British Gynaecological Cancer Society (BGCS) uterine cancer guidelines: Recommendations for practice

Screening and prevention of gynecologic malignancies in patients with lynch syndrome: following the guidelines

Lynch syndrome (LS), a hereditary condition caused by germline mutations in mismatch repair (MMR) genes, significantly elevates the lifetime risk of endometrial cancer (EC) (40-60%) and ovarian cancer (8-10%) in affected women. Despite advances in colorectal cancer screening for LS patients, optimal strategies for gynecologic cancer prevention remain under debate. Current recommendations for EC surveillance, including annual transvaginal ultrasound and endometrial biopsy starting at age 30-35, lack robust evidence for effectiveness. Risk-reducing hysterectomy with bilateral salpingo-oophorectomy (BSO) is frequently advised after childbearing to mitigate cancer risk. Emerging data suggest that hormonal interventions, such as oral contraceptives and progestin-based therapies, may reduce EC risk by up to 50%, offering non-surgical preventive options. Lifestyle modifications, including weight management and physical activity, further complement risk reduction strategies. Molecular diagnostic advancements, including immunohistochemistry and microsatellite instability testing, enhance early identification of LS-associated gynecologic malignancies. For patients with advanced or recurrent EC, the integration of immunotherapy into treatment regimens has demonstrated significant efficacy. Agents such as pembrolizumab and dostarlimab, particularly in combination with carboplatin and paclitaxel, have improved progression-free and overall survival rates for patients with MMR-deficient tumors. This review highlights the need for personalized, evidence-based approaches to gynecologic cancer screening and prevention in LS, emphasizing the importance of integrating genetic testing, patient education, and novel therapeutic options. Future research should focus on refining screening protocols and expanding non-invasive preventive strategies to improve outcomes for this high-risk population.

Uterine Carcinosarcoma-A Retrospective Cohort Analysis from a Tertiary Centre on Epidemiology, Management Approach, Outcomes and Survival Patterns

BACKGROUND/OBJECTIVES

Uterine carcinosarcoma (UCS) refers to a rare high-grade aggressive epithelial non-endometrioid endometrial carcinoma, with tumour cells demonstrating epithelial-mesenchymal metaplastic transition and composed of both carcinomatous epithelial and sarcomatous (homologous or heterologous) components.

METHODS

The aim of this study was to evaluate the epidemiology, management approach, outcomes and survival patterns of patients with UCS. Seventy-seven cases of UCS treated with primary surgery in a single tertiary centre underwent retrospective cohort analysis across a ten-year period. Observational data on clinicopathological variables and treatment pathways were reviewed and independent risk factors for relapse and mortality were analysed.

RESULTS

The 5-year disease-free and overall survival rates were 52.10% and 46.6%, respectively. Cervical stromal involvement was independently related to disease-free survival (HR = 6.26; 95%CI 1.82-21.59; p = 0.004) and overall survival (HR = 3.64; 95%CI 1.42-9.38; p = 0.007), whilst sarcomatous component type was independently related to recurrence only (HR = 3.62; 95%CI 1.38-9.51; p = 0.009) after adjusting for other pathological and treatment variables. No significant difference in recurrence or mortality was found when comparing the performance of pelvic lymph node dissection (p = 0.803 and p = 0.192 respectively) or the administration of adjuvant treatment (p = 0.546 and p = 0.627 respectively).

CONCLUSIONS

Whilst our data suggests an encouraging similarity in overall survival rates compared with the literature, UCS continues to represent significant treatment challenges-with a paucity of guidelines available. Data regarding molecular analysis was not systemically available in our cohort, the more recent introduction of which (alongside the revision of endometrial cancer staging) will undoubtedly provide UCS patients with improved therapeutic options in the future.

Global survey on training and practice in sentinel lymph node mapping for endometrial and cervical cancer among early-career gynecologic oncologists

OBJECTIVE

This survey was designed to evaluate exposure to sentinel mapping for cervical and endometrial cancers in addition to the quality and availability of surgical training in sentinel procedures around the world. Furthermore, we aimed to identify obstacles in surgical training in the sentinel procedure to support the adoption of this technique in clinical practice.

METHODS

A 52-item survey was developed and computed using Qualtrics XM and SurveyMonkey software. The target population were members of the European Society of Gynaecological Oncology and the International Gynecological Cancer Society aged ≤40 years. The study invitation was disseminated within both organizations' database. The survey hyperlink was active between September and December 2022. Respondents using the same Internet Protocol address were excluded to avoid duplication of responses. Responses to <50% questions were excluded.

RESULTS

Overall, 238 respondents joined the survey, and 182 (76.5%) provided answers that met the inclusion criteria. Sentinel mapping was implemented for a longer period and used more frequently in endometrial than in cervical carcinoma; 55% of the responders were initially trained in systematic lymph node dissection, and 22% were not yet trained in any lymph node staging. The main challenges in applying sentinel procedure for early-career gynecologic oncologists were no access to hands-on training (n = 22, 12.1%) and no clinical routine in performing systematic pelvic (n = 15, 8.2%) and para-aortic (n = 35, 19.2%) lymph node dissection in case of failed mapping.

CONCLUSIONS

Although sentinel lymph node biopsy is integrated in cervical and endometrial cancer guidelines, a significant number of institutions do not implement this procedure in clinical routine, and 22% of early-career gynecologic oncologists are not trained in any type of surgical lymph node staging. Support for sentinel mapping in national guidelines and guided training opportunities are needed to apply this method globally.

Canadian Association of Radiologists Cancer Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Cancer Expert Panel is made up of physicians from the disciplines of radiology, medical oncology, surgical oncology, radiation oncology, family medicine/general practitioner oncology, a patient advisor, and an epidemiologist/guideline methodologist. The Expert Panel developed a list of 29 clinical/diagnostic scenarios, of which 16 pointed to other CAR guidelines. A rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of the remaining 13 scenarios. Recommendations from 21 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop the recommendation for these scenarios. During recommendation formulation, one additional scenario was mapped to an existing CAR guideline scenario, leaving 12 scenarios with new recommendations. The guideline focuses on cancer diagnosis and does not cover cancer staging, follow-up, and surveillance. This guideline presents the methods of development and the referral recommendations for suspected pancreatic cancer, suspected liver cancer, incidental liver mass, incidental colon mass or suspected colon cancer, suspected anal cancer, suspected penile cancer, suspected cervical cancer, suspected endometrial/uterine cancer, suspected vulvar cancer, suspected vaginal cancer, suspected haematologic malignancies, and suspected skin cancer. The guideline also points to other CAR guidelines for suspected neck, thyroid, brain, lung, intracardiac/pericardial, esophageal/gastric, renal, adrenal, bladder, testicular, prostate and ovarian cancers, suspected soft tissue mass or tumour, suspected bone tumour, suspected bone tumour --myeloma, suspected spine tumours, and incidental lung cancer.

Implementing recommendations for routine mismatch repair (MMR) immunohistochemistry (IHC) testing of endometrial cancer and subsequent patient management

Lynch syndrome is associated with an increased risk of cancer, including endometrial cancer. We audited the introduction of a nurse-led testing and management pathway for Lynch syndrome. All 191 patients diagnosed with endometrial cancer at Somerset NHS Foundation Trust between January 2022 and December 2023 were tested for mis-match repair (MMR) protein immunohistochemistry; germline testing was offered to all 13 who were eligible. Seven patients were diagnosed with Lynch syndrome; all were referred for bowel screening and Helicobacter pylori testing. Information about prophylactic aspirin recommendations was missing for 3/7 patients. We established an effective, nurse-led Lynch syndrome testing pathway, in line with national guidelines.

Value of endometrial biopsy in patients with hysteroscopically atrophic endometrium in patients with postmenopausal bleeding

PURPOSE

To determine the rate of precancer and cancer in women presenting with PMB who have a visually atrophic endometrium at hysteroscopy and assess the value of endometrial biopsy in this situation and the adequacy of the samples obtained.

METHODS

Retrospective reviews of all patients with a visually atrophic endometrium at hysteroscopy who had presented with PMB and had an ET > / = 4 mm or ET < 4 mm with focal changes or irregular features between 2013 and 2024 at University Hospitals of Derby and Burton were included (n = 1096). Patients who had previously had cancer or precancer or had unclear hysteroscopy findings were excluded. The endometrial biopsy histology result was considered the main outcome measure.

