Endometriosis and the subsequent risk of epithelial ovarian cancer

Endometriosis Typology and Ovarian Cancer Risk

Importance

Endometriosis has been associated with an increased risk of ovarian cancer; however, the associations between endometriosis subtypes and ovarian cancer histotypes have not been well-described.

Objective

To evaluate the associations of endometriosis subtypes with incidence of ovarian cancer, both overall and by histotype.

Design, Setting, and Participants

Population-based cohort study using data from the Utah Population Database. The cohort was assembled by matching 78 893 women with endometriosis in a 1:5 ratio to women without endometriosis.

Exposures

Endometriosis cases were identified via electronic health records and categorized as superficial endometriosis, ovarian endometriomas, deep infiltrating endometriosis, or other.

Main Outcomes and Measures

Estimated adjusted hazard ratios (aHRs), adjusted risk differences (aRDs) per 10 000 women, and 95% CIs for overall ovarian cancer, type I ovarian cancer, and type II ovarian cancer comparing women with each type of endometriosis with women without endometriosis. Models accounted for sociodemographic factors, reproductive history, and past gynecologic operations.

Results

In this Utah-based cohort, the mean (SD) age at first endometriosis diagnosis was 36 (10) years. There were 597 women with ovarian cancer. Ovarian cancer risk was higher among women with endometriosis compared with women without endometriosis (aHR, 4.20 [95% CI, 3.59-4.91]; aRD, 9.90 [95% CI, 7.22-12.57]), and risk of type I ovarian cancer was especially high (aHR, 7.48 [95% CI, 5.80-9.65]; aRD, 7.53 [95% CI, 5.46-9.61]). Ovarian cancer risk was highest in women with deep infiltrating endometriosis and/or ovarian endometriomas for all ovarian cancers (aHR, 9.66 [95% CI, 7.77-12.00]; aRD, 26.71 [95% CI, 20.01-33.41]), type I ovarian cancer (aHR, 18.96 [95% CI, 13.78-26.08]; aRD, 19.57 [95% CI, 13.80-25.35]), and type II ovarian cancer (aHR, 3.72 [95% CI, 2.31-5.98]; aRD, 2.42 [95% CI, -0.01 to 4.85]).

Conclusions and Relevance

Ovarian cancer risk was markedly increased among women with ovarian endometriomas and/or deep infiltrating endometriosis. This population may benefit from counseling regarding ovarian cancer risk and prevention and could be an important population for targeted screening and prevention studies.

The malignant transformation of endometriosis: Is there a left lateral predisposition of ovarian clear cell and endometrioid carcinomas?

INTRODUCTION

Endometriosis affects 10% of women of reproductive age. There is evidence for a left lateral predisposition of endometriotic lesions and a 1.9-fold greater risk of ovarian cancer in endometriosis. The aim of this study is to determine whether a left lateral predisposition of ovarian clear-cell carcinoma (CCC) and endometrioid carcinoma (EC) exists.

MATERIALS AND METHODS

A retrospective cohort study of all EC and CCC patients in Northern Ireland between March-2011 and June-2018. ANOVA was used to analyse preoperative prediction of stage, chi-squared (χ2) was used to compare left- and right-sided masses. Survival was estimated using Kaplan-Meier and log-rank test. A p-value <0.05 was considered significant.

RESULTS

158 patients were identified (95 EC, 55 CCC, 8 mixed). Mean age was 57.65 years with 69% presenting at stage 1. The mean CA125 was 559 U/mL (p = 0.850) and mean abdominal mass size was 14.12 cm (p = 0.732). The most common presenting symptom was an abdominal mass (37%). Despite 67% of patients having endometriosis on final pathology, only 8.9% had a known history pre-operatively. 51% of tumours were located on the left (p = 0.036). For unilateral tumours this was significant for EC (P = 0.002) but not for CCC (P = 0.555). The 1-, 3- and 5-year overall survival for all types/stages was 85%, 78% and 71% respectively.

CONCLUSION

While CCC and EC are associated with endometriosis, only EC exhibits a left lateral predisposition. There is no association between preoperative CA125 or abdominal mass size and stage of disease.

Case report: Malignant transformation of ovarian endometrioma during long term use of dienogest in a young lady

Endometriosis is a benign disease, which is also regarded as a precursor to ovarian malignancy. Dienogest is a progestin treatment for endometriosis with efficacy and tolerability. A 35-year-old Taiwanese lady with ovarian endometrioma had taken dienogest for the last 5 years. During sonographic follow-up, surgery was suggested owing to suspicious of malignant transformation of ovarian endometrioma. While she hesitated and turned to receive two cycles of oocyte retrieval because of nulliparity. Meanwhile, more papillary growth in the ovarian endometrioma with intratumor flow was found during follow-up. Laparoscopic enucleation was performed later, and pathology revealed clear cell carcinoma with peritoneal involvement, at least FIGO stage IIB. She then underwent debulking surgery to grossly no residual tumor and received adjuvant chemotherapy with no tumor recurrence in post-operative 17-months follow-up. Considering fertility preservation, conservative treatment of ovarian endometrioma is typically indicated for those women who have not yet completed childbearing. However, malignant transformation may still occur despite long-term progestin treatment. Therefore, careful image follow-up is still indispensable.

