Endometrial adenocarcinoma in young patients: evaluation and fertility-preserving treatment

Endometrial Cancer in Reproductive-Aged Females: Etiology and Pathogenesis

Endometrial cancer is the most common gynecologic malignancy in developed countries, and the incidence is rising in premenopausal females. Type I EC is more common than Type II EC (80% vs. 20%) and is associated with a hyperestrogenic state. Estrogen unopposed by progesterone is considered to be the main driving factor in the pathogenesis of EC. Studies show that BMI > 30 kg/m2, prolonged duration of menses, nulliparity, presence of polycystic ovarian syndrome, and Lynch syndrome are the most common causes of EC in premenopausal women. Currently, there are no guidelines established to indicate premenopausal patients who should be screened. This review aims to synthesize current data on the etiology, risk factors, presentation, evaluation, and prognosis of endometrial cancer in this population.

Atypical endometrial hyperplasia in a 35-year-old woman: A case report and literature review

BACKGROUND

Atypical endometrial hyperplasia (AEH) is a common precancerous lesion of endometrial carcinoma (EC). The risk factors for AEH and EC directly or indirectly related to estrogen exposure include early menarche, nulliparity, polycystic ovarian syndrome, diabetes, and obesity. Both AEH and EC rarely occur in young patients (< 40-years-old), who may desire to maintain their fertility. Evaluating the cancer risk of AEH patients is helpful for the determination of therapeutic plans.

CASE SUMMARY

We report a rare case of AEH in a 35-year-old woman who presented to the Hunan Provincial Maternal and Child Health Care Hospital with a large mass in the uterus. She married at 20-years-old, and had been married for more than 15 years to date. Several characteristics of this patient were observed, including nulliparity, limited sexual activity (intercourse 1-2 times a year) in recent years, and irregular vaginal bleeding for 2 years. Gynecological examination revealed an enlarged uterus, similar to the uterus size in the fourth month of pregnancy, and the uterine wall was relatively hard. Curettage was performed based on transvaginal sonography and magnetic resonance imaging results. Findings from the pathological examination were typical for AEH. The patient was cured after treatment with the standard therapy of high-dose progesterone.

CONCLUSION

In patients with intrauterine lumps that may be malignant, a pathological report should be obtained.

Autophagy Machinery as a Promising Therapeutic Target in Endometrial Cancer

Endometrial cancer is the fourth most frequent neoplasia for women worldwide, and over the past two decades it incidence has increased. The most common histological type of endometrial cancer is endometrioid adenocarcinoma, also known as type 1 endometrial cancer. Endometrioid endometrial cancer is associated with diverse epidemiological risk factors including estrogen use, obesity, diabetes, cigarette smoking, null parity, early menarche, and late menopause. Clinical effectiveness of chemotherapy is variable, indicating that novel molecular therapies against specific cellular processes associated to cell survival and resistance to therapy, such as autophagy, urged to ameliorate the rates of success in endometrial cancer treatment. Autophagy (also known as macroautophagy) is a specialized mechanism that maintains cell homeostasis which is activated in response to cellular stressors including nutrients deprivation, amino acids starvation, hypoxia, and metabolic stress to prolong cell survival via lysosomal degradation of cytoplasmic macromolecules and organelles. However, in human cancer cells, autophagy has a controversial function due to its dual role as self-protective or apoptotic. Conventional antitumor therapies including hormones, chemotherapy and ionizing radiation, may activate autophagy as a pro-survival tumor response contributing to treatment resistance. Intriguingly, if autophagy continues above reversibility of cell viability, autophagy can result in apoptosis of tumor cells. Here, we have reviewed the mechanisms of autophagy described in endometrial cancers, including the role of PI3K/AKT/mTOR, AMPK-mTOR, and p53 signaling pathways that trigger or inhibit the process and thus representing potential molecular targets in therapeutic clinical approaches. In addition, we discussed the recent findings indicating that autophagy can be modulated using repurposing drugs which may leads to faster experimentation and validation, as well as more easy access of the medications to patients. Finally, the promising role of dietary compounds and microRNAs in autophagy modulation is also discussed. In conclusion, although the research about autophagy is scarce but ongoing in endometrial cancer, the actual findings highlight the promising usefulness of novel molecules for directing targeted therapies.

Gene aberration profile of tumors of adolescent and young adult females

There has been little improvement in the prognosis for adolescent and young adult (AYA) tumor patients. Hence, there is an urgent need to understand the etiology of tumor development and identify actionable gene aberrations to improve prevention and therapy. Here, 76 sporadic tumors (48 breast, 22 ovarian, and six uterine) from 76 AYA females (age range, 25–39 years) were subjected to whole exome and RNA sequencing to determine their mutational signatures and actionable gene profiles. Two individuals with breast cancer (4.2% of cases) and one with ovarian cancer (5.3% of cases) carried germline BRCA2 mutations. The two cases with breast tumors also each carried an additional deleterious germline mutation: one in TP53 and the other in CHEK2. Mutational signature analysis of the 76 tumors indicated that spontaneous deamination of 5-methylcytosine and activity of the APOBEC cytidine deaminase protein family are major causes of mutagenesis. In addition, 18 breast or ovarian tumors (18/70, 26%), including the three cases with germline BRCA2 mutations, exhibited a predominant “BRCAness” mutational signature, an indicator of functional BRCA1/BRCA2 deficiency. Actionable aberrations and high tumor mutation burdens were detected in 24 breast (50%), 17 ovarian (77%), and five uterine (83%) tumor cases. Thus, mutational processes and aberrant genes in AYA tumors are largely shared with those identified in non-AYA tumors. The efficacy of molecular targeting and immune checkpoint inhibitory therapies should be explored for both AYA and non-AYA patients.

