Significant risk of occult cancer in complex non-atypical endometrial hyperplasia

Prevalence of sonographic signs in women with uterine sarcoma: a systematic review and meta-analysis

OBJECTIVE

To assess the prevalence of sonographic signs in women with uterine sarcoma.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed. Five electronic databases were searched from inception to June 2022 for all studies allowing calculation of the prevalence of sonographic signs in women with uterine sarcoma. Pooled prevalence with 95% confidence intervals was calculated for each sonographic sign and was a priori defined as "very high" when it was ≥ 80%, "high" when it ranged from 80% to 70%, and less relevant when it was ≤ 70%.

RESULTS

6 studies with 317 sarcoma patients were included. The pooled prevalence was: · 25.0% (95%CI:15.4-37.9%) for absence of visibility of the myometrium. · 80.5% (95%CI:74.8-85.2%) for solid component. · 78.3% (95%CI:59.3-89.9%) for inhomogeneous echogenicity of solid component. · 47.9% (95%CI:41.1-54.8%) for cystic areas. · 80.7% (95%CI:68.3-89.0%) for irregular walls of cystic areas. · 72.3% (95%CI:16.7-97.2%) for anechoic cystic areas. · 54.8% (95%CI:34.0-74.1%) for absence of shadowing. · 73.5% (95%CI:43.3-90.9%) for absence of calcifications. · 48.7% (95%CI:18.6-79.8%) for color score 3 or 4. · 47.3% (95%CI:37.0-57.8%) for irregular tumor borders. · 45.4% (95%CI:27.6-64.3%) for endometrial cavity not visualizable. · 10.9% (95%CI:3.5-29.1%) for free pelvic fluid. · 6.4% (95%CI:1.1-30.2%) for ascites. · 21.2% (95%CI:2.1-76.8%) for intracavitary process. · 81.5% (95%CI:56.1-93.8%) for singular lesion..

CONCLUSION

Solid component, irregular walls of cystic areas, and singular lesions are signs with very high prevalence, while inhomogeneous echogenicity of solid component, anechoic cystic areas, and absence of calcifications are signs with high prevalence. The remaining signs were less relevant.

Integrated histological parameters define prognostically relevant groups in atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia

OBJECTIVE

To assess the risk of endometrial carcinoma following a diagnosis of atypical hyperplasia/endometrioid intraepithelial neoplasia by endometrial biopsy, stratified based on integrated histological parameters.

METHODS

All women with atypical hyperplasia/endometrioid intraepithelial neoplasia undergoing hysterectomy within 1 year of diagnosis without progestin treatment were included. Patients were subdivided into three study groups, based on two criteria: (a) grade of nuclear atypia and (b) foci (<2 mm) of confluent glands with no intervening stroma: low-grade, high-grade, and confluent glands. The rate of endometrial carcinoma on the subsequent hysterectomy was assessed in each study group, and differences between study groups were assessed using Fisher's exact test, with a significant p value <0.05. Reproducibility was assessed by using Cohen's κ.

RESULTS

Ninety-six patients were included. Overall, 36 of 96 patients (37.5%) had endometrial carcinoma on the subsequent hysterectomy. The number of endometrial carcinomas was 4 of 42 (9.5%) in the low-grade group, 14 of 28 (50.0%) in the high-grade group, and 18 of 26 (69.2%) in the confluent glands group. The rate of endometrial carcinoma was significantly higher in the high-grade group than in the low-grade group (p<0.001), whereas it did not significantly differ between the high-grade group and the confluent glands group (p=0.176). The reproducibility among pathologists was moderate for low-grade versus high-grade (κ=0.58) and substantial for confluent glands versus low-grade (κ=0.63) and high-grade (κ=0.63).

CONCLUSION

Atypical hyperplasia/endometrioid intraepithelial neoplasia can be stratified into prognostically relevant groups based on integrated histological parameters, with a possible major impact on patient management.

Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Magnetic resonance imaging (MRI) represents the second-line diagnostic method after ultrasound for the assessment of uterine masses.

OBJECTIVES

To assess the accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching five electronic databases from their inception to June 2023.

SELECTION CRITERIA

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma, which also comprehended a preoperative MRI evaluation of the uterine mass.

DATA COLLECTION AND ANALYSIS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic of MRI in differentiating uterine leiomyomas and sarcomas were calculated as individual and pooled estimates, with 95% confidence intervals (CI).

RESULTS

Eight studies with 2495 women (2253 with uterine leiomyomas and 179 with uterine sarcomas), were included. MRI showed pooled sensitivity of 0.90 (95% CI 0.84-0.94), specificity of 0.96 (95% CI 0.96-0.97), positive likelihood ratio of 13.55 (95% CI 6.20-29.61), negative likelihood ratio of 0.08 (95% CI 0.02-0.32), diagnostic odds ratio of 175.13 (95% CI 46.53-659.09), and area under the curve of 0.9759.

CONCLUSIONS

MRI has a high diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas.

Diagnostic Accuracy of Ultrasound in the Diagnosis of Uterine Leiomyomas and Sarcomas

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Ultrasound shows an uncertain role in the clinical practice given that pooled estimates about its diagnostic accuracy are lacking.

OBJECTIVES

To assess the accuracy of ultrasound in the differential diagnosis between uterine leiomyomas and sarcomas.

DATA SOURCES

A systematic review was performed searching 5 electronic databases (MEDLINE, Web of Sciences, Google Scholar, Scopus, and ClinicalTrial.gov) from their inception to June 2023.

METHODS OF STUDY SELECTION

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma that also comprised a preoperative ultrasonographic evaluation of the uterine mass.

