Preoperative diagnosis of tumor grade and type in endometrial cancer by pipelle sampling and hysteroscopy: Results of a French study

Updated endometrial cancer FIGO staging: the role of MRI in determining newly included histopathological criteria

PURPOSE

Endometrial cancer (EC) is among the prevalent malignancies in gynecology, showing an increasing occurrence and mortality rate. The updated 2023 FIGO staging integrates both histopathological and molecular analyses, which significantly impact the prognosis and treatment approaches. This research aims to examine the effectiveness of MRI in identifying essential histopathological tumor features, including histological subtype, grade, and lymphovascular space invasion.

METHODS

A total of 106 patients diagnosed with EC from February 2018 to December 2023 underwent preoperative pelvic MRI. Surgical procedures followed ESMO guidelines, with histopathological assessments using FIGO 2009 criteria. Two radiologists independently evaluated MRI images, measuring maximum tumor size, minimum tumor ADC value (using a free-hand ROI technique), and ADC tumor/myometrium ratio. MRI findings were compared with histopathological data.

RESULTS

Peritoneal implant presence and tumor size exhibited significant differences between endometrioid adenocarcinoma (EAC) and non-endometrioid endometrial carcinoma (NEEC), with p values of < 0.001 and 0.003, respectively. Significant differences in age, tumor size, ADC tumor, and ADC tumor/myometrium between low-grade and high-grade tumors were observed, with p values of < 0.001, 0.004, 0.006, and 0.011, respectively. Increased tumor size, reduced ADC tumor, ADC tumor/myometrium, and pelvic peritoneal implant presence were significantly associated with LVSI, with p values of < 0.001, 0.001, 0.002, and 0.001, respectively. The AUC values for tumor size, ADC tumor, and ADC tumor/myometrium were 0.842, 0.781 and 0.747, respectively, in distinguishing between low and high-grade endometrial tumors. Similarly, obtained AUC values for predicting LVSI were 0.836, 0.719, and 0.696, respectively.

CONCLUSION

Our study emphasizes MRI's role in predicting tumor characteristics such as histological subtype, grade, and LVSI based on updated FIGO criteria. By highlighting the potential of MRI, this research contributes to our comprehension of improving diagnostic and clinical management for EC. Further multicenter studies are warranted to validate these findings and establish MRI's role in EC management.

Intermediate-risk endometrial cancer treated with adjuvant brachytherapy using single dosimetric planning: long-term outcome and toxicity assessment

OBJECTIVE

Brachytherapy of the vaginal dome is the recommended adjuvant treatment for intermediate-risk endometrial cancer. This study assessed the results of dosimetric planning of high-dose-rate brachytherapy exclusively in the first treatment session.

STUDY DESIGN

This retrospective study included all patients who underwent hysterectomy for endometrial cancer followed by adjuvant brachytherapy of the vaginal dome between 2012 and 2015. Local recurrence rates, overall survival (OS) rates, recurrence-free survival (RFS) rates, and related acute and late toxicity rates were evaluated.

RESULTS

This analysis included 250 patients, of whom 208 were considered to be at high-intermediate risk of disease recurrence. After a median follow-up of 56 months, the cumulative incidence of local recurrence was 4.8% at 3 years [95% confidence interval (CI) 2.8-8.3] and 7.8% at 5 years (95% CI 4.8-12.6). The 5-year OS rate was 86.2% (95% CI 80.6-90.3), and the 5-year RFS rate was 77.5% (95% CI 71.1-82.7). Acute toxicity occurred in 20 (8%) patients, of which two patients had grade ≥3 toxicity. Only one patient (0.4%) presented with late grade ≥3 toxicity.

CONCLUSION

These findings confirm the tolerability of this brachytherapy approach, indicating minimal cases of late grade ≥3 toxicity, associated with a good 5-year OS rate. With the advent of molecular prognostic factors, the current focus revolves around discerning those individuals who gain the greatest benefit from adjuvant therapy, and tailoring treatment more effectively.

Oscillating Gradient Diffusion-Weighted MRI for Risk Stratification of Uterine Endometrial Cancer

BACKGROUND

Oscillating gradient diffusion-weighted imaging (DWI) enables elucidation of microstructural characteristics in cancers; however, there are limited data to evaluate its utility in patients with endometrial cancer.

