Comparative outcomes assessment of uterine grade 3 endometrioid, serous, and clear cell carcinomas

Oncological outcomes of minimally invasive surgery in non-endometrioid endometrial Cancer patients with varying prognostic risks: a retrospective cohort study based on the ESGO/ESTRO/ESP 2020 guidelines

BACKGROUND

Non-endometrioid endometrial carcinomas (NEEC) are characterized by their rarity and adverse prognoses. This study evaluates the outcomes of open versus minimally invasive surgery (MIS) in NEEC patients stratified by prognostic risks according to the 2020 ESGO-ESTRO-ESP risk classification guidelines.

METHODS

A retrospective analysis was performed on 99 NEEC patients who underwent initial surgery at Fujian University Cancer Hospital. Patients were categorized into two groups: those undergoing MIS and those undergoing open surgery. We compared disease-free survival (DFS) and overall survival (OS) between these groups. Cox regression analysis was employed to identify risk factors for DFS, which were further validated via bootstrap statistical methods.

RESULTS

The study included 31 patients in the MIS group and 68 in the open surgery group. The demographics and clinical characteristics such as age, body mass index, comorbidities, histological subtypes, and FIGO stage were similar between groups (P > 0.05). The MIS group experienced ten recurrences (1 vaginal, 2 lymph nodes, 7 distant metastases), whereas the open surgery group had seven recurrences (1 vaginal, 3 lymph nodes, 1 pelvis, 2 distant metastases), yielding recurrence rates of 10.3% versus 25.6% (P = 0.007). Besides lymphovascular space invasion (LVSI), surgical approach was also identified as an independent prognostic factor for DFS in high-risk patients (P = 0.037, 95% CI: 1.062-7.409). The constructed nomogram demonstrated a robust predictive capability with an area under the curve (AUC) of 0.767. Survival analysis for high- and intermediate-risk patients showed no significant differences in OS between the two groups (Phigh risk = 0.275; Pintermediate-risk = 0.201). However, high-risk patients in the MIS group exhibited significantly worse DFS (P = 0.001).

CONCLUSION

This investigation is the inaugural study to assess the impact of surgical approaches on NEEC patients within the framework of the latest ESGO-ESTRO-ESP risk classifications. Although MIS may offer clinical advantages, it should be approached with caution in high-risk NEEC patients due to associated poorer DFS outcomes.

Impact of adjuvant therapy on oncologic outcomes in uterine-confined clear cell carcinoma of the endometrium

OBJECTIVES

To determine the impact of adjuvant therapy on oncologic outcomes in patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage IA, IB, or II endometrial clear cell carcinoma (ECCC).

METHODS

We conducted a retrospective review at 4 international institutions. Patients with newly diagnosed clinical stage I or II disease of either clear cell or mixed histology with a clear cell component treated between 01/01/2000-12/31/2015 were included. Oncologic outcomes were assessed for patients based on adjuvant treatment received, including chemotherapy, radiation, or chemotherapy with radiation.

RESULTS

Of 125 patients identified and analyzed, 77 (61.6%) had clear cell histology and 118 (94.4%) had stage I disease. Median age at diagnosis was 65 years (range, 33-91). All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment. Twenty-five patients (20.0%) underwent surgical management alone and 100 (80.0%) received adjuvant therapy: 20 (16.0%) received postoperative chemotherapy, 47 (37.6%) received postoperative radiation, and 33 (26.4%) received postoperative chemotherapy with radiation. Median follow-up was 88.4 months (range, <1-234). Progression-free survival (PFS) or overall survival (OS) did not significantly differ between surgery alone and type of adjuvant therapy (P = 0.18 and P = 0.56, respectively). Patients with mixed ECCC did not have a survival advantage over those with pure ECCC (5-year PFS rate, 85.0% vs 82.7%, P = 0.77; 5-year OS rate, 88.3% vs 91.2%, P = 0.94).

CONCLUSIONS

Receipt of adjuvant therapy in surgically staged I/II ECCC did not appear to offer a survival advantage over observation alone. Adjuvant therapy in early-stage ECCC with consideration of molecular classification should be evaluated.

Clinical application of FIGO 2023 staging system of endometrial cancer in a Chinese cohort

OBJECTIVE

The International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system for endometrial cancer (EC) was released with incorporating histology, lympho-vascular space invasion, and molecular classification together. Our objective is to further explore the clinical utility and prognostic significance of the 2023 FIGO staging system in China.

