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Luzarraga Aznar A, Bebia V, López-Gil C, Villafranca-Magdalena B, Salazar-Huayna L, Castellvi J, Colàs E, Gil-Moreno A, Cabrera S. Molecular profile is a strong predictor of the pattern of recurrence in patients with endometrial cancer. Int J Gynecol Cancer 2024:ijgc-2023-005165. [PMID: 38378696 DOI: 10.1136/ijgc-2023-005165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
OBJECTIVES To investigate the pattern of first recurrence of disease in patients with endometrial cancer according to molecular classification, and to assess the independent role of molecular profiling in each type of failure. METHODS Retrospective single-center study including patients diagnosed with endometrial cancer stage I-IVB (International Federation of Gynecology and Obstetrics 2009) between December 1994 and May 2022, who underwent primary surgical treatment and had a complete molecular profile. First recurrence was classified as isolated or multiple, and as vaginal, pelvic, peritoneal, nodal, and distant according to its location. The log-rank test and univariate and multivariate adjusted Cox regression models were used for comparison between groups. RESULTS A total of 658 patients were included. Recurrence was observed in 122 patients (18.5%) with a recurrence rate of 12.4% among mismatch-repair deficient tumors, 14.5% among non-specific molecular profile, 2.1% among POLE-mutated, and 53.7% among p53-abnormal tumors. Recurrences were found to be isolated in 80 (65.6%) and multiple in 42 (34.4%) patients, with no differences in molecular subtype (p=0.92). Patients with p53-abnormal tumors had a recurrence mainly as distant (28.4%) and peritoneal (21.1%) disease, while patients with non-specific molecular profile tumors presented predominantly with distant failures (10.3%), and mismatch-repair deficient tumors with locoregional recurrences (9.4%).On multivariate analysis, p53-abnormal molecular profile was the only independent risk factor for peritoneal failure (OR=8.54, 95% CI 2.0 to 36.3). Vaginal recurrence was independently associated with p53-abnormal molecular profile (OR=6.51, 95% CI 1.1 to 37.4) and lymphovascular space invasion. p53-abnormal and non-specific molecular profiles were independent predictors for distant recurrence (OR=3.13, 95% CI 1.1 to 8.7 and OR=2.35, 95% CI 1.1 to 5.0, respectively), along with lymphovascular space invasion and high-grade tumors. Molecular profile was not independently associated with pelvic and nodal recurrences. CONCLUSIONS Endometrial cancer featured different patterns of recurrence depending on the molecular profile. p53-abnormal molecular profiling was the only independent risk factor for peritoneal relapse, while non-specific molecular profile showed a strong association with distant failures.
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Affiliation(s)
- Ana Luzarraga Aznar
- Department of Gynecologic Oncology, Universitat Autònoma de Barcelona (UAB), Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | - Vicente Bebia
- Department of Gynecologic Oncology, Universitat Autònoma de Barcelona (UAB), Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | - Carlos López-Gil
- Group of Biomedical Research in Gynecology, Vall Hebron Institute of Research Hospital, Vall d'Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona (UAB). CIBERONC, Barcelona, Catalunya, Spain
| | - Beatriz Villafranca-Magdalena
- Group of Biomedical Research in Gynecology, Vall Hebron Institute of Research Hospital, Vall d'Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona (UAB). CIBERONC, Barcelona, Catalunya, Spain
| | | | - Josep Castellvi
- Department of Pathology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | - Eva Colàs
- Group of Biomedical Research in Gynecology, Vall Hebron Institute of Research Hospital, Vall d'Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona (UAB). CIBERONC, Barcelona, Catalunya, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Department of Gynecologic Oncology, Universitat Autònoma de Barcelona (UAB), Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Group of Biomedical Research in Gynecology, Vall Hebron Institute of Research Hospital, Vall d'Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona (UAB). CIBERONC, Barcelona, Catalunya, Spain
- Department of Gynecology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | - Silvia Cabrera
- Department of Gynecologic Oncology, Universitat Autònoma de Barcelona (UAB), Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
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Capasso I, Garzon S, Kumar S, Weaver AL, Mc Gree M, De Vitis LA, Uccella S, Petersen I, Glaser G, Langstraat C, Scambia G, Fanfani F, Mariani A. Prognostic factors in patients with endometrial cancer with isolated lymphatic recurrence. Int J Gynecol Cancer 2023; 33:1169-1178. [PMID: 37321674 DOI: 10.1136/ijgc-2023-004435] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE To analyze the clinicopathological features and outcomes in patients with endometrial cancer with isolated lymphatic recurrence after lymphadenectomy, stratified by different isolated lymphatic recurrence sites and treatment approaches. METHODS We retrospectively reviewed all surgically treated patients with endometrial cancer, identifying those with recurrence. We defined primary isolated lymphatic recurrence as the first and unique evidence of recurrence in lymph node-bearing areas, without concomitant vaginal, hematogenous, or peritoneal recurrence. Isolated lymphatic recurrences were classified as pelvic, para-aortic, distant, or multiple sites. Our primary outcome was cause-specific survival after diagnosis of the recurrence. RESULTS Among 4216 patients with surgically staged endometrial cancer, we identified 66 (1.6%) women with isolated lymphatic recurrence. The overall median cause-specific survival for patients with isolated lymphatic recurrence was 24 months. Although cause-specific survival was not significantly different between the four isolated lymphatic recurrence groups (p=0.21), 7 of 15 (47%) patients with isolated lymphatic recurrence in the para-aortic area were long-term survivors. At multivariate Cox regression, the absence of lymphovascular space invasion and grade 1 histology in the primary tumor were significantly associated with improved cause-specific survival. In addition, patients with isolated lymphatic recurrence who underwent surgery for recurrence (with/without other associated therapies) had improved cause-specific survival compared with patients who did not undergo surgery, also after adjusting for age. CONCLUSIONS Low-grade histology and absence of lymphovascular space invasion in the primary tumor were predictors of improved prognosis in patients with endometrial cancer with isolated lymphatic recurrence. In addition, in this retrospective cohort, patients with isolated lymphatic recurrence who were selected for eradicative surgical treatment had improved cause-specific survival.
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Affiliation(s)
- Ilaria Capasso
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Sanjeev Kumar
- Department of Gynecologic Oncology, Baptist Memorial Hospital for Women, Memphis, Tennessee, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela Mc Gree
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giovanni Scambia
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Francesco Fanfani
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Andrea Mariani
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Wang J, Li X, Yang X, Wang J. Development and Validation of a Nomogram Based on Metabolic Risk Score for Assessing Lymphovascular Space Invasion in Patients with Endometrial Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192315654. [PMID: 36497730 PMCID: PMC9736227 DOI: 10.3390/ijerph192315654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/05/2022] [Accepted: 11/23/2022] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This study assessed the predictive value of the metabolic risk score (MRS) for lymphovascular space invasion (LVSI) in endometrial cancer (EC) patients. METHODS We included 1076 patients who were diagnosed with EC between January 2006 and December 2020 in Peking University People's Hospital. All patients were randomly divided into the training and validation cohorts in a ratio of 2:1. Data on clinicopathological indicators were collected. Univariable and multivariable logistic regression analysis was used to define candidate factors for LVSI. A backward stepwise selection was then used to select variables for inclusion in a nomogram. The performance of the nomogram was evaluated by discrimination, calibration, and clinical usefulness. RESULTS Independent predictors of LVSI included differentiation grades (G2: OR = 1.800, 95% CI: 1.050-3.070, p = 0.032) (G3: OR = 3.49, 95% CI: 1.870-6.520, p < 0.001), histology (OR = 2.723, 95% CI: 1.370-5.415, p = 0.004), MI (OR = 4.286, 95% CI: 2.663-6.896, p < 0.001), and MRS (OR = 1.124, 95% CI: 1.067-1.185, p < 0.001) in the training cohort. A nomogram was established to predict a patient's probability of developing LVSI based on these factors. The ROC curve analysis showed that an MRS-based nomogram significantly improved the efficiency of diagnosing LVSI compared with the nomogram based on clinicopathological factors (p = 0.0376 and p = 0.0386 in the training and validation cohort, respectively). Subsequently, the calibration plot showed a favorable consistency in both groups. Moreover, we conducted a decision curve analysis, showing the great clinical benefit obtained from the application of our nomogram. However, our study faced several limitations. Further external validation and a larger sample size are needed in future studies. CONCLUSION MRS-based nomograms are useful for predicting LVSI in patients with EC and may facilitate better clinical decision-making.
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Quintana-Bertó R, Padilla-Iserte P, Gil-Moreno A, Oliver-Pérez R, Coronado PJ, Martín-Salamanca MB, Pantoja-Garrido M, Lorenzo C, Beric D, Gilabert-Estellés J, Sánchez L, Roldán-Rivas F, Díaz-Feijoo B, Rodríguez-Hernández JR, Marcos-Sanmartin J, Muruzábal JC, Cañada A, Domingo S. Preoperative sampling in endometrial cancer: evaluation of the histopathological agreement with definitive surgical specimen. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2022; 24:2388-2394. [PMID: 35984612 DOI: 10.1007/s12094-022-02893-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/16/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE The main goal of this study is to assess the diagnostic agreement between preoperative biopsy and definitive histology of the surgical specimen to determine which sampling method is most suitable for diagnosis of early-stage endometrial cancer. METHODS We performed a retrospective multicentric study to assess the correlation between three endometrial sampling methods (hysteroscopy, pipelle and D&C) in patients who had undergone preoperative endometrial biopsy and received primary surgical treatment for endometrial cancer. The primary objective was the agreement rate between hysteroscopy (HSC), endometrial biopsy (pipelle) and dilatation and curettage (D&C). RESULTS A total of 1833 women who underwent preoperative sampling at 15 centers were included: 1042 biopsies were performed by HSC, 703 by pipelle and 88 by D&C. All three methods presented a moderate diagnostic concordance (κ = 0.40-0.61) with the definitive specimen's histology: HSC (κ = 0.47), pipelle sampling (κ = 0.48) and D&C (κ = 0.48). Likewise, a subgroup analysis was performed by histological subtype comparing HSC and endometrial biopsy, showing that neither is superior as a diagnostic method. CONCLUSIONS According to this study, the use of pipelle sampling could become an adequate diagnostic method in endometrial cancer due to its similar agreement to HSC, ease of use and affordability.
