Clinicopathologic insight of simultaneously detected primary endometrial and ovarian carcinomas

Synchronous endometrial and ovarian cancer and its recurrent risk factors: Case series

BACKGROUND

Synchronous endometrial and ovarian cancer (SEOC) is a relatively rare entity with indistinct clinical manifestation but have a better prognosis compared to metastatic malignancy of each organ. The aim of the study is to determine the prognosis and factors associated with recurrence of SEOC.

METHODS

This case-series study was performed on 37 histologically confirmed SEOC, diagnosed and treated in our tertiary hospital from March 2009 to September 2021. Disease-free survival (DFS) and overall survival (OS) rates following indicated procedure were calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analysis were used to determine risk factors of recurrence.

RESULTS

The mean age of participants was 49.38 (age range: 26-78). The most common complaints and symptoms were abdominal pain (40.5%), followed by abnormal uterine bleeding (29.7%). Most common histological presentation was endometroid type for both ovarian (46%) and endometrial (97.3%) cancers. Over the mean follow-up period of 85.54 months, 11 patients developed recurrence without mortality. Non-endometrioid histology of ovarian cancer, higher grade and stage of ovarian cancer, and omentum invasion were significantly associated with worse DFS in unvariate analysis. Lymphovascular invasion was the sole predictor of DFS in multivariate analysis.

CONCLUSION

While this study was not able to investigate the risk factors of overall survival associated with SEOC, the results of this study provides an overview of clinicopathological presentation of the disease and emphasizes the importance of lymphovascular invasion in determining prognosis and DFS in SEOC.

A Decade of Therapeutic Challenges in Synchronous Gynecological Cancers from the Bucharest Oncological Institute

The aim of our study is to present the particularities of a specific subset of gynecological cancer patients in Romania. We present a review of synchronous gynecological neoplasia (SGN) treated in the Bucharest Oncological Institute's surgery departments over a decade. Between 2012 and 2022, 7419 female patients with genital malignancies were treated. We identified 36 patients with invasive synchronous primary gynecological cancers (0.5%) and 12 cases with one primary gynecological and another primary invasive pelvic cancer (rectal/bladder). All recurrent, metastatic, or metachronous tumors detected were excluded. Demographic data, personal history, presenting symptoms, pathologic findings, staging, treatment, and evolution for each case were recorded. Usually, the most common SGN association is between ovarian and endometrial cancer of endometrioid differentiation (low-grade malignancies with very good prognosis). However, we noticed that, given the particularities of the Romanian medical system, the most frequent association is between cervical and endometrial, followed by cervical and ovarian cancers. Moreover, the cancer stage at diagnosis is more advanced. In countries with low HPV vaccination rate and low adherence to screening programs, SGNs can present as extremely advanced cases and require extensive surgery (such as pelvic exenterations) to achieve radicality. This multimodal treatment in advanced cases with high tumor burden determines a reduction in survival, time until progression, and quality of life.

Uterine involvement in epithelial ovarian cancer and its risk factors

Background

Epithelial ovarian cancer (EOC) is an extremely aggressive and lethal carcinoma. Specific data that identify high-risk groups with uterine involvement are not available. Thus, this study aimed to evaluate a gross number of women with EOC to obtain the frequency of uterine involvement and its risk factors.

Methods

This retrospective observational study was conducted on 1900 histologically confirmed EOC women, diagnosed and treated in our tertiary hospital from March 2009 to September 2020. Data including their demographic, medical and pathological findings were collected.

Results

From 1900 histologically confirmed EOC women, 347 patients were eligible for participations. The mean age of study patients was 51.31 ± 11.37 years with the age range of 25 to 87 years. Uterine involvement was detected in 49.6% (173) of the patients either macroscopic (47.4%) or microscopic (52.6%) types.

Uterine involvement was significantly associated with having AUB (P-value = 0.002), histological type of ovary tumor (P-value < 0.001), ovarian cancer stage (P-value < 0.001), and abnormal CA-125 concentration (P-value = 0.004).

