Medroxyprogesterone acetate (Depo-Provera) vs. hydroxyprogesterone caproate (Delalutin) in women with metastatic endometrial adenocarcinoma

Pharmacological Treatment of Advanced, Persistent or Metastatic Endometrial Cancer: State of the Art and Perspectives of Clinical Research for the Special Issue "Diagnosis and Management of Endometrial Cancer"

Patients with metastatic or recurrent endometrial cancer (EC) not suitable for surgery and/or radiotherapy are candidates for pharmacological treatment frequently with unsatisfactory clinical outcomes. The purpose of this paper was to review the results obtained with chemotherapy, hormonal therapy, biological agents and immune checkpoint inhibitors in this clinical setting. The combination of carboplatin (CBDCA) + paclitaxel (PTX) is the standard first-line chemotherapy capable of achieving objective response rates (ORRs) of 43-62%, a median progression-free survival (PFS) of 5.3-15 months and a median overall survival (OS) of 13.2-37.0 months, respectively, whereas hormonal therapy is sometimes used in selected patients with slow-growing steroid receptor-positive EC. The combination of endocrine therapy with m-TOR inhibitors or cyclin-dependent kinase 4/6 inhibitors is currently under evaluation. Disappointing ORRs have been associated with epidermal growth factor receptor (EGFR) inhibitors, HER-2 inhibitors and multi-tyrosine kinase inhibitors used as single agents, and clinical trials evaluating the addition of bevacizumab to CBDCA + PTX have reported conflicting results. Immune checkpoint inhibitors, and especially pembrolizumab and dostarlimab, have achieved an objective response in 27-47% of highly pretreated patients with microsatellite instability-high (MSI-H)/mismatch repair (MMR)-deficient (-d) EC. In a recent study, the combination of lenvatinib + pembrolizumab produced a 24-week response rate of 38% in patients with highly pretreated EC, ranging from 64% in patients with MSI-H/MMR-d to 36% in those with microsatellite stable/MMR-proficient tumors. Four trials are currently investigating the addition of immune checkpoint inhibitors to PTX + CBDCA in primary advanced or recurrent EC, and two trials are comparing pembrolizumab + lenvatinib versus either CBDCA + PTX as a first-line treatment of advanced or recurrent EC or versus single-agent chemotherapy in advanced, recurrent or metastatic EC after one prior platinum-based chemotherapy.

Estrogen Signaling in Endometrial Cancer: a Key Oncogenic Pathway with Several Open Questions

Endometrial cancer is the most common gynecological cancer in the developed world, and it is one of the few cancer types that is becoming more prevalent and leading to more deaths in the USA each year. The majority of endometrial tumors are considered to be hormonally driven, where estrogen signaling through estrogen receptor α (ER) acts as an oncogenic signal. The major risk factors and some treatment options for endometrial cancer patients emphasize a key role for estrogen signaling in the disease. Despite the strong connections between estrogen signaling and endometrial cancer, important molecular aspects of ER function remain poorly understood; however, progress is being made in our understanding of estrogen signaling in endometrial cancer. Here, we discuss the evidence for the importance of estrogen signaling in endometrial cancer, details of the endometrial cancer-specific actions of ER, and open questions surrounding estrogen signaling in endometrial cancer.

Influence of Cancer-Associated Endometrial Stromal Cells on Hormone-Driven Endometrial Tumor Growth

Cancer-associated fibroblasts have been shown to inhibit or stimulate tumor growth depending on stage, grade, and tumor type. It remains unclear, however, the effect of endometrial-cancer-associated fibroblasts on hormone-driven responses in endometrial cancer. In this study, we investigated the effect of normal and cancer-associated stromal cells from patients with and without endometrial cancer on endometrial tumor growth in response to estradiol (E2) and progesterone (P4). Compared to benign endometrial stromal cells, the low-grade and high-grade cancer-associated stromal cells exhibited a blunted hormone response for proliferation as well as IGFBP1 secretion. Additional analysis of the influence of stromal cells on hormone-driven tumor growth was done by mixing stromal cells from benign, low-grade, or high-grade tumors, with Ishikawa cells for subcutaneous tumor formation. The presence of both benign and high-grade cancer-associated stromal cells increased estradiol-driven xenografted tumor growth compared to Ishikawa cells alone. Low-grade cancer-associated stromal cells did not significantly influence hormone-regulated tumor growth. Addition of P4 attenuated tumor growth in Ishikawa + benign or high-grade stromal cells, but not in Ishikawa cells alone or with low-grade stromal cells. Using an angiogenesis focused real-time array TGFA, TGFB2 and TGFBR1 and VEGFC were identified as potential candidates for hormone-influenced growth regulation of tumors in the presence of benign and high-grade stromal cells. In summary, endometrial-cancer-associated cells responded differently to in vitro hormone treatment compared to benign endometrial stromal cells. Additionally, presence of stromal cells differentially influenced hormone-driven xenograft growth in vivo depending on the disease status of the stromal cells.

Systematic dissection of the mechanisms underlying progesterone receptor downregulation in endometrial cancer

Progesterone, acting through its receptor, PR (progesterone receptor), is the natural inhibitor of uterine endometrial carcinogenesis by inducing differentiation. PR is downregulated in more advanced cases of endometrial cancer, thereby limiting the effectiveness of hormonal therapy. Our objective was to understand and reverse the mechanisms underlying loss of PR expression in order to improve therapeutic outcomes. Using endometrial cancer cell lines and data from The Cancer Genome Atlas, our findings demonstrate that PR expression is downregulated at four distinct levels. In well-differentiated cancers, ligand-induced receptor activation and downregulation are intact. miRNAs mediate fine tuning of PR levels. As differentiation is lost, PR silencing is primarily at the epigenetic level. Initially, recruitment of the polycomb repressor complex 2 to the PR promoter suppresses transcription. Subsequently, DNA methylation prevents PR expression. Appropriate epigenetic modulators reverse these mechanisms. These data provide a rationale for combining epigenetic modulators with progestins as a therapeutic strategy for endometrial cancer.

