ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up

Sentinel lymph node biopsy in endometrial cancer: The new norm - A multicentre, international experience

OBJECTIVES

The landscape of early-stage endometrial cancer treatment has changed dramatically over the last decade. The aim of this study is to provide a real-world view of the impact sentinel lymph node (SLN) biopsy has had on both clinical practice and patient outcomes. We describe detection and recurrence rates, as well as our experience in managing low volume lymph node disease.

METHODS

We conducted an international, multicenter retrospective cohort study of 1012 patients with apparent early-stage endometrial cancer. Eligible patients underwent primary surgical staging and SLN biopsy in one of three large academic tertiary cancer centers in Canada or the Republic of Korea between 2015 and 2019. Demographic, surgical, clinicopathologic and recurrence data were collected through chart review.

RESULTS

A total of 1012 patients were included. Overall SLN detection rate for all tracer types was 94.1% and recurrence rate was 5.3%. Higher FIGO stage (III vs. I/II) was associated with failed bilateral mapping (OR 2.27, 95%CI 1.14-4.52). We identified seven patients with micrometastases and 12 with isolated tumor cells, of which only one patient with micrometastases recurred at 17 months. Recurrence rates based on risk groups were 2.1%, 5.3%, 8.1%, and 9.9% for low, intermediate, high-intermediate, and high risk, respectively.

CONCLUSION

SLN biopsy is safe and feasible. Detection rates are high, regardless of which tracer type is used and recurrence rates are low, especially in low and intermediate risk disease. Patients with low volume metastases appear to have low risk of recurrence, but replication of our findings by large prospective studies are needed to elucidate their clinical importance.

Prehabilitation in an ERAS program for endometrial cancer patients: impact on post-operative recovery

OBJECTIVES

Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways that aim to reduce stress response and improve perioperative outcomes. However, literature is limited regarding the impact of ERAS and prehabilitation in gynecologic oncology surgery. The aim of this study was to assess the impact of implementing an ERAS and prehabilitation program on post-operative outcomes of endometrial cancer patients undergoing laparoscopic surgery.

METHODS

We evaluated consecutive patients undergoing laparoscopy for endometrial cancer that followed ERAS and the prehabilitation program at a single center. A pre-intervention cohort that followed the ERAS program alone was identified. The primary outcome was length of stay, and secondary outcomes were normal oral diet restart, post-operative complications and readmissions.

RESULTS

A total of 128 patients were included: 60 patients in the ERAS group and 68 patients in the prehabilitation group. The prehabilitation group had a shorter length of hospital stay of 1 day (p<0.001) and earlier normal oral diet restart of 3.6 hours (p=0.005) in comparison with the ERAS group. The rate of post-operative complications (5% in the ERAS group and 7.4% in the prehabilitation group, p=0.58) and readmissions (1.7% in the ERAS group and 2.9% in the prehabilitation group, p=0.63) were similar between groups.

CONCLUSIONS

The integration of ERAS and a prehabilitation program in endometrial cancer patients undergoing laparoscopy significantly reduced hospital stay and time to first oral diet as compared with ERAS alone, without increasing overall complications or the readmissions rate.

Simple radiologic assessment of visceral obesity and prediction of surgical morbidity in endometrial cancer patients undergoing laparoscopic aortic lymphadenectomy: A reliability and accuracy study

AIM

To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy.

METHODS

We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty.

RESULTS

In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80).

CONCLUSIONS

u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.

UBE2J1 knockdown promotes cell apoptosis in endometrial cancer via regulating PI3K/AKT and MDM2/p53 signaling

Emerging evidence has demonstrated that ubiquitin conjugating enzyme E2 J1 (UBE2J1) exerts pivotal function in many cancers. UBE2J1 was reported to be dysregulated in endometrial cancer (EC). This study was designed to further investigate the regulatory character and mechanism of UBE2J1 in EC. Bioinformatic tools and databases were used to analyze gene expression pattern and gene expression correlation in EC tissues, and the prognosis of EC patients. Gene expression was evaluated by reverse-transcription quantitative polymerase chain reaction. Western blot was used for protein level detection. In vitro cell apoptosis was detected by flow cytometry analyses and TUNEL assays. In vivo cell apoptosis was evaluated by detecting Bax and Bcl-2 expression in tumor tissues via immunohistochemical and western blot analyses. In this study, UBE2J1 knockdown promoted cell apoptosis in EC cells and in mouse models of EC. PI3K and AKT expression is positively correlated with UBE2J1 level and is related to poor prognosis of EC patients. UBE2J1 knockdown repressed the PI3K/AKT pathway both in vitro and in vivo. UBE2J1 downregulation decreased MDM2 expression, but increased p53 expression. MDM2 overexpression reverses the promotion of UBE2J1 knockdown on cell apoptosis in EC. Overall, UBE2J1 knockdown induces cell apoptosis in EC by inactivating the PI3K/AKT signaling and suppressing the MDM2/p53 signaling.

Magnetic Resonance Imaging-Guided Stereotactic Body Radiation Therapy for Medically Inoperable Endometrial Cancer

Endometrial carcinoma is the most frequently diagnosed gynecological cancer among women aged 50 and older in developed countries. In patients who are not amenable to surgery, radiotherapy results in improved survival with acceptable adverse effect profiles. Definitive stereotactic body radiotherapy (SBRT) as a monotherapy remains an unaddressed concept in the literature. Here, we present the case of an 86-year-old woman who was diagnosed with early-stage endometrial carcinoma and was medically inoperable due to cardiac comorbidities. She was treated with magnetic resonance imaging-guided online adaptive radiotherapy-based SBRT. She tolerated the treatment well, with mild increased vaginal discharge. Complete metabolic and radiological responses were obtained. She continues to be disease free in the first year of treatment with no long-term side effects. Our protocol presents promising results with a safe toxicity profile for inoperable early-stage endometrial cancer. Future studies are warranted in light of the current knowledge.

Surgical restaging of patients with early‑stage endometrial cancer with lymphovascular invasion does not significantly impact their survival outcomes

Lymphovascular space invasion (LVSI) is considered to be a poor prognostic factor in endometrial cancer. However, management of patients with early-stage endometrial cancer with positive LVSI remains controversial. The main objective of the present study was to investigate whether surgical restaging of such patients has a significant effect on survival outcomes or may be otherwise omitted. A retrospective cohort study was conducted at the Gynaecologic Oncology Unit, Insitut Bergonie, Bordeaux, France for the period January 2003-December 2019. The present study included patients with definitive histopathological diagnosis of early-stage, grade 1-2 endometrial cancer with positive LVSI. Patients were divided into two groups: Those being restaged with pelvic and para-aortic lymphadenectomy (group 1) and those not restaged and receiving complementary therapy (group 2). The primary outcomes of the study were overall survival and progression-free survival. Epidemiological data, clinical and histopathological characteristics as well as complementary treatment received were also studied. Kaplan-Meier and Cox regression analyses were performed. Data from 30 patients were retrieved, of which restaging with lymphadenectomy was performed in 21 patients (group 1), while another 9 patients (group 2) were not restaged and received complementary therapy. Lymph node metastasis was observed in 23.8% of patients in group 1 (n=5). No significant difference was observed between groups 1 and 2 in terms of survival outcomes. The median overall survival was 91.31 months in group 1 and 90.61 months in group 2 [hazard ratio (HR), 0.71; 95% CI, 0.03-16.58; P=0.829]. The median disease-free survival was 87.95 months in group 1 and 81.52 months in group 2 (HR, 0.85; 95% CI, 0.12-5.91; P=0.869). In conclusion, restaging with lymphadenectomy did not alter prognosis of early-stage, LVSI-positive patients. As there was no clinical and therapeutic benefit, restaging with lymphadenectomy could be omitted in such patients.

Prognostic Factors for Survival in Patients with Carcinoma Endometrium

Francis. V. JamesObjective  The study aimed to see the clinical outcome and to identify prognostic factors for survival in patients with carcinoma endometrium. Methods  Patients registered at Regional Cancer Centre, Thiruvananthapuram, Kerala, India, with carcinoma endometrium from January 2009 to December 2013 were identified from hospital registry. Data regarding patient demographics, tumor characteristics, treatment schedules, and follow-up were collected using a structured proforma. Survival estimates were generated using the Kaplan-Meier method. Univariate analysis was done using chi-square and Fisher's exact tests. Multivariate analysis using the Cox regression model was performed to determine the impact of prognostic factors on outcome. The statistical analysis was done using SPSS software version 11. Results  The median follow-up of the 686 patients was 95 months (range 3-178 months).There were 432 stage 1 (63%), 100 stage II (14.6%), 108 stage III (15.7%), and 46 stage IV patients (6.7%). The 5-year overall survival was 89.2%. Prognostic factors for survival on univariate analysis were age 60 years or older, nonendometrioid histology, high-grade tumor, cervical stromal involvement, para-aortic node involvement, negative progesterone receptor expression, deep myometrial invasion advanced stage, surgery versus no surgery, serosal involvement, and ovarian and fallopian tube involvement. However, on multivariate analysis, age over 60 years, higher histological grade, advanced stage, and deep myometrial and parametrial invasion were associated with significantly poorer survival. Conclusion  We found that age over 60 years at presentation, higher grade, advanced stage, deep myometrial invasion, and parametrial invasion were associated with poorer survival.