Endometriosis-associated epithelial ovarian cancer: Primary synchronous different cellular type on each ovary

OBJECTIVE

Endometriosis-associated epithelial ovarian cancer (EOC) is a specific category of EOC, containing either endometrioid or clear cell carcinoma subtype. The characteristic of endometriosis-associated EOC includes an early stage at the diagnosis, presence of single histology type, and better prognosis. The synchronous two subtypes of endometriosis-associated EOC and presentation of far-advanced stage status at the initial diagnosis is rarely reported.

CASE REPORT

We reported a 60-year-old postmenopausal woman with FIGO IA endometriosis-associated endometrioid carcinoma at right ovary and FIGO IVA endometriosis-associated clear cell carcinoma at left ovary, right tube, omentum, lymph node and cytology of pleural effusion and ascites treated with optimal debulking surgery and dose-intensity taxane/platinum based chemotherapy.

CONCLUSION

This case report confirms the long-term concept that clear cell carcinoma has much more aggressive behavior than endometrioid cell carcinoma does, regardless of association of endometriosis or not.

Risk factors for endometriotic-cyst associated ovarian cancer: A case controlled study

OBJECTIVE

Primary objective is to identify risk factors of endometriotic-cyst associated ovarian cancer (EAOC). Secondary objective is to evaluate the clinical characteristics of EAOC patients.

MATERIALS AND METHODS

A retrospective case-control study was conducted by analyzing data of patients from 1999 to 2014. Cases were endometriotic-cyst associated ovarian cancer with pathologically confirmed diagnosis. Controls were randomly selected with year-matched patients with benign ovarian endometriotic cyst. Univariate and multivariate with logistic regression analyses were used to identify patients' characteristics that were risk factors for endometriotic-cyst associated ovarian cancer.

RESULTS

Altogether, 158 controls and 79 EAOC cases were recruited. Mean age of the EAOC group was 13 years older than that of the control group (49 vs. 36 years). The most common stage of EAOC was stage I (59.74%). Clear cell subtype is the most commonly found in this population (60.76%). Univariate analysis showed that age ≥42 years, menopause, weight loss, cyst diameter ≥8.33 cm, presence of solid area, bilaterality and CA 125 higher than 117.6 units/ml were significant. Multivariate analysis showed that patients with age ≥42 years (OR 7.69, 95%CI: 2.47, 23.87), menopause (OR 33.19, 95%CI: 2.37, 465.12), weight loss (OR 11.94, 95%CI: 1.52, 94.08), cyst diameter ≥ 8.3 cm (OR 10.56, 95%CI: 4.39, 25.35) and presence of solid area by ultrasonography (OR 6.70, 95%CI: 2.19, 22.35) were significant risk factors for EAOC.

CONCLUSION

Advanced age, menopause, weight loss, cyst diameter ≥ 8.33 cm and presence of solid area from ultrasonography were important risk factors for EAOC.

Endometriosis and cancer: a systematic review and meta-analysis

BACKGROUND

Endometriosis is an often chronic, inflammatory gynaecologic condition affecting 190 million women worldwide. Studies have reported an elevated cancer risk among patients with endometriosis. However, prior research has included methodologic issues that impede valid and robust interpretation.

OBJECTIVE AND RATIONALE

We conducted a meta-analysis of studies investigating the association between endometriosis and cancer risk and analysed the results by methodologic characteristics. We discuss the implications of cancer screening in patients and management challenges faced by clinicians.

SEARCH METHODS

We searched PubMed and Embase databases for eligible studies from inception through 24 October 2019. We included cohort and case-control studies examining the association between endometriosis and cancer risk; cross-sectional studies and case reports were excluded. Publications had to present risk/rate/odds estimates with 95% CI. Random effects meta-analysis was used to estimate summary relative risks (SRR) and CIs. Heterogeneity across studies was assessed by the Q test and I2 statistics, and publication bias using Egger's and Begg's tests. Risk of bias and quality of the included studies were assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool.