SIGNIFICANCE

Traditional hormonal therapy for women with endometrial cancer can be molecularly enhanced by combining progestins with epigenetic modulators, thereby increasing progesterone receptor expression and significantly improving treatment efficacy.

Current treatment options for endometrial cancer

In North America, endometrial cancer is the most prevalent cancer of the female genital tract. On the basis of clinical and histologic variables, two main types of endometrial cancer have been described: Type I tumors, which are usually well differentiated and endometrioid in histology and account for the majority of cases; and Type II, which are poorly differentiated tumors, often with serous papillary or clear cell histology. Due to the early declaration of the disease by vaginal bleeding, approximately 80% of endometrial cancers are diagnosed at an early stage. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymph node dissection remains the cornerstone of treatment. Tumor stage, histologic grade and depth of myometrial invasion are the most important prognostic factors. If myometrial invasion to 50% or more of the myometrial width and/or grade 2 or 3 histology is present, pelvic radiotherapy is indicated to reduce the risk of pelvic recurrence. Postoperative radiation therapy may improve local control but does not affect survival for Stage I endometrial cancer patients. Systemic chemotherapy is typically reserved for women with disseminated primary disease or extrapelvic recurrence. Although the combination of cisplatin plus doxorubicin is commonly used, carboplatin plus paclitaxel represents an efficacious, low-toxicity regimen for managing advanced or recurrent endometrial cancer. Recently, a significant percentage of Type II uterine tumors have been found to overexpress the epidermal growth factor Type II receptor. Anti-HER-2/neu-targeted therapy might be a novel and attractive therapeutic strategy in patients harboring this biologically aggressive variant of endometrial cancer.

Qualitative and quantitative measures of various compounded formulations of 17-alpha hydroxyprogesterone caproate

OBJECTIVE

17-alpha hydroxyprogesterone caproate (17-OHPC) is available both as an Food and Drug Administration (FDA)-approved medication and as a product prepared for individual patients by compounding pharmacies. Compounding pharmacies may omit the preservative that is used in the FDA-approved formulation or use an alternate preservative and may dispense 17-OHPC in containers that differ from the FDA-approved product. The objective of this study was to assess the stability and the microbiologic and pyrogen status of 17-OHPC formulations under various compounding and dispensing conditions.

STUDY DESIGN

17-OHPC was prepared by a local compounding pharmacy. The formulations that were prepared included 1 identical to the FDA-approved product with benzyl alcohol as a preservative, 1 with benzalkonium chloride as a preservative, and 1 without a preservative. These various formulations were dispensed into either single-dose 1-mL plastic syringes or glass vials or 10-mL glass vials. The concentration of 17-OHPC and microbial and pyrogen status were evaluated at various time intervals over the ensuing 19 weeks.

RESULTS

The concentration of 17-OHPC did not change over the duration of study, regardless of the dispensing medium that was used or the absence or presence of any preservatives. The preparations remained microbe- and pyrogen-free during the study period, regardless of the dispensing medium that was used or the absence of presence of any preservatives.

CONCLUSION

Products that contained 17-OHPC tested in this study were quite stable over the 19-week period of study in different dispensing containers and in the absence or presence of a different preservative. The compounded products remained sterile and pyrogen-free during the period of observation.

Hormonal therapy in advanced or recurrent endometrial cancer

BACKGROUND

Endometrial cancer is a cancer of the lining of the womb and worldwide is the seventh most common cancer in women. Treatment with hormones is thought to be beneficial in patients with endometrial cancer.

OBJECTIVES

To assess the indications, effectiveness and safety of hormone therapy for advanced or recurrent epithelial endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, MEDLINE, EMBASE up to May 2009 and and CENTRAL (Issue 2, 2009). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that studied hormonal therapy in adult women diagnosed with advanced or recurrent endometrial cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Comparisons were restricted to single-trial analyses so we did not synthesise data in meta-analyses.

MAIN RESULTS

We found six trials (542 participants) that met our inclusion criteria. These trials assessed the effectiveness of hormonal therapy in women with advanced or recurrent endometrial cancer as a single agent, as part of combination therapy and as low versus high dose. All comparisons were restricted to single-trial analyses, where we found no evidence that hormonal therapy as a single agent or as a combination treatment prolonged overall or five-year disease-free survival of women with advanced or recurrent endometrial cancer. However, low-dose hormonal therapy may have had a benefit in terms of overall and progression-free survival (PFS) compared to high-dose hormonal therapy (HR 1.31, 95% CI 1.04 to 1.66 and HR 1.35, 95% CI 1.07 to 1.71 for overall and PFS, respectively).

AUTHORS' CONCLUSIONS

We found insufficient evidence that hormonal treatment in any form, dose or as part of combination therapy improves the survival of patients with advanced or recurrent endometrial cancer. However, a large number of patients would be needed to demonstrate an effect on survival and none of the included RCTs had a sufficient number of patients to demonstrate a significant difference. In the absence of a proven survival advantage and the heterogeneity of patient populations, the decision to use any type of hormonal therapy should be individualised and with the intent to palliate the disease. It is debatable whether outcomes such as quality of life, treatment response or palliative measures such as relieving symptoms should take preference over overall and PFS as the major objectives of future trials.

Emerging drugs in endometrial cancers

IMPORTANCE OF THE FIELD

Endometrial cancer remains the most common gynecologic malignancy. The treatment of endometrial cancer is rapidly evolving.

AREAS COVERED IN THIS REVIEW

In this article, we aim to review current and future treatment options in the medical treatment of endometrial cancers.