Defining the Optimal Treatment Strategy in Patients With Uterine Serous Carcinoma

AIMS

Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer with high rates of relapse and death. As adjuvant therapy might be beneficial in early-stage disease, the impact of standard complete surgical staging is questioned. Therefore, we wanted to explore the optimal treatment strategy for women diagnosed with USC.

MATERIALS AND METHODS

A retrospective multicentre study of women diagnosed with primary USC in the UK and the Netherlands. Treatment strategy in relation to overall survival and progression-free survival was recorded and evaluated with Kaplan-Meier and Cox regression analysis. Furthermore, primary surgical staging and/or adjuvant treatment in relation to patterns of recurrence were evaluated.

RESULTS

In total, 272 women with a median age of 70 years were included. Most patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (44%). Overall, 48% of patients developed recurrent disease, most (58%) with a distant component. Women treated with chemotherapy showed significantly better overall survival (hazard ratio 0.50, 95% confidence interval 0.31-0.81; P = 0.005) and progression-free survival (hazard ratio 0.48, 95% confidence interval 0.28-0.80; P = 0.04) in multivariable analysis. Furthermore, even in surgically staged women with FIGO stage IA disease, a high recurrence rate of 42% was seen.

CONCLUSION

Women with USC who received adjuvant chemotherapy showed better survival rates compared with those who received other or no adjuvant treatment. The benefit of adjuvant chemotherapy was observed across all tumour stages, including surgically staged FIGO stage IA. These data question the role of surgical staging in the absence of macroscopic disease in USC.

Tumor Budding is an Independent Prognostic Factor to Predict Overall Survival in Endometrial Endometrioid Carcinoma: A Retrospective Study

Objective. Tumor budding defined as a tumor cell nest away from the main tumor, has been found to be associated with prognostic parameters in many cancer types. We aimed to investigate the relationship between tumor budding and clinicopathological parameters in endometrioid endometrial carcinomas, as well as its prognostic importance. Materials and Methods. One hundred four patients who underwent surgical resection with diagnosis of endometrioid endometrial carcinomas between June 2011 and May 2020 were included. The area where tumor budding was the most prominent was determined, and tumor budding was counted from hematoxylin and eosin-stained section at one high power field (X 200). By performing ROC analysis, the cut off value was obtained in order to divide the patients into low and high tumor budding groups. Results. The cut off value was determined as 1/0.95 mm² according to the ROC analysis. Tumor budding was observed in 24 (23%) patients. Tumor budding significantly associated with poor overall survival (P < .001), distant metastasis (P = .001), presence of angiolymphatic invasion (P < .001), lymph node metastasis (P = .024), cervical invasion (P < .001), high FIGO grade (P < .001), large tumor size (P = .004). In multivarate analysis, tumor budding and age were found to be an independent risk factor for overall survival (P = .003, P = .014 respectively). Conclusion. Tumor budding is a significant morphological parameter independent of other prognostic parameters in endometrioid endometrial carcinomas. Standardizing the assesment and scoring of tumor budding, as well as including this entity in routine pathology reports could light the way for ideas in the risk analysis of patients.

Clinical Significance of Lymphatic Infiltration Detected by Immunohistochemical Double Staining in Patients with Endometrial Cancer

Background

The presence of lymph-vascular space invasion is a powerful predictor of lymph node metastasis. However, most studies do not distinguish lymph vessel invasion (LVI) and blood vessel invasion (BVI). The aim of this study was to distinguish the role of LVI and BVI in lymphatic metastasis and recurrence in patients with endometrial cancer.

Methods

We examined 171 patients with endometrial cancer. Immunohistochemical double staining was used to distinguish lymphatic invasion and vascular invasion. First, the relationship between lymphatic/vascular invasion and clinicopathological features and lymphatic metastasis was studied. Then, the expression of D2-40/LVI and CD31/BVI in patients with recurrence was analyzed.

Results

Pathological grading (G3) and D2-40/LVI were independent high-risk factors for lymph node metastasis of endometrial cancer. The area under the receiver operating characteristic curve values for predicting lymphatic metastasis using pathological grading (G3) or D2-40/LVI alone were .642 and .680, respectively, and the area under the curve value for the combined detection of pathological grading (G3) and D2-40/LVI was .726, which was greater than the values obtained for the abovementioned independent variables. Among the 15 recurrent patients, 5 (33.3%) were D2-40/LVI positive, 2 (13.3%) were CD31/BVI positive, and 8 (53.3%) were both D2-40/LVI and CD31/BVI positive.

Conclusion

D2-40/LVI combined with G3 can effectively predict lymph node metastasis of endometrial carcinoma.

Analysis of prognostic factors of metastatic endometrial cancer based on surveillance, epidemiology, and end results database

Objective

To explore the risk factors for survival and prognosis of patients with metastatic endometrial cancer and to build and verify a reliable prediction model.

Methods

We retrospectively analyzed patients diagnosed with metastatic endometrial cancer in the US Surveillance, Epidemiology, and End Results (SEER) database between January 2010 and December 2015. Univariate and multivariate Cox regression analyses were used to assess clinical variables impact on survival and to construct nomograms. The results of the consistency index (C-index), subject operating characteristic (ROC) curve, and calibration curve were used to evaluate the predictive ability of the nomogram.

Results

This study included 3,878 patients with metastatic endometrial cancer. In the univariate analysis, variables associated with overall survival (OS) and cancer-specific survival (CSS) included age, race, marital status, pathological type, pathological grade, T-stage, N-stage, surgery, radiotherapy, chemotherapy, bone metastasis, brain metastasis, liver metastasis, and lung metastasis. In the multivariate analysis, age, race, pathological type, pathological grade, T-stage, N-stage, surgery, radiotherapy, chemotherapy, brain metastasis, liver metastasis, and lung metastasis were independent risk factors for OS and CSS (all P < 0.05). Combined with the results of the multiple factors, the 1-, 3-, 5-, and 8-year nomograms were constructed. For OS and CSS, T-stage had the greatest impact on the adverse prognosis of patients with metastatic endometrial cancer. The C-indexes of the OS and CSS nomograms in the training cohort were 0.749 (95% CI, 0.739-0.760) and 0.746 (95% CI, 0.736-0.756), respectively. The C-indices of OS and CSS in the validation cohort were 0.730 (95% CI, 0.714-0.746) and 0.728 (95% CI, 0.712-0.744), respectively. The ROC curve revealed our model's good prediction accuracy and clinical practicability. The calibration curve also confirmed the consistency between the model and actual existence. The Kaplan-Meier curves revealed statistically significant differences between the risk subgroups (P < 0.05).

Conclusion

Our SEER-based nomograms for predicting survival in patients with metastatic endometrial cancer were helpful for the clinical evaluation of patient prognosis.

Short-hairpin RNA-mediated suppression of cortactin may inhibit the migration and invasion abilities of endometrial cancer cells by reducing lamellipodia

Objectives

The prognosis of endometrial cancer (EC) is significantly affected by tumor infiltration and metastasis. Cortactin (CTTN) regulates infiltration and metastasis in other tumors. Studies on the role and mechanism of CTTN in EC are limited and further studies are needed.

Materials and Methods

Quantitative PCR and immunohistochemistry were used to detect Ras-associated C3 botulinum toxin substrate 1 (Rac1) and CTTN in EC and normal tissues. The relationship between the expression of these two genes and their prognostic factors was analyzed. A CTTN-RNAi lentiviral system was constructed and transfected into EC cells. Migration and invasion were evaluated by scratch assay, transwell migration, and invasion assays. Pseudopodia formation was observed by immunofluorescence staining. Western blotting was performed to detect the expression of Rac1.

Results

The expression levels of Rac1 and CTTN in EC tissues were significantly higher than those in normal tissues. In the EC group, Rac1 and CTTN levels were correlated. The protein expression levels of Rac1 and CTTN were related to myometrial invasion and stage. After CTTN knockdown, the migration rate, invasiveness, and migratory ability of EC cells decreased significantly. Lamellipodia was observed to disappear with the appearance of blebs. Rac1 protein expression was decreased after CTTN knockdown.

Conclusion

CTTN may promote the invasion and migration of EC by lamellipodia. This effect may be related to the regulation of Rac1 by CTTN.

High MutS homolog 2 expression predicts poor prognosis and is related to immune infiltration in endometrial carcinoma

Several studies have shown that MutS homolog 2 (MSH2) is highly expressed in many cancer tissues. Transcriptome expression data were collected from the Cancer Genome Atlas (TCGA) database. We analyzed the expression of MSH2 in normal and tumor tissues, the relationship between MSH2 expression and various prognostic factors, and the relationship between MSH2 expression and overall survival, disease specific survival, and progression free interval. We also examined MSH2 promoter methylation between endometrial cancer and normal endometrial tissues, and identified the prognostic value of MSH2 methylation in endometrial cancer. MSH2 was highly expressed in endometrial cancer tumor tissues compared with normal tissues. High MSH2 expression might be an independent prognostic factor for OS, DSS, and PFI. Further, high MSH2 expression was correlated with age and histological type, but not with BMI, clinical stage, tumor invasion, or other clinical features. MSH2 promoter methylation in endometrial cancer was significantly lower than in normal tissues. Additionally, MSH2 levels, OS, DSS, and PFI were associated with BMI, age, tumor invasion, and histological type. ssGSEA showed that MSH2 expression was positively correlated with the infiltration of Th2 cells, Tcm cells, T helper cells, and Tgd cells, whereas it was negatively correlated with NK CD56 bright cells, pDC cells, iDC cells, cytotoxic cells, and neutrophils. Increased MSH2 expression and reduced MSH2 methylation in endometrial cancer predicts poor prognosis. MSH2 may be used as a biomarker for the diagnosis and prognosis of endometrial cancer and as an immunotherapy target.