TABULATION, INTEGRATION, AND RESULTS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic were calculated for each included study and as pooled estimate, with 95% confidence interval (CI); 972 women (694 with uterine leiomyomas and 278 with uterine sarcomas) were included. Ultrasound showed pooled sensitivity of 0.76 (95% CI, 0.70-0.81), specificity of 0.89 (95% CI, 0.87-0.92), positive and negative likelihood ratios of 6.65 (95% CI, 4.45-9.93) and 0.26 (95% CI, 0.07-1.0) respectively, diagnostic odds ratio of 23.06 (95% CI, 4.56-116.53), and area under the curve of 0.8925.

CONCLUSIONS

Ultrasound seems to have only a moderate diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas, with a lower sensitivity than specificity.

Recent advances in the management of postmenopausal women with non-atypical endometrial hyperplasia

Non-atypical endometrial hyperplasia is a benign disease without significant somatic genetic changes. Postmenopausal women with non-atypical endometrial hyperplasia have a significant risk of progression to endometrial cancer and persistent endometrial hyperplasia. Most cases of atypical endometrial hyperplasia in postmenopausal women are treated surgically, including hysterectomy. At present, the treatment of postmenopausal women with non-atypical endometrial hyperplasia is still controversial. Correct and timely diagnosis and treatment are of great significance to prevent progression of the lesion. This study mainly provides an updated synthesis of the literature that investigates the etiology, diagnosis and treatment of postmenopausal women with non-atypical endometrial hyperplasia. As of December 2022, a literature search related to postmenopausal non-atypical endometrial hyperplasia was conducted on the PubMed database. For most postmenopausal patients with non-atypical endometrial hyperplasia, regular re-examination should be performed during conservative treatment. For postmenopausal patients with endometrial cancer risk factors, persistent non-atypical endometrial hyperplasia or progesterone contraindications, hysterectomy and bilateral salpingo-oophorectomy should be the first choice.

Application of molecular classification to guiding fertility-sparing therapy for patients with endometrial cancer or endometrial intraepithelial neoplasia

BACKGROUND

The aim of this study was to evaluate whether molecular classification was associated with treatment response in women with endometrial endometrioid carcinoma (EEC) or Endometrial atypical hyperplasia/endometrial intraepithelial neoplasia (EAH/EIN) treated with progestin.

METHODS

A retrospective analysis of 59 patients with EEC or EAH/EIN who received fertility-sparing therapy between 2013 and 2021 was performed. For each patient, medical records and pathological reports were reviewed. The treatment efficacy and tumor prognosis were evaluated. Immunohistochemistry analysis for p53 and MSH2, MSH6, PSM2, MLH1 were performed. Molecular classification was analyzed using a 11-gene panel based on next generation sequencing technology.

RESULTS

23 of 39 patients with EEC received complete response (CR) after fertility-sparing treatment which was significantly lower than the EAH/EIN group (58.97 % vs 80.0 %, P < 0.05). Molecular classification via the Cancer Genome Atlas (TCGA) algorithm was successfully applied to 59 cases. The distribution of specimens into the four molecular classes was as follows: 83.05 % (49/59) CNL(copy number-low)，6.78 % (4/59) MSI-H (microsatellite instability -high), 5.08 %(3/59) POLE-mutated and 5.08 % (3/59) CNH(copy number-high). MSI and TP53 sequencing results were concordant with immunohistochemistry analyses of MMR and p53 protein. The patients with CNH and MSI-H subtypes showed worse prognosis than those with POLE-mutated and CNL subtypes.

CONCLUSIONS

Molecular classification of EAH/EIN prior to management with progestin treatment was feasible and may predict patients at risk of progression.

Diagnostic and prognostic value of Bcl-2 in uterine leiomyosarcoma

BACKGROUND

Uterine leiomyosarcoma (uLMS) may show loss of expression of B-cell lymphoma-2 (Bcl-2) protein. It has been suggested that Bcl-2 loss may both be a diagnostic marker and an unfavorable prognostic marker in uLMS.

OBJECTIVE

To define the diagnostic and prognostic value of Bcl-2 loss in uLMS through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to May 2020 for all studies assessing the diagnostic and prognostic value of Bcl-2 loss of immunohistochemical expression in uLMS. Data were extracted to calculate odds ratio (OR) for the association of Bcl-2 with uLMS vs leiomyoma variants and smooth-muscle tumors of uncertain malignant potential (STUMP), and hazard ratio (HR) for overall survival; a p value < 0.05 was considered significant.

RESULTS

Eight studies with 388 patients were included. Loss of Bcl-2 expression in uLMS was not significantly associated with a diagnosis of uLMS vs leiomyoma variants and STUMP (OR = 2.981; p = 0.48). Bcl-2 loss was significantly associated with shorter overall survival in uLMS (HR = 3.722; p = 0.006). High statistical heterogeneity was observed in both analyses.

CONCLUSION

Loss of Bcl-2 expression appears as a significant prognostic but not diagnostic marker in uLMS. The high heterogeneity observed highlights the need for further research and larger studies.

Diagnostic accuracy of HIK1083 and MUC6 as immunohistochemical markers of endocervical gastric-type adenocarcinoma: A systematic review and meta-analysis

INTRODUCTION

HIK1083 and MUC6 have been used as immunohistochemical markers to differentiate gastric-type adenocarcinoma (GTAC) from other endocervical adenocarcinomas. We aimed to assess their diagnostic accuracy through a systematic review and meta-analysis.

METHODS

Three electronic databases were searched from their inception to July 2022 for all studies assessing the expression in endocervical GTAC vs other endocervical adenocarcinomas. Diagnostic accuracy was assessed as sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), diagnostic odds ratio (DOR), and area under the curve (AUC) on SROC curves.