METHODS

A retrospective analysis was conducted for patients who received standard surgeries and underwent genetic testing using multigene next-generation sequencing (NGS) panels between December 2018 and December 2023 at Fudan University Shanghai Cancer Center, Shanghai, China. The genomic and clinical data of all patients were analyzed, and stages were determined by both the 2009 and 2023 FIGO staging systems. Kaplan-Meier estimators and Cox proportional hazards models were used for survival analysis.

RESULTS

A total of 547 patients were enrolled in the study. After the restaged by the FIGO 2023 staging system, stage shifts occurred in 147/547 (26.9%) patients. In patients with early stages in FIGO 2009 (stage I-II), 63 cases were rearranged to IAmPOLEmut and 53 cases to IICmp53abn due to the molecular classification of POLEmut and p53abn. Altogether 345 cases were in stage I, 107 cases in stage II, 69 cases in stage III, and 26 cases in stage IV according to the FIGO 2023 staging criteria. For stage I diseases, the 3-year PFS rate was 92.7% and 95.3% in 2009 and 2023 FIGO staging systems, respectively. The 3-year PFS of stage II in 2023 FIGO was lower than that of FIGO 2009 (3-year PFS: 85.0% versus 90.9%), especially in substage IIC and IICmp53abn. Three cases (12%) of stage IIIA in FIGO 2009 were shifted to stage IA3 FIGO 2023, with 3-year PFS rates of 90.9% versus 100%, respectively. In NGS analysis, the most prevalent gene alterations were observed in PTEN and PIK3CA.

CONCLUSION

The FIGO 2023 staging system was proved to be a good predictor of survival for EC patients with enhanced precision compared to FIGO 2009. Predominant stage shifts were observed in early-stage diseases. Distinct gene alterations of different subtypes may help to explore more accurate target therapies.

Risk factors for omental metastasis and the effect of omentectomy on survival in type 2 endometrial cancer patients

To investigate the risk factors for occult omental metastasis and the effect of omentectomy on the survival of type 2 endometrial cancer (EC) patients. This study enrolled patients who were diagnosed with high-risk (grade 3, serous, clear cell, undifferentiated, carcinosarcoma, or mixed type) EC between 2000 and 2021 and underwent surgery in our center. Data from 482 patients were analyzed retrospectively. Omentectomy was performed in 405 (84.0%) patients. Omental metastases were detected in 61 (12.7%) patients. Eighteen (29.5%) of these metastases were occult. Adnexal involvement, malignant cytology, and peritoneal spread were independent risk factors for omental metastasis. The 5-year overall survival (OS) rate was 59.5% in patients who underwent omentectomy and 64.7% in those who did not (P = 0.558). In patients with and without omental metastases, the overall 5-year OS rates were 34.9% and 63.5%, respectively (P < 0.001). The 5-year OS rates of patients with a normal omentum, gross tumors, and occult metastases were 63.5%, 26.9%, and 52.5%, respectively (P < 0.001). Omental metastases is not uncommon in type II endometrial cancer; approximately one third of patients have occult metastases. Factors - positive cytology, adnexal involvement, and peritoneal involvement are associated with higher probability of omental metastases.

Clinical Characteristics and Outcomes of a High-grade Endometrial Cancer Cohort Treated at Instituto Nacional de Câncer, Brazil

OBJECTIVE

 To analyze the outcomes of a cohort of patients with high-risk histologies of endometrial cancer (EC) treated at Instituto Nacional de Câncer (National Cancer Institute, INCA, in Portuguese), in Brazil.

MATERIALS AND METHODS

 We reviewed the medical records of patients with high-risk histologies of EC in any stage registered at INCA between 2010 and 2016 to perform a clinical and demographic descriptive analysis and to evaluate the outcomes in terms of recurrence and survival.

RESULTS

 From 2010 to 2016, 2,145 EC patients were registered and treated at INCA, and 466 had high-grade histologies that met the inclusion criteria. The mean age of the patients was 65 years, 44.6% were Caucasian, and 90% had a performance status of 0 or 1. The most common histology was high-grade endometrioid (31.1%), followed by serous carcinoma (25.3%), mixed (20.0%), carcinosarcoma (13.5%), and clear cell carcinoma (9.4%). Considering the 2018 Fédération Internationale de Gynécologie et d'Obstétrique (International Federation of Gynecology and Obstetrics, FIGO, in French) staging system, 44.8%, 12.4%, 29.8%, and 12.9% of the patient were in stages I, II, III or IV respectively. Age (> 60 years), more than 50% of myoinvasion, higher stage, poor performance status, serous and carcinosarcoma histologies, and adjuvant treatment were independent factors associated with recurrence-free survival (RFS) and overall survival (OS) in the multivariate analysis.