Institutional Accuracy Matters: How the Correlation between Frozen Section and Final Pathology Depends on Institutes while Evaluating Lymph Node Involvement in Endometrial Adenocarcinoma

Background and Purpose: The frozen section analysis results help determine the appropriate surgery and treatment for patients with endometrial adenocarcinoma. This study investigates the degree of compliance between the results of frozen section analysis and final pathology reports in patients with endometrial cancer. Methods: This study included 357 patients with endometrial adenocarcinoma who underwent operation, follow-up, and treatment at our hospital. The patients’ demographic, clinical, surgical, and pathological data were retrospectively analyzed. We compared the results of the frozen section and pathological specimens in terms of final pathology, tumor grade, myometrial invasion, tumor size, and lymphovascular system involvement (LVSI). Results: The frozen section analysis and final pathology results for tumor size and LVSI were significantly correlated when patients were divided by tumor type (tumor size: P=0.006, LVSI: P=0.024) or by risk for lymph node involvement (P=0.000). Overall, the frozen section analysis had an accuracy of 70% for tumor grades. The histological results of the frozen section analysis had an accuracy of 77.1% for type 1 tumors and 72.7% for type 2 tumors. Overall, the frozen section analysis had an accuracy of 95% for myometrial invasion. Conclusion: Intraoperative frozen section analysis can prevent unnecessary lymph node dissection when performed at qualified institutions.

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp

ObjectiveOur study's primary aim was to compare the incidence of endometrial carcinoma in patients with a presurgical diagnosis of endometrial intraepithelial neoplasia confined to the endometrium (EIN-E) versus endometrial intraepithelial neoplasia confined to a polyp (EIN-P). Our secondary aim was to examine the difference in pathological features, prognostic risk groups and sentinel lymph node involvement between the two groups.

METHODS

We conducted a retrospective cohort study between January 2014 and December 2020 in a tertiary university-affiliated medical center. The study considered the characteristics of women who underwent hysterectomy with sentinel lymph node dissection for endometrial intraepithelial neoplasia (EIN). We compared EIN-E diagnosed by endometrial sampling via dilatation curettage or hysteroscopic curettage vs EIN-P. A multivariate logistic regression analysis was used to assess risk factors for endometrial cancer.

RESULTS

Eighty-eight women were included in the study, of those, 50 were women with EIN-P (EIN-P group) and 38 were women with EIN following an endometrial biopsy (EIN-E group).The median age was 57.5 years (range; 52-68) in the EIN-P group as compared with 63 years (range; 53-71) in the EIN-E group (p=0.47). Eighty-nine percent of the women in the EIN-E group presented with abnormal uterine bleeding whereas 46% of the women in the EIN-P group were asymptomatic (p=0.001). Pathology results following hysterectomy revealed concurrent endometrial carcinoma in 26% of women in the EIN-P group compared with 47% of women in the EIN-E group (p=0.038). Multivariate analysis showed that endometrial cancer was significantly less common in the EIN-P group (overall response (OR)=0.3 95% confidence interval (CI)=0.1-0.9, p=0.03). Eighty-four percent of cancers were grade one in the EIN-P group compared with 50% in the EIN-E group (p=0.048).

CONCLUSIONS

Concurrent endometrial cancer is less frequent with EIN-P than with EIN-E. The high incidence of endometrial carcinoma in both groups supports the current advice to perform hysterectomy for post-menopausal women. Our data does not support performing sentinel lymph node dissection for EIN-P that was completely resected. The benefit of sentinel lymph node dissection for women with pre-operative EIN-E is yet to be determined.

Malignant transformation of endometrial hyperplastic processes: immunohistochemical features

Background. Endometrial hyperplasia is one of the most common pathologies of the female reproductive system. There is a high risk of transformation of an atypical form of endometrial hyperplasia into endometrial cancer, which takes a leading position in oncogynecological morbidity. Immunohistochemical markers can become predictors of endometrial malignancy, their role is currently being actively studied.

Aim. Search for molecular predictors of malignant transformation of endometrial hyperplasia.

Materials and methods. Histological and immunohistochemical studies were performed in 107 patients with diagnoses of endometrial hyperplasia without atypia (EH), endometrial atypical hyperplasia (EIN), endometrioid adenocarcinoma (EC). The tumor receptor status, MSI, expression of ARID1A, PTEN, β-catenin, PAX2, proliferation index (Ki-67) were determined by the immunohistochemical method according to the standard protocol.

Results. Loss of PAX2 expression was most common in precancerous and malignant endometrial cells. Loss of PAX2 expression was found in 89 % of cases in the EIN samples, in 86 % of cases in the EC samples and only in 2 cases of EH. Loss of PTEN expression was less common: with an equal proportion in 67 % of the samples of EIN and EC, while practically not occurring in women with benign GE. MSI was detected in 36 % of endometrial cancer samples. There was a deficiency in the DNA repair system in 1 case of EIN. Loss of ARID1A expression was detected in endometrial cancer with a frequency of 33 %. This gene functioned normally in all cases of EIN and EH. The expression of β-catenin was more pronounced in EC than in cases of EH. The Ki-67 proliferation index was statistically higher in the EC group than in EH and EIN.

Conclusion. Evaluation of morphological data and expression of the panel of markers PAX2, PTEN, ARID1A, β-catenin, Ki-67 index, PMS2 and MLH1 will improve diagnostic search in case of suspected malignancy of endometrial hyperplasia.

Not all stage I and II endometrial cancers are created equal: Recurrence-free survival and cause-specific survival after observation or vaginal brachytherapy alone in all subgroups of early-stage high-intermediate and high-risk endometrial cancer

OBJECTIVE

To evaluate recurrence-free survival (RFS) and cause-specific survival (CSS) after observation or vaginal brachytherapy (VB) alone in all subgroups of early-stage high-intermediate (HIR) and high-risk endometrial cancer (EC).

METHODS

We identified patients with stage I HIR (GOG-249 criteria) and stage II endometrioid EC, and stage I and II non-endometrioid EC who underwent surgery at Mayo Clinic and Cleveland Clinic between 1999 and 2016. Three-year RFS and CSS after observation or VB only were estimated in 16 subgroups defined by risk factors.

RESULTS

Among 4156 ECs, we identified 447 (10.8%) stage I endometrioid HIR, 52 (1.3%) stage II endometrioid, 350 (8.4%) stage I non-endometrioid, and 17 (0.4%) stage II non-endometrioid ECs; observation or VB alone was applied in 349 (78.1%), 24 (46.2%), 187 (53.4%), and 2 (11.8%) patients, respectively. After observation or VB, stage I HIR endometrioid EC subgroups with <2 factors among grade 3, LVSI, or stage IB had a 3-year CSS >95% (lower 95% confidence intervals limit: 89.8%), whereas subgroups with ≥2 factors had poorer outcomes. No EC-related deaths after 3 years were reported in 97 stage IA non-endometrioid ECs without myometrial invasion. Stage II ECs had poor outcomes regardless of histology.

CONCLUSIONS

Observation or VB only may be sufficient in stage I endometrioid HIR ECs with <2 factors among grade 3, LVSI, or IB and in stage IA non-endometrioid ECs without myometrial invasion. Stratification of early-stage HIR and high-risk ECs into risk subgroups potentially alleviates the overtreatment and undertreatment risk and should be considered in future research.

IETA Ultrasonic Features Combined with GI-RADS Classification System and Tumor Biomarkers for Surveillance of Endometrial Carcinoma: An Innovative Study