RESULTS

Four studies with 343 patients were included. HIK1083 showed sensitivity= 0.64, specificity= 0.94, LR+ =8.30, LR-= 0.38, DOR= 33.36, AUC= 89.9%. MUC6 showed sensitivity= 0.51, specificity= 0.74, LR+ =1.96, LR-= 0.71, DOR= 3.48, AUC= 72.8%.

CONCLUSION

HIK1083 showed high specificity and low sensitivity as a marker of GTAC, with moderate overall accuracy; MUC6 showed moderate specificity and low sensitivity, with low overall accuracy.

Comparison between Laparoscopic and Robotic Approach for Sentinel Lymph Node Biopsy in Endometrial Carcinoma Women

Robotic surgery has been approved as an alternative to laparoscopy to improve surgical outcomes. There is neither a consensus nor a systematic assessment of the literature about the superiority of the robotic approach over the laparoscopic one for sentinel lymph node (SLN) biopsy in endometrial carcinoma (EC) women. Therefore, a systematic review and meta-analysis was performed to compare the laparoscopic and robotic approaches for SLN biopsy in EC patients. Five electronic databases were queried from their inception to May 2022 for peer-reviewed studies, comparing such approaches in SLN biopsy in EC patients. The rate of detected SLN, dissected SLN, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time were compared between the laparoscopic and robotic approaches for SLN biopsy in EC patients. Odds ratios with 95% confidence intervals were calculated when possible. Two studies with 660 EC women (364 who had undergone laparoscopy, and 296 who had robotic surgery) were included. No assessed outcome showed significant differences between the two approaches. In conclusion, the laparoscopic and robotic approaches for SLN biopsy in EC patients appeared to not differ, in terms of SLN detection, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time.

Vaginal micronized progesterone versus the levonorgestrel-releasing intrauterine system for treatment of non-atypical endometrial hyperplasia: A randomized controlled trial

OBJECTIVE

To compare the efficiency of vaginal micronized progesterone (VMP) with the levonorgestrel-releasing intrauterine system (LNG-IUS) in patients with non-atypical endometrial hyperplasia. A validated Menorrhagia Impact Questionnaire (MIQ) was used to assess the quality of life before and after the procedure.

METHODS

In this prospective trial, 144 women were randomly assigned to the VMP or LNG-IUS group. The primary endpoint was the regression rate of endometrial hyperplasia after 3 months of treatment. The protocol was approved by the institutional ethics committee and registered at ClinicalTrials.gov (NCT03992937).

RESULTS

In all, 138 patients were analyzed. The regression rate was not significantly different between the groups (95.8% with LNG-IUS vs. 90.8% with VMP; P = 0.194). Differences between pre- and post-treatment MIQ scores were similar, except that better scores were obtained in the VMP group for the perception of the amount of blood loss (P = 0.035).

CONCLUSION

VMP is as effective as the LNG-IUS as a local treatment of endometrial hyperplasia without atypia.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT03992937.

Comparison of the effectiveness of the levonorgestrel-intrauterine device and oral progestogens on regression of endometrial hyperplasia without atypia

Endometrial hyperplasia is caused by an excess of estrogen unopposed by progesterone. Oral progestogens are traditionally used for endometrial hyperplasia without atypia. However oral progestogen is not always successful at causing regression of endometrial hyperplasia. In addition, cyclic progestogens are less effective in delivering progestogen to the endometrium. Therefore, the levonorgestrel-intrauterine device (LNG-IUD), as an alternative option of delivery progestogen has been introduced in clinical practice. The effectiveness of LNG-IUD in causing regression of endometrial hyperplasia in the short-term had moderate-quality evidence, but the long-term (13 months to two years) effectiveness had low-quality evidence. In this study with relatively large sample size, we compared the effectiveness in the regression of endometrial hyperplasia without atypia for short-term and long-term between the treatment with LNG-IUD and oral progestogens or no treatment. Data on histology or ultrasound from 466 cases who received either LNG-IUD or oral progestogens or were untreated were collected. The primary treatment with LNG-IUD showed a 93% regression rate of endometrial hyperplasia, which was significantly higher than oral progestogens showing a 66% regression rate. The odds ratio of regression of endometrial hyperplasia in cases with LNG-IUD treatment was 7.128 (95%CI: 2.94, 16.76, p < 0.0001), compared to the cases with oral progestogen treatment. The regression rate in untreated cases was 16%. In addition, cases without regression by oral progestogens who then received the alternative treatment option by LNG-IUD also showed a 93% regression rate. While continuously receiving oral progestogens showed a 55% regression rate of endometrial hyperplasia, which was significantly lower than LNG-IUD treatment as an alternative option. Our data reports a significant response on regression of endometrial hyperplasia after LNG-IUD treatment in comparison with oral progestogen treatment.

Metabolomic analysis of endometrial cancer by high-resolution magic angle spinning NMR spectroscopy

PURPOSE

To analyze endometrial metabolite profiles between patients with endometrial cancer and controls.

METHODS

Seventeen (17) women with endometrium cancer and 18 controls were enrolled in this study. ¹H HR-MAS (High Resolution-Magic Angle Spinning) NMR (Nuclear Magnetic Resonance) spectroscopy data obtained from endometrial tissue samples of patients with endometrial cancer and control group were analyzed with bioinformatics methods.

RESULTS

Principal component analysis (PCA) and the partial least squares discriminant analysis (PLS-DA) score plots obtained with the multivariate statistical analysis of pre-processed spectral data shows a separation between the samples from patients with endometrial cancer and controls. Analysis results suggest that the levels of lactate, glucose, o-phosphoethanolamine, choline, glycerophosphocholine, phosphocholine, leucine, isoleucine, valine, glutamate, glutamine, n-acetyltyrosine, methionine, taurine, alanine, aspartate and phenylalanine are increased in patients with endometrial cancer compared to the controls.