RESULTS

188 patients did not have a biopsy performed (17.15%), 660 patients had benign pathology (60.22%), and 239 patients had an inadequate sample result (21.81%). Nine patients had precancerous changes (0.82%). The rate of cancer was 0.00% (n = 0). The NPV of a visually atrophic endometrial cavity at hysteroscopy in detecting precancer or cancer was 99.2%. Patients with an ET < 4 mm pre-hysteroscopy and an atrophic endometrial cavity at hysteroscopy were 2.25 times more likely than those whose ET is > 4 mm to have an inadequate sample (p < 0.001, 95% CI 1.61-3.16). 10 patients who had an inadequate sample at initial biopsy had a repeat inadequate sample (n = 23, 43.48%).

CONCLUSIONS

The incidence of precancer/cancer in patients presenting with PMB with a visually atrophic endometrium at hysteroscopy is low. Many patients within this cohort have an inadequate sample at biopsy, and therefore, repeat sampling is of questionable value.

Challenging the Binary Classification of Endometrioid Endometrial Adenocarcinoma: The Evaluation of Grade 2 as an Independent Entity Based on Prognostic Characteristics and Recurrence Patterns

Background: Although grade is a well-recognised prognostic factor for endometrioid endometrial cancer (EEC), in more studies grade 1 (G1) and grade 2 (G2) EEC are combined and compared together with grade 3 (G3) tumours. The aim of our study is to separately investigate the outcomes, prognostic factors and recurrence patterns of G2 EEC and whether the differentiation between G1 and G2 EEC is clinically useful. Methods: we retrospectively reviewed 523 patients with EEC treated with primary surgery over a decade (March 2010-January 2020) at Oxford University Hospitals NHS Trust, focusing on those with G2 disease. Results: Patients with G2 EEC had worse 5-year cancer-specific survival (93.3% vs. 98.5%, p < 0.01) compared to patients with G1 EEC, but a favourable prognosis compared to G3 EEG, both in terms of disease-free survival (91.6 vs. 83.8%, p = 0.04) and cancer-specific survival (93.3% vs. 78.5%, p < 0.01). Both stage and grade are independent risk factors for cancer-specific mortality in EEC. Cervical stromal involvement, parametrial involvement and distant metastatic disease are all independent risk factors for cancer-related mortality in G2 ECC. Only 12.5% of recurrences of G2 EEC were diagnosed with examination in routine follow up in asymptomatic patients. Conclusions: our results suggest that the grading system should continue to differentiate G1 EEC and G2 EEC for better prognosis interpretation.

Gynecological Insights into Lynch Syndrome-A Comprehensive Review of Cancer Screening and Prevention

Lynch syndrome, one of the most common genetic syndromes predisposing to cancer, is associated with a series of malignant conditions, among which the most frequent is colorectal cancer, but gynecologic cancers (especially endometrial) are also quite common. Despite the significant progress made in understanding this condition over time, there are still aspects in managing this condition that have not demonstrated clear benefits. This article aims to summarize the recommendations of international societies and present the latest developments in managing Lynch syndrome, focusing on gynecologic cancer screening and possible prevention strategies. Advances in genetic testing procedures and discoveries related to the association between oncological pathology frequency and the affected pathogenic variant type will probably lead to personalized medicine focused on the individual patient in the coming years. Although various screening methods for gynecological cancers in patients with Lynch syndrome have been used over time, they have not shown significant survival benefits. This highlights the need for studying and implementing new screening and diagnostic methods, which have been under investigation in recent years and are mentioned in this article.

Fertility-preserving treatment for stage IA endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

The increasing use of fertility-preserving treatments in reproductive-aged patients with early-stage endometrial cancer necessitates robust evidence on the effectiveness of oral progestins and levonorgestrel-releasing intrauterine device. We conducted a systematic review and meta-analysis to examine the outcomes following these 2 primary progestin-based therapies in reproductive-aged patients with early-stage endometrial cancer.

DATA SOURCES

We conducted a systematic review of observational studies and randomized controlled trials following the Cochrane Handbook guidance. We conducted a literature search of 5 databases and 1 trial registry from inception of the study to April 16, 2024.

STUDY ELIGIBILITY CRITERIA

Studies reporting complete response within 1 year in reproductive-aged patients with clinical stage IA endometrioid cancer undergoing progestin therapy treatment were included. We used data from both observational and randomized controlled studies.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary exposure assessed was the type of progestational treatment (oral progestins or LNG-IUD). The primary outcome was the pooled proportion of the best complete response (CR) within 1 year of primary progestational treatment. We performed a proportional meta-analysis to estimate the treatment response. Sensitivity analyses were performed by removing studies with extreme effect sizes or removing grade 2 tumors. The risk of bias was assessed in each study using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Our analysis involved 754 reproductive-aged patients diagnosed with endometrial cancer, with 490 receiving oral progestin and 264 receiving levonorgestrel-releasing intrauterine device as their primary progestational treatment. The pooled proportion of the best complete response within 12 months of oral progestin and levonorgestrel-releasing intrauterine device treatment were 66% (95% CI, 55-76) and 86% (95% CI, 69-95), respectively. After removing outlier studies, the pooled proportion was 66% (95% CI, 57-73) for the oral progestin group and 89% (95% CI, 75-96) for the levonorgestrel-releasing intrauterine device group, showing reduced heterogeneity. Specifically, among studies including grade 1 tumors, the pooled proportions were 66% (95% CI, 54-77) for the oral progestin group and 83% (95% CI, 50-96) for the levonorgestrel-releasing intrauterine device group. The pooled pregnancy rate was 58% (95% CI, 37-76) after oral progestin treatment and 44% (95% CI, 6-90) after levonorgestrel-releasing intrauterine device treatment.

CONCLUSION

This meta-analysis provides valuable insights into the effectiveness of oral progestins and levonorgestrel-releasing intrauterine device treatment within a 12-month timeframe for patients with early-stage endometrial cancer who desire to preserve fertility. These findings have the potential to assist in personalized treatment decision-making for patients.

British Gynaecological Cancer Society and British Menopause Society guidelines: Management of menopausal symptoms following treatment of gynaecological cancer

These guidelines have been developed jointly by the British Gynaecological Cancer Society and British Menopause Society to provide information for all healthcare professionals managing women treated for gynaecological cancer. Menopausal symptoms can have a significant impact on quality of life for women. Cancer therapies, including surgery, pelvic radiotherapy, chemotherapy and endocrine therapy, can all affect ovarian function. The benefits and risks of using hormone replacement therapy are considered by cancer type with guidance on the type of HRT and optimal time of commencement after cancer treatment. Vaginal estrogens can be very effective for improving urogenital symptoms and are safe for the majority of women, including those for whom systemic HRT is contraindicated with rare exceptions. Alternative options to HRT are reviewed including pharmacological and non-pharmacological approaches.

The oncological and reproductive outcomes of fertility-preserving treatments for stage 1 grade 1 endometrial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The number of patients desiring fertility-preserving treatment for endometrial cancer rather than standard surgical management continues to increase.

OBJECTIVE

We aimed to evaluate the efficacies of fertility-preserving treatments on the live birth rate, remission and relapse rates for women with stage 1a grade 1 endometrial carcinoma to support patient counselling.

METHODS

We performed a meta-analysis for our primary outcomes of overall remission and relapse rate, and for secondary analysis, we divided papers into treatment type: systemic progestins, intrauterine progestins or hysteroscopic resection and adjuvant hormonal treatment.

RESULTS

Thirty-five observational studies met inclusion criteria, with a total of 624 patients. Overall, conservative treatment of endometrial cancer showed a remission rate of 77% (95% CI: 70-84%), a relapse rate of 20% (95% CI: 13-27%) and a live birth rate of 20% (95% CI: 15-25%) with more favourable outcomes for the hysteroscopic resection group.

CONCLUSIONS

Hysteroscopic resection and adjuvant hormonal treatment had the most favourable fertility and oncological outcomes. Further high-quality prospective multi-centre trials are warranted to determine the optimal treatment regimen and dosage and risk stratification for these patients.

Trends in the incidence and mortality of cervical, ovarian, and corpus uteri cancers in Wales, UK: A joinpoint regression analysis from 2002 to 2021

OBJECTIVES

The primary objective of this study was to examine the secular trends of cervical, ovarian, and corpus uteri neoplasm in Wales, UK, over the period from 2002 to 2021. We aimed to identify changes in the incidence and mortality rates of these cancers to inform future healthcare policies and cancer prevention programs.

METHODS

We sourced incidence data from 2002 to 2019 and mortality data from 2002 to 2021 from the Welsh Cancer Intelligence and Surveillance Unit. The data were analysed using Joinpoint regression to compute the average annual percentage change (AAPC) in age-standardized incidence rates (ASIR) and mortality rates (ASMR) per 100,000 population for each type of cancer.

