Fertility-preserving treatment in young patients with endometrial adenocarcinoma

HOXA10 expression in endometrial adenocarcinoma

Homeobox (HOX) genes are highly evolutionarily conserved regulators of embryonic differentiation. HOX genes are also expressed in normal adult reproductive tissue where they are involved in regulating differentiation. We hypothesized that HOXA10 gene expression may be altered in endometrial adenocarcinoma. To assess HOXA10 gene expression, endometrial tissue was obtained from 32 subjects with normal endometrium or disease confined to the uterus. Nine specimens contained normal endometrium, 5 had endometrial hyperplasia and 18 had stage I and II endometrial adenocarcinoma. RNA was extracted, Northern blot analysis performed and expression of HOXA10 assessed by densitometry. Expression of estrogen receptor, progesterone receptor and p53 was analyzed by immunohistochemistry. HOXA10 was expressed in both normal and neoplastic endometrium. No significant difference in HOXA10 expression was found between normal, hyperplastic and FIGO nuclear grade 1 endometrial tissues. Expression of HOXA10 was increased by 25% in high nuclear grade endometrial adenocarcinomas compared with normal, hyperplastic and low nuclear grade endometrial adenocarcinomas. No difference was noted in expression of estrogen receptor, progesterone receptor or p53. HOXA10 expression is elevated in high nuclear grade stage I and II endometrial adenocarcinomas. Aberrant regulation of HOX gene expression is associated with abnormal differentiation of endometrial tissue.

A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment

BACKGROUND

The aim of this paper was to report two cases of extrauterine disease in patients with early stage endometrial cancer (EC) who desired fertility-sparing management.

CASES

Two patients presenting an apparent early stage EC and desiring conservative management. The two patients, aged 35 and 36 years old, had a grade 1 and grade 2 EC diagnosed after curettage or hysteroscopic resection of a polyp. Ultrasound (US) imaging was normal (ovary). Once informed about the risk of recurrence, both patients opted for conventional therapy (hysterectomy with bilateral salpingo-oophorectomy). A small ovarian carcinoma was found in one patient and isolated positive peritoneal cytology in the other.

CONCLUSIONS

These cases seem to suggest that laparoscopic evaluation including adnexal exploration and peritoneal cytology (and possibly pelvic lymphadenectomy) should be performed in patients with early stage EC selected for conservative management to confirm the absence of extrauterine disease.

Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review

OBJECTIVE

We reviewed reported cases of grade 1 endometrial adenocarcinoma that were conservatively managed with hormonal therapy in an effort to identify the most effective treatment regimen.

METHODS

We searched MEDLINE and other databases for English-language articles describing patients with grade 1 endometrial adenocarcinoma who were treated with hormonal therapy. The search included articles published between January 1966 and December 2003. The following key words were used: endometrial cancer, uterine cancer, adenocarcinoma, hormones, progesterone, medroxyprogesterone acetate, megestrol acetate, conservative therapy, fertility, and female. A total of 79 articles were found. Studies were excluded for the following reasons: advanced stage, metastatic or recurrent disease, progestin use after radiation, chemotherapy, or surgery, concurrent with radiation therapy or chemotherapy, administration of progestin other than orally or intramuscularly, tumor confined to a polyp, grade 2 or 3 disease, undocumented grade, nonendometrioid histology, progestin use in conjunction with ovarian wedge resection or other hormones, and hyperplasia. Our study ultimately included 81 patients in 27 articles.

RESULTS

Sixty-two patients (76%) responded to treatment. The median time to response was 12 weeks (range, 4-60 weeks). Fifteen patients (24%) who initially responded to treatment recurred. The median time to recurrence was 19 months (range, 6-44 months). Ten (67%) of the patients with recurrence ultimately underwent total abdominal hysterectomy. Residual endometrial carcinoma was found in six patients (60%). Nineteen patients never responded. Twenty patients were able to become pregnant at least once after completing treatment. The median follow-up was 36 weeks (range, 0 weeks-30 years). No patients died of their disease.

CONCLUSION

The majority of patients reported with well-differentiated endometrial adenocarcinoma who undergo conservative treatment with a progestational agent respond to treatment. When an initial response is not achieved or when disease recurs, carcinoma extending beyond the uterus is rare.