Objectives: We were the first to combine IETA ultrasonic features with GI-RADS and tumor biomarkers for the surveillance of endometrial carcinoma. The aim was to evaluate the efficacy of single IETA ultrasonography GI-RADS classification and combined tumor biomarkers in differentiating benign and malignant lesions in the uterine cavity and endometrium. Methods: A total of 497 patients with intrauterine and endometrial lesions who had been treated surgically between January 2017 and December 2021 were enrolled; all of them had undergone ultrasound examinations before surgery. We analyzed the correlation between the terms of ultrasonic signs of the uterine cavity and endometrial lesions defined by the expert consensus of IETA and the benign and malignant lesions and then classified these ultrasonic signs by GI-RADS. In addition, the tumor biomarkers CA125, CA15-3, CA19-9 and HE4 were combined by adjusting the classification. The results of the comprehensive analysis were compared with pathological results to analyze their diagnostic efficacy. Results: (1) The statistic analysis confirmed that there were seven independent predictors of malignant lesions, including thickened endometrium (premenopause ≥ 18.5 mm, postmenopause ≥ 15.5 mm), non-uniform endometrial echogenicity (heterogeneous with irregular cysts), endometrial midline appearance (not defined), the endometrial-myometrial junction (interrupted or not defined), intracavitary fluid (ground glass or "mixed" echogenicity), color score (3~4 points) and vascular pattern (focal origin multiple vessels or multifocal origin multiple vessels). (2) In traditional ultrasound GI-RADS (U-T-GI-RADS), if category 4a was taken as the cut-off value of benign and malignant, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy were 97.2%, 65.2%, 44.0%, 98.8% and 72.2%, respectively, and the area under the ROC curve (AUC) was 0.812. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 88.1%, 92.0%, 75.6%, 96.5% and 91.2%, 0.900, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.5%, 93.2%, 93.4%, 93.4% and 0.868, respectively, when taking category 5 as the cutoff point. In modified ultrasound GI-RADS (U-M-GI-RADS), if 4a was taken as the cut-off value, The diagnostic efficacy was the same as U-T-GI-RADS. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV, diagnostic accuracy and AUC were 88.1%, 92.3%, 76.2%, 96.5%, 91.3% and 0.902, respectively. If 4c was taken as the cutoff point, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.7%, 94.3%, 93.4%, 93.6% and 0.870, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 66.1%, 99.7%, 98.6%, 91.3%, 92.4% and 0.829, respectively, if taking category 5 as the cutoff point. (3) In the comprehensive diagnostic method of U-T-GI-RADS combined tumor biomarkers results, the AUC of class 4a, 4b and 5 as the cutoff value was 0.877, 0.888 and 0.738, respectively. The AUC of class 4a, 4b, 4c and 5 as the cutoff value in the comprehensive diagnostic method of U-M-GI-RADS combined tumor biomarkers results was 0.877, 0.888, 0.851 and 0.725, respectively. There was no significant difference in diagnostic efficiency between the two comprehensive diagnostic methods. Conclusions: In this study, no matter which diagnostic method was used, the best cutoff value for predicting malignant EC was ≥GI-RADS 4b. The GI-RADS classification had good performance in discriminating EC. The tumor biomarkers, CA125, CA19-9, CA15-3 and HE4, could improve the diagnostic efficacy for preoperative endometrial carcinoma assessment.

Preoperative Tumor Texture Analysis on MRI for High-Risk Disease Prediction in Endometrial Cancer: A Hypothesis-Generating Study

OBJECTIVE

To develop and validate magnetic resonance (MR) imaging-based radiomics models for high-risk endometrial cancer (EC) prediction preoperatively, to be able to estimate deep myometrial invasion (DMI) and lymphovascular space invasion (LVSI), and to discriminate between low-risk and other categories of risk as proposed by ESGO/ESTRO/ESP (European Society of Gynaecological Oncology-European Society for Radiotherapy & Oncology and European Society of Pathology) guidelines.

METHODS

This retrospective study included 96 women with EC who underwent 1.5-T MR imaging before surgical staging between April 2009 and May 2019 in two referral centers divided into training (T = 73) and validation cohorts (V = 23). Radiomics features were extracted using the MODDICOM library with manual delineation of whole-tumor volume on MR images (axial T2-weighted). Diagnostic performances of radiomic models were evaluated by area under the receiver operating characteristic (ROC) curve in training (AUCT) and validation (AUCV) cohorts by using a subset of the most relevant texture features tested individually in univariate analysis using Wilcoxon-Mann-Whitney.

RESULTS

A total of 228 radiomics features were extracted and ultimately limited to 38 for DMI, 29 for LVSI, and 15 for risk-classes prediction for logistic radiomic modeling. Whole-tumor radiomic models yielded an AUCT/AUCV of 0.85/0.68 in DMI estimation, 0.92/0.81 in LVSI prediction, and 0.84/0.76 for differentiating low-risk vs other risk classes (intermediate/high-intermediate/high).

CONCLUSION

MRI-based radiomics has great potential in developing advanced prognostication in EC.

Transperitoneal vs extraperitoneal approach for aortic sentinel node detection in endometrial cancer

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Overall, aortic and pelvic detection rate is not influenced by the surgical approach.

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The number of aortic sentinel nodes above or below the inferior mesenteric artery is not influenced by the surgical approach.

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The extraperitoneal approach detects a greater number of left lateroaortic aortic sentinel nodes.

BACKGROUND

Although the sentinel lymph node technique in endometrial cancer is currently replacing pelvic and aortic lymphadenectomy for the evaluation of lymph node status in endometrial cancer, its performance is not yet standardized.

OBJECTIVE

This study aimed to describe the detection rates and locations of aortic sentinel lymph node detection after dual cervical and fundal indocyanine green injection in patients with endometrial cancer, using the transperitoneal and extraperitoneal approaches.

STUDY DESIGN

Between June 26, 2014 and December 31, 2019, 278 patients underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed sentinel lymph node biopsy with dual cervical and fundal indocyanine green injection, and back-up lymphadenectomy in high-risk cases. A post hoc analysis was performed to evaluate differences between the transperitoneal and extraperitoneal approach to aortic sentinel lymph nodes.

RESULTS

The detection rates were as follows: overall detection rate: 93.2% (259/278); pelvic detection rate: 90.3% (251/278); bilateral pelvic detection rate: 68.0% (189/278); aortic detection rate: 66.9% (186/278); and isolated aortic detection rate: 2.88% (8/278). Transperitoneal and extraperitoneal aortic detection rates were similar (65.0% and 69.6%, respectively), with no significant differences (P=.441). Isolated aortic metastases were similar in both groups (2% vs 4.7%, respectively; P=.185). The laterality of aortic sentinel lymph node detection was influenced by the surgical approach (P=.002), but not its location above or below the inferior mesenteric artery (P=.166 and P=.556, respectively).

CONCLUSION

The detection rates at the aortic level were similar between the transperitoneal and extraperitoneal approaches, with no impact on subsequent pelvic detection. The transperitoneal approach detected more laterocaval, precaval, and interaortocaval nodes, whereas the extraperitoneal approach detected more preaortic and left lateroaortic nodes.

The amount of preoperative endometrial tissue surface in relation to final endometrial cancer classification

OBJECTIVE

To evaluate whether the amount of preoperative endometrial tissue surface is related to the degree of concordance with final low- and high-grade endometrial cancer (EC). In addition, to determine whether discordance is influenced by sampling method and impacts outcome.

METHODS

A retrospective cohort study within the European Network for Individualized Treatment of Endometrial Cancer (ENITEC). Surface of preoperative endometrial tissue samples was digitally calculated using ImageJ. Tumor samples were classified into low-grade (grade 1-2 endometrioid EC (EEC)) and high-grade (grade 3 EEC + non-endometroid EC).

RESULTS

The study cohort included 573 tumor samples. Overall concordance between pre- and postoperative diagnosis was 60.0%, and 88.8% when classified into low- and high-grade EC. Upgrading (preoperative low-grade, postoperative high-grade EC) was found in 7.8% and downgrading (preoperative high-grade, postoperative low-grade EC) in 26.7%. The median endometrial tissue surface was significantly lower in concordant diagnoses when compared to discordant diagnoses, respectively 18.7 mm2 and 23.5 mm2 (P = 0.022). Sampling method did not influence the concordance in tumor classification. Patients with preoperative high-grade and postoperative low-grade showed significant lower DSS compared to patients with concordant low-grade EC (P = 0.039).

CONCLUSION

The amount of preoperative endometrial tissue surface was inversely related to the degree of concordance with final tumor low- and high-grade. Obtaining higher amount of preoperative endometrial tissue surface does not increase the concordance between pre- and postoperative low- and high-grade diagnosis in EC. Awareness of clinically relevant down- and upgrading is crucial to reduce subsequent over- or undertreatment with impact on outcome.

Correlation between preoperative imaging biomarkers and histological prognostic factors in endometrial cancer: A prospective study

PURPOSE

We compared transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) for detecting myometrial infiltration, cervical involvement, and for measuring tumor volume in endometrial cancer patients. We also correlated tumor volume to worse histological prognostic factors.

METHODS

We recruited women with a histological diagnosis of endometrial cancer between March 2019 and March 2021. Inclusion criteria were: age ≥ 18 years, written informed consent, biopsy-proven endometrial cancer, absence of previous neoadjuvant chemo- or radiotherapy treatment, patient suitable for primary surgery. Exclusion criteria were: advanced disease stage and other coexisting malignant tumors. TVUS and MRI were used, in the absence of any contraindication. We compared the preoperative imaging results with final histopathology.

RESULTS

The accuracy of TVUS and MRI in evaluating myometrial infiltration, cervical invasion and tumor volume were comparable. A tumor volume ≥2 ml showed a positive correlation with worse histological prognostic factors, such as high tumor grade, diffuse lymphvascular space involvement (LVSI) and deep myometrial invasion (p < 0.05).