RESULTS

The results showed that the ASIR for cervical cancer remained stable between 2002 and 2019 (AAPC = -0.5; 95 %CI = -1.4-0.4). However, the ASMR significantly declined from 4.88 in 2002-3.03 in 2021 (AAPC = -2.3; 95 %CI = -3.4 to -1.1). The ASIR for ovarian cancer significantly decreased from 27.39 in 2002-17.87 in 2019 (AAPC = -2.6; 95 %CI = -3.0 to -2.1), and the ASMR showed a statistically significant decreasing trend from 15.92 in 2002-11.2 in 2021 (AAPC = -1.7; 95 %CI = -2.5 to -0.9). In contrast, the ASIR for corpus uteri neoplasm significantly increased from 22.24 in 2002-30.41 in 2019 (AAPC = 2.2; 95 %CI = 1.2-3.4), and ASMR also showed a statistically significant increasing trend from 3.27 in 2002-6.42 in 2021 (AAPC = 3.8; 95 %CI = 2.3-5.3).

CONCLUSIONS

The study concludes that while the incidence and mortality rates for cervical and ovarian cancers in Wales have significantly decreased, corpus uteri neoplasm rates have increased during the study period. These findings underscore the need for continued efforts to improve early detection and treatment strategies, including national screening programs and public health initiatives, to mitigate the burden of these cancers.

The optimal endometrial thickness threshold for prediction of endometrial cancer in postmenopausal women without bleeding remains uncertain-Systematic review and meta-analysis

The incidental finding of endometrial thickness (ET) >4 mm in the absence of postmenopausal bleeding (PMB) is a common cause of referring women to secondary care. However, there is lack of consensus amongst gynecologists as regards the management. It is estimated that up to 15 % of endometrial cancers occur in women without PMB. The aim this study was to determine the optimal ET threshold, on trans-vaginal ultrasound scan, that discriminates normal endometrium from endometrial hyperplasia and cancer in this cohort. On using a thorough search strategy, a total 16 studies including 4088 women were deemed eligible. However, the data were not amenable to meta-analysis. There were wide variations in the thresholds reported with potential bias given the retrospective nature of the majority of the studies. Despite contacting authors, we could not obtain the primary data to generate a Receiver Operating Characteristic (ROC) Curve. No linear or curvilinear association was found between ET thresholds and the percentage of women diagnosed with endometrial hyperplasia and cancer using either Pearson's correlation, linear or curvilinear regression, or a simple visual scan/scatter diagram. The result of this study reveals the lack of evidence to inform clinical practice in this area, and there is a need for a well-designed multi-center prospective study.

Molecular classification in fertility-sparing treatment of early-stage endometrial cancer: A potential tool for optimizing patient selection

OBJECTIVE

To investigate the prognostic significance of molecular classification on treatment outcomes of fertility-sparing treatment (FST) in early-stage endometrial cancer (EC), and its potential in optimizing fertility-sparing management.

METHODS

Patients with early-stage EC who received FST with ProMisE classification were investigated. Oncological and reproductive outcomes were compared across four molecular subtypes. Factors influencing complete response (CR) were analyzed.

RESULTS

Among 116 molecularly classified patients, 80 were evaluated for therapeutic effects, including 64 (80.0 %) p53wt, 7 (8.7 %) MMR-D, 5 (6.3 %) POLE EDM, and 4 (5.0 %) p53abn. Overall CR rates were comparable across four molecular subtypes, with 92.2 % of p53wt, 71.4 % of MMR-D, 100.0 % of POLE EDM, and 75.0 % of p53abn (P = 0.145). MMR-D patients needed the longest median treatment time to achieve CR (7.9 months, range 3.5-15.9), while POLE EDM required the shortest (3.0 months, range 2.8-6.4), followed by p53abn (3.5 months, range 3.0-3.7) and p53wt (3.7 months, range 2.2-22.8) (P = 0.049). Among 14 p53wt patients with superficial myometrial invasion (MI) or G2 histology, 13 (92.9 %) achieved CR, and of 8 who attempted to conceive,4 delivered. Multivariable analysis identified MMR-D, superficial MI and insulin resistance negatively predicted CR, while POLE EDM was a positive factor.

CONCLUSIONS

Molecular classification of EC may serve as a tool for predicting response to FST and assist in identifying candidates for FST. POLE EDM patients tended to obtain promising outcomes. MMR-D cases should be cautiously administrated for FST with close surveillance. Patients with p53wt demonstrated favorable outcomes, including those with superficial MI or G2 EC. Patients with endometrium-confined p53abn tumors may benefit from FST. However, given the small sample sizes of certain subtypes, further investigation is necessary to validate these findings.

Real-world patient characteristics and survival outcomes in patients with advanced or recurrent endometrial cancer in England: a retrospective, population-based study

OBJECTIVE

This study defined a retrospective cohort of patients in England with primary advanced or recurrent (A/R) endometrial cancer (EC) who may have been eligible for clinical trials evaluating immune checkpoint inhibitors (ICIs) in the first-line (1L) setting within a real-world dataset, and described the characteristics, treatment patterns and outcomes within this cohort.

DESIGN

This was a retrospective, population-based study.

SETTING

Routine population-level data from the National Cancer Registration and Analysis Service in England were used. Patients diagnosed with A/R EC between 1 January 2013 and 31 December 2019 were included (follow-up until 23 August 2021). ICI-eligible patients who received any 1L therapy (defined as first systemic treatment for A/R EC with or without radiotherapy) and met key eligibility criteria for the RUBY trial (NCT03981796; 1L cohort) were included. A subpopulation who solely received carboplatin-paclitaxel at 1L (carboplatin-paclitaxel subcohort) was identified.

METHODS

Demographics, characteristics and therapy received were reported. Overall survival (OS), time to next treatment (TTNT) and time to treatment discontinuation (TTD) from 1L chemotherapy initiation were assessed using Kaplan-Meier methodology.

RESULTS

Of 13 954 patients identified, 2376 ICI-eligible patients were included in the 1L cohort (median [range] age: 67.9 [26.7-94.0] years); 902 patients received solely carboplatin-paclitaxel at 1L. Demographics and disease characteristics were generally similar between cohorts. Median (95% CI) OS, TTNT and TTD from 1L chemotherapy were 27.2 (24.7, 30.2), 16.9 (15.8, 18.5) and 3.4 (3.4, 3.4) months, respectively, in the 1L cohort, and 17.2 (15.5, 19.0), 12.4 (11.6, 13.5) and 3.4 (3.4, 3.4) months, respectively, in the carboplatin-paclitaxel subcohort.

CONCLUSION

Long-term outcomes were poor for both cohorts, particularly the carboplatin-paclitaxel subcohort, where patients did not receive radiotherapy and had predominantly metastatic disease. This reflects the unmet need for more durable treatment options to prevent relapse and prolong survival in this patient population. This real-world study will help contextualise outcomes from ongoing phase III clinical trials investigating 1L ICI treatments.

Combined robotic surgery for concomitant treatment of endometrial cancer and obesity

BACKGROUND

Endometrial Cancer (EC) is strongly linked to obesity. Bariatric surgery is recognized as a long-term solution for weight loss in severely obese patients. This pilot study investigates the feasibility, intraoperative and 30-day morbidity outcomes of integrating gynecological surgical staging and bariatric robotic surgery in class II and III obese patients affected by early EC or Endometrial Intraepithelial Neoplasia (EIN).

METHODS

Patients aged over 18 years old with early EC or EIN and class II and III obesity (Body mass index (BMI) ≥ 35 kg/m2) who are surgical and anesthesiologic candidates. Standard robotic surgery for early EC staging performed alone (THBSO group) or in conjunction with sleeve gastrectomy (THBSO + SG group) for obesity management was proposed.

RESULTS

Of the 13 patients who met the inclusion criteria, 5 (38.46%) opted for combined surgery. The groups showed a significant difference in preoperative BMI (49.68 kg/m2 vs. 40.24 kg/m2 p = 0.017 with and without SG), preoperative weight (143.92 kg vs. 105.62 kg p = 0.004 with and without SG), preoperative (p = 0.01) and postoperative (p = 0.005) aspartate transaminase (AST). The THBSO + SG group had higher anesthesia induction end-tidal carbon dioxide (ETCO2) (p = 0.05), final Partial pressure of carbon dioxide (PaCO2) (p = 0.044), anesthesia induction lactate (p = 0.001) and final lactate (p = 0.011) without a significant difference in final pH (p = 0.31). Operative time was longer in the THBSO + SG group (p < 0.001), but this did not result in longer ICU (p = 0.351), total hospital stays (p = 0.208), nor increased blood loss and transfusion. The simultaneous combined approach had an 80% success rate. At 6 months, the THBSO + SG group achieved significantly greater weight loss than the THBSO group (ΔBMI - 11.81 kg/m2 vs - 1.72 kg/m2, p = 0.003, with and without SG).