Anastrozole, an aromatase inhibitor, and medroxyprogesterone acetate therapy in premenopausal obese women with endometrial cancer: a report of two cases successfully treated without hysterectomy

BACKGROUND

Hormonal therapy for endometrial cancer is occasionally warranted in the premenopausal woman who is interested in maintaining fertility. Combining progesterone with an agent that eliminates the adipose production of estrogen will theoretically be more effective than progesterone alone.

CASES

Two cases of reproductive-aged women with grade 1 endometrial cancer who were treated with medroxyprogesterone acetate and anastrozole daily for 3 and 6 months subsequently reverted to normal endometrium.

CONCLUSION

Progesterone combined with the elimination of adipose production of estrogen may be an effective therapy in well-differentiated endometrial cancer in the obese premenopausal woman.

The role of MRI in the conservative management of endometrial cancer

BACKGROUND

Young patients with endometrial cancer who desire to preserve their fertility often decline hysterectomy in favor of conservative progestin therapy. Proper candidates should have disease confined to the uterus and a well-differentiated tumor. One of the evolving techniques to evaluate the extent of the disease and myometrial or cervical invasion is magnetic resonance imaging (MRI).

CASE

A young patient with early-stage endometrial cancer initially declined surgery and was treated with megestrol. MRI suggested myoinvasion, and the patient consented to surgical staging. The final pathology revealed no residual carcinoma.

CONCLUSIONS

The accuracy of MRI in detecting myoinvasion is limited, and as such results should be interpreted with caution when this information is used in counseling a young patient regarding surgical staging for endometrial cancer.

Successful pregnancies in 2 infertile patients with endometrial adenocarcinoma

Two infertile patients with well-differentiated endometrial adenocarcinoma succeeded in having their own babies with assisted reproductive technology following treatment with a high dose of medroxyprogesterone acetate and repeated endometrial curettages. Their follow-up pathological examinations revealed no evidence of recurrent disease. Consequently, conservative treatment may be indicated in patients with well-differentiated endometrial adenocarcinoma at an early stage who desire to preserve their fertility.

Ovarian metastasis in women with clinical stage I endometrial carcinoma

BACKGROUND

The incidence of ovarian metastasis in women with clinical stage I endometrial carcinoma is generally reported to be 5%, leading to the practice of removing the ovaries at surgery even in young patients.

METHODS

A retrospective study of 84 patients with clinical stage I endometrial cancer was carried out. Patients were excluded if the pathologic study revealed any evidence of extrauterine, apart from adnexal, spread or if the peritoneal cytology was positive. Patients with serous papillary or clear cell tumor histology were also excluded.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria. Only three (4%) patients were found to be in surgical stage IIIA, all three had grade 3 tumors. Of these patients, two had uterine serosal involvement and one had a microscopic tumor implant in a fallopian tube; none had ovarian metastasis.

CONCLUSIONS

The risk of ovarian metastasis in women with well to moderately differentiated endometrial cancer, myometrial invasion limited to less than one half of the myometrium, negative peritoneal cytology and no evidence of metastatic lymph node spread is negligible. Young patients with a preoperative histological diagnosis of well to moderately differentiated endometrial carcinoma may be surgically staged, leaving the final decision regarding removal of the ovaries pending a thorough pathological review of the surgical specimens.

Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia

OBJECTIVE

The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia.

METHODS

A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology.

RESULTS

Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy.

CONCLUSION

This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.

[Endometrial cancer: what's new?]

OBJECTIVES

New and much debated data of the endometrial cancer concerning the preoperative assessment of myometrial invasion, the surgical staging, and the adjuvant treatment.

PATIENTS AND METHODS

Medline (1998-2002): searching for "endometrial carcinoma".