CONCLUSION

TVUS should be used as first-line imaging modality, being more available, cost-effective, and more acceptable by patients. A careful local staging of endometrial cancer patients before surgery is fundamental in order to improve tailored treatment and minimize costs.

p53, Pirh2, and L1CAM as Promising Prognostic Biomarkers of Endometrial Carcinoma: An Immunohistochemical and Genetic Study

Endometrial cancer (EC) is the most common gynecologic cancer and the current methods for the prediction of its prognosis and treatment response are unfortunately suboptimal. In this study, we evaluated the prognostic value of p53, Pirh2, and L1CAM in 60 cases of EC using immunohistochemistry (IHC) and polymerase chain reaction. TP53 missense mutations result in nuclear accumulation of p53 protein that can be detected as overexpression by IHC. This is in the form of diffuse strong nuclear positivity involving at least at least >50% of the tumor cells as a whole or if >50% of the tumor cells of a discrete geographical areas. Abnormal p53 IHC expression was expressed in 33.3% of the cases and significantly associated with the tumor grade, myometrial invasion (MI), lymphovascular invasion (LVSI), nodal metastasis, and FIGO stage, and the advanced European Society for Medical Oncology (ESMO) risk groups (P<0.001 for each). High IHC Pirh2 expression was noted in 58.3% of the cases, and significantly associated with MI, LVSI, nodal metastasis, FIGO stage, and high-risk group (P<0.001, P=0.011, P=0.010, P=0.024, P=0.005, respectively). There was a significant upregulation of Pirh2 mRNA expression in EC specimens as compared with the control adjacent tissues (P=0.001). Upregulated Pirh2 mRNA expression had a significant association with Pirh2 immunostaining, tumor grade, tumor stage, MI, lymph node involvement, LVSI, and relapse (P<0.001 for each). Positive L1CAM immunoexpression was noted in 26.7% and was significantly associated with grade, MI, LVSI, nodal metastasis, FIGO stage, and high-risk group (P=0.003, P=0.023, P=0.003, P<0.001, P<0.001, P=0.002, respectively). Analysis of follow-up period revealed that EC with abnormal p53 IHC expression, high pirh2 and positive L1CAM expression exhibited a potent relation with tumor relapse, shorter overall survival and disease-specific survival (P<0.001 for each). Mutant p53, high Pirh2, and L1CAM-positive EC are highly aggressive tumors with a shortened survival rate, dismal outcome, and high risk of relapse after the standard protocol of therapy.

Identification of inflammatory-related gene signatures to predict prognosis of endometrial carcinoma

Little is known about the prognostic risk factors of endometrial cancer. Therefore, finding effective prognostic factors of endometrial cancer is the vital for clinical theranostic. In this study, we constructed an inflammatory-related risk assessment model based on TCGA database to predict prognosis of endometrial cancer. We screened inflammatory genes by differential expression and prognostic correlation, and constructed a prognostic model using LASSO regression analysis. We fully utilized bioinformatics tools, including ROC curve, Kaplan-Meier analysis, univariate and multivariate Cox regression analysis and in vitro experiments to verify the accuracy of the prognostic model. Finally, we further analyzed the characteristics of tumor microenvironment and drug sensitivity of these inflammatory genes. The higher the score of the endometrial cancer risk model we constructed, the worse the prognosis, which can effectively provide decision-making help for clinical endometrial diagnosis and treatment.

Fertility-Sparing Approach in Patients with Endometrioid Endometrial Cancer Grade 2 Stage IA (FIGO): A Qualitative Systematic Review

Background

Endometrial cancer (EC) is one of the most common gynecologic malignancy, mostly in postmenopausal women. The gold standard treatment for EC is surgery, but in the early stages, it is possible to opt for conservative treatment. In the last decade, different clinical and pathological markers have been studied to identify women who respond to conservative treatment. A lot of immunohistochemical markers have been evaluated to predict response to progestin treatment, even if their usefulness is still unclear; the prognosis of this neoplasm depends on tumor stage, and a specific therapeutic protocol is set according to the stage of the disease.

Objective

(1) To provide an overview of the conservative management of Stage 1A Grade (G) 2 endometrioid EC (FIGO) and the oncological and reproductive outcomes related; (2) to describe the molecular alterations before and after progestin therapy in patients undergoing conservative treatment.

Materials and Methods

A systematic computerized search of the literature was performed in the main electronic databases (MEDLINE, Embase, Web of Science, PubMed, and Cochrane Library), from 2010 to September 2021, in order to evaluate the oncological and reproductive outcomes in patients with G2 stage IA EC who ask for fertility-sparing treatment. The expression of several immunohistochemical markers was evaluated in pretreatment phase and during the follow-up in relation to response to hormonal therapy. Only scientific publications in English were included. The risk of bias assessment was performed. Review authors' judgments were categorized as “low risk,” “high risk,” or “unclear risk” of bias.

Results

Twelve articles were included in the study: 7 observational studies and 5 case series/reports. Eighty-four patients who took progestins (megestrol acetate, medroxyprogesterone acetate, and/or levonorgestrel-releasing intrauterine devices) were analyzed. The publication bias analysis turned out to be “low.” 54/84 patients had a complete response, 23/84 patients underwent radical surgery, and 20/84 had a relapse after conservative treatment. Twenty-two patients had a pregnancy. The length of follow-up was variable, from 6 to 142 months according to the different studies analyzed. Several clinical and pathological markers have been studied to identify women who do not respond to conservative treatment: PR and ER were the most studied predictive markers, in particular PR appeared as the most promising; MMR, SPAG9, Ki67, and Nrf2-survivin pathway provided good results with a significant association with a good response to progestin therapy. However, no reliable predictive markers are currently available to be used in clinical practice.

Conclusions

The conservative treatment may be an option for patients with stage IA G2 EEC who desire to preserve their fertility. The immunohistochemical markers evaluation looks promising in predicting response to conservative treatment. Further large series and randomized clinical trials are needed to confirm these results.

The correlation between APOE expression and the clinical characteristics and prognosis of patients with endometrial cancer

To analyze the expression of apolipoprotein E (APOE) in endometrial cancer and its influence on the long-term prognostic survival of endometrial cancer patients. The specimens of tumor tissues and adjacent normal tissues from 96 endometrial cancer patients from January 2013 to December 2015 were included in this study. Immunohistochemistry was used to measure the expression of APOE in tumor tissues and adjacent normal tissues. Statistical analysis was used to examine the correlation between APOE expression and the clinicopathological characteristics and survival of patients. Kaplan-Meier survival curve was drawn to study the effects of APOE on the prognosis of patients. The positive rate of APOE in endometrial cancer tissue was higher than that in adjacent normal tissues. The expression level of APOE in endometrial cancer was correlated with histological grade, lymph node metastasis, and FIGO stage (P < .05). Lymph node metastasis and APOE were independent risk factors affecting the prognosis and survival of patients (P < .05). The results of Kaplan-Meier survival analysis showed that the survival time of APOE high expression group was shorter than that of low APOE expression. APOE is overexpressed in endometrial cancer tissues, and its expression level can provide important information for clinical diagnosis and treatment.

Clinical Application of Digital 3D Reconstruction and 3D Printing Technology in Endometrial Cancer (EC) Surgery

Aims

We use CTA and magnetic resonance data to use digital three-dimensional reconstruction and 3D printing technology to reproduce the solid replication of the uterus and surrounding tissues in vitro, fully evaluate the adjacency of tumor tissues with surrounding important organs, blood vessels, and lymph nodes, and reduce the impact. The normal organ structure and function of the surgeon can shorten the operation time, reduce the bleeding during the operation, and reduce the perioperative complications of the patient to improve the prognosis of the patient.

Materials and Methods

Select 40 EC patients and divide them into group A (3D reconstruction data is transmitted to 3D printing equipment according to the results of CTA and MRI examination, and a 3D model is printed out according to the ratio of 1 : 1 for evaluation and judgment before surgery) and group B (according to MRI imaging examination, there were 20 cases each). Different surgical conditions, quality of life, adverse reactions, and clinical efficacy were evaluated in each group.

Results

The operation time, the time of the first anus exhaust, the hospitalization time after the operation, and the blood loss of the operation in group A were significantly lower than those in group B. Statistics showed that the difference was significant (P < 0.05). The quality of life scores of emotion, cognition, society, and overall health of group A were significantly higher than those of group B, while physical score, fatigue, nausea, vomiting, and pain were lower than those of group B, which were statistically significant (P < 0.05). Both groups of patients had complications after the operation, and they were asked to be followed up at the outpatient clinic 3 months after the operation. All patients recovered well. There were 19 and 18 patients in groups A and B, respectively, complaining of improvement in clinical symptoms, and the difference was not statistically significant (P < 0.05).

Conclusion

With the support of digital three-dimensional reconstruction and 3D printing technology, complex operations can be accurately performed, improving the efficacy and safety of patients after EC surgery, improving patient outcomes and quality of life, improving EC positioning accuracy, and reducing tumor residue.

Cancer‑associated gene analysis of cervical cytology samples and liquid‑based cytology significantly improve endometrial cancer diagnosis sensitivity

To the best of our knowledge, there are no useful screening methods for early detection of endometrial cancer in asymptomatic individuals. The present study evaluated the usefulness of genetic analysis of liquid-based cytology (LBC) specimens by assessing whether pathological genetic mutations detected in cancer tissue sections were detected in LBC specimens from the cervix and uterus. The primary endpoint was genetic analysis of cervical cytology specimens and LBC for the detection of endometrial cancer. Endometrial thickening (>11 mm) assessed using transvaginal ultrasonography was present in 60% of cases and adenocarcinoma assessed using cervical cytology was present in 50% of cases. In 70% of cases, pathogenic mutations detected in cancer tissue sections were also detected in cervical and/or endometrial LBC specimens. The pathogenic variants identified were PTEN in four cases, tumor protein P53, PI3K catalytic subunit α and fibroblast growth factor receptor 2 in two cases each and APC regulator of WNT signaling pathway, KRAS and catenin β1 in one case each. In the present study, a combination of endometrial thickening assessed by transvaginal ultrasonography, cervical cytology and genetic analysis resulted in a high sensitivity of 90% for detection of endometrial cancer. The combination of these tests is more expensive than conventional methods, but delayed detection of uterine cancer requires multidisciplinary treatment, which increases healthcare costs. Increased spending on early detection of uterine cancer is better economically and may improve patient quality of life.