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Affiliation(s)
- Raquel Quintana-Bertó
- Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, Av. Abril Martorell, 106, 46026, Valencia, Spain.
| | - Pablo Padilla-Iserte
- Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, Av. Abril Martorell, 106, 46026, Valencia, Spain
| | - Antonio Gil-Moreno
- Gynecologic Oncology Unit, Gynecology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Reyes Oliver-Pérez
- Gynecologic Oncology-Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute, Complutense University of Madrid, Madrid, Spain
| | - Pluvio J Coronado
- Women's Health Institute of the Hospital Clínico San Carlos, IdISSC University Complutense, Madrid, Spain
| | | | - Manuel Pantoja-Garrido
- Department of Gynecology and Obstetrics, University Hospital Virgen Macarena, Seville, Spain
| | - Cristina Lorenzo
- Department of Obstetrics and Gynecology. Hospital, Nuestra Señora de la Calendaria, Tenerife, Spain
| | - Duska Beric
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrevieja, Alicante, Spain
| | - Juan Gilabert-Estellés
- Department of Obstetrics and Gynecology, University General Hospital of València, València, Spain
| | - Lourdes Sánchez
- Gynaecology and Obstetrics Department, University General Hospital of Ciudad Real, Castilla-La Mancha, Spain
| | - Fernando Roldán-Rivas
- Department of Obstetrics and Gynaecology, Clinico Lozano Blesa Hospital, Zaragoza, Spain
| | - Berta Díaz-Feijoo
- Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Juan Carlos Muruzábal
- Department of Gynecologic Oncology, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Antonio Cañada
- Department of Biostatistics, Health Research Institute La Fe, València, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, Av. Abril Martorell, 106, 46026, Valencia, Spain
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Vizza E, Bruno V, Cutillo G, Mancini E, Sperduti I, Patrizi L, Certelli C, Zampa A, Giannini A, Corrado G. Prognostic Role of the Removed Vaginal Cuff and Its Correlation with L1CAM in Low-Risk Endometrial Adenocarcinoma. Cancers (Basel) 2021; 14:cancers14010034. [PMID: 35008194 PMCID: PMC8750504 DOI: 10.3390/cancers14010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The aim of our study was to investigate the role of the excised vaginal cuff length as a prognostic factor in terms of DFS and recurrence rate/site, in low-risk endometrial cancer (EC) patients. Moreover, we correlated the recurrence with the expression of L1CAM. Material and Methods: From March 2001 to November 2016, a retrospective data collection was conducted of women undergoing surgical treatment for low-risk EC according to ESMO-ESGO-ESTRO consensus guidelines. Patients were divided into three groups according to their vaginal cuff length: V0 without vaginal cuff, V1 with a vaginal cuff shorter than 1.5 cm and V2 with a vaginal cuff longer than or equal to 1.5 cm. Results: 344 patients were included in the study: 100 in the V0 group, 179 in the V1 group and 65 in the V2 group. The total recurrence rate was 6.1%: the number of patients with recurrence was 8 (8%), 10 (5.6%) and 3 (4.6%), in the V0, V1 and V2 group, respectively. No statistically significant difference was found in the recurrence rate among the three groups. Although the DFS was higher in the V2 group, the result was not significant. L1CAM was positive in 71.4% of recurrences and in 82% of the distant recurrences. Conclusions: The rate of recurrence in patients with EC at low risk of recurrence does not decrease as the length of the vaginal cuff removed increases. Furthermore, the size of the removed vaginal cuff does not affect either the site of recurrence or the likelihood of survival.
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Affiliation(s)
- Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
- Correspondence: ; Tel.: +39-06-52666973
| | - Valentina Bruno
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
| | - Giuseppe Cutillo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
| | - Emanuela Mancini
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
| | - Isabella Sperduti
- Scientific Direction, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy;
| | - Lodovico Patrizi
- Department of Surgery, Section of Gynaecology and Obstetrics, Tor Vergata University, 00133 Rome, Italy;
| | - Camilla Certelli
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
| | - Ashanti Zampa
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (V.B.); (G.C.); (E.M.); (C.C.); (A.Z.)
| | - Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, “Sapienza University”, Rome 00185, Italy;
| | - Giacomo Corrado
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
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Gill SE, Garzon S, Multinu F, Hokenstad AN, Casarin J, Cappuccio S, McGree ME, Weaver AL, Cliby WA, Keeney GL, Mariani A. Ultrastaging of 'negative' pelvic lymph nodes in patients with low- and intermediate-risk endometrioid endometrial cancer who developed non-vaginal recurrences. Int J Gynecol Cancer 2021; 31:1541-1548. [PMID: 34706876 DOI: 10.1136/ijgc-2021-002924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/13/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Evidence on micrometastases and isolated tumor cells as factors associated with non-vaginal recurrence in low- and intermediate-risk endometrial cancer is limited. The goal of our study was to investigate risk factors for non-vaginal recurrence in low- and intermediate-risk endometrial cancer. METHODS Records of all patients with endometrial cancer surgically managed at the Mayo Clinic before sentinel lymph node implementation (1999-2008) were reviewed. We identified all patients with endometrioid low-risk (International Federation of Gynecology and Obstetrics (FIGO) stage I, grade 1 or 2 with myometrial invasion <50% and negative peritoneal cytology) or intermediate-risk (FIGO stage I, grade 1 or 2 with myometrial invasion ≥50% or grade 3 with myometrial invasion <50% and negative peritoneal cytology) endometrial cancer at definitive pathology after pelvic and para-aortic lymph node assessment. All pelvic lymph nodes of patients with non-vaginal recurrence (any recurrence excluding isolated vaginal cuff recurrences) underwent ultrastaging. RESULTS Among 1303 women, we identified 321 patients with low-risk (n=236) or intermediate-risk (n=85) endometrial cancer (median age 65.4 years; 266 (82.9%) stage IA; 55 (17.1%) stage IB). Of the total of 321, 13 patients developed non-vaginal recurrence (Kaplan-Meier rate 4.7% by 60 months; 95% CI 2.1% to 7.2%): 11 hematogenous/peritoneal and two para-aortic and distant lymphatic. Myometrial invasion and lymphovascular space invasion were univariately associated with non-vaginal recurrence. In these patients, the original hematoxylin/eosin slides review confirmed all 646 pelvic and para-aortic removed lymph nodes as negative. The ultrastaging of 463 pelvic lymph nodes did not identify any occult metastases (prevalence 0%; 95% CI 0% to 22.8% considering 13 patients; 95% CI 0% to 0.8% considering 463 pelvic lymph nodes). CONCLUSION There were no occult metastases in pelvic lymph nodes of patients with low- or intermediate-risk endometrial cancer with non-vaginal recurrence. Myometrial invasion and lymphovascular space invasion appear to be associated with non-vaginal recurrence.
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Affiliation(s)
- Sarah E Gill
- Division of Gynecologic Oncology, Nancy N and J C Lewis Cancer and Research Pavilion, Savannah, Georgia, USA
| | - Simone Garzon
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Francesco Multinu
- Division of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Alexis N Hokenstad
- Department of Obstetrics and Gynecology, Billings Clinic Cancer Center, Billings, Montana, USA
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Serena Cappuccio
- Department of Woman's, Child's and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michaela E McGree
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - William A Cliby
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gary L Keeney
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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Reyes-Baez FE, Garzon S, Mariani A. Lumping and splitting: The need for precision medicine and "personomics" in endometrial cancer. J Gynecol Oncol 2021; 32:e38. [PMID: 33650339 PMCID: PMC7930456 DOI: 10.3802/jgo.2021.32.e38] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Simone Garzon
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Andrea Mariani
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA.
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Akış S, Kabaca C, Keleş E, Öztürk UK, Özyürek E, Api M, Çetiner H, Bostancı E. Tumor diameter as a predictor of lymph node involvement in endometrioid type endometrial adenocarcinomas. J Obstet Gynaecol Res 2021; 47:3968-3978. [PMID: 34378275 DOI: 10.1111/jog.14979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 07/24/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022]
Abstract
AIM To analyze the risk factors of lymph node involvement in pure endometrioid type endometrial cancer and assess factors that necessitate lymphadenectomy. METHODS Patients who had been operated on due to endometrial cancer and whose final pathology was reported as pure endometrioid carcinoma between January 2014 and January 2020 were assessed. Hysterectomy, bilateral salpingo-oophorectomy, and systematic lymphadenectomy were performed in all patients. All specimens were reported by expert gynecopathologists. RESULTS The lymph node positivity rate was 14.4%. When the study population was classified according to the Mayo risk criteria; lymph node involvement in the low-risk and high-risk groups was 9.1% and 14.8%, respectively and there was no statistically difference (p > 0.05). The median of tumor size and the rate of deep myometrial invasion, lymphovascular space invasion, adnexal involvement, FIGO grade 3 tumor were found significantly higher in the positive lymph node group in univariate analysis. In the receiver operating characteristic curve analysis, the cut-off value of the tumor diameter was determined as 47.5 mm (sensitivity 85%, specificity 62%). Every 10 mm increase in tumor diameter increased the risk of lymph node involvement 10 times. CONCLUSION This study defined that the tumor diameter is an independent predictor for lymphatic dissemination. In the future, it could be shown that even with new modeling based on tumor diameter, lymphadenectomy or adjuvant radiotherapy requirements would be reevaluated.
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Affiliation(s)
- Serkan Akış
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Canan Kabaca
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Esra Keleş
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Uğur Kemal Öztürk
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Eser Özyürek
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Murat Api
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Handan Çetiner
- Department of Pathology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Evrim Bostancı
- Department of Gynecology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
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9
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Yang XL, Huang N, Wang MM, Lai H, Wu DJ. Comparison of Different Lymph Node Staging Schemes for Predicting Survival Outcomes in Node-Positive Endometrioid Endometrial Cancer Patients. Front Med (Lausanne) 2021; 8:688535. [PMID: 34307415 PMCID: PMC8298894 DOI: 10.3389/fmed.2021.688535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To compare the prognostic predictive performance of six lymph node (LN) staging schemes: American Joint Committee on Cancer (AJCC) N stage, number of retrieved lymph nodes (NRLN), number of positive lymph nodes (NPLN), number of negative lymph nodes (NNLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) among node-positive endometrioid endometrial cancer (EEC) patients. Methods: A total of 3,533 patients diagnosed with node-positive EEC between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. We applied X-tile software to identify the optimal cutoff value for different staging schemes. Univariate and multivariate Cox regression models were used to assess the relationships between different LN schemes and survival outcomes [disease-specific survival (DSS) and overall survival (OS)]. Moreover, Akaike information criterion (AIC) and Harrell concordance index (C-index) were used to evaluate the predictive performance of each scheme in both continuous and categorical patterns. Results: N stage (N1/N2) was not an independent prognostic factor for node-positive EEC patients based on multivariate analysis (DSS: p = 0.235; OS: p = 0.145). Multivariate model incorporating LNR demonstrated the most superior goodness of fit regardless of continuous or categorical pattern. Regarding discrimination power of the models, LNR outperformed other models in categorical pattern (OS: C-index = 0.735; DSS: C-index = 0.737); however, LODDS obtained the highest C-index in continuous pattern (OS: 0.736; DSS: 0.739). Conclusions: N stage (N1/N2) was unable to differentiate the prognosis for node-positive EEC patients in our study. However, LNR and LODDS schemes seemed to have a better predictive performance for these patients than other number-based LN schemes whether in DSS or OS, which revealed that LNR and LODDS should be more helpful in prognosis assessment for node-positive EEC patients than AJCC N stage.