RESULTS

The pap smears are useful when it is difficult to have a transvaginal ultrasonography or an MRI. We can perform the pap smears and the endometrial biopsy in the clinic. If a patient has pap smears with malignant cells or elevated preoperative CA 125, it probably is a cancer with poor prognostic factors. Surgical staging with abdominal and node evaluation is necessary. The MRI seems to be the best preoperative imaging because we have information about adnexal and abdominal metastases, pelvic or aortic nodes and the invasion of the myometrium. So it gives us information on the surgical route, and provides indication for a lymphadenectomy. The surgical staging is a part of the treatment of the endometrial cancer: an exploration of the peritoneal cavity, a pelvic lymphadenectomy, a para-aortic lymphadenectomy if the pelvic nodes are positive or if there are factors of bad prognosis (deep stage IC, grade 3, adnexal or abdominal involvement, serous carcinoma of the endometrium). It can be performed if technical conditions are correct. The adjuvant teletherapy in the documented stage IpN0 (surgical staging with pelvic lymphadenectomy) does not seem to be necessary. But we can perform an adjuvant brachytherapy (high-dose rate if it is possible) in patients with a high local recurrence (stage IC, stage I with grade 3, stage IB grade 2).

CONCLUSION

The preoperative MRI is useful choosing the surgical approach, and the depth of the myometrial invasion, which can be an indication for a pelvic lymphadenectomy. The surgical staging must be a part of the treatment of the endometrial cancer. So the adjuvant teletherapy in patients with stage IpN0 documented should not be used.

Hysteroscopy to detect Stage IA well-differentiated endometrioid adenocarcinoma of the endometrium

BACKGROUND

Well-differentiated Stage IA endometrial carcinoma may be managed conservatively with progestin treatment. However, even advanced imaging methods cannot overcome limitations in the correct determination of the absence of early microscopic myometrial invasion by endometrial carcinoma. Hysteroscopy has not yet been investigated as a tool for this purpose.

METHODS

Of 97 patients with well-differentiated endometrioid adenocarcinoma, 87 whose tumors were clinically confined to the uterine corpus were enrolled for inclusion in this study. The preoperative hysteroscopic appearance was correlated with the histological findings of the hysterectomy specimen.

RESULTS

Post-surgical FIGO stage was Stage IA in 36 cases, IB in 29, IC in 16, IIA in one, and Stage IIIA/C in five cases. Before surgery, the growth pattern of the disease was hysteroscopically diagnosed as pedunculated in 69.0% and sessile nodular in 31.0%. Surface ulceration was observed in 23.3% of the pedunculated tumors and in 74.1% of the sessile tumors ( p < 0.0001), and in 39.1% of all tumors. The incidence of absent myometrial invasion was significantly higher in the pedunculated tumors (56.3%) than in the sessile tumors (3.7%) ( p < 0.0001) and was higher in the nonulcerated tumors (64.2%) than in the ulcerated tumors (5.9%) ( p < 0.0001). When the statistical parameters were calculated in combination with the tumor growth pattern and the absence or presence of ulceration, the nonulcerated pedunculated growth pattern had a sensitivity of 92% and a positive predictive value of 72% for correct selection of Stage IA disease with no myometrial invasion.

CONCLUSION

Well-differentiated endometrioid adenocarcinoma was categorized by hysteroscopy into two growth patterns of pedunculated or sessile and with or without surface ulceration. This provided useful pretreatment diagnosis of Stage IA disease confined to the endometrium.

The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology

AIMS

The Mirena coil is a levonorgestrel releasing intrauterine device that is in widespread use. This study aims to document the endometrial morphology associated with this device.

METHODS

Endometrial specimens from 75 women with the Mirena coil were reviewed and the histological features detailed.

RESULTS

Morphological features found in most of the endometria were decidualisation of stroma (72 of 75 cases), atrophy of endometrial glands (65 of 75 cases), a surface papillary pattern (38 of 75 cases), and a stromal inflammatory cell infiltrate (59 of 75 cases). Additional common histological features were the presence of foci of stromal myxoid change (29 of 75 cases) and stromal haemosiderin pigment (24 of 75 cases). Reactive atypia of surface glands, glandular metaplastic changes, stromal necrosis, and stromal calcifications were found in small numbers of cases.

CONCLUSION

The endometrial features are characteristic and relatively constant and are in keeping with the effects of both a progestogenic compound and a mechanical device. Pathologists should be aware of these histological features because the Mirena coil is in widespread use.