PURPOSE

To investigate the utility of oscillating gradient DWI for risk stratification in patients with uterine endometrial cancer compared with conventional pulsed gradient DWI.

STUDY TYPE

Retrospective.

SUBJECTS

Sixty-three women (mean age: 58 [range: 32-85] years) with endometrial cancer.

FIELD STRENGTH/SEQUENCE

3 T MRI including DWI using oscillating gradient spin-echo (OGSE) and pulsed gradient spin-echo (PGSE) research sequences.

ASSESSMENT

Mean value of the apparent diffusion coefficient (ADC) values for OGSE (ADCOGSE) and PGSE (ADCPGSE) as well as the ADC ratio (ADCOGSE/ADCPGSE) within endometrial cancer were measured using regions of interest. Prognostic factors (histological grade, deep myometrial invasion, lymphovascular invasion, International Federation of Gynecology and Obstetrics [FIGO] stage, and prognostic risk classification) were tabulated.

STATISTICAL TESTS

Interobserver agreement was analyzed by calculating the intraclass correlation coefficient. The associations of ADCOGSE, ADCPGSE, and ADCOGSE/ADCPGSE with prognostic factors were examined using the Kendall rank correlation coefficient, Mann-Whitney U test, and receiver operating characteristic (ROC) curve. A P value of <0.05 was statistically significant.

RESULTS

Compared with ADCOGSE and ADCPGSE, ADCOGSE/ADCPGSE was significantly and strongly correlated with histological grade (observer 1, τ = 0.563; observer 2, τ = 0.456), FIGO stage (observer 1, τ = 0.354; observer 2, τ = 0.324), and prognostic risk classification (observer 1, τ = 0.456; observer 2, τ = 0.385). The area under the ROC curves of ADCOGSE/ADCPGSE for histological grade (observer 1, 0.92, 95% confidence intervals [CIs]: 0.83-0.98; observer 2, 0.84, 95% CI: 0.73-0.92) and prognostic risk (observer 1, 0.80, 95% CI: 0.68-0.89; observer 2, 0.76, 95% CI: 0.63-0.86) were significantly higher than that of ADCOGSE and ADCPGSE.

DATA CONCLUSION

The ADC ratio obtained via oscillating gradient and pulsed gradient DWIs might be useful imaging biomarkers for risk stratification in patients with endometrial cancer.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

D&C has the best concordance between preoperative and postoperative grades among morbidly obese endometrial cancer patients

AIM

Endometrial cancer is diagnosed by obtaining uterine biopsies by pipelle, dilatation and curettage (D&C), or hysteroscopy. In 15%-25% of the cases, the preoperative and postoperative grades do not match. This discrepancy may carry significant clinical and prognostic consequences. We aimed to assess how body mass index (BMI) affects preoperative and postoperative grade mismatches and whether biopsy methods mitigate this effect.

METHODS

We conducted a retrospective review of patients with endometrial cancer who underwent surgery at our center between 2014 and 2022. We stratified patients into six classes of BMI based on the WHO classification. Preoperative and postoperative grades were compared for concordance with regards to patient BMI and sampling method.

RESULTS

A total of 158 patients were included, diagnosed by pipelle (n = 99), hysteroscopy (n = 15), or D&C (n = 44). For all methods, every unit increase in BMI increased the odds of having a gap between histology grades by 5.2%. In the pipelle group, the odds of a larger gap between the histology grades was 62% higher than that of women in the other groups. Among the D&C group, the odds of having a bigger difference between histology grades were 91.8% lower compared to the other groups. Patients with BMI over 30 had nearly 50% discrepancy when diagnosed with pipelle or hysteroscopy, but less than 10% with D&C.

CONCLUSIONS

Increasing BMI is associated with decreasing concordance between preoperative and postoperative grades in endometrial cancer, especially when it exceeds 30. This effect is much less pronounced, however, when the diagnostic method is D&C.

Preoperative assessment of high-grade endometrial cancer using a radiomic signature and clinical indicators

Aim: To develop and validate a radiomics-based combined model (Model^RC) to predict the pathological grade of endometrial cancer. Methods: A total of 403 endometrial cancer patients from two independent centers were enrolled as training, internal validation and external validation sets. Radiomic features were extracted from T2-weighted images, apparent diffusion coefficient map and contrast-enhanced 3D volumetric interpolated breath-hold examination images. Results: Compared with the clinical model and radiomics model, Model^RC showed superior performance; the areas under the receiver operating characteristic curves were 0.920 (95% CI: 0.864-0.962), 0.882 (95% CI: 0.779-0.955) and 0.881 (95% CI: 0.815-0.939) for the training, internal validation and external validation sets, respectively. Conclusion: Model^RC, which incorporated clinical and radiomic features, exhibited excellent performance in the prediction of high-grade endometrial cancer.

