Endometrial carcinoma. Influence of prognostic factors on radiation management

Overexpression of Lysine-Specific Demethylase 1 Is Associated With Tumor Progression and Unfavorable Prognosis in Chinese Patients With Endometrioid Endometrial Adenocarcinoma

OBJECTIVE

Lysine-specific demethylase 1 (LSD1) is a kind of flavin adenine dinucleotide-dependent amine oxidase that regulates normal cellular differentiation, gene activation, tumorigenesis, and progression. This study aims to detect the expression level of LSD1 in endometrial cancer and to explore its role in the progression and prognosis of endometrioid endometrial adenocarcinoma (EEA).

METHODS

Immunohistochemistry was used to examine the expression of LSD1 in 206 EEA specimens, 50 benign endometrial lesion specimens, and 45 normal endometrium specimens. χ Analysis, Kaplan-Meier method, and multivariate Cox proportional hazard analysis were applied for the statistical analysis.

RESULTS

Compared with normal endometrium and benign endometrial lesion (both P < 0.001), LSD1 was overexpressed in EEA. LSD1 expression was correlated with histological grade, International Federation of Gynecology and Obstetrics (FIGO) stage, vascular/lymphatic invasion, depth of myometrial invasion, and lymph node metastasis. Results of the Kaplan-Meier analysis indicated that LSD1 expression was associated with overall survival (OS) and disease-free survival (DFS) of EEA. The negative expression LSD1 group had longer OS and DFS than did the positive expression group. The difference was significant (both P < 0.001, log-rank test). Multivariate Cox regression analysis revealed that the LSD1 expression status was an independent prognostic factor for both OS (P = 0.027) and DFS (P = 0.016) of patients with EEA.

CONCLUSIONS

Overexpression of LSD1 may contribute to the progression of EEA and may thus serve as a new biomarker to predict the prognosis of EEA.

Correlation of TNFAIP8 overexpression with the proliferation, metastasis, and disease-free survival in endometrial cancer

Tumor necrosis factor alpha-induced protein 8 (TNFAIP8) is an apoptosis regulator proven to have an important function in the proliferation, invasion, metastasis, and progression of malignancies. In this study, we investigated the clinical role of TNFAIP8 overexpression in endometrial cancer (EC) and determined the relationship of TNFAIP8 with the proliferative antigen Ki-67 and metastasis-related gene matrix metallopeptidase 9 (MMP9) in 225 tumor specimens by immunohistochemistry and western blot, in order to elucidate more information on the role of TNFAIP8 protein with regard to the pathogenesis of EC. An association was observed between TNFAIP8 overexpression and clinicopathologic factors, such as advanced International Federation of Gynecology and Obstetrics stage (P<0.001), higher histologic grade (P=0.017), deep myometrial invasion (P=0.030), lymphovascular space invasion (P=0.011), lymph node metastasis (P<0.001), and recurrence. Furthermore, TNFAIP8 overexpression was strongly correlated with MMP9 and Ki-67 expression in the progression of ECs. Patients with high expression of TNFAIP8 (P<0.001 for both) and Ki-67 (P=0.007 and P=0.008) had poor overall survival and disease-free survival (DFS) rates. MMP9 overexpression did not affect survival outcomes (P>0.05). Multivariate Cox regression analysis revealed that TNFAIP8 (P=0.029) and lymph node metastasis (P=0.022) were independent factors of DFS in patients with EC. These findings suggested that TNFAIP8 may be used as a prognostic marker for the recurrence of EC, and its promotion of the proliferation and metastasis in EC may be due to its mediation of Ki-67 and MMP9.

The role of para-aortic lymphadenectomy in endometrial cancer

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and the fourth most common cancer overall. Approximately 20 % of patients with EC harbor disease outside the uterus, and 10 % of patients initially diagnosed with cancer confined to the uterus are found to have lymph node metastases. Para-aortic lymph node involvement occurs in approximately 7-8 % of EC patients overall and in about 50 % of patients with positive pelvic nodes. Metastases to the para-aortic lymph nodes are associated with poor prognosis. Factors associated with para-aortic lymph node dissemination include advanced stage, high histological grade, deep myometrial invasion, cervical involvement, lymphovascular space involvement, and the presence of pelvic lymph node metastases. Approximately 77 % of patients with para-aortic nodal involvement are found to have metastases above the level of the inferior mesenteric artery. Systematic pelvic and para-aortic lymphadenectomy with dissection optimally carried out to the renal vessels is important in high-risk patients in order to identify nodes present at distant sites, particularly above the inferior mesenteric artery (IMA). While the definitive management of EC varies widely across the gynecological oncology community, there is a consensus that patients at risk for lymphatic metastases (high and intermediate risk) who are targeted with systematic lymphadenectomy may have an improved prognosis. Well-designed prospective studies evaluating the therapeutic role of systematic lymphadenectomy in EC are needed. Herein, we describe the role of para-aortic lymphadenectomy in the surgical staging of EC emphasizing its prerequisites, extent, and diagnostic and potential therapeutic advantages.

