] Open
Abstract
Circulating tumor markers are not routinely used in patients with endometrial cancer (EC). This pilot study evaluated the role of monitoring new biomarkers DJ1 and L1CAM, in correlation with CA125 and HE4, for the effects of anticancer treatment and preoperative management in EC patients. Serial serum levels of DJ1, L1CAM, CA125 and HE4 were collected in 65 enrolled patients. Serum DJ1, L1CAM, CA125 and HE4 levels were significantly higher at the time of diagnosis compared to those measured during follow-up (FU). In patients with recurrent disease, serum DJ1, CA125 and HE4 levels were significantly higher at the time of recurrence compared to levels in disease-free patients. Serum L1CAM levels were also higher in patients with recurrence but without reaching statistical significance. While DJ1 levels were not affected by any of the observed patient-related characteristics, L1CAM levels were significantly higher in patients with age ≥60 years who were overweight. At the time of EC diagnosis, DJ1 and L1CAM serum levels did not correlate with stage, histological type or risk of recurrence. This is a preliminary description of the potential of serial DJ1 and L1CAM serum level measurement for monitoring the effects of treatment in EC patients.
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Affiliation(s)
- Marketa Bednarikova
- Department of Internal Medicine, Hematology and Oncology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic;
| | - Petra Vinklerova
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (P.V.); (L.M.); (M.F.)
| | - Jana Gottwaldova
- Department of Laboratory Medicine, Department of Laboratory Methods, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (J.G.); (D.V.); (Z.C.)
- Department of Laboratory Medicine, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Petra Ovesna
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, 625 00 Brno, Czech Republic;
| | - Jitka Hausnerova
- Department of Pathology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic;
| | - Lubos Minar
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (P.V.); (L.M.); (M.F.)
| | - Michal Felsinger
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (P.V.); (L.M.); (M.F.)
| | - Dalibor Valik
- Department of Laboratory Medicine, Department of Laboratory Methods, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (J.G.); (D.V.); (Z.C.)
| | - Zdenka Cermakova
- Department of Laboratory Medicine, Department of Laboratory Methods, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (J.G.); (D.V.); (Z.C.)
- Department of Laboratory Medicine, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Vit Weinberger
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital, 625 00 Brno, Czech Republic; (P.V.); (L.M.); (M.F.)
- Correspondence:
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Green formulation, chemical characterization, and antioxidant, cytotoxicity, and anti-human cervical cancer effects of vanadium nanoparticles: A pre-clinical study. ARAB J CHEM 2021. [DOI: 10.1016/j.arabjc.2021.103147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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van Weelden WJ, Bretveld R, Romano A, van Erp S, Engels S, Lalisang R, Pijnenborg J, van der Aa M. Trends over time in the incidence and use of hormonal therapy in endometrial cancer: a population-based study in the Netherlands. Int J Gynecol Cancer 2021; 31:1014-1020. [PMID: 34001633 DOI: 10.1136/ijgc-2021-002444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION According to current guidelines, hormonal therapy may be applied in endometrioid type endometrial cancer as an alternative to surgery for fertility preservation and in medically unfit patients. Since it is unknown how often hormonal therapy is applied, the objective of this study was to investigate trends over time in hormonal therapy use in the background of the overall incidence of endometrial cancer. METHODS All patients with endometrial cancer (n=48 222) registered in the Netherlands Cancer Registry in the period 1989-2018 were included. European age-standardized incidence rates with corresponding estimated annual percentage change were calculated to describe trends in the incidence of endometrial cancer. The use of hormonal therapy was analyzed in the three periods 1989-1998, 1999-2008, and 2009-2018 for the following sub-groups: primary and adjuvant therapy, International Federation of Gynecology and Oncology (FIGO) stage I-II and III-IV, and by age group. RESULTS The European age-standardized incidence rate of endometrioid endometrial cancer peaked in 2004 with a significant increase from 1989 to 2004 (annual percentage change 0.55; 95% CI 0.10 to 0.99, p=0.020) and a subsequent decrease from 2005 to 2018 (annual percentage change -1.79; 95% CI -2.28 to -1.31, p<0.001). The incidence rate of non-endometrioid type endometrial cancer increased significantly in the study period. Hormonal therapy was used in 1482 (3.5%) patients with endometrioid endometrial cancer. Among patients with FIGO stage I aged ≤40 years, hormonal therapy increased from 0% in 1989-1998 to 27% in 2009-2018. Primary hormonal treatment increased from 175 patients (5.5%) to 329 patients (7.8%) in those aged ≥75 years. Adjuvant hormonal treatment was mostly used in advanced stage endometrial cancer. CONCLUSIONS The use of primary hormonal therapy in endometrioid type endometrial cancer increased over time in patients aged ≤40 years and among elderly patients. The observed trends in the current use of hormonal therapy support the need to study the effect of hormonal treatment in elderly patients and as adjuvant treatment in advanced stage endometrial cancer.
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Affiliation(s)
- Willem Jan van Weelden
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Reini Bretveld
- Netherland Comprehensive Cancer Organisation (IKNL), Utrecht, Utrecht, The Netherlands.,Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Andrea Romano
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, Maastricht, Limburg, The Netherlands.,GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Stephan van Erp
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Sam Engels
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Roy Lalisang
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands.,Department of Medical Oncology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Johanna Pijnenborg
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Maaike van der Aa
- Netherland Comprehensive Cancer Organisation (IKNL), Utrecht, Utrecht, The Netherlands
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Guo XM, Tanner EJ, Pavone ME. Management and Recommendations for Future Pregnancy in Patients with Early-Stage Endometrial Cancer: A Survey of Gynecologic Oncologists and Reproductive Endocrinology and Infertility Specialists. J Adolesc Young Adult Oncol 2021; 10:654-660. [PMID: 33960835 DOI: 10.1089/jayao.2020.0228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: To determine how young patients with early-stage endometrial cancer are counseled regarding fertility preserving therapy and pregnancy options by gynecologic oncology and reproductive endocrinology and infertility (REI) providers. Methods: Anonymous online survey of Society of Gynecology Oncology (SGO) and the Society for Reproductive Endocrinology and Infertility (SREI) members; data were analyzed using chi-square and t-tests. Results: Twelve percent (169/1433) of SGO and 6.5% (60/927) of SREI members responded to the survey request. Most providers manage fewer than 10 fertility preservation patients annually. All gynecologic oncologists offer conservative management to patients with grade 1 endometrial cancer without evidence of invasion, and 40% would offer it to patients with grade 2 or <50% invasion. Magnetic resonance imaging was the most common method of assessing invasion, and the progesterone intrauterine device was the preferred first-line treatment. Two-thirds of providers would recommend hysterectomy if no endometrial response was noted by 12 months, two-thirds would continue conservative management for more than a year if a partial response was noted, and 70% would recommend hysterectomy after a patient completes childbearing. Comparatively, 60% of REI providers would recommend hysterectomy after childbearing. More gynecologic oncologists than REI providers recommend attempting spontaneous conception and for longer durations before initiating fertility treatments. Conclusion: Heterogeneous management styles exist among and between gynecologic oncology and REI providers for patients with early-stage endometrial cancer desiring future pregnancy. Improved guidelines are needed regarding treatment and monitoring surrounding trials of conception and pregnancy.
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Affiliation(s)
- Xiaoyue M Guo
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Edward J Tanner
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Robert Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary Ellen Pavone
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Fertility-Sparing Treatment for Atypical Endometrial Hyperplasia and Endometrial Cancer: A Cochrane Systematic Review Protocol. Adv Ther 2021; 38:2717-2731. [PMID: 33830463 DOI: 10.1007/s12325-021-01693-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/02/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endometrial cancer is the fifth most common cancer in women and atypical endometrial hyperplasia is a precancerous lesion. Obesity is an important risk factor for endometrioid endometrial adenocarcinoma and endometrial hyperplasia. Progesterone is recommended as first-line treatment in endometrial cancer or atypical endometrial hyperplasia in women who wish to preserve fertility, but optimal treatment schedules have not been defined. Metformin or bariatric surgery may also be useful in these women. The effectiveness and safety of fertility-preserving treatments being used for women with atypical endometrial hyperplasia and stage IA grade 1 endometrial cancer is unclear. Therefore, the systematic review aims to determine this point. METHODS We will search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registers, conference proceedings, abstracts, cooperative trial groups and reference lists. We will include randomised controlled trials (RCTs) that compare fertility-preserving therapy including orally administered progesterone versus a levonorgestrel-releasing intrauterine system (IUS), metformin, other pharmacological interventions or bariatric surgery, and any of these interventions with womb-removing surgery. Quasi-randomised trials, non-randomised trials and cohort studies will be included. Two review authors will independently assess study eligibility and risk of bias and extract data. The primary outcomes are complete pathologic response and live birth rate. Secondary outcomes include overall survival, progression-free survival, pregnancy rate, need for hysterectomy, adverse events, psychological symptoms and quality of life. PLANNED OUTCOMES This review aims to clarify the effectiveness and risks of fertility-preserving treatments, including complete pathologic response rate, live birth rates, need for surgical treatment, adverse events, psychological symptoms and quality of life. The broad scope of the review includes the use of progesterone, metformin to reverse insulin resistance, and bariatric surgery or operative hysteroscopy. RESULTS The results may help to determine the optimal fertility-sparing treatment in endometrial cancer and atypical endometrial hyperplasia. SYSTEMATIC REVIEW REGISTRATION Prospero 2019 number CRD42019145991.