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Affiliation(s)
- Xi-Lin Yang
- Department of Radiation Oncology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Nan Huang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ming-Ming Wang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Lai
- Department of Radiology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Da-Jun Wu
- Department of Radiation Oncology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Wang Z, Zhang S, Ma Y, Li W, Tian J, Liu T. A nomogram prediction model for lymph node metastasis in endometrial cancer patients. BMC Cancer 2021; 21:748. [PMID: 34187416 PMCID: PMC8243766 DOI: 10.1186/s12885-021-08466-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/09/2021] [Indexed: 12/29/2022] Open
Abstract
Background This study aimed to explore the risk factors for lymph node metastasis (LNM) in patients with endometrial cancer (EC) and develop a clinically useful nomogram based on clinicopathological parameters to predict it. Methods Clinical information of patients who underwent staging surgery for EC was abstracted from Qilu Hospital of Shandong University from January 1st, 2005 to June 31st, 2019. Parameters including patient-related, tumor-related, and preoperative hematologic examination-related were analyzed by univariate and multivariate logistic regression to determine the correlation with LNM. A nomogram based on the multivariate results was constructed and underwent internal and external validation to predict the probability of LNM. Results The overall data from the 1517 patients who met the inclusion criteria were analyzed. 105(6.29%) patients had LNM. According the univariate analysis and multivariate logistic regression analysis, LVSI is the most predictive factor for LNM, patients with positive LVSI had 13.156-fold increased risk for LNM (95%CI:6.834–25.324; P < 0.001). The nomogram was constructed and incorporated valuable parameters including histological type, histological grade, depth of myometrial invasion, LVSI, cervical involvement, parametrial involvement, and HGB levels from training set. The nomogram was cross-validated internally by the 1000 bootstrap sample and showed good discrimination accuracy. The c-index for internal and external validation of the nomogram are 0.916(95%CI:0.849–0.982) and 0.873(95%CI:0.776–0.970), respectively. Conclusions We developed and validated a 7-variable nomogram with a high concordance probability to predict the risk of LNM in patients with EC. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08466-4.
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Affiliation(s)
- Zhiling Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, 250012, P. R. China
| | - Shuo Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, 250012, P. R. China
| | - Yifei Ma
- Department of Obstetrics and Gynecology, Jinan Central Hospital Affiliated to Shandong University, Jinan, 250013, Shandong Province, China
| | - Wenhui Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, 250012, P. R. China
| | - Jiguang Tian
- Department of Emergency, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Ting Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong Province, 250012, P. R. China.
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11
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Clinical biomarkers to predict preoperative lymph node metastasis in endometrial cancer. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.882342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Is It Possible to Develop a Prediction Model for Lymphovascular Space Invasion in Endometrioid Endometrial Cancer? Int J Gynecol Pathol 2021; 39:213-220. [PMID: 31033799 DOI: 10.1097/pgp.0000000000000596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this retrospective study was to define a risk index that would serve as a surrogate marker of lymphovascular space invasion (LVSI) in women with endometrioid endometrial cancer (EC). MATERIALS AND METHODS Final pathology reports of 498 women who underwent surgery with curative intent for endometrioid EC between January 2008 and June 2018 were retrospectively reviewed. Logistic regression was used to investigate clinicopathologic factors associated with positive LVSI status. Independent risk factors for LVSI were used to build a risk model and "risk of LVSI index" was defined as "tumor grade×primary tumor diameter×percentage of myometrium involved." The scores used in the "risk of LVSI index" were weighted according to the odds ratios assigned for each variable. The risk of LVSI index was noted for each patient. The diagnostic performance of the model was expressed as sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. RESULTS According to the "risk of LVSI index," presence of LVSI was correctly estimated in 89 of 104 LVSI-positive women at a cutoff of 161.0 (sensitivity 85.5%, specificity 79.4%, negative predictive value 95.4%, positive predictive value 52.3%, positive likelihood ratio 4.15, negative likelihood ratio 0.18). The area under curve of the receiver-operating characteristics was 0.90 (95% confidence interval, 0.87-0.93) at this cutoff. CONCLUSIONS It seems possible to predict the presence of LVSI in women with endometrioid EC when the "risk of LVSI index" is calculated. However, external validation of this model is warranted.
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13
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Güngördük K, Plett H, Gülseren V, Meydanlı M, Boyraz G, Özdemir İ, Şahin H, Şenol T, Yıldırım N, Turan T, Öge T, Gökçü M, Taşkın S, Ayhan A, Ataseven B. Is the Oncological Outcome of Early Stage Uterine Carcinosarcoma Different from That of Grade 3 Endometrioid Adenocarcinoma? Oncol Res Treat 2020; 44:43-51. [PMID: 33249415 DOI: 10.1159/000511288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022]
Abstract
AIM The clinicopathologic characteristics, recurrence patterns, and survival of patients with grade 3 endometrial cancer (G3-EAC) and uterine carcinosarcoma (UCS) were compared. MATERIALS AND METHODS The medical records of patients treated for G3-EAC and UCS between January 1996 and December 2016 at 11 gynecologic oncology centers in Turkey and Germany were analyzed. RESULTS Of all patients included in the study, 161 (45.1%) were diagnosed with UCS and 196 (54.9%) with G3-EAC at FIGO stage I-II (early stage) disease. The recurrence rate was higher in patients with UCS than in those with G3-EAC (17.4 vs. 9.2%, p = 0.02). The 5-year disease-free survival (DFS; 75.2 and 80.8%, respectively; p = 0.03) and overall survival (OS; 79.4 and 83.4%, respectively; p = 0.04) rates were significantly lower in the UCS group compared to the G3-EAC group. UCS histology was an independent prognostic factor for decreased 5-year DFS (HR 1.8, 95% CI 1.2-3.2; p = 0.034) and OS (HR 2.7, 95% CI 1.3-6.9; p = 0.041) rates. CONCLUSIONS The recurrence rate was higher in UCS patients than in G3-EAC patients, regardless of disease stage. DFS and OS were of shorter duration in UCS than in G3-EAC patients. Adequate systematic lymphadenectomy and omentectomy were an independent prognostic factor for increased 5-year DFS and OS rates.
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Affiliation(s)
- Kemal Güngördük
- Department of Gynecologic Oncology, Mugla Sıtkı Kocman University Education and Research Hospital, Izmir, Turkey
| | - Helmut Plett
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany.,Department of Gynecology, Charité University Hospital, Berlin, Germany
| | - Varol Gülseren
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey,
| | - Mutlu Meydanlı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Gökhan Boyraz
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - İsaAykut Özdemir
- Department of Gynecologic Oncology, Dr. Sadi Konuk Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Hanifi Şahin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Taylan Şenol
- Department of Gynecologic Oncology, Zenyep Kamil Women's Health Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Nuri Yıldırım
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ege University, Izmir, Turkey
| | - Taner Turan
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Tufan Öge
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Eskişehir Osman Gazi University, Eskişehir, Turkey
| | - Mehmet Gökçü
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Salih Taşkın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Ali Ayhan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Beyhan Ataseven
- Department of Obstetrics and Gynecology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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14
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Sinha S, Lazar A, Lam A, Anderson EM, Chen LM, Hsu ICJ, Yoshida EJ. Adjuvant radiation followed by chemotherapy is associated with improved overall survival in endometrial cancer. Gynecol Oncol 2020; 159:30-35. [PMID: 32811681 DOI: 10.1016/j.ygyno.2020.07.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although multimodality therapy has been shown to improve outcomes for patients with high-risk endometrial carcinoma, optimal type and timing of adjuvant therapies is unknown. METHODS Patients with stage I-IVA endometrial carcinoma diagnosed from 2004 to 2015, and treated with surgery, chemotherapy, and radiation were identified in the National Cancer Database. Adjuvant treatment was categorized as sequential radiation followed by chemotherapy (RT-CT), concurrent chemoradiation (CCRT, RT and CT started within 7 days), or sequential chemotherapy followed by radiation (CT-RT). Analysis for propensity score matched (PSM) cohorts comparing RT-CT to CCRT and CT-RT groups was additionally performed. RESULTS A total of 17,070 patients were identified, including 12,402 (72.7%) treated with RT-CT, 2,153 (12.6%) with CCRT, and 2,515 (14.7%) with CT-RT. Median follow-up was 44.3 months. Five-year overall-survival (OS) by adjuvant treatment regimen was 77.3% (95% CI 76.4%-78.2%), 74.3% (95% CI 72.0%-76.3%), and 74.4% (95% CI 72.5%-76.3%), respectively (p < .001). When unmatched cohorts were stratified by stage, adjuvant RT-CT was associated with improved OS in stage I and III patients. A similar survival advantage associated with RT-CT was observed in PSM cohorts comparing RT-CT group to CCRT/CT-RT group (5-year OS 77.4% vs 74.2%, p = .001). However, the difference in OS was significant only among stage III patients (RT-CT 73.9% compared to CCRT/CT-RT 69.7%, p =.002). CONCLUSION Our findings suggest survival benefit with adjuvant RT-CT compared to CT-RT or CCRT in patients undergoing trimodality therapy for endometrial cancer. This survival benefit may be limited to stage III patients.
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Affiliation(s)
- Sumi Sinha
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, Suite H1031, San Francisco, CA 94115, USA.
| | - Ann Lazar
- Department of Preventive and Restorative Dental Sciences, University of California San Francisco, 513 Parnassus Ave, San Francisco, CA 94143, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA, USA.
| | - Alexander Lam
- Department of Radiology, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Eric M Anderson
- Department of Radiation Oncology, Cedars-Sinai Medical Center, North Tower LL, 8700 Beverly Blvd, Los Angeles, CA 90048, USA.
| | - Lee-May Chen
- Division of Gynecologic Oncology, University of California San Francisco, 1825 4th St, San Francisco, CA 94115, USA.
| | - I-Chow J Hsu
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, Suite H1031, San Francisco, CA 94115, USA.
| | - Emi J Yoshida
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, Suite H1031, San Francisco, CA 94115, USA.
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15
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Aoki Y, Kanao H, Wang X, Yunokawa M, Omatsu K, Fusegi A, Takeshima N. Adjuvant treatment of endometrial cancer today. Jpn J Clin Oncol 2020; 50:753-765. [PMID: 32463094 DOI: 10.1093/jjco/hyaa071] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 01/15/2020] [Accepted: 04/30/2020] [Indexed: 01/22/2023] Open
Abstract
Endometrial cancer frequently occurs in post-menopausal women, and the endometrium is a well-known site of cancer affecting women. Endometrial cancer is found with genital bleeding and often at an early stage. However, there are some risks of recurrence after hysterectomy. As a medical treatment after the diagnosis of endometrial cancer, appropriate adjuvant therapy is considered to lead to a decrease in the rate of recurrence and improvement of prognosis according to the determination of the cancer stage from the surgical and histopathological results. In this review, we describe post-operative adjuvant therapy administered for endometrial cancer and advanced disease, focusing on chemotherapy, radiation therapy and the combination of both. These treatments are divided according to the risk of recurrence as based primarily on the reported evidence.
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Affiliation(s)
- Yoichi Aoki
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Xipeng Wang
- Department of Gynecology and Obstetrics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mayu Yunokawa
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Kohei Omatsu
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Atsushi Fusegi
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan.,Department of Perinatal and Women's Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobuhiro Takeshima
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
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16
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Reijnen C, Visser NC, Kasius JC, Boll D, Geomini PM, Ngo H, Van Hamont D, Pijlman BM, Vos MC, Bulten J, Snijders MP, Massuger LF, Pijnenborg JM. Improved preoperative risk stratification with CA-125 in low-grade endometrial cancer: a multicenter prospective cohort study. J Gynecol Oncol 2020; 30:e70. [PMID: 31328454 PMCID: PMC6658593 DOI: 10.3802/jgo.2019.30.e70] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/30/2019] [Accepted: 02/24/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The global obesity epidemic has great impact on the prevalence of low-grade endometrial carcinoma. The preoperative tumor serum marker cancer antigen 125 (CA-125) might contribute to improved identification of high-risk patients within this group. The study aimed to investigate the prognostic value of CA-125 in relation to established preoperative prognosticators, with a focus on identifying patients with poor outcome in low-grade endometrial carcinoma (EC) patients. METHODS Prospective multicenter cohort study including all consecutive patients surgically treated for endometrial carcinoma in nine collaborating hospitals from September 2011 until December 2013. All preoperative histopathological diagnoses were reviewed in a blinded manner. Associations between CA-125 and clinicopathological features were determined. Univariable and multivariable analysis by Cox regression were used. Separate analyses were performed for preoperatively designated low-grade and high-grade endometrial carcinoma patients. RESULTS A total of 333 patients were analyzed. CA-125 was associated with poor prognostic features including advanced International Federation of Gynecology and Obstetrics (FIGO) stage. In multivariable analysis, age, preoperative tumor and CA-125 were significantly associated with disease-free survival (DFS); preoperative grade, tumor type, FIGO and CA-125 were significantly associated with disease-specific survival (DSS). Low-grade EC patients with elevated CA-125 revealed a DFS of 80.6% and DSS of 87.1%, compared to 92.1% and 97.2% in low-grade EC patients with normal CA-125. CONCLUSION Preoperative elevated CA-125 was associated with poor prognostic features and independently associated with DFS and DSS. Particularly patients with low-grade EC and elevated CA-125 represent a group with poor outcome and should be considered as high-risk endometrial carcinoma.