CONCLUSION

 The current findings reinforced the international data showing poor outcomes of these tumors, especially for serous and carcinosarcomas and tumors with advanced stages, with shorter survival and high recurrence rates in distant sites, independently of the FIGO stage. Adjuvant therapy was associated with better survival.

Impact of sentinel lymph node assessment on the outcomes of patients with advanced endometrial cancer: A meta-analysis

BACKGROUND

Sentinel lymph node (SLN) assessment is used to treat early endometrial cancer; however, its application in advanced endometrial cancer remains controversial. Therefore, we assessed the effects of SLN assessment and lymphadenectomy (LND) on the prognosis (survival rate and primary outcome) of patients with advanced endometrial cancer.

METHODS

Pertinent studies were selected from PubMed, Embase, Web of Science, and the Cochrane Library until March 19, 2022. Relevant studies were strictly screened according to the inclusion and exclusion criteria. Data from the included studies were extracted and their quality was evaluated. Then RevMan5.4 software was used for the meta-analysis.

RESULTS

Four retrospective studies were included, which enrolled 7181 patients; 492 were treated with SLN and 6689 with LND. In terms of overall survival, there was no significant difference between the 2 groups (odds ratio = 1.14, 95% confidence interval: 0.92-1.41, I2 = 0%, P = .39).

CONCLUSIONS

SLN assessment is an alternative to LND as a treatment modality for advanced endometrial cancer.

Incorporating Molecular Classification When Stratifying the Survival Risk of Patients with High-Grade Endometrial Carcinomas

Assessing survival risk in patients with high-grade endometrial carcinomas has remained challenging. We aimed to investigate the distribution of molecular subtypes and assess their prognostic role in a large cohort of 355 patients with high-grade endometrial carcinoma. Molecular classification was determined using DNA polymerase epsilon (POLE) sequencing as well as immunohistochemical staining for p53 and mismatch repair (MMR) proteins. Endometrial carcinomas were stratified into four subtypes: POLE ultramutated, MMR-deficient, non-specific molecular profile (NSMP), and p53-mutant. This study included 177 and 178 patients with endometrioid and non-endometrioid carcinomas, respectively. Forty-two patients (11.8%) were categorized as POLE ultramutated, 106 (29.9%) as MMR-deficient, 128 (36.1%) as p53-mutant, and 79 (22.2%) as NSMP. Patients of different molecular subtypes had distinct survival times; molecular classification, but not histotype, was significantly associated with survival outcomes. When incorporating molecular classification into the stratification model, 52 patients (15.5%) switched risk groups, with 40 (11.9%) shifting to a lower risk for having a POLE mutation and 12 (3.6%) shifting to a higher risk owing to p53-mutant status. Molecular classification may provide more accurate prognostic information among patients with high-grade endometrial carcinomas and improve their stratification for purposes of clinical management.

Incidence of omental metastasis in uterine serous carcinoma: a systematic review and meta-analysis

OBJECTIVES

Previous studies examining the incidence of omental metastasis in uterine serous carcinoma generally suffered from the small sample size, retrospective observational design, and single-center setting. So far, there was no systematic review and meta-analysis available on this topic, we conducted this study to quantitatively synthesize the data relating to this topic.

DESIGN

systematic review and meta-analysis.

MATERIAL AND METHODS

PubMed, Embase, and Web of Science were searched up until August 15, 2020. Two reviewers independently performed study selection, data extraction, and quality assessment. I² was employed to assess the heterogeneity among included studies. Effect sizes along with 95% confidence intervals were calculated to analyze outcomes of interest. Funnel plots and the Egger test were used to detect the possibility of publication bias.

OUTCOME MEASURES

incidence of omental metastasis in uterine serous carcinoma.

RESULTS

A total of 16 studies involving 1012 women with uterine serous carcinoma were included in this systematic review and meta-analysis. All the included studies were at low risk of bias, and the heterogeneity among them was low. The pooled incidence of overall omental metastasis, occult omental metastasis, and gross omental metastasis in uterine serous carcinoma were 18% (95% CI, 0.15-0.20), 6% (95% CI, 0.04-0.08), and 10% (95% CI, 0.08-0.13), respectively.

CONCLUSIONS

Uterine serous carcinoma has a high tendency of omental metastasis. The main form of omentum involvement is gross metastasis. However, occult metastasis in the normal-looking omentum is also worthy of note.