CONCLUSION

The metabolomics signature of patients with endometrial cancer is different from that of benign endometrial tissue.

Risk of atypical hyperplasia and endometrial carcinoma after initial diagnosis of non-atypical endometrial hyperplasia: A long-term follow-up study

OBJECTIVES

The strong association between atypical endometrial hyperplasia and endometrial carcinoma is well established, but data on the risk of atypical hyperplasia and carcinoma in Danish women with non-atypical endometrial hyperplasia are almost non-existent. This study aimed to investigate the prevalence of atypical hyperplasia and endometrial carcinoma diagnosed within 3 months of initial diagnosis (defined as concurrent disease) and the risk of atypical hyperplasia and carcinoma more than 3 months after initial diagnosis (classified as progressive disease) in Danish women initially diagnosed with non-atypical endometrial hyperplasia.

DESIGN

This cohort study recruited 102 women diagnosed with non-atypical endometrial hyperplasia at Randers Regional Hospital in Randers, Denmark, between 2000 and 2015.

METHODS

The endometrium was evaluated by transvaginal ultrasound examination and office mini-hysteroscopy with biopsies in all non-hysterectomized women. Data regarding subsequent hysterectomy or endometrial sampling were obtained from medical records and the Danish Pathology Registry (Patobank).

RESULTS

A total of 15 women were diagnosed with atypical hyperplasia or carcinoma during follow-up. Concurrent atypical hyperplasia or carcinoma was seen in 2.9% (3/102), and among women who remained at risk for more than 3 months after initial diagnosis of non-atypical endometrial hyperplasia (n = 94), progression to atypical hyperplasia or carcinoma was seen in 13% (median follow-up 5.2 years, range 3.6 months to 15.1 years). Sixty-six percent of the women with progressive disease were diagnosed with atypical hyperplasia or carcinoma more than 1 year after initial diagnosis, but only two were diagnosed later than 5 years (5.2 and 9 years).

CONCLUSIONS

The risk of being diagnosed with atypical endometrial hyperplasia or endometrial carcinoma more than 5 years after an initial diagnosis of non-atypical endometrial hyperplasia seems to be low in Danish women. Specialized follow-up more than 5 years after diagnosis of non-atypical endometrial hyperplasia may not be warranted.

Comparative aspects of treatment of endometrial hyperplasia in women of reproductive age with overweight

The aim. Minimization of the frequency of recurrence of endometrial hyperplasia (EH) in women of reproductive age with overweight (OW) depending on the tactics of treatment. Materials and methods. 90 women of reproductive age with endometrial hyperplasia and OW were selected. They, in turn, were divided into three groups: group 1 – 30 women who took a gonadotropin-releasing hormone agonist (GnRH agonist), namely at a dose of 3.75 mg intramuscularly once every 28 days; group 2 – 30 women who used progestin (norethisterone) at a dose of 10 mg per day from day 16 to 25 of the cycle, group 3 – 30 women who took combined oral contraception (COC) (30 mcg ethinyl estradiol and 150 mcg desogestrel) in a cyclic mode 21/7. Evaluation of the effectiveness of therapy included a clinical picture of the disease 6 months after the start of treatment, assessment of the variability of the average values of endometrial thickness and uterine size on ultrasound (US) of the pelvis 6 months after treatment. Also analyzed the effectiveness of therapy based on the results of morphological examination of the endometrium in a biopsy of the uterine mucosa, performed 6 months after the start of treatment. In addition, a general analysis of the frequency of EH recurrence was performed 6–24 months after treatment. Results. The results showed that in the group in which women were prescribed GnRH agonist, there was a significantly higher effectiveness of treatment, in particular the absence of uterine bleeding and menstrual disorders (MD). At the same time, in the other norethisterone group, 53.3 % (16) of women had intermenstrual uterine bleeding. In patients in the group in which women received COC, uterine bleeding was observed in 30.0 % (i.e. 9) of patients (p <0.05). Immediately after treatment, the average values of endometrial thickness in patients of group 1, according to ultrasound, was 3.59±0.47 mm, which was significantly less than in women of groups 2 and 3 – 6.81±0.59 mm (p<0.001) and 7.58±0.69 mm (p<0.001). In addition, patients in group 1 at 3, 6, 12, 24 months after the end of hormone therapy were registered significantly lower average values of endometrial thickness, compared with patients receiving norethisterone and estrogen-progestogen drugs. Conclusions. In a comparative evaluation of the effectiveness of treatment of endometrial hyperplastic processes in overweight women, it was found that the recurrence rate after 6–24 months occurs in 6.7 % (i.e. 2) of patients after GnRH agonist therapy, in 33.3 % (i.e. in 10) patients receiving norethisterone (p<0.001), and in 50 % (i.e. 15) of women treated with COC (p<0.001).

Clinical Characteristics of Patients with Endometrial Cancer and Adenomyosis

Simple Summary

Endometrial cancer (EC) reportedly have a better prognosis in patients with coexistent adenomyosis. It is possible to hypothesize that this difference may be attributable to different clinical profiles. On this account, we aimed to define the clinical profile of endometrial cancer (EC) patients with and without adenomyosis through a systematic review and meta-analysis. We included 8 studies with 5681 patients and found that EC women with adenomyosis were less likely to be nulliparous than EC women without adenomyosis, while no significant differences were found with regard to age, BMI, and premenopausal status.