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Affiliation(s)
- Casper Reijnen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
| | - Nicole Cm Visser
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jenneke C Kasius
- Centre of Gynaecologic Oncology Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Dorry Boll
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - Peggy M Geomini
- Department of Obstetrics and Gynaecology, Màxima Medical Centre, Veldhoven, The Netherlands
| | - Huy Ngo
- Department of Obstetrics and Gynaecology, Elkerliek Hospital, Helmond, The Netherlands
| | - Dennis Van Hamont
- Department of Obstetrics and Gynaecology, Amphia Hospital, Breda, The Netherlands
| | - Brenda M Pijlman
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Maria Caroline Vos
- Department of Obstetrics and Gynaecology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Johan Bulten
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marc Plm Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Leon Fag Massuger
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johanna Ma Pijnenborg
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
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18
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Reijnen C, IntHout J, Massuger LFAG, Strobbe F, Küsters-Vandevelde HVN, Haldorsen IS, Snijders MPLM, Pijnenborg JMA. Diagnostic Accuracy of Clinical Biomarkers for Preoperative Prediction of Lymph Node Metastasis in Endometrial Carcinoma: A Systematic Review and Meta-Analysis. Oncologist 2019; 24:e880-e890. [PMID: 31186375 DOI: 10.1634/theoncologist.2019-0117] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In endometrial carcinoma (EC), preoperative classification is based on histopathological criteria, with only moderate diagnostic performance for the risk of lymph node metastasis (LNM). So far, existing molecular classification systems have not been evaluated for prediction of LNM. Optimized use of clinical biomarkers as recommended by international guidelines might be a first step to improve tailored treatment, awaiting future molecular biomarkers. AIM To determine the diagnostic accuracy of preoperative clinical biomarkers for the prediction of LNM in endometrial cancer. METHODS A systematic review was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies identified in MEDLINE and EMBASE were selected by two independent reviewers. Included biomarkers were based on recommended guidelines (cancer antigen 125 [Ca-125], lymphadenopathy on magnetic resonance imaging, computed tomography, and 18F-fluorodeoxyglucose positron emission tomography/computed tomography [18FDG PET-CT]) or obtained by physical examination (body mass index, cervical cytology, blood cell counts). Pooled sensitivity, specificity, area under the curve (AUC), and likelihood ratios were calculated with bivariate random-effects meta-analysis. Likelihood ratios were classified into small (0.5-1.0 or 1-2.0), moderate (0.2-0.5 or 2.0-5.0) or large (0.1-0.2 or ≥ 5.0) impact. RESULTS Eighty-three studies, comprising 18,205 patients, were included. Elevated Ca-125 and thrombocytosis were associated with a moderate increase in risk of LNM; lymphadenopathy on imaging with a large increase. Normal Ca-125, cytology, and no lymphadenopathy on 18FDG PET-CT were associated with a moderate decrease. AUCs were above 0.75 for these biomarkers. Other biomarkers had an AUC <0.75 and incurred only small impact. CONCLUSION Ca-125, thrombocytosis, and imaging had a large and moderate impact on risk of LNM and could improve preoperative risk stratification. IMPLICATIONS FOR PRACTICE Routine lymphadenectomy in clinical early-stage endometrial carcinoma does not improve outcome and is associated with 15%-20% surgery-related morbidity, underlining the need for improved preoperative risk stratification. New molecular classification systems are emerging but have not yet been evaluated for the prediction of lymph node metastasis. This article provides a robust overview of diagnostic performance of all clinical biomarkers recommended by international guidelines. Based on these, at least measurement of cancer antigen 125 serum level, assessment of thrombocytosis, and imaging focused on lymphadenopathy should complement current preoperative risk stratification in order to better stratify these patients by risk.
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Affiliation(s)
- Casper Reijnen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joanna IntHout
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon F A G Massuger
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fleur Strobbe
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Ingfrid S Haldorsen
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marc P L M Snijders
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Johanna M A Pijnenborg
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
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Monterossi G, Buca D, Dinoi G, La Fera E, Zannoni GF, Spadola S, Scambia G, Fanfani F. Intra-operative assessment of sentinel lymph node status by one-step nucleic acid amplification assay (OSNA) in early endometrial cancer: a prospective study. Int J Gynecol Cancer 2019; 29:1016-1020. [PMID: 31175137 DOI: 10.1136/ijgc-2018-000113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sentinel node mapping has been proposed to reduce surgical side effects, maintaining the accuracy in nodal status assessment for endometrial cancer. OBJECTIVE To investigate the role of one-step nucleic acid amplification assay (OSNA) analysis, in the intra-operative tailoring of full nodal dissection, and to analyze the correlation between the type of sentinel node metastasis and the risk of non-sentinel node metastasis. METHODS Surgical and pathological data were collected from 141 consecutive, clinical stage I patients with endometrial cancer undergoing surgical staging. Patients were excluded if they had previous pelvic or abdominal radiotherapy, chemotherapy, abdominal cancer, pelvic or abdominal lymphadenectomy, or contraindications to indocyanine green. All sentinel nodes were analyzed by OSNA, and full lymphadenectomy was performed in positive cases. Statistical analysis was performed using Χ2 and Fisher's exact test to determine whether any of these characteristics could accurately predict the non-sentinel nodes status in positive sentinel node patients. RESULTS A total of 141 patients were included in the analysis. Bilateral sentinel nodes were identified in 104 (73.8%) patients, with a median number of 2 (range 2-6) sentinel nodes per patient. In the remaining 37 patients (26.2%), a unilateral sentinel node was obtained, with a median of 1 (range 1-3) sentinel node per patient. Thirty-three (12.0%) positive nodes were found in 24 (17.0%) patients: micro-metastases and macro-metastases were detected in 22 and 2 patients, respectively. At final pathology, all patients with positive non-sentinel nodes had macro-metastases in the sentinel node, whereas in micro-metastatic sentinel nodes no other positive nodes were found at full lymphadenectomy (p<0.001). CONCLUSIONS Our results showed a correlation between the type of metastasis in the sentinel lymph node (SLN) and the incidence of positive non-SLNs. These data suggest a potential role of OSNA analysis in the surgical tailoring of patients with early endometrial cancer, with the goal of definitive risk stratification and a better individualization of adjuvant therapy.
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Affiliation(s)
| | - Danilo Buca
- Università degli Studi Gabriele d'Annunzio Chieti e Pescara Dipartimento di Scienze, Chieti Scalo, Italy
| | - Giorgia Dinoi
- Policlinico Universitario Agostino Gemelli, Roma, Italy
| | | | | | | | - Giovanni Scambia
- Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Policlinico Universitario Agostino Gemelli, Roma, Italy
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Sarı ME, Meydanlı MM, Yalçın I, Şahin H, Çoban G, Çelik H, Kuşçu E, Gungor T, Ayhan A. Risk Factors for Lymph Node Metastasis among Lymphovascular Space Invasion-Positive Women with Endometrioid Endometrial Cancer Clinically Confined to the Uterus. Oncol Res Treat 2018; 41:750-754. [DOI: 10.1159/000492585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/31/2018] [Indexed: 01/15/2023]
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Uccella S, Falcone F, Greggi S, Fanfani F, De Iaco P, Corrado G, Ceccaroni M, Mandato VD, Bogliolo S, Casarin J, Monterossi G, Pinelli C, Mangili G, Cormio G, Roviglione G, Bergamini A, Pesci A, Frigerio L, Uccella S, Vizza E, Scambia G, Ghezzi F. Survival in clinical stage I endometrial cancer with single vs. multiple positive pelvic nodes: results of a multi-institutional Italian study. J Gynecol Oncol 2018; 29:e100. [PMID: 30207108 PMCID: PMC6189435 DOI: 10.3802/jgo.2018.29.e100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To investigate survival outcomes in endometrioid endometrial cancer (EEC) patients with single vs. multiple positive pelvic lymph nodes. METHODS We performed a retrospective evaluation of all consecutive patients with histologically proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 EEC who underwent primary surgical treatment between 2004 and 2014 at seven Italian gynecologic oncology referral centers. Patients with pre- or intra-operative evidence of extra-uterine disease (including the presence of bulky nodes) and patients with stage IIIC2 disease were excluded, in order to obtain a homogeneous population. RESULTS Overall 140 patients met the inclusion criteria. The presence of >1 metastatic pelvic node was significantly associated with an increased risk of recurrence and mortality, compared to only 1 metastatic node, at both univariate (recurrence: hazard ratio [HR]=2.19; 95% confidence interval [CI]=1.2-3.99; p=0.01; mortality: HR=2.8; 95% CI=1.24-6.29; p=0.01) and multivariable analysis (recurrence: HR=1.91; 95% CI=1.02-3.56; p=0.04; mortality: HR=2.62; 95% CI=1.13-6.05; p=0.02) and it was the only independent predictor of prognosis in this subset of patients. Disease-free survival (DFS) and disease-specific survival (DSS) were significantly longer in patients with only 1 metastatic node compared to those with more than 1 metastatic node (p=0.008 and 0.009, respectively). CONCLUSION The presence of multiple metastatic nodes in stage IIIC1 EEC represents an independent predictor of worse survival, compared to only one positive node. Our data suggest that EEC patients may be categorized according to the number of positive nodes.
