Pulmonary metastases of endometrial carcinoma

Incidence, risk factors, and a prognostic nomogram for distant metastasis in endometrial cancer: A SEER-based study

OBJECTIVE

To evaluate the metastatic pattern, identify the risk factors, and establish a nomogram for predicting prognosis of endometrial cancer (EC) with distant metastasis.

METHODS

A retrospective cohort study of women diagnosed with EC was conducted according to the Surveillance, Epidemiology, and End Results (SEER) database during 2010-2017. Multivariate logistic analysis and Cox analysis were performed to identify the risk factors in promoting distant metastasis and predictors associated with overall survival (OS) in this particular subpopulation. A nomogram was then constructed and validated by the concordance index (C-index), the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis.

RESULTS

A total of 2799 cases of distant metastasis in EC patients were identified, with an overall incidence rate of 3.74% from 2010 to 2017. Black race, unmarried status, non-endometrioid histologic types, and grade IV were significant risk factors for distant metastasis in EC patients. Meanwhile, race, histology, grade, metastasis status, surgery, lymphadenectomy, and chemotherapy were identified as independent prognostic factors for OS. A nomogram to predict 1-, 3-, and 5-year OS was established, and presented favorable accuracy and clinical applicability. Patients were further divided into high- and low-risk groups according to the model.

CONCLUSION

The nomogram was developed as a highly accurate, individualized tool to better predict the prognosis of EC patients with distant metastasis, which would help clinicians to identify high-risk patients, and adjust and tailor their treatment strategies.

Endometrial adenocarcinoma recurring in the lung: impact of molecular profile and role of local therapies on prognosis

OBJECTIVES

The objective of our study was to describe the characteristics of patients with endometrial cancer diagnosed with a first recurrence involving the lung, and to describe the prognostic role of the molecular profile. We also aimed to describe the prognostic outcomes after local treatment of recurrence (resection of lung metastases or stereotactic body radiation therapy) in a group of patients with isolated lung recurrence.

METHODS

This was a retrospective, single-center study between June 1995 and July 2021. The study included patients diagnosed with a first recurrence of endometrial cancer involving the lung. We defined two groups of patients: patients with isolated lung recurrence (confined to the lung) and patients with multisystemic recurrence (in the lung and other locations).

RESULTS

Among 1413 patients diagnosed with endometrial cancer in stage IA to IVA of the International Federation of Gynecology and Obstetrics (FIGO) 2009, 64 (4.5%) patients had a first recurrence involving the lung. Of these, 15 (39.1%) were of a non-specific molecular profile, 16 (25%) were p53-abnormal, 15 (23.4%) were mismatch-repair deficient, and 0% POLE-mutated. P53-abnormal patients had the shortest 3 year progression-free survival after recurrence and those with mismatch-repair deficient had the longest 3 year progression-free survival (14.3% (range; 1.6-40.3) and 47.6% (range; 9.1-79.5) respectively, p=0.001). We found no differences on overall survival after recurrence by molecular profile. Thirty-one of 64 (48.4%) patients had an isolated recurrence in the lung, and 16 (25%) patients received local treatment. When comparing patients with isolated lung recurrence, locally treated patients had a longer median progression-free survival than patients treated systemically (41.9 (range, 15.4-NA) vs 7.8 (range, 7.2-10.6) months respectively, p=0.029), a complete response rate of 80% for stereotactic body radiation therapy and a complete resection of 90.9% for surgery.

CONCLUSION

Although few patients will benefit from local treatment (stereotactic body radiation therapy or resection) after a recurrence involving the lung, local therapies might be considered as an option in oligometastatic lung recurrences as they achieve high local control rates and better oncological outcomes than systemic treatment alone.

Radiation Therapy for Uterine Cervical Cancer With Lung Metastases Including Oligometastases

BACKGROUND/AIM

To investigate the role and outcomes of radiation therapy (RT) for stage IVB uterine cervical cancer (UCC) patients with lung (oligo) metastases due to the lack of recent reports on the subject.