Comparison among fertility-sparing therapies for well differentiated early-stage endometrial carcinoma and complex atypical hyperplasia

OBJECTIVE

To compare fertility-sparing therapies including oral progestogens, hysteroscopic resection (HR), and the levonorgestrel- releasing intrauterine system (LNG-IUS) in achieving disease regression, recurrence and live birth rate in well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia(CAH).

STUDY DESIGN

This was a meta-analysis of previous studies focus on the fertility-sparing therapy for well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia (CAH).

DATE SOURCES

Medline, the Cochrane Library and Embase was searched with the terms and Synonyms: words similar to eEC and CAH with therapies associated with fertility-sparing.

MAIN OUTCOME MEASURES

The number of all patients accepted fertility sparing therapies, patients got regressed, relapsed and delivered were extracted from each study, and the regression, recurrence, and live birth rate of each study were calculated. The regression, recurrence and live birth rates between each two interventions were compared with the aid of meta-regression in packages of "meta" and "meta for" written in R.

RESULTS

Fifty-four studies reported fertility sparing therapies in young women with eEC and CAH were included. Meta-analysis showed that HR followed by progestogens achieved a higher pooled regression (98.06% vs 77.20% P < 0.0001) and live birth rate (52.57% vs 33.38%, P = 0.0944) and a lower recurrence rate compared with oral progestogens alone (4.79% vs 32.17% P = 0.0004). At the same time, the pooled live birth rate (52.57% vs 18.09% P =0.0399) of HR followed by progestogens are significantly higher than the LNG-IUS alone. Which no statistical difference in regression (98.06% vs 94.24%; P = 0.4098) and recurrence rates (4.79% vs 3.90% P = 0.8561) was seen.

CONCLUSIONS

Of the available fertility-sparing therapeutic options, HR followed by progestogens may be a more effective one.

PI3K/AKT/mTOR pathway promotes progestin resistance in endometrial cancer cells by inhibition of autophagy

Endometrial cancer (EC) is now one of the most common malignant tumors in young women. In all, 90% of young patients with EC have a high expression of progesterone recep tor, can be treated with progestin, and have very good prognosis. However, some of the young EC patients are resistant to progestin, the mechanism of which is unclear. To illuminate the mechanism by which endometrial cells acquire progestin resistance, we treated Ishikawa cells by slowly increasing dosage of progestin and established a progestin-resistant cell subline. We show here that progesterone resistant cells acquire increased proliferation rate and interestingly decreased autophagy. To uncover the mechanism by which cells increase proliferation and bypass autophagy, we found higher activation of phosphatidylinositol 3-kinase/AKT/mTOR signaling pathway was necessary to this malignant acquirement by RNAi technique. Further, we elucidated that activation of mTOR was sufficient and necessary for progestin resistance. RAD001, an inhibitor of mTOR, decreased phosphorylation of mTOR and inhibited proliferation of progestin-resistant cancer cells by promoting autophagy. Thus, our results indicated that mTOR can be a target to treat the progestin-resistant EC.

Mig-6 Mouse Model of Endometrial Cancer

Endometrial cancer is a frequently occurring gynecological disorder. Estrogen-dependent endometrioid carcinoma is the most common type of gynecological cancer. One of the major pathologic phenomena of endometrial cancer is the loss of estrogen (E2) and progesterone (P4) control over uterine epithelial cell proliferation. P4 antagonizes the growth-promoting properties of E2 in the uterus. P4 prevents the development of endometrial cancer associated with unopposed E2 by blocking E2 actions. Mitogen inducible gene 6 (Mig-6, Errfi1, RALT, or gene 33) is an immediate early response gene that can be induced by various mitogens and common chronic stress stimuli. Mig-6 has been identified as an important component of P4-mediated inhibition of E2 signaling in the uterus. Decreased expression of MIG-6 is observed in human endometrial carcinomas. Transgenic mice with Mig-6 ablation in the uterus develop endometrial hyperplasia and E2-dependent endometrial cancer. Thus, MIG-6 has a tumor suppressor function in endometrial tumorigenesis. The following discussion summarizes our current knowledge of Mig-6 mouse models and their role in understanding the molecular mechanisms of endometrial tumorigenesis and in the development of therapeutic approaches for endometrial cancer.

Fertility-Sparing Treatment of Early Endometrial Cancer and Complex Atypical Hyperplasia in Young Women of Childbearing Potential

OBJECTIVE

To evaluate oncologic and reproductive outcome with levonorgestrel-releasing intrauterine system combined with gonadotropin-releasing hormone agonist in women with grade 1 endometrial carcinoma, and the levonorgestrel monotherapy in women with complex atypical hyperplasia.