OUTCOMES

Forty-nine population-based case-control and cohort studies were included. Twenty-six studies were scored as having a 'serious'/'critical' risk of bias, and the remaining 23 'low'/'moderate'. Cancer-specific analyses showed a positive association between endometriosis and ovarian cancer risk (SRR = 1.93, 95% CI = 1.68-2.22; n = 24 studies) that was strongest for clear cell (SRR = 3.44, 95% CI = 2.82-4.42; n = 5 studies) and endometrioid (SRR = 2.33, 95% CI = 1.82-2.98; n = 5 studies) histotypes (Pheterogeneity < 0.0001), although with significant evidence of both heterogeneity across studies and publication bias (Egger's and Begg's P-values < 0.01). A robust association was observed between endometriosis and thyroid cancer (SRR = 1.39, 95% CI =1.24-1.57; n = 5 studies), a very small association with breast cancer (SRR = 1.04, 95% CI =1.00-1.09; n = 20 studies) and no association with colorectal cancer (SRR = 1.00, 95% CI =0.87-1.16; n = 5 studies). The association with endometrial cancer was not statistically significant (SRR = 1.23, 95% CI =0.97-1.57; n = 17 studies) overall and wholly null when restricted to prospective cohort studies (SRR = 0.99, 95% CI =0.72-1.37; n = 5 studies). The association with cutaneous melanoma was also non-significant (SRR = 1.17, 95% CI =0.97-1.41; n = 7 studies) but increased in magnitude and was statistically significant when restricted to studies with low/moderate risk of bias (SRR = 1.71, 95% CI = 1.24-2.36, n = 2 studies). The most robust finding both in terms of statistical significance and magnitude of effect was an inverse association with cervical cancer (SRR = 0.68, 95% CI =0.56-0.82; n = 4 studies); however, this result has a high potential to reflect heightened access to detection of dysplasia for women who reached an endometriosis diagnosis and is thus likely not causal. Several additional cancer types were explored based on <4 studies.

WIDER IMPLICATIONS

Endometriosis was associated with a higher risk of ovarian and thyroid, and minimally (only 4% greater risk) with breast cancer, and with a lower risk of cervical cancer. However, this meta-analysis confirms that: a majority of studies had severe/critical risk of bias; there is impactful heterogeneity across studies-and for ovarian cancer, publication bias; and causal inference requires temporality, which in many studies was not considered. We discuss the implications of these potential associations from the perspectives of patients with endometriosis, clinicians involved in their care, and scientists investigating their long-term health risks.

Genetic variants in the nucleotide excision repair genes are associated with the risk of developing endometriosis

Endometriosis is a major health issue among women of reproductive age. However, its etiology has not yet been completely understood. We investigated 10 single nucleotide polymorphisms from six novel nucleotide excision repair genes and the susceptibility to endometriosis. A total of 153 patients with endometriosis were recruited during 2000-2010 from central Taiwan. Pathological confirmation was necessary for all patients, and exclusion criteria included the presence of leiomyoma, adenomyosis, or cancer of the uterine, cervix, or ovary and a prescription of hormone therapy. Furthermore, a total of 636 age-matched individuals without endometriosis were recruited during the same time period from central Taiwan. The polymerase chain reaction coupled with restriction fragment length polymorphism methodology was applied for genotyping. The multivariate logistic regression analysis showed that subjects carrying the ERCC1 rs11615 TT (OR = 2.04, 95% CI = 1.36-3.41), ERCC2 rs1799793 AA (OR = 1.86, 95% CI = 1.14-3.11), and ERCC6 rs2228528 AA genotypes (OR = 1.79, 95% CI = 1.13-2.83) exhibited significantly increased risks of developing endometriosis compared with their counterparts carrying the wild-type genotypes. This study suggests that certain single nucleotide polymorphisms of nucleotide excision repair genes excision repair cross-complementation group 1 (ERCC1, ERCC2, and ERCC6) predispose women to the development of endometriosis.

Subsequent Development of Epithelial Ovarian Cancer After Ovarian Surgery for Benign Ovarian Tumor: A Population-Based Cohort Study

Purpose

The goal of the current study is to determine the risk of subsequent development of epithelial ovarian cancer (EOC) in women after ovarian surgery for benign ovarian tumors.

Patients and Methods

We conducted the nationwide population-based historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan. Eleven thousand six hundred twenty women who underwent ovarian surgery for ovarian benign diseases were analyzed. The collected data included age, types of ovarian surgery, medical history by Charlson comorbidity index (CCI), infertility (yes/no), pelvic inflammatory disease (PID) (yes/no), tubal ligation (yes/no), total/subtotal hysterectomy (TH/STH) (yes/no), and endometrioma (yes/no). We used the Kaplan-Meier method and the Log-rank test to evaluate the risk factors. Cox proportional hazard methods were used to evaluate risk factors for the subsequent development of EOC. Multivariate analysis using Cox stepwise forward regression was conducted for the covariate selected in univariate analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Wald test.

Results

Subsequent EOC incidence rate (IR, incidence per 10,000 person-years) of women after ovarian surgery for benign ovarian tumors was 2.98. Separating into four groups based on different age, IR of EOC was 1.57 (<30 years), 4.71 (30-39 years), 3.59 (40-49 years) and 0.94 (≥50 years), respectively. Univariate and multivariate analyses identified only high level of CCI (≥2 or more) as an independent risk factor for subsequent development of EOC in women after ovarian surgery for benign ovarian tumors (HR 59.17, 95% CI 7.50-466.80 in women with CCI level of 2 and HR 190.68, 95% CI 24.33-2494.19, in women with CCI level ≥3, respectively).

Conclusion

Our results, if confirmed, suggest that women with other comorbidities (CCI) should be well informed that they may have a higher risk of subsequent development of EOC when ovarian surgery is planned even though the final pathology showed a benign ovarian tumor.

Long-term Health Consequences of Endometriosis - Pathways and Mediation by Treatment

Purpose of review

The purpose of this review is to discuss the most up to date research on endometriosis and chronic disease risk, highlighting the role treatments for endometriosis may play in these associations.