Compared to the other study patient, the patients with metastatic uterine involvement had significantly higher stage (p-value< 0.001), higher grade of ovary tumor (p-value = 0.008), serous histological type (p-value< 0.001), and a higher level of CA-125 concentration (p-value< 0.001).

on the other hand, the patients with synchronous uterine cancer were significantly younger (p-value = 0.013), nulliparous (p-value< 0.001), suffered from AUB symptoms (p-value< 0.001) and had endometroid histological type (p-value = 0.010) of ovary cancer in comparison to other study patients.

Conclusion

Considering the high prevalence of uterine involvement in EOC patients, ultrasound evaluation and/or endometrium biopsy assessment should be done before planning any treatment.

A Review of the Clinical Characteristics and Novel Molecular Subtypes of Endometrioid Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers that has the highest mortality rate. Endometrioid ovarian cancer, a distinct subtype of epithelial ovarian cancer, is associated with endometriosis and Lynch syndrome, and is often accompanied by synchronous endometrial carcinoma. In recent years, dysbiosis of the microbiota within the female reproductive tract has been suggested to be involved in the pathogenesis of endometrial cancer and ovarian cancer, with some specific pathogens exhibiting oncogenic having been found to contribute to cancer development. It has been shown that dysregulation of the microenvironment and accumulation of mutations are stimulatory factors in the progression of endometrioid ovarian carcinoma. This would be a potential therapeutic target in the future. Simultaneously, multiple studies have demonstrated the role of four molecular subtypes of endometrioid ovarian cancer, which are of particular importance in the prediction of prognosis. This literature review aims to compile the potential mechanisms of endometrioid ovarian cancer, molecular characteristics, and molecular pathological types that could potentially play a role in the prediction of prognosis, and the novel therapeutic strategies, providing some guidance for the stratified management of ovarian cancer.

SPOCK2 Affects the Biological Behavior of Endometrial Cancer Cells by Regulation of MT1-MMP and MMP2

Abnormal expression of SPARC (osteonectin), cwcv and kazal-like domains proteoglycan 2 (SPOCK2) plays a significant role in the development and progression of various human cancers, yet a relationship between SPOCK2 and endometrial cancer (EC) has not been reported. Here, we assessed the potential role and mechanism by which SPOCK2 acts in the pathogenesis and progression of EC. First, protein expression of SPOCK2 in EC tissue from patients was detected by immunohistochemistry and associated clinical data were analyzed. Then, HEC-1A and Ishikawa cells were transfected with an adenoviral vector containing an SPOCK2 recombinant fragment and the biological behavior of transfected cells was observed. Finally, the expression of membrane type 1 matrix metalloproteinase (MT1-MMP) and MMP2 in the transfected cells was detected by Western blot and zymography gel assay to analyze the effect of SPOCK2 on the regulation of the MT1-MMP/MMP2 pathway. We found that there was significantly less SPOCK2 protein expression in the EC tissue than in the normal endometrium tissue, and lack of SPOCK2 protein expression in EC tissue was associated with distant metastasis and myometrial invasion. Upregulation of SPOCK2 in HEC-1A and Ishikawa cells inhibited cell proliferation, invasion, adhesion, and apoptosis. Upregulation of SPOCK2 inhibited the expression of MT1-MMP and MMP2 and activation of MMP2 in HEC-1A and Ishikawa cells. Collectively, our data indicated that SPOCK2 contributed to the progression of EC by regulating the biological behavior of cancer cells, which is achieved partly through regulating protein expression of MT1-MMP and MMP2 and activation of MMP2.

Combination of Scoring Criteria and Whole Exome Sequencing Analysis of Synchronous Endometrial and Ovarian Carcinomas

OBJECTIVES

The purpose of this study was to distinguish synchronous primary endometrial and ovarian carcinomas from single primary tumor with metastasis by clinical pathologic criteria and whole exome sequencing (WES).

MATERIAL AND METHODS

Fifty-two patients with synchronous endometrial and ovarian carcinomas (SEOCs) between 2010 and 2017 were reviewed and subjected to WES.