MATERIALS/METHODS

A prospective study was conducted. We analyzed the clinical characteristics of 70 patients younger than 42 years (mean age, 33 years) with a diagnosis of complex atypical endometrial hyperplasia (AEH) or grade 1 endometrial adenocarcinoma who were treated with hormonal therapy at the Division of Gynecologic Oncology of P.A. Hertsen Moscow Cancer Research Institute from February 2009 to December 2012. Patients with complex AEH received monotherapy with levonorgestrel-releasing intrauterine system (Mirena, Shering, Finland; 52 mg). Patients with a diagnosis of grade 1 endometrial cancer were treated with levonorgestrel-releasing intrauterine system combined with gonadotropin-releasing hormone agonist (Zoladex; AstraZeneca UK Limited, UK; 3.6-mg depot). All the patients received hormonal therapy for a minimum of 6 months. Pretreatment evaluation consisted of transabdominal and transvaginal ultrasound in grayscale, color Doppler ultrasound, contrast-enhanced magnetic resonance imaging, cervical hysteroscopy, Pipelle endometrial biopsy, and morphological and immunohistochemical characteristics of the tissue.

RESULTS

Seventy patients were included in study analyses. Twenty three (72%) of 32 patients with adenocarcinoma and 35 (92%) of 38 patients with AEH had complete remission, defined as the absence of any carcinoma or hyperplasia on endometrial sampling specimens. Among these cases, 2 patients with adenocarcinoma and 1 patient with AEH had recurrence after their complete response. Nine patients had persistent disease. Eight patients had 10 conceptions, resulting in 8 live births.

CONCLUSIONS

The suggested conservative treatment strategy can be considered as a valid therapeutic option for young women of childbearing potential with atypical endometrial hyperplasia and grade 1 endometrial adenocarcinoma who wish to preserve their fertility and thus may be recommended as an alternative to hysterectomy. Close follow-up during and after the treatment period is strictly required.

Endometrial Adenocarcinoma in A 31-Year Old Woman: A Case Report

Endometrial adenocarcinoma (EC) usually occurs after menopause, whereas in 2-14% of cases, it occurs in young patients (less than 40 years old) who may desire to keep their fertility. It is of importance to evaluate women for EC when they develop polycystic ovarian syndrome and abnormal uterine bleeding. Its treatment includes hysterectomy, bilateral salpingo-oo- phorectomy and pelvic lymphadenectomy and in some cases, radiation therapy. We report a case of EC in a 31-year-old woman who presented to Royan Institute. She complained about oligomenorrhea with a 10-year history of primary infertility.

Gynecologic oncologic imaging with PET/CT

FDG-PET/CT has been evaluated in a variety of gynecologic malignancies in a variety of settings and is approved by the Centers for Medicare & Medicaid Services for the initial and subsequent treatment strategies of these malignancies. Cervical cancer is typically very FDG avid, and FDG-PET/CT appears to be most valuable for initial staging, radiation therapy planning, and detection of recurrent disease. For ovarian cancer, the most value of FDG-PET/CT appears to be for detecting recurrent disease in the setting of rising CA-125 level and negative or equivocal anatomical imaging studies. Initial studies evaluating response to therapy are promising and further work in this area is needed. FDG uptake in both nonmalignant and physiological processes in the pelvis can make interpretation of FDG-PET/CT in this region challenging and knowledge of these entities and patterns can avoid misinterpretation. Some of the most common findings relate to the cyclic changes that occur as part of the menstrual cycle in premenopausal women. Mucinous tumors and low-volume or peritoneal carcinomatosis are causes of false-negative results on FDG-PET/CT studies. As new tracers are developed, comparisons with patient outcomes and standards of care (eg, FDG-PET/CT) will be needed.

Emotional and sexual concerns in women undergoing pelvic surgery and associated treatment for gynecologic cancer

The surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, emotional well being, reproductive function, and overall quality of life (QoL). Fortunately, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae; however, these side effects of treatment are still prevalent. In this article, we provide an overview of the various standard-of-care pelvic surgeries and multimodality cancer treatments (chemotherapy and radiation therapy) by anatomic site and highlight the potential emotional and sexual consequences that can influence cancer survivorship and QoL. Potential screening tools that can be used in clinical practice to identify some of these concerns and treatment side effects and possible solutions are also provided. These screening tools include brief assessments that can be used in the clinical care setting to assist in the identification of problematic issues throughout the continuum of care. This optimizes quality of care, and ultimately, QoL in these women. Prospective clinical trials with gynecologic oncology populations should include patient-reported outcomes to identify subgroups at risk for difficulties during and following treatment for early intervention.

Progestins in the fertility-sparing treatment and retreatment of patients with primary and recurrent endometrial cancer

Endometrial cancer is the most common gynecologic cancer in developed countries. Approximately 3%-14% of endometrial cancers are diagnosed in young women under 40 who want to preserve their fertility. The incidence of endometrial cancer in this age group is increasing, for which fertility-sparing therapy is increasingly used because it is one of the most important quality of life issues in these women. Progestin therapy is the most common type of fertility-sparing therapy. In this review, the most up-to-date findings regarding fertility-sparing progestin therapy for young women with primary and recurrent endometrial cancer is addressed in terms of diagnosis, treatment, follow-up, and oncologic and reproductive outcomes. Fertility-sparing progestin therapy is highly effective in selected young women with primary and recurrent endometrial cancer. The selection of appropriate patients through comprehensive pretreatment evaluation is of paramount importance to achieve the best outcomes without compromising survival. Because of the high rate of recurrence after successful fertility-sparing therapy, close surveillance is mandatory, and prophylactic hysterectomy is the best option for patients who have completed family planning. Pregnancy outcomes are very promising with the aid of assisted reproductive technologies. Continuous daily oral medroxyprogesterone acetate and megestrol acetate are the preferred progestins for fertility-sparing therapy, but future studies should be performed to determine the optimal dose and treatment duration of these agents.