Recent findings

Previous studies have shown a consistent association between endometriosis and risk for epithelial ovarian cancer but the association with other cancers is less clear. Current research indicates that endometriosis may in be associated with risk of systemic lupus erythematosus, and potentially other autoimmune diseases. Limited evidence is also present for the association between endometriosis and cardiovascular disease and related conditions (e.g,. hypertension, hypercholesterolemia). A potential explanation for a portion of the increased risk of chronic diseases among women with endometriosis may relate to treatments for endometriosis impacting these outcomes.

Summary

Given the prevalence of endometriosis, understanding the relation between endometriosis and other chronic diseases has the potential to impact the health of many women. However, few high-quality studies with limited biases and adequate follow-up currently exist. Future multi-disciplinary research in prospective cohorts, with ample follow-up time, and detailed information on endometriosis characteristics and treatment is critical to advancing our understanding of this disease and its consequences.

Immunology and ovarian cancers

The current standard therapy of epithelial ovarian cancer (EOC) is the combination of surgery and multiagent chemotherapy with/without adding targeted therapy. After treatment, response rate is high and nearly all patients can achieve complete remission, even though they are advanced diseases; however, the majority of patients will relapse and subsequently die of diseases within several years after initial treatment. When treatment options are limited, there is the urgent need for new novel therapeutic approaches for precise cancer control. The development of chemoresistance and evading of the anticancer immune response may be one of the important causes contributing to the therapeutic failure, and therefore, it represents a paradigm shift in cancer research. An individual's immune response and interaction with EOC cells might be one of the key factors for cancer treatment. There are many interventions, including targeting certain type immunogenic EOC-associated antigens, immune checkpoint blockade, and adoptive cellular therapy, which present a profound opportunity to revolutionize EOC treatment. This review will encompass the interaction between EOC and immune system and highlight recent data regarding the research of immunotherapy in EOC.

Risk of Endometriosis and Subsequent Ovary and Breast Cancers in Nurses: A Population-Based Cohort Study in Taiwan

Background: Endometriosis has been associated with the subsequent development of ovarian and breast cancers. This study evaluated whether nurses were at increased risks of developing endometriosis and subsequent ovarian and breast cancers. Methods: From Taiwan National Health Insurance Research Database during 2000 to 2011, we established 3 study cohorts, consisting of 23,801 nurses, 11,973 other hospital employees, and 143,096 general women free of endometriosis and cancer. Women in all cohorts were followed to the end of 2011 to measure the occurrences of endometriosis and subsequent ovarian and breast cancers. The incident endometriosis cases and related hazard ratio (HR) and 95% confidence interval (CI) were calculated. The incident cases of ovarian cancer and breast cancer and related odds ratio were calculated. Results: The incidence of endometriosis was the highest in the nurse cohort (4.23 per 100, n = 966) followed by other health professionals (3.74 per 100, n = 427) and control cohort (3.06 per 100, n = 4193), with adjusted hazard ratios of 1.28 (95% CI = 1.20–1.38) and 1.13 (95% CI = 1.02–1.25), respectively, comparing to controls. Among those who developed endometriosis, nurses had higher subsequent ovarian cancer and lower breast cancer, but not significant. Conclusions: Nurses are at a higher risk of developing endometriosis. However, the link between endometriosis and subsequent cancers is weak.

Contralateral ovarian endometrioma recurrence after unilateral salpingo-oophorectomy

Background

The recurrence rate after unilateral salpingo-oophorectomy (USO) for unilateral endometrioma has not been reported. We evaluated the rate of and risk factors for endometrioma recurrence after USO.

Methods

In this retrospective observational study, we enrolled 110 women (age, 35–45 years) who underwent laparoscopic USO (n = 50) or cystectomy (n = 60) for unilateral ovarian endometrioma from January 2010 through December 2012. We compared patients’ characteristics between patients who underwent USO and those who underwent cystectomy. We also compared patients with and without an endometrioma recurrence after USO using univariate and multivariate stepwise logistic regression models to identify recurrence risk factors. Endometrioma recurrence was defined as an ovarian cyst (> 2 cm) with features typical of an endometrioma identified by postoperative transvaginal sonography.

Results

Endometrioma recurred in 8 (16%) patients after USO (mean follow-up, 46.0 ± 12.9 months [range, 15–73]). The post-USO cumulative recurrence rates at 12, 24, 36, and 60 months were 8.0, 10.2, 12.7, and 24.7%, respectively (Kaplan-Meier analysis). In logistic regression analysis, a contralateral side adhesion score ≥ 4 was an independent risk factor for endometrioma recurrence after USO (odds ratio, 19.48, 95% confidence interval, 1.59–237.72). The post-USO cumulative recurrence rates at 12, 24, 36, and 57 months were 19.5, 24.1, 31.0, and 54.0%, respectively, in cases with contralateral side adhesion scores ≥4, and 0.0, 0.0, 0.0, and 5.9%, respectively, in cases with scores < 4 (log-rank test, P = 0.0023).