Comparison of prognosis of patients with endometrial cancer after hysteroscopy versus dilatation and curettage: A multicenter retrospective study

Introduction

Hysteroscopy is a useful procedure for diagnosing endometrial cancer. There is controversy regarding whether hysteroscopy affects the prognosis of endometrial cancer by prompting cancer cell into intraperitoneal dissemination. Our purpose was to confirm whether hysteroscopy could be a risk factor of the tumor stage, recurrence and survival rate of endometrial cancer.

Methods

This multicenter retrospective study included all consecutive patients who had endometrial carcinoma diagnosed preoperatively with hysteroscopy and directed endometrial biopsy (HSC, group A) and dilatation and curettage (D&C, group B) between February 2014 and December 2018 at the Fujian Provincial, China. We compared the demographic feature, clinical characteristics and prognosis between the two groups.

Results

A total of 429 patients were included in the study (Group A, n = 77; Group B, n = 352). There was no significant difference between their baseline characteristics [including age, BMI, histological type and International Federation of Gynecology and Obstetrics (FIGO) stage]. By comparing several pathological conditions that may affect prognosis, there were no significant differences between the two groups in the peritoneal cytology, depth of myometrial invasion, the positivity of lymph nodes, lymphovascular space invasion and paraaortic lymph node dissection. Finally, no significant difference was found between the two groups in overall survival (OS) (P = 0.189) or recurrence free survival (RFS) (P = 0.787).

Conclusion

Under certain inflation pressure and distension medium, hysteroscopic examination and lesion biopsy ensure the safety and have no adverse effects on prognosis compared to conventional curettage.

MRI- and Histologic-Molecular-Based Radio-Genomics Nomogram for Preoperative Assessment of Risk Classes in Endometrial Cancer

High- and low-risk endometrial carcinoma (EC) differ in whether or not a lymphadenectomy is performed. We aimed to develop MRI-based radio-genomic models able to preoperatively assess lymph-vascular space invasion (LVSI) and discriminate between low- and high-risk EC according to the ESMO-ESGO-ESTRO 2020 guidelines, which include molecular risk classification proposed by "ProMisE". This is a retrospective, multicentric study that included 64 women with EC who underwent 3T-MRI before a hysterectomy. Radiomics features were extracted from T2WI images and apparent diffusion coefficient maps (ADC) after manual segmentation of the gross tumor volume. We constructed a multiple logistic regression approach from the most relevant radiomic features to distinguish between low- and high-risk classes under the ESMO-ESGO-ESTRO 2020 guidelines. A similar approach was taken to assess LVSI. Model diagnostic performance was assessed via ROC curves, accuracy, sensitivity and specificity on training and test sets. The LVSI predictive model used a single feature from ADC as a predictor; the risk class model used two features as predictors from both ADC and T2WI. The low-risk predictive model showed an AUC of 0.74 with an accuracy, sensitivity, and specificity of 0.74, 0.76, 0.94; the LVSI model showed an AUC of 0.59 with an accuracy, sensitivity, and specificity of 0.60, 0.50, 0.61. MRI-based radio-genomic models are useful for preoperative EC risk stratification and may facilitate therapeutic management.

Preoperative sampling in endometrial cancer: evaluation of the histopathological agreement with definitive surgical specimen

PURPOSE

The main goal of this study is to assess the diagnostic agreement between preoperative biopsy and definitive histology of the surgical specimen to determine which sampling method is most suitable for diagnosis of early-stage endometrial cancer.

METHODS

We performed a retrospective multicentric study to assess the correlation between three endometrial sampling methods (hysteroscopy, pipelle and D&C) in patients who had undergone preoperative endometrial biopsy and received primary surgical treatment for endometrial cancer. The primary objective was the agreement rate between hysteroscopy (HSC), endometrial biopsy (pipelle) and dilatation and curettage (D&C).