Abstract

A better endometrial cancer (EC) prognosis in patients with coexistent adenomyosis has been reported. Unfortunately, it is still unclear if this better prognosis is related to a more favorable clinical profile of adenomyosis patients. We aimed to evaluate differences in the clinical profiles of EC patients with and without adenomyosis. A systematic review and meta-analysis was performed by searching seven electronics databases for all studies that allowed extraction of data about clinical characteristics in EC patients with and without adenomyosis. Clinical characteristics assessed were: age, Body Mass Index (BMI), premenopausal status, and nulliparity. Mean difference in mean ± standard deviation (SD) or odds ratio (OR) for clinical characteristics between EC patients with and without adenomyosis were calculated for each included study and as a pooled estimate, and graphically reported on forest plots with a 95% confidence interval (CI). The Z test was used for assessing the overall effect by considering a p value < 0.05 as significant. Overall, eight studies with 5681 patients were included in the qualitative analysis, and seven studies with 4366 patients in the quantitative analysis. Pooled mean difference in mean ± SD between EC women with and without adenomyosis was −1.19 (95% CI: −3.18 to 0.80; p = 0.24) for age, and 0.23 (95% CI: −0.62 to 1.07; p = 0.60) for BMI. When compared to EC women without adenomyosis, EC women with adenomyosis showed a pooled OR of 1.53 (95% CI: 0.92 to 2.54; p = 0.10) for premenopausal status, and of 0.60 (95% CI: 0.41 to 0.87; p = 0.007) for nulliparity. In conclusion, there are not significant differences in clinical characteristics between EC patients with and without adenomyosis, with the exception for nulliparity. Clinical features seem to not underlie the better EC prognosis of patients with adenomyosis compared to patients without adenomyosis.

Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment

Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79–14.06) than the others of being identified postoperatively with more advanced lesions.

Risk factors of endometrial cancer in patients with endometrial hyperplasia: implication for clinical treatments

Background

Endometrial hyperplasia (EH) is commonly-seen in the patients with endometrial cancer (EC), we aimed to evaluated the risk factors of EC in patients with EH, to provide evidence to the clinical prevention and treatment of EC.

Methods

This study was a retrospective study design. EH patients confirmed by pathological examinations and treated with hysterectomy in our hospital from June 1, 2018 to February 28, 2021 were included. The clinical characteristics of EC and no-EC patients were compared and analyzed. Logistics regression analyses were conducted to evaluate the risk factors of EC in patients with EH.

Results

A total of 228 EH patients were included, the incidence of EC in the EH patients was 31.58%. There were significant differences in the age, BMI, diabetes, hypertension and pathology of EH between EC and no EC groups (all P < 0.05), no significant differences in the hyperlipidemia, preoperative CA₁₂₅, number of deliveries, menopause and endometrial thickness between EC and no EC groups were found (all P > 0.05). Logistic regression analyses indicated that age > 50 y (OR 3.064, 95% CI 1.945–5.931), BMI ≥ 25 kg/m² (OR 2.705, 95% CI 1.121–3.889), diabetes (OR 3.049, 95% CI 1.781–5.114), hypertension (OR 2.725, 95% CI 1.108–3.431) and severe hyperplasia (OR 3.181, 95% CI 1.496–4.228) were the risk factors of EC in patients with EH (all P < 0.05).

Conclusions

The risk of EC in EH patients is high, especially for those patients with age > 50 y, BMI ≥ 25 kg/m², diabetes, hypertension and severe hyperplasia, special attentions should be paid for occurrence of EC and early diagnosis and early treatment are needed for those patients.

Laparotomic versus robotic surgery in elderly patients with endometrial cancer: A systematic review and meta-analysis

Background

Although robotics has been shown to improve outcomes in some high‐difficulty surgical category patients, it is unclear if such an approach may improve outcomes in elderly patients with endometrial carcinoma (EC).

Objective

To compare robotic and laparotomic surgery in the treatment and staging of elderly EC patients.

Materials and methods

A systematic review and meta‐analysis was performed assessing the risk of overall, intra‐operative, and peri‐operative complications associated with the surgical approach (laparotomic vs robotic) for elderly patients with EC by relative risk (RR). Pooled means ± standard deviation of length of stay were compared with the unpaired t test. Subgroup analyses for overall complications were performed based on different age cut‐offs (>70, >65, and >75 years) and severity of complications (minor and major). A value of P less than 0.05 was considered significant.

Results

Five studies with 7629 EC patients were included. Pooled RR for robotic compared with laparotomic surgery was 0.40 (P < 0.001) for overall, 0.46 (P = 0.18) for intra‐operative, and 0.43 (P < 0.001) for peri‐operative complications. Pooled difference between means ± standard deviation of length of stay for robotic versus laparotomic surgery was −3.34 (P < 0.001). At subgroup analyses, pooled RR of overall complications for robotic surgery versus laparotomic surgery was 0.34 (P < 0.001) in the >70 years, 0.51 (P < 0.01) in the >65 years, 0.20 (P = 0.12) in the >75 years groups. Pooled RR was 0.50 (P = 0.1) in the minor complications subgroup, and 0.42 (P = 0.002) in the major complications subgroup.

Conclusion

Robotics might be a viable alternative to the laparotomic approach for EC in elderly patients because it significantly decreases the risk of overall and peri‐operative complications (mainly major complications), and the length of stay when compared with laparotomy. The decrease in risk of overall complications is greater with increasing patient age.