WHAT THE READER WILL GAIN

The cornerstone of curative therapy for patients with endometrial cancer is surgical treatment. Cytotoxic chemotherapy is the mainstay of therapy for metastatic and advanced endometrial cancer. The most active chemotherapy agents are anthracyclines, platinum compounds and taxanes. Combination chemotherapy has produced higher response rates than single agent therapy. Cisplatin and doxorubicin combination chemotherapy has served as the control arm in many trials. Three-drug combination regimen has shown the highest response rate but with increased toxicity. Despite the lack of published data supporting the superiority of the paclitaxel plus carboplatin combination over doxorubicin and cisplatin, many centers prefer this regimen as a standard of care. Hormonal therapy should be considered in patients with low grade tumors and in those with a poor performance status. Recent advances in the understanding of the molecular biology of endometrial cancer have led to development of targeted therapies. Among these the more promising ones are mTOR inhibitors and antiangiogenic agents.

TAKE HOME MESSAGE

Clinical trials are planned to further explore how to best incorporate novel agents into the current treatment algorithm with the aim to improve outcome for women with endometrial adenocarcinomas.

Treatment for advanced and recurrent endometrial carcinoma: combined modalities

Women with recurrent or advanced endometrial cancer constitute a heterogeneous group of patients. Depending on previous treatment, women with recurrent endometrial cancer may be appropriate candidates for surgery, radiation therapy, hormonal therapy, or chemotherapy. Women with advanced stage disease at presentation may also be appropriate candidates for systemic and local therapies. We review the treatment options available to treat recurrent and locally advanced endometrial cancer. Treatment choice depends largely on the localization of disease, the patient's performance status and previous treatment history, as well the tumor's hormonal receptor status. Radiation therapy is appropriate for isolated vaginal recurrences in patients with no previous history of radiation therapy. Patients with recurrent low-grade tumors overexpressing estrogen and progesterone receptors may be treated with progestin therapy. Systemic therapy is appropriate for patients with disseminate recurrences or advanced stage disease at presentation, or for those with receptor-negative tumors. We review all these different treatment strategies available to patients with advanced or recurrent endometrial cancer.

Role of progesterone in endometrial cancer

Progesterone is a key hormone in the endometrium that opposes estrogen-driven growth. Insufficient progesterone will result in unopposed estrogen action that could lead to the development of endometrial hyperplasia and adenocarcinoma. Although these endometrial neoplasias can regress in response to progestin treatment, this does not occur in all instances. To understand this resistance to progesterone and to improve on existing hormonal therapies, it is imperative that the molecular mechanisms of progesterone action through its receptor be deciphered in endometrial cancer. This review highlights what is known thus far regarding the efficacy of progestin therapy in the clinic and the role of progesterone in endometrial cancer cell behavior and gene regulation.

The fertility-sparing treatment in patients with endometrial atypical hyperplasia and early endometrial cancer: a debated therapeutic option

Fertility-sparing treatment may represent a realist option for accurately selected young patients with endometrial atypical hyperplasia or well differentiated, early endometrial cancer. Oral progestins, and especially medroxyprogesterone acetate (MPA) and megestrol acetate with different doses and schedules, represent the most commonly used hormone agents in this clinical setting. Approximately three fourths of the women achieve a histologically documented complete response, with an mean response time of 12 weeks, but about one third of these subsequently developed a recurrence after a mean time of 20 months. The expression of receptor for progesterone receptor (PR), PTEN gene, DNA mismatch repair gene MLH1 and phospho-AKT on tissue specimens may be useful for selecting patients fit for a conservative management. Several successful pregnancies have occurred after a fertility-sparing treatment of endometrial atypical hyperplasia or endometrial cancer, more frequently with assisted reproductive technologies. The implementation of in vitro fertilisation techniques not only increases the chance of conception, but it may also decrease the interval to conception. The opportunity of a demolitive surgery after delivery or after childbearing being no longer required is a still debated issue. Large multicenter trials are strongly warranted to better define the selection criteria for a conservative treatment, endocrine regimen of choice, the optimal dosing, the duration of treatment and follow-up protocols. In any case, the patient should be accurately informed about the relatively high recurrence rates after complete response to hormone treatment and expectations for pregnancy.

Current treatment of metastatic endometrial cancer

BACKGROUND

Endometrial cancer is the most common gynecologic malignancy. The majority of patients have disease confined to the uterus and have an excellent overall prognosis. However, subgroups of patients have advanced primary disease or recurrences following primary treatment.

METHODS

The management of metastatic disease is variable, depending on factors such as comorbidities, tumor grade, performance status, and prior treatments. Management options include hormonal therapy and cytotoxic chemotherapy, as well as targeted therapies that inhibit angiogenesis and the cellular signaling pathways involved in cell growth and proliferation. A comprehensive review of these treatments for metastatic endometrial cancer was conducted and is discussed.

RESULTS

Hormonal therapy and cytotoxic chemotherapy have traditionally been used in the treatment of metastatic endometrial cancer. Advances in molecular biology have led to multiple potential targeted therapies to be used in the treatment of metastatic endometrial cancer.

CONCLUSIONS

While several treatment modalities are now available to treat patients who present with metastatic endometrial cancer, overall prognosis remains poor.

Management of Surgical Stage III and IV Endometrioid Endometrial Carcinoma: An Overview

This paper covers an overview of the literature on the management of advanced endometrial cancer, concentrating on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described and management recommendations are proposed.

The standard surgical procedure includes an extrafacial total hysterectomy with bilateral salpingo-oophorectomy, collection of peritoneal washings for cytology, and exploration of the intraabdominal contents. In cases of extensive disease in the abdomen, an optimal surgical cytoreduction is associated with improved survival. Further treatment with radiotherapy may be indicated based on the pathological staging information to improve loco-regional control. Primary radiotherapy is indicated in cases where surgery is contraindicated. Systemic treatment can either be hormone therapy or chemotherapy. Progesterons are the cornerstone of hormone therapy. Prognostic factors for response are the presence of high levels of progesterone and estrogen receptors and low grade histology. Paclitaxel is the most active single agent drug. The combination therapy with paclitaxel and carboplatin is adopted as first choice in patients with endometrial cancer because of the efficacy and low toxicity, although not proven in a randomized trial.

The literature on the management of patients with advanced endometrial cancer is discussed in detail. Each stage of advanced disease is presented separately, and management recommendations are proposed, and alternative approaches are given.