RESULTS

A total of 1833 women who underwent preoperative sampling at 15 centers were included: 1042 biopsies were performed by HSC, 703 by pipelle and 88 by D&C. All three methods presented a moderate diagnostic concordance (κ = 0.40-0.61) with the definitive specimen's histology: HSC (κ = 0.47), pipelle sampling (κ = 0.48) and D&C (κ = 0.48). Likewise, a subgroup analysis was performed by histological subtype comparing HSC and endometrial biopsy, showing that neither is superior as a diagnostic method.

CONCLUSIONS

According to this study, the use of pipelle sampling could become an adequate diagnostic method in endometrial cancer due to its similar agreement to HSC, ease of use and affordability.

The use of hysteroscopy in endometrial cancer: old questions and novel challenges

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.

Interlaboratory Concordance of ProMisE Molecular Classification of Endometrial Carcinoma Based on Endometrial Biopsy Specimens

Molecular classifiers improve the consistency of categorization of endometrial carcinoma and provide valuable prognostic information. We aimed to evaluate the interlaboratory agreement in ProMisE assignment across 3 dedicated Canadian gynecologic oncology centers. Fifty cases of endometrial carcinoma diagnosed on biopsy were collected from 3 centers and 3 unstained sections were provided to each participating site so that immunohistochemistry for MSH6, PMS2, and p53 could be performed and interpreted at each center, blinded to the original diagnoses and the results from other centers. A core was taken for DNA extraction and POLE mutation testing. Overall accuracy and κ statistic were assessed. MSH6, PMS2, and p53 could be assessed for all 50 cases, with agreement for 140/150 results. There was a high level of agreement in molecular classification (κ=0.82), overall. Cases with a discordant result for one of the features used in classification (n=10) were reviewed independently and the most common reason for disagreement was attributable to the weak p53 staining in 1 laboratory (n=4). Interpretive error in PMS2 (n=1) and MSH6 (n=2) assessment accounted for 3 of the remaining disagreements. Interpretive error in the assessment of p53 was identified in 2 cases, with very faint p53 nuclear reactivity being misinterpreted as wild-type staining. These results show strong interlaboratory agreement and the potential for greater agreement if technical and interpretive factors are addressed. Several solutions could improve concordance: central quality control to ensure technical consistency in immunohistochemical staining, education to decrease interpretation errors, and the use of secondary molecular testing.

Relevance of sentinel lymph node biopsy in early endometrial cancer: A series of 249 cases

OBJECTIVE

We aimed to evaluate the impact of the sentinel lymph node (SLN) biopsy on adjuvant therapy, recurrence and survival in early endometrial cancer (EC).

STUDY DESIGN

We retrospectively included all patients who underwent SLN biopsy for EC between February 2007 and March 2018.

RESULTS

Of the 249 EC patients included, the overall SLN detection rate was 91 %. SLNs were positive in 36 (14.4 %) cases. Nine of the 13 preoperative low-risk patients with positive SLNs were re-operated and 22 % presented positive non-SLNs. No second surgery was required for the 10 patients upstaged to intermediate risk after negative SLN biopsy. Nine of the 11 preoperative intermediate-risk patients with positive SLNs were re-operated and 33 % presented positive non-SLNs. Eleven of the 24 preoperative high-risk patients with negative SLNs were re-operated and 27 % presented positive non-SLNs. For the whole population, 3-year overall survival was 99 % (CI 95 % (97-1)) and 3-year recurrence-free survival (RFS) was 92 % (CI 95 % (0.87-0.95)).

CONCLUSION

Our study supports the feasibility of the SLN procedure for assessing risk recurrence in patients with early-stage EC. SLN biopsy should lead to major reductions in secondary staging and better adaptation of adjuvant therapy.

Preoperative assessment of endometrial cancer

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.

Accuracy of preoperative sampling diagnosis for predicting final pathology in patients with endometrial carcinoma: a review