PATIENTS AND METHODS

The cohort for this retrospective study comprised 23 consecutive patients with UCC (squamous cell carcinoma, n=13) and lung metastases who had received pelvic RT. Ten had lung metastases only, including 7 with oligometastases (≤4 lung metastases); the remaining 13 also had other distant metastases.

RESULTS

Nine (39.1%) of the 22 patients (95.7%) completed RT without interruption. The 1-year primary progression-free rate was 95.2%. The 1-year overall survival rate was 47.2 % (estimated median survival: 9 months). Significant prognostic factors for survival included: i) ≤4 lung metastases (p=0.035), ii) unilateral lung metastases (p=0.039), iii) primary tumor diameter <100 mm (p<0.001), and iv) ECOG performance status <1 (p=0.015).

CONCLUSION

RT is safe and effective for stage IVB UCC patients with lung metastases.

Pulmonary metastasectomy in uterine malignancies: outcome and prognostic factors

Background

This retrospective study is designed to evaluate factors affecting survival in a population of patients receiving pulmonary metastasectomy after gynecologic cancers.

Methods

Nineteen patients with isolated lung metastases (one or two) were surgically treated with R0 resection. Four of them underwent lobectomies.

Results

Six patients (31.6%) received adjuvant therapy and 11 (58%) experienced recurrences after metastasectomy. Five- and ten-year survival were 40.9% and 31.4%, respectively. Five-year survival in patients receiving adjuvant therapy was 52.4%. At multivariate analysis factors negatively influencing survival were a disease-free interval (DFI) of less than 24 months and recurrence after pulmonary metastasectomy.

Conclusions

Pulmonary resection for metastatic gynecologic cancer is feasible and effective; adequate selection of patients is mandatory to achieve satisfactory results and long-term survival.

Evaluation of Preoperative Chest Imaging in Low-Risk Endometrial Cancer Patients

OBJECTIVE

Current national guidelines recommend preoperative thoracic imaging for all patients undergoing surgery for endometrial cancer. The objective of this project was to report the incidence of pulmonary metastasis in endometrial cancer patients and describe tumor and patient characteristics to better identify a low-risk population for thoracic involvement. We evaluated the ideal modality of preoperative imaging for both low-risk and high-risk populations based on the risk of pulmonary involvement.

METHODS

A retrospective cross-sectional study of patients undergoing surgical evaluation for endometrial cancer at a single institution from 2010 to 2014 was performed. Low-risk patients were defined as having a preoperative pathology sample showing grade 1 or 2 endometrioid endometrial cancer and a physical examination not concerning for extrauterine disease spread.

RESULTS

A total of 352 patients were evaluated, of which 327 (92.9%) had preoperative thoracic imaging. Twenty-six patients had benign pathology or no preoperative sampling, leaving 301 patients for analysis. There were 228 (75.7%) of 301 patients classified as low-risk by our criteria. There were 20 (8.8%) of 228 low-risk patients with initial imaging concerning for pulmonary metastasis, but follow-up showed no evidence of disease. No low-risk patients (0/228; 95% confidence interval [CI], 0%-0.02%) had pulmonary metastasis. There were 4 (1.3%) of 301 (95% CI, 0%-0.04%) patients diagnosed with pulmonary metastasis based on preoperative imaging, and 4 (1.3%) of 301 (95% CI, 0.01%-0.04%) patients with recurrent pulmonary disease. Median time to pulmonary recurrence was 20 months.

CONCLUSIONS

The incidence of pulmonary metastasis found on preoperative imaging is exceptionally low in our defined low-risk population. All of the patients with pulmonary involvement either initially or upon recurrence had high-risk features. Given our findings, we would recommend that providers consider chest x-ray as the appropriate screening modality for the low-risk population and chest computed tomography for the high-risk population.

Pulmonary metastasectomy in uterine malignancy: outcomes and prognostic factors

OBJECTIVE

The aim of this study was to investigate outcomes in uterine cancer patients undergoing pulmonary metastasectomy and prognostic factors associated with survival after the procedure.