Steroid hormone intervenes in the endometrial tumorigenesis of pten ablation

Background:

Endometrial cancer, the most common gynecological cancer, is closely associated with endometrial hyperplasia, unopposed estrogen exposure, and genetic alterations. Phosphatase and tensin homologue (PTEN) is a tumor suppressor genes completely lost or mutated in >50% of primary endometrioid endometrial cancers. Estrogen-dependent endometrioid carcinoma is the most common type of endometrial cancer. Progesterone is a hormone that antagonizes the growth-promoting properties of estrogen in the uterus. Progestin is used as a conservative endocrine treatment of early endometrial cancer in order to preserve fertility as well as a palliative measure for advanced-stage patients. Progesterone therapy has been shown to be effective in preventing endometrial cancer as well as controlling growth of the endometrium. However, the effectiveness of progestin for women with endometrial cancer is less clear.

Methods:

In order to understand the effect of steroid hormone on endometrial cancer progression, we used a mouse endometrial cancer model with conditional loss of Pten in the mouse uterus (PR^cre/+Pten^f/f, Pten^d/d). To assess the effect of steroid hormones, ovariectomized Pten^f/f and Pten^d/d mice were treated with estrogen or progesterone over a period of three month.

Results:

Uterine weight gain was significantly decreased in ovariectomized PR^cre/+Pten^f/f mice compared to intact PR^cre/+Pten^f/f mice. Ovariectomized PR^cre/+Pten^f/f mice treated with P4 or vehicle also exhibited decreased uterine cancer size compared with intact PR^cre/+Pten^f/f mice. Proliferation of ovariectomized PR^cre/+Pten^f/f mice treated with P4 is highly decreased compared to other groups. The levels of stromal progesterone receptor were highly increased in ovariectomized PR^cre/+Pten^f/f mice treated with P4 which resulted in decreased epithelial proliferation.

Conclusions:

These results suggest that P4 treatment significantly reduces tumor mass but does not affect cancer progression in PR^cre/+Pten^f/f mice.

Complex atypical hyperplasia of the endometrium: differences in outcome following conservative management of pre- and postmenopausal women

OBJECTIVE

To compare the safety and regression rates of conservative treatments for complex atypical hyperplasia (CAH) between pre- and postmenopausal women.

METHODS

Historical cohort study of pre- and postmenopausal women with CAH managed conservatively at one center (Royal Women's Hospital, Melbourne, Australia) between September 1999 to June 2012.

RESULTS

Of the 153 women with CAH, 92 (60%) underwent hysterectomy and the remaining 61 were managed conservatively with oral or intrauterine progestogen: 42 were premenopausal and 19 were postmenopausal. Within 12 months, 32 (76%) premenopausal women demonstrated regression of CAH and none developed endometrial cancer. In contrast, only 4 (21%) postmenopausal women showed disease regression and 4 (21%) progressed to endometrial cancer. Over a median of 24 months, 3 premenopausal women relapsed with CAH and 2 developed endometrial cancer. Four premenopausal women had successful pregnancies.

CONCLUSION

Conservative treatment with progestogen in premenopausal women with CAH leads to high regression rates within the first 12 months. In contrast, postmenopausal women have high rates of ongoing disease and cancer progression and conservative therapy should be avoided.

The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues

INTRODUCTION

Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae.

AIM

To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients.

MAIN OUTCOME MEASURES

Comprehensive overview of the literature on gynecologic oncology surgery.

METHODS

Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided.

RESULTS

The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited.

CONCLUSIONS

It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.

Critical tumor suppressor function mediated by epithelial Mig-6 in endometrial cancer

Endometrial cancer is preceded by endometrial hyperplasia, unopposed estrogen exposure, and genetic alterations, but the precise causes of endometrial cancer remain uncertain. Mig-6, mainly known as a negative regulator of the EGF receptor, is an important mediator of progesterone signaling in the uterus, where it mediates tumor suppression by modulating endometrial stromal-epithelial communications. In this study, we investigated the function of Mig-6 in the uterine epithelium using a tissue-specific gene knockout strategy, in which floxed Mig-6 (Mig-6(f/f)) mice were crossed to Wnt7a-Cre mice (Wnt7a(cre+)Mig-6(f/f)). Wnt7a(cre+)Mig-6(f/f) mice developed endometrial hyperplasia and estrogen-dependent endometrial cancer, exhibiting increased proliferation in epithelial cells as well as apoptosis in subepithelial stromal cells. We documented increased expression of NOTCH1 and BIRC3 in epithelial cells of Wnt7a(cre+)Mig-6(f/f) mice and decreased expression of the progesterone receptor (PR) in stromal cells. Progesterone therapy controls endometrial growth and prevents endometrial cancer, but the effectiveness of progesterone as a treatment for women with endometrial cancer is less clear. We noted that the hyperplasic phenotype of Wnt7a(cre+)Mig-6(f/f) mice was prevented by progesterone treatment, whereas this treatment had no effect in PR(cre/+)Mig-6(f/f) mice where Mig-6 was deleted in both the epithelial and stromal compartments of the uterus. In contrast, activation of progesterone signaling in the stroma regulated proliferation and apoptosis in the epithelium via suppression of ERα signaling. In summary, our results establish that epithelial Mig-6 functions as a critical tumor suppressor that mediates the ability of progesterone to prevent the development of endometrial cancer.