Endometrial cancer (EC) is the most common gynecologic cancer. The most frequent symptom of this disease is postmenopausal bleeding. Diagnosis of EC must be histologically confirmed, and there are several methods for endometrial sampling to obtain cells or endometrial tissue. The first step in diagnosis should be ultrasound measurement of endometrial thickness, followed by endometrial sampling, which can be performed by office endometrial biopsy, hysteroscopic biopsy, or dilatation and curettage (D&C). The review in this article was carried out to present previously published studies, comprehensively evaluate method performance (i.e., overall accuracy of preoperative sampling in patients with endometrial carcinoma, and overall agreement on grade and histological subtype between preoperative endometrial sampling and final diagnosis), and determine which sampling method is most accurate on the basis of the statistical data in the studies analyzed. From the literature analyzed and examined, it can be concluded that preoperative endometrial sampling is not always the best predictor of final histology in EC and has its limitations. In surgical decisions based only on preoperative sampling, a biopsy should be made with caution, and it is necessary to take other parameters into account. Inadequate grading leads to suboptimal clinical management, mainly in early-stage tumors. This review showed that, although hysteroscopic biopsy was mainly associated with the highest tumor grade agreement, and although D&C showed the highest overall accuracy in detecting endometrial carcinoma, the data do not therefore reliably indicate which method yields the most precise results. The results of this review indicate that further studies on larger samples and with greater statistical power are needed to accurately define the role and type of preoperative sampling methods.

Assessment of Preoperative Endometrial Histopathological Sampling as a Predictor of Final Surgical Pathology in Endometrial Cancer

OBJECTIVE

 To evaluate the agreement between the histopathological diagnoses of preoperative endometrial samples and surgical specimens and correlate the agreement between the diagnoses with the impact on surgical management and the survival of patients with endometrial adenocarcinomas.

METHODS

 Sixty-two patients treated for endometrial cancer at a university hospital from 2002 to 2011 were retrospectively evaluated. The histopathological findings of preoperative endometrial samples and of surgical specimens were analyzed. The patients were subjected to hysterectomy as well as adjuvant treatment, if necessary, and clinical follow-up, according to the institutional protocol. Lesions were classified as endometrioid tumor (type 1) grades 1, 2, or 3 or non-endometrioid carcinoma (type 2).

RESULTS

 The agreement between the histopathological diagnoses based on preoperative endometrial samples and surgical specimens was fair (Kappa: 0.40; p < 0.001). However, the agreement was very significant for tumor type and grade, in which a higher concordance occurred at a higher grade. The percentage of patients with lymph nodes affected was 19.2%. Although most patients presenting with disease remission or cure were in the early stages (90.5%), there were no significant differences between those patients who had a misdiagnosis (11/16; 68.8%) and those who had a correct diagnosis (25/33; 75.8%) based on preoperative endometrial sampling (p = 0.605).

CONCLUSION

 Our findings corroborate the literature and confirm the under staging of preoperative endometrial samples based on histopathological assessment, especially for lower grade endometrial tumors. We suggest that the preoperative diagnosis should be complemented with other methods to better plan the surgical management strategy.

Accuracy of preoperative endometrial biopsy and intraoperative frozen section in predicting the final pathological diagnosis of endometrial cancer

BACKGROUND

Histotype and grade of endometrial cancer (EC) are prognostic factors of nodal involvement and thus of survival. Preoperative biopsy (PB) and intraoperative frozen section (FS) are usually used to guide surgical staging on which the choice of adjuvant therapy will be based successively.

OBJECTIVE

The aim of this study was to assess the agreement rate between PB and FS with final diagnosis (FD) in a series of surgically resected EC.

MATERIALS

All patients submitted to hysterectomy for EC or atypical endometrial hyperplasia in the Reggio Emilia Province hospitals from 2007 to 2018 were included. Concordance rate differences in histotype, grading, myoinvasion, risk of recurrence between PB, FS and FD were assessed with Fisher's exact test and Mc Nemar contingency test.

