Predictive model of venous thromboembolism in endometrial cancer

Platelet Parameters as Biomarkers for Thrombosis Risk in Cancer: A Systematic Review and Meta-analysis

Cancer-associated thrombosis (CAT) is a major cause of both morbidity and mortality in cancer patients. Platelet count has been investigated as a predictor of CAT in various settings while knowledge on platelet activation parameters is sparse. This report provides a systematic review and meta-analysis on available literature on associations between platelet count and/or function and arterial and venous thrombosis in adult cancer patients. The review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched up to March 2022. The National Heart, Lung, and Blood Institute's tools were used for quality assessment. In total, 100 studies were included which investigated the association between CAT and platelet count (n = 90), platelet indices (n = 19), and platelet function/activation markers (n = 13) in patients with solid cancers (n = 61), hematological cancers (n = 17), or mixed cancer types (n = 22). Eighty-one studies had venous thrombosis as their outcome measure, while 4 had arterial thrombosis and 15 studies had both. We found significantly elevated odds ratio of 1.50 (95% confidence interval: 1.19-1.88) for thrombosis with higher platelet counts. We saw a tendency toward an association between markers of platelet activation in forms of mean platelet volume and soluble P selectin and both arterial and venous thrombosis. Only one study investigated dynamic platelet function using flow cytometry. In conclusion, platelet count is associated with CAT across different cancer types and settings. Platelet function or activation marker analysis may be valuable in assisting thrombosis risk assessment in cancer patients but is sparsely investigated so far.

Extended Venous Thromboembolism Prophylaxis after Robotic Staging for Endometrial Cancer

OBJECTIVES

Our objectives were to estimate the incidence of venous thromboembolism (VTE) after robotic staging for endometrial cancer and to compare the incidence of VTE in patients who received a single dose of preoperative prophylaxis of enoxaparin with those who received extended postoperative prophylaxis.

METHODS

This study is a retrospective chart review of patients who underwent robot-assisted surgical staging for endometrial cancer. Patients were categorized into two groups: preoperative prophylaxis (PP), patients who received a single dose of enoxaparin preoperatively, and extended prophylaxis (EP), patients who received 28 days of enoxaparin postoperatively.

RESULTS

In total, 148 patients were included, with 117 patients in the PP group and 31 patients in the EP group. The overall incidence of VTE within 30 days postoperatively was 0.67%. No significant difference was found between the PP and the EP groups (0.9% and 0%, respectively; P = 1.00). Most patients in the cohort had endometrioid adenocarcinoma (78%) with low-grade disease (70%), although there were a greater number of patients in the PP group with uterine serous carcinoma compared with the EP group (17% vs 10%; P = 0.034). The PP group had higher estimated blood loss (106 vs 81 mL; P = 0.009) and longer operative times (178 vs 151 min; P = 0.028) compared with the EP group. Significantly more patients in the PP group underwent lymph node dissection compared with the EP group (32% vs 7%; P = 0.008).

CONCLUSIONS

The incidence of VTE following robot-assisted surgical staging for endometrial cancer in this study was 0.67%. No significant difference was found in VTE incidence between the PP group compared with the EP group. Mechanical prophylaxis plus a single dose of preoperative pharmacologic prophylaxis may suffice for low-risk patients following robotic surgical staging for endometrial cancer.

Use of the Khorana score to predict venous thromboembolism in patients undergoing chemotherapy for uterine cancer

Objective

Gynecologic cancers are associated with a high risk of venous thromboembolism (VTE). The Khorana score is a validated tool to assess risk of VTE in cancer patients. The purpose of this study is to determine if the Khorana score can be used as a risk stratification tool for VTE in patients with uterine cancer undergoing chemotherapy.

Methods

A retrospective cohort study of patients with newly diagnosed uterine cancer receiving chemotherapy over a 4-year period was conducted. The patients were stratified based on their Khorana score as well as their chemotherapy sequence, neoadjuvant or definitive versus adjuvant.

Results

A total of 276 patients were included: 40 received neoadjuvant or definitive, 236 adjuvant chemotherapy. Most patients had advanced stage disease (64.5%). 18 (6.5%) patients developed VTE within 180 days of initiating chemotherapy. High Khorana score was associated with a non-significant increase in VTE (K ≥ 2 OR 1.17, CI 0.40-3.39, K ≥ 3 OR 1.69, CI 0.61-4.69) but had poor predictive accuracy based on area under the curve (K ≥ 2 0.51, K ≥ 3 0.55). The VTE rate was higher in the neoadjuvant/definitive chemotherapy group to adjuvant (12.5% vs 5.5%, p = 0.11). While the former group had a higher average Khorana score (2.35 vs 1.93, p = 0.0048), this was not predictive of VTE.

Conclusions

While validated in other cancer types, the Khorana score was found to be a poor predictor of VTE in patients with uterine cancer. The use of the Khorana score to guide routine thromboprophylaxis in these patients should be used with caution and further investigation is warranted.

Venous Thromboembolism in Japanese Patients with Gynecologic Cancer

OBJECTIVE

Gynecologic cancer, including cervical, endometrial, and ovarian cancer, comprises the fifth leading type of cancer and is an important malignant disease in women. Previous studies in Western countries have reported respective prevalence rates for venous thromboembolism (VTE) of 3.3%-18.7%, 0.8%-8.1%, and 7.2%-20.9%. In this study, we aimed to identify the characteristics associated with VTE in Japanese patients.

METHODS

We carried out a retrospective cohort study to compare the clinicopathological characteristics of patients with each gynecologic cancer with and without concomitant VTE. Patients: Patients with cervical, endometrial, or ovarian cancer treated at Fukui Prefectural Hospital, Japan, from April 2010 to March 2020.

RESULTS

Among 699 patients with gynecologic cancer, 50 developed VTE within 5 years after their cancer diagnosis, including 16/357 patients with cervical cancer (5.6%), 12/185 with endometrial cancer (6.8%), and 22/157 with ovarian cancer (14.6%). The 1-year mortality rate after symptomatic VTE onset was 47.8%. The VTE group included significantly more older patients and more patients with advanced cancer or poor performance status compared with the non-VTE group. There was no significant difference in the rate of surgical treatment. Symptomatic, but not asymptomatic VTE, was associated with shorter survival.

CONCLUSION

Several baseline characteristics differed between patients with and without VTE. The incidences of VTE and some risk factors were similar in Japanese patients with gynecologic cancers compared with patients in other countries. Patients with VTE had some factors that worsened their prognosis, with patients with gynecologic cancer and symptomatic VTE having an especially poor prognosis.

Postoperative venous thromboembolism risk stratification in patients with uterine cancer

BACKGROUND

Uterine cancers are associated with a high risk for venous thromboembolisms. The American Society of Clinical Oncology practice guidelines recommend that all patients undergoing pelvic surgery for cancer should receive extended pharmacologic thromboprophylaxis with the duration being dependent on risk. However, risk stratification for patients with uterine cancer is not clearly defined. The Caprini score is the most widely used risk assessment model but it has been found to have limited use in the gynecologic oncology population. A modified Caprini score has been explored in other populations. The Khorana score is an additional risk assessment model that has not been studied in this context.

OBJECTIVE

Our objective was to evaluate the ability of a modified Caprini model and the Khorana score to risk stratify patients with uterine cancer for postoperative venous thromboembolisms within 90 days of surgery.

STUDY DESIGN

Following institutional review board approval, a retrospective cohort study was performed, and all patients with uterine cancer who underwent a hysterectomy over a 4-year period were included. The Caprini and Khorana scores were calculated for each patient. The Caprini score cutoff for highest risk was evaluated at ≥7, ≥8, and ≥9 (modified Caprini) and the Khorana score cutoff was evaluated at ≥2 and ≥3. To determine the prognostic use of each score and other clinico-pathologic criteria related to the development of a venous thromboembolism, univariate analyses were performed using independent t tests, chi-square tests, or Fisher's exact tests; a multivariate analysis was performed using logistic regression.

RESULTS

A total of 954 patients were included. The rate of venous thromboembolism development was 1.7% (16/954). A minimally invasive surgical approach was used in 90.5% (863/954) of patients. The mean Caprini score for patients with a venous thromboembolism was 10.3 compared with 8.1 for patients without a venous thromboembolism (95% confidence interval, 1.17-3.33; P<.0001). The mean Khorana score for the venous thromboembolism group was 2.4 vs 1.9 for those without (95% confidence interval, 0.04-0.82; P=.03). Both the Caprini and Khorana scores were found to be associated with venous thromboembolisms, but only a Caprini score with a cutoff of ≥8 or ≥9 was statistically significant (risk ratio, 31.25; 95% confidence interval, 1.88-519.49; risk ratio, 4.59; 95% confidence interval, 1.49-14.13, respectively), with high accuracy based on the area under the curve (0.75 and 0.68, respectively). Of the minimally invasive subgroup, 11.7% (101/863) of patients had same-day discharge with no postoperative thromboprophylaxis; none of these patients developed venous thromboembolisms. Despite extended prophylaxis among the laparotomy patients (30 days), the rate of venous thromboembolisms was more than 3 times that of the minimally invasive group (5.49% vs 1.7%). Advanced tumor stage and leukocytosis were noted to be independent risk factors for venous thromboembolisms.