CONCLUSION

Integrating robotic EC staging with SG in obese women with early EC increased the operative time without increasing intraoperative risks, early and 30 days post-surgery complication and offering a promising approach to simultaneously treating both conditions.

Endometrial Cancer: Analysing Patterns of Recurrence and Real-Life Outcome Data Using the 2020 ESGO-ESTRO-ESP Risk Stratification System

AIMS

To evaluate patterns of recurrence and explore the prognostic differences between the 2018 FIGO staging system and the 2020 ESGO-ESTRO-ESP risk stratification system of endometrial cancer with an emphasis on early-stage disease.

BACKGROUND

The incidence of endometrial cancer has risen by around 60% since the 90's. It is projected that by 2035 endometrial cancer will be the sixth most common cause of cancer-related death amongst females.

METHODS

This was a retrospective cohort study which included patients treated between 2010 and 2017. Primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meyer survival analysis was used to assess OS and RFS across different risk groups. Cox proportional hazards regression was used to evaluate prognostic risk factors implicated in recurrence. Different recurrence patterns across the subgroups were analysed with Pearson's chi-square test.

RESULTS

The study included 692 patients with a recurrence rate of 14.9%. The median time to recurrence was 17.1 months (IQR:8.8-28.4). The mean OS varied between 97.2 months in the low-risk group to 63.1 months in the high-risk group (p < 0.001). Mean RFS was 96.1 in the low-risk group and 58.9 in the high-risk group (p < 0.001). RFS was predicted by the following factors; high risk group (OR=3.87; p = 0.041), LVSI (OR=2.54, p = 0.005), carcinosarcoma (OR=2.20, p = 0.021) and serous subtype (OR=1.91, p = 0.01). Logistic regression was used to evaluate risk factors for loco-regional and distant recurrence. Patients in the low-risk group were less likely to have distant recurrence (OR=0.08, p = 0.004). Similarly, negative LVSI and Grade 1 cancers were associated with decreased risk of distant recurrence (OR=0.34, p = 0.006 and OR=0.33, p = 0.007, respectively). There were no significant risk factors for loco-regional recurrence.

CONCLUSIONS

The 2020 ESGO-ESTRO-ESP risk stratification provides accurate estimates of recurrence risk and survival. Those treated in line with current guidance have significantly better outcomes.

Current Management Practices for Endometrial Cancer (EC) in the UK: A National Healthcare Professional Survey (KNOW-EC)

The clinical landscape for endometrial cancer in the UK is evolving to include new management guidelines and targeted treatment options. An understanding of current treatment and management practices in the UK will help services plan and adapt to upcoming changes.

AIM

The purpose of this survey was to understand current and anticipated real-world practices for endometrial cancer care in the UK and potential areas for optimisation.

MATERIALS AND METHODS

Telephone interviews were conducted in November/December 2021 with UK-based healthcare professionals involved in endometrial cancer management. Questions were aligned with the British Gynaecological Cancer Society/European Society for Medical Oncology recommendations, covering the pathway from diagnosis and treatment to follow-up.

RESULTS

A total of 63 healthcare professionals (HCPs) involved in the management of patients with endometrial cancer participated in telephone interviews. The results highlighted variations in management and treatment practices for endometrial cancer and suggest that current UK practice appears to diverge from national and international guidance in some instances. While somatic mismatch repair deficiency testing was used by 89.7% of respondents as mainstream testing, the survey highlighted a lack of access to other key molecular biomarker tests, such as polymerase epsilon (POLE) sequencing (used by only 9.8% of HCPs at the time of the survey).

CONCLUSION

The results highlighted several perceived practical barriers to the swift adoption of new therapeutic options, including funding access, limited staff, treatment-related resources, staff education, and support. Our findings support the need for better access to biomarkers that could enable more effective and targeted treatments.

Analysis of Predictive Factors Associated with Unsuccessful Sentinel Lymph Node Mapping in Endometrial Carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is recommended over systematic lymphadenectomy in early-stage endometrial cancer due to its lower morbidity and comparable detection rate. The objective of this study was to identify clinical factors associated with unsuccessful mapping.

METHODS

Between April 2020 and June 2024, 120 patients over the age of 18 and diagnosed with early-stage endometrial cancer were enrolled in this prospective study at a single institution. Demographic, clinicopathologic, and treatment data were collected and analyzed using descriptive statistics. Univariate and multiple linear regressions were performed to identify predictors of failed mapping.

RESULTS

The mean age of the patient cohort was 62.5 years (range 33 to 83), and the mean body mass index (BMI) was 32 kg/m2 (range 18 to 50). Patients underwent intracervical injections with methylene blue (MB), indocyanine green (ICG), or a combination of both tracers, with 40 patients in each group. A total of 108 patients (90.0%) were diagnosed with endometrioid carcinoma and 12 (10.0%) with non-endometrioid cancers. Additionally, 110 patients (91.7%) were diagnosed in early stages of the disease. The overall SLN detection rate was 73.4%, with bilateral detection at 49.2% and unilateral detection at 24.2%. Univariate analysis showed that older age (p < 0.001), menopause (p = 0.001), the use of MB as the sole tracer (p = 0.006), a shorter tumor-to-serosa distance (p = 0.048), and bulky lymph nodes (p = 0.18) were associated with unsuccessful mapping. Multiple linear regression model analysis identified age (p = 0.007), tracer type (p = 0.013), and enlarged lymph nodes (p = 0.013) as independent predictors of SLN mapping failure.

CONCLUSIONS

Advanced age, tracer type, and intraoperative detection of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.

Management of Endometrial Cancer: A Comparative Review of Guidelines

Endometrial cancer is the most frequently diagnosed gynecological cancer. The aim of this study was to summarize and compare the most recent guidelines regarding its management. A comparative review of guidelines from the European Society of Gynecological Oncology, the European Society for Radiotherapy and Oncology, the European Society of Pathology, the European Society for Medical Oncology, the Cancer Council of Australia, the British Gynecological Cancer Society, the National Comprehensive Cancer Network, and the American College of Obstetricians and Gynecologists was carried out. The comparison of guidelines highlighted common recommendations and key differences regarding the most basic aspects of endometrial cancer management. Certain differences were identified in the options of surgical procedures based on endometrial biopsy and lymph node infiltration. Minor differences were identified in the management of recurrent disease, while the more pronounced differences were found in the follow-up procedure. The development of consistent international protocols in similar resource settings may lead to a more consistent classification, as well as to common lines regarding surgical approaches, risk stratification and the way patients should be monitored following the remission of endometrial cancer.

Loss of vimentin expression in preoperative biopsies independently predicts poor prognosis, lymph node metastasis and recurrence in endometrial cancer

BACKGROUND

Precise preoperative risk classification of endometrial cancer is crucial for treatment decisions. Existing clinical markers often fail to accurately predict lymph node metastasis and recurrence risk. Loss of vimentin expression has emerged as a potential marker for predicting recurrence in low-risk endometrial cancer patients. We assessed whether vimentin expression in preoperative biopsies predicts poor prognosis and lymph node metastasis in a large multicentre cohort.

METHODS

Vimentin expression was evaluated using immunohistochemistry in 1483 patients diagnosed with endometrial cancer across 14 hospitals in Europe. Expression levels of vimentin were analyzed in conjunction with clinical characteristics for predicting disease-specific survival and lymph node metastases.

RESULTS

Vimentin loss was significantly associated with aggressive disease and poor survival. Adjusted for clinicopathological variables, vimentin remained independently prognostic with a hazard ratio (HR) of 1.68 (95% CI 1.16-2.42, P = 0.006). Vimentin expression remained independently prognostic in endometrioid endometrial cancer- and FIGO staged 1 patient. Interestingly, vimentin loss independently predicted lymph node metastases, with an HR of 1.83 (95% CI 1.13-2.95, P = 0.014).

CONCLUSIONS

Loss of vimentin in preoperative biopsies serves as an independent predictor of poor prognosis and lymph node metastases. Incorporating vimentin as a clinical marker can improve risk stratification and treatment decisions.