RESULTS

A total of 352 patients were identified. For 345 patients it was possible to compare PB and FD results. FS examination was performed in 201/352 (57%) cases, while for 21/352 (6%) patients only an intraoperative macroscopic evaluation was done; in the remaining women, FS-exam was omitted. In 14/201 (7%) cases the tumor wasn't grossly identifiable and the random FS-sampling wasn't able to find the tumor site. High diagnostic concordance of tumor type between PB and FD was observed: no significant differences were registered in type 1 and type 2-endometrial cancer identification (83%, 73%, p = 0.121). Significant differences (p = 0.005) were observed comparing FS and FD results: 95% of type 1-ECs were correctly diagnosed by FS, while only 76% of type 2-ECs received a correct diagnosis on FS. PB showed a concordance with FD among tumor grading close to 55% whilst concordance achieved 71% grouping low grade (G1-G2) EC. No significant differences in FS and FD concordance rate were observed between tumor grades. Concordance for low grade was significantly higher than for high grade ECs (89% vs 50%, respectively, p value = 0.014). The concordance rate in evaluating the myoinvasion status between FS and FD was 80% (n: 199 patients), reaching 99% after combining the first 2 groups (0-49% vs ≥ 50%). Twenty-two cases underwent only intraoperative macroscopic evaluation of the myoinvasion, with an accuracy of 91%: only in 1 case the invasion of the cervical stroma was not detected (Stage II), and 1 case the patient was overstaged as Ib. Discrepancies were observed in FS capacity to correctly predict the final ESMO risk group in stage I patients: FS resulted particularly reliable in predicting a low-risk (concordance with FD: 91%) while the accuracy sharply decreased for intermediate- and high-risk patients (62% and 40%, respectively). To investigate the usefulness of FS in EC management, we compared patients who underwent FS (FS-group) or not (no-FS-group). Especially for low risk patients, the FS significantly increased the adequacy of surgical treatment from 53% (no-FS-group) to 72% (FS-group) (p = 0.016).

CONCLUSIONS

FS remains a useful tool to tailor surgery in EC-patients, avoiding secondary surgery to complete staging particularly in patients with AH + AHBA, low and intermediate risk ECs that could benefit from adjuvant therapy.

Hysteroscopic resectoscope-directed biopsies and outpatient endometrial sampling for assessment of tumor histology in women with endometrial cancer or atypical hyperplasia

OBJECTIVE

To evaluate and compare the diagnostic efficiency of outpatient endometrial sampling (OES) and hysteroscopic resectoscope-directed biopsies (HY_biopsy) to distinguish between endometrial cancer (EC) and atypical hyperplasia (AH) and to assess tumor type and grade (histotype) in women with EC.

DESIGN

Patients with AH or EC (n = 266) among 1013 patients consecutively referred because of postmenopausal bleeding were included. Identification of EC versus AH, and unfavorable tumor types (endometrioid grade 3 or non-endometrioid tumors) using OES and HY_biopsy was compared to final histopathology at hysterectomy. AH or EC were identified by OES in 184 patients and by HY_biopsy in212.

RESULTS

OES had only sufficient tissue samples in 72.7% of intended samples. Even when OES did provide sufficient material, addition of HY_biopsy was a better technique than OES alone to distinguish between EC and AH, with an AUC of 95.9% and 79.8%; sensitivity of 97.4% and 64.6% and a specificity of 94.4% and 95.0%, respectively (p = 0.008). AH was falsely diagnosed with OES in 58 (35.4%) of 164 women with a final diagnose of EC. A final diagnosis of stage 1b or more was seen in 22 of these 58 women, while 5 of 194 patients with EC all stage 1a grade 1 had AH by HY_biopsy. HY_biopsy had higher correlation in assessment of tumor type and grade than OES, but OES and HY_biopsy had comparable AUC of 90.3% and 92.4% for identification of unfavorable tumors when tumor histotype was successfully identified. Regarding identification of unfavorable tumors (n = 57), a successfully assessment of histotype by OES combined with HY_biopsy in women without successfully diagnosed histotype by OES alone had AUC of 91.3%.

CONCLUSION

Addition of HY_biopsy may improve diagnosis when preoperative OES identifies AH or is insufficient for explicit diagnosis of tumor type and grade. However, there is limited benefit of the addition of HY_biopsy in the presence of definite diagnosis of grade 1-2 endometrioid tumors by OES.

Prediction of tumor grade and lymphovascular space invasion in endometrial adenocarcinoma with MR imaging-based radiomic analysis

PURPOSE

To evaluate the capabilities of two-dimensional magnetic resonance imaging (MRI)-based texture analysis features, tumor volume, tumor short axis and apparent diffusion coefficient (ADC) in predicting histopathological high-grade and lymphovascular space invasion (LVSI) in endometrial adenocarcinoma.

MATERIALS AND METHODS

Seventy-three women (mean age: 66±11.5 [SD] years; range: 45-88 years) with endometrial adenocarcinoma who underwent MRI of the pelvis at 1.5-T before hysterectomy were retrospectively included. Texture analysis was performed using TexRAD® software on T2-weighted images and ADC maps. Primary outcomes were high-grade and LVSI prediction using histopathological analysis as standard of reference. After data reduction using ascending hierarchical classification analysis, a predictive model was obtained by stepwise multivariate logistic regression and performances were assessed using cross-validated receiver operator curve (ROC).