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The Prediction of Recurrence in Low-Risk Endometrial Cancer: Is It Time for a Paradigm Shift in Adjuvant Therapy? Reprod Sci 2021; 29:1068-1085. [DOI: 10.1007/s43032-021-00565-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
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Kim SW, Kim YY, Kim H, Ku SY. Recent Advancements in Engineered Biomaterials for the Regeneration of Female Reproductive Organs. Reprod Sci 2021; 28:1612-1625. [PMID: 33797052 DOI: 10.1007/s43032-021-00553-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/17/2021] [Indexed: 12/14/2022]
Abstract
Various gynecologic diseases and chemoradiation or surgery for the management of gynecologic malignancies may damage the uterus and ovaries, leading to clinical problems such as infertility or early menopause. Embryo or oocyte cryopreservation-the standard method for fertility preservation-is not a feasible option for patients who require urgent treatment because the procedure requires ovarian stimulation for at least several days. Hormone replacement therapy (HRT) for patients diagnosed with premature menopause is contraindicated for patients with estrogen-dependent tumors or a history of thrombosis. Furthermore, these methods cannot restore the function of the uterus and ovaries. Although autologous transplantation of cryopreserved ovarian tissue is being attempted, it may re-introduce malignant cells after cancer treatment. With the recent development in regenerative medicine, research on engineered biomaterials for the restoration of female reproductive organs is being actively conducted. The use of engineered biomaterials is a promising option in the field of reproductive medicine because it can overcome the limitations of current therapies. Here, we review the ideal properties of biomaterials for reproductive tissue engineering and the recent advancements in engineered biomaterials for the regeneration of female reproductive organs.
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Affiliation(s)
- Sung Woo Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, 03080, South Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Yoon Young Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, 03080, South Korea. .,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Hoon Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, 03080, South Korea. .,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 2024 E. Monument St, Baltimore, MD, 21205, USA.
| | - Seung-Yup Ku
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, 03080, South Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
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Xiang M, English DP, Kidd EA. Role of brachytherapy in stage III endometrial cancer treated with adjuvant chemotherapy: Identifying factors predictive of a survival benefit. Brachytherapy 2021; 20:701-709. [PMID: 33781714 DOI: 10.1016/j.brachy.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/24/2021] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine which patients with stage III endometrial cancer receiving adjuvant chemotherapy derive benefit from the addition of vaginal brachytherapy, as stage III is a highly heterogeneous population with substantial variations in practice. METHODS Patients with FIGO stage III endometrial carcinoma diagnosed 2004-2016 who underwent at least total hysterectomy and adjuvant multiagent chemotherapy were identified in the National Cancer Database. The primary outcome was overall survival according to receipt of brachytherapy, stratified by histologic type, pathological features, and status of pelvic external beam radiotherapy (EBRT), and analyzed using the Kaplan-Meier method and Cox multivariable regression. RESULTS In total, 9369 patients were identified (24% stage IIIA, 5% stage IIIB, 71% stage IIIC; 61% endometrioid, 39% nonendometrioid histology), and 28% received brachytherapy. In the endometrioid cohort, brachytherapy was associated with a 5% absolute increase in 3-year overall survival (87% vs. 82%, p < 0.0001), which persisted in multivariable analysis (adjusted hazard ratio 0.74, 95% confidence interval 0.64-0.84, p < 0.0001). The benefit of brachytherapy was greater in patients not also receiving EBRT, and in patients with vaginal/parametrial extension, grade 3 disease, lymphovascular invasion, and/or deep myometrial invasion. In the nonendometrioid cohort, brachytherapy was associated with a significant survival benefit in univariable but not multivariable analysis, regardless of EBRT status or pathological features. CONCLUSIONS Factors predictive of brachytherapy benefit were endometrioid histology and pathological risk factors for local recurrence. Additionally, brachytherapy appeared more beneficial in patients not already receiving pelvic EBRT. Further research is warranted to determine which stage III patients may be best served by brachytherapy, EBRT, or both.
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Affiliation(s)
- Michael Xiang
- Department of Radiation Oncology, University of California, Los Angeles, CA; Former affiliation: Physician, Palo Alto Veterans Affairs Hospital; Palo Alto, CA
| | - Diana P English
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of South Florida; Tampa, FL
| | - Elizabeth A Kidd
- Department of Radiation Oncology, Stanford University; Stanford, CA.
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Schnarr KL, Seow H, Elit LM, Pond GR, Helpman L, O'Leary E, Kong I. The use of imaging in endometrial cancer prior to potential surgery: Are guidelines being followed? Gynecol Oncol 2021; 161:361-366. [PMID: 33750604 DOI: 10.1016/j.ygyno.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Clinical practice guidelines recommend against routine preoperative axial imaging studies (CT/MRI) for endometrial cancer, except for cases of locally advanced disease or aggressive histologies. This study utilized population-based data to evaluate the use of preoperative imaging and factors associated with its use. METHODS A population-based cohort of women diagnosed with endometrial cancer from 2006 to 2016 were identified from the Ontario Cancer Registry in Ontario, Canada. Patients were excluded if they had: hysterectomy prior to the date of diagnosis, non-epithelial histology or a prior cancer diagnosis within 5 years. Preoperative imaging (CT or MRI) rates were calculated over time. Predictive factors for preoperative imaging use were determined using multi-variable regression analysis. RESULTS 17,718 cases were eligible for analysis. From 2006 to 2016, the proportion of patients receiving preoperative imaging increased from 22.2% to 39.3%. In a subgroup of patients with low-risk disease (stage 1, endometrioid adenocarcinoma), imaging increased from 16.3% to 29.5%. Multivariate analysis showed an association between preoperative imaging and advanced stage, advanced grade, non-endometrioid morphology, surgery with a gynecologic oncologist, surgery at a teaching hospital and a later year of diagnosis. From 2006 to 2016, the yearly incidence of endometrial cancer increased from 22.3/100,000 to 36.1/100,000, representing a mean annual increase of 3.6% per year. CONCLUSIONS Endometrial cancer incidence and the use of preoperative imaging are increasing. Factors most associated with preoperative imaging are high-risk features. However, preoperative imaging is still being performed in low-risk patients, indicating non-adherence to guidelines, which has implications for constrained healthcare resources.
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Affiliation(s)
- Kara L Schnarr
- Division of Radiation Oncology, Department of Oncology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada
| | - Lorraine M Elit
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada
| | - Gregory R Pond
- Department of Oncology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada; Escarpment Cancer Research Institute Juravinski Hospital & Cancer Centre, 699 Concession Street, Hamilton, ON L8V5C2, Canada
| | - Limor Helpman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada
| | - Erin O'Leary
- Department of Oncology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada
| | - Iwa Kong
- Division of Radiation Oncology, Department of Oncology, McMaster University Juravinski Cancer Centre, 699 Concession St, Hamilton, ON L8V 5C2, Canada.
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Fertility-Sparing Treatment for Early-Stage Cervical, Ovarian, and Endometrial Malignancies. Obstet Gynecol 2021; 136:1157-1169. [PMID: 33156194 DOI: 10.1097/aog.0000000000004163] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Approximately 20% of gynecologic malignancies are diagnosed in reproductive-aged women, and standard-of-care surgical treatment often precludes future fertility. In early-stage disease, shared decision making about fertility-sparing medical and surgical approaches may give well-selected patients the opportunity to pursue their family-building goals without compromising long-term survival. Although future fertility is an important consideration for young women with cancer, rates of fertility-sparing procedures remain low. Moreover, because data on pregnancy rates and outcomes after fertility-sparing treatments are limited, it is challenging to counsel patients on realistic expectations. This review examines the critical oncologic outcomes of fertility-sparing approaches in early-stage gynecologic malignancies and highlights pregnancy outcomes in this population.
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Hamilton CA, Pothuri B, Arend RC, Backes FJ, Gehrig PA, Soliman PT, Thompson JS, Urban RR, Burke WM. Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations, part II. Gynecol Oncol 2021; 160:827-834. [PMID: 33451724 DOI: 10.1016/j.ygyno.2020.12.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/19/2020] [Indexed: 12/20/2022]
Abstract
In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. This manuscript, Part II in a two-part series, includes specific recommendations on treatment of recurrent disease, post treatment surveillance and survivorship, considerations for younger women, and special situations. Part I covered histopathology and molecular pathology, risk factors, presentation and diagnostic approach, surgical approach and adjuvant therapy.
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Affiliation(s)
- Chad A Hamilton
- Gynecologic Oncology Section, Women's Services and the Ochsner Cancer Institute, Ochsner Health, New Orleans, LA, United States of America.
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, NYU School of Medicine, New York City, NY, United States of America
| | - Rebecca C Arend
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Floor J Backes
- Division of Gynecologic Oncology, Ohio State University and James Cancer Hospital, Columbus, OH, United States of America
| | - Paola A Gehrig
- Professor and Chief, Division of Gynecologic Oncology, University of North Carolina, Chapel Hill, NC, United States of America
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - J Spencer Thompson
- Division of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, United States of America
| | - Renata R Urban
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - William M Burke
- Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University Cancer Center, Stony Brook, NY, United States of America
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Preoperative predictive factor analysis of ovarian malignant involvement in premenopausal patients with clinical stage I endometrioid endometrial carcinoma. Sci Rep 2021; 11:1219. [PMID: 33441576 PMCID: PMC7806745 DOI: 10.1038/s41598-020-78953-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022] Open
Abstract
Earlier literature suggests that ovarian preservation in young premenopausal clinical stage I endometrioid endometrial carcinoma patients does not negatively impact prognosis. The main purpose of this study was to clarify the incidence of ovarian malignant involvement in this group and further identify potential preoperative predictive factors of ovarian malignant involvement. A total of 511 premenopausal (age ≤ 50 years) patients were enrolled for the study at Women’s Hospital, Zhejiang University School of Medicine, between January 2002 and December 2016. Ovarian malignant involvements were detected in 23 of the patients (4.5%). Univariate and multivariate logistic analysis validated preoperative imaging of myometrial invasion depth and preoperative serum carbohydrate antigen 125 (CA125) level as independent risk predictors of postoperative ovarian malignant involvement. Receiver operating characteristic (ROC) curves was generated for a combination of the two factors. The area under curve (AUC) was 0.772 (95% confidence interval [CI] 0.661–0.884) for the combined two factors. The incidence of postoperative ovarian malignant involvement was relatively minimal. Preoperative imaging of myometrial invasion depth and serum CA125 level were independent risk predictors of ovarian malignant involvement. These findings may facilitate preoperative counseling of patients and informed clinical decision-making on ovarian preservation in these patients.