METHODS

A retrospective study was performed in 29 uterine cancer patients who underwent surgical resection of pulmonary metastatic lesions at Samsung Medical Center between June 1995 and December 2011.

RESULTS

Histopathology showed carcinoma in 17 patients (58.6%) and sarcoma in 12 patients (41.4%). Of the 29 patients, 17 (58.6%) had less than three pulmonary metastatic lesions. Eight (27.6%) had symptoms related to lung metastasis. The 5-year survival rate after pulmonary metastasectomy for the entire cohort was 48.2%. On univariate and multivariate analysis, the presence of pulmonary symptoms and more than three lesions of metastasis were associated with poor survival after pulmonary metastasectomy.

CONCLUSION

Pulmonary metastasectomy for uterine cancer is an acceptable treatment in selected patients. Patients with more than three pulmonary metastatic lesions and pulmonary symptoms related to lung metastasis could expect to have worse prognosis after pulmonary metastasectomy.

The value of imaging of the lungs in the diagnostic workup of patients with endometrial cancer

OBJECTIVE

Imaging of the lungs is part of the routine diagnostic workup of patients with endometrial cancer. The present study aimed to determine the incidence of lung metastases in patients with endometrial cancer and to evaluate the clinical relevance of preoperative chest imaging in this population.

METHODS

A retrospective cross-sectional study was performed in four regional and one university hospital in the southeastern part of the Netherlands. A total of 784 patients with epithelial endometrial cancer diagnosed between 2002 and 2010 in five hospitals were included. Patients were followed up for at least 1 year.

RESULTS

Of 784 patients, 541 (69.0%) underwent thoracic imaging and 11 showed findings suspicious for metastases perioperatively or during the 1-year follow-up period. In eight patients, the thoracic metastases were related to their endometrial cancer, resulting in an overall incidence of 1.0% (8/784, 95% CI=0.3-1.7%). These eight patients had high-risk subtypes of endometrial cancer (serous, clear cell or poorly differentiated endometrioid), and the incidence was 4.1% (8/193, 95% CI=1.9-8.3%) for these subtypes. Lung metastases were not detected in any of the patients with low-risk subtypes of endometrial cancer (n=566) at the time of diagnosis (95% CI=0-0.8%).

CONCLUSIONS

The probability of detecting thoracic metastases during the diagnostic workup of patients with endometrial cancer is low. The present data suggest that thoracic imaging could be omitted from the diagnostic workup of patients with low-risk endometrial cancer.

Generation and characterization of orthotopic murine models for endometrial cancer

We describe the generation of two orthotopic murine models for endometrial cancer (EC).The first model is generated from endometrial Hec-1A cancer cells transfected with luciferase and injected directly into the uterus of female mice. This model allows a follow-up with bioluminescence imaging (BLI) along the experiment and generates abdominal dissemination and lymphatic and hematogenous metastases in high percentages, also detectables with BLI. The dissemination pattern of this model imitates the advanced stages of EC in patients, and its molecular profile corresponds to aggressive type 2 EC (p53 positive, hormone receptors negative, high percentage of Ki67 positive cells). The second model is derived from endometrioid human tissue collected from surgical pieces. By injecting this tissue inside the uterine cavity of a mouse we obtain orthotopic growth with pelvic dissemination and lymph node metastasis. The molecular pattern observed in human type 1 endometrioid EC (p53 negative, low Ki67 index, presence of hormone receptors) is conserved after the murine growth in orthotopic tumor and metastases. This model supposes a singular pre-clinical tool to study therapeutic agents, though it mimics clinical and molecular behavior of endometrioid EC, which is the most common histology in the patient.