Uterine papillary serous and clear cell carcinomas: Comparison of characteristics and clinical outcomes

INTRODUCTION

To assess the rate of disease control and survival after adjuvant treatment in patients with uterine papillary serous (PSC) and clear cell carcinoma (CCC) and compare the results between these two subtypes.

METHODS

The medical charts of 199 patients with de novo uterine PSC or CCC who underwent radiotherapy (RT) following surgery between 2001 and 2019 in three radiation oncology departments were retrospectively evaluated. Adjuvant treatment was decided by a multidisciplinary tumor board. All patients were planned to undergo adjuvant 4-6 cycles of chemotherapy with external beam RT (EBRT) and/or vaginal brachytherapy (VBT).

RESULTS

Median age was 63 years for all, 64 years for PSC, and 59 years for CCC, respectively. Complete surgical staging was applied in 98% of patients. Histopathologic subtype was PSC in 142 (71%) and pure CCC in 57 (29%) patients, respectively. FIGO stage was I in 107 (54%), II in 35 (18%), and III in 57 (28%) patients, respectively. Lympho-vascular space invasion and positive peritoneal cytology (PPC) were present in 42% and 10% of patients, respectively. All patients but 23 (12%) underwent adjuvant chemotherapy. Median follow-up was 49.5 months for all patients, 43.9 months for patients with PSC, and 90.4 months for patients with CCC, respectively. During follow-up, 20 (10%) patients developed pelvic recurrence (PR) and 37 (19%) developed distant metastasis (DM). PSC subtype increased the PR and DM rates, although the latter not statistically significant. The 5-year overall survival and disease-free survival rate was 73% and 69% for all patients, 71% and 66% for patients with PSC, and 77% and 75% for patients with CCC, respectively. The difference was more prominent in patients with stage ≥ IB disease. In multivariate analysis, advanced age and PPC significantly decreased all survival rates.

CONCLUSION

PSC has a worse prognosis than CCC with regard to pelvic and distant recurrence with a trend for decreased survival rates. Therefore, a more aggressive therapy is needed for patients with uterine PSC, particularly in patients with stage ≥ IB disease.

Survival outcomes of women with grade 3 endometrioid endometrial cancer: the impact of adjuvant treatment strategies

AIM

This multicenter investigation was performed to evaluate the adjuvant treatment options, prognostic factors, and patterns of recurrence in patients with grade 3 endometrioid endometrial cancer (G3-EEC).

MATERIALS AND METHODS

The medical reports of patients undergoing at least total hysterectomy and salpingo-oophorectomy for G3-EEC between 1996 and 2018 at 11 gynecological oncology centers were analyzed. Optimal surgery was defined as removal of all disease except for residual nodules with a maximum diameter ≤ 1 cm, as determined at completion of the primary operation. Adequate systematic lymphadenectomy was defined as the removal of at least 15 pelvic and at least 5 paraaortic LNs.

RESULTS

The study population consists of 465 women with G3-EEC. The 5-year disease-free survival (DFS) and overall survival (OS) rates of the entire cohort are 50.3% and 57.6%, respectively. Adequate systematic lymphadenectomy was achieved in 429 (92.2%) patients. Optimal surgery was achieved in 135 (75.0%) patients in advanced stage. Inadequate lymphadenectomy (DFS; HR 3.4, 95% CI 3.0-5.6; P = 0.016-OS; HR 3.2, 95% CI 1.6-6.5; P = 0.019) was independent prognostic factors for 5-year DFS and OS.

CONCLUSION

Inadequate lymphadenectomy and LVSI were independent prognostic factors for worse DFS and OS in women with stage I-II G3-EEC. Adequate lymphadenectomy and optimal surgery were independent prognostic factors for better DFS and OS in women with stage III-IV G3-EEC.

Comparison of survival outcomes and effects of therapy between subtypes of high-grade endometrial cancer - a population-based study

BACKGROUND

Similarities in outcome between grade 3 endometrioid cancer and non-endometrioid histologies have been reported by a number of studies. Other reports, however, stated a significantly better prognosis for G3 endometrioid compared to type II histology. In this population-based study, we compared the outcome and treatment approaches of high-grade endometrial cancer patients with FIGO stages I-III depending on their histology.

MATERIAL AND METHODS

284 high-grade endometrial cancer patients diagnosed between 1998 and 2015 were retrospectively analyzed. Overall survival (OS), recurrence-free survival (RFS), and recurrence rates were compared depending on histology.