RESULTS

A total of 72 texture features per tumor were computed. Texture model yielded 52% sensitivity and 75% specificity for the diagnosis of high-grade tumor (areas under ROC curve [AUC]=0.64) and 71% sensitivity and 59% specificity for the diagnosis of LVSI (AUC=0.59). Volumes and tumor short axis were greater for high-grade tumors (P=0.0002 and P=0.004, respectively) and for patients with LVSI (P=0.004 and P=0.0279, respectively). No differences in ADC values were found between high-grade and low-grade tumors and for LVSI. A tumor short axis≥20mm yielded 95% sensitivity and 75% specificity for the diagnosis of high-grade tumor (AUC=0.86).

CONCLUSION

MRI-based texture analysis is of limited value to predict high grade and LVSI of endometrial adenocarcinoma. A tumor short axis≥20mm is the best predictor of high grade and LVSI.

Prognostic classification of endometrial cancer using a molecular approach based on a twelve-gene NGS panel

Endometrial Cancer (EC) is one of the most common malignancies in women in developed countries. Molecular characterization of different biotypes may improve clinical management of EC. The Cancer Genome Atlas (TCGA) project has revealed four prognostic EC subgroups: POLE, MSI; Copy Number Low (CNL) and Copy Number High (CNH). The goal of this study was to develop a method to classify tumors in any of the four EC prognostic groups using affordable molecular techniques. Ninety-six Formalin-Fixed Paraffin-embedded (FFPE) samples were sequenced following a NGS TruSeq Custom Amplicon low input (Illumina) protocol interrogating a multi-gene panel. MSI analysis was performed by fragment analysis using eight specific microsatellite markers. A Random Forest classification algorithm (RFA), considering NGS results, was developed to stratify EC patients into different prognostic groups. Our approach correctly classifies the EC patients into the four TCGA prognostic biotypes. The RFA assigned the samples to the CNH and CNL groups with an accuracy of 0.9753 (p < 0.001). The prognostic value of these groups was prospectively reproduced on our series both for Disease-Free Survival (p = 0.004) and Overall Survival (p = 0.030).Hence, with the molecular approach herein described, a precise and suitable tool that mimics the prognostic EC subtypes has been solved and validated. Procedure that might be introduced into routine diagnostic practices.

Final validation of the ProMisE molecular classifier for endometrial carcinoma in a large population-based case series

Background

We have previously developed and confirmed a pragmatic molecular classifier for endometrial cancers; ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer). Inspired by the Cancer Genome Atlas, ProMisE identifies four prognostically distinct molecular subtypes and can be applied to diagnostic specimens (biopsy/curettings) enabling earlier informed decision-making. We have strictly adhered to the Institute of Medicine (IOM) guidelines for the development of genomic biomarkers, and herein present the final validation step of a locked-down classifier before clinical application.

Patients and methods

We assessed a retrospective cohort of women from the Tübingen University Women's Hospital treated for endometrial carcinoma between 2003 and 2013. Primary outcomes of overall, disease-specific, and progression-free survival were evaluated for clinical, pathological, and molecular features.

Results

Complete clinical and molecular data were evaluable from 452 women. Patient age ranged from 29 to 93 (median 65) years, and 87.8% cases were endometrioid histotype. Grade distribution included 282 (62.4%) G1, 75 (16.6%) G2, and 95 (21.0%) G3 tumors. 276 (61.1%) patients had stage IA disease, with the remaining stage IB [89 (19.7%)], stage II [26 (5.8%)], and stage III/IV [61 (13.5%)]. ProMisE molecular classification yielded 127 (28.1%) MMR-D, 42 (9.3%) POLE, 55 (12.2%) p53abn, and 228 (50.4%) p53wt. ProMisE was a prognostic marker for progression-free (P = 0.001) and disease-specific (P = 0.03) survival even after adjusting for known risk factors. Concordance between diagnostic and surgical specimens was highly favorable; accuracy 0.91, κ 0.88.

Discussion

We have developed, confirmed, and now validated a pragmatic molecular classification tool (ProMisE) that provides consistent categorization of tumors and identifies four distinct prognostic molecular subtypes. ProMisE can be applied to diagnostic samples and thus could be used to inform surgical procedure(s) and/or need for adjuvant therapy. Based on the IOM guidelines this classifier is now ready for clinical evaluation through prospective clinical trials.