Ongoing clinical trials are described, and the focuses of ongoing research are mentioned.

Management of Recurrent Endometrioid Endometrial Carcinoma: An Overview

In this paper, an overview of the literature on the management of recurrent endometrial cancer is presented, focusing on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described, and a management recommendation scheme is presented. Indications for surgical treatment depend on resectability, site and size of the tumor, and performance status of the patient. Indications for radiotherapy depend on the site of the recurrence and also on the initial therapy received. When considering systemic treatment for patients with recurrent endometrial cancer, it is important to take into account the general health status and condition of the patient as well as which prior therapy the patient has received. The treatments of choice for patients with hormone-sensitive tumors (positive receptor levels, low-grade tumors, and long disease-free interval) are progestagens as first-line treatment and tamoxifen as second-line treatment. Patients with high-grade tumors, negative hormone receptor levels, and short treatment-free interval are best treated with chemotherapy. Paclitaxel, doxorubicin, and cisplatin are the most active combination therapy for these patients but with significant toxicity. In phase II studies, the combination therapy with paclitaxel and carboplatin seems to be as effective but less toxic and can be administered in outpatient clinic. The literature on the management of patients with recurrent endometrial cancer is discussed in detail. The different sites of recurrent disease (ie, local, regional, and/or distant) are evaluated separately; management recommendations are proposed, and alternative approaches are given.

Recurrent endometrial carcinoma regression with the use of the aromatase inhibitor anastrozole

Recurrent/metastatic endometrial adenocarcinoma that is not amenable to cure with local or regional therapy and/or chemotherapy represents a discouraging clinical entity for the clinician. We report the case of 58-year-old woman with recurrent endometrial carcinoma that was resistant to chemotherapy that was treated successfully with the aromatase inhibitor anastrozole.

Hormone therapy in advanced and recurrent endometrial cancer: a systematic review

Endometrial cancer is a hormone-dependent malignancy, and the majority has a precursor phase of endometrial hyperplasia. Histologic subtypes have been recognized with differing natural history. The relationship between hormone response, histology, and molecular profile is not established, but the relevant biology is summarized. This study was a systematic review of the literature to identify which populations should be considered for hormone interventions. Systematic searches were carried out in the English literature for randomized controlled trials and phase II studies of hormone interventions in endometrial cancer. Five randomized trials and 29 phase II studies were identified comprising a total of 2471 patients. In previously untreated patients with grade 1 (G1) or G2 tumors, the response rate for progestogens and the progression-free survival is in the range of 11–56% and 2.5–14 months, respectively. Higher response rates are seen in progesterone receptor–positive cases. Phase II studies comprise the majority of the data and many are of poor quality. There was considerable heterogeneity in patient selection, prior treatment, and type of regimen, and meta-analysis was not possible. G3 or G4 toxicity was less than 5%. We conclude that hormone receptor assessments should be carried out in all patients entered on clinical trials and may aid clinical management in selected cases. Receptor-negative status should not be an absolute contraindication to hormone intervention. Integration of hormone treatment with conventional chemotherapy and growth factor–targeted therapy needs to be explored.

Relationship of estrogen and progesterone receptors to clinical outcome in metastatic endometrial carcinoma: A Gynecologic Oncology Group Study

INTRODUCTION

The goal of this study was to explore the relationship between the expression of hormone receptors in metastatic endometrial tumors and clinical response to daily tamoxifen citrate and intermittent weekly medroxyprogesterone acetate.

STUDY DESIGN

Patients with measurable recurrent or advanced endometrial cancer were enrolled on a clinical trial, Gynecologic Oncology Group Study 119. A pretreatment tumor biopsy was obtained and subjected to immunohistochemical analyses. Estrogen receptor-alpha (ER-alpha) and progesterone receptor (PR) were assessed on frozen tissues, and PR isoforms A and B were detected on fixed tissues. The receptors were scored using a semi-quantitative HSCORE, with a cut off greater than 75 considered positive.

RESULTS

Of the 60 eligible patients, 45 had evaluable tissues for all receptors. For ER, 40% of the cases were positive; for PR, 45% were positive. The sub-cellular distribution of PRA was exclusively nuclear, and 16% of the tumors demonstrated positive staining. PRB was nuclear and cytoplasmic, with 22% of the tumors staining for nuclear PRB and 36% of the tumors staining for cytoplasmic PRB. ER and PR from frozen tissues and PRA and cytoplasmic PRB from fixed tissues significantly decreased with increasing tumor grade. The co-expression of ER-alpha with PR from the frozen tissues (r=0.68, p<0.001) and PRA (r=0.58, p<0.001) from the fixed tissues was statistically significant. The ER HSCORE was related to both response and overall survival; there was no statistically significant correlation of PR with clinical response in this small number of patients.

CONCLUSION

ER-alpha measured in metastatic endometrial carcinoma tissue prior to hormonal therapy was statistically significantly related to clinical response to daily tamoxifen and intermittent medroxyprogesterone acetate.

Salvage cytoreductive surgery for recurrent endometrial cancer

OBJECTIVE

To determine the survival impact of salvage cytoreductive surgery, and other prognostic variables, among patients with recurrent endometrial cancer.

METHODS

All patients diagnosed with endometrial cancer recurrence between 7/1/97 and 6/30/05 were retrospectively identified from the tumor registry database. Demographic, pathological, and clinical data were abstracted from the medical record. Survival estimates were calculated using the Kaplan and Meier method. Univariate and multivariate regression analyses were used to identify characteristics associated with overall survival from time of recurrence.