RESULTS

Type I G3 patients had a statistically significant OS advantage over women suffering from type II carcinoma (HR 1.527, 95%-CI 1.024-2.276; p = 0.038) and carcinosarcoma (HR 2.106, 95%-CI 1.270-3.493; p = 0.004) in univariable and multivariable Cox-regression analysis. RFS in Type I G3 was significantly superior compared to patients with carcinosarcoma (HR 1.719, 95%-CI 1.018-2.901; p = 0.043) and not significantly superior to type II patients (HR 1.368, 95%-CI 0.920-2.036; p = 0.122). Cumulative recurrence rates were significantly higher in carcinosarcoma compared to type I G3 (HR 2.217, 95%-CI 1.096-4.485; p = 0.027) in univariable analysis, but not after risk adjustment (HR of 1.472, 95%-CI 0.654-3.311; p = 0.350).

CONCLUSION

The prognosis of patients with type I G3 endometrial cancer patients seems to be significantly superior to patients with type II cancer and particularly carcinosarcoma. Systematic LND seemed to be beneficial in all of the three subtypes. The benefit of adjuvant treatment methods may differ between histologies.

Clinicopathologic and Genomic Analysis of TP53-Mutated Endometrial Carcinomas

PURPOSE

Copy number-high endometrial carcinomas were described by The Cancer Genome Atlas as high-grade endometrioid and serous cancers showing frequent copy-number alterations (CNA), low mutational burden (i.e., non-hypermutant), near-universal TP53 mutation, and unfavorable clinical outcomes. We sought to investigate and compare the clinicopathologic and molecular characteristics of non-hypermutant TP53-altered endometrial carcinomas of four histologic types.

EXPERIMENTAL DESIGN

TP53-mutated endometrial carcinomas, defined as TP53-mutant tumors lacking microsatellite instability or pathogenic POLE mutations, were identified (n = 238) in a cohort of 1,239 endometrial carcinomas subjected to clinical massively parallel sequencing of 410-468 cancer-related genes. Somatic mutations and CNAs (n = 238), and clinicopathologic features were determined (n = 185, initial treatment planning at our institution).

RESULTS

TP53-mutated endometrial carcinomas encompassed uterine serous (n = 102, 55.1%), high-grade endometrial carcinoma with ambiguous features/not otherwise specified (EC-NOS; n = 44, 23.8%), endometrioid carcinomas of all tumor grades (n = 28, 15.1%), and clear cell carcinomas (n = 11, 5.9%). PTEN mutations were significantly more frequent in endometrioid carcinomas, SPOP mutations in clear cell carcinomas, and CCNE1 amplification in serous carcinomas/EC-NOS; however, none of these genomic alterations were exclusive to any given histologic type. ERBB2 amplification was present at similar frequencies across TP53-mutated histologic types (7.7%-18.6%). Although overall survival was similar across histologic types, serous carcinomas presented more frequently at stage IV, had more persistent and/or recurrent disease, and reduced disease-free survival.

CONCLUSIONS

TP53-mutated endometrial carcinomas display clinical and molecular similarities across histologic subtypes. Our data provide evidence to suggest performance of ERBB2 assessment in all TP53-mutated endometrial carcinomas. Given the distinct clinical features of serous carcinomas, histologic classification continues to be relevant.

Immune checkpoint expression, microsatellite instability, and mutational burden: Identifying immune biomarker phenotypes in uterine cancer

OBJECTIVES

Increasing grade of endometrioid endometrial cancer (EEC) is associated with aggressive behavior and poor prognosis. The traditional classification system is limited in its ability to guide treatment planning and prognostication. We identify distinct immune biomarker phenotypes using known markers of immunogenicity to identify patients who may benefit from immune therapy (IT).

METHODS

621 tumors were analyzed by multiplatform profiling. NextGen sequencing was performed on 592 genes. Tumor mutational burden (TMB) was defined as high (H) ≥10mutations/megabase. Microsatellite Instability (MSI) by NGS was ≥46 loci. PD-L1 positivity was ≥2+, >5% by IHC. Chi-square tests were used.

RESULTS

Overall, MSI-H was found in 33% of EECs, most frequent in grade 3 (G3), followed by grade 2 (G2) and grade 1 (G1) tumors (G3: 37%, G2: 32%, G1: 22%, p = 0.007). TMB-H was identified in 25% of EECs. TMB-H was most common in G3, followed by G2 and G1 tumors (G3: 34%, G2: 23%, G1: 13%, p = 0.006). Overall, PD-L1 expression was found in 5.5% of EECs. G3 EECs had the most frequent PD-L1 expression, followed by G2 and G1 tumors (G3: 12%, G2: 3.0%, G1: 0.9%, p < 0.0001). We identified POLE mutations in 4.5% (28/618). All POLE mutated tumors harbored TMB-H phenotypes but MSI-H and PD-L1 were only present in 10.7% and 14.8% of tumors respectively, suggesting upregulation of T-cell immune response in only a fraction of POLE mutated EECs. Triple negative (TN) biomarker phenotype (ER-/PR-/Her2-) was evaluated as a potential surrogate marker of tumor immunogenicity. We identified TN phenotype in 4% of G1 EEC compared with 9% in G2 and 33% in G3, suggesting loss of hormone expression and possible greater immunogenicity with increasing tumor grade.