Current issues in the management of endometrial cancer

Endometrial cancer (EC) remains the most common gynecologic malignancy in the United States. It is expected to become more common as the prevalence of obesity, one of the most common risk factors for EC, increases worldwide. The 2 main histologic subcategories of EC, endometrioid and nonendometrioid EC, show unique molecular aberrations and are responsible for markedly disparate clinical behaviors. The primary treatment of EC is surgery, ie, hysterectomy, removal of the adnexa, and pelvic and para-aortic lymphadenectomy, either via laparotomy or endoscopic techniques. Adjuvant therapy is necessary for patients at high risk of recurrence and consists of vaginal brachytherapy, teletherapy, systemic chemotherapy, or some combination thereof. Multi-institutional trials are in progress in this country and in Europe to better define optimal adjuvant treatment for subsets of patients, as well as the role of surgical staging in reducing both overuse and underuse of radiation therapy. Hormonal therapy is an option for some young women with EC who wish to preserve fertility. This review summarizes the diagnosis and management of EC and discusses current controversies and upcoming investigations pertaining to EC staging and adjuvant treatment.

Replicative MCM7 protein as a proliferation marker in endometrial carcinoma: a tissue microarray and clinicopathological analysis

AIMS

To assess, in tissue microarray (TMA), the proliferative activity of endometrial carcinoma using one of the minichromosome maintenance (MCM) proteins (MCM7), and to explore its potential value for prognosis. MCM proteins are essential for eukaryotic DNA replication and have recently been used to define the proliferative compartments in human tissues.

METHODS AND RESULTS

Immunohistochemistry for MCM7 and Ki67 was performed on TMAs constructed from 212 cases of endometrial carcinoma. MCM7 and Ki67 expression was quantified according to the extent of nuclear staining. An analysis was carried out of the association between MCM7 expression and that of Ki67 and the clinicopathological characteristics of endometrial carcinoma. MCM7 and Ki67 immunoreactivity was clearly evident in the nuclei of tumour cells. MCM7 and Ki67 labelling indices in endometrial carcinomas correlated with each other (P < 0.001). A significant correlation existed between the MCM7 labelling index and histological grade (P = 0.008) and patients' age at diagnosis (P < 0.001). Well-differentiated carcinomas and younger patients had a lower MCM7 index. Poor survival was observed in patients with endometrial carcinoma with a high MCM7 index (P = 0.03) and MCM7 was found to be an independent prognostic factor by multivariate analysis (P = 0.04). The Ki67 labelling index correlated with histological grade (P = 0.01) but had no significant prognostic impact (P = 0.50).

CONCLUSIONS

In this TMA study on endometrial carcinoma, MCM7 was found to be a more reliable and useful marker than Ki67 in assessing tumour proliferation and in the prognosis of patients.

Stage I-II endometrial adenocarcinoma evolution of therapeutic paradigms: the role of surgery and adjuvant radiation

The objective was to review the English-language literature regarding the utility of adjuvant radiation therapy following surgery for endometrial adenocarcinoma. An OVID software (Ovid Technologies, Inc., New York, NY) search of Medline articles from 1975 to 2001 was conducted using the keywords "endometrial neoplasm," "surgery," and "radiation therapy." The papers were assessed with regard to (a) extent of surgical staging (b) type of adjuvant radiotherapy utilized: external vs. brachytherapy vs. combination therapy; and (c) whether the patients were treated as part of prospective trial or reported as a descriptive series reflecting an institution's practice pattern. Survival rates are excellent for patients with early stage disease treated in either paradigm of extended-surgical staging with more restricted use of the adjuvant therapy or simple hysterectomy bilateral salpingoophorectomy with more frequent use of adjuvant radiotherapy. All three prospective-randomized trials (PRCT) have shown an improvement in local control but no overall survival benefit for the entire accrued group. All three PRCTs have shown a higher risk of disease recurrence in older patients or those with grade 3 histology or deep invasion. Each suggests there may be a survival benefit for the subset of patients with such high-risk features, but at present there is no prospective data that demonstrates adjuvant radiotherapy will improve the overall survival for the highest-risk subset of older patients with high-grade deeply invasive disease.

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.

High-dose-rate postoperative vaginal cuff irradiation alone for stage IB and IC endometrial cancer

PURPOSE

To evaluate the effectiveness of postoperative high-dose-rate (HDR) vaginal cuff irradiation alone (1500 cGy in 3 fractions) in patients with Stage Ib and Ic endometrial cancer.

