Aggressive stage I grade 1 endometrial carcinoma

Clinical patterns and genomic profiling of recurrent 'ultra-low risk' endometrial cancer

OBJECTIVE

Despite good prognosis for patients with low-risk endometrial cancer, a small subset of women with low-grade/low-stage endometrial cancer experience disease recurrence and death. The aim of this study was to characterize clinical features and mutational profiles of recurrent, low-grade, non-myoinvasive, 'ultra-low risk' endometrioid endometrial adenocarcinomas.

METHODS

We retrospectively identified patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA endometrioid endometrial cancers who underwent primary surgery at our institution, between January 2009 and February 2017, with follow-up of ≥12 months. 'Ultra-low risk' was defined as FIGO tumor grade 1, non-myoinvasive, and lacking lymphovascular space invasion. Tumor-normal profiling using massively parallel sequencing targeting 468 genes was performed. Microsatellite instability was assessed using MSIsensor. DNA mismatch repair (MMR) protein proficiency was determined by immunohistochemistry.

RESULTS

A total of 486 patients with ultra-low risk endometrioid endometrial cancers were identified: 14 (2.9%) of 486 patients developed a recurrence. Median follow-up for non-recurrent endometrioid endometrial cancers: 34 (range 12-116) months; for recurrent endometrioid endometrial cancers: 50.5 (range 20-116) months. Patients with recurrent disease were older, had lower body mass index, and were most commonly non-White (p=0.025, p<0.001, and p<0.001, respectively). Other clinical characteristics did not differ. MMR immunohistochemistry was obtained for 211 (43%) tumors: 158 (75%) MMR-proficient and 53 (25%) MMR-deficient. Primary tumors of 9 recurrent and 27 non-recurrent endometrioid endometrial cancers underwent mutational profiling. Most were microsatellite stable (6/9, 67% recurrent; 25/27, 93% non-recurrent). Recurrent PTEN and PIK3CA mutations were present in both groups. Exon 3 CTNNB1 hotspot mutations were found in 4/9 (44%) recurrent and 8/27 (30%) non-recurrent (p=0.44).

CONCLUSIONS

Patients diagnosed with ultra-low risk endometrioid endometrial cancers have an overall excellent prognosis. However, in our study, 2.9% of patients with no identifiable clinical or pathologic risk factors developed recurrence. Further work is warranted to elucidate the mechanism for recurrence in this population.

Prediction of lymph node metastasis in patients with apparent early endometrial cancer

Objective

The purpose of this study is to investigate the incidence of lymph node metastasis in early endometrial cancer patients and to evaluate preoperative clinicopathological factors predicting lymph node metastasis.

Methods

We identified 142 patients with endometrial cancer between January 2000 and February 2013. All patients demonstrated endometrioid adenocarcinoma with grade 1 or 2 on preoperative endometrial biopsy. Preoperative magnetic resonance imaging showed that tumors were confined to the uterine corpus with superficial myometrial invasion (less than 50%), and there were no lymph nodes enlargements. All patients had complete staging procedures and were surgically staged according to the 2009 FIGO (International Federation of Gynecology and Obstetrics) staging system. Clinical and pathological data were obtained from medical records and statistically analyzed.

Results

Of the 142 patients, 127 patients (89.4%) presented with stage 1A, 8 (5.6%) with stage IB, 3 (2.1%) with stage II, and 4 (2.8%) with stage III disease. Three patients (2.1%) had lymph node metastasis-2 IIIC1 and 1 IIIC2 disease. Age, preoperative tumor grade, and myometrial invasion less than 50% on preoperative MRI were not associated with lymph node metastasis. A high preoperative serum CA-125 level (>35 IU/mL) was a statistically significant factor for predicting lymph node metastasis on univariate and multivariate analyses. Lymph node metastasis was only found in patients with preoperative grade 2 tumors or a high serum CA-125 level.

Conclusion

Preoperative tumor grade and serum CA-125 level can predict lymph node metastasis in apparent early endometrial cancer patients.

Sentinel lymph node detection using 99mTc combined with methylene blue cervical injection for endometrial cancer surgical management: a prospective study

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a combined technique for sentinel lymph node (SLN) localization and surgical staging of endometrial carcinoma.

METHODS

This is a single-center prospective observational study carried out from September 2011 to December 2013 including women with a diagnosis of endometrial cancer and scheduled for surgery. A regional lymph node mapping was obtained using SPECT-CT (cervical injection of Tc) the day before surgery. On the day of surgery, methylene blue was injected in the cervical tissue. The SLNs were identified intraoperatively guided both by a γ-probe and visual inspection of the blue dye. A pelvic and/or para-aortic lymphadenectomy was completed. A histological analysis was performed on all the removed lymph nodes. We calculated the detection rate for SLN and its negative predictive value (NPV) for malignancy.

RESULTS

Fifty patients underwent surgery. The SLN was isolated in 46 patients with detection rate of 92% (95% confidence interval, 80.77-97.78). The mean number of detected SLNs per patient was 1.54 (range, 1-5); the average number of non-SLNs removed was 17 (5-34) per patient. The most common SLN location was the external iliac lymph node chain, 33 (46.47%). Five SLNs (7.1%) were isolated in the para-aortic chain. Three SLN cases (5.9%) were positive for malignant cells; the totality of the remaining non-SLNs was negative. The NPV of the SLN was 100% (95% confidence interval, 89.79-99.79). Finally, pathologic findings were 42 endometrioid types (84%), 3 carcinosarcomas (6%), 4 clear cell (8%), and 1 serous papillary tumor (2%).

CONCLUSIONS

The SLN analysis may be useful to assess the presence or absence of lymph node metastases. Its high NPV may be used as criteria to avoid unnecessary lymphadenectomies in endometrial cancer patients.