Clinical applications of levonorgestrel-releasing intrauterine system to gynecologic diseases

The levonorgestrel-releasing intrauterine system (LNG-IUS), originally designed for contraception, has since been applied to various gynecologic diseases. This article summarizes the current status of clinical applications of LNG-IUS to the treatment of gynecologic diseases such as heavy menstrual bleeding, endometriosis, leiomyoma, adenomyosis, endometrial hyperplasia, and early-stage endometrial cancer.

Metformin sensitizes endometrial cancer cells to chemotherapy by repressing glyoxalase I expression

AIM

Metformin plays an important role in the inhibition of cancer cell growth and prolongs remission durations. It reverses progestin-resistance in endometrial cancer cells by downregulating glyoxalase I (GloI) expression. This study aimed to investigate the effect of metformin on endometrial cancer cell chemotherapeutic sensitivity and explore the underlying molecular mechanisms.

MATERIAL AND METHODS

MTT assay was performed to determine the rate of cell death after cisplatin and paclitaxel with or without metformin. Western blot was carried out to analyze GloI expression. SiRNA-targeting of GloI was used to knockdown GloI expression before further treatment with chemotherapeutic agents to examine the effect of GloI downregulation on chemotherapy-induced cell killing. In addition, plasmid transfection was used to overexpress GloI and determine whether high GloI levels blocked metformin-enhanced cell sensitivity to chemotherapy. PCR was used to analyze the efficiency of RNA interference and plasmid transfection.

RESULTS

The addition of metformin enhanced the sensitivity of endometrial cells to cisplatin and paclitaxel, which was associated with reduced levels of GloI expression. Moreover, low-dose chemotherapeutic drugs alone could not significantly reduce GloI expression, whereas the addition of metformin potently downregulated GloI protein levels. Cisplatin and paclitaxel markedly inhibited the proliferative ability of GloI-depleted endometrial cancer cells. However, the overexpression of GloI abolished the effect of metformin-enhanced cell sensitivity to chemotherapeutic drugs.

CONCLUSION

Metformin enhances the rate of cell-killing induced by chemotherapeutic agents by repressing GloI expression.

Contemporary quality of life issues affecting gynecologic cancer survivors

Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials.

Metformin reverses progestin resistance in endometrial cancer cells by downregulating GloI expression

INTRODUCTION

A long-term treatment with progestin commonly results in progestin resistance in endometrial cancer. So, the aim of this study was to investigate the role of glyoxalase I (GloI), a mediator of chemotherapy resistance, in metformin reversal of progestin resistance in endometrial carcinoma.

METHODS

The proliferation variety of endometrial cancer cells was determined by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-Diphenyltetrazolium (MTT) assay after exposure to medroxyprogesterone acetate, metformin, or both reagents; apoptosis rates were assessed by flow cytometry. Real-time polymerase chain reaction was used to evaluate the effect of small interfering RNA sequence on target gene expression. Western immunoblotting was performed to determine the expression of GloI and the molecules of the mammalian target of rapamycin (mTOR) pathway.

RESULT

Knocking down GloI sensitized progestin-resistant Ishikawa cells to progestin. Metformin downregulated GloI expression, reversed progestin resistance, enhanced progestin-induced cell proliferation inhibition, and induced apoptosis in progestin-resistant Ishikawa cells. In addition, medroxyprogesterone acetate-induced mTOR phosphorylation was blocked by metformin. Metformin abolishes mTOR phosphorylation and inhibits GloI expression, attenuating proliferation and inducing apoptosis in progestin-resistant Ishikawa cells.

CONCLUSIONS

Dysregulation of GloI expression in endometrial cancer may be part of the molecular mechanisms for progestin resistance.

Inhibiting the PI3K/Akt pathway reversed progestin resistance in endometrial cancer

Progestin resistance is the main obstacle to successful conservative therapy in young endometrial cancer patients. To investigate the molecular events that lead to progestin resistance and to find a possible way to reverse progestin resistance in endometrial cancer, we established a progestin-resistant Ishikawa cell line by long-term progestin treatment to downregulate progesterone receptor (PR) expression. Both medoxyprogesterone acetate (MPA) and LY294002, a phosphatidylinositol 3-kinase (PI3K) inhibitor, were assayed for their effects on the proliferation of progestin-sensitive and progestin-resistant cancer cells, respectively. The MPA inhibited the PI3K/Akt pathway and suppressed cell proliferation in progestin-sensitive Ishikawa cells, but activated the PI3K/Akt pathway and had no effect on cell proliferation in progestin-resistant Ishikawa cells or HEC-1A cells. Inhibiting the PI3K/Akt pathway by LY294002 upregulated PR expression and diminished cell growth, especially in progestin-resistant endometrial cancer cells. In vivo endometrial cancer xenograft studies in nude mice also showed that inhibiting the PI3K/Akt pathway reversed progestin resistance in endometrial cancer. Our results indicate that activation of the PI3K/Akt pathway by progestin without PR mediation plays an important role in progestin resistance to endometrial cancer cells. In addition, inhibiting the PI3K/Akt pathway might reverse progestin resistance in endometrial cancer.

Conservative treatment of early endometrial cancer: preliminary results of a pilot study

OBJECTIVE

This study evaluated the feasibility and efficacy of combined operative hysteroscopy (HSC) and hormone therapy as fertility-preserving treatment in a cohort of selected young women with early endometrial carcinoma (EC).