Conclusions

To our knowledge, this is the first report on the recurrence rate and risk factors associated with recurrence after USO. Endometrioma recurrence rates were 24.7% during the first 5 years after USO. The post-USO recurrence rate increased significantly in cases with contralateral side adhesions. Our findings could improve the planning of USO and patient selection for postoperative hormonal therapy.

Asian Society of Gynecologic Oncology International Workshop 2018

The Asian Society of Gynecologic Oncology International Workshop 2018 on gynecologic oncology was held in the Ajou University Hospital, Suwon, Korea on the 24th to 25th August 2018. The workshop was an opportunity for Asian doctors to discuss the latest findings of gynecologic cancer, including cervical, ovarian, and endometrial cancers, as well as the future of fertility-sparing treatments, minimally invasive/radical/debulking surgery, radiotherapy, chemotherapy, targeted therapy, and immunotherapy. Clinical guidelines and position statement of Asian countries were presented by experts. Asian clinical trials for gynecologic cancers were reviewed and experts emphasized the point that original Asian study is beneficial for Asian patients. In Junior session, young gynecologic oncologists presented their latest research on gynecologic cancers.

Endometriosis-associated ovarian cancer: What have we learned so far?

Endometriosis is defined as the presence of ectopic endometrial tissue outside of the uterine cavity, most commonly in the ovaries and peritoneum. It is a complex disease that is influenced by multiple factors. It is also a common gynecological disorder and affects approximately 10-15% of all women of reproductive age. Recent molecular and pathological studies indicate that endometriosis may serve as a precursor of ovarian cancer (endometriosis-associated ovarian cancer, EAOC), particularly endometrioid and clear cell ovarian cancers. Although histological and epidemiological studies have demonstrated that endometriosis has a malignant potential, the molecular mechanism that underlies the malignant transformation of endometriosis is still controversial, and the precise mechanism of carcinogenesis must be fully elucidated. Currently, the development and improvement of a new sequencing technology, next-generation sequencing (NGS), has been increasingly relevant in cancer genomics research. Recently, NGS has also been utilized in clinical oncology to advance the personalized treatment of cancer. In addition, the sensitivity, speed, and cost make NGS a highly attractive platform compared to other sequencing modalities. For this reason, NGS may lead to the identification of driver mutations and underlying pathways associated with EAOC. Here, we present an overview of the molecular pathways that have led to the current opinions on the relationship between endometriosis and ovarian cancer.

Maternal pregnancy-induced hypertension increases the subsequent risk of transient tachypnea of the newborn: A nationwide population-based cohort study

OBJECTIVE

To determine the association between pregnancy-induced hypertension (PIH) and transient tachypnea of the newborn (TTN) and to identify the predictive risk factors.

MATERIALS AND METHODS

Pregnant women with a newly diagnosed PIH (between 2000 and 2013) from the Taiwan National Health Insurance Research Database (NHIRD) were compared with a matched (with respect to age and year of delivery) cohort of pregnant women without PIH. The occurrence of TTN was evaluated in both cohorts.

RESULTS

Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. According to a multivariate analysis, PIH (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.69-2.03, p < 0.0001), age ≥ 30 years (OR = 1.38, 95% CI = 1.26-1.51, p < 0.0001), primiparity (OR = 1.37, 95% CI = 1.24-1.5, p < 0.0001), preterm birth (OR = 3.4, 95% CI = 3.09-3.75, p < 0.0001), multiple births (OR = 2.54, 95% CI = 2.24-2.89, p < 0.0001), and cesarean section (OR = 1.71, 95% CI = 1.56-1.88, p < 0.0001) were independent risk factors for the development of TTN.

CONCLUSION

Women with PIH have an increased risk of having infants who develop TTN compared with those without PIH. Additionally, age ≥30 years, primiparity, preterm birth, multiple births, and cesarean section were independent risk factors for the development of TTN.

Impact of endometriosis on risk of ovarian, endometrial and cervical cancers: a meta-analysis

PURPOSE

The risks of gynecologic cancer have not been well established in women with endometriosis. The objective of the present study was to investigate the influence of endometriosis on the risk for three gynecologic cancer (ovarian cancer, endometrial cancer and cervical cancer).

METHODS

We gathered updated evidence about the risk relationship between endometriosis and gynecologic cancers by conducting a comprehensive search of several medical literature electronic databases, including PubMed, Embase and the Cochrane Library. The design and quality of all studies were evaluated using the Newcastle-Ottawa Scale (NOS), and a random-effects model was used to calculate pooled risk ratio (RR).

RESULTS

Of the 8538 articles our search produced, we selected 25 qualified studies, including 16 cohort studies and 9 case-control studies. Patients with endometriosis had both an increased risk of ovarian cancer [RR  1.964; 95% CI (1.685, 2.290)]. The risk of endometrial cancer (EC) is not necessarily higher in patients with endometriosis [RR 1.176, 95% CI (0.878, 1.575)]. Endometriosis was not associated with an increased risk for cervical cancer (CC) [RR 0.670, 95% CI (0.537, 0.838)].

CONCLUSIONS

Patients with endometriosis need to be closely observed and rechecked regularly to prevent malignant changes.