Distribution of estrogen and progesterone receptors isoforms in endometrial cancer

Background

70–80% of sporadic endometrial carcinomas are defined as endometrioid carcinoma (EC). Early-stage, well differentiated endometrial carcinomas usually retain expression of estrogen and progesterone receptors (ER and PR, respectively), as advanced stage, poorly differentiated tumors often lack one or both of these receptors. Well-described EC prognosis includes tumor characteristics, such as depth of myometrial invasion. Therefore, in the current study, we evaluated the expression profile of ER and PR isoforms, including ER-α, PR-A and PR–B, in correlation to EC tumor histological depth.

Methods

Using immunohistochemistry and image analysis software, the expression of ER-α, PR-A, PR–B and Ki67 was assessed in endometrial stroma and epithelial glands of superficial, deep and extra-tumoral sections of 15 paraffin embedded EC specimens, and compared to 5 biopsies of non-malignant endometrium.

Results

Expression of PR-A and ER-α was found to be lower in EC compared to nonmalignant tissue, as the stromal expression was dramatically reduced compared to epithelial cells. Expression ratios of both receptors were significantly high in superficial and deep portions of EC; in non-tumoral portion of EC were close to the ratios of nonmalignant endometrium. PR-B expression was low in epithelial glands of EC superficial and deep portions, and high in the extra-tumoral region. Elevated PR-B expression was found in stroma of EC, as well.

Conclusions

The ratio of ER-α and PR-A expression in the epithelial glands and the stroma of EC biopsies may serve as an additional parameter in the histological evaluation of EC tumor.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1155060506119016

Histological features associated with occult lymph node metastasis in FIGO clinical stage I, grade I endometrioid carcinoma

AIMS

Lymph node involvement affects prognosis/treatment in endometrial carcinoma patients. We assessed various histological features associated with nodal metastasis in patients with grade I, stage I endometrial endometrioid carcinoma (EEC).

METHODS AND RESULTS

Eighteen stage I EECs with occult positive lymph nodes and 36 controls were assessed for depth of myoinvasion; microcystic, elongated and fragmented (MELF) pattern of myometrial invasion; lymphovascular invasion (LVI); and epithelial metaplasia. Nodal metastases were subclassified as isolated tumour cells (ITCs; ≤0.2 mm), micrometastasis (>0.2 mm and <2 mm), or macrometastasis (≥2 mm). Node-positive cases had significantly higher rates of LVI (P < 0.001) and MELF invasion (P = 0.003) on univariate analysis. Only LVI was associated significantly with nodal metastasis on multivariate analysis (P = 0.002). Tumours with MELF invasion demonstrated reduced E-cadherin expression. Macrometastases were identified in seven cases (39%) with or without micrometastasis/ITCs. Eight (44%) contained only ITCs. Eleven (61%) had histiocyte-like nodal metastases. Biopsy material from four of six (67%) and five of 17 (29%) cases with and without nodal metastasis showed detached eosinophilic tumour cell buds. Of the former, three were associated with histiocyte-like nodal metastases - a feature absent in biopsies without tumour budding.

CONCLUSIONS

Lymph nodes from grade I EEC exhibiting cellular budding or LVI should be examined for occult metastases, especially in the form of histiocyte-like cells.

Phosphohistone H3 and Ki-67 labeling indices in cytologic specimens from well-differentiated neuroendocrine tumors of the gastrointestinal tract and pancreas: a comparative analysis using automated image cytometry

BACKGROUND

Ki-67 proliferation index was recently incorporated in the grading of neuroendocrine neoplasms (NENs) of the gastrointestinal tract (GIT) and pancreas. These are now divided into well-differentiated neuroendocrine tumors (WDNETs, grades 1 and 2) and poorly differentiated neuroendocrine carcinomas (grade 3). While Ki-67 is an established proliferation marker in NENs, phosphohistone H3 (PHH3), a newer marker of mitotic activity, is not.

METHODS

We determined Ki-67 and PHH3 indices on cytologic samples from WDNETs of the GIT and pancreas using an automated cellular imaging system (ACIS®).

RESULTS

There was a strong correlation between Ki-67 and PHH3 indices generated by ACIS on cytologic samples. However, in some cases the two stains caused conflicting grades within the same tumor.

CONCLUSION

Both antibodies stain cells in different phases of the cell cycle which may cause discordant grades, thus affecting patient management and prognostication. Ki-67 staining is stronger than PHH3, making 'hot spots' easier to identify on ACIS. Ki-67 is more ideal than PHH3 for staining NENs, especially in tumors with borderline grades. Because PHH3 generates lower mitotic indices it should not be used as a proliferation marker in NENs until its expression has been further characterized.

pHH3 and survivin are co-expressed in high-risk endometrial cancer and are prognostic relevant

BACKGROUND

Phosphohistone-H3 (pHH3) is a promising reliable mitotic count biomarker. Our purpose was to study the relationship between the novel proliferation marker pHH3 and the established anti-apoptotic marker survivin and consider their prognostic relevance in endometrial cancer.

METHODS

A total of 106 patients with endometrial cancer (type I/endometrioid, n=81; type II carcinomas, n=18) and simple hyperplasia without atypia (n=7) were investigated. pHH3 and survivin expression were assessed using immunohistochemistry from paraffin-embedded tissue blocks.

RESULTS

A strong positive correlation was observed between pHH3 and survivin expression (P<0.0001). Patients with high-grade tumours and patients with type II carcinomas expressed significantly more pHH3 and survivin than low grade and endometrioid tumours (P<0.0001, P<0.0001, P<0.0001, and P<0.0001, respectively). In univariate survival analysis, overexpression of pHH3 and survivin were associated with increased recurrence and mortality (P<0.0001, P<0.0001, P<0.0001, and P<0.0001, respectively), in the multivariable Cox regression analyses both pHH3 and survivin could be identified as independent parameters for overall survival (P=0.004, and P=0.023, respectively).