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Carugno J, Marbin SJ, LaganÀ AS, Vitale SG, Alonso L, DI Spiezio Sardo A, Haimovich S. New development on hysteroscopy for endometrial cancer diagnosis: state of the art. Minerva Med 2021; 112:12-19. [PMID: 33438376 DOI: 10.23736/s0026-4806.20.07123-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.
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Affiliation(s)
- Jose Carugno
- Miller School of Medicine, Unit of Minimally Invasive Gynecology, Division of Obstetrics, Department of Gynecology and Reproductive Sciences, University of Miami, Miami, FL, USA -
| | - Staci J Marbin
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Antonio S LaganÀ
- Department of Obstetrics and Gynecology, Filippo del Ponte Hospital, University of Insubria, Varese, Italy
| | - Salvatore G Vitale
- Unit of Obstetrics and Gynecology, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Luis Alonso
- Unit of Gynecology Endoscopy, Gutenberg Center, Malaga, Spain
| | | | - Sergio Haimovich
- Rappaport Faculty of Medicine, Hillel Yaffe Medical Center, Technion, Israel
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Prospective Non-randomized Control Trial on Role of Systematic High Para-Aortic Lymphadenectomy in Endometrial Cancer: Indian Study. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-020-00482-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Shan W, Wu P, Yang B, Zhang H, Sun L, Lv Q, Luo X, Cheng Y, Zhu Q, Chen X. Conservative management of grade 2 stage IA endometrial carcinoma and literature review. J Obstet Gynaecol Res 2021; 47:984-991. [PMID: 33403812 DOI: 10.1111/jog.14646] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To explore the clinical outcomes of megestrol acetate alone or plus metformin in young women with grade 2 stage IA endometrial carcinoma who ask for preserved fertility. METHODS Patients with stage IA grade 2 endometrial carcinoma who asked for fertility-sparing treatment in the Obstetrics and Gynecology Hospital of Fudan University between 2015 and 2017 were enrolled and retrospectively reviewed. RESULTS Four patients were included and treated with oral megestrol acetate (160 mg per day), while metformin (500 mg, thrice daily) was added for patients with metabolic syndrome. Regular hysteroscopic examination was performed every 3 months during the conservative treatment. Overall, 75% (3/4) of the patients had a complete response, one relapsed and achieved a complete response after changing the therapy plan, and one patient had an indication of myometrial invasion during fertility-sparing treatment and chose to remove uterus. CONCLUSIONS Fertility-sparing treatment for stage IA grade 2 endometrial carcinoma patients is worth exploration. Megestrol acetate with or without metformin combined with hysteroscopic lesion ablation may be an effective therapy.
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Affiliation(s)
- Weiwei Shan
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Pengfei Wu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Bingyi Yang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Hongwei Zhang
- Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.,Department of Cervix, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Li Sun
- Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.,Department of Ultrasound, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Qiaoying Lv
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Xuezhen Luo
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Yali Cheng
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Qin Zhu
- Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.,Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Department of Gynecology, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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Prognostic Value of Preoperative Imaging: Comparing 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography to Computed Tomography Alone for Preoperative Planning in High-risk Histology Endometrial Carcinoma. Am J Clin Oncol 2021; 43:714-719. [PMID: 32804777 DOI: 10.1097/coc.0000000000000735] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) increases the sensitivity for preoperative detection of lymph nodes and distant metastases in endometrial cancer. The objective of this investigation was to determine the prognostic value of preoperative PET-CT compared with computed tomography (CT) alone for high-risk endometrial carcinoma. MATERIALS AND METHODS We performed a retrospective review of high-risk histology endometrial cancer from 2008 to 2015. Clinical variables including surgical procedure, preoperative imaging modality, and outcome were collected. Survival analysis was performed utilizing the Kaplan-Meier and Cox proportional hazards methodologies. RESULTS Of the 555 women treated for high-risk histology endometrial cancer, 88 (16%) had preoperative PET-CT, and 97 (17%) CT without PET available. PET-CT demonstrated positive findings in 37 women (42%) compared with 33 (30%) with preoperative CT alone. PET-CT had a positive predictive value of 96% for nodal metastasis compared with 60% for CT alone. The median follow-up time for the entire cohort was 59 months (range, 12 to 96 mo). Patients with a negative preoperative PET-CT (n=54) had a median progression-free survival (PFS) that was not reached, whereas the median PFS in the PET-CT positive group was 13 months (n=34). Women with a negative PET-CT had a longer median overall survival (OS) not yet reached compared with 34 months in the PET-CT positive cohort (hazard ratio, 2.4; P<0.001). CT findings did not associate with PFS or OS. CONCLUSIONS PET-CT demonstrated superior sensitivity for lymph node metastasis and detecting distant disease compared with CT. Preoperative PET-CT, whether positive or negative, offered OS and PFS prognostic value not observed with CT alone.
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Şenkardeş S, Türe A, Ekrek S, Durak AT, Abbak M, Çevik Ö, Kaşkatepe B, Küçükgüzel İ, Güniz Küçükgüzel Ş. Novel 2,6-disubstituted pyridine hydrazones: Synthesis, anticancer activity, docking studies and effects on caspase-3-mediated apoptosis. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2020.128962] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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71
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Kolehmainen A, Pasanen A, Tuomi T, Koivisto-Korander R, Bützow R, Loukovaara M. Clinical factors as prognostic variables among molecular subgroups of endometrial cancer. PLoS One 2020; 15:e0242733. [PMID: 33232359 PMCID: PMC7685425 DOI: 10.1371/journal.pone.0242733] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background Clinical factors may influence endometrial cancer survival outcomes. We examined the prognostic significance of age, body mass index (BMI), and type 2 diabetes among molecular subgroups of endometrial cancer. Methods This was a single institution retrospective study of patients who underwent surgery for endometrial carcinoma between January 2007 and December 2012. Tumors were classified into four molecular subgroups by immunohistochemistry of mismatch repair (MMR) proteins and p53, and sequencing of polymerase-ϵ (POLE). Overall, cancer-related, and non-cancer-related mortality were estimated using univariable and multivariable survival analyses. Results Age >65 years was associated with increased mortality rates in the whole cohort (n = 515) and in the “no specific molecular profile” (NSMP) (n = 218) and MMR deficient (MMR-D) (n = 191) subgroups during a median follow-up time of 81 months (range 1‒136). However, hazard ratios for cancer-related mortality were non-significant for NSMP and MMR-D. Diabetes was associated with increased overall and non-cancer-related mortality in the whole cohort and MMR-D subgroup. Overweight/obesity had no effect on outcomes in the whole cohort, but was associated with decreased overall and cancer-related mortality in the NSMP subgroup, and increased overall and non-cancer-related mortality in the MMR-D subgroup. Overweight/obesity effect on cancer-related mortality in the NSMP subgroup remained unchanged after controlling for confounders. High-risk uterine factors were more common, and estrogen and progesterone receptor expression less common in NSMP subtype cancers of normal-weight patients compared with overweight/obese patients. No clinical factors were associated with outcomes in p53 aberrant (n = 69) and POLE mutant (n = 37) subgroups. No cancer-related deaths occurred in the POLE mutant subgroup. Conclusions The prognostic effects of age, BMI, and type 2 diabetes do not appear to be uniform for the molecular subgroups of endometrial cancer. Our data support further evaluation of BMI combined with genomics-based risk-assessment.
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Affiliation(s)
- Anne Kolehmainen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Annukka Pasanen
- Department of Pathology, Helsinki University Hospital and Research Program in Applied Tumor Genomics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Taru Tuomi
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Riitta Koivisto-Korander
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ralf Bützow
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Pathology, Helsinki University Hospital and Research Program in Applied Tumor Genomics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko Loukovaara
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
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72
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Won S, Kim MK, Seong SJ. Fertility-sparing treatment in women with endometrial cancer. Clin Exp Reprod Med 2020; 47:237-244. [PMID: 33181010 PMCID: PMC7711095 DOI: 10.5653/cerm.2020.03629] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/14/2020] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer (EC) in young women tends to be early-stage and low-grade; therefore, such cases have good prognoses. Fertility-sparing treatment with progestin is a potential alternative to definitive treatment (i.e., total hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and/or lymphadenectomy) for selected patients. However, no evidence-based consensus or guidelines yet exist, and this topic is subject to much debate. Generally, the ideal candidates for fertility-sparing treatment have been suggested to be young women with grade 1 endometrioid adenocarcinoma confined to the endometrium. Magnetic resonance imaging should be performed to rule out myometrial invasion and extrauterine disease before initiating fertility-sparing treatment. Although various fertility-sparing treatment methods exist, including the levonorgestrel-intrauterine system, metformin, gonadotropin-releasing hormone agonists, photodynamic therapy, and hysteroscopic resection, the most common method is high-dose oral progestin (medroxyprogesterone acetate at 500–600 mg daily or megestrol acetate at 160 mg daily). During treatment, re-evaluation of the endometrium with dilation and curettage at 3 months is recommended. Although no consensus exists regarding the ideal duration of maintenance treatment after achieving regression, it is reasonable to consider maintaining the progestin therapy until pregnancy with individualization. According to the literature, the ovarian stimulation drugs used for fertility treatments appear safe. Hysterectomy should be performed after childbearing, and hysterectomy without oophorectomy can also be considered for young women. The available evidence suggests that fertility-sparing treatment is effective and does not appear to worsen the prognosis. If an eligible patient strongly desires fertility despite the risk of recurrence, the clinician should consider fertility-sparing treatment with close follow-up.