High RIG-I and EFTUD2 expression predicts poor survival in endometrial cancer

PURPOSE

Endometrial cancer is the most common gynecological malignancy. The helicase RIG-I, a part of the innate immune system, and EFTUD2, a splicing factor which can upregulate RIG-I expression, are shown to influence tumor growth and disease progression in several malignancies. For endometrial cancer, an immunogenic cancer, data about RIG-I and EFTUD2 are still missing. The aim of this study was to examine the expression of RIG-I and EFTUD2 in endometrial cancer.

METHODS

225 specimen of endometrial cancer were immunohistochemically stained for RIG-I and EFTUD2. The results were correlated to clinicopathological data, overall survival (OS) and progression-free survival (PFS).

RESULTS

High RIG-I expression correlated with advanced tumor stages (FIGO: p = 0.027; pT: p = 0.010) and worse survival rates (OS: p = 0.009; PFS: p = 0.022). High EFTUD2 expression correlated to worse survival rates (OS: p = 0.026; PFS: p < 0.001) and was determined to be an independent marker for progression-free survival.

CONCLUSION

Our data suggest that the expression of RIG-I and EFTUD2 correlates with survival data, which makes both a possible therapeutic target in the future.

Clinical Profile and Survival Outcome of Endometrial Cancer with p53 Mutation

Clinicopathologic classification of endometrial cancer imperfectly reflects the tumor biology. Pathologic categorization - especially in high-grade tumors - results in an imprecise estimation of the risk of disease, recurrence, and death. Molecular subtyping is emerging as the standard of care in diagnosis and treatment of endometrial cancers. Molecular markers are important prognostic factors in tumor dissemination and early recurrence of endometrial cancers. TP53 mutation is an important prognostic factor for both serous and endometrioid cancers. The study aims to compare the clinical profile and overall survival of endometrial cancers with and without p53 mutation. Sixty-three patients who underwent surgical staging for carcinoma endometrium were included in the study.TP53 mutation status was determined based on p53 expression by immunohistochemistry (IHC) as a p53 wild or p53 mutant type. Data were analyzed for the clinical profile, p53 mutation status on IHC, histological pattern, tumor grade, stage of the disease, lymph node spread, recurrence pattern, treatment received, 2-year disease-free survival, and overall survival. Recurrence was noted in 12.7% patients after 2-year follow-up, of which 75% patients had p53 mutation. Significant association was seen between p53 expression and high-grade tumors, stage, cervical involvement, and adnexal involvement. The 2-year overall survival of the p53 wild type was 97.2% and the p53 mutant type was 91.7%. The 2-year disease-free survival for the p53 wild type was 94.3% and the disease-free survival of the p53 mutant variety was 83.5%. The 2-year disease-free survival for endometrioid carcinoma with p53 wild type was 100% and p53 mutant variety was 86.2% (p value 0.033). About 15.9% (10) patients were reassigned to the high-risk group needing chemotherapy and radiation according to the ESGO ESTRO 2021 consensus classification, due to their p53 mutation status. IHC to assess somatic p53 mutation may be done in endometrial biopsies irrespective of their histology. This may help to identify that the aggressive tumors thereby help in tailoring surgery, planning adjuvant treatment, and follow-up.

Less is more in endometrial cancer (SLN, conservative treatment, radical hysterectomy, molecular classification)

PURPOSE OF REVIEW

The management of endometrial cancer has known many evolutions within the last decades. In this review, we aim to summarize recent evolutions (mainly toward less aggressive management) that have occurred in the management of endometrial cancer.

RECENT FINDINGS

Enhanced by molecular classification, the determination of lymph node status, in young women, in case of cervical invasion, the treatment is evolving toward a less aggressive strategy.

SUMMARY

The predictive value and the safety of sentinel lymph node biopsy explain why most societies propose to abandon systematic pelvic and para aortic lymphadenectomy. For young women, the safety of fertility preservation is now well established and efficient protocols have been validated. In stage II endometrial cancer (stromal cervical invasion), radical hysterectomy appears excessive. The Cancer Genome Atlas classification increases prognostic evaluation in association with the traditional pathological classification and permits to tailor adjuvant treatment more accurately.

Recurrent Endometrial Cancer: Which Is the Best Treatment? Systematic Review of the Literature

Simple Summary

Endometrial cancer is the most common gynaecological tumour in developed countries. The aim of this systematic review is to compare different therapeutic strategies in the treatment of endometrial cancer recurrence to evaluate their prognostic and curative effects. The treatment of choice should be assessed according to the relapse location and to the presence of single or multiple lesions. A crucial role is also played by the type of adjuvant treatment received at the time of the first diagnosis. The molecular pattern will also be investigated in future studies. This will make it possible to personalise treatments.

Abstract

Background: Endometrial cancer is the most common gynaecological tumour in developed countries. The overall rate of relapse has remained unchanged in recent decades. Recurrences occur in approximately 20% of endometrioid and 50% of non-endometrioid cases. The aim of this systematic review is to compare different therapeutic strategies in the treatment of endometrial cancer recurrence to evaluate their prognostic and curative effects based on site and type of recurrence. Methods: This systematic review of literature was conducted in accordance with the PRISMA guidelines. The study protocol was registered on PROSPERO (CRD42020154042). PubMed, Embase, Chocrane and Cinahl databases were searched from January 1995 to September 2021. Five retrospective studies were selected. Results: A total of 3571 studies were included in the initial search. Applying the screening criteria, 299 articles were considered eligible for full-text reading, of which, after applying the exclusion criteria, 4 studies were selected for the final analysis and included in the systematic review. No studies were included for a quantitative analysis. We divided the results according to the location of the recurrence: locoregional recurrence, abdominal recurrence and extra abdominal recurrence. Conclusion: the treatment of choice should be assessed according to the relapse location and to the presence of single or multiple lesions. A crucial role in the decision-making algorithm is also the type of adjuvant treatment received at the time of the first diagnosis.

Update on MRI in Evaluation and Treatment of Endometrial Cancer

Endometrial cancer is the second most common gynecologic cancer worldwide and the most common gynecologic cancer in the United States, with an increasing incidence in high-income countries. Although the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer is a surgical staging system, contemporary published evidence-based data and expert opinions recommend MRI for treatment planning as it provides critical diagnostic information on tumor size and depth, extent of myometrial and cervical invasion, extrauterine extent, and lymph node status, all of which are essential in choosing the most appropriate therapy. Multiparametric MRI using a combination of T2-weighted sequences, diffusion-weighted imaging, and multiphase contrast-enhanced imaging is the mainstay for imaging assessment of endometrial cancer. Identification of important prognostic factors at MRI improves both treatment selection and posttreatment follow-up. MRI also plays a crucial role for fertility-preserving strategies and in patients who are not surgical candidates by helping guide therapy and identify procedural complications. This review is a product of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel and reflects a multidisciplinary international collaborative effort to summarize updated information highlighting the role of MRI for endometrial cancer depiction and delineation, treatment planning, and follow-up. The article includes information regarding dedicated MRI protocols, tips for MRI reporting, imaging pitfalls, and strategies for image quality optimization. The roles of MRI-guided radiation therapy, hybrid PET/MRI, and advanced MRI techniques that are applicable to endometrial cancer imaging are also discussed. Online supplemental material is available for this article. ^©RSNA, 2022.

Aziz NH, Md Zin RR, Tan GC, Shafiee MN. PD-L1 Expression in Endometrial Cancer and Its Association with Clinicopathological Features: A Systematic Review and Meta-Analysis

Simple Summary

In women, endometrial cancer is a crucial cancer cause-death, which is still not fully explored in its pathogenesis and immune system. Early detection is essential for proper treatment and follow-up in affected patients. This systematic review and meta-analysis aim to pool the prevalence of PD-L1 in endometrial cancer and its association with clinicopathological features. The pooled prevalence of PD-L1 was 34.26% in tumour cells, and 51.39% in immune cells among endometrial cancer patients. There was significant association of PD-L1 expression in both tumour cells and immune cells with advanced stage endometrial cancer. The presence of lympho-vascular invasion and poor overall survival were also associated with PD-L1 expression in immune cells. These information enable clinicians to stratify endometrial cancer patients for anti-PD-1/PD-L1 immune therapy.

Abstract

Endometrial cancer (EC) is one of the most common malignancies of the female genital tract and its current treatment mainly relies on surgical removal of the tumour bulk, followed by adjuvant radiotherapy with or without chemotherapy/hormonal therapy. However, the outcomes of these approaches are often unsatisfactory and are associated with severe toxicity and a higher recurrence rate of the disease. Thus, more clinical research exploring novel medical intervention is needed. Involvement of the immune pathway in cancer has become important and the finding of a high positive expression of programmed cell death-ligand 1 (PD-L1) in EC may offer a better targeted therapeutic approach. Numerous studies on the PD-L1 role in EC have been conducted, but the results remained inconclusive. Hence, this systematic review was conducted to provide an update and robust analysis in order to determine the pooled prevalence of PD-L1 expression in EC and evaluate its association with clinicopathological features in different focuses of tumour cells (TC) and immune cells (IC). A comprehensive literature search was conducted using the PubMed, Web of Science, and Scopus databases. Twelve articles between 2016 and 2021 with 3023 EC cases met the inclusion criteria. The effect of PD-L1 expression on the outcome parameters was estimated by the odds ratios (ORs) with 95% confidence intervals (CIs) for each study. The pooled prevalence of PD-L1 was 34.26% and 51.39% in the tumour cell and immune cell, respectively, among women with EC. The PD-L1 expression was significantly associated with Stage III/IV disease (in both TC and IC) and correlated to the presence of lympho-vascular invasion in IC. However, the PD-L1 expression in TC was not associated with the age groups, histology types, myometrial invasion, and lympho-vascular invasion. In IC, PD-L1 expression was not associated with age group, histology type, and myometrial invasion. The meta-analysis survival outcomes of PD-L1 high expression had a significant association with worse OS in IC but not in TC.