CONCLUSION

Our study suggests that using a modified Caprini score could help to identify the highest-risk patients who would benefit from prolonged thromboprophylaxis, could reduce the incidence of postoperative venous thromboembolisms, and could minimize the cost and harm of overtreatment. These findings need to be validated in a prospective manner, and further research is needed to determine the optimal duration of therapy.

A Prediction Model Based on Blood Biomarker for Mortality Risk in Patients with Acute Venous Thromboembolism

Background

Most studies to date have focused on predicting the risk of venous thromboembolism (VTE), but prediction models about mortality risk in VTE are rarely reported. We sought to develop and validate a multivariable model to predict the all-cause mortality risk in patients with acute VTE in emergency settings.

Methods

A total of 700 patients were included from Qilu Hospital of Shandong University and were randomly assigned into training set (n=490) and validation set (n=210) in an 7:3 ratio. Multivariate logistics regression analysis was performed to identify independent variables and develop a prediction model, which was validated internally using bootstrap method. The discrimination, calibration and clinical utility were evaluated by receiver operating characteristic curve (ROC) analysis, Hosmer-Lemeshow (HL) test, Kaplan-meier (KM) analysis and decision curve analysis (DCA).

Results

There were 52 patients (10.6%) dying and 437 (89.4%) surviving in training set. Age (odds ratio [OR]: 4.158, 95% confidence interval [CI]: 2.426–7.127), pulmonary embolism (OR: 1.779, 95% CI: 1.124–2.814), platelet count (OR: 0.507, 95% CI: 0.310–0.830), D-dimer (OR: 1.826, 95% CI: 1.133–2.942) and platelet/lymphocyte ratio (OR: 2.166, 95% CI: 1.259–3.727) were independent risk variables associated with all-cause mortality. The model had good predictive capability with an AUC of 0.746 (95% CI: 0.668,0.825), a sensitivity of 0.769 (95% CI: 0.607,0.889), a specificity of 0.672 (95% CI: 0.634,0.707). The validation model had an AUC of 0.739 (95% CI: 0.685,0.793), a sensitivity of 0.690 (95% CI: 0.580,0.787), a specificity of 0.693 (95% CI: 0.655,0.729). The model is well calibrated and the HL test showed a good fit (χ²=5.291, p=0.726, Nagelkerke R²=0.137). KM analysis and DCA showed a good clinical utility of the nomogram.

Conclusion

This study identified independent variables affecting all-cause mortality in patients with acute VTE, and developed a prediction model and provided a nomogram with good prediction capability and clinical utility.

Standardization of risk prediction model reporting in cancer-associated thrombosis: Communication from the ISTH SSC subcommittee on hemostasis and malignancy

Since the development of the Khorana score to predict risk of cancer-associated venous thromboembolism (VTE), many modified and de novo risk prediction models (RPMs) have been proposed. Comparison of the prognostic performance across models requires comprehensive reporting and standardized methods for model development, validation and evaluation. To improve the standardization of RPM reporting, the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) tool was published in 2015. To better understand the quality of reporting and development of RPMs for cancer-associated VTE, we performed a literature search of published RPMs and assessed each model using the TRIPOD checklist. Our results yielded 29 RPMs for which 30 items were evaluated. There was a non-significant (p = 0.15) improvement in reporting of the 30 items in the post-TRIPOD era (81%) versus the pre-TRIPOD era (75%). Of seven items (title, sample size, missing data handling, baseline demographics, methods and results for model performance, and supplemental resources) with the lowest reporting in the pre-TRIPOD era (<70%), there was an average improvement of 22% in the post-TRIPOD era. Only two of the 22 studies published in the post-TRIPOD era acknowledged compliance with TRIPOD. Informed by the results of this assessment, the Scientific and Standardization Committee (SSC) Subcommittee on Hemostasis & Malignancy of the International Society on Thrombosis and Hemostasis (ISTH) advocates for standardization of four key elements of RPMs for cancer-associated VTE: (1) inclusion of the TRIPOD checklist, (2) clear definition of the derivation population, with justification of sample size, (3) clear definition of predictors, and (4) external validation prior to implementation.

Optimizing Perioperative Venous Thromboembolism Chemoprophylaxis on a Gynecologic Oncology Service

BACKGROUND

Perioperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality after gynecologic cancer surgery. Here we report a quality improvement intervention to increase perioperative VTE chemoprophylaxis compliance.

STUDY DESIGN

All operations performed by a gynecologic oncologist at a tertiary urban university medical center admitted to the hospital for at least one midnight were included. Using a pre/post design with a washout period, we sought to increase perioperative VTE chemoprophylaxis compliance from 22% in the historical control (HC) cohort to 90% in the quality improvement (QI) cohort. The perioperative VTE chemoprophylaxis process was standardized by addressing four domains: preoperative VTE chemoprophylaxis, surgical time-out, postoperative VTE chemoprophylaxis, and intervention education and compliance tracking. Pearson's chi-square test was used to compare HC vs QI cohort compliance.

RESULTS

There were 130 surgical cases in the HC cohort and 131 in the QI cohort. Forty-two percent underwent laparotomy, and 57% had cancer at the time of operation. VTE chemoprophylaxis compliance improved from 22% in the HC cohort to 82% in the QI cohort (p < 0.001). Preoperative VTE chemoprophylaxis compliance improved from 76% in the HC cohort to 94% in the QI cohort (p < 0.001), and postoperative VTE chemoprophylaxis compliance improved from 27% to 87% (p < 0.001). Thirty-day postoperative VTE occurred in three patients (2%) in the HC cohort and none in the QI cohort (p = 0.08).

CONCLUSIONS

A low-cost and low-technology QI initiative intervention improved perioperative compliance with VTE chemoprophylaxis.

Derivation and validation of a clinical prediction model for risks of venous thromboembolism in diabetic and general populations

Most studies on the prediction of venous thromboembolism (VTE) focused on hospitalized, surgery, and cancer patients or women receiving hormonal contraceptives or menopausal hormone therapy. No study considered diabetic and general populations to establish a VTE prediction model, especially in Asia. We developed a predictive model for VTE among type 2 diabetic patients and the general population.This study considered 2 nationwide retrospective cohort studies consisting of 52,427 diabetic participants and 508,664 participants from the general population aged 30 to 85 years during 2001 to 2004 in Taiwan. All participants were followed up until VTE event, death, or December 2011. The outcome event was VTE, including deep venous thrombosis and pulmonary embolism. Candidate predictors consisted of socio-demographic factors, diabetes-related factors and biomarkers, comorbidities, and medicine use. Our study followed the procedures proposed by the Framingham Heart Study to develop prediction models by using a Cox regression model. The predictive accuracy and performance characteristics were assessed using the area under curve of receiver operating characteristics curve and calibration of a risk score were performed by Hosmer-Lemeshow goodness-of-fit test.The common factors for persons with type 2 diabetes and general population included age, hospitalization status 1 year before the baseline, hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and anti-diabetes medications; the specific factors for persons with type 2 diabetes consisted of body mass index, glycosylated hemoglobin A1C, and creatinine; and the factors for general population included gender, peripheral vascular disease, cancer, hypertension medication, cardiovascular medication, and non-steroidal anti-inflammatory drug. The area under curve of 3-, 5-, and 8-year VTE prediction models were 0.74, 0.71, and 0.69 in the diabetic population and 0.77, 0.76, and 0.75 in the general population, respectively.The new clinical prediction models can help identify a high risk of VTE and provide medical intervention in diabetic and general populations.

Effects of aspirin and statin use on venous thromboembolism prophylaxis and survival in patients with endometrial cancer

INTRODUCTION

Acetylsalicylic acid (aspirin) and statins are commonly used to manage and prevent cardiovascular diseases. Recent studies have suggested the benefits of aspirin or statin use in venous thromboembolism (VTE) prophylaxis and survival outcome improvement in women with endometrial cancer.

AREAS COVERED

In this study, we reviewed the effects of aspirin or statin use on VTE prophylaxis and survival outcome in women with endometrial cancer.

EXPERT OPINION

Among women with endometrial cancer, aspirin use exerted a modest effect on VTE prophylaxis, whereas statin use was associated with a decreased prevalence of VTE, especially in women with obesity and type II cancer, compared with those in non-users. Aspirin use improved cause-specific survival in women with endometrial cancer, aged less than 60 years, who were obese and presented with type I cancer. Statin use was associated with better cause-specific survival in women with type II cancer. The combination of aspirin and statins may be the most effective strategy in improving on VTE prophylaxis and survival outcomes in obese women with type II cancer. Targeting of the appropriate population with endometrial cancer may enhance the efficacy of aspirin or statins on VTE prophylaxis and survival outcomes in women with endometrial cancer.