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Affiliation(s)
- Stefano Uccella
- Department of Woman and Child Health, Fondazione Policlinico Gemelli, I.R.C.C.S., Catholic University of the Sacred Heart, Rome, Italy
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Francesca Falcone
- Department of Gynecologic Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale", I.R.C.C.S., Naples, Italy
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Stefano Greggi
- Department of Gynecologic Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale", I.R.C.C.S., Naples, Italy
| | - Francesco Fanfani
- Department of Medicine and Ageing Sciences, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Pierandrea De Iaco
- Department of General Surgery and Gynecologic Oncology Unit, Sant'Orsola Hospital, Bologna, Italy
| | - Giacomo Corrado
- Department of Woman and Child Health, Fondazione Policlinico Gemelli, I.R.C.C.S., Catholic University of the Sacred Heart, Rome, Italy
- Department of Oncological Surgery, Gynecologic Oncologic Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Vincenzo Dario Mandato
- Unit of Obstetrics and Gynecology, Azienda USL-I.R.C.C.S. di Reggio Emilia, Reggio Emilia, Italy
| | - Stefano Bogliolo
- Unit of Gynecologic Cancer Surgery European Institute of Oncology, Milan, Italy
- Department of Obstetrics and Gynaecology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Giorgia Monterossi
- Department of Woman and Child Health, Fondazione Policlinico Gemelli, I.R.C.C.S., Catholic University of the Sacred Heart, Rome, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Giorgia Mangili
- Department of Gynecology and Obstetrics, I.R.C.C.S. San Raffaele Hospital, Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, I.R.C.C.S., National Cancer Institute "Giovanni Paolo II", Bari, Italy
- Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Alice Bergamini
- Department of Gynecology and Obstetrics, I.R.C.C.S. San Raffaele Hospital, Milan, Italy
| | - Anna Pesci
- Department of Pathology, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Luigi Frigerio
- Department of Obstetrics and Gynecology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Uccella
- Department of Medicine and Surgery, Unit of Pathology, University of Insubria, Varese, Italy
| | - Enrico Vizza
- Department of Oncological Surgery, Gynecologic Oncologic Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health, Fondazione Policlinico Gemelli, I.R.C.C.S., Catholic University of the Sacred Heart, Rome, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
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Kumar A, Wallace SA, Cliby WA, Glaser GE, Mariani A, Leitao MM, Frumovitz M, Langstraat CL. Impact of Sentinel Node Approach in Gynecologic Cancer on Training Needs. J Minim Invasive Gynecol 2018; 26:727-732. [PMID: 30138740 DOI: 10.1016/j.jmig.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/12/2018] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions. DESIGN Retrospective multi-institution cohort (Canadian Task Force classification II-2). SETTING Three tertiary cancer referral cancer centers. PATIENTS Patients with endometrial and vulvar cancer undergoing lymph node evaluation. INTERVENTIONS Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment. MEASUREMENTS AND MAIN RESULTS Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins. CONCLUSIONS Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.
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Affiliation(s)
- Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota.
| | - Sumer A Wallace
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Mario M Leitao
- Department of Gynecologic Oncology (Dr. Leitao), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Frumovitz
- Department of Gynecologic Oncology (Dr. Frumovitz), MD Anderson Cancer Center, Houston, Texas
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
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Yordanov A, Karamanliev M, Strashilov S. Delayed Inguinal Site Metastasis in Early-Stage Endometrial Cancer: A Case Report. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2018. [DOI: 10.1007/s40944-018-0183-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Preoperative Serum Human Epididymis Protein 4 Levels in Early Stage Endometrial Cancer: A Prospective Study. Int J Gynecol Cancer 2018; 27:1200-1205. [PMID: 28557834 DOI: 10.1097/igc.0000000000001015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of the study was to evaluate the prognostic value of human epididymis protein 4 (HE4) and cancer antigen 125 markers with pathological prognostic factor to complete the preoperative clinical panel and help the treatment planning. METHODS This prospective multicenter study was conducted in 2 gynecologic oncology centers between 2012 and 2014 (Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste and Catholic University of the Sacred Heart in Rome, Italy). We enrolled 153 patients diagnosed with clinical early (International Federation of Gynecology and Obstetrics stages I-II) type I endometrial cancer. RESULTS Human epididymis protein 4 levels seemed to be strictly related to age (P < 0.001) and menopausal status (P < 0.002). Compared with myometrial invasion (MI), the HE4 values were significantly higher in case of invasion of greater than 50% of the thickness: MI of greater than 50%, median of 94.85 pmol/L (38.3-820.8 pmol/L), versus MI of less than 50%, median of 65.65 pmol/L (25.1-360.2 pmol/L), (P < 0.001). The HE4 levels increase significantly with increasing tumor size: diameter of larger than 2 cm, median of 86.9 pmol/L (35.8-820.8 pmol/L), versus diameter of smaller than 2 cm, median of 52.2 pmol/L (33.3-146.8 pmol/L), (P < 0.001). In our population, HE4 did not correlate with the histological grade, endometrial cancer type I versus type II (P = 0.86), the lymphovascular infiltration (P = 0.12), and the cervical invasion (P = 0.6). We established a new variable, considering 3 high-risk tumor features: MI of greater than 50% and/or histological G3 and/or type II. Human epididymis protein 4 levels significantly increase in high-risk tumors (high risk HE4, 93.6 pmol/L vs low-medium risk, 65.5 pmol/L; P < 0.001). CONCLUSIONS A preoperative HE4 evaluation could help stratify patients with deep invasion and/or metastatic disease and is correlated with other relevant prognostic factors to be considered to tailor an adequate surgical strategy.
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Vizza E, Corrado G, De Angeli M, Carosi M, Mancini E, Baiocco E, Chiofalo B, Patrizi L, Zampa A, Piaggio G, Cicchillitti L. Serum DNA integrity index as a potential molecular biomarker in endometrial cancer. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2018; 37:16. [PMID: 29382392 PMCID: PMC5791183 DOI: 10.1186/s13046-018-0688-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/23/2018] [Indexed: 12/18/2022]
Abstract
Background Circulating cell-free DNA (cfDNA) and its integrity index may represent a rapid and noninvasive “liquid biopsy” biomarker, which gives important complementary information for diagnosis, prognosis, and treatment stratification in cancer patients. The aim of our study was to evaluate the possible role of cfDNA and its integrity index as a complementary tool for endometrial cancer (EC) management. Methods Alu-quantitative real-time PCR (qPCR) analysis wasprformed on 60 serum samples from preoperative EC patients randomly recruited. Both cfDNA content and DNA integrity index were measured by qPCR-Alu115 (representing total cfDNA) and qPCR-Alu247 (corresponding to high molecular weight DNA) and correlated with clinicopathologic characteristics. Lymphovascular space invasion (LVSI) was detected by hematoxylin and eosin staining. In case of doubt, LVSI status was further evaluate by immunohistochemistry using anti-CD31 and anti-CD34 antibodies. Results Total cfDNA content significantly increases in high grade EC. A significant decrease of DNA integrity index was detected in the subset of hypertensive and obese high grade EC. Serum DNA integrity was higher in samples with LVSI. The ordinal regression analysis predicted a significant correlation between decreased integrity index values and hypertension specifically in tumors presenting LVSI. Conclusions Our study supports the utility of serum DNA integrity index as a noninvasive molecular biomarker in EC. We show that a correlation analysis between cfDNA quantitative and qualitative content and clinicopathologic features, such as blood pressure level, body mass index (BMI) and LVSI status, could represent a potential predictive signature to help stratification approaches in EC. Electronic supplementary material The online version of this article (doi:10.1186/s13046-018-0688-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Enrico Vizza
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giacomo Corrado
- Department of Health of Woman and Child, Gynecologic Oncology Unit, Catholic University of the Sacred Heart, Rome, Italy.
| | - Martina De Angeli
- Department of Biomedicine and Prevention, Obstetrics and Gynecology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Mariantonia Carosi
- Department of Research, Advanced Diagnostics and Technological Innovation, Anatomy Pathology Unit Regina Elena National Cancer Institute, Rome, Italy
| | - Emanuela Mancini
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Ermelinda Baiocco
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Benito Chiofalo
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Lodovico Patrizi
- Department of Biomedicine and Prevention, Obstetrics and Gynecology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Ashanti Zampa
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulia Piaggio
- Department of Research, Advanced Diagnostics and Technological Innovation, Area of Translational Research, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Lucia Cicchillitti
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Taşkın S, Şükür YE, Varlı B, Koyuncu K, Seval MM, Ateş C, Yüksel S, Güngör M, Ortaç F. Nomogram with potential clinical use to predict lymph node metastasis in endometrial cancer patients diagnosed incidentally by postoperative pathological assessment. Arch Gynecol Obstet 2017; 296:803-809. [PMID: 28762064 DOI: 10.1007/s00404-017-4477-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 07/25/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the clinical and pathological risk factors for lymph node metastasis (LNM) in patients with endometrial cancer and to create a nomogram to predict LNM in patients without surgical staging. METHODS All patients with endometrial adenocarcinoma who were treated surgically at a university based gynecologic oncology clinic between January 2011 and December 2014 were recruited. Women with endometrial adenocarcinoma who were surgically staged including lymphadenectomy were included in the study. Data regarding clinical and pathological risk factors were recorded. The histopathologic slides from the staging surgeries were re-evaluated microscopically by a gynecologic pathologist for all parameters along with lymphovascular space invasion (LVSI). RESULTS A total of 279 patients with endometrial cancer were analyzed. Among those, 31 (11.1%) had lymph node metastasis. According to the univariate analyses, elevated CA 125 (>35 U/mL), LVSI, myometrial invasion ≥50%, grade 3 disease, non-endometrioid type, and cervical stromal involvement were significantly associated with LNM. The multivariate logistic regression analysis showed that LVSI, non-endometrioid type, elevated CA 125, and cervical stromal involvement increased the risk of LNM. However, myometrial invasion and grade did not significantly affect the risk of LNM. A nomogram to predict LNM was constructed using these factors (concordance index 0.92). CONCLUSIONS LVSI is the most important predictor for LNM. The present nomogram can be useful to decide if adjuvant therapy is required for patients who undergo simple hysterectomy for a benign etiology and incidentally diagnosed with endometrial cancer by pathological evaluation.
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Affiliation(s)
- Salih Taşkın
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey
| | - Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey.
| | - Bulut Varlı
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey
| | - Kazibe Koyuncu
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey
| | - Mehmet Murat Seval
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey
| | - Can Ateş
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
| | - Selcen Yüksel
- Department of Biostatistics, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Mete Güngör
- Department of Obstetrics and Gynecology, Acıbadem University School of Medicine, Istanbul, Turkey
| | - Fırat Ortaç
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey
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Topfedaisi Ozkan N, Meydanlı MM, Sarı ME, Demirkiran F, Kahramanoglu I, Bese T, Arvas M, Şahin H, Haberal A, Celik H, Coban G, Oge T, Yalcin OT, Akbayır Ö, Erdem B, Numanoğlu C, Özgül N, Boyraz G, Salman MC, Yüce K, Dede M, Yenen MC, Taşkın S, Altın D, Ortaç UF, Aydın Ayık H, Şimşek T, Güngör T, Güngördük K, Sancı M, Ayhan A. Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone. J Gynecol Oncol 2017; 28:e65. [PMID: 28657226 PMCID: PMC5540724 DOI: 10.3802/jgo.2017.28.e65] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/11/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Abstract
Objective To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone. Methods A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected. Results We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors. Conclusion Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.
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Affiliation(s)
- Nazli Topfedaisi Ozkan
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Mutlu Meydanlı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mustafa Erkan Sarı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Fuat Demirkiran
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilker Kahramanoglu
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tugan Bese
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Macit Arvas
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hanifi Şahin
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ali Haberal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Husnu Celik
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Gonca Coban
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Tufan Oge
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Omer Tarik Yalcin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Özgür Akbayır
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Baki Erdem
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Ceyhun Numanoğlu
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Nejat Özgül
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gökhan Boyraz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet Coşkun Salman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kunter Yüce
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Murat Dede
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Mufit Cemal Yenen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Salih Taşkın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Duygu Altın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Uğur Fırat Ortaç
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Hülya Aydın Ayık
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayup Şimşek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayfun Güngör
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Kemal Güngördük
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Muzaffer Sancı
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Ali Ayhan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Akbar SAM, Tunio MA, AlShakweer W, AlObaid A, AlAsiri M. Inguinal lymph node presenting as the delayed site of metastasis in early stage endometrial carcinoma: Case report. Int J Surg Case Rep 2017; 32:12-15. [PMID: 28213066 PMCID: PMC5312497 DOI: 10.1016/j.ijscr.2017.01.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
Inguinal lymph nodes metastasis are rare in endometrial carcinoma. Proper preoperative assessment is important. CT-PET imaging is important tool in obese patients. Treatment is surgery and adjuvant chemo-radiotherapy.