A Comprehensive Analysis of Interferon Regulatory Factor Expression: Correlation with Immune Cell Infiltration and Patient Prognosis in Endometrial Carcinoma

As a family of transcription factors, the correlations between expression pattern of nine interferon regulatory factor (IRF) family members, the immune invasion pattern, and the associated patient survival rate in endometrial carcinoma (EC) remain to be elucidated. Based on The Cancer Genome Atlas (TCGA), the expression profiles of the high and low IRF mRNA expression groups were analyzed using R (3.6.3) statistical software. Gene annotation and pathway analyses were performed using Metascape. GSEA was performed using the R package clusterProfiler (3.6.3). The single-sample gene set enrichment analysis (ssGSEA) was used to quantify the relative tumor infiltration levels of immune cell types. Immunohistochemistry data provided by HPA database was used to study the expression of the IRF proteins. Using the GEPIA dataset, the correlation between the expression of IRFs and the tumor stage of EC was analyzed. The correlations between the different IRFs were analyzed using cBioPortal. The expression of IRF2, IRF3, IRF5, IRF6, IRF7, IRF8, and IRF9 was different when comparing EC and normal endometrial samples. IRF2, IRF6, IRF7, and IRF8 were indicated to be potential diagnostic markers for EC. In combination with receiver operating characteristic analysis results, IRF2, IRF6, IRF7, and IRF8 were indicated to be potential diagnostic markers for EC. Levels of individual IRFs were associated with alternate outcomes, with the expression of IRF3 being correlated with the stage of EC and high expression of IRF4 being positively correlated with overall survival (OS); conversely, high expression of IRF5 was negatively correlated with OS. Additionally, high expression levels of both IRF2 and IRF4 were positively correlated with the disease-specific survival rate, and high expression of IRF4 was positively correlated with the progression-free interval. These data suggest a role for IRF2, IRF4, and IRF5 in the prognosis of EC. The expression of IRFs is associated with immune infiltration.

Impact of pre-treatment prognostic nutritional index and the haemoglobin, albumin, lymphocyte and platelet (HALP) score on endometrial cancer survival: A prospective database analysis

Purpose

The Onodera’s prognostic nutritional index (PNI) and the haemoglobin, albumin, lymphocyte and platelet (HALP) score are immune-nutritional indices that correlate with survival outcomes in several adult solid malignancies. The aim of this study was to investigate whether PNI and HALP are associated with survival outcomes in endometrial cancer.

Patients and methods

Women undergoing management for endometrial cancer were recruited to a single centre prospective cohort study. Pre-treatment PNI and HALP scores were computed for study participants and analysed as continuous variables and by selecting cut-off values based on previous publications. Both parameters were analysed in relation to overall, endometrial cancer-specific and recurrence-free survival using Kaplan-Meier estimation and multivariable Cox proportional regression.

Results

A total of 439 women, with a median age of 67 years (interquartile range (IQR), 58, 74) and BMI of 31kg/m² (IQR 26, 37) were included in the analysis. Most had low-grade (63.3%), early-stage (84.4% stage I/II) endometrial cancer of endometrioid histological subtype (72.7%). Primary treatment was surgery in 98.2% of cases. Adjusted overall mortality hazard ratios for PNI and HALP as continuous variables were 0.97(95%CI 0.94–1.00, p = 0.136) and 0.99(95%CI 0.98–1.01, p = 0.368), respectively. Women with pre-treatment PNI ≥45 had a 45% decrease in both overall (adjusted HR = 0.55, 95% CI 0.33–0.92, p = 0.022) and cancer-specific mortality risk (adjusted HR = 0.55, 95%CI 0.30–0.99, p = 0.048) compared to those with PNI <45. There was no evidence for an effect of PNI on recurrence free survival. HALP scores were associated with adverse clinico-pathologic factors, but not overall, cancer-specific or recurrence-free survival in the multivariable analysis.

Conclusion

PNI is an independent prognostic factor in endometrial cancer and has the potential to refine pre-operative risk assessment.

Cuttlefish bone powder as an efficient solid-phase extraction sorbent of anti-SARS-CoV-2 drugs in environmental water

Many antiviral drugs were developed to counteract coronavirus disease, 2019 (COVID-19) with severe acute respiratory syndrome. Therefore, the scientific community's efforts have focused on the detection and quantification of antiviral compounds currently being tested for COVID-19 treatment. Cuttlefish bone powder (CFBP) has been used for the first time as solid-phase extraction (SPE) sorbent for the extraction of SARS CoV-2 antiviral drugs (chloroquine, ritonavir and indomethacin) from water samples. An effective and sensitive method was developed by combining SPE and liquid chromatography- UV detection (LC-UV). An experimental design was applied for the optimization of extraction process. Experimental variables were optimized using Doehlert matrix. The developed method included 50 mg of CFBP sorbent, 20 mL of water sample at pH = 9 and 5 mL of ACN/KH₂PO₄ buffer solution (80:20, v/v) in the elution step. For validation of the method, selectivity, linearity precision, and sensitivity were evaluated. Extraction recovery percentage of all Sars cov-2 antivirals were above 98.2%. The detection and quantification limits were between 0.1 and 0.5 µg L⁻¹ and 0.6 and 2 µg L⁻¹, respectively. The current study suggested that CFBP has the application potential for the enhanced SPE of SARS CoV-2 antiviral drugs from water samples.

Prognostic values of human epididymis protein 4 expression in patients with endometrial cancer: A systematic review and meta-analysis

BACKGROUND

There is no consensus on the correlation between human epididymis protein 4 (HE4) and prognosis of endometrial cancer (EC). Therefore, we performed a meta-analysis to assess the relationship between HE4 and prognosis of EC.

METHODS

In this systematic review and meta-analysis, the databases were searched. Correlation of serum or tissue HE4 with clinicopathological characteristics was determined by odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval (CI), respectively. The hazard ratio (HR) with 95% CI was calculated to evaluate the correlation between HE4 and survival outcome.

RESULTS

A total of 38 published studies were eligible. We found that high levels of serum HE4 were associated with FIGO III-IV stage (SMD = 1.58, 95%CI: 1.18-1.98, p < 0.001), grade 3 (SMD = 0.66, 95%CI: 0.39-0.93, p = 0.001), ≥50% myometrial invasion (SMD = 0.78, 95%CI: 0.58-0.99, p < 0.001), lymphovascular space invasion (SMD = 0.82, 95%CI: 0.54-1.11, p = 0.001), lymph node metastasis (SMD = 1.27, 95%CI: 0.84-1.69, p < 0.001), cervical involvement (SMD = 0.71, 95%CI: 0.43-0.98, p = 0.003), parametrial involvement (SMD = 1.03, 95%CI: 0.71-1.35, p < 0.001) and peritoneal cytology (SMD = 0.49, 95%CI: 0.22-0.75, p < 0.001). High expression of tissue HE4 was only significantly associated with lymph node metastasis (OR = 6.19, 95%CI: 2.07-18.50, p = 0.001). High levels of serum HE4 were significantly associated with poor overall survival (univariate: HR = 3.77, 95%CI: 1.94-7.32, p < 0.001; multivariate: HR = 2.15, 95%CI: 1.65-2.80, p < 0.001) and disease-free survival (univariate: HR = 2.89, 95%CI: 2.14-3.88, p < 0.001; multivariate: HR = 2.31, 95%CI:1.20-2.67, p < 0.001) in EC. Compared with cancer antigen 125, serum HE4 may be a better prognostic indicator for EC.

CONCLUSIONS

High HE4 expression is associated with poor prognosis of EC and may be a potential prognostic biomarker for EC.

Evaluation of the efficiency and safety of adjuvant chemotherapy alone for patients with advanced endometrial carcinoma: A protocol for systematic review and meta-analysis

BACKGROUND

Endometrial cancer is a tumor that affects many women. Essentially, patients who have high-risk endometrial cancer tend to have a disproportionately high rate of metastasis as well as relapse than the general population. Regardless of complete resection, individuals who are having stages III or IV cancer appear to be at substantial risk of recurrence, either locally or distantly. Chemotherapy and radiation therapy are examples of systemic adjuvant treatment. However, the ideal scheduling strategy remains a mystery. Undertaking this research can help in examining the efficacy as well as safety of adjuvant chemotherapy alone in patients with advanced endometrial cancer in the future.

