Non-invasive modalities for predicting lymph node spread in early stage endometrial cancer?

Preoperative CA-125 predicts extra-uterine disease and survival in uterine papillary serous carcinoma patients

Objective

We determined the clinical utility of preoperative serum CA-125 as predictor of extra-uterine disease and as prognosticator for survival in patients with uterine papillary serous carcinoma (UPSC).

Methods

Patients diagnosed with UPSC, identified between 1992 and 2009, and with preoperative CA-125 measurement were included. A receiver operator characteristic (ROC) curve was used to quantify marker performance. Overall and progression free survival were analyzed using the Kaplan-Meier method. Regression analyses were used to investigate the association of preoperative CA-125 levels and other clinicopathological variables with the presence of extra-uterine disease and the effects on survival.

Results

Sixty-six patients met the study criteria. Using ROC, the CA-125 concentration of 45 U/mL as cutoff level provided the best sensitivity (75%) and specificity (74%) for extra-uterine disease, with a positive predictive value of 86%. Survival was significantly longer in patients with preoperative CA-125 =45 U/mL (p<0.001). Only preoperative CA-125 >45 U/mL remained significantly associated with extra-uterine disease (OR=6.30, 95% CI 1.93–20.62). Furthermore, advanced FIGO stage (HR=4.53, 95% CI 1.50–13.62) and preoperative CA-125 >45 U/mL (HR=3.12, 95% CI 1.13–8.73) were associated with decreased survival.

Conclusion

Preoperative elevated serum CA-125 is an independent predictor for the presence of extra-uterine disease and an independent risk factor for survival in UPSC patients.

Agreement between preoperative transvaginal ultrasound and intraoperative macroscopic examination for assessing myometrial infiltration in low-risk endometrioid carcinoma

OBJECTIVE

To compare diagnostic performance of preoperative transvaginal ultrasound (TVS) and intraoperative macroscopic examination for determining myometrial infiltration in women with low-risk endometrial cancer, and to estimate the agreement between the two methods.

METHODS

This was a single-center observational study comprising women with preoperative diagnosis of well- or moderately differentiated endometrioid carcinoma of the endometrium. All women underwent preoperative TVS by a single examiner. According to the examiner's subjective impression, myometrial infiltration was stated as ≥ 50% or < 50%. Surgical staging was performed in all cases. Intraoperative macroscopic examination of the removed uterus was performed by pathologists who were unaware of the ultrasound findings, and myometrial infiltration was stated as ≥ 50% or < 50%. Definitive histological diagnosis of myometrial infiltration was made by frozen section analysis and was used as the gold standard. Sensitivity and specificity with 95% CIs were calculated for TVS and intraoperative macroscopic inspection and compared using McNemar's test. Agreement between TVS and intraoperative macroscopic inspection was estimated using Cohen's kappa index (κ) and percentage of agreement.

RESULTS

Of 209 eligible women, 152 were ultimately included. Mean (± SD) age was 60.9 ± 10.2 years, with a range of 32-91 years. Definitive histological diagnosis revealed that myometrial infiltration was < 50% in 114 women and ≥ 50% in 38 women. Sensitivity and specificity of TVS for detecting deep myometrial infiltration were 81.6% and 89.5%, respectively, whereas the respective values for intraoperative macroscopic examination were 78.9% and 90.4% (McNemar's test, P > 0.05 when comparing TVS and intraoperative macroscopic examination). Agreement between methods was moderate with κ = 0.54 (95% CI, 0.39-0.69) and percentage of agreement of 82%.

CONCLUSIONS

Although the agreement between preoperative TVS and intraoperative macroscopic examination for detecting deep myometrial infiltration was only moderate, both methods had similar accuracy when compared with frozen section histology. Preoperative TVS might reasonably be proposed as a method for assessing myometrial infiltration as an alternative to intraoperative macroscopic examination, especially when performed by an experienced examiner and image quality is not poor. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Transvaginal/transrectal ultrasound for preoperative identification of high-risk cases in well- or moderately differentiated endometrioid carcinoma

OBJECTIVE

To evaluate the role of transvaginal/transrectal ultrasound for preoperative identification of high-risk cases among women with well-differentiated (G1) or moderately differentiated (G2) endometrioid carcinoma of the endometrium.