RESULTS

On the basis of the Scully criteria, 11 cases were supposed as synchronous primary endometrial and ovarian carcinomas, 38 cases as single primary tumor with metastasis, and the remaining 3 cases (S50-S52) cannot be defined. Through a quantization scoring analysis, 9 cases that were scored 0-1 point were defined as synchronous primary endometrial and ovarian carcinomas, and 42 cases that were scored 3-8 points were defined as single primary tumor with metastasis. Two of the undefined cases were classified into metastatic disease, and another one that scored 2 points (S52) was subjected to WES. S52 was deemed synchronous primary endometrial and ovarian carcinomas, with few shared somatic mutations and overlapping copy number varieties. The finding of a serous component examined from the uterine endometrium samples further illustrated that the case was synchronous primary endometrial and ovarian carcinomas.

CONCLUSION

By scoring criterion, SEOCs were divided into 2 groups: synchronous primary endometrial and ovarian carcinoma group and single primary tumor with metastasis group. The analysis of clonality indicated that the case that scored 2 (S52) can be considered as synchronous primary endometrial and ovarian carcinomas. Scoring criteria of clinical pathology, along with the study of the WES, may further identify the classification of SEOCs.

SPOCK2 Affects the Biological Behavior of Endometrial Cancer Cells by Regulation of MT1-MMP and MMP2

Abnormal expression of SPARC (osteonectin), cwcv and kazal-like domains proteoglycan 2 (SPOCK2) plays a significant role in the development and progression of various human cancers, yet a relationship between SPOCK2 and endometrial cancer (EC) has not been reported. Here, we assessed the potential role and mechanism by which SPOCK2 acts in the pathogenesis and progression of EC. First, protein expression of SPOCK2 in EC tissue from patients was detected by immunohistochemistry and associated clinical data were analyzed. Then, HEC-1A and Ishikawa cells were transfected with an adenoviral vector containing an SPOCK2 recombinant fragment and the biological behavior of transfected cells was observed. Finally, the expression of membrane type 1 matrix metalloproteinase (MT1-MMP) and MMP2 in the transfected cells was detected by Western blot and zymography gel assay to analyze the effect of SPOCK2 on the regulation of the MT1-MMP/MMP2 pathway. We found that there was significantly less SPOCK2 protein expression in the EC tissue than in the normal endometrium tissue, and lack of SPOCK2 protein expression in EC tissue was associated with distant metastasis and myometrial invasion. Upregulation of SPOCK2 in HEC-1A and Ishikawa cells inhibited cell proliferation, invasion, adhesion, and apoptosis. Upregulation of SPOCK2 inhibited the expression of MT1-MMP and MMP2 and activation of MMP2 in HEC-1A and Ishikawa cells. Collectively, our data indicated that SPOCK2 contributed to the progression of EC by regulating the biological behavior of cancer cells, which is achieved partly through regulating protein expression of MT1-MMP and MMP2 and activation of MMP2.

Prognostic factors of synchronous endometrial and ovarian endometrioid carcinoma

Objective

Gynecologists occasionally encounter synchronous endometrial and ovarian endometrioid carcinoma (SEO-EC) patients who show favorable prognosis than locally advanced or metastatic disease patients. This study aimed to elucidate prognostic factors of SEO-EC and identify patients who have a sufficiently low risk of recurrence without receiving adjuvant chemotherapy.

Methods

We retrospectively reviewed 46 patients with pathologically confirmed SEO-EC who underwent surgery at the National Cancer Center Hospital between 1997 and 2016. Immunohistochemical evaluation of DNA mismatch repair (MMR) protein expression were performed for both endometrial and ovarian tumors. Patient outcomes were analyzed according to clinicopathologic factors.

Results

From the multivariate analysis, cervical stromal invasion indicated a worse prognosis for progression-free survival (hazard ratio [HR]=6.85; 95% confidence interval [CI]=1.50–31.1) and overall survival (HR=6.95; 95% CI=1.15–41.8). Lymph node metastasis and peritoneal dissemination did not significantly affect survival. MMR deficiency was observed in 13 patients (28.3%), with both endometrial and ovarian tumors showing the same MMR expression status. MMR deficiency was not significantly associated with survival. Of 23 patients with lesions confined to only the uterine body and adnexa, only 2 had recurrence in the group receiving adjuvant therapy, while none of the 10 patients who did not receive adjuvant therapy had recurrence.