Incidence and Risk Factors for Venous Thromboembolism Following 2462 Major Abdomino-Pelvic Surgeries in Tertiary Hospital

Purpose

To determine the incidence and risk factor of postoperative venous thromboembolism (VTE) in Thai populations and to evaluate morbidity, mortality, bleeding complications and the benefit of thromboprophylaxis in real-world practice.

Patients and Methods

We performed a retrospective, single-center, cohort study of patients from all age groups who underwent elective open or laparoscopic major abdomino-pelvic surgery between January 2008 and December 2018 at Chulabhorn Hospital, Bangkok, Thailand. We collected general medical information and specific data based on items from the Caprini risk scoring system.

Results

A total of 2462 major abdomino-pelvic surgeries were included. The study population consisted of 742 males (30.1%) and 1720 females (69.9%) aged 54.59 ± 13.27 years. The incidence of VTE in Thai patients that underwent major abdominal surgery was 0.48%. The most frequent influencing factor for VTE was a history of pulmonary embolism, which increased the risk of VTE 98.28-fold, whereas a history of deep vein thrombosis increased the risk of VTE by 12.34-fold. Other factors influencing VTE development were obesity, anticoagulant use, postoperative chemotherapy, preoperative chemotherapy, endometrium cancer, tumor-node-metastasis (TNM) stage 4 and American College of Chest Physicians (ACCP) class 4. Protective factors included no history of VTE, laparoscopic surgery, TNM stage 0 and benign disease and BMI<30. VTE significantly increased mortality whereas following ACCP guideline reduced mortality.

Conclusion

Post-operative VTE incidence in Thai patients undergoing major abdomino-pelvic surgery was lower compared with Western patients. Factors influencing for VTE were history of VTE, anticoagulant use, postoperative chemotherapy, preoperative chemotherapy, endometrium cancer, TNM stage 4 and ACCP class 4. Following ACCP guideline reduced the incidence of mortality.

Risk factors for venous thromboembolism in endometrial cancer

Background

Venous thromboembolism (vte) in malignancy is associated with poor outcomes. We conducted a retrospective review of vte in patients with endometrial cancer to characterize the vte incidence, identify factors that contribute to vte risk, and compare survival outcomes in patients with and without vte.

Methods

A retrospective chart review identified 422 eligible patients who underwent surgery for endometrial cancer (1 January 2014 to 31 July 2016). The primary outcome was vte. Binary logistic regression identified risk factors for vte; significant risk factors were included in a multivariate analysis. Kaplan-Meier estimates are reported, and log rank tests were used to compare the Kaplan-Meier curves. Risk-adjusted estimates for overall survival based on vte were determined using a multivariate Cox proportional hazards model.

Results

The incidence of vte was 6.16% overall and 0.7% within 60 days postoperatively. Non-endometrioid histology, stages 3 and 4 disease, laparotomy, and age (p < 0.1) were identified as factors associated with vte and were included in a multivariate analysis. The overall death rate in patients with vte was 42% (9% without vte): hazard ratio, 5.63; 95% confidence interval, 2.86 to 11.08; p < 0.0001. Adjusting for age, stage of disease, and histology, risk of death remained significant for patients with a vte: hazard ratio, 2.20; 95% confidence interval, 1.09 to 4.42; p = 0.0271.

Conclusions

A method to identify patients with endometrial cancer who are at high risk for vte is important, given the implications of vte for patient outcomes and the frequency of endometrial cancer diagnoses. Factors identified in our study might assist in the recognition of such patients.

Prevalence of venous thromboembolism at pretreatment screening and associated risk factors in 2086 patients with gynecological cancer

AIM

Postoperative pulmonary embolism can be a fatal surgical complication and is thought to occur secondary to asymptomatic venous thromboembolism (VTE) that exists preoperatively in some patients. The purpose of this study was to clarify the frequency and risk factors of pretreatment VTE in gynecological cancer patients.

METHODS

This study investigated 2086 patients with gynecological cancer (cervix, n = 754; endometrium, n = 862; ovary, n = 470) who underwent initial treatment between 2004 and 2017. Pretreatment VTE screening was performed with D-dimer (DD) levels in these patients. Based on this, the associated risk factors were retrospectively analyzed.

RESULTS

Pretreatment VTE was discovered in 7.3% of patients with cervical cancer, 11.5% of those with endometrial cancer and 27.0% of those with ovarian cancer. Significant independent risk factors were: age greater than or equal to 60 years and tumor long diameter greater than or equal to 40 mm for cervical cancer; age greater than or equal to 60 years, stage III/IV advanced disease, clear cell carcinoma and tumor long diameter greater than or equal to 60 mm for endometrial cancer; and age greater than or equal to 60 years, clear cell carcinoma and massive ascites for ovarian cancer.

CONCLUSION

Pretreatment asymptomatic VTE is very frequent in gynecological cancer patients. It may be beneficial to consider measuring DD or performing venous ultrasonography in patients with the above risk factors.

Adoption of enhanced recovery after laparotomy in gynecologic oncology

INTRODUCTION

Enhanced recovery after surgery (ERAS) pathways combine a comprehensive set of peri-operative practices that have been demonstrated to hasten patient post-operative recovery. We aimed to evaluate the adoption of ERAS components and assess attitudes towards ERAS among gynecologic oncologists.

METHODS

We developed and administered a cross-sectional survey of attending, fellow, and resident physicians who were members of the Society of Gynecologic Oncology in January 2018. The χ2 test was used to compare adherence to individual components of ERAS.

RESULTS

There was a 23% survey response rate and we analyzed 289 responses: 79% were attending physicians, 57% were from academic institutions, and 64% were from institutions with an established ERAS pathway. Respondents from ERAS institutions were significantly more likely to adhere to recommendations regarding pre-operative fasting for liquids (ERAS 51%, non-ERAS 28%; p<0.001), carbohydrate loading (63% vs 16%; p<0.001), intra-operative fluid management (78% vs 32%; p<0.001), and extended duration of deep vein thrombosis prophylaxis for malignancy (69% vs 55%; p=0.003). We found no difference in the use of mechanical bowel preparation, use of peritoneal drainage, or use of nasogastric tubes between ERAS and non-ERAS institutions. Nearly all respondents (92%) felt that ERAS pathways were safe.

DISCUSSION

Practicing at an institution with an ERAS pathway increased adoption of many ERAS elements; however, adherence to certain guidelines remains highly variable. Use of bowel preparation, nasogastric tubes, and peritoneal drainage catheters remain common. Future work should identify barriers to the implementation of ERAS and its components.

Pre-treatment thrombocytosis predicts prognosis of endometrial cancer: A meta-analysis of 11 studies

The aim of the present meta-analysis study was to determine the association between pre-treatment thrombocytosis and prognosis of patients with endometrial cancer. Articles published prior to December 2018 containing information on platelet count and endometrial cancer were searched in the PubMed, Embase and the Cochrane Library databases. A platelet count of ≥350 or >400×109/l was considered to indicate thrombocytosis. Hazard ratios (HRs) with 95% CI were calculated using a random- or fixed-effects model to assess the strength of the associations. A Funnel plot and Egger's test were used to evaluate the publication bias and sensitivity analyses were performed to estimate the robustness of the present results by using Stata 13.0 software. A pooled analysis of 11 studies that met the inclusion criteria was performed, involving a total of 2,590 patients with endometrial cancer. The overall survival (OS), progression-free survival (PFS) and disease-free survival (DFS) time of patients with endometrial cancer who exhibited pre-treatment thrombocytosis were shorter than those in patients without pre-treatment thrombocytosis (OS, HR=2.25, 95% CI=1.26-4.00; PFS, HR=2.60, 95% CI=1.23-5.50; DFS, HR=2.23, 95% CI=1.45-3.42). However, pre-treatment thrombocytosis was not associated with disease-specific survival time in patients with endometrial cancer (HR=2.17, 95% CI=0.51-9.27; P=0.296). Subgroup analysis indicated that pre-treatment thrombocytosis was not associated with OS time in patients of Asian and European ethnicity. Furthermore, pre-treatment thrombocytosis (platelet count >400×109/l) was an independent predictor of OS, PFS and DFS regardless of the clinical stage.

Characterization of Risk Factors and Timing of Venous Thromboembolism in Patients With Uterine Serous Carcinoma

OBJECTIVE

To characterize risk factors and timing of venous thromboembolism in women with uterine serous carcinoma.

METHODS

A retrospective cohort study was performed including all women diagnosed with uterine serous carcinoma from 1999 to 2016 at our institution. Clinicopathologic data and information regarding timing of venous thromboembolism were abstracted from the medical record. Logistic regression and Cox proportional hazards modeling were used to examine the association between covariates and risk and timing of venous thromboembolism.