CONCLUSION

In endometrial cancer, pHH3 and survivin were strongly positive correlated and were both associated with type II and high-grade tumours. Increasing expression levels of pHH3 and survivin were associated with adverse prognostic factors.

Clinical value of immunohistochemically detected lymphatic and vascular invasions in clinically staged endometrioid endometrial cancer

BACKGROUND

A novel technique to differentiate lymphatic from vascular invasion and to assess the clinicopathological significance in patients with early endometrial cancer.

METHODS

Dual immunohistochemical techniques against pancytokeratin epithelial cell marker (PCK), D6 lymphatic endothelial marker, and CD31 nonspecific endothelial marker were deployed for differentiation. Seventy-seven patients were included with a median follow-up of 161 months. Tumors with positive evidence of lymphovascular space invasion on PCK-CD31 immunohistochemistry and absence of lymphatic space invasion on PCK-D6 were regarded as cases with vascular space invasion only.

RESULTS

Significant association between depth of myometrial invasion, recurrence rate, and hematoxylin and eosin that detected lymphovascular space invasion were noted (P < 0.0001 and P = 0.009, respectively). The 5-year recurrence-free survival was 45% for the group with hematoxylin and eosin evidence of lymphovascular space invasion compared with 89% for the group without (P = 0.0014). Pancytokeratin epithelial cell marker-D6 dual immunostaining detected lymphatic space invasion in 22 (29%) patients. There was significant association between lymphatic space invasion and depth of myometrial invasion (P = 0.046). Lymphatic space invasion detected on immunohistochemistry was present in 8 (72%) of 11 patients with recurrent disease. Of the remaining 49 patients with no evidence of recurrent disease, only 11 (22%) had presented with lymphatic space invasion. Positive association between tumor recurrence rate and lymphatic space invasion was noted (P = 0.003). The 5-year recurrence-free survival was 53% for the group with lymphatic invasion compared with 93% for the group without. This difference was similarly shown to be of significance (P = 0.0009). There were no apparent association between immunohistochemically detected lymphovascular or vascular space invasion and any clinicopathological factor.

CONCLUSIONS

Lymphatic space invasion detected by using dual immunostaining is of significant value in identifying high-risk patients.

Assessment of Uterine Wall Thickness and Position of the Vascular Plexus in the Deep Myometrium: Implications for the Measurement of Depth of Myometrial Invasion of Endometrial Carcinomas

Accurate discrimination between FIGO stages IB and IC endometrial carcinomas has important prognostic and therapeutic implications, but depth of invasion as a percentage of myometrial thickness can be difficult to ascertain. In such cases, pathologists often presume that infiltration that reaches the arcuate vascular plexus (AVP) in the myometrium indicates >50% myoinvasion. The further assumption is sometimes made that the anterior and posterior uterine walls are of the same thickness. To our knowledge, neither supposition is based on published data. We performed a prospective study of myometrial thickness and the position of the AVP in 50 normal uteruses from patients aged 27 to 84 years. Myometrial thickness varied inversely with age (p < 0.0001); however, anterior and posterior wall myometrial thickness did not differ significantly in the cohort as a whole (p = 0.059) and in individual cases was highly correlated (p < 0.0001). The position of the AVP was variable. On average, its inner limit was situated at a depth of 47.3% of the thickness of the myometrium in both uterine walls, but the position varied between individuals and sometimes differed considerably between the anterior and posterior walls of the same uterus. The position of the AVP did not differ significantly with age. We conclude that carcinomatous infiltration well into or through the AVP usually signifies >50% myoinvasion; however, if infiltration barely extends into the AVP, the depth of invasion should be calculated with reference to the thickness of the myometrium in the opposite uterine wall.

Upstaging based solely on positive peritoneal washing does not affect outcome in endometrial cancer

Surgical staging of endometrial carcinoma includes the collection of peritoneal washings in the abdomen and pelvis. A positive finding upstages patients to International Federation of Gynecology and Obstetrics stage IIIA. However, the prognostic significance of such an upstaging, and thus the justification for the routine performance of this procedure, is unclear. This 5-year retrospective study was conducted to determine the frequency and prognostic significance of upstaging of endometrial carcinoma based solely on positive washings. The cohort for the study was collected by review of pathology reports of all washings that were performed prior to hysterectomies for suspected endometrial carcinomas over a 5-year period (01/1995-12/1999). Cases with positive cytology were selected if there was no grossly apparent intraperitoneal disease, no histologic evidence of extra-uterine tumor and the cases would otherwise have been considered stage I or II (case group). An age-matched control group was selected of stage I and II patients with the same histologic subtypes and negative washings (n=19). Of 220 endometrial carcinomas, peritoneal washing cytology was abnormal in 19 (8.6%) and was solely responsible for upstaging only 10 patients (4.5% of all cases, eight-endometrioid, one-serous, one-mixed; nine stage IA or IB and one stage IIB). Adjuvant therapy was administered in 90% of the case group and 74% of the control group. After a median follow-up of 51 months (case group) and 63 months (control group), we found only a single patient with progression of disease (recurrence, metastases or death) in the control group. It is concluded that abnormal cytology without other evidence of extrauterine disease leads to upstaging of a minority of endometrial carcinoma patients (4.5%), but does not appear to affect their overall outcome. Although this is a small single site study, it raises questions about the value of this procedure in patients with endometrial cancer.