Conclusion

SEO-EC patients with tumors localized to the uterine body and adnexa lesions had a low risk for recurrence and may not require adjuvant therapy. SEO-EC may have prognostic factors different from those of endometrial and ovarian cancer.

Synchronous endometrial and ovarian carcinomas: predictors of risk and associations with survival and tumor expression profiles

PURPOSE

Synchronous endometrial and ovarian tumors (SEOs) are diagnosed in 10% of ovarian cancer patients. We examined predictors of SEOs, evaluated associations of SEOs with survival and characterized ovarian tumor profiles using immunohistochemistry.

METHODS

We included patients with endometrioid (n = 180) and clear cell (n = 165) ovarian carcinoma identified from the Alberta Cancer Registry between 1979 and 2010 for whom we abstracted medical records and constructed tumor tissue microarrays (TMAs). A concurrent diagnosis of endometrial cancer was obtained from the medical chart. We used unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) and Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs. Protein expression in ovarian tumors of patients with and without SEOs was evaluated using Fisher's exact test.

RESULTS

Comparing 52 patients with SEO tumors to 293 patients with endometrioid or clear cell ovarian carcinomas, endometriosis at the ovary (OR = 0.45, 95% CI = 0.23-0.87, p = 0.02) was the strongest predictor of decreased risk in multivariable models. Premenopausal status (OR = 2.17, 95% CI = 0.92-5.13, p = 0.08) and lower pre-treatment CA125 levels (OR = 0.17, 95% CI = 0.02-1.32, p = 0.09) showed weaker associations. There were no significant differences in survival between patients with or without SEO tumors. More patients with SEO tumors compared to endometrioid ovarian carcinoma were deficient in MLH1, PMS2 and PTEN (p ≤ 0.03).

CONCLUSIONS

Endometriosis may not be the mechanism by which SEO cancers arise. Altered tumor oncoprotein expression between women with and without SEOs indicates important biological differences although this did not translate into prognostic differences.

Does synchronous endometrioid endometrial cancer have any prognostic effect on Stage I endometrioid ovarian cancer?

OBJECTIVE

To determine the effect of synchronous endometrial endometrioid cancer (SEEC) on the prognosis of patients with Stage 1 endometrioid ovarian cancer (EOC).

STUDY DESIGN

Clinicopathological data of cases with Stage 1 EOC from January 2000 to November 2013 were retrieved from the computerized database of Etlik Zubeyde Hanim Women's Health and Research Hospital. Of the 31 patients included in the study, 15 patients had primary synchronous endometrial and ovarian cancer (SEOC) (Group 1) and 16 patients had EOC alone (Group 2).

RESULTS

Ovarian cancer substage and grade were compared between the two groups, and no significant differences were found. Most of the patients with SEEC had Grade 1 tumours (n=13, 86.7%). In Group 1, nine (60.0%) patients had endometrial tumours with superficial myometrial invasion, and six (40.0%) patients had deep myometrial invasion. Median follow-up was 94 months. Ten-year disease-free survival rates were 92.9% for Group 1 and 84.6% for Group 2 (p=0.565).

CONCLUSION

Patients with Stage 1 EOC have excellent long-term survival. The presence of SEEC does not influence the prognosis of patients with Stage 1 EOC, even in the presence of deep myometrial invasion.

Massively Parallel Sequencing-Based Clonality Analysis of Synchronous Endometrioid Endometrial and Ovarian Carcinomas

Synchronous early-stage endometrioid endometrial carcinomas (EECs) and endometrioid ovarian carcinomas (EOCs) are associated with a favorable prognosis and have been suggested to represent independent primary tumors rather than metastatic disease. We subjected sporadic synchronous EECs/EOCs from five patients to whole-exome massively parallel sequencing, which revealed that the EEC and EOC of each case displayed strikingly similar repertoires of somatic mutations and gene copy number alterations. Despite the presence of mutations restricted to the EEC or EOC in each case, we observed that the mutational processes that shaped their respective genomes were consistent. High-depth targeted massively parallel sequencing of sporadic synchronous EECs/EOCs from 17 additional patients confirmed that these lesions are clonally related. In an additional Lynch Syndrome case, however, the EEC and EOC were found to constitute independent cancers lacking somatic mutations in common. Taken together, sporadic synchronous EECs/EOCs are clonally related and likely constitute dissemination from one site to the other.