RESULTS

Seventy of the 413 included patients (17%) developed venous thromboembolism, with a median time from presentation to venous thromboembolism of 7.2 months (interquartile range 1.0-24.8) and from surgery to venous thromboembolism of 13.2 months (interquartile range 3.5-33.6). Fifty-nine of the 70 patients (84%) who developed venous thromboembolism were diagnosed either before surgery or greater than 6 weeks postoperatively. Twenty-two of the 70 patients (31%) who developed clots were on chemotherapy at the time of diagnosis. Venous thromboembolism was highly associated with cancer stage and presence of hypertension (P<.01). Cox proportional hazards modeling revealed that only cancer stages III and IV (hazard ratio [HR] 3.20, 95% CI 1.54-6.64 and HR 8.68, 95% CI 4.50-16.73, respectively) and hypertensive or cardiovascular diseases (HR 2.29, 95% CI 1.08-4.85 and HR 1.82, 95% CI 1.05-3.13) were associated with time to venous thromboembolism.

CONCLUSION

Patients with uterine serous carcinoma are at high risk of developing venous thromboembolism even many months after their cancer diagnosis. This study generates the hypothesis that venous thromboembolism prophylaxis may be beneficial in patients with uterine serous carcinoma during other time points along the continuum of disease rather than only in the postoperative period, especially for those with advanced cancer.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Association of statins, aspirin, and venous thromboembolism in women with endometrial cancer

OBJECTIVE

The anti-thrombogenic effects of statins and aspirin have been reported in various malignancies but have not been well examined in endometrial cancer. This study examined the association between statin and/or aspirin use and venous thromboembolism (VTE) risk in endometrial cancer.

METHODS

This is a multi-center retrospective study examining 2527 women with endometrial cancer between 2000 and 2015. Statin and aspirin use at diagnosis was correlated to VTE risk during follow-up on multivariable analysis.

RESULTS

There were 132 VTE events with a 5-year cumulative incidence rate of 6.1%. There were 392 (15.5%) statin users and 219 (8.7%) aspirin users, respectively. On multivariable analysis, statin use was associated with an approximately 60% decreased risk of VTE when compared to non-users (5-year cumulative rates 2.5% versus 6.7%, adjusted-hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.19-0.92, P = 0.030) whereas aspirin did not demonstrate statistical significance (2.0% versus 6.5%, adjusted-HR 0.54, 95%CI 0.19-1.51, P = 0.24). There was a trend of joint effect between statin and aspirin although it did not demonstrate statistical significance: VTE risks for dual statin/aspirin user (adjusted-HR 0.27, 95%CI 0.04-2.07), statin alone (adjusted-HR 0.40, 95%CI 0.18-0.93), and aspirin alone (adjusted-HR 0.51, 95%CI 0.16-1.64) compared to non-use after adjusting for patient characteristics, tumor factors, treatment types, and survival events (P-interaction = 0.090). When stratified by statin type, simvastatin demonstrated the largest reduction of VTE risk (5-year cumulative rates 1.1% versus 6.7%, adjusted-HR 0.17, 95%CI 0.02-1.30, P = 0.088). Obesity, absence of diabetes mellitus, type II histology, and recurrent disease were the factors associated with decreased VTE risk with statin use (all, P-interaction<0.05).

CONCLUSION

Our study suggests that statin use may be associated with decreased risk of VTE in women with endometrial cancer.

Significance of Lymphovascular Space Invasion by the Sarcomatous Component in Uterine Carcinosarcoma

OBJECTIVE

The aim of this study was to examine the significance of lymphovascular space invasion (LVSI) with a sarcomatous component on the tumor characteristics and clinical outcomes of women with uterine carcinosarcoma (UCS).

METHODS

This was a secondary analysis of a prior multicenter retrospective study that examined women with stage I-IV UCS who underwent primary hysterectomy. Archived histopathology slides were reviewed and LVSI was scored as follows: LVSI with a carcinomatous component alone (LVSI-carcinoma; n = 375, 76.8%) or LVSI containing a sarcomatous component with or without a carcinomatous component (LVSI-sarcoma; n = 113, 23.2%). Qualitative metrics of LVSI were correlated to clinicopathological factors and survival outcome.

RESULTS

Tumors in the LVSI-sarcoma group were more likely to have sarcoma dominance (82.1 vs. 26.4%) heterologous sarcomatous component (51.3 vs. 37.9%), low-grade carcinoma (42.5 vs. 22.4%), and large tumor size (81.0 vs. 70.2%) in the primary tumor site compared with tumors in the LVSI-carcinoma group (all p < 0.05). On multivariate analysis, LVSI-sarcoma was independently associated with decreased progression-free survival (5-year rates: 34.9 vs. 40.8%, adjusted hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.36-2.50, p < 0.001), and cause-specific survival (5-year rates: 41.8 vs. 55.9%, adjusted HR 1.95, 95% CI 1.39-2.75, p < 0.001) compared with LVSI-carcinoma. Postoperative radiotherapy for women with LVSI-sarcoma had a higher reduction rate of recurrence/progression of disease (54% reduction, p = 0.04) compared with postoperative radiotherapy for women with LVSI-carcinoma (26% reduction, p = 0.08).

CONCLUSION

In UCS, the presence of a sarcomatous component in LVSI is particularly prevalent when a tumor has sarcoma dominance. Our study suggests that LVSI containing a sarcomatous component may be a predictor of decreased survival for women with UCS.

Independent predictors of survival in endometrium cancer: platelet-to-lymphocyte ratio and platelet/neutrophil/monocyte-to-lymphocyte ratio

Objective:

To evaluate the association between ratios of inflammatory markers and survival in endometrium cancer (EC).

Material and Methods:

Four hundred ninety-seven patients with epithelial EC were included. The evaluated ratios were neutrophil (N)/lymphocyte (L), neutrophil count divided by the lymphocyte count; platelet (P)/lymphocyte, platelets divided by the lymphocyte count; lymphocyte/monocyte (M), lymphocytes divided by the monocyte count; NM/L, neutrophil plus monocyte divided by the lymphocyte count; PNM/L, the sum total counts of platelets, neutrophils and monocytes divided by the lymphocyte count.

Results:

The median follow-up time was 24 months (1-129). Recurrence and exitus occurred in 34 (7%) and 18 (3.7%) patients, respectively. Metastasis in pelvic or para-aortic lymph nodes were significantly related only with low L/M. None of the inflammatory ratios were associated with disease-free survival. In multi-variant analysis, only high P/L (>168) and high PNM/L (>171) were related with a statistically significant hazard ratio for death of 2.91 (p=0.024) and 2.93 (p=0.023), respectively.

Conclusion:

The P/L and PNM/L were in relation with worse overall survival and also independent prognostic factors for OS.

Cancer prognosis in patients with venous thromboembolism (VTE) and patients with clinical and laboratory biomarkers predictive of VTE risk

Venous thromboembolism (VTE) is a well-documented complication of cancer and its treatment. While VTE contributes significant morbidity and some thrombotic mortality to cancer patients, a growing body of clinical and experimental data supports the finding that VTE is an important prognostic marker for cancer progression and mortality. This would suggest that hemostatic activation is an expression of an aggressive tumor phenotype. A number of clinical and laboratory biomarkers have been shown to be predictive of an increased risk of cancer-associated VTE. In addition, it is now becoming apparent that these same biomarkers are also predictive of cancer mortality. The application of this information to reduce cancer-associated VTE and improve cancer survival await the results of ongoing prophylaxis antithrombotic studies.

Significance of abnormal peritoneal cytology on survival of women with stage I-II endometrioid endometrial cancer

OBJECTIVE

To examine survival of women with stage I-II endometrioid endometrial cancer whose peritoneal cytology showed malignant or atypical cells (abnormal peritoneal cytology).

METHODS

This is a multi-center retrospective study examining 1668 women with stage I-II endometrioid endometrial cancer who underwent primary hysterectomy with available peritoneal cytology results between 2000 and 2015. Abnormal peritoneal cytology was correlated to clinico-pathological characteristics and oncological outcome.

RESULTS

Malignant and atypical cells were seen in 125 (7.5%) and 58 (3.5%) cases, respectively. On multivariate analysis, non-obesity, non-diabetes mellitus, cigarette use, and lympho-vascular space invasion were independently associated with abnormal peritoneal cytology (all, P<0.05). Abnormal peritoneal cytology was independently associated with decreased disease-free survival (hazard ratio 3.07, P<0.001) and cause-specific survival (hazard ratio 3.42, P=0.008) on multivariate analysis. Abnormal peritoneal cytology was significantly associated with increased risks of distant-recurrence (5-year rates: 8.8% versus 3.6%, P=0.001) but not local-recurrence (5.2% versus 3.0%, P=0.32) compared to negative cytology. Among women with stage I disease, abnormal peritoneal cytology was significantly associated with an increased risk of distant-recurrence in the low risk group (5-year rates: 5.5% versus 1.0%, P<0.001) but not in the high-intermediate risk group (13.3% versus 10.8% P=0.60). Among 183 women who had abnormal peritoneal cytology, postoperative chemotherapy significantly reduced the rate of peritoneal recurrence (5-year rates: 1.3% versus 9.2%, P=0.039) whereas postoperative radiotherapy did not (7.1% versus 5.5%, P=0.63).