METHODS

Fourteen patients (median age 38 years, range 26-40) with FIGO stage IA (intramucous) EC wishing to preserve fertility were enrolled with the following inclusion criteria: age ≤40 years; no evidence of Lynch II syndrome; well-differentiated estrogen/progesterone receptor positive (ER+/PR+) endometrioid EC; no evidence of myoinvasion, multifocal tumor, node metastasis, ovarian mass; normal serum CA 125. Treatment consisted of hysteroscopic ablation of the lesion and the myometrial tissue below, followed by oral megestrol acetate (MA) 160 mg/day for 6 months (6 pts) or 52 mg levonorgestrel-medicated intrauterine device (LNG-IUD) for 12 months (8 pts).

RESULTS

With a median follow-up of 40 months (range 13-79), one patient recurred after 5 months from operative HSC and underwent definitive surgery, one patient showed an endometrial hyperplasia without atypia at the 3 and 6 month HSC control, with negative controls thereafter. Three patients have attempted to conceive and one of them conceived and term delivered a healthy baby.

CONCLUSIONS

Combined operative HSC and progestin therapy may have a role for safe and effective conservative management of early EC in selected patients wishing to preserve fertility.

Endometrial adenocarcinoma in a 27-year-old woman

BACKGROUND

Endometrial adenocarcinoma usually occurs after menopause, but in 2%-14% of cases, it occurs in young patients (less than 40 years of age) who are eager to preserve their fertility. Its treatment includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy, and, in some cases, radiation therapy.

AIM

To describe a case of endometrial adenocarcinoma occurring in a young woman and to undertake a literature review of risk factors and therapeutic options proposed for young women wishing to preserve their fertility.

CASE

We report a case of endometrial cancer in a 27-year-old woman treated for resistant menorrhagia and cared for in our department as well as in the Salah Azaiez Institute.

CONCLUSION

Endometrial adenocarcinoma rarely occurs in young women. In such cases, other therapeutic options can be proposed: progesterone therapy and LH-RH (Luteinzing-Hormone-Releasing-Hormone) agonists therapy in order to preserve fertility in younger patients.

PET/CT Imaging in Gynecologic Malignancies Other than Ovarian and Cervical Cancer

Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) is an imaging modality used for staging, assessing response to therapy, and diagnosis of recurrent cervical and ovarian cancer. The potential role of FDG-PET/CT in other gynecologic malignancies such as endometrial cancer, uterine sarcomas, vaginal, and vulvar cancer has not been fully explored.

Successful twin pregnancy achieved by assisted reproductive technology in a patient with polycystic ovary syndrome with complex atypical endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system

Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrinopathy and a major cause of infertility. PCOS may be associated with chronic anovulation and endometrial hyperplasia. Conservative treatment should be considered in young women wishing to preserve their fertility. Standard treatment for complex endometrial hyperplasia is the use of high-dose progesterone, whereas we preferred levonorgestrel-releasing intrauterine system (LNG-IUS) as a last resort in our patient who was resistant to oral gestagens. We present a case with complex atypical endometrial hyperplasia treated conservatively in a long-term period first by oral gestagens, then by LNG-IUS. In our case, LNG-IUS was more effective than oral systemic progestins, not only for reducing the menstrual blood loss but also for improving the pathological findings. After extraction of LNG-IUS rapid achievement of pregnancy was carried out by intracytoplasmic sperm injection and embryo transfer and she took home twin babies. To the best of our knowledge, this is the first successful twin pregnancy case with ICSI and ET in a patient with oral gestagen resistant endometrial complex/atypical hyperplasia achieved after application of LNG-IUS. In complex atypical hyperplasia, LNG-IUS should be kept in mind as an effective alternative treatment modality before assisted reproductive technology (ART).

Progesterone receptor action in leiomyoma and endometrial cancer

Progesterone is a key hormone in the regulation of uterine function. In the normal physiological context, progesterone is primarily involved in remodeling of the endometrium and maintaining a quiescent myometrium. When pathologies of the uterus develop, specifically, endometrial cancer and uterine leiomyoma, response to progesterone is usually altered. Progesterone acts through mainly two isoforms of the progesterone receptor (PR), PRA and PRB which have been reported to exhibit different transcriptional activities. Studies examining the expression and function of the PRs in the normal endometrium and myometrium as well as in endometrial cancer and uterine leiomyoma are summarized here. The clinical use of progestins and the transcriptional activity of the PR on genes specific to endometrial cancer and leiomyoma are described. An increased understanding of the differential expression of PRs and response to progesterone in these two diseases is critical in order to develop more efficient and targeted therapies.

The fertility-sparing treatment in patients with endometrial atypical hyperplasia and early endometrial cancer: a debated therapeutic option

Fertility-sparing treatment may represent a realist option for accurately selected young patients with endometrial atypical hyperplasia or well differentiated, early endometrial cancer. Oral progestins, and especially medroxyprogesterone acetate (MPA) and megestrol acetate with different doses and schedules, represent the most commonly used hormone agents in this clinical setting. Approximately three fourths of the women achieve a histologically documented complete response, with an mean response time of 12 weeks, but about one third of these subsequently developed a recurrence after a mean time of 20 months. The expression of receptor for progesterone receptor (PR), PTEN gene, DNA mismatch repair gene MLH1 and phospho-AKT on tissue specimens may be useful for selecting patients fit for a conservative management. Several successful pregnancies have occurred after a fertility-sparing treatment of endometrial atypical hyperplasia or endometrial cancer, more frequently with assisted reproductive technologies. The implementation of in vitro fertilisation techniques not only increases the chance of conception, but it may also decrease the interval to conception. The opportunity of a demolitive surgery after delivery or after childbearing being no longer required is a still debated issue. Large multicenter trials are strongly warranted to better define the selection criteria for a conservative treatment, endocrine regimen of choice, the optimal dosing, the duration of treatment and follow-up protocols. In any case, the patient should be accurately informed about the relatively high recurrence rates after complete response to hormone treatment and expectations for pregnancy.