METHODS

To recognize all randomized controlled trials evaluating the efficacy and safety of adjuvant chemotherapy alone in those patients with advanced endometrial carcinoma, a comprehensive systematic review along with meta-analysis were undertaken in PubMed, EMBASE, Cochrane Library, Web of Science, Wanfang, China National Knowledge Infrastructure (CNKI), and Chinese Biological Medical Database (CBM). In accordance with traditional Cochrane methodology, 2 independent authors will review search results, choose studies for inclusion, extract study characteristics and outcome data, and examine the risk of bias in the researches they pick. The P values and the I² statistic shall be employed in determining the levels of heterogeneity. Meanwhile, the heterogeneity will be explored via the use of sensitivity analyses, and the meta-analysis will be conducted utilizing the RevMan 5.3 software package.

RESULTS

Patients with advanced endometrial cancer will benefit from this research since it will offer a high-quality synthesis of existing information on the utilization of adjuvant chemotherapy alone.

CONCLUSION

The outcomes of the proposed investigation will summarize the current evidence of adjuvant chemotherapy alone for patients with advanced endometrial carcinoma.

Immune Checkpoint Inhibitors and Mismatch Repair Status in Advanced Endometrial Cancer: Elective Affinities

Since endometrial cancers (ECs) are frequently TMB-H and MSI-H/dMMR tumors, this element has provided the rationale for testing immune checkpoint inhibitors (ICIs), which have recently emerged as a potential game-changer. However, several questions remain to be addressed, including the identification of patients who may benefit from the addition of ICIs as well as those who do not need immunotherapy. In the current paper, we provide an overview of the clinical development of immunotherapy in advanced or recurrent EC, discussing the role of MMR and the "elective affinities" between ICIs and this predictive biomarker in this setting.

A comparison of malignant histopathological diagnoses on uterine curettings and hysterectomy specimens

Background. Endometrial carcinoma (EC) is a common gynaecological malignancy in postmenopausal females. Diagnosis is made onendometrial biopsy, where histological subtype and tumour grade are used to predict disease progression and to plan surgical management.Objectives. To determine the accuracy of preoperative biopsies compared with the final diagnosis on hysterectomy specimens.Methods. This was a retrospective, cross-sectional study in which 126 biopsies and corresponding hysterectomy specimens, collected over a 3-year period, were reviewed. Patient demographics and histological features were recorded and statistically analysed.Results. The most prevalent tumours were endometrioid endometrial carcinoma (EEC) (48.5%), serous carcinomas (25.4%) and carcinosarcomas (16.7%). The majority (66.7%) of tumours were high-grade tumours on biopsy and hysterectomy specimens (58.7%). EECs had a poor sensitivity level (65.1%) compared with other subtypes but had a high specificity rate (90%). There was moderateagreement between biopsy and excision specimen diagnoses. High-grade tumours had a high sensitivity level (94.3%).Conclusions. Our study showed moderate agreement between histopathological diagnoses on biopsy and excision specimens. There was a high sensitivity level for biopsies of high-grade tumours, concordant with other studies. Accurate preoperative tumour subtyping and grading are needed to guide surgical management. It is envisaged that use of a combined histological and molecular tumour classificationwill better guide patient treatment and allow for reproducible results.

Oncological Safety of Diagnostic Hysteroscopy for Apparent Early-Stage Type II Endometrial Cancer: A Multicenter Retrospective Cohort Study

Objective

To study the oncological safety of diagnostic hysteroscopy for women with apparent early-stage type II endometrial cancer.

Patients and Methods

A total of 429 women with presumed early-stage type II endometrial cancer were included. The 5-year disease-free survival (DFS) and overall survival (OS) were estimated and compared using the Kaplan-Meier method and the log-rank test among patients diagnosed by Dilation &amp; Curettage (D&amp;C) or diagnostic hysteroscopy. The Cox proportional hazards regression model was employed to adjust for potential confounding factors.

Results

160 cases underwent D&amp;C and 269 cases were diagnosed by diagnostic hysteroscopy. The 5-year DFS rate was 72.17% in the diagnostic hysteroscopy group and 76.16% in the D&amp;C group, diagnostic hysteroscopy was not associated with deteriorated 5-year DFS rate (HR 1.25, 95% CI 0.84-1.86, P=0.281). The 5-year OS rate was 67.23% in the diagnostic hysteroscopy group and 70.71% in the D&amp;C group, diagnostic hysteroscopy did not increase the risk of all-cause death (HR 1.11, 95% CI 0.78-1.57, P=0.573). Multivariable analysis showed that the method of endometrial sampling was not independently associated with DFS (aHR 1.38, 95% CI 0.92-2.07, P=0.122) and OS (aHR 1.23, 95% CI 0.85-1.77, P=0.272).

Conclusion

For apparent early-stage type II endometrial cancer, endometrial sampling by diagnostic hysteroscopy was as safe as D&amp;C.

Previously treated recurrent or advanced endometrial cancer in England: A real-world observational analysis

OBJECTIVES

In patients with recurrent/advanced endometrial cancer who have progressed after first-line treatment, there are a lack of real-world data on treatment patterns, characteristics, and survival outcomes. A novel study was conducted to determine real-world treatment patterns and outcomes in England.

METHODS

This non-interventional study used routine, administrative health data from the National Cancer Registration and Analysis Service in England to identify patients diagnosed with recurrent/advanced endometrial cancer between 1 January 2013 and 31 December 2018, inclusive. A cohort of patients who progressed to second-line treatment were identified as the 'immune checkpoint inhibitor-eligible second-line' cohort. The co-primary objectives were to summarise baseline demographics, disease characteristics, treatments received, and depict overall survival and time-to-next-treatment (a proxy for progression-free survival) from the start of second-line therapy using Kaplan-Meier methodology.

RESULTS

Overall, 12,058 patients were diagnosed with recurrent/advanced endometrial cancer; 999 patients were included in the immune checkpoint inhibitor-eligible second-line cohort and 77.9% (778 of 999) had advanced disease (Stage III/IV). The most common treatments received at second-line were carboplatin plus paclitaxel (27.9%), carboplatin plus liposomal doxorubicin (14.1%), liposomal doxorubicin monotherapy (13.0%), and paclitaxel monotherapy (11.6%). From initiation of second-line therapy, median (95% confidence interval) overall survival was 10.3 months (9.2-11.1), and median time-to-next-treatment was 7.7 months (7.1-8.2).

CONCLUSIONS

Treatments received in the relapsed setting were variable and survival outcomes poor at second-line, highlighting the need for standard of care guidance and innovative therapies to improve patient outcomes in England and in countries with similar treatment patterns.

FUNDING

GSK.

Multimodal MRI-Based Radiomics-Clinical Model for Preoperatively Differentiating Concurrent Endometrial Carcinoma From Atypical Endometrial Hyperplasia

Objectives

To develop and validate a radiomics model based on multimodal MRI combining clinical information for preoperative distinguishing concurrent endometrial carcinoma (CEC) from atypical endometrial hyperplasia (AEH).

Materials and Methods

A total of 122 patients (78 AEH and 44 CEC) who underwent preoperative MRI were enrolled in this retrospective study. Radiomics features were extracted based on T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. After feature reduction by minimum redundancy maximum relevance and least absolute shrinkage and selection operator algorithm, single-modal and multimodal radiomics signatures, clinical model, and radiomics-clinical model were constructed using logistic regression. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis were used to assess the models.

Results

The combined radiomics signature of T2WI, DWI, and ADC maps showed better discrimination ability than either alone. The radiomics-clinical model consisting of multimodal radiomics features, endometrial thickness >11mm, and nulliparity status achieved the highest area under the ROC curve (AUC) of 0.932 (95% confidential interval [CI]: 0.880-0.984), bootstrap corrected AUC of 0.922 in the training set, and AUC of 0.942 (95% CI: 0.852-1.000) in the validation set. Subgroup analysis further revealed that this model performed well for patients with preoperative endometrial biopsy consistent and inconsistent with postoperative pathologic data (consistent group, F1-score = 0.865; inconsistent group, F1-score = 0.900).

Conclusions

The radiomics model, which incorporates multimodal MRI and clinical information, might be used to preoperatively differentiate CEC from AEH, especially for patients with under- or over-estimated preoperative endometrial biopsy.

The roles and therapeutic applications of cytokines in endometrial cancer

Endometrial cancer (EC) is a common gynecological cancer globally and the most frequent gynecologic malignancy in industrialized countries. Patients are typically diagnosed when the disease is still restricted to the uterus. 5-year overall survival ranges from 70 % to 90 % in patients without metastatic disease; however, the metastatic form of the disease affects 16 % of EC patients, with a 5-year survival rate of 16.8 %. The immune system can detect abnormal cells as non-self in the early stages of carcinogenesis, producing the appropriate pro-inflammatory environment to eliminate cancer cells. In a second phase, cancer cells use various immune-editing systems to alter the profile of the immune response from pro to anti-inflammatory, resulting in immune escape. The directors of this immune switching mechanism are cytokines. Studies have reported the increased expression of several pro-and anti-inflammatory cytokines in EC tissues and cell lines, including Interleukin (IL)- 6, IL-8, IL-31, IL-33, IL-10, TGF-β, VEGF, and IL-1Ra. Immune cells producing these cytokines have also been reported to be present in EC tissues. Therefore, in this study, we aimed to show the possible mechanisms of the mentioned cytokines on EC progression, as well as the most current and prospective advancements in cytokine-based therapeutic applications.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis

AIM

The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer.

METHODS

We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software.

RESULTS

This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03).

CONCLUSIONS

This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.