CONCLUSION

Our study suggests that abnormal peritoneal cytology may be a prognostic factor for decreased survival in women with stage I-II endometrioid endometrial cancer, particularly for low-risk group.

Contributing factors for menopausal symptoms after surgical staging for endometrial cancer

OBJECTIVE

The aim of the study was to examine contributing factors associated with developing menopausal symptoms after surgical staging in women with endometrial cancer.

METHODS

This is a retrospective study examining patients with endometrial cancer who were premenopausal at the time of hysterectomy-based surgical staging including bilateral oophorectomy between January 2000 and October 2013. Cox proportional hazard regression model was used to evaluate demographics, medical comorbidity, liver function tests, tumor factors, and medication history for menopausal symptoms.

RESULTS

There were 269 premenopausal women who were eligible. Mean age was 44.5 years, and the majority had endometrioid histology (91.1%), grade 1 tumor (60.2%), and stage I disease (65.8%). Postoperatively, 73 (27.1%) women developed menopausal symptoms, with hot flushes (20.1%) being the most common symptom followed by night sweats (4.1%). On multivariate analysis, younger age was independently associated with increased risk of developing menopausal symptoms (hazard ratio per unit 0.91, 95% CI 0.88-0.94, P < 0.01). In addition, lower albumin level remained an independent predictor for decreased risk of developing menopausal symptoms (hazard ratio per unit 2.16, 95% CI 1.19-3.93, P = 0.012). Lower albumin level was associated with medical comorbidity (hypertension and diabetes mellitus), use of antihypertensive/glycemic agents (angiotensin-converting enzyme inhibitors or receptor blocker, hydrochlorothiazide, sulfonylurea, and insulin), aggressive tumor (high cancer antigen 125 level, nonendometrioid histology, and advanced stage), and abnormal liver function (high alkaline phosphatase level and low total protein level; all, P < 0.05).

CONCLUSIONS

Assessing albumin level, medical comorbidity, and medication type for the development of postoperative menopausal symptoms is a valuable step in the preoperative management of women with endometrial cancer.

Significance of venous thromboembolism in women with uterine carcinosarcoma

OBJECTIVE

To identify risk factors for venous thromboembolism (VTE) and to examine the association of VTE and survival in women with uterine carcinosarcoma.

METHODS

This multicenter retrospective study examined 906 women who underwent primary surgical treatment for stage I-IV uterine carcinosarcoma. Time-dependent analyses were performed for cumulative incidence of VTE after surgery on multivariate models.

RESULTS

There were 72 (7.9%) women who developed VTE after surgery with 1-, 2-, and 5-year cumulative incidences being 5.1%, 7.3%, and 10.2%, respectively. On multivariate analysis, older age (hazard ratio [HR] per year 1.03, P=0.012), non-Asian race (HR 6.28, P<0.001), large body habitus (HR per kg/m² 1.04, P=0.014), residual disease at surgery (HR 3.04, P=0.003), tumor size ≥5cm (HR 2.73, P=0.003), and stage IV disease (HR 2.12, P=0.025) were independently associated with increased risk of developing VTE. A risk pattern analysis identified that obese Non-Asian women with large tumors (13.7% of population) had the highest incidence of VTE (2-year cumulative rate, 26.1%) whereas Asian women with no residual disease (47.1% of population) had the lowest (2-year cumulative rate, 1.6%) (P<0.001). Presence of carcinoma/sarcoma in metastatic sites was significantly associated with increased risk of VTE compared to carcinoma alone (2-year rates, 31.2% versus 8.4%, P=0.049). VTE was independently associated with decreased progression-free survival on multivariate models (5-year rates, 24.9% versus 47.2%, HR 1.46, 95%CI 1.05-2.04, P=0.026).

CONCLUSION

Our study suggests that VTE represents a surrogate marker of aggressive tumor behavior and diminished patient condition in uterine carcinosarcoma; obese Non-Asian women with large tumors carry a disproportionally high risk of VTE, suggesting that long-term prophylaxis may benefit this population.

Aspirin use and endometrial cancer risk and survival

The role of acetylsalicylic acid (aspirin) as a chemo-preventive and adjuvant therapeutic agent for cancers is generating attention. Mounting evidence indicates that aspirin reduces the incidence and mortality of certain obesity-related cancers, particularly colorectal cancer. In endometrial cancer, previous studies examining the effect of aspirin remain inconsistent as to the reduction in the risk of endometrial cancer. While some evidence indicates protective effects in obese women, other studies have showed a potential deleterious effect of these medications on endometrial cancer outcomes. However, exposure measurement across studies has been inconsistent in recording dose, duration, and frequency of use; thus making comparisons difficult. In this article, we review the evidence for the association between endometrial cancer and obesity, the pharmacological differences between regular- and low-dose aspirin, as well as the potential anti-tumor mechanism of aspirin, supporting a possible therapeutic effect on endometrial cancer. A proposed mechanism behind decreased cancer mortality in endometrial cancer may be a result of inhibition of metastasis via platelet inactivation and possible prostaglandin E₂ suppression by aspirin. Additionally, aspirin use in particular may have a secondary benefit for obesity-related comorbidities including cardiovascular disease in women with endometrial cancer. Although aspirin-related bleeding needs to be considered as a possible adverse effect, the benefits of aspirin therapy may exceed the potential risk in women with endometrial cancer. The current evidence reviewed herein has resulted in conflicting findings regarding the potential effect on endometrial cancer outcomes, thus indicating that future studies in this area are needed to resolve the effects of aspirin on endometrial cancer survival, particularly to identify specific populations that might benefit from aspirin use.

Predictive Factor of Conversion to Laparotomy in Minimally Invasive Surgical Staging for Endometrial Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with laparotomy conversion during total laparoscopic hysterectomy for endometrial cancer.

METHODS

This is a retrospective study examining endometrial cancer cases that underwent hysterectomy-based surgical staging initiated via conventional laparoscopic approach. Factors related to patient, tumor, and surgeon were examined to establish risk of laparotomy conversion using a multivariate logistic regression model.

RESULTS

There were 251 cases identified including 30 cases (12.0%) of laparotomy conversion. The most common indication for laparotomy conversion was a large uterus (27.0%), followed by extensive adhesions (24.3%) and surgical complications (18.9%). Outcomes of cases resulting in laparotomy conversion include longer surgical time (333 vs 224 minutes, P < 0.001), larger blood loss (350 vs 100 mL, P < 0.001), longer hospital stay (4 vs 2 days, P < 0.001), and increased risk of hospital readmission (10% vs 1.4%, P = 0.024). In multivariate analysis, morbid obesity (odds ratio [OR], 4.51; P = 0.011), suboptimal pelvic examination or enlarged uterus during preoperative evaluation (OR, 3.55; P = 0.034), para-aortic lymphadenectomy (OR, 10.5; P = 0.001), uterine size 250 g or greater (OR, 3.49; P = 0.026), and extrauterine disease (OR, 4.68; P = 0.012) remained the independent predictors for laparotomy conversion. The following numbers of risk factors were significantly correlated with laparotomy-conversion rate: none, 1.1%; single risk factor, 5.3% (OR, 5.00; P = 0.15); double risk factors, 21.7% (OR, 24.9; P = 0.002); and triple or more risk factors, 50% (OR, 90.0; P < 0.001). Ultrasonographic 3-dimensional volumes of 496 cm in preoperative uterine size correlate with actual uterine weight of 250 g (Y = 61.5 + 0.38X, P < 0.001).

CONCLUSIONS

Laparotomy conversion significantly impacts outcomes of patients with endometrial cancer. In this setting, our predictive model for laparotomy conversion will be useful to guide the surgical management of endometrial cancer.

Surgical menopause and increased risk of nonalcoholic fatty liver disease in endometrial cancer

OBJECTIVE

Our objective was to examine risk factors associated with development of nonalcoholic fatty liver disease (NAFLD) among women with endometrial cancer who underwent surgical staging with or without oophorectomy.

METHODS

This is a retrospective study that evaluated endometrial cancer cases that underwent surgical staging (n = 666) and endometrial hyperplasia cases that underwent hysterectomy-based treatment (n = 209). This study included 712 oophorectomy cases and 163 nonoophorectomy cases. Archived records were reviewed for participant demographics, medical comorbidities, operative notes, histology results, and radiology reports for NAFLD. Cumulative risks of NAFLD after surgical operation were correlated to demographics and medical comorbidities.