The role of α2,3-linked sialylation on clear cell type epithelial ovarian cancer

OBJECTIVE

Our previous study has shown that high expression of α2,3-sialytransferase type I was associated with advanced stage serous type epithelial ovarian cancer (EOC). The aim of the current study further attempts to evaluate the altered α 2,3-sialylation on the behavior of clear cell type EOC (C-EOC).

MATERIALS AND METHODS

Immunohistochemistry staining, bioinformatics analysis and tissue array were used to disclose the clinical significance of over α2,3-sialylation in C-EOC. An α2,3 sialylation inhibitor, soyasaponin I (SsaI) was used to investigate the behavior change of the C-EOC cell line.

RESULTS

We reconfirmed that α2,3-sialylation, instead of α2,6- sialylation, was associated with late-stage C-EOC. Soyasaponin I could inhibit α2,3-sialylation of C-EOC cell lines and increase E-cadherin expression with subsequently suppressing migration of C-EOC cells.

CONCLUSIONS

The current study demonstrated the important role of α2,3-linked sialylation in C-EOC and targeting of α2,3-linked sialylation might offer as a potential therapeutic strategy in the future.

New knowledge and insights about the malignant transformation of endometriosis

Endometriosis may be a definitive risk factor for ovarian cancer, the most fatal gynecological cancer. The ability of endometriosis to transform into malignancy, first described by Dr. Sampson in 1925, is considered a rare occurrence, affecting approximately 1% of ovarian endometriomas. Recently we conducted a retrospective study regarding the malignant transformation of endometriosis in Japanese women. Many studies have reported a consistent correlation between endometriosis and ovarian cancer according to histological subtypes. However, the existing epidemiological evidence linking this association is insufficient to define the role of endometriosis as a cause of ovarian cancer and to influence changes to current clinical practice. Prospective cohort studies are therefore needed to clarify this issue. Additionally, the results of many molecular studies are conflicting, and earlier studies showing the molecular aberrations involved in genomic instability and mutation that enable malignant transformation have not been replicated in later studies. Careful long-term observation of a patient with endometrioma is required to detect possible subsequent incidence of malignant transformation. More importantly, a precise strategy should be set up for better prevention, early detection, specific diagnosis and treatment targeting molecular pathogenesis to understand the mechanisms of endometriosis-associated ovarian cancer. Clinicians need to be aware of the increased ovarian cancer risk in women with endometriosis.

Risks of female genital tract related cancers (gynecological cancers) or breast cancer in women with and without chronic kidney disease: A population-based cohort study in Taiwan

This article aims to test the hypothesis that the risk of female genital tract related cancer (gynecological cancer: GC) or breast cancer (BC) of women with chronic kidney disease (CKD) might be different from that of those women without CKD.A nationwide 17-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 3045 women with a diagnosis of CKD from 1996 to 2013 and 3045 multivariable-matched controls (1:1) were selected. We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CIs) to determine the risk of GC or BC in women.The GC incidence rates (IRs, per 10,000 person-years) of the CKD and non-CKD women were 11.02 and 19.09, respectively, contributing to a significantly decreased risk of GCs (crude HR 0.57, 95% CI 0.39-0.81; adjusted HR 0.44, 95% CI 0.30-0.65) in the CKD women. The GC IR was relatively constant in the CKD women among the different age categories (IR ranged from 8.10 to 12.29). On contrast, the non-CKD women had a progressive and continuous increase of GC IR in the advanced age, which was more apparent at age ≥50 years (IR 17.16 for 50-59; IR 23.05 for 60-69; and IR 31.62 for ≥70, respectively), contributing to the lower risk of GC in the CKD women than that in the non-CKD women. There was no difference of BC incidence between women with and without CKD.The findings of the lower risk of GCs in the CKD women in Taiwan are worthy of further evaluation.

Clinical implication for endometriosis associated with ovarian cancer

We reviewed current literature regarding the association of endometriosis and epithelial ovarian cancer based on epidemiology studies, molecular researches and clinical observations. Our methods include a review of literature research of MEDLINE, PubMed, Cochrane Library of Systematic Reviews and reference search in selected papers. The life time risk of epithelial ovarian cancer in women with endometriosis is low, yet there might be a cluster of individuals who have higher risk of developing epithelial ovarian cancer from endometriosis. Endometriosis associated ovarian cancer (EAOC) is predominant in particular histological subtypes of epithelial ovarian carcinoma and are related to some specific molecular aberrations. Clinical observations showed age as an important variable to the development of EAOC. Rapid growth of tumor and solid components in sonography are key features to detect malignant transformation of endometriosis. Evidence is not clear about prophylactic oophorectomy in preventing EAOC in patients with endometriosis. This review provided rationale data for identifying, monitoring, counseling and management of women with endometriosis who are potentially high risk for malignant transformation.

Unexpected epithelial ovarian cancers arising from presumed endometrioma: A 10-year retrospective analysis

OBJECTIVE

To evaluate the incidence and prognosis of unexpected epithelial ovarian cancers (EOCs) occurring in presumed benign endometrioma.