CONCLUSIONS

High grade tumors appear to be more immunogenic than low grade tumors and may preferentially benefit from IT.

Adjuvant External Radiation Impacts Outcome of Pelvis-limited Stage III Endometrial Carcinoma: A Multi-institutional Study

BACKGROUND

Adjuvant therapy choice for women with FIGO stage III endometrial carcinoma (EC) is controversial. We investigate the comparative benefit of adjuvant chemotherapy (CT) alone, radiation therapy alone (RT) or in combination (chemotherapy and radiation therapy [CRT]) with respect to recurrence-free survival (RFS) and overall survival (OS) in women with pelvis-limited (PL) EC (stage IIIA, IIIB, and IIIC1).

MATERIALS AND METHODS

A multi-institutional database of 270 surgically staged women with PLEC was analyzed. Univariate log-rank analyses and Cox regression multivariate analyses (MVA) were performed to identify factors associated with RFS and OS.

RESULTS

Median RFS and OS were 112 and 130 months, respectively, for the full cohort. Adjuvant treatment was CT in 21%, RT in 27%, and CRT in 47%. Age, year of treatment, grade, histology, and adjuvant treatment were significantly associated with RFS and OS on univariate analysis. PLEC patients receiving CT alone fared worse in terms of RFS (P=0.07 relative to RT and <0.01 relative to CRT). On MVA, CRT retained significantly improved RFS relative to CT (hazard ratio for recurrence 0.38, P<0.01). PLEC patients receiving RT or CRT had improved OS compared with CT, P<0.01 and 0.03, respectively. On MVA, both RT only and CRT retained association with improved OS relative to CT alone (hazard ratio for death, 0.43, P=0.02 and 0.40, P<0.01, respectively).

CONCLUSIONS

For surgically staged PL stage III EC, treatment regimens incorporating RT were associated with improved survival endpoints relative to CT alone. As such, RT should be considered an important component in the adjuvant management of stage III PLEC.

Addition of IMP3 to L1CAM for discrimination between low- and high-grade endometrial carcinomas: a European Network for Individualised Treatment of Endometrial Cancer collaboration study

Discrimination between low- and high-grade endometrial carcinomas (ECs) is clinically relevant but can be challenging for pathologists, with moderate interobserver agreement. Insulin-like growth factor-II mRNA-binding protein 3 (IMP3) is an oncofoetal protein that is associated with nonendometrioid endometrial carcinomas but has been limited studied in endometrioid carcinomas. The aim of this study is to investigate the diagnostic and prognostic value of IMP3 in the discrimination between low- and high-grade ECs and its added value to L1CAM. IMP3 and L1CAM expression was assessed in tumors from 378 patients treated for EC at 1 of 9 participating European Network for Individualised Treatment of Endometrial Cancer centers. IMP3 was expressed in 24.6% of the tumors. In general, IMP3 was more homogeneously expressed than L1CAM. IMP3 expression was significantly associated with advanced stage, nonendometrioid histology, grade 3 tumors, deep myometrial invasion, lymphovascular space invasion, distant recurrences, overall mortality, and disease-related mortality. Simultaneous absence of IMP3 and L1CAM expression showed the highest accuracy for identifying low-grade carcinomas (area under the curve 0.766), whereas simultaneous expression of IMP3 and L1CAM was strongly associated with high-grade carcinomas (odds ratio 19.7; 95% confidence interval 9.2-42.2). Even within endometrioid carcinomas, this combination remained superior to IMP3 and L1CAM alone (odds ratio 8.6; 95% confidence interval 3.4-21.9). In conclusion, IMP3 has good diagnostic value and together with L1CAM represents the optimal combination of diagnostic markers for discrimination between low- and high-grade ECs compared to IMP3 and L1CAM alone. Because of the homogenous expression of IMP3, this marker might be valuable in preoperative biopsies when compared to the more patchy L1CAM expression.