RESULTS

The cumulative prevalence of NAFLD in 875 women with endometrial tumor was 14.1%, 20.5%, and 38.4% at 1, 2, and 5 years after surgical operation, respectively. On multivariate analysis, after controlling for age, ethnicity, body mass index, medical comorbidities, tumor type, hormonal treatment pattern, and oophorectomy status, age younger than 40 years (2-y cumulative prevalence, 26.6% vs 16.8%; hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = 0.001) and age 40 to 49 years (2-y cumulative prevalence, 23.1% vs 16.8%; HR, 1.49; 95% CI, 1.08-2.04; P = 0.015) remained significant predictors for developing NAFLD after surgical operation compared with age 50 years or older. Oophorectomy was an independent predictor for increased risk of NAFLD (20.9% vs 15.9%; HR, 1.70; 95% CI, 1.01-2.86; P = 0.047). In addition, NAFLD was significantly associated with postoperative development of diabetes mellitus (39.2% vs 15.3%; HR, 2.26; 95% CI, 1.52-3.35; P < 0.0001) and hypercholesterolemia (34.3% vs 17.5%; HR, 1.71; 95% CI, 1.12-2.63; P = 0.014).

CONCLUSIONS

Oophorectomy in young women with endometrial cancer significantly increases the risk of NAFLD. This is associated with development of diabetes mellitus and hypercholesterolemia after oophorectomy.

Association of Nonalcoholic Fatty Liver Disease and Venous Thromboembolism in Women With Endometrial Cancer

OBJECTIVE

Recent studies have demonstrated that surgical menopause results in a significantly increased risk of nonalcoholic fatty liver disease (NAFLD) in women with endometrial cancer. In addition, venous thromboembolism (VTE) is known to be one of the major prognostic factors for decreased survival in endometrial cancer. Given the fact that coagulation factors are produced in the liver, the correlation between NAFLD and VTE was examined in endometrial cancer.

METHODS

A retrospective study was conducted to examine patients with endometrial cancer who underwent surgical staging including oophorectomy between 2000 and 2013 (n = 714). Cumulative risk of VTE was examined based on the NAFLD status. A Cox proportional hazard regression model was used to determine the independent risk predictors of VTE.

RESULTS

Venous thromboembolism and NAFLD were seen in 57 (8.0%) and 181 (25.4%) cases, respectively. Two-year cumulative risks of VTE and NAFLD were 7.9% and 19.3%, respectively. In univariate analysis, VTE was significantly associated with decreased disease-free survival (2-year rate, 43.6% vs 91.4%, P < .001) and overall survival (65.8% vs 96.8%, P < .001), whereas NAFLD was associated with decreased risk of VTE (1.7% vs 10.4%, P < .001). In multivariate analysis controlling for clinicopathological factors, NAFLD remained an independent predictor of decreased risk of VTE (hazard ratio [HR]: 0.24, 95% confidence interval [CI]: 0.07-0.79, P = .02). Thrombocytosis (HR: 2.30, 95% CI: 1.22-4.35, P = .01), cancer antigen 125 ≥ 35 (HR: 3.81, 95% CI: 1.78-8.17, P < .001), and recurrent disease (HR: 4.57, 95% CI: 1.97-10.6, P < .001) remained as independent predictors of increased risk of VTE.

CONCLUSION

Our results suggest that NAFLD may be associated with decreased VTE risk in women with endometrial cancer.

Relative Morbidity and Mortality of Panniculectomy-Combined Surgical Staging in Endometrial Cancer

OBJECTIVE

To examine intraoperative and postoperative complication rates for surgical staging combined with panniculectomy for endometrial cancer.

METHODS

A prospectively collected institutional surgical database was used to identify patients with endometrial cancer who underwent hysterectomy-based surgical staging between December 2008 and August 2014 (n = 551). The cases were grouped into surgical staging with panniculectomy (panniculectomy group, n = 11 [2.0%]), laparotomy without panniculectomy (laparotomy group, n = 208 [37.7%]), and laparoscopy (minimally invasive surgery group, n = 332 [60.3%]). Major complication and surgical wound complication rates within 30 days from surgery were compared.

RESULTS

The panniculectomy group had a significantly higher body mass index compared with other approaches (panniculectomy group, laparotomy group, and minimally invasive surgery group: 60.4, 35.7, and 34.1; P < 0.001) and had a high stage I disease rate (90.9%, 61.5%, and 88.3%; P < 0.001). Mean pannus weight was 5733 g (4.4% of body weight). Intraoperative major complication rates were statistically nonsignificant across the groups (0%, 7.2%, and 4.2%; P = 0.23); however, the panniculectomy group had a significantly higher postoperative major complication rate compared with other approaches (36.4%, 16.3%, and 5.1%; P < 0.001). In multivariate analysis controlling for age, ethnicity, body habitus, medical comorbidities, and tumor factors, panniculectomy remained an independent predictor for increased risk of postoperative major complications (adjusted odds ratio, 4.37; P = 0.043). Surgical mortality rates were similar across the groups (0%, 0.5%, and 0%; P = 0.44). Among superobese patients (n = 50), intraoperative and postoperative complication rates were statistically similar across the 3 groups (all, P > 0.05).

CONCLUSION

Although panniculectomy-combined surgical staging is associated with an increased risk of postoperative complications, the majority recovered uneventfully, making this approach a feasible treatment option, especially for superobese patients with endometrial cancer.

Significance of venous thromboembolism in women with cervical cancer

OBJECTIVE

To characterize risk factors of venous thromboembolism (VTE) and to examine effects of VTE on survival of women with cervical cancer.

METHODS

This is a retrospective study examining consecutive stage I-IV cervical cancer cases diagnosed between 2000 and 2014. Cumulative risk of VTE after cervical cancer diagnosis was evaluated by a time-dependent analysis, expressing adjusted-hazard ratio [HR] and 95% confidence interval [CI]. Survival analysis was performed to determine independent risk factors for progression-free survival (PFS) and disease-specific overall survival (OS).

RESULTS

VTE was recorded in 98 (12.3%, 95%CI 11.6-22.8) out of 798 cases with 1-, 2-, and 5-year cumulative incidences after cervical cancer diagnosis being 8.4%, 11.3%, and 18.7%, respectively. On multivariable analysis, advanced-stage disease (2-year cumulative risk, distant metastatic disease 44.8% [HR 4.13, 95%CI 1.06-10.7, P=0.003], and locally-advanced disease 13.4% [HR 2.46, 95%CI 1.17-4.43, P=0.004]) were independently associated with increased risk of VTE compared to early-stage disease (stage IA1-IB1 4.1%). In addition, low albumin level (HR per unit change, 0.59, 95%CI 0.40-0.85, P=0.005) and chemotherapy treatment (HR 2.46, 95%CI 1.30-4.66, P=0.006) remained independent risk factors associated with increased risk of VTE. On univariate analysis, VTE was significantly associated with decreased PFS (5-year rates, 22.3% versus 68.7%, P<0.001) and OS (5-year rates, 55.1% versus 90.0%, P<0.001). On multivariable analysis, VTE remained an independent prognostic factor associated with decreased PFS (HR 1.95, 95%CI 1.43-2.67, P<0.001) and OS (HR 3.54, 95%CI 2.04-6.13, P<0.001).

CONCLUSION

VTE represents aggressive tumor behavior and poor patient condition, and is an independent prognostic factor for decreased survival in women with cervical cancer.

Signs and Symptoms of Venous Thromboembolism and Survival Outcome of Endometrial Cancer

Objective

This study aimed to evaluate if the presence of venous thromboembolism (VTE) diagnosed with subjective and objective measurements correlates with the survival outcome in patients with endometrial cancer.

Methods

A retrospective study was conducted on patients with endometrial cancer who developed VTE between cancer diagnosis and follow-up from 1999 to 2013. Disease-specific survival after VTE diagnosis was evaluated according to VTE symptoms and vital signs.

Results

Among 827 endometrial cancer cases during the study period, there were 72 (8.7%) patients with VTE identified (pulmonary embolism [PE] with or without deep vein thrombosis [DVT], n = 34; and DVT alone n = 38). In the PE group, decreased disease-specific survival after the diagnosis of VTE was associated with fatigue, systolic blood pressure (BP) less than 120 mm Hg, diastolic BP less than 70 mm Hg, and a heart rate 90 beats per minute or greater (all,P< 0.05) in a univariate analysis. Symptomatic PE was associated with decreased survival as compared to asymptomatic PE (2-year rate; 23.1% vs 77.8%,P< 0.01). In a multivariate analysis controlling for symptoms of VTE, signs, and tumor factors, a diastolic BP less than 70 mm Hg (adjusted-hazard ratio [HR], 10.0; 95% confidence interval, 2.70–37.1;P< 0.01) and HR greater than 90 beats per minute (adjusted-HR, 8.06; 95% confidence interval, 2.36–27.5;P< 0.01) remained as independent prognostic factors for decreased disease-specific survival after PE diagnosis. Patients with PE presenting with low diastolic BP and high heart rate resulted in a dismal survival outcome (diastolic BP < 70 mm Hg/heart rate ≥ 90 beats per minute vs diastolic BP ≥ 70 mm Hg/heart rate < 90 beats per minute; 0% vs 85.7%,P< 0.01). In the group of patients with DVT alone, no signs or symptoms correlated with survival outcome (all,P> 0.05).