METHODS AND MATERIALS

This is a retrospective review of 102 patients with Stage Ib and Ic endometrial cancer treated with a hysterectomy and postoperative HDR intracavitary therapy alone during the period of 1/1/90-12/31/96. Each patient received 1500 cGy in 3 weekly treatments, dosed to a depth of 0.5 cm. Pathologic features such as depth of invasion, tumor grade, lower uterine segment (LUS) involvement, and lymphvascular invasion (LVI) were evaluated for their impact on recommended postoperative treatment. All survival curves were generated utilizing Kaplan-Meier methods and all statistical comparisons were via a Wilcoxon rank sum test.

RESULTS

The 5-year actuarial overall survival (OS) is 84% and the 5-year disease-free survival (DFS) is 93%. Locoregional disease control (pelvic control) was excellent with 97% of the patients free of pelvic disease at 5 years. Of the three pelvic failures only one was in the vaginal cuff. LVI, LUS involvement, Grade 3 and/or outer third myometrial involvement were identified in 41 patients. Thirty-one of these patients underwent a lymphadenectomy and there were two regional failures within this increased-risk group.

CONCLUSIONS

We obtained an excellent level of locoregional control with minimal morbidity and minimal time commitment for treatment with vaginal HDR brachytherapy alone. Our dose per fraction and total dose is lower than most reported series and there is no apparent loss in locoregional control. In addition, intermediate-risk patients and patients with an increased risk of recurrence (Grade 3, outer third myometrial involvement, LVI, LUS) may be treated with cuff irradiation alone, after surgical staging and a negative lymphadenectomy.

Prognostic significance of angiogenesis and Ki-67, p53, and p21 expression: a population-based endometrial carcinoma study

PURPOSE

For endometrial carcinoma patients, there is a need for improved identification of high-risk groups that may benefit from postoperative adjuvant therapy. We therefore studied the prognostic impact of markers for cell proliferation, cell-cycle regulation, and angiogenesis among endometrial carcinoma patients in a population-based setting.

PATIENTS AND METHODS

All patients diagnosed with endometrial carcinoma between 1981 and 1985 in Hordaland County, Norway, were studied. The median follow-up for the survivors was 11.5 years (range, 8 to 15 years), with no patient lost because of insufficient follow-up information. Paraffin-embedded tumor tissue, available in 96% of the cases (n = 142), was studied immunohistochemically for microvessel density (MVD) and expression of Ki-67, p53, and p21 proteins. We used the hot spot method for calculation of MVD, and expression of Ki-67 and p21 protein, because this approach may increase the probability of detecting small aggressive clones of possible prognostic relevance. The importance of these tumor markers was investigated in univariate survival analyses and Cox regression analysis.

RESULTS

The majority of traditional clinicopathologic variables was significantly associated with the tumor biomarkers. Age, International Federation of Gynecology and Obstetrics (FIGO) stage, histologic type, histologic grade, MVD, as well as Ki-67, p53, and p21 protein expression, all significantly influenced survival in univariate analyses (P < or = .05). In the Cox regression analysis, age, FIGO stage, MVD, Ki-67 expression, and p53 expression were the only variables with independent prognostic impact (P < or = .05), whereas histologic type, histologic grade, and p21 expression had no independent influence. A group of high-risk patients with more than one unfavorable marker was identified.

CONCLUSION

In addition to age and FIGO stage, MVD, Ki-67, and p53 protein expression showed an independent prognostic impact. Thus, information derived from routine histologic specimens identified a subgroup of high-risk endometrial carcinoma patients in this population-based study.

[Low-dose postoperative vaginal brachytherapy of adenocarcinoma of the endometrium]

PURPOSE

Surgery is the primary treatment for endometrial carcinoma. Methods of complementary treatment are still debated, with the potential association of external radiotherapy and/or brachytherapy before or after surgery. This study was aimed at evaluating local control and complications rates in a series of patients treated by hysterectomy followed by postoperative vaginal low-dose rate brachytherapy (BT) combined with pelvic irradiation in case of poor prognosis factors.

PATIENTS AND METHODS

From 1978 to 1993, 101 patients were treated at the Centre Alexis-Vautrin, France according to this scheme. Forty five had deep myometrial invasion, and thirteen cervical involvement. Fifty patients received pelvic irradiation (median dose 46 Gy) combined with BT (dose 14 Gy, median volume 127 cm3); 51 patients had BT alone (dose 60 Gy, median volume 71 cm3).

RESULTS

The 5-year overall survival rate was 83% and the local control rate 97% with a median follow-up of 7 years. Multivariate analysis showed two factors of bad prognosis, i.e., deep myometrial invasion and cervical involvement. Three severe complications occurred in two patients for whom the treated volume was larger than the theoretical target volume. Eleven patients developed metastases.