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Affiliation(s)
- Seyeon Won
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
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The role of 18F-FDG PET/CT in endometrial adenocarcinoma: a review of the literature and recent advances. Clin Transl Imaging 2020. [DOI: 10.1007/s40336-020-00385-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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74
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O'Connor SK, Ryley DA, Obasiolu CW, Esselen KM, Skiadas CC, Kuohung W. Vaginal cuff dehiscence following transvaginal oocyte retrieval: a case report. FERTILITY RESEARCH AND PRACTICE 2020; 6:16. [PMID: 32905306 PMCID: PMC7469333 DOI: 10.1186/s40738-020-00085-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022]
Abstract
Background Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14–1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility. Case presentation Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day. Conclusions Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.
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Affiliation(s)
- Sarah K O'Connor
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA USA
| | | | | | - Katharine M Esselen
- Division of Gynecologic Oncology, Beth Israel Lahey Health Boston, Boston, MA USA
| | | | - Wendy Kuohung
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA USA
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Huang AB, Huang Y, Hur C, Tergas AI, Khoury-Collado F, Melamed A, St Clair CM, Hou JY, Ananth CV, Neugut AI, Hershman DL, Wright JD. Impact of quality of care on racial disparities in survival for endometrial cancer. Am J Obstet Gynecol 2020; 223:396.e1-396.e13. [PMID: 32109459 DOI: 10.1016/j.ajog.2020.02.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/30/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Black women experience poorer survival compared with white women across all endometrial cancer stages and histologies. The incidence of endometrial cancer is 30% lower in black women compared with white women, yet mortality is 80% higher in black women. Differences in adherence to evidence-based guidelines have been proposed to be major contributors to this disparity. OBJECTIVES We examined whether adherence to evidence-based treatment recommendations for endometrial cancer could mitigate survival disparities between black and white women. STUDY DESIGN The National Cancer Database was used to identify women with endometrial cancer treated from 2004 through 2016. We established 5 evidence-based quality metrics based on review of primary literature and accepted guidelines: surgical treatment within 6 weeks of diagnosis (Q1), use of minimally invasive surgery (stage I-IIIC; Q2), pelvic nodal assessment (high-risk tumors; Q3), adjuvant radiation (high intermediate risk; Q4), and systemic chemotherapy (stage III-IV; Q5). The rates of 30 and 90 day mortality and 5 year survival were compared between black and white women. To determine the influence of quality on outcomes, we compared outcomes among perfectly adherent black and white women with stage I and III endometrial cancer. RESULTS We identified 310,208 women including 35,035 (11.3%) black women and 275,173 (88.3%) white women. Black women were less likely than white women to receive Q1 (65.8 vs 75.6%), Q2 (58.5 vs 72.9%), Q3 (71.3 vs 74.2%), and Q5 (72.7 vs 73.2%) (P < .05 for all). Adherence to each quality metrics was associated with improved survival. Among women with stage I disease, perfect adherence to the relative quality metrics was seen in 53.1% of white and 41.5% of black women. Among perfectly adherent stage I patients, outcomes in black women improved relative to unselected black women; however, they still experienced higher risk of 30 day (adjusted relative risk, 2.25; 95% confidence interval, 1.30-3.90), 90 day (adjusted relative risk, 1.84; 95% confidence interval, 1.23-2.76), and 5 year mortality (adjusted hazard ratio, 1.42; 95% confidence interval, 1.26-1.59) compared with similar white women. Among women with stage III tumors, perfect adherence to the relative quality metrics was seen in 56.6% of white and 44.1% of black women. Perfectly adherent black women with stage III disease had improved outcomes but remained at increased risk of 30 day (adjusted relative risk, 1.86; 95% confidence interval, 1.01-3.44) and 5 year mortality (adjusted hazard ratio, 1.35; 95% confidence interval, 1.22-1.50) compared with white women. CONCLUSION Black women are less likely than white women with endometrial cancer to receive evidence-based care. However, receipt of evidence-based care mitigates but does not eliminate racial disparities in outcomes and black women remain at greater risk of death from endometrial cancer.
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Peigné M, Maumy L, Koskas M. A survey of French gynecologists' knowledge and attitudes toward conservative treatment for fertility preservation in young patients with endometrial cancer. J Gynecol Obstet Hum Reprod 2020; 49:101794. [PMID: 32416273 DOI: 10.1016/j.jogoh.2020.101794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To describe knowledge and attitudes toward fertility preservation (FP) in patients with endometrial atypical hyperplasia or adenocarcinoma (EC/AH) among French gynecologists MATERIALS AND METHODS: A national survey among French gynaecologists: one questionnaire with one common part and two specific parts for gynecological surgeon (GS) or for specialists in reproductive medicine (SRM) was sent from April 2017 to April 2018. Knowledge and attitudes toward FP in EC/AH were evaluated with a "knowledge score" and an "attitudes score" using a four- or five-point Likert scale. RESULTS One hundred forty physicians completed the survey (87 GS, 53 SRM). The knowledge score was low (59.3% medium/low), but it was significantly higher for GS compared to SRM. The better-known treatments were oral progestins and hysteroscopic resection. Among the participants treating EC/AH, 52.6% found it "difficult" to manage patients and 61.8% regretted the lack of official recommendations. Most physicians seemed to be uncomfortable/unsupportive with FP in EC/AH (57.2% "attitude score' below 11/20). There was a positive correlation between knowledge and attitude scores. GS "usually/always" give advice to patients about FP before EC/AH treatment. After maximum 3-6 months, 56.6% of SRM chose In Vitro Fecundation (IVF) to reduce time-to-pregnancy, with GnRH antagonist protocols (28%) or mild-stimulation (15.1%) to avoid hyperoestrogenism. CONCLUSIONS Despite reassuring results in the literature, French gynecologists are uncomfortable with FP using EC/AH conservative management, which may be because of a lack of confidence in their knowledge. Specific guidelines are needed to help physicians manage these young patients and their fertility.
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Affiliation(s)
- Maëliss Peigné
- AP-HP, Department of Obstetrics and Gynecology, Hôpital Bichat-Claude Bernard, F-75018 Paris, France.
| | - Louise Maumy
- AP-HP, Department of Obstetrics and Gynecology, Hôpital Bichat-Claude Bernard, F-75018 Paris, France
| | - Martin Koskas
- AP-HP, Department of Obstetrics and Gynecology, Hôpital Bichat-Claude Bernard, F-75018 Paris, France; Université de Paris, France
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77
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Using Deep Learning with Convolutional Neural Network Approach to Identify the Invasion Depth of Endometrial Cancer in Myometrium Using MR Images: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165993. [PMID: 32824765 PMCID: PMC7460520 DOI: 10.3390/ijerph17165993] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022]
Abstract
Myometrial invasion affects the prognosis of endometrial cancer. However, discrepancies exist between pre-operative magnetic resonance imaging staging and post-operative pathological staging. This study aims to validate the accuracy of artificial intelligence (AI) for detecting the depth of myometrial invasion using a deep learning technique on magnetic resonance images. We obtained 4896 contrast-enhanced T1-weighted images (T1w) and T2-weighted images (T2w) from 72 patients who were diagnosed with surgico-pathological stage I endometrial carcinoma. We used the images from 24 patients (33.3%) to train the AI. The images from the remaining 48 patients (66.7%) were used to evaluate the accuracy of the model. The AI then interpreted each of the cases and sorted them into stage IA or IB. Compared with the accuracy rate of radiologists’ diagnoses (77.8%), the accuracy rate of AI interpretation in contrast-enhanced T1w was higher (79.2%), whereas that in T2w was lower (70.8%). The diagnostic accuracy was not significantly different between radiologists and AI for both T1w and T2w. However, AI was more likely to provide incorrect interpretations in patients with coexisting benign leiomyomas or polypoid tumors. Currently, the ability of this AI technology to make an accurate diagnosis has limitations. However, in hospitals with limited resources, AI may be able to assist in reading magnetic resonance images. We believe that AI has the potential to assist radiologists or serve as a reasonable alternative for pre-operative evaluation of the myometrial invasion depth of stage I endometrial cancers.
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Radiation and hormonal therapy for primary treatment of stage I endometrial cancer and long-term survival. Gynecol Oncol 2020; 158:331-338. [DOI: 10.1016/j.ygyno.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/13/2020] [Indexed: 12/29/2022]
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79
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Floyd JL, Campbell S, Rauh-Hain JA, Woodard T. Fertility preservation in women with early-stage gynecologic cancer: optimizing oncologic and reproductive outcomes. Int J Gynecol Cancer 2020; 31:345-351. [PMID: 32565487 DOI: 10.1136/ijgc-2020-001328] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 12/22/2022] Open
Abstract
Almost all standard therapies for gynecologic cancer, including surgical intervention, gonadotoxic chemotherapy, and radiation therapy, threaten a woman's childbearing potential. Preservation of fertility should be discussed with premenopausal women with early-stage gynecologic cancer shortly after diagnosis and, for women who desire to preserve fertility, during treatment planning. Many authors have investigated both oncologic and reproductive outcomes following fertility-sparing therapy, and there is ongoing development of assisted reproduction techniques available to cancer patients and survivors. Women with early-stage (IA1-IB1) cervical cancer may be candidates for fertility-sparing cervical conization, simple trachelectomy, or radical trachelectomy. In women with stage I epithelial ovarian cancer, fertility-sparing surgery appears safe overall, although controversy remains in patients with high-risk features (eg, high pathologic grade, clear cell histology, or stage IC disease). In women with low-grade, early-stage endometrial cancer, hormonal therapy has emerged as a viable option. Criteria for patient selection for fertility-sparing therapy are not well defined, thus patients and providers must carefully discuss potential risks and benefits. In general, in carefully selected patients, survival outcomes do not appear to differ significantly between radical and fertility-sparing approaches. Women who undergo fertility-sparing therapies may experience a number of fertility and obstetric complications. Preconception counseling with high-risk obstetric specialists is important to optimize health before a woman attempts to conceive. Identifying appropriate candidates for fertility-sparing treatments, assessing fertility potential, and helping women conceive after cancer treatment is best accomplished through multidisciplinary collaboration between gynecologic oncologists and fertility specialists.