Conclusions

Our results suggested that both signs and symptoms of PE are important consideration in the management of patients with endometrial cancer with PE.

Weight Change Pattern and Survival Outcome of Women with Endometrial Cancer

OBJECTIVE

The aim of this study was to determine the association between weight change patterns and survival outcomes of women with endometrial cancer.

METHODS

This retrospective study examined surgically-staged endometrial cancer cases with available weight information between 1999 and 2013 (n = 665). Proportional body mass index (delta-BMI) change at 6 months, 1 and 2 years after hysterectomy was compared with baseline BMI and correlated to patient demographics, tumor characteristics, treatment type, and disease-free survival (DFS) and overall survival (OS).

RESULTS

Mean BMI was 35.6, and 69 % of cases were obese. At 6 months, 1 and 2 years after surgery, 39.1, 51.6, and 57.0 % of the study population, respectively, gained weight compared with pre-treatment baseline. In univariate analysis, 6-month delta-BMI change was significantly associated with DFS and OS, demonstrating bidirectional effects (both p < 0.001): 5-year rates, ≥15.0 % delta-BMI loss (33.5 and 59.1 %), 7.5-14.9 % loss (67.3 and 70.0 %), <7.5 % loss (87.8 and 95.7 %), <7.5 % gain (87.2 and 90.3 %), 7.5-14.9 % gain (64.6 and 67.6 %), and ≥15.0 % gain (32.5 and 66.7 %). In multivariable analysis controlling for age, ethnicity, baseline BMI, histology, grade, stage, chemotherapy, and radiotherapy, 6-month delta-BMI change remained an independent prognostic factor for DFS and OS (all p < 0.05): adjusted hazard ratios, ≥15 % delta-BMI loss (3.35 and 5.39), 7.5-14.9 % loss (2.35 and 4.19), 7.5-14.9 % gain (2.58 and 3.33), and ≥15.0 % gain (2.50 and 3.45) compared with <7.5 % loss. Similar findings were observed at a 1-year time point (p < 0.05). Baseline BMI was not associated with survival outcome (p > 0.05).

CONCLUSION

Our results demonstrated that endometrial cancer patients continued to gain weight after hysterectomy, and post-treatment weight change had bidirectional effects on survival outcome.

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70-year-old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low-grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.

Adjuvant therapy of uterine clear cell carcinoma: a review

PURPOSE

Uterine clear-cell carcinoma (UCCC) is a rare subset of type II endometrial carcinoma with a poor prognosis relative to the most common type of endometrioid carcinoma. Due to its rarity, there has been limited direct evidence of the efficacy of specific adjuvant therapy posthysterectomy in women with UCCC. We present a review of current literature regarding adjuvant therapy of uterine clear cell carcinoma.

METHODS

We searched for English-language publications through Pubmed using a combination of the following key words: endometrial carcinoma, clear cell carcinoma, recurrence, prognosis, adjuvant therapy, radiation treatment and chemotherapy. Due to the rarity of UCCC, studies were not limited by design or number of patients.

RESULTS

There is a paucity of randomized prospective controlled studies focusing on UCCC adjuvant therapy. Findings have largely been derived from retrospective studies of type II endometrial carcinomas or all endometrial cancers as a group. Very few retrospective studies were found to focus on UCCC adjuvant therapy, although certain larger studies did have subset analyses of UCCC patients.

CONCLUSIONS

For early stage disease, locoregional radiotherapy, especially vaginal brachytherapy, has evidence of efficacy. The therapeutic gain of radiotherapy may be further improved with the addition of systemic chemotherapy. Evidence for combined radiation therapy with systemic chemotherapy in women with advanced stage UCCC has remained debatable. UCCC-specific studies are needed to determine the best adjuvant therapy for UCCC without the confounding effects of USC and other endometrial cancers.

Tumor Characteristics and Survival Outcome of Endometrial Cancer Arising in Adenomyosis: An Exploratory Analysis

BACKGROUND

Endometrial cancer arising in adenomyosis (EC-AIA) is a rare entity of endometrial cancer, and its clinical significance has not been well studied. This study aimed to examine the tumor characteristics and survival outcomes of EC-AIA.

METHODS

An exploratory analysis was performed to compare EC-AIA and historical control cases. For this study, EC-AIA cases were identified via a systematic literature search using PubMed/MEDLINE with entry keywords "endometrial cancer OR uterine cancer" AND "adenomyosis" (n = 46). The control group comprised consecutive non-EC-AIA cases from four institutions that had hysterectomy-based surgical staging (n = 1294). Patient demographics, pathology results, and survival outcomes were evaluated between the two groups.

RESULTS

The EC-AIA group was significantly older than the control group (58.9 vs. 55.3 years; P = 0.032). In terms of tumor characteristics, 56.5% of the EC-AIA cases showed tumor within the myometrium without endometrial extension, and the EC-AIA group was significantly more likely to have tumors with more than 50% myometrial invasion (51.6 vs. 26.6%; P = 0.002) and serous/clear cell histology (22.2 vs. 8.2%, P = 0.002) while less likely to express estrogen receptor (14.3 vs. 84.6%; P < 0.001). Grade and stage distributions were similar (P > 0.05). In the univariate analysis, the EC-AIA group had a significantly poorer disease-free survival than the control group (5-year rate: 71.4 vs. 80.6%; P = 0.014). In the multivariate analysis, with control for age, ethnicity, histology, grade, and stage, EA-CIC remained an independent prognostic factor for decreased disease-free survival (adjusted hazard ratio, 3.07; 95% confidence interval 1.55-6.08; P = 0.001).

CONCLUSIONS

The study suggested that endometrial cancer arising in adenomyosis may be an aggressive variant of endometrial cancer.

Impact of depth and extent of lymphovascular space invasion on lymph node metastasis and recurrence patterns in endometrial cancer

BACKGROUND AND OBJECTIVES

To determine the significance of depth and extent of lymphovascular space invasion (LVSI) on lymph node metastasis and recurrence in endometrial cancer.

METHODS

A case-control study was conducted to examine LVSI-positive (n = 70) and LVSI-negative (n = 641) stage I-III endometrial cancer cases that underwent hysterectomy-based surgical staging. The risk of lymph node metastasis and distant recurrence was estimated based on LVSI patterns.

RESULTS

In multivariate analysis, deep (>50% invasion), and extensive (≥7 foci/slide) LVSI patterns had a significantly increased risk of lymph node metastasis (incidence 57.6% and 72.7%, odds ratio 33.8 and 49.9, respectively, P < 0.001) as compared to other traditional uterine factors (>50% myometrial tumor invasion, cervical stromal invasion, and adnexal involvement: incidence range 30.4-37.9%, odds ratio range 3.80-7.03). Deep and extensive of LVSI patterns were both significantly correlated to distant recurrence (P < 0.001). Among women who received postoperative chemotherapy, deep and extensive LVSI patterns did not have increased risks for distant recurrence compared to no LVSI (P = 0.47 and 0.32, respectively). Among women who received postoperative radiotherapy, the depth of LVSI was significantly associated with recurrence outside the radiated field (P = 0.02).

CONCLUSIONS

Depth and extent of LVSI are important predictors for lymph node metastasis and distant recurrence in endometrial cancer.

VEGF gene promoter polymorphisms and risk of VTE in chemotherapy-treated cancer patients

Among the possible genetic contributors to cancer-related venous thromboembolism (VTE), vascular endothelial growth factor (VEGFA) could play an important role, as an imbalance of the VEGFA system (either disease-related or drug-induced) may result in a disturbance of vascular homeostasis. Thus, this study was designed to investigate the predictive role of eight different VEGFA gene promoter single nucleotide polymorphisms (SNPs) for a first VTE episode in cancer out-patients undergoing chemotherapy. To this purpose, VEGFA gene promoter polymorphisms were analysed in 297 cancer patients using polymerase chain reaction amplification and direct DNA sequencing analysis. One hundred forty unrelated healthy subjects from the same geographical area were also analysed in order to evaluate and compare genotype/haplotype frequencies in our ethnicity. VTE occurred in 26 (9%) of cancer patients with a median time-to-event of 3.4 months. Association analyses showed that -1154G/A polymorphism was significantly associated with the risk of chemotherapy-triggered VTE, with the A allele exerting a protective role both in the overall population (hazard ratio [HR]: 0.21; 95% confidence interval [CI]: 0.07-0.58) or in bevacizumab-treated metastatic patients (HR: 0.09, 95%CI: 0.01-0.86) in whom VEGFA -1154AA genotype also conferred a reduced risk of early progression (HR: 0.58, 95%CI: 0.34-0.98). These results suggest that VEGFA may represent a candidate gene contributing to VTE development in chemotherapy treated cancer patients and that -1154G/A SNP might provide useful clinical information on the efficacy and toxicity of bevacizumab in metastatic patients. Validation studies are needed for translation into clinical practice.