Endometriosis: recent advances that could accelerate diagnosis and improve care

Endometriosis is a common disorder associated with pain, gastrointestinal and urinary symptoms, infertility, and fatigue. It is defined by the presence of endometrial-like lesions found predominantly in the pelvis. Mechanisms that contribute to disease aetiology include changes in hormonal, inflammatory, and pain pathways. In this article, we focus on recent developments in imaging technologies, on our improved understanding of mechanisms contributing to infertility, on drug therapies that are in clinical trials, and on insights from studies on the gut that offer potential to support self-management strategies. We postulate that improvements in the quality of life of patients will be accelerated by reframing endometriosis as a multi-system disorder and learning from treatments targeting symptoms shared between endometriosis, neuroinflammatory, and gastrointestinal disorders.

Qualitative exploration of uterine cancer care for lesbian, gay, bisexual, trans and queer (LGBTQ+) patients in the UK: shifting from equality to equity

OBJECTIVE

Patients identifying as lesbian, gay, bisexual, transgender and/or queer/questioning (LGBTQ+) report significant disparities in cancer care and are disproportionally affected by a cancer diagnosis on a number of health-related indicators. This study aimed to explore uterine cancer (UC) care from the perspectives of LGBTQ+ patients and stakeholders, to identify this population's care needs, which have been underprioritised thus far.

METHODS AND ANALYSIS

Qualitative interview data were collected from three cohorts of participants: LGBTQ+ UC patients, partners of UC patients and stakeholders who provide advocacy and/or support within the UC care pathway, including healthcare professionals (HCPs). Semi-structured qualitative interviews were conducted and data were analysed using inductive reflexive thematic analysis.

RESULTS

Fifteen participants (three patients, one partner, eight HCPs and three cancer support charity representatives) were recruited. Data analysis identified themes which represented participants' reflections on the relevance and opportunities for identity disclosure during the diagnostic pathway; feelings and implications of not fitting into the gynaecological cancer environment and, opportunities and challenges surrounding HCP education, and protocolled sexual and gender identity data collection.

CONCLUSION

UC patients who identify as LGBTQ+ have specific care needs and considerations, particularly related to transvaginal procedures and survivorship. Opportunities for disclosure of patients' LGBTQ+ identity during the UC care pathway are essential for these needs to be recognised. Despite this, there are conflicting agendas between HCPs and stakeholders on the best approach to integrate disclosure processes. The current findings highlight the need for public health agendas and clinical services to address the needs of LGBTQ+ UC patients.

Is p53 immunohistochemistry alone useful for delineating adjuvant endometrial treatment in low-middle-income countries?

OBJECTIVE

Endometrial cancer (EC) treatment changed substantially with the introduction of molecular classification. Low-middle income (LMIC) countries will face barriers to including molecular classification to guide treatment. This study aims to analyse the value of p53 immunohistochemistry to delineate adjuvant treatment in FIGO stages I and II.

METHODS

Patients with EC treated between 2010 and 2016 were retrospectively evaluated. Patients included in this analysis must have reviewed FIGO stage I/II high-grade histologies (endometrioid grade 3, serous, clear cell, carcinosarcoma, mixed and undifferentiated). Samples were subjected to p53 immunohistochemistry. Recurrence-free and overall survival were analysed using the Kaplan-Meier method and log-rank test. Cox proportional hazards regression was performed for multivariable analysis.

RESULTS

From 2010 to 2016, 265 patients met the inclusion criteria. Patients with aberrant p53 (71.4 %) were associated with older age (59.7 % vs 77.8 % with more than 60 years), relapse (12.5 vs 29.6 %) and death (22.2 vs 46.7 %). The pattern of relapse was not different, with most being at extrapelvic sites (55.5 % vs 62.3 % for p53 wild type and aberrant, respectively). The median overall survival was not reached versus 92.2 months for p53 wild type and aberrant, respectively (p = 0.003). In multivariate analysis, chemotherapy decreased death (p = 0.014) in p53 aberrant tumours, a benefit not seen in the wild-type cohort (p = 0.22).

CONCLUSION

This retrospective analysis corroborates the finding of worse outcomes for p53 aberrant tumours in stage I/II EC and the benefit of more aggressive adjuvant treatment (systemic therapy and radiotherapy). Although not ideal as a sole molecular marker, p53 immunohistochemistry could complement the classical anatomopathological features and be part of the decision-making process with patients in LMIC.

Ultrasound and blind endometrial sampling for detection of endometrial cancer in women with postmenopausal bleeding

OBJECTIVES

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To assess the diagnostic accuracy of endometrial sampling with histology in the diagnosis of endometrial cancer in women with postmenopausal bleeding and thickened endometrium on ultrasound. Diagnosis will be verified by the reference standards, hysteroscopy with histology, obtained by targeted (such as grasp biopsy of the endometrium or resection of focal pathology) or global sampling (with dilation and curettage), and histology of hysterectomy specimens. Secondary objectives To determine the diagnostic accuracy of different sampling devices and methods in the detection of endometrial cancer To assess the diagnostic accuracy of endometrial sampling devices and methods to detect endometrial hyperplasia To determine accuracy in diagnosing endometrial cancer and endometrial hyperplasia at different endometrial thicknesses of 3 mm, 4 mm and 5 mm To investigate sources of heterogeneity.

National Survey of Current Follow-up Protocols for Patients Treated for Endometrial Cancer in the UK

AIMS

The aim of this study was to establish a baseline of national practice for follow-up after treatment for endometrial cancer in the UK.

MATERIALS AND METHODS

An online cross-sectional survey was developed and distributed through the Royal College of Radiologists via an email link to the audit leads of radiotherapy centres in the UK. The survey was conducted from November 2021 to 5 January 2022. The main themes assessed in the survey were the form, frequency and duration of follow-up practices.

RESULTS

There were a total of 43/61 (70%) complete responses. 93% of centres had a standard follow-up protocol and 7% who did not have a follow-up protocol discharged patients after the post-operative review. Five centres (13%) used molecular profiling to inform follow-up practices. Patient-initiated follow-up was mainly used in the cohort of patients who had surgery alone with no adjuvant treatment (68%, (19/28)). In the cohort who had face-to-face follow-up, the majority had pelvic examinations as part of their review and total follow-up for five years. 93% of respondents are interested in a national follow-up protocol.

CONCLUSION

Our data shows that there is national variation in practise with regard to follow-up of women treated for endometrial cancer. Many of the follow-up practises are based on conventional follow-up regimens and these may fail to address the more holistic needs of cancer survivors. Recent publication of updated guidance from the British Gynaecological Cancer Society may help standardise practise and provide a more relevant approach to follow-up for women treated for endometrial cancer.

Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time

Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.

Patterns of cytotoxic T-cell densities in immunogenic endometrial cancers reveal a potential mechanism for differences in immunotherapy efficacy

Objective

To explore the impact of molecular subtype in endometrial cancer (EC) on CD8+T cell densities. Furthermore, this work will test the assumption that all mismatch repair deficient (MMRd) tumours are immunologically similar which would enable current trial data to be generalised to all MMRd ECs.

Methods and analysis

All tumours were characterised into the four clinical molecular subtypes. For analysis, the TP53 mutant and no-specific molecular profile tumours were grouped together and described as the low mutational burden (LMB) cohort. CD8+T cell counts were taken from four regions of interest which sampled the tumour-stromal interface and the tumour core. CD8+T cell counts were analysed as mean averages.

Results

In total, 607 ECs contributed to the analysis. CD8+T cell counts in confirmed Lynch syndrome (LS) ECs were significantly higher than MLH1-methylated ECs in all tumour locations excluding the tumour stroma. Confirmed LS and path_POLE ECs had significantly higher CD8+T cell counts across all tumour locations when compared with LMB ECs. There were limited significant differences in CD8+T cell counts between path_POLE versus confirmed LS ECs. There was no significant difference in the CD8+T cells counts and gene (MLH1, MSH2, MSH6, PMS2) in which the LS pathogenic variant was found; however, this analysis was limited by small numbers.

Conclusion

These data indicate that CD8+T cell numbers and distribution is not equal between MLH1-methylated and confirmed LS ECs. This is relevant when interpreting current trial data looking to the application of checkpoint inhibition treatments in MMRd cancers.

The endometrial cancer detection using non-invasive hypermethylation of CDO1 and CELF4 genes in women with postmenopausal bleeding in Northwest China

Objective

The objective of this study was to verify the clinical predictive performance of methylated cysteine dioxygenase type 1 (CDO1m) and CUGBP Elav-like family member 4 (CELF4m) in endometrial cancer (EC) women with postmenopausal bleeding (PMB).