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Affiliation(s)
- Jessica Lauren Floyd
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Sukhkamal Campbell
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Baylor College of Medicine, Houston, TX, USA
| | - Jose Alejandro Rauh-Hain
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri Woodard
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Baylor College of Medicine, Houston, TX, USA .,Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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80
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Xu L, Qiu Y, Feng L, Zhou L, Chen X, Yu D. Correlation between single nucleotide polymorphisms of DACH1 gene microRNA binding site and susceptibility of patients with endometrial cancer. Medicine (Baltimore) 2020; 99:e20793. [PMID: 32569224 PMCID: PMC7310827 DOI: 10.1097/md.0000000000020793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To study the relationship between single nucleotide polymorphism (SNP) of the 3 primer untranslated region (UTR) variants of the cell fate determination factor Dachshund 1(DACH1) gene and the susceptibility of patients with endometrial cancer (EC). METHODS Genomic DNA was extracted from the peripheral venous blood of 235 EC patients and 235 healthy controls, and the DACH1 gene rs9285274, rs9529895, rs17088351, and rs59352399 loci were analyzed by Sanger sequencing. Patients progression-free survival (PFS) was recorded after 3 years follow-up from October 2016 to October 2019. RESULTS Carriers of the C allele of the DACH1 gene rs9529895 locus had a significantly lower risk for EC than T allele carriers (odds ratio = 0.56, 95%confidence interval: 0.38-0.84, P < .01). The correlation between DACH1 gene rs9529895 locus SNP and the risk for EC was affected by age, body mass index, smoking, drinking, and diabetes. Age, and rs9285274, rs9529895, and rs59352399 locus SNP were the best models for predicting the risk for EC. The accuracy rate was 57.02%, and the Cross-validation Consistency was 10/10 (x = 4.33, P = .04). The DACH1 gene rs9529895 locus C allele (TC+CC) carriers had significantly higher PFS than the TT genotype carriers (P = .04). The DACH1 gene was expressed in decreased amounts in the cancer tissues of EC patients, and the DACH1 mRNA expression level in the CC genotype, TC genotype, and TT genotype of rs9529895 locus was also decreased (P = .02). CONCLUSION DACH1 gene rs9529895 locus SNP is significantly related to the risk for EC and PFS of EC patients. The possible mechanism behind this relationship is that the DACH1 gene rs9529895 locus SNP affects DACH1 expression level.
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Affiliation(s)
- Liyan Xu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang
| | - Yafen Qiu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang
| | - Ling Feng
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang
| | - Li Zhou
- Department of Gynecology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine
| | - Xufeng Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, China
| | - Dongqi Yu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang
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81
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Fedorko AM, Kim TH, Broaddus R, Schmandt R, Chandramouli GVR, Kim HI, Jeong JW, Risinger JI. An immune competent orthotopic model of endometrial cancer with metastasis. Heliyon 2020; 6:e04075. [PMID: 32490257 PMCID: PMC7260377 DOI: 10.1016/j.heliyon.2020.e04075] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/11/2019] [Accepted: 05/21/2020] [Indexed: 01/04/2023] Open
Abstract
Endometrial cancer is the most common gynecologic malignancy in the U.S. with metastatic disease remaining the major cause of patient death. Therapeutic strategies have remained essentially unchanged for decades. A significant barrier to progression in treatment modalities stems from a lack of clinically applicable in vivo models to accurately mimic endometrial cancer; specifically, ones that form distant metastases and maintain an intact immune system. To address this problem, we have established the first immune competent murine orthotopic tumor model for metastatic endometrial cancer by creating a green fluorescent protein labeled cell line from an endometrial cancer that developed in a Pgr cre/+ Pten f/f Kras G12D genetically engineered mouse. These cancer cells were grafted into the abraded uterine lumen of ovariectomized recipient mice treated with estrogen and subsequently developed local and metastatic endometrial tumors. We noted primary tumor formation in 59% mixed background and 86% of C57BL/6 animals at 4 weeks and distant lung metastases in 78% of mice after 2 months. This immunocompetent orthotopic tumor model closely resembles some human metastatic endometrial cancer, modeling both local metastasis and hematogenous spread to lung and has significant potential to advance the study of endometrial cancer and its metastasis.
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Affiliation(s)
- Alyssa M Fedorko
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids MI, USA.,Spectrum Health, Grand Rapids MI, USA
| | - Tae Hoon Kim
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids MI, USA
| | - Russell Broaddus
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Rosemarie Schmandt
- Department of Gynecological Oncology & Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston TX, USA
| | | | - Hong Im Kim
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids MI, USA
| | - Jae-Wook Jeong
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids MI, USA.,Spectrum Health, Grand Rapids MI, USA
| | - John I Risinger
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids MI, USA.,Spectrum Health, Grand Rapids MI, USA
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Pei C, Liu C, Wang Y, Cheng D, Li R, Shu W, Zhang C, Hu W, Jin A, Yang Y, Wan J. FeOOH@Metal-Organic Framework Core-Satellite Nanocomposites for the Serum Metabolic Fingerprinting of Gynecological Cancers. Angew Chem Int Ed Engl 2020; 59:10831-10835. [PMID: 32237260 DOI: 10.1002/anie.202001135] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/05/2020] [Indexed: 12/11/2022]
Abstract
High-throughput metabolic analysis is of significance in diagnostics, while tedious sample pretreatment has largely hindered its clinic application. Herein, we designed FeOOH@ZIF-8 composites with enhanced ionization efficiency and size-exclusion effect for laser desorption/ionization mass spectrometry (LDI-MS)-based metabolic diagnosis of gynecological cancers. The FeOOH@ZIF-8-assisted LDI-MS achieved rapid, sensitive, and selective metabolic fingerprints of the native serum without any enrichment or purification. Further analysis of extracted serum metabolic fingerprints successfully discriminated patients with gynecological cancers (GCs) from healthy controls and also differentiated three major subtypes of GCs. Given the low cost, high-throughput, and easy operation, our approach brings a new dimension to disease analysis and classification.
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Affiliation(s)
- Congcong Pei
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - Chao Liu
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - You Wang
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai, 200001, P. R. China.,Department of Obstetrics and Gynecology, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200001, P. R. China
| | - Dan Cheng
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Rongxin Li
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - Weikang Shu
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - Chaoqi Zhang
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - Wenli Hu
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
| | - Aihua Jin
- Institute of Molecular Bioscience, The University of Queensland, St Lucia, Queensland, 4072, Australia
| | - Yannan Yang
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Jingjing Wan
- School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, 200241, P. R. China
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83
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Pei C, Liu C, Wang Y, Cheng D, Li R, Shu W, Zhang C, Hu W, Jin A, Yang Y, Wan J. FeOOH@Metal–Organic Framework Core–Satellite Nanocomposites for the Serum Metabolic Fingerprinting of Gynecological Cancers. Angew Chem Int Ed Engl 2020. [DOI: 10.1002/ange.202001135] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Congcong Pei
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - Chao Liu
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - You Wang
- Shanghai Key Laboratory of Gynecologic OncologyRenji Hospital Shanghai 200001 P. R. China
- Department of Obstetrics and GynecologySchool of MedicineShanghai Jiao Tong University Shanghai 200001 P. R. China
| | - Dan Cheng
- Australian Institute for Bioengineering and NanotechnologyThe University of Queensland Brisbane QLD 4072 Australia
| | - Rongxin Li
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - Weikang Shu
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - Chaoqi Zhang
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - Wenli Hu
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
| | - Aihua Jin
- Institute of Molecular BioscienceThe University of Queensland St Lucia Queensland 4072 Australia
| | - Yannan Yang
- Australian Institute for Bioengineering and NanotechnologyThe University of Queensland Brisbane QLD 4072 Australia
| | - Jingjing Wan
- School of Chemistry and Molecular EngineeringEast China Normal University Shanghai 200241 P. R. China
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Narasimhulu DM, Cope A, Riaz IB, Petersen I, Cliby W, Langstraat C, Glaser G, Kumar A, Cappuccio S, Murad MH, West C, Mariani A. External beam radiotherapy versus vaginal brachytherapy in patients with stage II endometrial cancer: a systematic review and meta-analysis. Int J Gynecol Cancer 2020; 30:797-805. [DOI: 10.1136/ijgc-2020-001199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
ObjectiveThe choice of adjuvant treatment for women with stage II endometrial cancer is challenging, given the known increase in morbidity with external beam radiation compared with vaginal brachytherapy, and the lack of consensus on its benefits. We summarized the evidence on survival and recurrence for stage II endometrial cancer, defined as cervical stromal invasion, after adjuvant postoperative external beam radiotherapy and vaginal brachytherapy.MethodsWe searched the MEDLINE, EMBASE, CENTRAL, and Scopus databases from inception to January 2019 to identify studies that compared adjuvant postoperative external beam radiotherapy with or without vaginal brachytherapy and vaginal brachytherapy alone in stage II endometrial cancer. Our primary outcome was the locoregional recurrence rate, defined as recurrence in the pelvis or vagina. Secondary outcomes included the rate of recurrence at any site, distant recurrence rate, vaginal recurrence rate, pelvic recurrence rate, and 5 year overall survival. Study selection, assessment, and data abstraction were performed by an independent set of reviewers. Random effects models were used to synthesize quantitative data.ResultsWe included 15 cohort studies reporting data on 1070 women. Most women with stage II endometrial cancer (848/1070, 79.3%) were treated with external beam radiotherapy with or without vaginal brachytherapy. Subgroup analysis was stratified by whether >90% of the women included underwent pelvic lymph node assessment (sampling or full dissection). Locoregional recurrence (pelvic and vaginal recurrence) was significantly reduced with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (14 studies (n=1057); odds ratio (OR) 0.33 (95% confidence interval (CI) 0.16 to 0.68); I2=5%) regardless of pelvic lymph node assessment. Most women (81.8%) who recurred locoregionally had a least one uterine risk factor (grade 3 tumor, myometrial invasion >50%, or lymphovascular invasion). There was no difference in overall survival with external beam radiotherapy with or without vaginal brachytherapy compared with vaginal brachytherapy alone (five studies (n=463); OR 0.78 (95% CI 0.34 to 1.80); I2=48%).ConclusionsExternal beam radiotherapy with or without vaginal brachytherapy decreased the locoregional recurrence threefold for stage II endometrial cancer, regardless of pelvic lymph node assessment. Most women who suffered recurrence locoregionally had a least one high risk factor. Vaginal brachytherapy alone may be sufficient therapy for node negative stage II endometrial cancer without uterine risk factors, while those with uterine risk factors should be considered for external beam radiotherapy with or without vaginal brachytherapy to improve locoregional control.