Prognostic impact of histological grade and vascular invasion compared with tumour cell proliferation in endometrial carcinoma of endometrioid type

AIMS

The relative impact of different prognostic factors is important for endometrial carcinoma patients. The aim of our study was to examine the combined value of histological grade [International Federation of Gynaecology and Obstetrics (FIGO)] and vascular invasion in comparison with tumour cell proliferation assessed by mitotic count and Ki67. The recently proposed binary architectural grade was also evaluated, in addition to age, depth of myometrial infiltration and FIGO stage in our population-based series of 237 endometrioid carcinomas.

METHODS AND RESULTS

The tumours were studied for several histological features, including FIGO grade, binary grade, vascular invasion, mitotic count, myometrial invasion and expression of Ki67. FIGO grade was significantly associated with all investigated histological features, including Ki67 expression. Vascular invasion was significantly more frequent in FIGO grade 3 tumours, and was associated with a diffusely infiltrative growth pattern, solid growth, necrosis and deep myometrial invasion. All variables showed a highly significant relationship with patient survival in univariate analysis. In multivariate models, FIGO grade, vascular invasion, and proliferation assessed by Ki67 expression all had independent prognostic influence in this population-based study. Comparing tumour cell proliferation (Ki67) with vascular invasion as a marker of metastatic spread, the latter had a stronger survival impact.

CONCLUSIONS

Vascular invasion and tumour cell proliferation measured by Ki67 both had independent prognostic influence, and should be considered to identify aggressive tumours of the endometrioid subtype.

A significance of immunohistochemical determination of steroid receptors, cell proliferation factor Ki-67 and protein p53 in endometrial carcinoma

OBJECTIVES

The aim of the study was to preoperatively predict the biologic behavior of the endometrial carcinoma using immunohistochemical analysis of the p53 protein and Ki-67 expression, and estrogen receptor (ER) and progesterone receptor (PR) status, in the material obtained by fractional curettage.

METHODS

One hundred and thirty-six patients with primary endometrial carcinoma were included in the study. In all 136 patients, the fractional curettage was performed before the hysterectomy, and the diagnosis of endometrial carcinoma was confirmed pathohistologically after the surgical procedure on the hysterectomy specimens. The significance of the prognostic factors was assessed using univariate and multivariate analyses. The cutoff values of the percentage of ER, PR, p53, and Ki-67 positive cells in terms of survival probability determination were obtained as the values of the highest chi-square test, using proportional-risk regression method. A multivariate Cox regression analysis was performed to estimate the influence of several clinical, pathohistologic, and immunohistochemical covariates to patients' survival. Survival curves were determined by the Kaplan-Meier product-limit method based on the most recent clinical status.

RESULTS

According to the histologic type of the tumor, fractional curettage specimens revealed 111 histologically favorable types (81.6%) and 25 unfavorable types (18.4%). The data indicate that ER, PR, Ki-67, and p53 levels of the hysterectomy specimens and those of the preoperative specimens were in fairly good agreement. The patients with the most favorable tumor grade (G I) had significantly better prognosis when the percentage of p53 positive cells was less than 15%. In the group of patients with histologic grade II, the survival was affected by ER expression (more than 30% of positive cells) and p53 levels (less than 15% of positive cells). None of the parameters was predictive in the group of patients with histologic grade III.

CONCLUSIONS

We found that determination of immunohistochemical parameters (ER, PR, and p53) on well-differentiated and moderately differentiated endometrial carcinoma of favorable histologic type obtained by curettage enables the recognition of the patients with favorable prognosis, who should not be treated by radical surgery.

Clinical value of immunohistochemically detected lymphovascular invasion in endometrioid endometrial cancer

INTRODUCTION

Lymphovascular Invasion (LVSI) of tumour cells is marked as an important step in the process of tumour metastases and is an important prognostic factor in Endometrial Cancer (EC). Currently, the standard method for assessing LVSI is light microscopic examination of H&E stained sections. Tumour cells within lymphovascular spaces can evade detection on H&E staining if they are present in very small numbers or surrounded by a greater number of circulating cells. Dual immunostaining for epithelial and endothelial cell markers cell markers has been shown to increase detection rate of LVSI significantly.

OBJECTIVES

To investigate the clinical significance of LVSI as detected by H&E (LVSI-H&E) and immunohistochemically (LVSI-IHC) in clinically stage I endometrioid EC patients. Methods. Single representative section of 90 patients with stage I endometriod EC were immunostained in accordance with established streptavidin-biotin peroxidase method using a mouse monoclonal pancytokeratin (PCK), clone AE1/AE3 and CD31 endothelial cell marker. The H&E sections and their corresponding immunostained sections were re-examined to identify LVSI. Clinical records were available on 72 patients. The following data were collected: age, race, parity, presentation, associated medical disorders (obesity, diabetes and hypertension), use of Tamoxifen or HRT, menopausal state, recurrence and survival.

RESULTS

Overall, LVSI was present in 45 (50%) cases and absent in 45 (50%) cases on IHC, as compared with 17 (19%) and 73 (81%) cases, respectively, on H&E. Statistical analysis revealed significant association between LVSI-H&E and depth of myometrial invasion (P < 0.0001). The median follow-up period was 161 months (range 5-207 months). During the follow-up period, six of 14 cases with evidence of LVSI-H&E presented with recurrence as opposed to six of 58 patients with no evidence (OR = 6.26, 95%: CI = 1.3-30.6). There was a significant association between tumour recurrence rate and LVSI-H&E (P = 0.01). The 5-year recurrence-free survival was 54% for the group with H&E evidence of LVSI (95%: CI = 44-64%) compared with 89% for the group without (95%: CI = 82-97%). There was a significant difference in the recurrence-free survival between the two groups (Chi-square = 6.96, P = 0.008). In contrast, LVSI-IHC was found to be significantly associated only with high-grade tumours (P = 0.01) and survival analysis revealed no statistically significant association with recurrence or survival.