Stanford parameters stratify the risk of recurrence in gynecologic smooth muscle tumors of uncertain malignant potential

Smooth muscle tumor of uncertain malignant potential (STUMP) is an ill-defined category of neoplasms, which represent a diagnostic challenge. We aimed to assess whether the Stanford parameters, that is, high mitotic index (≥10/10HPF), significant atypia (moderate-to-severe), and coagulative tumor cell necrosis (CTCN), even when focal or ambiguous, may be used to stratify the risk of recurrence in gynecological smooth muscle tumor of uncertain malignant potential (STUMP). Electronic databases were searched from their inception to October 2019. All studies assessing the Stanford parameters in gynecological STUMP series were included. STUMPs were subdivided according to the presence of the three Stanford parameters: high mitotic index, significant atypia, and CTCN. A Kaplan-Meier survival analysis was performed for recurrence-free survival; hazard ratio (HR) was calculated in each category. Fourteen studies with 219 STUMPs were included. In 15.5% of cases, none of the three Stanford parameters were present, with a recurrence risk of 5.9%; 2.7% of cases showed high mitotic index alone, with a recurrence risk of 0% (HR = not calculable); 43.8% of cases showed significant atypia alone, with a recurrence risk of 18.7% (HR = 3.3; p = 0.012); 26.5% of cases showed CTCN alone, with a recurrence risk of 17.2% (HR = 3.1; p = 0.029); and 11.4% of cases showed at least two Stanford parameters, with a recurrence risk of 32% (HR = 7.5; p = 0.003). Stanford parameters may stratify the risk of recurrence of STUMP. Significant atypia and CTCN, but not high mitotic index, may be stand-alone risk factors for recurrence in STUMP. The presence of at least two Stanford parameters, even if equivocal (e.g., uncertain or focal CTCN, focal significant atypia, mitotic index around 10/10HPF), might still be enough to support a diagnosis of leiomyosarcoma. Further studies are necessary in this field.

Non-atypical endometrial hyperplasia: risk factors for occult endometrial atypia and malignancy in patients managed with hysterectomy

Objective

To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy.

Methods

All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis.

Results

In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m². Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m², P=0.033), and BMI ≥30 kg/m² (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia.

Conclusion

Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.

Prognostic significance of atypical mitotic figures in smooth muscle tumors of uncertain malignant potential (STUMP) of the uterus and uterine adnexa

We aimed to assess whether the presence of atypical mitotic figures (AMF) in smooth muscle tumors of uncertain malignant potential (STUMP) of the uterus and uterine adnexa is associated with increased risk of recurrence, and the association of AMF with the Stanford criteria, that is, significant cytologic atypia, mitotic index ≥ 10/10HPF, and coagulative tumor cell necrosis (CTCN). A systematic review was performed to identify all studies reporting the presence of AMF and oncologic outcomes in STUMP series. Fisher's exact test was used to assess the association of AMF with the three Stanford parameters. Kaplan-Meier and Cox regression survival analyses with hazard ratio (HR) calculation were performed to assess the association between AMF and STUMP recurrence. A p-value < 0.05 was considered significant. Five studies with 80 STUMPs were included, out of which 23.8% had AMF. AMF were significantly associated with the presence of significant atypia (p = 0.023), but not with the presence of a mitotic index ≥ 10/10HPF (p = 0.769), CTCN (p = 1), or more than one Stanford parameter (p = 0.171). AMF was not significantly associated with the risk of STUMP recurrence at both univariate (HR = 0.366; p = 0.188) and multivariate analyses (HR = 0.528; p = 0.463). In STUMP of the uterus and uterine adnexa, AMF are more common in the case of significant cytologic atypia, but do not seem to increase the risk of recurrence. Further studies are necessary in this regard.

Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis

INTRODUCTION

Several studies have assessed the histological co-existence of endometrial carcinoma (EC) and adenomyosis. However, the significance of this association is still unclear.

OBJECTIVE

To assess the prevalence of adenomyosis in women with EC for a better understanding of the association between the two diseases.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed by searching electronics databases from their inception to March 2020, for all studies that allowed extraction of data about prevalence of adenomyosis in EC patients. Adenomyosis prevalence was calculated for each included study and as pooled estimate, with 95% confidence interval (CI).

RESULTS

Eight retrospective cohort studies assessing 5573 EC patients were included in our analysis. Of total, 1322 were patients with adenomyosis, and 4251 were patients without adenomyosis. Pooled prevalence of adenomyosis in EC patients was 22.6% (95% CI 12.7-37.1%).

CONCLUSION

Adenomyosis prevalence in EC patients was not different from that reported for other gynecological conditions. The supposed association between the two diseases appears unsupported.

Risk of occult atypical hyperplasia or cancer in women with nonatypical endometrial hyperplasia

AIM

The aim of this study was to identify subsets of patients diagnosed with nonatypical endometrial hyperplasia (NAEH) by endometrial biopsy who had high risk for occult atypical endometrial hyperplasia (AEH) or endometrial cancer (EC).

METHODS

We retrospectively reviewed the medical records of 281 patients who underwent hysterectomy within 6 months after a diagnosis of NAEH. We collected data on age, body mass index, menopausal status, tamoxifen use, previous history of NAEH, details of endometrial biopsy (location, curettage vs. pipelle sampling), NAEH subtype (simple vs. complex), interval between endometrial biopsy and hysterectomy, indication of hysterectomy and the presence of occult AEH or EC in hysterectomy specimen. Associations between variables and occult AEH or EC were analyzed. Risk of occult AEH or EC in subsets were calculated and visualized using a heatmap.

RESULTS

Among 281 patients, 34 (12.1%) and 9 (3.2%) had occult AEH and EC in hysterectomy specimens, respectively. Using univariate analysis, we found age, menopausal status and subtype were associated with occult AEH or EC. Using multivariate analysis, older age (odds ratio = 1.09, P < 0.01) and complex subtype (odds ratio = 3.34, P < 0.01) were independent risk factors. Patients at an age ≥ 51 years with complex NAEH had about 50% risk of occult AEH or EC.

CONCLUSION

Women at an age ≥ 51 years with complex NAEH had high risk for occult AEH or EC and surgical treatment can be considered for these patients.