High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations

This review of challenging diagnostic issues concerning high-grade endometrial carcinomas is derived from the authors' review of the literature followed by discussions at the Endometrial Cancer Workshop sponsored by the International Society of Gynecological Pathologists in 2016. Recommendations presented are evidence-based, insofar as this is possible, given that the levels of evidence are weak or moderate due to small sample sizes and nonuniform diagnostic criteria used in many studies. High-grade endometrioid carcinomas include FIGO grade 3 endometrioid carcinomas, serous carcinomas, clear cell carcinomas, undifferentiated carcinomas, and carcinosarcomas. FIGO grade 3 endometrioid carcinoma is diagnosed when an endometrioid carcinoma exhibits >50% solid architecture (excluding squamous areas), or when an architecturally FIGO grade 2 endometrioid carcinoma exhibits marked cytologic atypia, provided that a glandular variant of serous carcinoma has been excluded. The most useful immunohistochemical studies to make the distinction between these 2 histotypes are p53, p16, DNA mismatch repair proteins, PTEN, and ARID1A. Endometrial clear cell carcinomas must display prototypical architectural and cytologic features for diagnosis. Immunohistochemical stains, including, Napsin A and p504s can be used as ancillary diagnostic tools; p53 expression is aberrant in a minority of clear cell carcinomas. Of note, clear cells are found in all types of high-grade endometrial carcinomas, leading to a tendency to overdiagnose clear cell carcinoma. Undifferentiated carcinoma (which when associated with a component of low-grade endometrioid carcinoma is termed "dedifferentiated carcinoma") is composed of sheets of monotonous, typically dyscohesive cells, which can have a rhabdoid appearance; they often exhibit limited expression of cytokeratins and epithelial membrane antigen, are usually negative for PAX8 and hormone receptors, lack membranous e-cadherin and commonly demonstrate loss of expression of DNA mismatch repair proteins and SWI-SNF chromatin remodeling proteins. Carcinosarcomas must show unequivocal morphologic evidence of malignant epithelial and mesenchymal differentiation.

The Effect of Histological Subtypes on Outcomes of Stage IV Epithelial Ovarian Cancer

Introduction: To examined survival outcome by histological subtypes in de novo stage IV epithelial ovarian cancer (EOC).

Methods: Between 2004 and 2015, patients with stage IV EOC were included using the Surveillance, Epidemiology, and End Results program. The effects of histological subtypes on overall survival (OS) were assessed using Kaplan–Meier and multivariable Cox regression analyses.

Results: We identified 5,953 patients including 5,351 (89.9%), 249 (4.2%), 145 (2.4%), and 208 (3.4%) patients with high-grade serous, endometrioid, mucinous, and clear cell subtypes, respectively. The 5-year OS rates were 28.1, 38.6, 14.2, and 18.8% in patients with high-grade serous, endometrioid, mucinous, and 18.8% clear cell subtypes, respectively, (p < 0.001). Multivariate analyses indicated that histological subtype was an independent predictor of OS. Using the high-grade serous subtype as a reference, OS was comparable for the endometrioid subtype (hazard ratio (HR) 0.915, 95% confidence interval) (CI 0.772–1.085, p = 0.305), but significantly lower for mucinous (HR 3.292, 95% CI 2.701–4.011, p < 0.001) and clear cell subtypes (HR 1.820, 95% CI 1.546–2.141, p < 0.001). Patients with no residual tumor had better OS in the high-grade serous and endometrioid subtypes compared to patients with residual tumors. However, the residual tumor size was not a prognostic factor for OS in mucinous and clear cell carcinoma.

Conclusions: Our study suggest a markedly mortality rate in patients with stage IV mucinous and clear cell carcinoma, but better survival in patients with high-grade serous and endometrioid subtypes. Aggressive radical surgery to leave no residual disease would improve survival for high-grade serous and endometrioid carcinoma. More studies are needed to assess the value of aggressive radical surgery in patients with mucinous and clear cell subtypes.

Comparison of clinicopathologic and survival characteristics of high grade endometrial cancers; single center experience

PURPOSE

Approximately a quarter of endometrial cancers are of high grade. We aimed to perform clinicopathologic and survival evaluation of high grade endometrial cancer in our study.

METHOD

We evaluated the data of 78 high grade patients; 30 G3EC (Grade 3 Endometrioid Carcinoma), 48 nonendometrioid carcinomas; 32 USC (uterine serous carcinoma), 16 CCC (clear cell carcinoma), from 312 patients who were followed with endometrial cancer between years 2006 and 2016.