Magnetic resonance imaging of endometrial and cervical cancer

In this article we review the current and developing roles of magnetic resonance imaging (MRI) in endometrial and cervical cancer. In endometrial cancer, the purpose of MRI is to stage the primary tumor and in particular to identify myometrial and cervical invasion and extra-uterine disease, thereby informing preoperative surgical planning. MRI is also used to safely select young patients suitable for fertility-preserving medical management. In cervical cancer, MRI has an established role in local staging and in assessing proximal extension of tumors in young women for feasibility of fertility-preserving surgery. It is used to plan radiotherapy for primary tumors in cervical cancer and particularly for conformal radiotherapy to deliver optimal doses to the tumor sites, while limiting unwanted exposure of bowel and other pelvic organs. In both cancers, MRI is used for diagnosing nodal disease, surveillance, detection of recurrence, and evaluation of complications secondary to treatment.

Occult myometrial recurrence after progesterone therapy to preserve fertility in a young patient with endometrial cancer

OBJECTIVE

We report a case of endometrial cancer treated by fertility-preserving P therapy, who subsequently presented with an abnormal magnetic resonance imaging (MRI) of the myometrium despite normal endometrial biopsies.

DESIGN

Case report.

SETTING

Tertiary referral university hospital.

PATIENT(S)

A 31-year-old patient with grade 1, stage I endometrial cancer presented for treatment with fertility-preserving P therapy. Multiple endometrial samples were all normal. Four years later, she presented with an abnormal pelvic MRI in the absence of any other signs or symptoms. Hysterectomy and oophoropexy confirmed normal endometrium with deeply invasive cancer. She remains cancer-free 2 years later with two normal children from surrogacy.

INTERVENTION(S)

Progestogen therapy, laparoscopic-assisted vaginal hysterectomy, oophoropexy, and assisted reproductive techniques (ART) and surrogate.

MAIN OUTCOME MEASURE(S)

Cancer disease status and fertility preservation.

RESULT(S)

Eight years after initial diagnosis, the patient remains cancer free and has conceived by surrogate reproductive techniques.

CONCLUSION(S)

Reproductive options remains a meaningful quality of life goal even for patients with cancer. Routine pelvic MRI should be considered for follow-up of endometrial cancer patients who retain their uterus. Hysteroscopy and dilation and curettage may not be sufficient.

Fertility after the treatment of gynecologic tumors

In a young woman with gynecologic cancer, preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian cancer of certain histological subtypes such as ovarian tumors of low malignant potential, malignant ovarian germ cell tumors, and ovarian sex cord stromal tumors. For women with invasive epithelial ovarian cancer who have early-stage disease, fertility-sparing surgery may be an option. In some cases, fertility-sparing surgery may be followed by postoperative chemotherapy. The concept of fertility-preserving surgery in early cervical cancer has been adopted by several leading centers worldwide as an option for stage Ia and small Ib disease without the presence of lymphovascular involvement. Nonsurgical options such as hormonal therapy may be considered for women with early-stage, low-grade endometrial cancer. Improvements in cancer cure rates and the development of conservative treatments mean that many young women with early gynecologic cancer can hope to start a new pregnancy after the treatment. Patients are generally advised to wait 2 years after treatment for any malignancy before attempting pregnancy, but the optimal interval between cure and conception must be carefully determined by a multidisciplinary team including oncologist and obstetrician. Gynecologic surgery and hemotherapy can have an impact not only on fertility, but also on the course of a next pregnancy (increased risk of miscarriage and premature delivery, etc.) These risks must be taken into account by the obstetrician. Management of young women diagnosed with gynecologic cancer should be individualized, with the risk of conservative therapy balanced against the disadvantages of more radical treatment. The patient and the family should be extensively counseled. The alternatives to the traditional and standard radical procedures should be discussed, and the limitation of data regarding many conservative treatment options should be explained. The patients should be aware that by accepting fertility-sparing treatment they are assuming a small but undefined risk for recurrence of the disease. They need to know that these conservative therapeutic approaches are yet not considered "standard." Furthermore, patients need to be assessed for the realistic probabilities of achieving conception on the basis on their age, history, and infertility evaluation. Some of them will require assisted reproduction technology (ARTS) to help achieve a pregnancy, especially in vitro fertilization (IVF). They may also consider ovarian tissue, oocyte, or embryo cryopreservation before definitive cancer therapies. And, finally, patients also need to understand the risk of premature delivery and the consequences of prematurity. The care of the young patient with gynecologic malignancy is extremely complex and challenging. It necessarily requires a multidisciplinary approach with the close collaboration of gynecologist-oncologist, reproductive endocrinologist, and perinatologist.

Outcome of in vitro fertilization treatment in infertile women conservatively treated for endometrial adenocarcinoma

OBJECTIVE

To evaluate IVF characteristics and outcome of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma.

DESIGN

Observational case series study.

SETTING

The Department of Gynecology Oncology and IVF unit of Chaim Sheba Medical center, Tel-Hashomer, Israel.

PATIENT(S)

Eight women referred to IVF treatment because of failure of other fertility treatments after conservative treatment of endometrial adenocarcinoma. All women were selected carefully for conservative treatment at the Department of Gynecology Oncology of the Chaim Sheba Medical Center after a thorough metastatic workup.