Prediction of concurrent endometrial carcinoma in women with endometrial hyperplasia

OBJECTIVE

Although a fraction of endometrial hyperplasia cases have concurrent endometrial carcinoma, patient characteristics associated with concurrent malignancy are not well described. The aim of our study was to identify predictive clinico-pathologic factors for concurrent endometrial carcinoma among patients with endometrial hyperplasia.

METHODS

A case-control study was conducted to compare endometrial hyperplasia in both preoperative endometrial biopsy and hysterectomy specimens (n=168) and endometrial carcinoma in hysterectomy specimen but endometrial hyperplasia in preoperative endometrial biopsy (n=43). Clinico-pathologic factors were examined to identify independent risk factors of concurrent endometrial carcinoma in a multivariate logistic regression model.

RESULTS

The most common histologic subtype in preoperative endometrial biopsy was complex hyperplasia with atypia [CAH] (n=129) followed by complex hyperplasia without atypia (n=58) and simple hyperplasia with or without atypia (n=24). The majority of endometrial carcinomas were grade 1 (86.0%) and stage I (83.7%). In multivariate analysis, age 40-59 (odds ratio [OR] 3.07, p=0.021), age≥60 (OR 6.65, p=0.005), BMI≥35kg/m(2) (OR 2.32, p=0.029), diabetes mellitus (OR 2.51, p=0.019), and CAH (OR 9.01, p=0.042) were independent predictors of concurrent endometrial carcinoma. The risk of concurrent endometrial carcinoma rose dramatically with increasing number of risk factors identified in multivariate model (none 0%, 1 risk factor 7.0%, 2 risk factors 17.6%, 3 risk factors 35.8%, and 4 risk factors 45.5%, p<0.001). Hormonal treatment was associated with decreased risk of concurrent endometrial cancer in those with ≥3 risk factors.

CONCLUSIONS

Older age, obesity, diabetes mellitus, and CAH are predictive of concurrent endometrial carcinoma in endometrial hyperplasia patients.

Venous thromboembolism, interleukin-6 and survival outcomes in patients with advanced ovarian clear cell carcinoma

BACKGROUND

We compared survival outcomes and risk of venous thromboembolism (VTE) among patients with advanced and early-stage ovarian clear cell carcinoma (OCCC) and serous ovarian carcinoma (SOC), as well as potential links with interleukin-6 (IL-6) levels.

METHODS

A multicenter case-control study was conducted in 370 patients with OCCC and 938 with SOC. In a subset of 200 cases, pretreatment plasma IL-6 levels were examined.

FINDINGS

Patients with advanced OCCC had the highest 2-year cumulative VTE rates (advanced OCCC 43.1%, advanced SOC 16.2%, early-stage OCCC 11.9% and early-stage SOC 6.4%, P<0.0001) and the highest median levels of IL-6 (advanced OCCC 17.8 pg/mL, advanced SOC 9.0 pg/mL, early-stage OCCC 4.2 pg/mL and early-stage SOC 5.0 pg/mL, P=0.006). Advanced OCCC (hazard ratio [HR] 3.38, P<0.0001), thrombocytosis (HR 1.42, P=0.032) and elevated IL-6 (HR 8.90, P=0.046) were independent predictors of VTE. In multivariate analysis, patients with advanced OCCC had significantly poorer 5-year progression-free and overall survival rates than those with advanced SOC (P<0.01), and thrombocytosis was an independent predictor of decreased survival outcomes (P<0.01). Elevated IL-6 levels led to poorer 2-year progression-free survival rates in patients with OCCC (50% versus 87.5%, HR 4.89, P=0.016) than in those with SOC (24.9% versus 40.8%, HR 1.40, P=0.07).

INTERPRETATION

Advanced OCCC is associated with an increased incidence of VTE and decreased survival outcomes, which has major implications for clinical management of OCCC.

Significance of monocyte counts on tumor characteristics and survival outcome of women with endometrial cancer

OBJECTIVE

Tumor-associated macrophages are known to be associated with decreased survival of patients with endometrial cancer. Given the physiological link of circulating monocytes as a progenitor of tumor-associated macrophages, monocyte counts were examined for tumor characteristics and survival in endometrial cancer.

METHODS

A retrospective study was conducted to examine consecutive patients with endometrial cancer with all histologic types who underwent hysterectomy-based surgical staging between 2003 and 2013 (n=541). Preoperative monocyte counts were correlated to patient demographics, pathological findings, complete blood count results, and survival outcomes.

RESULTS

Median monocyte counts were 0.5×10(9)/L. Monocyte counts significantly correlated with all other complete blood count components, with neutrophil counts having the most significant association (r=0.52, p<0.001). Elevated monocyte counts (defined as >0.7×10(9)/L) when compared to lower counts were significantly associated with an increased risk of >50% myometrial tumor invasion (29.2% versus 22.0%, odds ratio [OR] 1.59, 95% confidence interval [CI] 1.01-2.45, p=0.045), pelvic lymph node metastasis (39.0% versus 18.8%, OR 2.76, 95%CI 1.35-5.62, p=0.007), and advanced-stage (stage I through IV, 18.5%, 24.6%, 32.5%, and 41.5%, p=0.001). In survival analysis, elevated monocyte counts were associated with decreased disease-free survival (5-year rates, 71.0% versus 84.5%, p=0.001) and overall survival (77.2% versus 89.3%, p<0.001). In multivariate analysis, elevated monocyte counts remained an independent prognostic factor for decreased disease-free (hazard ratio [HR] 1.74, 95% CI 1.02-2.96, p=0.041) and overall (HR 2.63, 95% CI 1.37-5.05, p=0.004) survival.

CONCLUSIONS

Elevated monocyte counts were associated with aggressive tumor features and poor survival outcomes of patients with endometrial cancer.

Time interval between endometrial biopsy and surgical staging for type I endometrial cancer: association between tumor characteristics and survival outcome

OBJECTIVE

To examine whether wait time between endometrial biopsy and surgical staging correlates with tumor characteristics and affects survival outcomes in patients with type I endometrial cancer.

METHODS

A retrospective study was conducted to examine patients with grade 1 and 2 endometrioid adenocarcinoma diagnosed by preoperative endometrial biopsy who subsequently underwent hysterectomy-based surgical staging between 2000 and 2013. Patients who received neoadjuvant chemotherapy or hormonal treatment were excluded. Time interval and grade change between endometrial biopsy and hysterectomy were correlated to demographics and survival outcomes.

RESULTS

Median wait time was 57 days (range 1-177 days) among 435 patients. Upgrading of the tumor to grade 3 in the hysterectomy specimen was seen in 4.7% of 321 tumors classified as grade 1 and 18.4% of 114 tumors classified as grade 2 on the endometrial biopsy, respectively. Wait time was not associated with grade change (P>.05). Controlling for age, ethnicity, body habitus, medical comorbidities, CA 125 level, and stage, multivariable analysis revealed that wait time was not associated with survival outcomes (5-year overall survival rates, wait time 1-14, 15-42, 43-84, and 85 days or more; 62.5%, 93.6%, 95.2%, and 100%, respectively, P>.05); however, grade 1 to 3 on the hysterectomy specimen remained as an independent prognosticator associated with decreased survival (5-year overall survival rates, grade 1 to 3 compared with grade change 1 to 1, 82.1% compared with 98.5%, P=.01). Among grade 1 preoperative biopsies, grade 1 to 3 was significantly associated with nonobesity (P=.039) and advanced stage (P=.019).

CONCLUSION

Wait time for surgical staging was not associated with decreased survival outcome in patients with type I endometrial cancer.

Venous thromboembolism during primary treatment of ovarian clear cell carcinoma is associated with decreased survival

OBJECTIVES

To determine the impact of venous thromboembolism (VTE) during primary treatment of ovarian clear cell carcinoma (OCCC) on survival.

METHODS

After Institutional Review Board approval, 74 cases of OCCC were retrieved from our pathology files. Clinical and pathological data were obtained by medical record and pathology review. Standard statistical analyses were performed.

RESULTS

Among 74 patients with OCCC, VTE was diagnosed in 11 (15%) during primary treatment and 7 (9%) at time of cancer recurrence. 56 (76%) patients never developed VTE. Patients with VTE during OCCC primary treatment had shorter progression-free survival (PFS) and overall survival (OS) than OCCC patients without VTE (median PFS 11 vs. 76 months, p=0.01, median OS 19 vs. 90 months, p=0.001). Patients with VTE during OCCC primary treatment had a 3.9-fold increase in risk of recurrence (p=0.007) and a 6.3-fold increase in risk of death (p<0.001). After controlling for cancer stage, VTE during OCCC primary treatment remained an independent prognostic factor for death (HR=3.6, p=0.005). No patient died of VTE.

CONCLUSIONS

VTE during OCCC primary treatment is associated with a significantly higher risk of cancer recurrence and death. This increased risk is not attributable to VTE-related mortality and raises the possibility that a paracrine circuit involving thrombosis might contribute to a more aggressive tumor biology.