RESULTS

Sixty-one patients were identified with endometrial cancer recurrence a median of 18.5 months after initial diagnosis. Median age at recurrence was 63 years, and the median post-recurrence follow-up time was 22.0 months. Thirty-five patients underwent salvage cytoreductive surgery and had a median survival time of 28.0 months, compared to 13.0 months for patients treated non-surgically (P < 0.0001). Complete cytoreduction (no gross residual) was achieved in 23/35 surgical patients (65.7%). The median EBL was 350 cc and 28.6% of patients received blood products. There were no peri-operative deaths; however, 31.4% of patients experienced minor morbidity. Patients undergoing complete salvage cytoreduction had a median post-recurrence survival time of 39.0 months, compared to 13.5 months for those patients with gross residual disease (P = 0.0005). On multivariate analysis, salvage surgery and residual disease status were significant and independent predictors of post-recurrence survival.

CONCLUSIONS

Complete salvage cytoreductive surgery for recurrent endometrial cancer is associated with prolonged post-recurrence survival compared to patients left with any gross residual disease. Additional studies are warranted to define appropriate surgical indications and selection criteria.

Paclitaxel/carboplatin versus cyclophosphamide/adriamycin/cisplatin as postoperative adjuvant chemotherapy for advanced endometrial adenocarcinoma

AIM

There is no standard chemotherapy regimen for patients with advanced endometrial adenocarcinoma. In our hospital, a cyclophosphamide/adriamycin/cisplatin (CAP) regimen was commonly used as adjuvant chemotherapy. However, since October 1999 a paclitaxel/carboplatin regimen has been substituted for CAP. To evaluate the antitumor activity and toxic effects of those regimens, we retrospectively reviewed cases that were treated in our hospital.

METHODS

Twenty-eight patients who underwent surgery and had histologically confirmed advanced endometrial adenocarcinoma, International Federation of Gynecology and Obstetrics stage III/IV, received combination chemotherapy. Treatment consisted of cisplatin, adriamycin and cyclophosphamide (CAP group, n = 16), or paclitaxel and carboplatin (paclitaxel/carboplatin group, n = 12). The response rate (RR), progression-free survival (PFS), overall survival (OS), and toxicities were evaluated.

RESULTS

In the CAP group, complete response (CR) was observed in six patients and partial response (PR) in three, for an RR of 64.3%. In the paclitaxel/carboplatin group, CR was observed in five and PR in two, for an RR of 77.8%. The 3-year PFS and OS rates were 50.0% and 75.0% in the paclitaxel/carboplatin group, and 37.5% and 50.0% in the CAP group, respectively, and there was no significant difference between the two groups. National Cancer Institute Common Toxicity Criteria grade 3-4 thrombocytopenia and gastrointestinal toxicities occurred significantly less frequently in the paclitaxel/carboplatin group (0% and 16.7%) than in the CAP group (31.3% and 68.8%) (P = 0.0389 and P = 0.0062).

CONCLUSIONS

We conclude that paclitaxel/carboplatin is a promising regimen which could be substituted for CAP, with major activity and a highly acceptable toxicity profile for the treatment of advanced endometrial adenocarcinomas.

Old and new perspectives in the pharmacological treatment of advanced or recurrent endometrial cancer: Hormonal therapy, chemotherapy and molecularly targeted therapies

Hormonal therapy and chemotherapy play a major role in the management of advanced or recurrent endometrial cancer. Progesterone therapy obtains overall response rates ranging from 11% to 25% in patients with endometrioid-type tumours, and oral medroxyprogesterone acetate 200mg daily appears to be a reasonable therapeutic option for those lesions that are well differentiated and/or have a high progesterone receptor (PgR) content. However, the activity of progestins is often compromised by the down-regulation of PgR within the target tissues, and therefore therapeutic strategies designed to enhance PgR expression are warranted. Little data are currently available about the new aromatase inhibitors and selective estrogen receptor modulators. As for chemotherapy, the combination of doxorubicin [DOX]+cisplatin [CDDP] achieves overall response rates ranging from 34% to 60%, and the addition of paclitaxel (TAX) seems to improve response rates, progression-free survival and overall survival, but to worsen toxicity profile. A phase III study is currently comparing TAX+DOX+CDDP versus the less toxic combination of TAX+carboplatin. Chemotherapy is active against both endometrioid-type carcinoma and uterine serous papillary carcinoma. However, this latter endometrial malignancy is less chemosensitive than the histologically similar high-grade serous ovarian carcinoma. Interesting fields of research are represented by investigational agents directed against specific intracellular signal transduction pathways involved in the proliferation, invasiveness and metastatic spread of endometrial cancer. Mammalian target of the rapamycin (mTOR) inhibitors, epidermal growth factor receptor inhibitors (gefitinib, erlotinib, lapatinib, the monoclonal antibody cetuximab), imatinib, the monoclonal antibody trastuzumab, and the Clostridium perfrigens enterotoxin are currently under evaluation as molecularly targeted therapies for endometrial cancer. Further investigations addressed to better understand the signal transduction pathways that are disregulated in endometrial carcinogenesis could identify novel biological targets suitable for tailored therapies.

Randomized evidence on chemotherapy and hormonal therapy regimens for advanced endometrial cancer: An overview of survival data

Several chemotherapy and hormonal therapy regimens have been used in advanced endometrial cancer. In this review we have systematically evaluated the available data from randomized trials on survival. We searched MEDLINE, EMBASE and the Cochrane Library (last search April 2005) for randomized controlled trials evaluating various chemotherapy or hormonal therapy regimens in locally advanced or metastatic endometrial cancer. We focused on survival outcomes and examined trial characteristics pertaining to quality and potential biases. Across 17 eligible trials (2964 patients randomized), only 4 regimens were involved in more than one trial, and only two trials had used the same comparison of regimens. A statistically significant effect in survival was seen only in one recent trial, but it was borderline (P = 0.032) and amounted to only 3 months difference in median survival. Three more trials reported some survival benefits, but these were seen only after specific adjustments, and the difference was against the experimental arm in one of these three trials. Only four trials (24%) apparently analyzed all randomized patients and none of the trials were blinded. Median survival was seemingly longer in more recent compared with older trials, but this effect was driven by the inclusion of significantly fewer patients with poor performance status in more recent trials (P < 0.001). Overall, randomized evidence on systemic treatment in advanced endometrial cancer is fragmented and survival benefits for specific regimens are questionable.