METHODS

This was a single-center prospective observational cohort study comprising a consecutive series of women with a preoperative diagnosis of G1/G2 endometrioid carcinoma of the endometrium. All women underwent transvaginal or transrectal ultrasound examination by a single examiner. According to the examiner's subjective impression, patients were considered high risk if myometrial infiltration was ≥ 50% and/or involvement of the cervix and/or adnexa was suspected. FIGO surgical staging was performed in all cases. According to definitive histological data regarding myometrial infiltration, cervical involvement and adnexal involvement, women were classified as low risk (no myometrial infiltration, no cervical involvement and no adnexal involvement) or high risk (myometrial infiltration ≥ 50% and/or cervical involvement and/or adnexal involvement). Sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios, with 95% CIs, of transvaginal/transrectal ultrasound for detecting stage ≥ IB were calculated. Agreement between risk determined by transvaginal/transrectal ultrasound and postoperative definitive histology was calculated.

RESULTS

Of 209 eligible women, 169 were included in the study. Mean (± SD) age of the study cohort was 60.7 ± 10.3 years, with a range of 32-91 years. Sensitivity, specificity, LR+ and LR- of transvaginal/transrectal ultrasound identifying high-risk cases according to myometrial infiltration, cervical involvement and adnexal involvement were 78.0% (95% CI, 63.7-88.0%), 89.1% (95% CI, 81.7-93.8%), 7.14 (95% CI, 4.19-12.18) and 0.25 (95% CI, 0.15-0.42), respectively.

CONCLUSIONS

Preoperative transvaginal/transrectal ultrasound may play a significant role in identifying high-risk cases among those with G1/G2 endometrioid carcinoma of the endometrium according to preoperative biopsy, and could be a useful test in this clinical setting. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Prognostic value of human epididymis protein 4 in endometrial cancer and its utility for surgical staging

AIM

An optimal surgical staging in the group of patients with the high-risk type of endometrial cancer is often limited by age and serious internal comorbidities. Therefore, in this study we focused on human epididymis protein 4 and its contribution to the preoperative differentiation of prognostically distinct groups of patients and to individualized surgical treatment as compared with cancer antigen (CA) 125 and imaging methods.

MATERIAL AND METHODS

The study included 115 patients with endometrioid adenocarcinoma diagnosed through endometrial biopsy. Before the final operation, blood sampling was performed for the determination of human epididymis protein 4 (HE4) and CA125 levels. Serum levels of both biomarkers were analyzed in relation to individual prognostic factors (stage of disease, depth of myometrial invasion, tumor grade, risk type of disease).

RESULTS

In the case of HE4, we demonstrated a statistically significant difference (P < 0.001) between patients with low and high risk of the disease. In our model, achieving the maximum sum of sensitivity and specificity, HE4 shows a sensitivity of 72.4% and a specificity of 75.4% for the cut-off 76.5 pmol/L and is a better predictor in distinguishing the high-risk patients than CA125 (area under the curve 0.77 for HE vs 0.71 for CA125).

CONCLUSION

HE4 is a marker that could complement the findings of imaging techniques and that may be useful in decision-making on how to individualize surgical staging. The possibility of its introduction as an independent marker in routine practice remains, at the moment however, limited. The optimal cut-off for HE4 has not been established yet and further studies are needed.

Magnetic resonance imaging and intraoperative frozen sectioning for the evaluation of risk factors associated with lymph node metastasis in endometrial cancer

INTRODUCTION

To analyze the accuracy of magnetic resonance imaging (MRI) and intraoperative frozen sectioning (IFS) for predicting the low- and high-risk patients and risk factors associated with lymph node (LN) metastasis in patients with surgically staged endometrial cancer.

METHODS

The medical records of 175 patients with endometrial cancer who underwent comprehensive surgical staging including pelvic and para-aortic LN dissection between January 2008 and July 2011 were retrospectively analyzed. Results of MRI and IFS of the uterus for the evaluation of risk factors were correlated with final pathology.

RESULTS

Our results showed a high specificity and negative predictive value of MRI and IFS for the evaluation of myometrial invasion and cervical stromal invasion. Of the 41 patients identified as low risk by both MRI and IFS, none had pelvic or para-aortic LN metastases in the final pathology.

CONCLUSIONS

The results indicate that MRI and IFS may be useful for the evaluation of risk factors associated with LN metastasis in patients with endometrial cancer. Magnetic resonance imaging and IFS can be used to accurately identify low-risk patients who do not need comprehensive surgical staging and may prevent unnecessary lymphadenectomy.