Introduction Inguinal lymph nodes are the frequent sites of metastasis for malignant lymphoma, squamous cell carcinoma of anal canal, vulva and penis, malignant melanoma and squamous cell carcinoma of skin over lower extremities or trunk. Anatomically, endometrial carcinoma is less likely to spread to the superficial or deep inguinal lymph nodes, thus metastatic involvement of these lymph nodes can easily be overlooked. Case presentation Here-in we report a case of a 65-year old Saudi morbid obese female, who presented with left inguinal lymphadenopathy as initial delayed site of metastasis almost 19 months after the initial treatment for FIGO IA endometrial carcinoma. Patient underwent left inguinal lymph node dissection. Histopathology confirmed metastatic endometrial adenocarcinoma, positive for cytokeratin (CK-7), estrogen receptor (ER) and progesterone receptors (PR), negative for CK-20 and CDX2. Following the post-surgery recovery, she was given extended field radiation therapy to para-aortic, pelvis and bilateral inguinal lymph nodes with concurrent cisplatin chemotherapy followed by high dose rate brachytherapy. Conclusion Inguinal lymph nodes as delayed site of metastasis in early endometrial carcinoma is extremely rare entity. Incorporation of FDG-PET during the preoperative screening of inguinal nodes may be helpful. The impact of lymph node dissection and adjuvant radiation therapy on survival needs to be established.
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Affiliation(s)
- Shomaila Amir M Akbar
- Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, 59046, Saudi Arabia.
| | - Mutahir A Tunio
- Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, 59046, Saudi Arabia.
| | - Wafa AlShakweer
- Histopathology, Department of Cytogenetics, Pathology, King Fahad Medical City, Riyadh, 11525, Saudi Arabia.
| | - AbdulAziz AlObaid
- Women's Specialized Hospital, King Fahad Medical City, Riyadh, 59046, Saudi Arabia.
| | - Mushabbab AlAsiri
- Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, 59046, Saudi Arabia.
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Zhou X, Wang H, Wang X. Preoperative CA125 and fibrinogen in patients with endometrial cancer: a risk model for predicting lymphovascular space invasion. J Gynecol Oncol 2016; 28:e11. [PMID: 27894164 PMCID: PMC5323282 DOI: 10.3802/jgo.2017.28.e11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to build a model to predict the risk of lymphovascular space invasion (LVSI) in women with endometrial cancer (EC). METHODS From December 2010 to June 2013, 211 patients with EC undergoing surgery at Shanghai First Maternity and Infant Hospital were enrolled in this retrospective study. Those patients were divided into a positive LVSI group and a negative LVSI group. The clinical and pathological characteristics were compared between the two groups; logistic regression was used to explore risk factors associated with LVSI occurrence. The threshold values of significant factors were calculated to build a risk model and predict LVSI. RESULTS There were 190 patients who were negative for LVSI and 21 patients were positive for LVSI out of 211 patients with EC. It was found that tumor grade, depth of myometrial invasion, number of pelvic lymph nodes, and International Federation of Gynecology and Obstetrics (FIGO) stage (p<0.05) were associated with LVSI occurrence. However, cervical involvement and age (p>0.05) were not associated with LVSI. Receiver operating characteristic (ROC) curves revealed that the threshold values of the following factors were correlated with positive LVSI: 28.1 U/mL of CA19-9, 21.2 U/mL of CA125, 2.58 mg/dL of fibrinogen (Fn), 1.84 U/mL of carcinoembryonic antigen (CEA) and (6.35×10⁹)/L of white blood cell (WBC). Logistic regression analysis indicated that CA125 ≥21.2 (p=0.032) and Fn ≥2.58 mg/dL (p=0.014) were significantly associated with LVSI. CONCLUSION Positive LVSI could be predicted by CA125 ≥21.2 U/mL and Fn ≥2.58 mg/dL in women with EC. It could help gynecologists better adapt surgical staging and adjuvant therapies.
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Affiliation(s)
- Xingchen Zhou
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University, Shanghai, China
| | - Husheng Wang
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University, Shanghai, China
| | - Xipeng Wang
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University, Shanghai, China.
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Therapeutic role of systematic lymphadenectomy in early-stage endometrial cancer: A systematic review. Oncol Lett 2016; 11:3849-3857. [PMID: 27313706 DOI: 10.3892/ol.2016.4467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/18/2016] [Indexed: 12/29/2022] Open
Abstract
The purpose of the current review was to examine whether systematic lymphadenectomy is safe and effective for treating early-stage endometrial cancer. PubMed, Embase, the Cochrane Library and the China National Knowledge Infrastructure databases were systematically searched during April 2014 to identify studies comparing the use of systematic lymphadenectomy and no systematic lymphadenectomy in parallel for the treatment of early-stage endometrial cancer. A total of 13 eligible studies involving 51,155 patients were included in this review. The median overall survival (OS) rate at 5 years following lymphadenectomy was 90% (range, 73.1-98.3%) for patients undergoing the systematic procedure and 88.2% (range, 68-98.4%) for patients not undergoing the systematic procedure. For the two types of lymphadenectomy, OS has tended to improve over the last 20 years. The combined rate of disease-free and progression-free survival was higher in patients who underwent systematic lymphadenectomy, and the recurrence rate was lower. In particular, systematic lymphadenectomy was associated with markedly higher OS than the non-systematic procedure for patients with intermediate- and high-risk endometrial cancer when ≥11 lymph nodes were removed. Systematic lymphadenectomy demonstrates clinical benefit in patients with early-stage endometrial cancer and should thus be a standard treatment option. In conclusion, systematic lymphadenectomy leads to higher OS than no systematic lymphadenectomy in intermediate- and high-risk patients with early-stage endometrial cancer, particularly when the procedure removes ≥11 lymph nodes.
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Jorge S, Hou JY, Tergas AI, Burke WM, Huang Y, Hu JC, Ananth CV, Neugut AI, Hershman DL, Wright JD. Magnitude of risk for nodal metastasis associated with lymphvascular space invasion for endometrial cancer. Gynecol Oncol 2016; 140:387-93. [PMID: 26768835 DOI: 10.1016/j.ygyno.2016.01.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/31/2015] [Accepted: 01/03/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVES While lymphvascular space invasion (LVSI) is a risk factor for nodal metastasis in endometrial cancer, the magnitude of risk is poorly described. We examined the risk of nodal metastasis associated with LVSI for various combinations of tumor grade and depth of invasion and examined the effect of LVSI on survival. METHODS We identified patients with T1A (<50% myoinvasion) and T1B (>50% myoinvasion) endometrioid adenocarcinomas of the endometrium diagnosed between 2010 and 2012 and recorded in the National Cancer Database. The risk of nodal metastasis associated with LVSI stratified by grade and stage is reported. The association of LVSI and survival was examined using Kaplan-Meier analyses and Cox proportional hazards models. RESULTS We identified 25,907 patients, including 3928 (15.2%) with LVSI. Among patients with LVSI, 21.0% had positive lymph nodes, compared to 2.1% in patients without LVSI (P<0.0001). In analyses stratified by stage and grade, LVSI was associated with increased risks of LN metastasis by a magnitude of 3 to over 10-fold. In a multivariable model controlling for clinical and demographic characteristics, the risk ratio of nodal disease with LVSI was 9.29 (95% CI, 7.29-11.84) for T1A tumors and 4.64 (95% CI 3.99-5.39) for T1B tumors. LVSI was associated with decreased survival even after adjustment for the presence of lymph node metastases (HR=1.92, 95% CI 1.56-2.36). CONCLUSIONS LVSI is independently associated with lymph node metastases in women with apparent early-stage endometrial cancer and an independent predictor of survival even after adjustment for the presence of lymph node metastases.
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Affiliation(s)
- Soledad Jorge
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States
| | - Jim C Hu
- Department of Urology, Weill Cornell Medical College, United States; New York Presbyterian Hospital, United States
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University, United States
| | - Alfred I Neugut
- Department of Medicine, Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States.
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Roma AA, Rybicki LA, Barbuto D, Euscher E, Djordjevic B, Frauenhoffer E, Kim I, Hong SR, Montiel D, Ali-Fehmi R, Malpica A, Silva EG. Risk factor analysis of recurrence in low-grade endometrial adenocarcinoma. Hum Pathol 2015; 46:1529-39. [DOI: 10.1016/j.humpath.2015.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 06/03/2015] [Accepted: 06/10/2015] [Indexed: 11/27/2022]
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Mahdi H, Jernigan A, Nutter B, Michener C, Rose PG. Lymph node metastasis and pattern of recurrence in clinically early stage endometrial cancer with positive lymphovascular space invasion. J Gynecol Oncol 2015; 26:208-13. [PMID: 25686395 PMCID: PMC4510337 DOI: 10.3802/jgo.2015.26.3.208] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/03/2015] [Accepted: 01/13/2015] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the rate, predictors of lymph node metastasis (LNM) and pattern of recurrence in clinically early stage endometrial cancer (EC) with positive lymphovascular space invasion (LVSI). Methods Women with clinically early stage EC and positive LVSI 2005 to 2012 were identified. Kaplan-Meier curves and logistic regression models were used. Results One hundred forty-eight women were identified. Of them, 25.7% had LNM (21.7% pelvic LNM, 18.5% para-aortic LNM). Among patients with LNM who had both pelvic and para-aortic lymphadenectomy, isolated pelvic, para-aortic and both LNM were noted in 51.4%, 17.1%, and 31.4% respectively. Age and depth of myometrial invasion were significant predictors of LNM in LVSI positive EC. Node positive patients had high recurrence rate (47% vs. 11.8%, p<0.05) especially distant (60.9% vs. 7.9%, p<0.001) and para-aortic (13.2% vs. 1.8%, p=0.017) recurrences compared to node negative EC. LNM was associated with lower progression-free survival (p=0.002) but not overall survival (p=0.73). Conclusion EC with positive LVSI is associated with high risk of LNM. LNM is associated with high recurrence rate especially distant and para-aortic recurrences. Adjuvant treatments should target prevention of recurrences in these areas.
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Affiliation(s)
- Haider Mahdi
- Division of Gynecologic Oncology, Ob/Gyn & Women's Health Institute, Cleveland, OH, USA.
| | - Amelia Jernigan
- Division of Gynecologic Oncology, Ob/Gyn & Women's Health Institute, Cleveland, OH, USA
| | - Benjamin Nutter
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Chad Michener
- Division of Gynecologic Oncology, Ob/Gyn & Women's Health Institute, Cleveland, OH, USA
| | - Peter G Rose
- Division of Gynecologic Oncology, Ob/Gyn & Women's Health Institute, Cleveland, OH, USA
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Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer. Br J Cancer 2013; 110:609-15. [PMID: 24366295 PMCID: PMC3915129 DOI: 10.1038/bjc.2013.766] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 12/03/2022] Open
Abstract
Background: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer. Methods: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed. Results: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1–2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases. Conclusions: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.