An orthotopic endometrial cancer mouse model demonstrates a role for RUNX1 in distant metastasis

Endometrial carcinoma is the most common malignancy of the female genital tract in industrialized countries. Metastasis is the major cause of endometrial cancer deaths. Therefore, there is a vital need for clinically relevant in vivo models allowing the elucidation of the molecular and cellular mechanisms underlying metastatic behavior. In this study, we describe an innovative experimental orthotopic model of human endometrial carcinoma. Implantation in the bifurcation of the uterine horns resulted in tumors integrated into the myometrial compartment, which can be used and further exploited for the study of in vivo angiogenesis, myometrial invasion, and the metastatic capacity of endometrial cancer cells. This orthotopic model also represents a suitable tool to analyze how tumorigenesis and distant metastasis of endometrial cancer might be influenced by gene alteration, by modulating its expression in the original cancer cell line. One of the candidate genes implicated in endometrial cancer is the transcription factor RUNX1. The over-expression of RUNX1 in the endometrial cancer cell line HEC1A and the transplantation of these cells to the uterus of nude mice were associated specifically with distant metastasis in the lung. RUNX1 plays a role in the establishment of metastases in endometrial cancer. Translated to the clinics, these models would be equivalent to an advanced undifferentiated carcinoma with node affectation (stage IIIC) and distant metastasis (stage IVB). These patients would be candidates for adjuvant therapy, not efficient until today, and therefore, our models are actually suitable for the design and evaluation of experimental therapies.

Complete remission of an endometrial carcinoma with bilateral multiple pulmonary and extrapelvic metastases treated by surgery and chemotherapy consisting of paclitaxel and carboplatin

Successful management of a patient with endometrioid type, grade 2 endometrial carcinoma with bilateral multiple pulmonary and extrapelvic abdominal metastases has been reported. A 61-year-old woman with the preoperative diagnosis of stage IVB endometrial carcinoma underwent surgery followed by six cycles of chemotherapy consisting of paclitaxel (175 mg/m2) and carboplatin (area under curve 5). After the sixth course, there were no abnormal findings on chest and abdominal computed tomography. She has no evidence of disease recurrence 24 months after the induction of chemotherapy. Tumor markers are within normal limits. Endometrial carcinoma with pulmonary metastases, especially those with bilateral multiple pulmonary metastases associated with additional extrapulmonary spread can be successfully treated by extensive surgery followed by chemotherapy consisting of paclitaxel and carboplatin.

Role of surgical resection for lung, liver, and central nervous system metastases in patients with gynecological cancer: a literature review

Many reports of ovarian, cervical, and uterine cancers metastatic to lung, liver, and brain have been published. A fewer number of them focused on the surgical treatment for these patients. We reviewed the published literature, regarding surgical management of metastatic disease in patients with gynecological cancer. Some prognostic factors in the patients with metastatic lesions from these three different cancers were found in common. Favorable prognostic factors for a prolonged survival were good performance status of the patients, long disease-free interval, absence of other systemic disease, and the resectability, preferably with a clear margin. These factors should be considered as the criteria for surgery. In well-selected patients, survival could be extended from the surgical procedure with minimal complications. Other types of treatment such as radiation therapy or chemotherapy could also be given in conjunction with surgery, depending on tumor type and disease status of the primary cancer, other systemic diseases, and residual metastatic lesions after surgery.

Thoracic manifestations of common nonpulmonary malignancies of women

Metastatic, gender-related, nonpulmonary malignancy can exhibit different patterns of tumor spread and different natural histories. The pulmonologist often is involved in the diagnosis and treatment of patients with pulmonary metasteses; and a thorough understanding of the patterns of metastasis from these cancers can help to guide appropriate work-up and therapy. In the case of solitary pulmonary metastases, a surgical approach may not be unreasonable based on current clinical evidence. Knowledge of the clinical spectrum of these diseases, together with their unique molecular biology, may improve the clinical care of patients.

Pulmonary metastasis from endometrial carcinoma

The objective of this article is to investigate the clinical features of pulmonary metastasis (PM) from endometrial adenocarcinoma, in particular, the predictors of prolonged survival after PM detection. Fifteen patients who developed PM and underwent chest computed tomography (CT) scans for evaluation of PM were studied: 12 patients with pulmonary recurrence and 3 patients with PM on presentation. All patients with bilateral nodules or lymphangitic spread had metastases in other sites prior to or concomitant with PM, most of which were detected in para-aortic lymph nodes and/or the vaginal wall, while only one of five patients with a limited number (n < or = 5) of unilateral nodules had these metastases. The median survival time for the 10 patients with bilateral PMs was significantly shorter than that of the 5 patients with a limited number of unilateral nodules who were treated with surgery (7 versus 50 months, P = 0.005). Patients who developed pulmonary recurrence 2 years after the initial therapy had a significantly longer survival than those who developed it within 2 years (31 versus 10 months, P = 0.01). In conclusion, the distribution of PM determined by CT scans and the time interval between the initial therapy and the detection of pulmonary recurrence are the predictors of survival after PM detection.