MATERIALS AND METHODS

Patients who underwent primary surgery at Chang Gung Memorial Hospital between November 2003 and October 2013 were searched with the Systematized Nomenclature of Medicine code followed by chart review.

RESULTS

The incidence of unexpected EOCs in presumed ovarian endometrioma was 0.14%, as 11 patients were revealed after reviewing 497 patients of pathology-proven EOCs in the current series. All patients were aged ≥ 40 years; seven (63.6%) had inward mass within ovarian cyst in preoperative images, six had cancer antigen-125 (CA-125) > 200 U/mL, and two with CA-125 > 1500 U/mL. Ten patients underwent laparoscopy initially, including five with ovarian preservation at the beginning. Ten patients subsequently completed concurrent or secondary staging surgery, including four totally with laparoscopy. The histologic subtypes had clear-cell (8/11), endometrioid (1/11), mixed clear-cell and endometrioid (1/11), and low-grade serous adenocarcinoma (1/11). Seven patients had endometriosis-associated ovarian carcinoma (EAOC), while the other four were non-EAOC with no endometriosis component. The only mortality was a patient of non-EAOC in Stage IIIc, whereas the other 10 in Stage I were alive. The overall survival rate was 90.9% (10/11) with follow-up ranging from 23 months to 130 months.

CONCLUSION

Unexpected EOCs occurring in presumed ovarian endometrioma was rare and, if present, the prognosis was good in Stage I disease with laparoscopic management. Combining parameters of patient's age, CA-125 level, and inward solid mass at imaging could help to raise the precautions.

Uterine sarcoma part III-Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Endometriosis Might Be Inversely Associated with Developing Chronic Kidney Disease: A Population-Based Cohort Study in Taiwan

This study was conducted to determine the risk of chronic kidney disease (CKD) among women with endometriosis in Taiwan. We conducted a retrospective cohort study using the National Health Insurance Research Database of Taiwan. A total of 27,973 women with a diagnosis of endometriosis and 27,973 multivariable-matched controls (1:1) from 2000 to 2010 were selected. Cox regression and computed hazard ratios (HR) with 95% confidence intervals (95% CI) were used to determine the risk of CKD among women with endometriosis. The incidence rates (IR, per 10,000 person-years) of CKD among women with and without endometriosis were 4.64 and 7.01, respectively, with a significantly decreased risk of CKD (crude HR 0.65, 95% CI 0.53–0.81; adjusted HR 0.69, 95% CI 0.56–0.86) among women with endometriosis. The IR of CKD progressively increased with age, but the trend of lower CKD risk among women with endometriosis was consistent. However, the lower risk of CKD in women with endometriosis was no longer statistically significant after adjusting for menopausal status (adjusted HR 0.85, 95% CI 0.65–1.10). The results suggest that endometriosis is inversely associated with CKD, but this effect was mediated by menopause. The possible mechanism of this association is worthy of further evaluation.

Targeted next-generation sequencing for molecular diagnosis of endometriosis-associated ovarian cancer

Recent molecular and pathological studies suggest that endometriosis may serve as a precursor of ovarian cancer (endometriosis-associated ovarian cancer, EAOC), especially of the endometrioid and clear cell subtypes. Accordingly, this study had two cardinal aims: first, to obtain mutation profiles of EAOC from Taiwanese patients; and second, to determine whether somatic mutations present in EAOC can be detected in preneoplastic lesions. Formalin-fixed paraffin-embedded (FFPE) tissues were obtained from ten endometriosis patients with malignant transformation. Macrodissection was performed to separate four different types of cells from FFPE sections in six patients. The four types of samples included normal endometrium, ectopic endometriotic lesion, atypical endometriosis, and carcinoma. Ultra-deep (>1000×) targeted sequencing was performed on 409 cancer-related genes to identify pathogenic mutations associated with EAOC. The most frequently mutated genes were PIK3CA (6/10) and ARID1A (5/10). Other recurrently mutated genes included ETS1, MLH1, PRKDC (3/10 each), and AMER1, ARID2, BCL11A, CREBBP, ERBB2, EXT1, FANCD2, MSH6, NF1, NOTCH1, NUMA1, PDE4DIP, PPP2R1A, RNF213, and SYNE1 (2/10 each). Importantly, in five of the six patients, identical somatic mutations were detected in atypical endometriosis and tumor lesions. In two patients, genetic alterations were also detected in ectopic endometriotic lesions, indicating the presence of genetic alterations in preneoplastic lesion. Genetic analysis in preneoplastic lesions may help to identify high-risk patients at early stage of malignant transformation and also shed new light on fundamental aspects of the molecular pathogenesis of EAOC.

KEY MESSAGES

Molecular characterization of endometriosis-associated ovarian cancer genes by targeted NGS. Candidate genes predictive of malignant transformation were identified. Chromatin remodeling, PI3K-AKT-mTOR, Notch signaling, and Wnt/β-catenin pathway may promote cell malignant transformation.

Effects of dehydroepiandrosterone supplementation on women with poor ovarian response: A preliminary report and review

OBJECTIVE

To investigate the effect of dehydroepiandrosterone (DHEA) supplementation on women with poor ovarian response (POR).