TCGA Classification of Endometrial Cancer: the Place of Carcinosarcoma

In 2013, The Cancer Genome Atlas (TCGA) Research Network found four novel prognostic subgroups of endometrial carcinoma: POLE/ultramutated (POLE), microsatellite-instable/hypermutated (MSI), copy-number-low/TP53-wild-type (CNL), and copy-number-highTP53-mutant (CNH). However, poor is known regarding uncommon histotypes of endometrial cancer. We aimed to assess the genetic profile of uterine carcinosarcoma (UCS) on the light of these findings. A systematic review and meta-analysis was performed through electronic databases searching (up to July 2019). All studies assessing UCS series for the TCGA classification were included. For each TCGA subgroup, pooled prevalence on the total UCS number was calculated. Four studies with 231 patients were included. Pooled prevalence of the TCGA subgroups were: 5.3% for the POLE subgroup, 7.3% for the MSI subgroup, 73.9% for the CNH subgroup, 13.5% for the CNL subgroup. The CNH subgroup predominates in UCS, while subgroups with high mutational load (POLE and MSI) are less common. UCS appears as a preferential evolution of CNH carcinomas.

Diagnostic accuracy of p53 immunohistochemistry as surrogate of TP53 sequencing in endometrial cancer

Aberrant p53 immunohistochemical expression is used to identify the copy-number-high/TP53-mutant subgroup of endometrial cancer (EC). We aimed to determine the diagnostic accuracy of p53 immunohistochemistry as surrogate for TP53 sequencing through a systematic review and meta-analysis. Electronic databases were searched from their inception to June 2019. All studies assessing p53 expression and TP53 mutations in EC were included. Diagnostic accuracy was assessed based on area under the curve (AUC). Immunohistochemical criteria used to define aberrant p53 expression were "overexpression" and "overexpression or complete absence". Subgroup analysis was based on the sequencing technique adopted (Polymerase Chain Reaction + sequencing, or next generation sequencing, NGS). Thirteen observational studies with 727 endometrial cancers were included. Both "overexpression" and "overexpression or complete absence" showed high diagnostic accuracy (AUC = 0.9088 and 0.9030, respectively). The subgroup with "overexpression" and NGS showed the best results, with very high diagnostic accuracy (AUC = 0.9927). In conclusion, immunohistochemistry for p53 is a highly accurate surrogate of TP53 sequencing. Overexpression of p53 in ≥70-80% showed the best accuracy in predicting TP53 mutations. Further studies in this field should adopt optimized immunohistochemical procedures and take into account less common p53 patterns (e.g. cytoplasmic expression).

Sjögren Syndrome in Primary Salivary Gland Lymphoma

OBJECTIVES

Sjögren syndrome (SS) is considered as a major etiologic factor for primary salivary gland lymphoma (SGL). However, the percentage of SGL that is caused by SS (and thus the real impact of SS on SGL epidemiology) is unclear. We aimed to assess the prevalence of SS in patients with SGL through a systematic review and meta-analysis.

METHODS

Electronic databases were searched for studies assessing the presence of SS in patients with SGL. Pooled prevalence of SS in SGL was calculated, with a subgroup analysis based on histotype (mucosa-associated lymphoid tissue [MALT] vs non-MALT).

RESULTS

Sixteen studies with 665 SGLs were included. Pooled prevalence of SS in SGL was 18.2%, with high heterogeneity among studies. In MALT SGL, the prevalence of SS was 29.5%, with moderate heterogeneity. In non-MALT SGL, the prevalence of SS was 0%, with null heterogeneity.

CONCLUSIONS

SS seems to be responsible for a significant but minor portion of SGLs. SS appears involved in MALT-type SGL but not in other histotypes.

Concurrent and future risk of endometrial cancer in women with endometrial hyperplasia: A systematic review and meta-analysis

BACKGROUND

To inform treatment decisions in women diagnosed with endometrial hyperplasia, quantification of the potential for concurrent endometrial cancer and the future risk of progression to cancer is required.

METHODS

We identified studies up to September 2018 that reported on the prevalence of concurrent cancer (within three months of endometrial hyperplasia diagnosis), or the incidence of cancer, identified at least three months after hyperplasia diagnosis. Random-effects meta-analyses produced pooled estimates and 95% confidence intervals (CIs).

RESULTS

A total of 36 articles were identified; 15 investigating concurrent and 21 progression to cancer. In pooled analysis of 11 studies of atypical hyperplasia, the pooled prevalence of concurrent endometrial cancer was 32.6% (95% CI: 24.1%, 42.4%) while no studies evaluated concurrent cancer in non-atypical hyperplasia. The risk of progression to cancer was high in atypical hyperplasia (n = 5 studies, annual incidence rate = 8.2%, 95% CI 3.9%, 17.3%) and only one study reported on non-atypical hyperplasia (annual incidence rate = 2.6%, 95% CI: 0.6%, 10.6%).

CONCLUSIONS

Overall, a third of women with atypical hyperplasia had concurrent endometrial cancer, although the number of studies, especially population-based, is small. Progression to cancer in atypical hyperplasia was high, but few studies were identified. Population-based estimates are required, in both atypical and non-atypical hyperplasia patients to better inform treatment strategies.

Impact of endometrial carcinoma histotype on the prognostic value of the TCGA molecular subgroups

BACKGROUND

The Cancer Genome Atlas (TCGA) identified four prognostic subgroups of endometrial carcinoma: copy-number-low/p53-wild-type (p53wt), POLE-mutated/ultramutated (POLEmt), microsatellite-instability/hypermutated (MSI), and copy-number-high/p53-mutated (p53mt). However, it is still unclear if they may be integrated with the current histopathological prognostic factors, such as histotype.