Hormonal treatment of endometrial cancer: past, present and future

The concept that hormonal therapy may be useful in the treatment of endometrial cancer antedated the pharmaceutical availability of progestational compounds. By 1959, initial studies demonstrated the ability of progestins to reverse endometrial hyperplasias. Thereafter, progestins and other hormonal agents have been used in various roles as treatment for endometrial cancers. This chapter reviews the use of hormonal agents for the treatment of primary and metastatic/recurrent endometrial cancer, as well as such treatment in an adjuvant setting. Major problems in enhancing the efficacy of endocrine therapy of cancers arising from hormonally responsive tissues are also considered. The regulations of steroid-hormone receptor expression in endometrial and breast cancers continues to be an active area of research interest.

A phase II trial of anastrozole in advanced recurrent or persistent endometrial carcinoma: a Gynecologic Oncology Group study

BACKGROUND

Some endometrial cancers are hormonally dependent. A principal source of circulating estrogen is conversion of adrenal androstenedione by aromatase. Anastrozole (Arimidex) is an oral nonsteroidal aromatase inhibitor which is active in recurrent breast cancer. This Phase II study was undertaken to evaluate anastrozole in recurrent endometrial carcinoma.

METHODS

Patients with advanced or recurrent endometrial cancer not curable with either surgery or radiation therapy and with measurable disease, a GOG (Zubrod) performance status of < or = 2, no more than one prior hormonal therapy regimen, and no prior chemotherapy were eligible. Anastrozole was administered at a dose of 1 mg/day orally for at least 28 days.

RESULTS

Twenty-three patients were entered on this trial. On central pathology review, 9 of them had grade 2 and 14 had grade 3 tumors. One to 24 courses (median: 1) of therapy were administered. Two partial responses were noted (9%; 90% confidence interval 3 to 23%). Two additional patients had short-term stable disease. With the exception of 1 case of venous thrombosis, the toxicity profile was mild. Median durations of progression-free survival and overall survival are 1 and 6 months, respectively.

CONCLUSIONS

Anastrozole has minimal activity in an unselected population of patients with recurrent endometrial cancer.

Metastatic endometrial cancer in lung and liver: complete and prolonged response to hormonal therapy with progestins

A double complete and prolonged response of metastatic endometrial carcinoma to medroxyprogesterone is reported. A 61-year-old woman with metastatic endometrial carcinoma in lung and liver achieved a complete clinical response with medroxyprogesterone lasting for 2 years. She discontinued the therapy by herself and developed a pulmonary relapse, which disappeared after retreatment with the same hormonal therapy. At present, she is alive without evidence of disease 6 years after starting progestins for metastatic disease and 14 years after treatment of the primary tumor. Progestin therapy in metastatic endometrial carcinoma is discussed, emphasizing the factors predicting response.

Hormonal treatment of endometrial cancer

This article summarizes the endocrine background of women with endometrial cancer at both peripheral and tissue levels, and the current status of clinical trials of hormonal, cytotoxic, and combination regimens. Because significant advances in systemic therapy are required to improve the prognosis of endometrial cancer, recommendations for future clinical investigations will be based on these recent biologic observations.

Endometrial cancer

Carcinoma of the uterine corpus (endometrial cancer) remains the gynecologic malignant disease with the highest annual prevalence in the United States. The most common histologic type is adenocarcinoma, although more aggressive variants (e.g., papillary serous carcinoma and clear cell carcinoma) have been identified. Risk factors that are strongly associated with the development of endometrial cancer include tamoxifen therapy, obesity, and stimulation from unopposed estrogen (from exogenous sources or endogenously secreting ovarian tumors). The current staging system of the International Federation of Gynecology and Obstetrics is based on surgical-pathologic findings. Survival has been directly correlated with tumor stage in this staging system. The cornerstone of therapy is total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pelvic and para-aortic lymphadenectomy may provide additional prognostic information but probably does not confer a therapeutic advantage. Moreover, such nodal dissections predispose to the development of complications, especially in women who subsequently receive pelvic irradiation. Other than surgical treatment, irradiation is the single most active therapy for endometrial carcinoma. In fact, some women who are not candidates for hysterectomy because of medical contra-indications can be cured with radiation alone. Adjuvant therapy following hysterectomy is based on patient- and tumor-related features that provided prognostic information for incidence and pattern of recurrence. Adjuvant treatment usually includes pelvic irradiation for selected patients. Current investigational strategies are directed at the role of whole-abdomen irradiation, extended-field irradiation, and systemic chemotherapy. The most active systemic agents include cisplatin, doxorubicin, paclitaxel, and progestins.

Flow cytometric studies of ploidy and proliferative indices in the Yorkshire trial of adjuvant progestogen treatment of endometrial cancer

OBJECTIVE

To estimate whether flow cytometric indices provide independent measures of prognosis or predict response to prophylactic progestogens in endometrial cancer.

DESIGN

Endometrial tumour specimens were retrieved and analysed by flow cytometry from 257 women who had been randomly allocated in a previous trial to receive prophylactic progestogen in addition to conventional therapy for endometrial carcinoma.

SETTING

Fourteen district and two teaching hospitals in West Yorkshire.

SUBJECTS

Women developing primary endometrial cancer between 1975 and 1983.

MAIN OUTCOME MEASURES

Tumour ploidy status and proliferative indices and the relation of these to tumour stage and grade, to prognosis and to response to progestogens.

RESULTS

Ploidy status and proliferative indices were related to tumour stage, grade and patient survival but were not independent predictors of survival. They did not predict patients who would respond to progestogens although there was a nonsignificant trend towards patients with diploid tumours surviving longer after progestogen treatment.

CONCLUSIONS

Flow cytometry adds little to established prognostic indicators for endometrial cancer.