Clinicopathologic analysis with immunohistochemistry for DNA mismatch repair protein expression in synchronous primary endometrial and ovarian cancers

OBJECTIVE

Synchronous primary endometrial and ovarian cancers have been an important topic in clinical medicine because it is sometimes difficult to distinguish whether there are 2 primary tumors or a single primary tumor and an associated metastasis. In addition, although these tumors are recommended for either immunohistochemistry for DNA mismatch repair (MMR) proteins or a microsatellite instability test in the Bethesda guidelines as Lynch syndrome-associated cancers, few studies have completed these analyses. In this study, we characterized the clinicopathologic features and the expression pattern of MMR proteins in synchronous primary endometrial and ovarian cancers.

METHODS

Clinicopathologic features and the expression pattern of MMR proteins (MLH1, MSH2, and MSH6) were characterized and analyzed in 32 synchronous primary endometrial and ovarian cancers.

RESULTS

Most synchronous cancers are endometrioid type (endometrioid/endometrioid) (n = 24, 75%), grade 1 (n = 19, 59.4%), and diagnosed as stage I (n = 15, 46.9%) in both endometrium and ovary. It is worth mentioning that 75% of the patients (n = 24) had endometriosis, which was more common (n = 21, 87.5%) in endometrioid/endometrioid cancers, whereas only 3 cases (37.5%) were of different histology (P = 0.018). Loss of expression of at least 1 MMR protein was observed in 17 (53.1%) of the endometrial tumors and in 10 (31.3%) of ovarian tumors. Only 4 cases (12.5%) that had specific MMR protein loss showed the same type of loss for both endometrial and ovarian tumors, in which 3 of the cases were losses in MLH1. One case showed concordant MSH6 protein loss, although the cases did not meet the Amsterdam criteria II.

CONCLUSIONS

These results suggest that most synchronous primary endometrial ovarian cancers are not hereditary cancers caused by germ line mutations but rather sporadic cancers.

Clinicopathologic and survival analyses of synchronous primary endometrial and epithelial ovarian cancers

AIM

The aim of the study was to describe clinicopathologic characteristics, survival outcomes and the factors associated with recurrence in patients diagnosed with synchronous primary endometrial and epithelial ovarian cancers.

MATERIAL AND METHODS

In this retrospective study, 50 patients who were diagnosed with synchronous primary endometrial and epithelial ovarian cancers and underwent surgery between 1998 and 2010 were reviewed.

RESULTS

In our study, the median age at the time of diagnosis was 53 years (range 28-79). The most common presenting symptom was abnormal uterine bleeding with a ratio of 36%. Fifty-four percent of the patients had endometrioid type endometrial cancer and endometrioid type ovarian cancer. All patients were surgically staged and the majority of the patients were in stage I for both endometrial cancer (58%) and ovarian cancer (60%). Nearly one-third (32%) of the patients had a recurrence during the follow-up period and by Cox regression analysis the level of cancer antigen 125 (P = 0.023) at diagnosis, serous or clear-cell histopathologic type ovarian cancer (P = 0.029) and stage of endometrial cancer above I (P = 0.048) were found to be independent risk factors associated with development of recurrence. Patients with endometrioid type endometrium histology and endometrioid type ovarian histology had favorable prognosis with 120.00 months mean disease-free survival and 92% disease-free survival rate at 36 months.

CONCLUSION

In our cohort, we found that endometrioid/endometrioid type synchronous primary endometrial and ovarian cancer had different clinical histopathologic characteristics and favorable prognosis compared to the other histologic types of these cancers. Histopathologic type of the ovarian cancer component, stage of endometrial cancer and level of cancer antigen 125 at diagnosis were observed to have a great influence on the development of recurrence and survival of synchronous primary carcinomas of the endometrium and ovary.