CONCLUSIONS

LVSI-H&E in stage I EC remains an important predictive factor of recurrent disease and reduced disease-free interval. Immunohistochemically detected LVSI is a common event, associated with tumour grade and appears to be of no statistically significant clinical value.

Markers of proliferative activity are predictors of patient outcome for low-grade endometrioid adenocarcinoma but not papillary serous carcinoma of endometrium

On the basis of pathogenesis, two types of endometrial cancer can be recognized. Type 1 endometrial carcinomas are relatively indolent tumors that develop after prolonged estrogen stimulation, on a background of endometrial hyperplasia. Type 2 endometrial carcinomas are aggressive tumors that are not associated with hyperplasia or estrogen excess. The aim of this study is to evaluate the prognostic significance of tumor proliferative activity in early-stage endometrial cancer by using mitotic index and immunostaining, comparing Type 1 (endometrioid) and Type 2 (papillary serous carcinoma) tumors. The mitotic index, MIB-1, and p53 immunostaining in 39 tumors from patients with low-grade Stage Ia or Ib endometrioid adenocarcinoma; as well as 23 tumors from patients with Stage I papillary serous carcinoma. In low-grade endometrioid adenocarcinoma, mitotic and MIB-1 indices were statistically significant independent prognostic indicators (P =.004 and P =.018, respectively), and both were strongly correlated with p53 expression (P =.01 and P =.006, respectively). The mean mitotic index was 5 mitoses/10 high-power fields, and mean MIB-1 index was 27.5%. There was no significant correlation between mitotic or MIB-1 indices and patient outcome or p53 expression in papillary serous carcinoma. The mean mitotic index was 31 mitoses/10 high-power fields, and mean MIB-1 index was 30.5% in these tumors. p53 expression and proliferative indices are strongly correlated in low-grade endometrioid adenocarcinoma. MIB-1 and mitotic indices are independent prognostic indicators in these tumors. Papillary serous carcinoma of endometrium is rapidly proliferative in tumors even at an early stage, and quantification of proliferative activity in these tumors does not allow prediction of patient outcome.

Is vascular and lymphatic space invasion a main prognostic factor in uterine neoplasms with a sarcomatous component? A retrospective study of prognostic factors of 60 patients stratified by stages

BACKGROUND

Sarcomatous neoplasms of the uterine corpus are still a challenge in terms of obtaining prognostic factors and the most optimum complementary treatment to surgery. The most important prognostic factor is stage; relapses usually appear during the first 2 years, and most patients die within the first 3 years. We have performed a multivariate study of prognostic factors, stratifying patients by stage, to determine their impact on overall survival, disease-free survival, local relapse-free survival, and distant metastasis-free survival. Special emphasis has been given to vascular and lymphatic space invasion (VLSI).

METHODS

Sixty patients diagnosed with uterine neoplasms with a main sarcomatous component were treated at Hospital Clínic i Universitari of Barcelona between January 1975 and June 1999. Pathologic type: 32 carcinosarcomas, 14 leiomyosarcomas, 9 adenosarcomas, and 5 endometrial stromal sarcomas.

TREATMENT

58/60 surgery, 35/60 postoperative radiotherapy, 2/60 exclusive chemotherapy, and 3/60 complementary chemotherapy. FIGO stages: 43 Stage I, 4 Stage II, 11 Stage III, and 2 Stage IV. Variables analyzed: age, stage, vascular and lymphatic space invasion, myometrial invasion, mitotic index, tumor size, unicentricity/multicentricity, necrosis, and radiotherapy.

STATISTICS

the S and Cox proportional risk models. The partial effect of each risk factor was calculated by hazard ratio (HR) with a confidence interval of 95%.

RESULTS

Early stages: Multivariate analysis showed that tumor size larger than 8 cm and VLSI had an impact on overall survival (HR = 4.01 and HR = 24.45, respectively). VLSI was present in 23% of the cases. Myometrial invasion greater than 50% had an impact on disease-free survival and local relapse-free survival (HR was 9.75 and 3.20, respectively). VLSI had an impact on distant metastasis-free survival (HR = 2.92). Advanced stages: VLSI was present in 89% of the cases. Only leiomyosarcoma type made the overall survival worse (HR = 10.54).

CONCLUSIONS

Vascular and lymphatic space invasion was a relevant prognostic factor in our series, with an impact on overall survival and distant metastasis-free survival in early stages. In advanced stages, VLSI had no impact on survival, but was present in 89% of cases. Myometrial invasion >50% had an impact on local relapse. Advanced stages had a more aggressive behavior, and there was a higher incidence of poor prognostic factors in these stages. Nevertheless, prospective studies are still needed on prognostic factors and on the best treatment option.

High telomerase activity is associated with cell cycle deregulation and rapid progression in endometrioid adenocarcinoma of the uterus