Systemic treatment in disseminated endometrial cancer

Both hormonal agents and chemotherapy are of value in the treatment of selected patients with endometrial cancer. In unselected patients with advanced disease about 25% respond to progestational agents and 40% to combination chemotherapy. The choice between the two treatments is made on the basis of a number of prognostic factors, such as receptor status, tumour grade, performance status and tumour burden. Further improvement of treatment outcome is to be expected from new agents such as gonadotrophin releasing hormone analogues, taxol and modulation of 5-fluorouracil.

A prospective trial of progesterone therapy for malignant peritoneal cytology in patients with endometrial carcinoma

From February 1982 to February 1991, 45 patients with endometrial carcinoma confined to the uterus except for malignant peritoneal cytology were treated with 1 year of progesterone therapy. Thirty-six patients have undergone planned second-look laparoscopy with repeat peritoneal washings and the remaining 9 patients either refused second-look laparoscopy or the procedure was medically contraindicated. Of the 36 who underwent second-look laparoscopy, 34 (94.5%) were NED (no evidence of disease) and had negative repeat peritoneal cytology and 2 (5.5%) had persistent malignant cytology. The latter two patients, after an additional year of progesterone therapy, were found to be NED and had negative peritoneal cytology at third-look laparoscopy. Of the 45 women enrolled in this protocol, no patient has developed recurrent endometrial cancer, and the expected 5-year disease-free survival was 88.6%.

Immunohistochemical study of the human 17 beta-hydroxysteroid dehydrogenase and steroid receptors in endometrial adenocarcinoma

17 beta-Hydroxysteroid dehydrogenase (17HSD) and estrogen (ER) and progestin (PR) receptors were analyzed immunohistochemically in tissue specimens of 66 patients with endometrial adenocarcinoma. Plasma steroid concentrations were correlated to immunohistochemical data. 17HSD was detected in 48% of the specimens and was stained in the cytoplasm of epithelial cells. The tissues were characterized by a heterogeneous staining pattern for 17HSD. In some patients, intensively stained epithelial cell clusters were seen, indicating that local factors were responsible for the expression of the protein. Poorly differentiated adenocarcinoma specimens tended to have no 17HSD more frequently than did well or moderately differentiated tissues. ER and PR were detectable in 24% and 28% of patients, respectively, and were localized in the nuclei of epithelial and stromal cells. There was a significant correlation between 17HSD and PR staining and an inverse correlation between plasma progesterone concentrations and 17HSD staining. This is contrary to the data obtained with normal endometrium. The main reason for this inverse relation between endometrial 17HSD staining and plasma progesterone concentrations was that, in some postmenopausal patients with low plasma progesterone concentrations, intense staining for 17HSD was detectable in the endometrial carcinoma specimens. This indicates a major difference in the regulation of 17HSD expression in endometrial adenocarcinomas, compared with normal tissues of premenopausal women.

Immunohistochemical study of the human 17 beta-hydroxysteroid dehydrogenase and steroid receptors in endometrial adenocarcinoma

17 beta-Hydroxysteroid dehydrogenase (17HSD) and estrogen (ER) and progestin (PR) receptors were analyzed immunohistochemically in tissue specimens of 66 patients with endometrial adenocarcinoma. Plasma steroid concentrations were correlated to immunohistochemical data. 17HSD was detected in 48% of the specimens and was stained in the cytoplasm of epithelial cells. The tissues were characterized by a heterogeneous staining pattern for 17HSD. In some patients, intensively stained epithelial cell clusters were seen, indicating that local factors were responsible for the expression of the protein. Poorly differentiated adenocarcinoma specimens tended to have no 17HSD more frequently than did well or moderately differentiated tissues. ER and PR were detectable in 24% and 28% of patients, respectively, and were localized in the nuclei of epithelial and stromal cells. There was a significant correlation between 17HSD and PR staining and an inverse correlation between plasma progesterone concentrations and 17HSD staining. This is contrary to the data obtained with normal endometrium. The main reason for this inverse relation between endometrial 17HSD staining and plasma progesterone concentrations was that, in some postmenopausal patients with low plasma progesterone concentrations, intense staining for 17HSD was detectable in the endometrial carcinoma specimens. This indicates a major difference in the regulation of 17HSD expression in endometrial adenocarcinomas, compared with normal tissues of premenopausal women.

Determination of hormonal response in uterine cancer cell lines by the ATP bioluminescence assay and flow cytometry

Although progesterone receptor status has been shown to correlate with response to hormonal therapy, not all progesterone receptor-positive patients respond to this treatment and additional biologic assays are needed to help better predict clinical response to hormonal therapy. This study explored the potential of the ATP bioluminescence assay and flow cytometry as biological assays of hormonal response. Five uterine cancer cell lines were used: AE7, ECC-1, HEC1A, AN3, and SKUT1B. Cells were exposed to Provera or tamoxifen at 0.1, 0.2, 0.5, 1, 2, and 5X (X equal to peak plasma concentrations: 1.0 micrograms/ml Provera and 0.1 micrograms/ml tamoxifen). For correlation, estrogen and progesterone receptors were determined by the standard dextran-coated charcoal method. Only AE7 and ECC-1 were positive for progesterone receptors (501 fmol/mg AE7, 194 fmol/mg ECC-1) and the rest were negative (less than 8 fmol/mg). Tamoxifen exerted no inhibition to the above cell lines. Meanwhile, Provera exerted dose-response inhibition on both AE7 and ECC-1 cell lines. The effects of accumulation of G0-G1 phase and reduction of S, G2 cells (P less than 0.05), but not on the HEC1A cell line (P = 0.4). These changes confirmed the antiproliferative property of Provera. Further studies are needed to establish the role of the ATP bioluminescence assay and flow cytometry as biological assays of hormonal response.