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Han G, Lim D, Leitao MM, Abu-Rustum NR, Soslow RA. Histological features associated with occult lymph node metastasis in FIGO clinical stage I, grade I endometrioid carcinoma. Histopathology 2013; 64:389-98. [PMID: 24215212 DOI: 10.1111/his.12254] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/09/2013] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Guangming Han
- Department of Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Loizzi V, Cormio G, Lorusso M, Latorre D, Falagario M, Demitri P, Scardigno D, Selvaggi LE. The impact of lymph vascular space invasion on recurrence and survival in patients with early stage endometrial cancer. Eur J Cancer Care (Engl) 2013; 23:380-4. [PMID: 24112088 DOI: 10.1111/ecc.12115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 11/27/2022]
Abstract
The aim of this study was to determine impact of lymph vascular space involvement (LVSI) on recurrence and survival in early stage of endometrial cancer. From 1991 through 2010, all endometrial cancer patients at University Hospital of Bari, Italy were identified. The Log-rank test and Kaplan-Meyer methods were used for time-to-event analysis to evaluate the effects of on lymph vascular space involvement recurrence rate and survival time. Of the 560 endometrial cancer patients, 525 underwent primary surgery. Of those, 399 had early stage disease. Three hundred and forty women were not found to have LVSI, whereas 59 were found to have lymph vascular space involvement. Forty-nine (12%) patients developed a recurrence and 20 of them showed lymph vascular space involvement. The statistical analysis demonstrated that LVSI was strongly associated with a poor survival (P < 0.0001). Lymph vascular space involvement is associated with a high risk of recurrence and poor overall survival in early stage of endometrial cancer; therefore, the clinical decision to decide whether or not a patient with early stage endometrial cancer should receive adjuvant therapy should be included the evaluation of lymph vascular space involvement.
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Affiliation(s)
- V Loizzi
- Department of Gynecology, Obstetrics and Neonatology, University of Bari, Bari, Italy
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The risk of lymph node metastasis with positive peritoneal cytology in endometrial cancer. Int J Gynecol Cancer 2013. [PMID: 23196758 DOI: 10.1097/igc.0b013e318275afd2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To determine the correlation between positive peritoneal cytology (PPC) and lymph node metastasis in patients with endometrial cancer grossly confined to the uterus. METHODS Data were extracted from the Surveillance, Epidemiology, and End Results database between 1988 and 2005. Only patients with endometrial cancer grossly confined to the uterus who had undergone a complete staging procedure (lymph node removal) were included. Statistical analysis used the χ2 test and logistic regression models. RESULTS A total of 22,947 patients were identified. Positive peritoneal cytology was present in 3.5% of the patients. The incidence of lymph node metastasis was significantly higher among patients with PPC compared to those with negative peritoneal cytology for all histologic types examined (P < 0.0001): endometrioid adenocarcinoma, 28.7% versus 6.9%; adenocarcinoma not otherwise specified, 35.4% versus 5.8%; clear cell/serous carcinoma, 41.4% versus 19.0%, and carcinosarcoma,; 38.4% versus 14.4%. After adjusting for other contributing factors in the multivariable model, PPC remained an independent predictor of lymph node metastasis (P < 0.0001). CONCLUSION Our data indicate that patients with positive washings are at significant risk of nodal metastasis and adverse prognosis. Although no longer a part of the current International Federation of Gynecology and Obstetrics staging criteria, peritoneal cytology status should continue to inform clinical decision making in endometrial cancer.
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Patterns of recurrence in stage I endometrioid endometrial adenocarcinoma with lymphovascular space invasion. Int J Gynecol Cancer 2013; 23:98-104. [PMID: 23221731 DOI: 10.1097/igc.0b013e318276d9b6] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine the patterns of recurrence of stage IB-IIA endometrioid endometrial adenocarcinoma (EMCA) with lymphovascular invasion (LVSI). METHODS A multicenter retrospective study of 1988 International Federation of Gynecology and Obstetrics stage IB-IIA EMCA patients with LVSI treated with surgery with or without radiation was conducted. Those with papillary serous or clear cell histologies and women treated with chemotherapy were excluded. Data regarding surgical-pathologic factors, treatment, and outcome were collected. Data were analyzed using χ test, Kaplan-Meier estimates, and Cox multivariate proportional hazards models. RESULTS From 1997 to 2008, we identified 131 patients with LVSI who met entry criteria among 5 institutions. Median age was 67 years (25%-75%: 60-75 years), and median follow-up was 4.25 years (25%-75%: 3-10 years). Following surgery, 45 patients were observed (Obs), and 86 patients received adjuvant radiation. We observed 30 total relapses 30/131 (23%): 11/45 (24%) in the Obs group and 19/86 (22%) in the adjuvant radiation group. Recurrence rates were similar between staged and unstaged patients: 24% (20/84) and 21% (10/47), respectively. Among Obs patients, 82% of relapses were local, whereas in patients treated with adjuvant radiation, 84% were distant. Relapses were significantly associated with invasion of the lower uterine segment (LUS) (P = 0.035). Both cancer-related survival and overall survival (OS) were not significantly impacted by adjuvant radiation, because of distant failure rates. Adjuvant radiation significantly improved pelvic control (P = 0.007). In a multivariate analysis, OS correlated with LUS invasion (P = 0.008) and was borderline-associated with stage (P = 0.06), whereas age (P = 0.12), grade (P = 0.31), myometrial invasion (P = 0.99), and radiation treatment (P = 0.23) were not. CONCLUSIONS Overall recurrence rates for stage IB-IIA EMCA patients with LVSI are high (23%). Although adjuvant radiation therapy improved pelvic control, it did not impact recurrence rates, cancer-related survival, and OS, likely secondary to distant failures. The role of systemic therapy with or without radiotherapy for early-stage EMCA with LVSI should be evaluated, particularly in patients with high-grade tumors or involvement of the LUS.
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Hahn HS, Lee IH, Kim TJ, Lee KH, Shim JU, Kim JW, Lim KT. Lymphovascular space invasion is highly associated with lymph node metastasis and recurrence in endometrial cancer. Aust N Z J Obstet Gynaecol 2013; 53:293-7. [DOI: 10.1111/ajo.12089] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 03/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Ho-Suap Hahn
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - In-Ho Lee
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - Tae-Jin Kim
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - Ki-Heon Lee
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - Jae-Uk Shim
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - Jae-Wook Kim
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
| | - Kyung-Taek Lim
- Department of Obstetrics and Gynecology; Cheil General Hospital and Women's Healthcare Center; Kwandong University College of Medicine; Seoul; Korea
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Detection of lymphovascular invasion by D2-40 (podoplanin) immunoexpression in endometrial cancer. Int J Gynecol Cancer 2013; 22:1442-8. [PMID: 22964524 DOI: 10.1097/igc.0b013e318269139b] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Lymph node involvement is a major feature in tumor spread of endometrial cancer and predicts prognosis. Therefore, evaluation of lymph vessel invasion (LVI) in tumor tissue as a predictor for lymph node metastasis is of great importance. Immunostaining of D2-40 (podoplanin), a specific marker for lymphatic endothelial cells, might be able to increase the detection rate of LVI compared with conventional hematoxylin-eosin (H-E) staining. The aim of this retrospective study was to analyze the eligibility of D2-40-based LVI evaluation for the prediction of lymph node metastases and patients' outcome. PATIENTS AND METHODS Immunohistochemical staining with D2-40 monoclonal antibodies was performed on paraffin-embedded tissue sections of 182 patients with primary endometrioid adenocarcinoma treated in 1 gynecologic cancer center. Tumors were screened for the presence of LVI. Correlations with clinicopathological features and clinical outcome were assessed. RESULTS Immunostaining of D2-40 significantly increased the frequency LVI detection compared with conventional H-E staining. Lymph vessel invasion was identified by D2-40 in 53 (29.1%) of 182 tumors compared with 34 (18.3%) of 182 carcinomas by routine H-E staining (P = 0.001). D2-40 LVI was detectable in 81.0% (17/21) of nodal-positive tumors and significantly predicted lymph node metastasis (P = 0.001). Furthermore, D2-40 LVI was an independent prognostic factor for patients overall survival considering tumor stage, lymph node involvement, and tumor differentiation (P < 0.01). D2-40-negative tumors confined to the inner half of the myometrium showed an excellent outcome (5-year overall survival, 97.8%). CONCLUSIONS D2-40-based LVI assessment improves the histopathological detection of lymphovascular invasion in endometrial cancer. Furthermore, LVI is of prognostic value and predicts lymph node metastasis. D2-40 LVI detection might help to select endometrial cancer patients who will benefit from a lymphadenectomy.
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Chattopadhyay S, Bryant A, Al Moundhri M, Galaal K. Surgery plus adjuvant radiotherapy versus surgery alone for stage II endometrial cancer. Hippokratia 2013. [DOI: 10.1002/14651858.cd010353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Supratik Chattopadhyay
- St James's University Hospital; Gynaecological Oncology; Level 4, Bexley Wing Beckett Street Leeds UK LS9 7TF
| | - Andrew Bryant
- Newcastle University; Institute of Health & Society; Medical School New Build Richardson Road Newcastle upon Tyne UK NE2 4AX
| | - Mansour Al Moundhri
- College of Medicine and Health Sciences and Sultan Qaboos University Hospital; Medical Oncology Unit, Department of Medicine; Sutlan Qaboos University Al-Khod Oman 123
| | - Khadra Galaal
- Princess Alexandra Wing, Royal Cornwall Hospital; Gynaecological Oncology; Truro UK TR1 3LJ
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Prognostic significance of lymphovascular space invasion and nodal involvement in intermediate- and high-risk endometrial cancer patients treated with curative intent using surgery and adjuvant radiotherapy. Int J Gynecol Cancer 2012; 22:260-6. [PMID: 22080878 DOI: 10.1097/igc.0b013e318230c264] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess whether lymphovascular space invasion (LVSI) and nodal status provide adequate prognostic information in comparison with the entire set of traditional prognostic factors in intermediate- and high-risk endometrial cancer patients treated and staged with primary surgery and adjuvant radiotherapy. METHODS Three hundred twenty-four previously untreated high-intermediate- and high-risk endometrial cancer patients with FIGO (International Federation of Gynecology and Obstetrics) stage I to IIIC; endometrioid, serous, or clear cell histology; diagnosed between November 1995 and December 2006; who presented to Peter MacCallum Cancer Centre for adjuvant radiotherapy were included in these analyses. All traditionally recognized prognostic factors and newly created 4 pairs of combination of LVSI and nodal status were studied with respect to survival and patterns of failure. RESULTS The median follow-up time was 4.8 years. Five-year failure-free survival for all patients according to FIGO stage I, II, and III were 87.4%, 89.0%, and 62.4 %, respectively. In multivariable analysis for relapse, positive LVSI had a hazard ratio of 4.9 (P = 0.000), which increased to 8.8 (P = 0.004) in the presence of positive nodes. For overall survival, only LVSI was significant, with a hazard ratio of 3.02 (P = 0.003). In particular, in the presence of LVSI and nodes, histological type, grade, and myometrial invasion were not significant prognosticators for relapse or overall survival. CONCLUSIONS This model enables the separation of good prognosis patients even among poorly differentiated endometrioid, serous, and clear cell carcinoma patients and can be used in simplifying the staging of endometrial cancer and for selecting patients for high-risk endometrial cancer studies.