Telomerase activity, a mechanism granting cellular immortality, has been detected in most cancer entities, but its association with clinical, histopathologic, and prognostic parameters is not fully understood. We investigated whether quantitative telomerase levels are correlated to established prognostic factors, telomere lengths, cell cycle kinetics, and the clinical course in endometrioid adenocarcinoma of the uterus (EC). A modified telomeric repeat amplification protocol (TRAP) was used to quantify the relative telomerase activity in a series of 53 primary tumors. Mean telomere length was determined by Southern blot analysis. Cell cycle kinetics were studied immunohistochemically on paraffin sections using monoclonal antibodies to 2 distinct proliferation-specific proteins: Ki-67, which is expressed throughout the cell cycle, and a novel cell cycle-associated protein, repp86, the expression of which is restricted to the cell cycle phases S, G2, and M. The ratio of the 2 immunolabeling indices defines the rate of transition through the restriction point. Telomerase activity was detected in 50 of 53 ECs (94%). Its levels correlated significantly with FIGO stage (P =.01) and FIGO grade (P =.003) but not with myometrial invasion. They were weakly associated with the overall proliferative activity (Ki-67, r =.48) but significantly with the repp86 index (r =.64) and even more strongly with the repp86:Ki-67 ratio (r =.77). There was no correlation with mean telomere length. In the group of tumors with high telomerase activity, 5 patients had relapses and 2 died of the disease within a median follow-up period of 29 months. Recurrence showed no relation to FIGO grade and stage. No events were observed in the group with low telomerase activity. In a multivariate model including tumor stage, histopathologic grade, depth of myometrial invasion, and Ki-67 indices, telomerase activity emerged as the only independent predictor of disease progression (P =.0002). It is concluded that beyond a link to proliferation, high telomerase activity reflects a deregulation of the cell cycle associated with an increased rate of cells entering S phase and a higher degree of malignancy. Therefore, quantitative analysis of telomerase activity may be useful for identifying EC patients at high risk for recurrence.

Adenocarcinoma of the endometrium treated with combined irradiation and surgery: study of 437 patients

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas.

METHODS AND MATERIALS

Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system (225 Stage IB, 107 Stage IC, 4 Stage IIA, 35 Stage IIB, 30 Stage IIIA, 6 Stage IIIB, and 30 Stage IIIC), underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of adjuvant RT was not randomized and depended on the usual practices of the surgical teams. Seventy-nine pts (Group I) received preoperative low-dose-rate uterovaginal brachytherapy (mean dose [MD]: 57 Gy). Three hundred fifty-eight pts (Group II) received postoperative RT. One hundred ninety-six pts received low-dose-rate vaginal brachytherapy alone (MD: 50 Gy). One hundred fifty-eight pts had external beam pelvic RT (MD: 46 Gy) followed by low-dose-rate vaginal brachytherapy (MD: 17 Gy). Four pts had external beam pelvic RT alone (MD: 47 Gy). The mean follow-up from the beginning of treatment was 128 months.

RESULTS

The 10-year disease-free survival rate was 86%. From 57 recurrences, only 12 were isolated locoregional recurrences. The independent factors decreasing the probability of disease-free survival were as follows: histologic type (clear-cell carcinoma, p = 0.038), largest histologic tumor diameter >3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.005), and 1988 FIGO staging system (p = 9.10(-8)). In Group II, the addition of external beam pelvic RT did not seem to independently improve vaginal or pelvic control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were stage FIGO (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for Grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. External beam pelvic RT independently increased the rate for Grade 3 and 4 late complication (RR: 5.6, p = 0.0096).

CONCLUSION

Postoperative external beam pelvic RT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in subgroup of "intermediate-risk" patients (Stage IA Grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with Stage III tumor are not satisfactory.

Postoperative irradiation in endometrial cancer: still a matter of controversy

Although endometrial cancer is the most common female malignancy, evidence-based uniform guidelines for postoperative therapy have not been established. The most logical management is adjuvant irradiation tailored to the extent of surgery, the tumour grade, depth of myometrial invasion, degree of lymph node involvement and age of the patient. Currently, the only widely accepted treatment recommendations are no further therapy in low-risk patients who underwent extensive surgical staging, and external beam radiotherapy (EBRT) in high-risk patients. Most authors recommend postoperative application of only one radiotherapy modality: either brachytherapy (BRT) or EBRT, as their routine combination does not clearly improve the outcome but does increase the risk of late complications. A combination of BRT and EBRT should however be considered in patients with stage II disease, for infiltration of the lower uterine segment, vaginal involvement, positive or close surgical margins, capillary space involvement or unfavourable histology. Two recent randomized studies including mostly intermediate-risk patients managed with either extensive surgical staging or total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH&BSO) with or without postoperative EBRT, showed better local control but no survival benefit from adjuvant irradiation. Two ongoing Gynecologic Oncology Group (GOG) studies compare adjuvant chemotherapy with pelvic or abdominal irradiation in patients with high risk of local relapse. The role of adjuvant radiotherapy (EBRT with or without BRT) in high-risk patients as well as the value of lymphadenectomy in patients fit for such surgery is being addressed in a trial co-ordinated by the Medical Research Council. Future studies are warranted to define whether any irradiation should be employed in intermediate-risk patients and which radiotherapy modality should be used in high-risk node-negative patients with stage I tumours (stage Ib grade 3 and all stage Ic). Other issues which should be addressed in future studies include the extent of surgery, the role of systemic therapies, the relevance of novel biologic prognostic factors, salvage therapies after recurrence, cost-benefit analysis and quality of life.

Prognostic significance of a novel proliferation marker, anti-repp 86, for endometrial carcinoma: a multivariate study

Traditional prognostic factors often fail to identify a subgroup of endometrial carcinoma (EC) patients with an apparently paradoxical poor outcome. We therefore analyzed tumor cell proliferation immunohistochemically in a series of 164 endometrial carcinomas (EC) and compared its prognostic impact with that of the standard prognostic factors patient age, FIGO stage, FIGO grading, and histopathologic subtype. In addition to the established proliferation markers Ki-S5 (Ki-67) and KiS4 (topoisomerase IIalpha), we used a novel monoclonal antibody (MAb), anti-repp 86, which binds to a recently described proliferation-specific protein (p86) expressed exclusively in the S, G2, and M phases of the cell cycle. anti-repp 86, Ki-S4, and Ki-S5 immunoreactive labeling indices (LI) correlated significantly with FIGO stage, FIGO grade, and myometrial invasion, but not with histopathologic subtype. By univariate analysis, conventional prognostic factors and proliferation indices were all predictive of disease-related mortality. A multivariate Cox regression analysis selected anti-repp 86 LI (P = .002), FIGO stage (P = .02), and histopathologic type as significant prognosticators of recurrence; anti-repp 86 LI (P = .001) and histopathologic type (P = .0106) also emerged as relevant predictors of mortality. A hierarchical forward regression model with the conventional prognosticators entered first and with anti-repp 86 entered next showed that anti-repp 86 and histopathologic subtype were the superior independent prognostic indicators for an increased risk of recurrence and cancer-related death. We conclude that the evaluation of anti-repp 86 immunostaining is an easily performable and exceptionally reliable method for identifying EC patients with adverse prognosis.