Material and Methods

A single-center, prospective, and case-control study was conducted in the Gansu Provincial Maternity and Child-care Hospital with 138 female postmenopausal patients enrolled in 2022. All patients underwent body mass index (BMI) detection, transvaginal ultrasonography (TVUS) detection, carbohydrate antigen 125 detection, and the cervical exfoliated cell CDO1/CELF4 gene methylation detection to analyze the sensitivity, specificity, and accuracy of different screening tests statistically with the biopsy and/or dilation and curettage (D&C) pathological diagnosis under hysteroscopy as the gold standard.

Results

There was no significant difference in age between the EC group and the non-EC group, P = 0.492. Using quantitative polymerase chain reaction (qPCR) technology, we validated the CDO1 and CELF4 methylation detection with 87.5% sensitivity and 95.9% specificity as a useful strategy for the triage of women with PMB for the detection of EC. In addition, 100% of type II EC (n = 6) were positively detected by the CDO1 or CELF4 methylation test.

Conclusion

The CDO1 and CELF4 methylation test with high specificity as an auxiliary diagnostic tool or alternative method provides physicians with a reference to distinguish between benign and malignant tumors in women with postmenopausal bleeding, to justify the necessity of using invasive methods to confirm diagnosis.

Visualization Methods for Uterine Sentinel Lymph Nodes in Early-Stage Endometrial Carcinoma: A Comparative Analysis

BACKGROUND

Sentinel lymph node (SLN) biopsy in early-stage endometrial cancer is recommended over systematic lymphadenectomy due to reduced morbidity and comparable detection rates. The main objective of this study was to compare the overall and bilateral detection rates of SLN in early-stage endometrial cancer using three techniques.

METHODS

a prospective cohort study was designed to detect the difference in SLN detection rate in three cohorts: Indocyanine green (ICG), methylene blue (MB), and tracer combination (ICG + MB). Mapping characteristics, detection rate, number of SLNs, and positive SLNs of the three cohorts were compared.

RESULTS

A total of 99 patients were enrolled. A total of 109 SLN sites with 164 lymph nodes were detected. No differences were found between the three cohorts in terms of age, BMI, tumor diameter, or other histologic characteristics. The overall SLN detection rate (DR) was 54.3% in the MB group, 72.7% in ICG, and 80.6% in the ICG-MB group. Bilateral DR was 22.9%, 39.4%, and 54.8% in groups, respectively, with the MB method yielding significantly inferior results.

CONCLUSIONS

The ICG-MB group demonstrated superior overall and bilateral detection rates, but a significant difference was found only in the MB cohort. Combining tracer agents can enhance the accuracy of SLN identification in initial-stage endometrial cancer without additional risk to the patient.

Clinicopathological Implications of Mismatch Repair Status in Endometrioid Endometrial Cancer in Duhok City

BACKGROUND

DNA mismatch repair (MMR) is a specialized system that corrects errors in DNA replication, namely, base substitution mismatches and minor insertion-deletion mismatches. The deficient mismatch repair (d-MMR) protein plays a vital role in predicting the prognosis of endometrioid carcinoma. The study aimed to determine the prevalence of MMR errors in endometrial cancer (EC) and their correlation with clinicopathological features.

METHODS

We examined the immunohistochemistry presence of four MMR proteins in 50 samples of EC tissues that were preserved in formalin and embedded in paraffin. The proteins identified were MutL homolog 1 (MLH1), post-meiotic segregation increased 2 (PMS2), MutS homolog 2 (MSH2), and MutS homolog 6 (MSH6). The study examined several clinicopathological characteristics and conducted MMR phenotyping.

RESULTS

The findings revealed that among the 50 cases of EC, 40% of patients had grade I disease and 78% had stage I malignancy. Furthermore, among the 50 individuals evaluated, 56% exhibited competence in MMR, whereas 44% displayed loss in nuclear expression of MMR. The rate of MLH1 and PMS2 protein loss was recorded as the greatest, at 18%, while the loss of MSH2 and MSH6 was documented at 6%. Within the same range, the majority of patients with d-MMR were above the age of 50 years.

CONCLUSION

The majority of the recruited EC patients in this study showed advanced age and a high percentage of d-MMR status.

Racioethnic Disparities in Endometrial Cancer Outcomes

Black women are twice as likely to die from endometrial cancer (EC) compared with white women. This represents one of the worst racioethnic disparities amongst all cancers globally. Compared with white women, black women are more likely to be diagnosed with advanced EC, have more barriers to accessing care and experience increased delays in obtaining an EC diagnosis and commencing treatment. Histological and molecular differences place black women at higher risk of being diagnosed with more aggressive EC subtypes that carry less favourable outcomes. Furthermore, EC diagnostic pathways are less reliable in black women, and black women are less likely to receive evidence-based treatment for EC. This racioethnic disparity in EC outcomes exists both in the UK and US, despite differences in healthcare systems. This review methodically describes the key factors along the patient journey that contribute to the disparity in black women and proposes multifaceted approaches to lessen these gaps.

Robotic-assisted surgery in high-risk surgical patients with endometrial cancer

Many patients diagnosed with an endometrial cancer are at high-risk for surgery due to factors such as advanced age, raised body mass index or frailty. Minimally-invasive surgery, in particular robotic-assisted, is increasingly used in the surgical management of endometrial cancer however, there are a lack of clinical trials investigating outcomes in high-risk patient populations. This article will review the current evidence and identify areas of uncertainty where future research is needed.

Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020

BACKGROUND

Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact.

METHODS AND FINDINGS

In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance.

CONCLUSIONS

The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.

Prediction of recurrence risk factors in patients with early-stage cervical cancers by nomogram based on MRI handcrafted radiomics features and deep learning features: a dual-center study

PURPOSE

To establish and validate a deep learning radiomics nomogram (DLRN) based on intratumoral and peritumoral regions of MR images and clinical characteristics to predict recurrence risk factors in early-stage cervical cancer and to clarify whether DLRN could be applied for risk stratification.

METHODS

Two hundred and twenty five pathologically confirmed early-stage cervical cancers were enrolled and made up the training cohort and internal validation cohort, and 40 patients from another center were enrolled into the external validation cohort. On the basis of region of interest (ROI) of intratumoral and different peritumoral regions, two sets of features representing deep learning and handcrafted radiomics features were created using combined images of T2-weighted MRI (T2WI) and diffusion-weighted imaging (DWI). The signature subset with the best discriminant features was chosen, and deep learning and handcrafted signatures were created using logistic regression. Integrated with independent clinical factors, a DLRN was built. The discrimination and calibration of DLNR were applied to assess its therapeutic utility.

RESULTS

The DLRN demonstrated satisfactory performance for predicting recurrence risk factors, with AUCs of 0.944 (95% confidence interval 0.896-0.992) and 0.885 (95% confidence interval 0.834-0.937) in the internal and external validation cohorts. Furthermore, decision curve analysis revealed that the DLRN outperformed the clinical model, deep learning signature, and radiomics signature in terms of net benefit.

CONCLUSION

A DLRN based on intratumoral and peritumoral regions had the potential to predict and stratify recurrence risk factors for early-stage cervical cancers and enhance the value of individualized precision treatment.

Severe hemoperitoneum from spontaneous rupture of uterine tumor resembling ovarian sex-cord tumor: A very rare case

A case of uterine tumor resembling ovarian sex‐cord tumor with an unfamiliar presentation. Management was performed based on the clinical findings and the literature recommendations.

Molecular subtyping in endometrial cancer: A promising strategy to guide fertility preservation

OBJECTIVES

To investigate the association of molecular subtype with progesterone response in patients with endometrial cancer (EC) or atypical endometrial hyperplasia (AEH).

METHODS

Premenopausal patients aged ≤48 years with tumor-normal sequencing data who received progesterone for EC/AEH from 1/1/2010-6/30/2021 were identified. Tumors were classified as POLE-ultramutated, microsatellite instability-high (MSI-H), copy number-high (CN-H), or copy number-low (CN-L) molecular subtype. Best response to progesterone was compared by subtype. Appropriate statistical tests were performed.