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Kim HS, Suh DH, Kim MK, Chung HH, Park NH, Song YS. Systematic Lymphadenectomy for Survival in Patients with Endometrial Cancer: A Meta-analysis. Jpn J Clin Oncol 2012; 42:405-12. [DOI: 10.1093/jjco/hys019] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kuru O, Topuz S, Sen S, Iyibozkurt C, Berkman S. Sentinel lymph node biopsy in endometrial cancer: description of the technique and preliminary results. J Turk Ger Gynecol Assoc 2011; 12:204-8. [PMID: 24591995 DOI: 10.5152/jtgga.2011.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 09/16/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To measure the feasibility of sentinel lymph node technique in endometrial cancer. MATERIAL AND METHODS The study was designed as a prospective non-randomized case-control trial. Between 2010-2011, in Istanbul University, Istanbul Medical Faculty, Gynecologic Oncology department, 26 patients who were preoperatively evaluated as endometrial cancer enrolled in the study. Patients' detailed informed consent and ethics committee approval were obtained. Sentinel lymph node (SLN) detection rate was determined as the primary outcome. Sensitivity, specificity, positive and negative predictive values and particularly false negative results were determined as secondary outcomes. As a technique of SLN, injection of methylene blue to the subserosal myometrium of the uterine fundus via 5 cc syringe following peritoneal aspiration cytology procedure was obtained. Surgery was made after injection for an average of 5 minutes due to the physiological spread of the blue dye. Then, the standard protocol of hysterectomy was performed and the retroperitoneum was opened to perform lymphadenectomy. The presence of lymph node regions, and presence of a sentinel node was recorded on the trial record form. Positive staining nodes were sent separately for pathological examination. In the course of the study due to insufficient rate of staining, the technique has been changed to cervical and multiple uterine injections. RESULTS As the primary outcome, an SLN positivity rate of 23% in 6 patients with a total of 8 lymph nodes were found. The remarkable finding was that in the first technique, the rate was 1/16 (6%), while the second technique, 5/10 (50%), respectively. The difference is statistically significant (p=0.001). In endometrial cancer stage I and II, secondary outcomes for sensitivity, specificity, positive predictive value, negative predictive value were 23%, 0%, 100%, 43%, respectively. Because there were no metastatic lymph nodes found, false negative rate was 0%. CONCLUSION SLN approach is not valuable enough to eliminate the need for lymphadenectomy. On the other hand, it facilitates scanning micrometastases and ultrastaging, while its clinical value has not yet been established. However, according to the recent pilot studies, it provides a means for assessing micrometastases for the medium-risk group for local recurrence.
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Affiliation(s)
- Oğuzhan Kuru
- Department of Obstetrics and Gynecology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Samet Topuz
- Department of Obstetrics and Gynecology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Serhat Sen
- Department of Obstetrics and Gynecology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Cem Iyibozkurt
- Department of Obstetrics and Gynecology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Sinan Berkman
- Department of Obstetrics and Gynecology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
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Kalogera E, Scholler N, Powless C, Weaver A, Drapkin R, Li J, Jiang SW, Podratz K, Urban N, Dowdy SC. Correlation of serum HE4 with tumor size and myometrial invasion in endometrial cancer. Gynecol Oncol 2011; 124:270-5. [PMID: 22037318 DOI: 10.1016/j.ygyno.2011.10.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/21/2011] [Accepted: 10/22/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the utility of serum (HE4) as a marker for high risk disease in patients with endometrial cancer (EC). METHODS Preoperative serum HE4 levels were measured from a cohort of 75 patients surgically treated for EC. Cases were compared to matched controls without a history of cancer. HE4 levels were analyzed as a function of primary tumor diameter, grade, stage and histological subtype. Wilcoxon rank-sum test, ROC curve, Spearman rank correlation coefficient and contingency tables were used for statistical analyses. RESULTS Stage distribution was as follows: 49 stage I, 2 stage II, 20 stage III, 4 stage IV. Type I EC was present in 54 patients, type II in 21. Median HE4 was significantly elevated in both types I and II EC compared to controls (P<0.001 and P=0.019, respectively). There was significant correlation between type I EC, median HE4, deep myometrial invasion (MI) (>50%, P<0.001) and primary tumor diameter (PTD) (>2 cm, P=0.002). Low risk patients (type I, MI ≤ 50% and PTD ≤ 2 cm) had significantly lower median HE4 compared to all other type I EC patients (P<0.01). In comparison to prior investigations, HE4 (cutoff of 8 mfi) was more sensitive than CA125 in detecting advanced stage disease. CONCLUSION Our data suggest that HE4 is elevated in a high proportion of EC patients, is correlated with PTD and MI, and is more sensitive than CA125 in EC. These observations suggest potential utility of HE4 in the preoperative prediction of high risk disease and the necessity for definitive surgical staging.
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Bakkum-Gamez JN, Mariani A, Dowdy SC, Weaver AL, McGree ME, Cliby WA, Gostout BS, Stanhope CR, Wilson TO, Podratz KC. The impact of surgical guidelines and periodic quality assessment on the staging of endometrial cancer. Gynecol Oncol 2011; 123:58-64. [PMID: 21741696 DOI: 10.1016/j.ygyno.2011.06.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 06/06/2011] [Accepted: 06/15/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the impact of surgical guidelines and transparent periodic assessment of surgical quality on endometrial cancer (EC) staging by gynecologic oncologists in a single institution and to identify process-of-care, patient-specific, and disease-specific risk factors that influence surgical quality. METHODS In January 2004, a prospective treatment algorithm was implemented for EC at our institution. The number of nodes harvested was a surrogate, and staging quality from 2004 to 2008 (quality assessment [QA] interval) was compared with the previous 5 years (pre-QA interval). Since 2004, low-risk cases based on frozen section examination had not undergone lymphadenectomy and were excluded. Independent patient-specific, disease-specific, and surgery-related risk factors influencing lymphadenectomy quality during both intervals were identified with multivariable logistic regression analysis. RESULTS Pelvic and para-aortic lymph node dissection (LND) in surgical EC management before QA (n=420) were 77.9% and 48.8% vs 89.3% and 83.4% during the QA (n=561) (P<.001). The median number of pelvic and para-aortic nodes harvested in LND was 29 and 10 before QA vs 34 and 16 during the QA interval (P<.001). With acceptance of stringent criteria for defining systematic LND (mean node count-1 SD) during the QA, systematic pelvic (≥22 nodes) and para-aortic (≥10 nodes) LNDs occurred in 57.4% and 25.7% of cases before QA vs 77.9% and 70.7% during the QA interval (P<.001). In patients with LND, rates of systematic pelvic and para-aortic LND were 73.7% and 53.0% before vs 87.2% and 84.8% after QA (P<.001). Multivariable logistic regression analysis showed independent factors influencing systematic pelvic and para-aortic LND (P<.01): surgeon and stage during the pre-QA interval vs surgical approach; intraoperative ascites; body mass index; surgeon; patient age; and myometrial invasion after QA implementation. CONCLUSION Inclusion of detailed surgical guidelines and transparent periodic assessment of surgical quality translated to dramatic improvement in quality of surgical EC staging. This implementation was associated with a transition to more patient-specific risk factors influencing systematic LND. Although surgical quality metrics were markedly enhanced during QA, persistent variability observed among surgeons and the change in surgical approach render continuous QA and improvement obligatory.
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Kawamura L, Carvalho FM, Alves BGL, Bacchi CE, Goes JCS, Calil MA, Baracat EC, Carvalho JP. Association between intratumoral lymphatic microvessel density (LMVD) and clinicopathologic features in endometrial cancer: a retrospective cohort study. World J Surg Oncol 2010; 8:89. [PMID: 20946633 PMCID: PMC2964720 DOI: 10.1186/1477-7819-8-89] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 10/14/2010] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Lymph node metastasis in endometrial cancer significantly decreases survival rate. Few data on the influence of intratumoral lymphatic microvessel density (LMVD) on survival in endometrial cancer are available. Our aim was to assess the intratumoral LMVD of endometrial carcinomas and to investigate its association with classical pathological factors, lymph node metastasis and survival. METHODS Fifty-seven patients with endometrial carcinoma diagnosed between 2000 and 2008 underwent complete surgical staging and evaluation of intratumoral LMVD and other histologic variables. Lymphatic microvessels were identified by immunohistochemical staining using monoclonal antibody against human podoplanin (clone D2-40) and evaluated by counting the number of immunostained lymphatic vessels in 10 hot spot areas at 400× magnification. The LMVD was expressed by the mean number of vessels in these 10 hot spot microscopic fields. We next investigated the association of LMVD with the clinicopathologic findings and prognosis. RESULTS The mean number of lymphatic vessels counted in all cases ranged between 0 and 4.7. The median value of mean LMVD was 0.5, and defined the cut-off for low and high LMVD. We identified low intratumoral LMVD in 27 (47.4%) patients and high LMVD in 30 (52.6%) patients. High intratumoral LMVD was associated with lesser miometrial and adnaexal infiltration, lesser cervical and peritoneal involvement, and fewer fatal cases. Although there was lower lymph node involvement among cases with high LMVD, the difference did not reach significance. No association was seen between LMVD and FIGO staging, histological type, or vascular invasion. On the other hand, low intratumoral LMVD was associated with poor outcome. Seventy-five percent of deaths occurred in patients with low intratumoral LMVD. CONCLUSION Our results show association of high intratumoral LMVD with features related to more localized disease and better outcome. We discuss the role of lymphangiogenesis as an early event in the endometrial carcinogenesis.
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Affiliation(s)
- Lecy Kawamura
- Department of Pathology of Faculdade de Medicina da Universidade de São Paulo, Sao Paulo (SP), Brazil
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Feddock J, Kudrimoti M, Randall M. No cookie-cutter oncology: individualized treatment approaches for women with corpus endometrial cancer. Expert Rev Anticancer Ther 2010; 10:1087-100. [PMID: 20645698 DOI: 10.1586/era.10.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometrial adenocarcinoma is the most common gynecologic malignancy and, for the majority of patients who present with stage I (approximately 70%) or stage II ( approximately 10%) disease, 5-year overall survival rates approach 85%. However, the complicated mix of medical comorbidities, the broad spectrum of techniques and treatment modalities and controversial clinical trial outcomes makes treating this heterogeneous group of patients unique and challenging. Similar management controversies exist and, when one factors in histologic variability, no flow-chart treatment algorithm can be easily constructed. This article will discuss data from key clinical trials, consider the role of routine lymphadenectomy as a component of surgical staging, discuss the heterogeneity of stage III patients in both presentation and response to treatment, review options for medically inoperable patients and reflect on current and upcoming protocols.
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Affiliation(s)
- Jonathan Feddock
- Department of Radiation Medicine, University of Kentucky Chandler Medical Center and Markey Cancer Center, Lexington, KY, USA.
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Affiliation(s)
- Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Alexander-Sefre F, Nibbs R, Rafferty T, Ayhan A, Singh N, Jacobs I. Clinical value of immunohistochemically detected lymphatic and vascular invasions in clinically staged endometrioid endometrial cancer. Int J Gynecol Cancer 2009; 19:1074-9. [PMID: 19820371 DOI: 10.1111/igc.0b013e3181abb0c0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Farhad Alexander-Sefre
- Department of Gynaecological Oncology, Glasgow Royal Infirmary, Castle Street, Glasgow, United Kingdom.
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