Surgery followed by radiotherapy in endometrial cancer: analysis of survival and patterns of failure

We performed a retrospective evaluation of survival and patterns of failure in 317 consecutive endometrial cancer patients treated between 1974 and 1991 with surgery and adjuvant radiotherapy. Two hundred and forty seven patients (78%) had FIGO stage I disease, 30 (9%) - stage II, 35 (11%) - stage III and 5 (2%) - stage IV. Both low dose rate brachytherapy (BRT) and external beam radiation (EBRT) were applied in 247 patients (78%), only BRT in 49 (15%), and only EBRT in 21 (7%). Median follow-up was 7.3 years. Five-year overall survival was 75%, and five-year disease free survival was 81%. Both overall and disease free survival rates were correlated with stage (P = 0.001 and P = 0.000, respectively). Recurrence occurred in 70 patients (22%): 11 (3.5%) in the pelvis, 51 (16%) outside the pelvis and 6 (2%) both in- and outside the pelvis. Independent risk factors for local recurrence included older age (P = 0.03) and variant histologic subtypes (P = 0.039), whereas independent risk factors for distant spread were stage (P = 0.000) and older age (P = 0.011). Normalized Total Dose (the sum of EBRT and BRT doses, based on linear-quadratic equation), type of radiotherapy regimen, overall radiotherapy time and surgery-to-radiotherapy interval did not correlate with the risk of relapse. Severe early and late radiotherapy complications were observed in 21 (7%) and 35 patients (11%), respectively. In view of the relatively low risk of exclusive pelvic recurrences and the high rate of severe late radiotherapy complications, indications for postoperative radiotherapy and its scheme should be verified. A relatively high rate of extrapelvic recurrences calls for effective systemic adjuvants to surgery. Further definition of high risk patients is warranted in order to tailor postoperative therapy to the prognostic factors and to increase the therapeutic index of management of endometrial cancer.

Diffusely infiltrative endometrial adenocarcinoma: an adenoma malignum pattern of myoinvasion

The prognostic significance of a diffusely infiltrative intramyometrial growth pattern was evaluated in 110 cases of low-stage (stages I and II) endometrial adenocarcinoma. Fifty cases were associated with diffuse infiltration (DI group), and 50 cases had more conventional granulation tissue type intramyometrial infiltration (GTT group). Ten cases with carcinomatous involvement of deeply situated adenomyosis (ADMY group) were also studied. The diffusely infiltrative "adenoma malignum" growth pattern featured typically round, regular individual glands, clearly within myometrium but with minimal or absent stromal or inflammatory cell response. Myoinvasion of the conventional sort was characterized by irregular, sharply angulated abnormal glands within myometrium without interposed normal glands or endometrial stroma. The abnormal glands were surrounded, at least focally, by edematous stroma with granulation tissue type reaction and/or an inflammatory cell infiltrate. Mean follow-up was 77.8 months (range 3-219 months) for the patients with diffusely infiltrative myoinvasion and deep adenomyosis and 86.9 months (range 1-206 months) for the patients with conventional myoinvasion. Recurrence-free survival for patients with stage I disease and conventional myoinvasion (94%) was similar to that of patients with diffuse adenoma malignum infiltration (98%; p = 0.13). Survival rates for both groups were also similar. Two (4%) of the 50 patients with diffusely infiltrative adenoma malignum pattern of myoinvasion died of endometrial carcinoma 36 and 72 months after hysterectomy, and 2 (4%) of the 50 patients with conventional myoinvasion died 34 and 67 months after hysterectomy (p = 0.41). Survival in these patients correlated with depth of myometrial invasion and stage. There were no recurrences in the patients with deep adenomyosis. These results suggest that although endometrial carcinomas with diffuse myometrial infiltration are fully capable of aggressive clinical behavior, they do not appear to behave any more aggressively than those with conventional myometrial invasion. Prognostic indicators of clinically aggressive disease are similar to those that have been previously identified for endometrial carcinomas with the more conventional pattern of myometrial infiltration. They include cervical involvement, deep myometrial invasion, higher histologic grade, and lymph-vascular space invasion. Endometrial carcinomas with extensive involvement of adenomyosis and adjacent foci of minimal myometrial infiltration appear to have very low malignant potential, but the number of cases with this finding and adequate clinical follow-up is limited. This finding needs to be confirmed in a much larger series of cases.

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.