INTERVENTION(S)

In vitro fertilization/intracytoplasmic sperm injection treatment.

MAIN OUTCOME MEASURE(S)

Serum E(2) levels at hCG administration, endometrial thickness, number of oocytes retrieved, fertilization rate, pregnancy and delivery rate.

RESULT(S)

All women were nulliparous before IVF treatment, and only one woman was older than 35 years. In four of them, endometrial adenocarcinoma was diagnosed during infertility workup or treatment. A total of 31 IVF cycles were performed. The mean number of oocytes retrieved was 9.4 (95% confidence interval, 5.1-13.6), and fertilization rate was 58.6%. Six women (75%) conceived, and four (50%) delivered six healthy offspring.

CONCLUSION(S)

In vitro fertilization treatment of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma is highly successful and offers the opportunity to cryopreserve embryos for future use.

Aggressive mixed type endometrial carcinoma in a young woman with rapid progression and fatal outcome

INTRODUCTION

Endometrial carcinoma in young ages is uncommon and tends to be a well differentiated endometrioid type and has an excellent prognosis. Nevertheless, in this report mixed type endometrial cancer including serous, clear cell and endometrioid components in a young patient with rapid progression and fatal outcome is presented.

CASE

A 26-year-old virgin female was admitted with menometrohagia lasting for 9 months, leading to severe anemia. Transabdominal ultrasonography demonstrated 30 x 27 mm intramural mass consistent with leiomyoma in uterine corpus posterior. The patient did not permit any vaginal intervention including endometrial sampling, therefore laparotomy was decided. Mixed type endometrial carcinoma was diagnosed and she was treated with comprehensive surgery plus adjuvant chemotherapy. After 7 months of surgery she deceased.

CONCLUSION

We suggest that persistent uterine bleeding associated with severe anemia should be evaluated for malignancy even in young women to avoid delay in diagnosis. Imaging studies especially magnetic resonance imaging may be helpful when endometrial sampling cannot be done.

Safe fertility-preserving management in gynecological malignancies

OBJECTIVE

To provide a review in the available literature about the safe fertility-preserving management in gynecological malignancies, focusing on the selection criteria of the patients, treatment options and follow-up.

DESIGN

Literature survey.

RESULTS

The incidence of cancer in women who still want to get pregnant is increasing significantly. An early detection in gynecological malignancies allows less aggressive approaches to cure such disorders. A more conservative management, which preserves fertility, is considered safe and an option for those who have not completed their child-bearing.

CONCLUSIONS

Selected patients with cervical, endometrial and ovarian cancer may be candidates to a safe fertility-preserving management. A careful stage and follow-up of the patients is essential to achieve success with this practice.

Endometrial cancer and fertility

PURPOSE OF REVIEW

Endometrial cancer can affect reproductive-age women who may desire fertility preservation. This article discusses the current, available data about conservative management of endometrial cancer in young women.

RECENT FINDINGS

Reproductive-age women with well differentiated endometrial carcinoma have an overall favorable prognosis provided that the tumor is identified at an early, noninvasive stage; however, advanced disease can be present. This article discusses current modalities to evaluate and clinically stage endometrial cancer including hysteroscopy, dilation and curettage, pelvic ultrasound, abdominopelvic computed tomography scan, pelvic magnetic resonance imaging, tumor marker CA125 level, and surgical exploration with laparoscopy or laparotomy. Thorough evaluation is critical as 10 to 29% of young women with endometrial cancer have a synchronous ovarian malignancy. Detailed counseling about the risks and benefits of conservative management, and expectations for fertility after treatment, surveillance, and definitive surgical management is essential. Multiple effective protocols exist for conservative treatment of endometrial cancer, and the initial response rates are as high as 57 to 75%. Successful pregnancies have occurred after conservative management, spontaneously, and with assisted reproductive technologies.

SUMMARY

There are no standard recommendations for selection of appropriate women, treatment protocols, or long-term surveillance for conservative management of clinical stage I endometrial adenocarcinoma, and larger prospective clinical studies are warranted.

The role of hormones for the treatment of endometrial hyperplasia and endometrial cancer

PURPOSE OF REVIEW

Hormone therapy has been palliative for advanced/ recurrent endometrial cancer. High remission rates are seen in well-selected stage I, grade 1 endometrial cancer of young women using hormone therapy (usually progestins) as fertility-preserving treatment. Many other hormones, such as gonadotropin-releasing hormone analogs (GnRHa), selective estrogen receptor modulators, aromatase inhibitors, intrauterine progestins, and others are potential modalities. This review updates the recent publications in this area.

RECENT FINDINGS

Two reports investigating different scheduling of tamoxifen and progestins indicated that tamoxifen may be a valuable adjunct to progestin therapy. GnRHa has been used adjunctively to tamoxifen as second-line hormone therapy for fertility sparing after progestin failed. Aromatase inhibitors have shown their potential in treating endometrial cancer and endometrial hyperplasia as single agent or in combination with progestins. Intrauterine progestins seem efficacious in treating endometrial hyperplasia; its applications on endometrial cancer patients, however, have been limited to postmenopausal women with poor surgical risk.

SUMMARY

Translational research based on molecular mechanisms is mandatory to a more appropriate utilization of hormone therapy. The role of dose, scheduling, route of administration of progestins as well as the addition of other hormonal agents should be further explored by well designed randomized controlled trials.