CONCLUSION

Results obtained from this series are comparable with those of previous studies, particularly in regard to pre-operative BT. The complication rate is also satisfactory and depends on the irradiation precision and the definition of the target volume.

Stage I corpus cancer: is teletherapy necessary?

OBJECTIVE

Our aim was to evaluate the perioperative morbidity after hysterectomy and lymphadenectomy as primary treatment of endometrial cancer and to analyze the recurrence and survival of patients classified as having surgical stage I disease who did not receive adjunctive teletherapy.

STUDY DESIGN

Over a 10-year interval 444 patients underwent extensive surgical staging for corpus cancer. Perioperative events were recorded prospectively. Outcome events were updated after the last year of study.

RESULTS

After patients with high-risk histologic types of cancer were excluded, 396 patients were evaluable. The risk of extrauterine disease, detected in 21.8% of patients, increased with increasing lack of tumor differentiation. The associated surgical morbidity, including blood loss (mean 336 ml), surgical site infection (3.5%), thromboembolic events (1.5%), and urinary injury (0.6%), and deaths (0.6%) did not differ from those in reports of women undergoing lesser operative procedures. Late complications, including lymphocyst (1.2%), leg edema (1.8%), and hernia (2.9%), were infrequent. Recurrence and survival analysis indicated a calculated 5-year survival of 97% of all patients with surgical stage I disease. There was a significant survival difference related to grade and stage for women in whom disease was confined to the uterus. Overall survival in patients with stage IA (100%) was significantly different (p < 0.0001) from that of patients with stage IB (97%) and stage IC (93%). All recurrences included a distal component.

CONCLUSION

Extensive surgical staging including lymphadenectomy can be performed safely. Our results suggest that the risk of pelvic recurrence is not increased and the risk of survival is not compromised in those women not receiving adjunctive teletherapy.

Expression of component desmosomal proteins in uterine endometrial carcinoma and their relation to cellular differentiation

BACKGROUND

While the assessment of the malignancy of neoplasms is based on morphologic studies of cells and tissues, use of objective molecular markers is leading to a better understanding and more biologically meaningful classification of neoplasms. In recent years, changes in the expression of cell adhesion molecules, especially E-cadherin, catenin, and adenomatous polyposis coli (APC), in carcinomas have attracted the attention of researchers. However, little is known about desmosomes in the uterine endometrium or in endometrial carcinomas. In this study, we semiquantified the desmosomal components desmoplakin I and II and desmoglein, in tissue sections using confocal laser scanning microscopy (LSM), and examined their relationship to the pathological type, the occurrence of lymph node metastases, and the extent of myometrial invasion.

METHOD

Frozen sections of 31 specimens of normal endometrium, 5 specimens of atypical hyperplasia, and 41 specimens of endometrial carcinoma were stained by the immunofluorescence method using antidesmoplakin I and II and antidesmoglein, and these markers were then semiquantified in tissue sections by LSM.

RESULTS

The expression and location of desmoplakin I and II and desmoglein were similar, and their expression decreased with loss of differentiation. The expression was lower in cases of lymph node metastasis than in negative cases and was lower in the cases with > one-half myometrial invasion than in cases with < one-half myometrial invasion.

CONCLUSIONS

Reduction of desmoplakin I and II and desmoglein expression may play an important role in the invasiveness and metastatic activity of human endometrial carcinoma. They can therefore be used as differentiation markers for endometrial carcinoma.

Uterine cancer (corpus uteri)

This synthesis of the literature on radiotherapy for cancer originating in the endometrium of the uterus (corpus uteri) is based on 55 scientific articles, including 2 randomized studies, 1 prospective study, and 48 retrospective studies. These studies involve 13597 patients. Endometrial cancer is a radiosensitive cancer. Research findings compiled for the period 1948 to 1954 showed that 69% of the patients could be cured by radiotherapy alone. During the 1970s it was shown that combined radiotherapy and surgery yielded better results. There is agreement that patients at stage I should receive primary surgery. According to the literature, there is controversy about whether patients with poorly differentiated tumors should be given preoperative radiotherapy. Radiotherapy alone can be used successfully in patients who are inoperable because of age, general condition, or advanced spread of cancer. Vaginal postoperative radiotherapy is used in most patients and reduces the percentage of patients who develop vaginal metastases from 7%-20% to less than 1%. Patients with good prognostic factors have such a low risk for metastasis that withholding radiotherapy may be considered in this group. Postoperative external radiotherapy improves survival in patients with unfavorable prognostic factors, such as deep myometrium invasion or signs of node metastasis. Radiotherapy is delivered, in principle, to all patients with poorly differentiated disease. It can be expected that most cases of endometrial cancer will continue to be referred for some form of radiotherapy.