Endometrial carcinomas--flow cytometric DNA content and S-phase values

The purpose of the investigation was to determine the DNA content and S-phase value in a large material of fresh tumour tissue from endometrial carcinomas and to correlate these parameters to tumour type, grade of differentiation, depth of myometrial invasion and stage. The prospective study consisted of 290 unselected cases of endometrial carcinomas, FIGO stage I-IV where flow cytometry was performed on fresh tumour tissue blocks from hysterectomy specimens. 223 cases had more than 10% tumour tissue in tissue blocks taken adjacent to the blocks for flow cytometry. Non-diploidy was defined as 0.9 > or = DNA index > 1.10 and high S-phase value was defined as > 15%. Non-diploidy was found in 46% of the endometrioid adenocarcinoma and in 85% of the non-endometrioid carcinomas (clear cell adenocarcinoma, serous adenocarcinoma and malignant mixed mesodermal tumour) (p < 0.001). S-phase value was > 15% in 39% of the endometrioid adenocarcinoma and in 100% of the non-endometrioid carcinomas (p < 0.0001). In endometrioid adenocarcinoma there was a statistical significant relation between non-diploidy and grade of histological differentiation (p < 0.006), as well as with depth of myometrial invasion (p < 0.05). There was no relation between non-diploidy and the presence of squamous differentiation, whether benign or malignant or to FIGO stage. High S-phase values (> 15%) was related to the grade of differentiation (p < 0.002). No relation was demonstrated between S-phase > 15% and squamous differentiation, depth of myometrial invasion or FIGO stage. In conclusion, 50% of all the endometrial carcinomas were non-diploid and 43% had S-phase value > 15%. Ploidy correlated with histologic tumour types, grade of differentiation and depth on myometrial invasion while S-phase values only correlated with histologic tumour types and grade of differentiation.

Non-primary cervical adenocarcinomas

We reviewed 16 non-primary cervical adenocarcinomas collected during a six year period. Ten tumors originated in the endometrium, three in the ovary and one each in the bladder, colon and fallopian tube. Tumor spread was identified by combined lymphovascular involvement and stromal invasion in five of the 16 cervices, lymphovascular involvement alone in four cervices, stromal invasion alone in two cervices, lymphovascular involvement with stromal invasion and cervical implantation in two cervices and cervical implantation alone in three cervices. The three tumors with surface implantation alone were of endometrial origin, had minimal if any myometrial invasion, no extrauterine metastases and two had malignant peritoneal washings. Of the 13 tumors with cervical lymphovascular involvement and/or stromal metastases, 11 had ovarian, nodal and/or peritoneal metastases. We conclude that cervical implantation occurs exclusively with endometrial adenocarcinomas, that it follows previous cervical instrumentation and that the prognosis is dependent on the histoprognostic features of the primary endometrial tumor. In contrast, cervical lymphovascular involvement and/or stromal metastases usually reflects disseminated pelvic or abdominal malignancy with a poor prognosis. However histological examination may not afford separation of these two lesions if local cervical invasion is advanced, if spread has occurred by more than one mode or if insufficient clinical/surgical information is provided.

The prognostic significance of vascular invasion by endometrial carcinoma

BACKGROUND

Recently, invasion of vascular spaces by endometrial carcinoma has received particular attention as a prognostic factor. The goal of the current investigation was to re-examine the effect of vascular invasion on tumor recurrence and survival in patients with endometrial carcinoma.

METHODS

Surgical specimens from 238 patients with endometrial carcinoma were examined for the presence of vascular invasion by tumor cells. Vascular invasion was compared with clinicopathologic features and postoperative survival. Survival curves by vascular invasion were evaluated by the Kaplan-Meier method.

RESULTS

In a histopathologic review of 238 cases of endometrial carcinoma, 82 neoplasms demonstrated vascular invasion. Vascular invasion significantly correlated with the extension of primary tumor, depth of myometrial invasion, and histologic grade. Patients with lymph node metastasis had a significantly higher incidence of vascular invasion. Survival at 5 years for patients with vascular invasion was 73.4%. This was significantly lower than the survival rate of 91.5% for women without this finding (P < 0.001). Among patients with lymph node metastasis, 80.2% of the patients with vascular invasion survived for 5 years compared with 95.3% of the patients without vascular invasion (P < 0.05). Ten of 47 patients with no lymph node metastasis but with vascular invasion developed recurrent carcinoma. Nine of these ten patients apparently had extrapelvic recurrences.

CONCLUSIONS

The presence of vascular invasion is a reliable prognostic indicator. Recording of tumor recurrence pattern may lead to a better selection of patients for adjuvant systemic therapy after surgery.

Characterization of extracellular matrix-degrading proteinase and its inhibitor in gynecologic cancer tissues with clinically different metastatic form

BACKGROUND

The authors conducted a comparison study of matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase-1 (TIMP-1) activities in clinically different metastatic types of ovarian cancer, cervical cancer, and endometrial cancer tissues.

METHODS

Gelatinase activity in culture medium obtained from each cancer tissue was detected by zymography and was quantitated by densitometer. Tissue inhibitor of metalloproteinase-1 activity was measured in culture medium by the human TIMP-1 enzyme immunoassay kit.

RESULTS

Six dominant gelatinases were detected in ovarian, cervical, and endometrial cancers: 200-kDa; 130-kDa; 92-kDa (MMP-9); 83-kDa, which is an active form of 92-kDa gelatinase; 72-kDa (MMP-2); and 66-kDa gelatinase, which is an active form of 72-kDa gelatinase. The 92-kDa and 72-kDa gelatinolytic bands were present in all samples. The expression rates of 200-, 130-, and 83-kDa gelatinase in endometrial cancer and cervical cancer tissues were higher than that observed in ovarian cancer tissue. Densitometric analysis showed that the 92-kDa/72-kDa ratio was significantly higher in cervical cancer tissue than in ovarian and endometrial cancer tissues (P < 0.05), and the 66-kDa/72-kDa ratio was significantly higher in endometrial cancer tissue than in ovarian cancer tissue (P < 0.01). Tissue inhibitor of metalloproteinase-1 activity was significantly lower in cervical cancer tissue than in ovarian and endometrial cancer tissues (P < 0.01).

CONCLUSIONS

These results reflect the difference of metastatic forms and are indicative of the possibility of the strong relationship to MMP activity in the invasion and metastasis of cervical cancer and endometrial cancer, compared with those of ovarian cancer.