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85
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Pathogenesis and Clinical Management of Uterine Serous Carcinoma. Cancers (Basel) 2020; 12:cancers12030686. [PMID: 32183290 PMCID: PMC7140057 DOI: 10.3390/cancers12030686] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023] Open
Abstract
Uterine serous carcinoma (USC) is an aggressive variant of endometrial cancer that has not been well characterized. It accounts for less than 10% of all endometrial cancers and 80% of endometrial cancer–related deaths. Currently, staging surgery together with chemotherapy or radiotherapy, especially vaginal cuff brachytherapy, is the main treatment strategy for USC. Whole-exome sequencing combined with preclinical and clinical studies are verifying a series of effective and clinically accessible inhibitors targeting frequently altered genes, such as HER2 and PI3K3CA, in varying USC patient populations. Some progress has also been made in the immunotherapy field. The PD-1/PD-L1 pathway has been found to be activated in many USC patients, and clinical trials of PD-1 inhibitors in USC are underway. This review updates the progress of research regarding the molecular pathogenesis and putative clinical management of USC.
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86
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Kwan SY, Au-Yeung CL, Yeung TL, Rynne-Vidal A, Wong KK, Risinger JI, Lin HK, Schmandt RE, Yates MS, Mok SC, Lu KH. Ubiquitin Carboxyl-Terminal Hydrolase L1 (UCHL1) Promotes Uterine Serous Cancer Cell Proliferation and Cell Cycle Progression. Cancers (Basel) 2020; 12:cancers12010118. [PMID: 31906456 PMCID: PMC7016780 DOI: 10.3390/cancers12010118] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/23/2019] [Indexed: 11/16/2022] Open
Abstract
Uterine serous carcinoma (USC) is the most aggressive form of endometrial cancer, with poor survival rates and high recurrence risk. Therefore, the purpose of this study was to identify therapeutic targets that could aid in the management of USC. By analyzing endometrial cancer samples from The Cancer Genome Atlas (TCGA), we found Ubiquitin Carboxyl-Terminal Hydrolase L1 (UCHL1) to be highly expressed in USC and to correlate with poorer overall survival. UCHL1 silencing reduced cell proliferation in vitro and in vivo, cyclin B1 protein levels and cell cycle progression. Further studies showed that UCHL1 interacts with cyclin B1 and increases cyclin B1 protein stability by deubiquitination. Treatment of USC-bearing mice with the UCHL1-specific inhibitor reduced tumor growth and improved overall survival. Our findings suggest that cyclin B1 is a novel target of UCHL1 and targeting UCHL1 is a potential therapeutic strategy for USC.
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Affiliation(s)
- Suet-Ying Kwan
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Chi-Lam Au-Yeung
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Tsz-Lun Yeung
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Angela Rynne-Vidal
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Kwong-Kwok Wong
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - John I. Risinger
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI 48824, USA
| | - Hui-Kuan Lin
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Graduate Institute of Basic Medical Science, China Medical University, Taichung 404, Taiwan
- Department of Biotechnology, Asia University, Taichung 413, Taiwan
| | - Rosemarie E. Schmandt
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Melinda S. Yates
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Samuel C. Mok
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-792-1442
| | - Karen H. Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
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87
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Myers AP, Konstantinopoulos PA, Barry WT, Luo W, Broaddus RR, Makker V, Drapkin R, Liu J, Doyle A, Horowitz NS, Meric-Bernstam F, Birrer M, Aghajanian C, Coleman RL, Mills GB, Cantley LC, Matulonis UA, Westin SN. Phase II, 2-stage, 2-arm, PIK3CA mutation stratified trial of MK-2206 in recurrent endometrial cancer. Int J Cancer 2019; 147:413-422. [PMID: 31714586 DOI: 10.1002/ijc.32783] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 09/27/2019] [Accepted: 10/09/2019] [Indexed: 12/26/2022]
Abstract
Endometrial cancers have high rates of phosphoinositide 3-kinase (PI3K) pathway alterations. MK-2206 is an allosteric inhibitor of AKT, an effector kinase of PI3K signals. We hypothesized patients with tumors harboring PIK3CA mutations would be more likely to benefit from MK-2206 than those without PIK3CA mutation. A Phase II study was performed in patients with recurrent endometrial cancer; all histologies except carcinosarcoma were eligible. Up to two prior chemotherapy lines were permitted, excluding prior treatment with PI3K pathway inhibitors. The first 18 patients were treated with MK-2206 200 mg weekly. Due to unacceptable toxicity, dose was reduced to 135 mg. Co-primary endpoints were objective response rate (ORR) and progression-free survival at 6 months (6moPFS). Thirty-seven patients were enrolled (one ineligible). By somatic PIK3CA mutation analysis, nine patients were mutant (MT) [one with partial response (PR)/6moPFS, two with 6moPFS]. Twenty-seven patients were wild-type (WT) (one PR and four 6moPFS). Most common toxicities were rash (44%), fatigue (41%), nausea (42%) and hyperglycemia (31%). Grade 3 and 4 toxicities occurred in 25 and 17% of patients, respectively. Exploratory analysis found serous histology had greater 6moPFS as compared to all other histologies (5/8 vs. 2/28, p = 0.003). PTEN expression was associated with median time to progression (p = 0.04). No other significant associations with PI3K pathway alterations were identified. There is limited single agent activity of MK-2206 in PIK3CA MT and PIK3CA WT endometrial cancer populations. Activity was detected in patients with serous histology and due to their poor outcomes warrants further study (NCT01307631).
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Affiliation(s)
- Andrea P Myers
- Division of Hematology/Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | | | | | - Weixiu Luo
- Division of Hematology/Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Russell R Broaddus
- Department of Pathology, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Ronny Drapkin
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Joyce Liu
- Division of Hematology/Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Austin Doyle
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Dana Farber Cancer Institute, Boston, MA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Michael Birrer
- Division of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Carol Aghajanian
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Robert L Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Gordon B Mills
- Department of Systems Biology, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Lewis C Cantley
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ursula A Matulonis
- Division of Hematology/Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M. D. Anderson Cancer Center, Houston, TX
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Song J, Lai X, Zhang Y, Zheng X, Su J. Preoperative platelet morphology parameters as prognostic predictors for endometrial malignant carcinoma stage and progesterone receptor. Medicine (Baltimore) 2019; 98:e17818. [PMID: 31764773 PMCID: PMC6882632 DOI: 10.1097/md.0000000000017818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
To investigate preoperative platelet morphology parameters and other whole blood cells in patients of malignant endometrial carcinoma compared with benign disease.Retrospective analysis was performed through collecting patients' hematological parameters before performing total abdominal/vaginal hysterectomy and standard radical surgery due to benign and malignant endometrial disease between 2006 and 2017. Parameters required included white blood cell (WBC), hemoglobin, platelet count (PLT), platelet distribution width (PDW), mean platelet volume (MPV), and platelet thrombocytocrit (PCT). And neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were calculated. For malignant carcinoma, Ki-67 percentage and progesterone receptor (PR) status were further collected.A total of 288 patients were included with 145 benign cases and 143 malignant cases. Patients of confirmed endometrial carcinoma showed a significant lower value of PDW (55.21 ± 4.72 vs 49.54 ± 5.89, P < .001), meanwhile significant higher values of MPV (7.12 ± 1.56 vs 8.89 ± 1.67, P < .001) and PCT (24.18 ± 6.89 vs 27.93 ± 8.93, P = .003). Further analysis of endometrial carcinoma patients showed that no significant difference in platelet parameters was found between patients with stage I to II and stage III to IV (P > .05), while increased value in PDW and reduced value in MPV was found in PR negative compared with positive patients.Preoperative platelet morphology parameters seemed to be used as one kind of predictive factors to discriminate malignant and benign endometrial disease. Limited by present study design, further prospective studies are required to support this finding.