OBJECTIVE

To assess the impact of histotype on the prognostic value of the TCGA molecular subgroups of endometrial carcinoma.

METHODS

A systematic review and meta-analysis was performed by searching 7 electronic databases from their inception to April 2019 for studies assessing prognosis in all TCGA subgroups of endometrial carcinoma. Pooled hazard ratio (HR) for overall survival (OS) was calculated in two different groups ("all-histotypes" and "endometrioid"), using p53wt subgroup as reference standard; HR for non-endometrioid histotypes was calculated indirectly. Disease-specific survival and progression-free survival were assessed as additional analyses.

RESULTS

Six studies with 2818 patients were included. In the p53mt subgroup, pooled HRs for OS were 4.322 (all-histotypes), 2.505 (endometrioid), and 4.937 (non-endometrioid). In the MSI subgroup, pooled HRs were 1.965 (all-histotypes), 1.287 (endometrioid), and 6.361 (non-endometrioid). In the POLEmt subgroup, pooled HRs were 0.763 (all-histotypes), 0.481 (endometrioid), and 2.634 (non-endometrioid). Results of additional analyses were consistent for all subgroups except for non-endometrioid POLEmt carcinomas.

CONCLUSION

Histotype of endometrial carcinoma shows a crucial prognostic value independently of the TCGA molecular subgroup, with non-endometrioid carcinomas having a worse prognosis in each TCGA subgroup. Histotype should be integrated with molecular characterization for the risk stratification of patients in the future.

Metabolomics in endometrial cancer diagnosis: A systematic review

INTRODUCTION

Endometrial cancer (EC) is the most common gynecological malignancy in the developed world. The prognosis of EC strongly depends on tumor stage, hence the importance of improving diagnosis. Metabolomics has recently appeared as a promising test for a non-invasive diagnosis of several diseases. Nevertheless, no metabolic marker has been approved for use in the routine practice. We aimed to provide an overview of metabolomics findings in the diagnosis of EC.

MATERIAL AND METHODS

A systematic review was performed by searching eight electronic databases from their inception to October 2019 for studies assessing metabolomics in EC diagnosis. Extracted data included characteristics of patients and EC, serum concentration of metabolites in women with and without EC and its association with EC diagnosis, tumor behavior and pathological characteristics.

RESULTS

Six studies with 732 women (356 cases and 376 controls) were included. Several metabolites were found able to predict the presence of EC, tumor behavior (progression and recurrence) and pathological characteristics (histotype, myometrial invasion and lymph vascular space invasion).

CONCLUSIONS

Metabolomics might be suitable for a non-invasive diagnosis and screening of EC, offering the possibility to predict tumor behavior and pathological characteristics. Further studies are necessary to validate these results.

TCGA molecular subgroups and FIGO grade in endometrial endometrioid carcinoma

BACKGROUND

International Federation of Gynecology and Obstetrics (FIGO) grade is a crucial factor in the current system for the risk stratification of endometrial endometrioid carcinoma (EC). The Cancer Genome Atlas (TCGA) demonstrated four molecular prognostic subgroups for EC: POLE (good prognosis), microsatellite-instable (MSI, intermediate prognosis), copy-number-high (CNH, poor prognosis), and copy-number-low (CNL, variable prognosis).

OBJECTIVE

To assess how the prevalence of the TCGA molecular subgroups changes from low-grade (G1-2) to high-grade (G3) EC, to understand how it may affect the current risk-assessment system.

METHODS

A systematic review and meta-analysis was carried out by searching seven electronic databases from January 2013 to September 2019 for studies assessing the TCGA classification G1-2 and G3 EC. Pooled prevalence of the TCGA subgroups was calculated in EC. The association of each subgroup with grade was assessed using odds ratio (OR), with a significant p value < 0.05.

RESULTS

Nine studies with 3185 patients were included. G3 EC showed significantly higher prevalence of the POLE subgroup (12.1% vs 6.2%; OR = 2.13; p = 0.0001), of the MSI subgroup (39.7% vs 24.7%; OR = 2.15; p = 0.0003) and of the CNH subgroup (21.3% vs 4.7%; OR = 5.25; p < 0.00001), and significantly lower prevalence of the CNL subgroup (28% vs 63.5%; OR = 0.2; p < 0.00001) than G1-2 EC.

CONCLUSION

The prevalence of the TCGA subgroups is not in accordance with the prognostic value of FIGO grade, indicating that the current risk stratification of EC will be heavily affected by molecular signature.

TCGA Molecular Subgroups in Endometrial Undifferentiated/Dedifferentiated Carcinoma

We aimed to classify undifferentiated/dedifferentiated carcinoma (UDC/DDC) according to the four TCGA molecular subgroups of endometrial cancer: microsatellite-instable/hypermutated (MSI), POLE-mutant/ultramutated (POLE), copy-number-low/p53-wild-type (p53wt), and copy-number-high/p53-abnormal (p53abn), through a systematic review and meta-analysis. Electronic databases were searched from January 2013 to July 2019 for studies assessing the TCGA classification in endometrial UDC/DDC series. Pooled prevalence of each TCGA subgroup on the total UDC/DDCs was calculated. Three studies with 73 patients were included. Pooled prevalence of the TCGA subgroups were: 12.4% for the POLE subgroup, 44% for the MSI subgroup, 18.6% for the p53abn subgroup, 25% for the p53wt group. All TCGA groups are represented in UDC/DDC, with a predominance of the MSI group, indicating a biological heterogeneity. Hypermutated/ultramutated cancers constitute the majority of UDC/DDC, suggesting a crucial difference with other high-risk histologies of endometrial carcinoma.