[Lymph node management in endometrial cancer]

In 2018, around 382,100 new cases of endometrial cancer (EC) were reported worldwide, accounting for about 4.4% of all new cases of cancer in women. In France, in 2018, the EC is the first gynecological cancer in incidence and the fourth cancer in women. The rationale for the therapeutic management of EC is based on the estimation of a theoretical risk of recurrence and lymph node metastasis using MRI and preoperative biopsy criteria. However, lymph node status remains the determining factor of adjuvant treatment. In order to reduce the morbidity of lymphadenectomy, the concept of sentinel lymph node biopsy (SLN) has been developed. The SLN technique has evolved in recent years, thanks to the advent of robotics and the creation of fluorescence detection cameras. It has been shown that detection of SLN with Indocyanine Green (ICG) allows for more frequent bilateral migration of 88 to 100% and better detection of pelvic GS in 97% of cases with a decrease in morbidity. Recently, in view of the absence of a therapeutic role of lymph node staging, the operational risks and the delay of adjuvant treatments, in case of pelvic lymph node metastasis on definitive histological examination, the question of secondarily performing paraaortic lymphadenectomy arises. The SLN procedure, extended to all early-stage endometrial cancers, should lead to a major reduction in the use of secondary staging and better adaptation of adjuvant therapy.

The Use of microRNAs in the Management of Endometrial Cancer: A Meta-Analysis

Introduction: Endometrial cancer (EC) is the most important gynecological cancer in terms of incidence. microRNAs (miRs), which are post-transcriptional regulators implicated in a variety of cellular functions including carcinogenesis, are particularly attractive candidates as biomarkers. Indeed, several studies have shown that the miR expression pattern appears to be associated with prognostic factors in EC. Our objective is to review the current knowledge of the role of miRs in carcinogenesis and tumor progression and their association with the prognosis of endometrial cancer. Materials and Method: We performed a literature search for miR expression in EC using MEDLINE, PubMed (the Internet portal of the National Library of Medicine) and The Cochrane Library, Cochrane databases “Cochrane Reviews” and “Clinical Trials” using the following keywords: microRNA, endometrial cancer, prognosis, diagnosis, lymph node, survival, plasma, FFPE (formalin-fixed, paraffin-embedded). The miRs were classified and presented according to their expression levels in cancer tissue in relation to different prognostic factors. Results: Data were collected from 74 original articles and 8 literature reviews which described the expression levels of 261 miRs in ECs, including 133 onco-miRs, 110 miR onco-suppressors, and 18 miRs with discordant functions. The review identified 30 articles studying the expression pattern of miR in neoplastic endometrial tissue compared to benign and/or hyperplastic tissues, 12 articles detailing the expression profile of miRs as a function of lymph node status, and 14 articles that detailed the expression pattern of miRs in endometrial tumor tissue according to overall survival or in the absence of recurrence. Conclusions: The findings presented here suggest that miR analysis merits a role as a prognostic factor in the management of patients with endometrial cancer.

[Primary management of endometrial carcinoma. Joint recommendations of the French society of gynecologic oncology (SFOG) and of the French college of obstetricians and gynecologists (CNGOF)]

OBJECTIVES

The management of endometrial carcinoma is constantly evolving. The SFOG and the CNGOF decided to jointly update the previous French recommendations (Institut national du cancer 2011) and to adapt to the French practice the 2015 recommendations elaborated at the time of joint European consensus conference with the participation of the three concerned European societies (ESGO, ESTRO, ESMO).

MATERIAL AND METHODS

A strict methodology was used. A steering committee was put together. A systematic review of the literature since 2011 has been carried out. A first draft of the recommendations has been elaborated, with emphasis on high level of evidence. An external review by users representing all the concerned discipines and all kinds of practice was completed. Three hundred and four comments were sent by 54 reviewers.

RESULTS

The management of endometrial carcinoma requires a precise preoperative workup. A provisional estimate of the final stage is provided. This estimation impact the level of surgical staging. Surgery should use a minimal invasive approach. The final pathology is the key of the decision concerning adjuvant therapy, which involves surveillance, radiation therapy, brachytherapy, or chemotherapy.

CONCLUSION

The management algorithms allow a fast, state of the art based, answer to the clinical questions raised by the management of endometrial cancer. They must be used only in the setting of a multidisciplinary team at all stages of the management.