MATERIALS AND METHODS

Women with POR treated with flexible daily gonadotropin-releasing hormone antagonist in vitro fertilization (IVF) cycles at The Reproductive Center in Kaohsiung Veterans General Hospital between January 2013 and October 2013, were enrolled for this prospective study. When patients failed to become pregnant during the first IVF cycle, they were treated with DHEA supplementation (30 mg, 3 times a day, orally) for 3 months (mean 12.2 weeks) before the next IVF cycle. Parameters of biochemical, ultrasound and treatment outcomes were compared before and after DHEA supplementation.

RESULTS

Ten patients with a mean age of 36.6 ± 4.2 years were identified. After DHEA treatment, there was a significant increase in antral follicle count, from 2.8 ± 1.0 to 4.1 ± 1.2 (p < 0.05), and anti-Müllerian hormone, from 0.4 ± 0.2 ng/mL to 0.84 ± 0.2 ng/mL (p < 0.001). A significant decrease of Day 3 follicle-stimulating hormone and estradiol, from 14.4 ± 1.7 mIU/mL to 10.1 ± 0.7 mIU/mL and from 51.2 ± 6.3 pg/mL to 35.2 ± 4.2 pg/mL, respectively (both p < 0.001), was noted. Increased numbers of retrieved oocytes (from 2.4 ± 1.1 to 4.2 ± 1.2; p < 0.01), fertilized oocytes (from 1.7 ± 0.5 to 3.8 ± 1.1; p < 0.001), Day 3 embryos (from 1.7 ± 0.5 to 3.7 ± 1.1; p < 0.001) and transferred embryos (from 1.7 ± 0.8 to 2.8 ± 0.8; p < 0.01) were also seen in these women with POR after DHEA treatment. Three women became pregnant after DHEA treatment.

CONCLUSION

The potential benefits of DHEA supplementation in women with POR were suggested by the biochemical parameters and IVF outcomes.

The Risk of Epithelial Ovarian Cancer of Women With Endometriosis May be Varied Greatly if Diagnostic Criteria Are Different: A Nationwide Population-Based Cohort Study

This article aims to test the hypothesis that the risk of epithelial ovarian cancer (EOC) in women with endometriosis might be changed by enrolling different population. A nationwide 14-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 239,385 women aged between 20 and 51 years, with at least 1 gynecologic visit after 2000, were analyzed. Cases included women with a diagnosed endometriosis, which was established along a spectrum from at least 1 medical record of endometriosis (recalled endometriosis) to tissue-proved ovarian endometriosis (n = X). Controls included women without any diagnosis of endometriosis (n = 239,385 - X). We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CI) to determine the risk of EOC in patients. The EOC incidence rates (IRs, per 10,000 person-years) of women with endometriosis ranged from 1.90 in women with recalled endometriosis to 18.70 in women with tissue-proved ovarian endometrioma, compared with those women without any diagnosis of endometriosis (0.77-0.89), contributing to crude HRs ranging from 2.59 (95% CI, 2.09-3.21; P < 0.001) to 24.04 (95% CI, 17.48-33.05; P < 0.001). After adjustment for pelvic inflammatory disease, infertility, Charlson co-morbidity index, and age, adjusted HRs were ranged from the lowest of 1.90 (95% CI, 1.51-2.37; P < 0.001) in recalled endometriosis to the highest of 18.57 (95% CI, 13.37-25.79; P < 0.001) in tissue-proved ovarian endometrioma, which was inversely related to the prevalence rate of endometriosis (from the highest of 30.80% in recalled endometriosis to the lowest of 1.54% in tissue-proved ovarian endometrioma). The risk of EOC in women with endometriosis varied greatly by different criteria used. Women with endometriosis might have a more apparently higher risk than those reported by systematic review and meta-analysis.

Endometriosis and ovarian cancer: potential benefits and harms of screening and risk-reducing surgery

Although endometriosis is well recognized as a benign gynecologic condition, its association with ovarian cancer (OVCA) has frequently been reported. Review articles on this topic are voluminous, yet there seems to be no consensus as to whether endometriosis is truly a precursor of OVCA and whether any screening or risk-reducing surgery should be instituted, on the basis of our current knowledge. In this review, published data are compiled and critically appraised. Through this critical appraisal, it seems clear that the strongest evidence seems to come from prevalence data. This type of data also suggests a reduced risk of certain histotypes (mainly type II) of OVCA in women with endometriosis. This may explain the rather moderate increase in risk as shown in epidemiologic studies. Even with this moderate increase in OVCA risk, caution should be exercised because of apparent bias in favor of publication of positive results, extensive heterogeneities among prevalence estimates, and inverse relationship between estimates and sizes of the studies. Many molecular studies are conflicting, and earlier studies showing molecular aberrations involved in genomic instability and mutation that enable malignant transformation are not replicated in later studies. Given the low incidence of OVCA and the rather moderate increase in risk of mostly type I tumors, screening seems to be ill-advised, and risk-reducing surgery such as salpingectomy with or without oophorectomy does not seem to yield any substantial benefit to women with endometriosis.