Pulmonary resection in metastatic uterine and cervical malignancies

OBJECTIVE

Although thoracotomy for removal of pulmonary metastasis is well documented in a wide variety of solid tumors, data are sparse regarding management of patients with gynecologic malignancies metastatic to the lung.

METHODS

We retrospectively reviewed the Roswell Park Cancer Institute experience between 1982 and 1999. Of 82 eligible patients with gynecologic tumors metastatic and confined to the lung, 25 underwent pulmonary resection.

RESULTS

There were 60 uterine and 22 cervix cancer patients with pulmonary metastases. Among patients with uterine cancer primaries undergoing pulmonary resection (n = 19) median survival was 26 months. Uterine cancer patients who underwent surgical resection for leiomyosarcomas (n = 11) had a median survival of 25 months compared to 46 months in patients with adenocarcinoma (n = 6, P = 0.02). Median survival in cervix cancer patients undergoing resection for pulmonary metastases (n = 6) was 36 months.

CONCLUSIONS

Pulmonary resection may provide a survival advantage for selected patients with uterine and cervical malignancies with metastases isolated to the lung.

Natural history of patients with pulmonary metastases from uterine cancer

BACKGROUND

Endometrial cancer is the most common female genital cancer and approximately 90% of the cases are diagnosed while they are still confined to the uterus. However, the natural history and treated course after the development of pulmonary metastasis (PM) have not been studied systematically in a large series of patients.

METHODS

Between 1962 and 1992, 100 patients (6%) with PM were identified by computerized search of the medical records from 1.665 patients admitted to our hospitals with the diagnosis of uterine cancer. The median age of the patients was 65.5 years (range: 42-87 yrs). The usual histologic types of the uterine neoplasms were 59 adenocarcinomas (59%), 21 sarcomas, and 14 adenosquamous carcinomas. Of the 83 patients with reported tumor grade, 11 had Grade 1 tumor, 12 Grade II, and 60 Grade III.

RESULTS

Lung metastases were found at the time of diagnosis of the primary tumor in 22 patients. Hemoptysis was the first symptom of 3 of the 22; the majority had no respiratory symptoms. In the remaining 78 patients with PM appearing after primary therapy, the mean interval time between primary diagnosis and PM was 29.4 months, whereas between PM and death was 15.7 months. Of all patients with lung metastases, 75% did not survive 1 year; however 6% survived more than 5 years after diagnosis of metastatic disease. Patients with isolated PM had prolonged survival (36.1 mos, P=0.001), whether treated medically or with pulmonary resection. Progestin therapy was given to 39 patients, with complete response consisting of radiographic resolution of all disease in 6 patients (15%) and prolonged stabilization in an additional 5 (13%). The histologic grade of the primary tumor was predictive of clinical response to progestine therapy.

CONCLUSIONS

Asymptomatic pulmonary metastases represent a common site of extra pelvic spread of disease. The majority of patients with PM (75%) do not survive 1 year. Low grade uterine tumors are more likely to respond to progestin therapy and do so for extended periods of time.