The effects of Provera on chemotherapy of uterine cancer cell lines

Even though progestin is commonly added to many chemotherapy regimens in the treatment of uterine cancers, its role is still unproven. Since progestin is antiproliferative, its tendency to arrest cells in G1 phase may interfere with cytotoxic mechanisms. The ATP chemosensitivity assay and flow cytometry were used to study the effects of a progestational compound such as Provera on three single agents and four drug combinations. Uterine cancer cell lines included progesterone-receptor (PR)-positive AE7 and ECC1 and PR-negative HEC1A, HEC1B, AN3, and SKUT1B. Provera selectively affected only PR-positive cell lines. It imposed an antiproliferative effect on drug-induced cell-cycle perturbations by reducing G2 and S blocks and minimizing G1 depletion. When using IC50s (concentrations required for 50% growth inhibition) of 0.5 as a cutoff for drug sensitivity and resistance, Provera significantly improved the IC50s of the drug-resistant subgroup from 1.95 +/- 0.36 to 0.71 +/- 0.19 (P = 0.009) but not those of the drug-sensitive subgroup (P = 0.13). In summary, Provera appeared to work independently from cytotoxic mechanisms. Its improvement of cytotoxicity was most pronounced in resistant cell lines bearing progesterone receptors.

A prospective trial of postoperative vaginal radium/cesium for grade 1-2 less than 50% myometrial invasion and pelvic radiation therapy for grade 3 or deep myometrial invasion in surgical stage I endometrial adenocarcinoma

A prospective trial was performed to evaluate the recurrence rate and 5-year disease-free survival rate in patients with surgical Stage I endometrial adenocarcinoma. Patients with Stage I, Grade 1 or 2 disease, less than 50% myometrial invasion, and no evidence of disease outside the corpus of the uterus were treated by hysterectomy and bilateral salpingo-oophorectomy and postoperative vaginal radium/cesium (Group 1). Patients with surgical Stage I, Grade 3 disease or deep myometrial invasion, and histologically negative paraaortic lymph nodes were treated with postoperative pelvic radiation therapy (5000-5040 cGY) (Group 2). Patients with malignant peritoneal cytologic findings also received progesterone therapy. Of the 92 Group 1 patients, there have been no recurrences and the 5-year estimated disease-free survival rate was 99%. Of the 41 Group 2 patients, there have been four (9.7%) recurrences but only one (2.4%) within the treated field (pelvis), and the 5-year estimated disease-free survival rate was 88%. Of the 133 patients, the 5-year estimated disease-free survival rate was 96%, and only one patient (0.7%) had a local pelvic recurrence. Of the 16 patients with malignant peritoneal cytologic findings who were treated with progesterone therapy, none has had a recurrence.

Hormonal therapy in endometrial carcinoma

Although hormonal agents have been used to treat endometrial cancer for nearly 30 years, response rates have remained essentially unchanged. Furthermore, objective response rates vary considerably from institution to institution, presumably because of differences in accepted response criteria and patient selection. The latter is particularly influenced by the distribution within the treated population of well-differentiated and poorly differentiated tumor histologic types. Nevertheless, the rapid attrition after hormonal therapy begins and the limited long-term salvage in nonselected patients with advanced primary or recurrent disease suggest primary nonresponsiveness or acquired tumor refractoriness to hormonal therapy. The determination of tumor progesterone receptor levels has made it easier to identify patients with sensitivity to such therapy. Recent investigations have shown favourable response rates (72%) after administration of progestational agents in patients with progesterone receptor-rich tumors. Similarly, responses have been reported with antiestrogens and combination progestin-antiestrogen therapy, recent laboratory observations having suggested potential benefit from sequential administration. Although these clinical and laboratory findings are encouraging, the limited duration of objective responses and the poor long-term survival rates continue to temper enthusiasm for routine hormonal therapy. Properly stratified (according to pathologic, biochemical, and clinical criteria), prospective, randomized, double-blind studies with more definitive end points, such as progression-free survival and overall survival, are mandatory to further evaluate the merits of various therapeutic regimens using gonadal hormones.

Identification of putative nonfunctional steroid receptors in breast and endometrial cancer

A nuclear binding assay was developed for the purpose of having available a more predictive assay for hormone responsiveness in human cancers. The BNB assay identified specific and saturable steroid nuclear binding in human target tissues and human carcinomas. When the BNB assay was applied to a large set of breast and endometrial carcinomas, we speculate that nonfunctional receptors were detected in 20%-50% of the patients who were receptor-positive by the DCC assay. Lastly, as responsiveness to hormonal therapy in these cancer patients becomes known, the predictive value of the BNB assay can be established.

Treatment of recurrent and metastatic endometrial cancer with cisplatin, doxorubicin, cyclophosphamide, and megestrol acetate

The combination of cisplatin, doxorubicin, cyclophosphamide, and megestrol acetate was used to treat 15 patients with recurrent and metastatic endometrial cancer. Four patients had a complete response and one patient had a partial response, yielding a total response rate of 33%. Five patients had stable disease. The median survival for the whole group was 38 weeks. The median survival for responders was 60 weeks, and that for nonresponders was 21 weeks. The median progression-free survival for the whole group was 17 weeks. The median progression-free survival for responders was 32 weeks, and that for patients with stable disease was 25 weeks. The toxic reactions noted were primarily nausea, vomiting, and myelosuppression. The combination of cisplatin, doxorubicin, cyclophosphamide, and megestrol acetate has modest effectiveness in the treatment of metastatic or recurrent carcinoma of the endometrium.

A randomized trial of adjuvant progestagen in early endometrial cancer

A randomized, controlled trial was designed to determine whether adjuvant progestagen therapy improves survival in patients with Stage I or Stage II endometrial cancer. After surgery, 1148 patients were randomly assigned to adjuvant treatment with progesterone or were given no additional therapy. The duration of follow-up ranged from 42 to 132 months (median follow-up, 72 months). Crude survival and relapse rates were similar for both groups. Death due to intercurrent disease was higher in the progesterone group (P = 0.04). The median survival of the group of patients with cancer-related death was higher in the progestagen group than in the control group (30 and 22 months, respectively; P = 0.03). In 461 high-risk patients, a tendency towards fewer cancer-related deaths and a better disease-free survival in the treatment group was observed, but crude survival was unchanged. We conclude that there is little to gain from adjuvant progestagen therapy in patients with low-risk endometrial cancer, and that further studies are needed in high-risk patients.