RESULTS

Of 20 patients, 7 (35%) had AEH and 13 (65%) had EC. Sixteen tumors (80%) were CN-L, 3 (15%) were MSI-H, and 1 (5%) was POLE-ultramutated. Median time on progesterone was 22 months (range, 3-115). Ten patients (50%) had complete response (CR); median time to CR was 9 months (range, 3-32). Four patients (20%) had stable disease (SD) and 6 (30%) had progressive disease (PD). For CN-L tumors, 10 patients (62%) had CR, 3 (19%) had SD, and 3 (19%) had PD. For MSI-H tumors, 1 patient (33%) had SD and 2 (66%) had PD. For POLE-ultramutated tumors, 1 patient had PD. Median follow-up was 48 months (range, 12-123). Four of 10 patients (40%) with CR recurred; median time from CR to recurrence was 16 months (range, 5-102).

CONCLUSION

Molecular subtype may be associated with progesterone response in patients with EC/AEH. CN-L tumors had the best response, and MSI-H tumors had the poorest. Recurrence after CR is common, and close surveillance is warranted. Larger studies investigating the role of molecular classification in medical management of EC/AEH are needed.

Treatment Patterns and Outcomes Among Patients With Advanced or Recurrent Endometrial Cancer Initiating First-Line Therapy in the United States

Background: Patients with advanced or recurrent endometrial cancer (EC) typically have limited treatment options and poor long-term survival outcomes following first-line therapy. Real-world treatment patterns and survival outcomes data are limited for patients in this setting. Objectives: The objective of this retrospective study was to describe real-world demographics, clinical characteristics, treatment patterns, and overall survival among patients in the United States with primary advanced or recurrent EC who initiated at least 1 line of therapy (LOT). Methods: Patients with a diagnosis of primary advanced or recurrent EC in a real-world database from January 1, 2013, to July 31, 2021, were included. The date for inclusion was the date of EC diagnosis documentation; patients were indexed for treatment patterns and outcomes at the start of the first LOT and at the start of each subsequent LOT they initiated. Data were stratified by subgroups of patients who had mismatch repair deficient (dMMR) or microsatellite instability-high (MSI-H) tumors. Results: A total of 1961 patients who received at least 1 LOT were included. Most patients in this cohort, and the dMMR/MSI-H subgroup, received a platinum combination as first-line treatment, with carboplatin-paclitaxel being the most common regimen. Only 53% of patients who received first-line treatment subsequently received second-line therapy. Of the patients who received at least 1 LOT, use of immunotherapy in the second-line setting was more common in the dMMR/MSI-H subgroup. Median overall survival ranged from 14.1 to 31.8 months across the 5 most frequently used first-line treatment regimens in the ≥1 LOT cohort and became shorter with each subsequent LOT. Discussion: The use of platinum-based chemotherapy for first-line treatment of advanced or recurrent EC predominates in the real-world setting, despite the poor long-term survival outcomes associated with most of these regimens. Conclusions: Patients with recurrent/advanced EC have a poor prognosis, highlighting the need for therapies with more durable benefits.

Expression of PD-1 and PD-L1 in Endometrial Cancer: Molecular and Clinical Significance

The landscape of diagnosing and treating endometrial cancer is undergoing a profound transformation due to the integration of molecular analysis and innovative therapeutic approaches. For several decades, the cornerstone treatments for endometrial cancer have included surgical resection, cytotoxic chemotherapy, hormonal therapy, and radiation therapy. However, in recent years, the concept of personalised medicine has gained momentum, reshaping the way clinicians approach cancer treatment. Tailoring treatments based on specific biomarkers has evolved into a standard practice in both initial and recurrent therapy protocols. This review aims to provide an in-depth exploration of the current state of molecular analysis and treatment strategies in the context of endometrial cancer, focusing on the immunological aspect of the PD-1/PD-L1 axis. Furthermore, it seeks to shed light on emerging and innovative approaches that hold promise for the future modulation of endometrial cancer treatments. In essence, as researchers delve into the complex molecular landscape of endometrial cancer and harness the understanding of the PD-1/PD-L1 axis, we are paving the way for more targeted, effective, and personalised therapies that have the potential to significantly improve the outcomes and quality of life for patients with this challenging disease.

Robotic and laparoscopic gynaecological surgery: a prospective multicentre observational cohort study and economic evaluation in England

OBJECTIVE

To compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional 'straight stick' laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy.

DESIGN

Multicentre prospective observational cohort study.

SETTING

Patients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020.

PARTICIPANTS

275 patients recruited with 159 RALS, 73 CLS eligible for analysis.

OUTCOME MEASURES

Primary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018-2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS.

RESULTS

No difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI -£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI -0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of -£188 (95% CI -£1321 to £827) and QALY difference of 0.0024 (95% CI -0.0008 to 0.0057).

CONCLUSIONS

Findings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross-sectional survey for JSGOE members

AIM

Minimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross-sectional questionnaire survey to ascertain the status of MIS for endometrial cancer.

METHODS

The survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed.

RESULTS

The total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board-certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan.

CONCLUSION

This study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra-fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy

A longitudinal, descriptive, prospective, and prolective study of individuals with endometrial or cervical cancer/pre-cancer diagnoses and high BMI (over 35 kg/m2) undergoing RH was conducted. Of the 53 participants recruited, 3 (6%) were converted to open surgery. The 50 RH participants had median BMI 42 kg/m2 (range 35 to 60): the range 35-39.9 kg/m2 had 17 cases; the range 40-44.9 kg/m2 had 15 cases; 45-49.9 kg/m2 8 cases; and those ≥50 kg/m2 comprised 10 cases. The mean RH operating time was 128.1 min (SD 25.3) and the median length of hospital stay was 2 days (range 1-14 days). Increased BMI was associated with small, but statistically significant, increases in operating time and anaesthetic time, 65 additional seconds and 37 seconds, respectively, for each unit increase in BMI. The median self-reported time for individuals who underwent RH to return to their pre-operative activity levels was 4 weeks (range 2 to >12 weeks). There was a significant improvement in pain and physical independence scores over time (p = 0.001 and p < 0.001, respectively) and no significant difference in scores for overall QOL, pain, or physical independence scores was found between the BMI groups. Patient-reported recovery and quality of life following RH is high in individuals with high BMI (over 35 kg/m2) and does not appear to be impacted by the severity of obesity.

Four differentially expressed exosomal miRNAs as prognostic biomarkers and therapy targets in endometrial cancer: Bioinformatic analysis

Endometrial cancer (EC) is one of the most common gynecological malignancies worldwide. Accumulated evidence has demonstrated exosomes of cancer cells carry microRNAs (miRNAs) to nonmalignant cells to induce metastasis. Our study aimed to find possible biomarkers of EC. Data for miRNA expression related with exosome from EC patients were downloaded from The Cancer Genome Atlas database, and the miRNA expression profiles associated with exosomes of EC were downloaded from the National Center for Biotechnology Information. We used different algorithms to analyze the differential miRNA expression, infer the relative proportion of immune infiltrating cells, predict chemotherapy sensitivity, and comprehensively score each gene set to evaluate the potential biological function changes of different samples. The gene ontology analysis and Kyoto encyclopedia of genome genomics pathway analysis were performed for specific genes. A total of 13 differential miRNAs were identified, of which 4 were up-regulated. The 4 miRNAs, that is hsa-miR-17-3p, hsa-miR-99b-3p, hsa-miR-193a-5p, and hsa-miR-320d, were the hub exosomal miRNAs that were all closely related to the clinic phenotypes and prognosis of patients. This study preliminarily indicates that the 4 hub exosomal miRNAs (hsa-miR-17-3p, hsa-miR-99b-3p, hsa-miR-193a-5p, and hsa-miR-320d) could be used as prognostic biomarkers or therapy targets in EC. Further studies are required to make sure of their real feasibility and values in the EC clinic and the relative research.