Prognostic factors and sites of failure in FIGO Stage I, Grade 3 endometrial carcinoma

The results of therapy and patterns of failure were analyzed for 60 patients with Stage I, Grade 3 endometrial cancer seen at Yale-New Haven Hospital between 1960 and 1980. Fifty-eight patients were treated with a combination of surgery and radiation; one was treated with surgery only; and one received radiation only. The overall absolute 5-year survival rate was 72.9% with poorer prognosis noted for patients greater than 65 years of age, older at time of their menopause, and with Stage IA disease. Of the 14 patients who recurred, distant sites were involved in 93% (13/14), with the lung the most common site of distant failure (5/14), followed by the upper abdomen (4/14). Pelvic sites were involved in 43% (6/14) of the treatment failures. The use of pelvic external beam radiation resulted in a reduction in pelvic recurrences, but did not improve overall survival. The predominance of distant failures despite pelvic radiation suggests the possibility of early vascular and transcoelomic spread in Stage I, Grade 3 endometrial adenocarcinomas. Thorough exploration of the upper abdomen, paraaortic nodes, and the obtaining of pelvic washings for cytology at the time of initial surgery, are recommended in addition to chest CT scans to help identify those patients with occult metastases. Prospective randomized trials in Stage I, Grade 3 patients employing adjuvant cytotoxic chemotherapy, hormonal therapy, and/or whole abdominal-pelvic radiation, should be considered in an attempt to improve survival in high-risk patients.

Stage IV endometrial carcinoma: a clinical and histopathological study of 83 patients

From 1960 to 1977, eighty-three patients with stage IV endometrial carcinoma were treated in the Norwegian Radium Hospital. The lung was the main site of extrapelvic tumor extension (36%), followed by "multiple sites" (23%), lymph nodes (inguinal, supraclavicular, axillar; 13%), and bladder (13%). The actuarial 5-year-survival rate was 10%. Complete clinical remission was achieved in 5 patients with lung metastases, in 2 with inguinal lymph node metastases, and in 1 patient with ascites with positive cytology. Control of pelvic disease could be achieved in 20 of 72 patients (28%) by radiotherapy alone or combined with surgery and/or progestagens. Progestational agents proved to be of benefit especially for patients with lung metastases. A complete remission of all visible lesions was observed in 8 out of 26 patients (31%). Patients with well- and moderately differentiated primary adenocarcinoma had a response rate of 83% as opposed to 14% for patients with poorly differentiated adenocarcinomas and adenosquamos carcinomas. Extrapelvic tumor localizations, suitable for radiotherapy, were supraclavicular and axillary lymph nodes and bone metastases.

The role of the radiation oncologist in the management of gynecologic cancer

Optimal management of patients with gynecologic malignancies requires a multidisciplinary approach with close cooperation between the primary care physician, the gynecologic oncologist and the radiation therapist. In order to obtain maximum survival rates with minimal morbidity, treatment should be based on a detailed knowledge of tumor localization, potential sites of occult spread, and tumor-host interactions. A careful delineation of patterns of recurrence will permit the identification of patients at increased risk for treatment failure and will aid in the design of alternative treatment protocols tailor-made to control potential site(s) of tumor spread. The technological advances in radiation oncology and their influence on survival rates are presented, with illustrations taken from the literature and from the recent results of the Patterns of Care Study for treatment of carcinoma of the cervix. The role of radiation therapy in the treatment of carcinomas of the cervix, uterus, and the epithelial tumors of the ovary are reviewed, emphasizing treatment protocols based on consideration of technical, tumor, and host factors. Ongoing clinical research trials and potential areas for further improvement in the management of gynecologic malignancies are discussed.

Prognosis and treatment of endometrial cancer

An understanding of the patterns of spread and prognostic factors influencing survival is necessary to develop rational treatment programs for patients with endometrial cancer. The most important risk factors include the stage of tumor, status of pelvic lymph nodes, depth of myometrial penetration, tumor grade, cell type, and patient age. Because of the inherent inaccuracies of staging based on pelvic examination and the inability to assess the status of lymph nodes or myometrial penetration clinically, errors in management often result when radiation therapy is delivered prior to operation. Therefore, a rationale is offered for primary operative management of patients with Stage I disease, with consideration of adjunctive radiation therapy following operation based on extend of disease and a thorough evaluation of the high-risk factors. It is suggested that patients with more advanced stages of disease be considered for pretreatment operative evaluation. Data are presented which refute theoretical objections to this approach.