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Harrison RF, He W, Fu S, Zhao H, Sun CC, Suidan RS, Woodard TL, Rauh-Hain JA, Westin SN, Giordano SH, Meyer LA. National patterns of care and fertility outcomes for reproductive-aged women with endometrial cancer or atypical hyperplasia. Am J Obstet Gynecol 2019; 221:474.e1-474.e11. [PMID: 31128110 DOI: 10.1016/j.ajog.2019.05.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although it is uncommon, the incidence of endometrial cancer and atypical hyperplasia among reproductive-aged women is increasing. The fertility outcomes in this population are not well described. OBJECTIVE We aim to describe the patterns of care and fertility outcomes of reproductive-aged women with endometrial cancer or atypical hyperplasia. MATERIALS AND METHODS A cohort of women aged ≤45 years with endometrial cancer or atypical hyperplasia diagnosed in 2000 to 2014 were identified in Truven Marketscan, an insurance claims database of commercially insured patients in the United States. Treatment information, including use of progestin therapy, hysterectomy, and assisted fertility services, was identified and collected using a combination of Common Procedural Terminology codes, International Statistical Classification of Diseases and Related Health Problems codes, and National Drug Codes. Pregnancy events were identified from claims data using a similar technique. Patients were categorized as receiving progestin therapy alone, progestin therapy followed by hysterectomy, or standard surgical management with hysterectomy alone. Multivariable logistic regression was performed to assess factors associated with receiving fertility-sparing treatment. RESULTS A total of 4007 reproductive-aged patients diagnosed with endometrial cancer or atypical hyperplasia were identified. The majority of these patients (n = 3189; 79.6%) received standard surgical management. Of the 818 patients treated initially with progestins, 397 (48.5%) subsequently underwent hysterectomy, whereas 421 (51.5%) did not. Patients treated with progestin therapy had a lower median age than those who received standard surgical management (median age, 36 vs 41 years; P < .001). The proportion of patients receiving progestin therapy increased significantly over the observation period, with 24.9% treated at least initially with progestin therapy in 2014 (P < .001). Multivariable analysis shows that younger age, a diagnosis of atypical hyperplasia diagnosis rather than endometrial cancer, and diagnosis later in the study period were all associated with a greater likelihood of receiving progestin therapy (P < .0001). Among the 421 patients who received progestin therapy alone, 92 patients (21.8%; 92/421) had 131 pregnancies, including 49 live births for a live birth rate of 11.6%. Among the 397 patients treated with progestin therapy followed by hysterectomy, 25 patients (6.3%; 25/397) had 34 pregnancies with 13 live births. The median age of patients who experienced a live birth following diagnosis during the study period was 36 years (interquartile range, 33-38). The use of some form of assisted fertility services was observed in 15.5% patients who were treated with progestin therapy. Among patients who experienced any pregnancy event following diagnosis, 54% of patients used some form of fertility treatment. For patients who experienced a live birth following diagnosis, 50% of patients received fertility treatment. Median time to live birth following diagnosis was 756 days (interquartile range, 525-1077). Patients treated with progestin therapy were more likely to experience a live birth if they had used assisted fertility services (odds ratio, 5.9; 95% confidence interval, 3.4-10.1; P < .0001). CONCLUSION The number of patients who received fertility-sparing treatment for endometrial cancer or atypical hyperplasia increased over time. However, the proportion of women who experience a live birth following these diagnoses is relatively small.
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Affiliation(s)
- Ross F Harrison
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Weiguo He
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shuangshuang Fu
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rudy S Suidan
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Terri L Woodard
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon H Giordano
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Westin SN, Sill MW, Coleman RL, Waggoner S, Moore KN, Mathews CA, Martin LP, Modesitt SC, Lee S, Ju Z, Mills GB, Schilder RJ, Fracasso PM, Birrer MJ, Aghajanian C. Safety lead-in of the MEK inhibitor trametinib in combination with GSK2141795, an AKT inhibitor, in patients with recurrent endometrial cancer: An NRG Oncology/GOG study. Gynecol Oncol 2019; 155:420-428. [PMID: 31623857 DOI: 10.1016/j.ygyno.2019.09.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to determine safety and efficacy of the AKT inhibitor, GSK2141795, combined with the MEK inhibitor, trametinib, in endometrial cancer. METHODS Patients with measurable recurrent endometrial cancer were eligible. One to two prior cytotoxic regimens were allowed; prior use of a MEK or PI3K pathway inhibitor was excluded. Initial trial design consisted of a KRAS mutation stratified randomized phase II with a safety lead-in evaluating the combination. For the safety lead in, the previously recommended phase 2 dose (RP2D; trametinib 1.5 mg, GSK2141795 50 mg) was chosen for Dose Level 1 (DL1). RESULTS Of 26 enrolled patients, 14 were treated on DL1 and 12 were treated on DL-1 (trametinib 1.5 mg, GSK2141795 25 mg). Most common histologies were endometrioid (58%) and serous (27%). Four of 25 (16%) patients were KRAS mutant. Dose limiting toxicities (DLTs) were assessed during cycle 1. DL1 had 8 DLTs (hypertension (n = 2), mucositis (2), rash (2), dehydration, stroke/acute kidney injury). DL1 was deemed non-tolerable so DL-1 was explored. DL-1 had no DLTs. Sixty-five percent of patients had ≥ grade 3 toxicity. There were no responses in DL1 (0%, 90%CI 0-15%) and 1 response in DL-1 (8.3%, 90%CI 0.4-33.9%). Proportion PFS at 6 months for DL1 is 14%, and 25% for DL-1. CONCLUSION The combination of trametinib and GSK2141795 had high levels of toxicity in endometrial cancer at the previously RP2D but was tolerable at a reduced dose. Due to insufficient preliminary efficacy at a tolerable dose, the Phase II study was not initiated.
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Affiliation(s)
- Shannon N Westin
- Department of Gynecologic Oncology, University of Texas M. D Anderson Cancer Center, USA.
| | - Michael W Sill
- NRG Oncology Statistics and Data Management Center Buffalo Office, Roswell Park Cancer Institute, USA.
| | - Robert L Coleman
- Department of Gynecologic Oncology, University of Texas M. D Anderson Cancer Center, USA.
| | - Steven Waggoner
- Department of Gynecologic Oncology, Case Western Reserve University, USA.
| | - Kathleen N Moore
- Department of Gynecologic Oncology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, USA.
| | - Cara A Mathews
- Department of Gynecologic Oncology, Women & Infants Hospital, USA.
| | - Lainie P Martin
- Department of Hematology/Oncology, Fox Chase Cancer Center, USA.
| | - Susan C Modesitt
- Director of Gynecologic Oncology Division, University of Virginia, USA.
| | - Sanghoon Lee
- Department of Medicine and the UVA Cancer Center, University of Virginia, USA.
| | - Zhenlin Ju
- Department of Bioinformatics and Computational Biology, University of Texas M. D Anderson Cancer Center, USA.
| | - Gordon B Mills
- Department of Medicine and the UVA Cancer Center, University of Virginia, USA.
| | - Russell J Schilder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University Hospital, USA.
| | - Paula M Fracasso
- Department of Systems Biology, University of Texas M.D Anderson Cancer Center, USA.
| | | | - Carol Aghajanian
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, USA.
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Zhang D, Sun X, Zhang Y. Downregulation Of LncRNA PMS2L2 In Endometrial Adenocarcinoma Upon Carboplatin Treatment. Cancer Manag Res 2019; 11:8905-8910. [PMID: 31632150 PMCID: PMC6791671 DOI: 10.2147/cmar.s221274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/05/2019] [Indexed: 12/02/2022] Open
Abstract
Background LncRNA PMS2L2 plays critical protective roles in chondrocytes during lipopolysaccharide-induced inflammation. Our preliminary deep sequencing revealed the altered expression of PMS2L2 in endometrial adenocarcinoma (EA) during chemotherapy. This observation triggered our interest to explore the functions of PMS2L2 in EA. Methods Levels of PMS2L2 in plasma were measured by qPCR. ROC curve analysis was used for diagnostic analysis. Cell viability was analyzed by cell viability assay. Results We showed that plasma PMS2L2 was downregulated in EA patients compared with healthy controls, and downregulation of PMS2L2 distinguished early-stage EA patients from healthy controls. During carboplatin-based chemotherapy, plasma levels of PMS2L2 were significantly downregulated in endometrial cancer patients. Overexpression of PMS2L2 led to decreased viability of EA cells, while PMS2L2 siRNA silencing led to increased viability of EA cells. Conclusion LncRNA PMS2L2 in endometrial cancer was downregulated during carboplatin treatment and regulates chemosensitivity.
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Affiliation(s)
- Dan Zhang
- Department of Gynaecology, General Hospital of Fushun Mining Bureau of Liaoning Health Industry Group, Fushun City, Liaoning Province 113008, People's Republic of China
| | - Xiuyun Sun
- Department of Gynaecology, General Hospital of Fushun Mining Bureau of Liaoning Health Industry Group, Fushun City, Liaoning Province 113008, People's Republic of China
| | - Yuyang Zhang
- The Second Department of Oncology, General Hospital of Fushun Mining Bureau of Liaoning Health Industry Group, Fushun City, Liaoning Province 113008, People's Republic of China
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Assessing endometrial cancer risk among US women: long-term trends using hysterectomy-adjusted analysis. Am J Obstet Gynecol 2019; 221:318.e1-318.e9. [PMID: 31125544 DOI: 10.1016/j.ajog.2019.05.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/02/2019] [Accepted: 05/15/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Commonly reported incidence rates for endometrial cancer fail to take into account both the large number of hysterectomies performed each year and the dynamic change in hysterectomy rate over the past decade. Large racial differences in premenopausal hysterectomy rates between Black and White women in the United States likely affect calculation of race-based risk. OBJECTIVES The objectives of the study were to determine how the long-term trends in Black-White differences in endometrial cancer incidence and histology type have changed over time for women at risk. STUDY DESIGN Using longitudinal Surveillance, Epidemiology, and End Results data from 1997 to 2014 and state-level hysterectomy prevalence from the Behavioral Risk Factor Surveillance System, we calculated hysterectomy-adjusted incidence rates of endometrial cancer and the proportion of high vs low-risk endometrial cancer, by race, over time. RESULTS In women older than 50 years who have not had a hysterectomy, endometrial cancer incidence is 87 per 100,000 from 1997 to 2014. Among White women endometrial cancer incidence changed from 102 (1997-2001) to 86 (2012-2014) cases per 100,000, with a nonsignificant decreasing linear trend (adjusted risk ratio, 0.95; 95% confidence interval, 0.91-1.00; p=0.05). In contrast, incidence for Black women was 88 (1997-2001), 101 (2002-2006), 100 (2007-2011), and 102 (2012-2014) cases per 100,000 with no decreasing trend (adjusted risk ratio, 1.02; 95% confidence interval, 0.96-1.10, P = .449). High-risk histology increased among both groups (White: adjusted risk ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .015; Black: adjusted risk ratio, 1.06; 95% confidence interval, 1.02-1.10, P = .007). Racial difference in the proportion of high-risk disease remained stable. CONCLUSION Updated hysterectomy-adjusted incidence demonstrates that endometrial cancer is the second most common cancer among women older than 50 years with a uterus and that endometrial cancer has been more common among Black women compared with White women in the United States since 2002. A clinical approach of proactive communication and routine screening for early symptoms in the perimenopausal and menopausal years, especially among Black women, is warranted. These findings can also inform equitable distribution of research funding for endometrial cancer and serve to promote public awareness of this common cancer.