Efficacy and Safety of PD-1/PD-L1 Inhibitor as Single-Agent Immunotherapy in Endometrial Cancer: A Systematic Review and Meta-Analysis

The programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway plays a crucial role in the immune escape mechanism and growth of cancer cells in endometrial cancer (EC). Clinical trials investigating PD-1/PD-L1 inhibitor have shown promising results in other cancers, but their efficacy in EC still remains uncertain. Therefore, this meta-analysis aims to provide an updated and robust analysis of the effectiveness and safety of PD-1/PDL1 inhibitor as single-agent immunotherapy in EC, focusing on the objective response rate (ORR), disease control rate (DCR), and adverse events (AEs). This meta-analysis utilized STATA version 17 and RevMan version 5.4 software to pool the results of relevant studies. Five studies conducted between 2017 and 2022, comprising a total of 480 EC patients enrolled for PD-1/PD-L1 inhibitor immunotherapy met the inclusion criteria. The pooled proportion of EC patients who achieved ORR through PD-1/PD-L1 inhibitor treatment was 26.0% (95% CI: 16.0-36.0%; p < 0.05). Subgroup analysis based on mismatch repair (MMR) status showed an ORR of 44.0% (95% CI: 38.0-50.0%; p = 0.32) for the deficient mismatch repair (dMMR) group and 8.0% (95% CI: 0.0-16.0%; p = 0.07) for the proficient mismatch repair (pMMR) group. Pooled proportion analysis by DCR demonstrated an odds ratio (OR) of 41.0% (95% CI: 36.0-46.0%, p = 0.83) for patients undergoing PD-1/PD-L1 inhibitor treatment. Subgroup analysis based on MMR status revealed DCR of 54.0% (95% CI: 47.0-62.0%; p = 0.83) for the dMMR group, and 31.0% (95% CI: 25.0-39.0%; p = 0.14) for the pMMR group. The efficacy of PD-1/PD-L1 inhibitors was significantly higher in the dMMR group compared to the pMMR group, in terms of both ORR (OR = 6.30; 95% CI = 3.60-11.03; p < 0.05) and DCR (OR = 2.57; 95% CI = 1.66-3.99; p < 0.05). In terms of safety issues, the pooled proportion of patients experiencing at least one adverse event was 69.0% (95% CI: 65.0-73.0%; p > 0.05), with grade three or higher AEs occurring in 16.0% of cases (95% CI: 12.0-19.0%; p > 0.05). Based on the subgroup analysis of MMR status, PD-1/PD-L1 inhibitor immunotherapy showed significantly better efficacy among dMMR patients. These findings suggest that patients with dMMR status may be more suitable for this treatment approach. However, further research on PD-1/PD-L1 inhibitor immunotherapy strategies is needed to fully explore their potential and improve treatment outcomes in EC.

Risk-reducing surgery for individuals with cancer-predisposing germline pathogenic variants and no personal cancer history: a review of current UK guidelines

Identifying healthy carriers of germline pathogenic variants in high penetrance cancer susceptibility genes offers the potential for risk-reducing surgery. The NHS England National Genomic Test Directory offers germline and somatic testing to patients with certain cancers or rare and inherited diseases, or, in some cases, to their relatives. This review summarises current UK guidelines for risk-reducing surgical interventions available for individuals with no personal history of cancer, who are determined to carry germline pathogenic variants. An electronic literature search of NICE guidelines and PubMed citable articles was performed. NICE guidelines are available for bilateral mastectomy and are currently in development for risk-reducing bilateral salpingo-oophorectomy. Guidelines developed with affiliation to, or through relevant British Surgical Societies or international consensus, are available for risk-reducing hysterectomy, polypectomy, gastrectomy, and thyroidectomy. There is a disparity in the development and distribution of national guidelines for interventions amongst tumour types. Whilst we are focusing on UK guidelines, we anticipate they will be relevant much more generally and so of interest to a wider audience including where there are no national guidelines to refer to. We suggest that, as genetic testing becomes rapidly more accessible, guideline development for interventions should be more closely aligned to those for testing.

Micro-histology combined with cytology improves the diagnostic accuracy of endometrial lesions

BACKGROUND

In the study, we aimed to evaluate the ability of micro-histology combined with cytology to improve the quality of slides and diagnose endometrial lesions.

METHODS

Endometrial specimens were collected from Li Brushes. Every specimen was prepared for micro-histological and cytological slides, using cell block (CB) and liquid-based cytology (LBC) technologies. Semi-quantitative scoring system was used to evaluate the qualities of slides. CB slides were assessed by 5-category scoring system. Diagnostic accuracy was calculated in LBC, CB, and LBC + CB groups based on the histological gold standard. Endometrial atypical hyperplasia, and endometrial cancer were considered positive, whereas others were considered negative.

RESULTS

A total of 167 patients were enrolled. CB slides were inferior to LBC slides only in cellularity (p < 0.001), but superior in the other six parameters (all p < 0.001). The satisfaction rate of micro-histology accounted for 92.3%. The accuracy index in the CB group was higher than in the LBC group in terms of sensitivity (85.5% vs. 82.7%) and specificity (98.9% vs. 95.7%). The sensitivity and specificity in the LBC + CB group were increased to 94.2% and 99.0%, respectively.

CONCLUSIONS

The quality of micro-histological slides was higher than that of cytological slides. By combining micro-histology with cytology, higher accuracy was achieved for endometrial lesions diagnosis.

Clinical and Management Dilemmas Concerning Early-Stage Cervical Cancer in Pregnancy - A Case Report

Background

Cervical cancer in pregnancy is rare and its management remains a formidable challenge. Clinical upstaging is a serious concern. Presentation may mimic pregnancy-related conditions, thus delaying diagnosis and leading to an advanced stage at presentation. In addition, concerns regarding chemotherapy safety in pregnancy may hinder its administration. Definitive therapy may also be delayed due to pregnancy.

Case Report

A 37-year-old G3P2A0 10-11 weeks pregnant woman was diagnosed with stage IB2 cervical cancer. We originally planned to perform neoadjuvant chemotherapy with paclitaxel 175mg/m2 and carboplatin 6 AUC every 21 days followed by caesarean section and radical hysterectomy. However, preoperatively, the tumor had grown further and progressed to stage IIB. Postpartum radiotherapy was thus indicated. Lower segmental caesarean section along with bilateral salpingectomy and ovarian transposition were performed. Radiotherapy was administered through external beam radiation therapy and brachytherapy. The patient delivered a small for gestational age male baby with no abnormalities. At 2-month follow-up, the infant appeared generally healthy.

Conclusion

Cancer diagnosis during pregnancy adversely impacts women's physical and psychological states. Symptoms may mimic pregnancy-related conditions, thus delaying diagnosis. Its management involves a multidisciplinary team to protect both maternal and fetal health.

Serum HE4 predicts progestin treatment response in endometrial cancer and atypical hyperplasia: A prognostic study

OBJECTIVE

To investigate serum human epididymis-4 (HE4) as a predictive biomarker of intrauterine progestin response in endometrial cancer and atypical endometrial hyperplasia (AEH).

DESIGN

Prospective prognostic factor study.

SETTING

Consecutive sample of women attending a tertiary gynaecological oncology centre in northwest England.

POPULATION

Women with AEH or early-stage, low-grade endometrial cancer who were unfit for or declined primary surgical management.

METHODS

A total of 76 women, 32 with AEH and 44 with endometrial cancer, were treated with a levonorgestrel intrauterine system (LNG-IUS) for 12 months. Endometrial biopsies and imaging were performed to assess treatment response. Pretreatment serum HE4 was analysed by chemiluminescence immunoassay and diagnostic accuracy and logistic regression analyses were performed.

MAIN OUTCOME MEASURES

Progestin response at 12 months defined by histology and imaging.

RESULTS

The median age and body mass index (BMI) of the final cohort were 52 years (interquartile range [IQR] 33-62 years) and 46 kg/m2 (IQR 38-54 kg/m2 ), respectively. Baseline serum HE4 was significantly higher in non-responders than responders (119.2 pmol/L, IQR 94.0-208.4 pmol/L versus 71.8 pmol/L, IQR 56.1-84.2 pmol/L, p < 0.001). Older age (odds ratio [OR] 0.96, 95% CI 0.93-0.99, p = 0.02), baseline serum HE4 (OR 0.97, 95% CI 0.96-0.99, p = 0.001) and endometrial cancer histology (OR 0.22, 95% CI 0.72-0.68, p = 0.009) were associated with a lower likelihood of progestin treatment response. Serum HE4 remained independently associated with progestin treatment failure when adjusted for age and histology (adjusted hazard ratio 0.97, 95% CI 0.96-0.99, p = 0.008).

CONCLUSION

Serum HE4 shows promise as a predictive biomarker of progestin treatment response in endometrial cancer and AEH.

The role of fibroblast growth factor 18 in cancers: functions and signaling pathways

Fibroblast growth factor 18(FGF18) is a member of the fibroblast growth factor family (FGFs). FGF18 is a class of bioactive substances that can conduct biological signals, regulate cell growth, participate in tissue repair and other functions, and can promote the occurrence and development of different types of malignant tumors through various mechanisms. In this review, we focus on recent studies of FGF18 in the diagnosis, treatment, and prognosis of tumors in digestive, reproductive, urinary, respiratory, motor, and pediatric systems. These findings suggest that FGF18 may play an increasingly important role in the clinical evaluation of these malignancies. Overall, FGF18 can function as an important oncogene at different gene and protein levels, and can be used as a potential new therapeutic target and prognostic biomarker for these tumors.