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94
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Association of TTTA polymorphism in CYP19 gene with endometrial and ovarian cancers risk in Basrah. GENE REPORTS 2019. [DOI: 10.1016/j.genrep.2019.100453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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95
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Wang L, Wang X, Zhang Q, Ran J, Geng Y, Feng S, Li C, Zhao X. Is there a role for carbon therapy in the treatment of gynecological carcinomas? A systematic review. Future Oncol 2019; 15:3081-3095. [PMID: 31426679 DOI: 10.2217/fon-2019-0187] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This Systematic Review summarizes the literatures of clinical trials on the efficacy and safety of carbon ion therapy for gynecological carcinomas. The protocol is detailed in the online PROSPERO database, registration no. CRD42019121424, and a final set of eight studies were included. In the treatment of cervical carcinomas, both carbon ion therapy alone and carbon ion therapy concurrent chemotherapy have presented good efficacy. Besides, the efficacy of inoperable endometrial carcinomas and gynecological melanoma are similar to that of surgical treatment. In terms of safety, gastrointestinal and genitourinary toxicities are low and could be controlled by limiting the volume and dose of intestinal tract and bladder. Carbon ion radiotherapy could be considered a safe, effective and feasible therapy for gynecological carcinomas.
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Affiliation(s)
- Lina Wang
- Radiotherapy Department, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu, PR China.,The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Xiaohu Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China.,Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu, PR China
| | - Qiuning Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China.,Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu, PR China
| | - Juntao Ran
- Radiotherapy Department, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Yichao Geng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Shuangwu Feng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Chengcheng Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
| | - Xueshan Zhao
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu, PR China
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Horn LC, Emons G, Aretz S, Bock N, Follmann M, Lax S, Nothacker M, Steiner E, Mayr D. [S3 guidelines on the diagnosis and treatment of carcinoma of the endometrium : Requirements for pathology]. DER PATHOLOGE 2019; 40:21-35. [PMID: 30756154 DOI: 10.1007/s00292-019-0574-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The present article summarises the relevant aspects of the S3 guidelines on endometrioid carcinomas. The recommendations include the processing rules of fractional currettings as well as for hysterectomy specimens and lymph node resections (including sentinel lymph nodes). Besides practical aspects, the guidelines consider the needs of the clinicians for appropriate surgical and radiotherapeutic treatment of the patients. Carcinosarcomas are assigned to the endometrial carcinoma as a special variant. For the first time, an algorithmic approach for evaluation of the tumour tissue for Lynch syndrome is given. Prognostic factors based on morphologic findings are summarised.
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Affiliation(s)
- L-C Horn
- Abteilung Mamma‑, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Liebigstraße 24, 04103, Leipzig, Deutschland.
| | - G Emons
- Frauenklinik, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - S Aretz
- Institut für Humangenetik, Universitätsklinikum Bonn, Bonn, Deutschland
| | - N Bock
- Frauenklinik, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - M Follmann
- Deutsche Krebsgesellschaft, Berlin, Deutschland
| | - S Lax
- Institut für Pathologie, Landeskrankenhaus Graz West, Graz, Österreich
| | - M Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF), Berlin, Deutschland
| | - E Steiner
- Frauenklinik, GPR Klinikum Rüsselsheim, Rüsselsheim, Deutschland
| | - D Mayr
- Pathologisches Institut, Medizinische Fakultät, Ludwig-Maximilians-Universität München, München, Deutschland
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Recurrent early stage endometrial cancer: Patterns of recurrence and results of salvage therapy. Gynecol Oncol 2019; 154:38-44. [DOI: 10.1016/j.ygyno.2019.04.676] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/11/2019] [Accepted: 04/14/2019] [Indexed: 11/23/2022]
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Zinovkin DA, Achinovich SL, Zubritskiy MG, Whatmore JL, Pranjol MZI. High Expression of Galectin-1, VEGF and Increased Microvessel Density Are Associated with MELF Pattern in Stage I-III Endometrioid Endometrial Adenocarcinoma. J Pathol Transl Med 2019; 53:280-288. [PMID: 31243940 PMCID: PMC6755649 DOI: 10.4132/jptm.2019.05.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/13/2019] [Indexed: 11/17/2022] Open
Abstract
Background In this study, we investigate the expression of markers of angiogenesis and microvessel density (MVD) in cases of microcystic, elongated and fragmented (MELF) pattern, with its prognostic role in the survival of endometrioid endometrial adenocarcinomas (EA) patients. Methods In this study, 100 cases of EA, 49 cases with MELF pattern and 51 without, were immunohistochemically stained for galectin-1, vascular endothelial growth factor (VEGF), and MVD. Morphometry and statistical (univariate and multivariate) analyses were performed to assess overall survival (OS) and disease-free survival. Results The expression of VEGF (p<.001) and galectin-1 (p<.001), as well as MVD area (p<.001) and number of vessels/mm2 (p<.050), were significantly higher in the +MELF pattern group compared to the –MELF group. A low negative correlation between MELF-pattern and the number of days of survival (p<.001, r=–0.47) was also found. A low positive correlation of MELF-pattern with galectin-1 expression (p<.001, r=0.39), area of vessels/mm2 (p<.001, r=0.36), outcome of EA (p<.001, r=0.42) and VEGF expression (p<.001, r=0.39) suggests potential pathological relevance of these factors in the prognosis of EA. A univariate survival analysis indicated a role for all parameters of survival. Multivariate Cox proportional hazard regression analysis revealed that only area of vessels/mm2 (hazard ratio [HR], 1.018; 95% confidence interval [CI], 1.002 to 1.033), galectin-1 (HR, 1.049; 95% CI, 1.025 to 1.074) and VEGF (HR, 1.049; 95% CI, 1.022 to 1.077) play key roles in OS. Conclusions This study reports an increase in MVD, VEGF and galectin-1 expression in EA with MELF pattern and suggests that MELF pattern, along with the angiogenic profile, may be a prognostic factor in EA.
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Affiliation(s)
| | | | | | - Jacqueline Linda Whatmore
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, Devon, UK
| | - Md Zahidul Islam Pranjol
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry Queen Mary University of London, London, UK
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Reijnen C, Küsters-Vandevelde HVN, Prinsen CF, Massuger LFAG, Snijders MPML, Kommoss S, Brucker SY, Kwon JS, McAlpine JN, Pijnenborg JMA. Mismatch repair deficiency as a predictive marker for response to adjuvant radiotherapy in endometrial cancer. Gynecol Oncol 2019; 154:124-130. [PMID: 31103324 DOI: 10.1016/j.ygyno.2019.03.097] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mismatch repair (MMR) deficiency is found in 20 to 40% of endometrial cancers (ECs) and was recently identified as a discerning feature of one of the four prognostic subgroups identified by The Cancer Genome Atlas. There is accumulating evidence that MMR proteins are involved in the DNA repair processes following radiotherapy. We investigated the predictive value of MMR status for response to adjuvant radiotherapy in patients with stage IB/II, grade 3 endometrioid endometrial cancer (EEC). METHODS A retrospective multicenter cohort study was performed to compare patients with histopathologically confirmed stage IB/II grade 3 EEC with and without adjuvant radiotherapy. Patients were classified according to the Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) identifying ECs as either MMR-deficient, POLE, p53abn or p53wt. Multivariable Cox regression analysis explored associations between adjuvant treatment and outcome. RESULTS A total of 128 patients were analyzed, including 57 patients (43.0%) with MMR-deficient EECs. Baseline characteristics were comparable, except a higher proportion of MMR-deficient EECs were stage II (36.8% vs. 15.5%, p = 0.006). Eighty-two patients (64.1%) received adjuvant radiotherapy (external beam [n = 55], vaginal brachytherapy [n = 27]). In multivariable analysis, adjuvant radiotherapy was associated with improved disease-specific survival in patients with MMR-deficient EECs (hazard ratio 0.19, 95%-CI 0.05-0.77), but not in patients with MMR-proficient EECs (hazard ratio 0.92, 95%-CI 0.37-2.31). CONCLUSION Adjuvant radiotherapy improved survival in patients with MMR-deficient EECs. MMR status could be used as a predictive biomarker to select patients that benefit most from adjuvant radiotherapy.
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Affiliation(s)
- Casper Reijnen
- Department Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.
| | | | - Clemens F Prinsen
- Department of Pathology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Leon F A G Massuger
- Department Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc P M L Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Stefan Kommoss
- Department of Women's Health, Tübingen University Hospital, Tübingen, Germany
| | - Sara Y Brucker
- Department of Women's Health, Tübingen University Hospital, Tübingen, Germany
| | - Janice S Kwon
- Division of Gynecologic Oncology, University of British Columbia and British Columbia Cancer Agency, Vancouver, Canada
| | - Jessica N McAlpine
- Division of Gynecologic Oncology, University of British Columbia and British Columbia Cancer Agency, Vancouver, Canada
| | - Johanna M A Pijnenborg
- Department Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
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