RESULTS

Mean age was 62 years (range 43-83) in all patients, the age in histologic subtypes was 56.5, 65, 66.3, years for G3EC, USC, and CCC, respectively. The G3EC mean age is significantly smaller than other histologic subtypes (P = 0.00). The median follow-up time was 39 months (range 6-136). The 5-year overall survival was 55%, 44%, G3EC, and nonendometrioid carcinoma (USC and CCC), respectively (P = 0.127). In the univariate model; age > 65, ECOG-PS ≥ 2, stage 3-4 disease, LVI presence were poor prognostic factors (P < 0.05). Effect of the stage of the disease, the age of the patients and ECOG-PS on survival was demonstrated with multivariate analysis. The clinicopathologic features of the patients were similar.

CONCLUSION

G3EC is seen at a younger age than other high grade endometrial carcinomas. Grade 3 endometrioid carcinomas have an increasing trend in survival compared to high grade nonendometrioid carcinomas.

Undifferentiated Endometrial Carcinomas: Clinicopathologic Characteristics and Treatment Outcomes

OBJECTIVE

Undifferentiated endometrial carcinoma (UEC) represents a recently recognized and rare diagnosis that is commonly misclassified on histopathologic evaluation. These cancers account for less than 10% of carefully reviewed series of endometrial cancers from academic medical centers. We reviewed a single-institutional experience with the management of UEC focusing on clinicopathologic characteristics and treatment outcomes.

METHODS

The medical records of all patients treated for histologically proven endometrial carcinoma between 2007 through 2016 were reviewed. Analysis was limited to 24 consecutive patients with histologically proven endometrial carcinomas that had at least a component of undifferentiated carcinoma on central pathology review. All patients were initially treated by definitive surgical resection. Grade 3 endometrioid carcinomas treated over the same period were used as a control group. The Kaplan-Meier method was used to estimate survival outcomes.

RESULTS

The median age at diagnosis was 66 years (range, 37-74 years). Ten patients presented with locally advanced or metastatic disease (42%). Fifteen patients (63%) received adjuvant chemotherapy with carboplatin and paclitaxel, 12 patients (50%) received adjuvant pelvic external beam radiation, and 10 patients (42%) received adjuvant vaginal cuff brachytherapy. With a median follow-up of 14 months (range, 0.5-115 months), 4 patients (21%) had developed disease recurrence and/or progression, 2 patients (11%) had died of disease, and 1 patient died of treatment complications. Twelve patients (63%) were alive with no evidence of disease at last contact. Outcomes were comparable to those with grade 3 endometrioid carcinoma.

CONCLUSIONS

Our data are consistent with prior studies demonstrating that UEC represents a rare clinical entity characterized by high rates of locally advanced disease at presentation. However, survival outcomes appear to be comparable to other high-grade endometrial cancers. Further studies investigating optimal adjuvant therapy in these patients are warranted.

Overexpression of HOMER2 predicts better outcome in low-grade endometrioid endometrial adenocarcinoma

We have previously shown that HOMER2 (Homer scaffolding protein 2), a protein coding gene, was highly expressed in low grade (LG) endometrioid adenocarcinoma (EAC) of the uterus. The role of HOMER2 in endometrial cancer (EC) is widely unknown; therefore, the aim of this study was to determine the expression and the predictive value of HOMER2 protein expression in series of patients with EC. HOMER2 protein expression was detected on paraffin-embedded tissues from 336 cases using immunohistochemistry (IHC). Tumours were categorised in two groups; group 1 (EAC, FIGO grade 1 and 2; n = 191) and group 2 (all other subtypes including grade 3 EAC; n = 145). Statistical analysis was performed to evaluate associations between HOMER2 protein expression and pathological parameters (histological type, grade, stage, lymphovascular invasion, myometrial depth of invasion) and patient outcome [progression-free survival (PFS) and cancer-specific survival (CSS)]. HOMER2 was significantly overexpressed in group 1 compared to group 2 cancers (67% versus 30%; p < 0.001) and with low tumour grade (p < 0.001). In group 1, HOMER2 overexpression was an independent prognostic factor for improved CSS (adjusted-hazard ratio 0.28; 95% confidence interval 0.08-0.96; p = 0.042). HOMER2 expression was not associated with survival in group 2 (p > 0.05). This is the first study of HOMER2 protein expression in EC. We speculate that HOMER2 may be involved in tumourigenesis of endometrioid uterine tumours and suggest that HOMER2 should be studied further for potential clinical and therapeutic applications.

Impact of lymph node ratio on survival in stage IIIC endometrioid endometrial cancer: a Turkish Gynecologic Oncology Group study

Objective

The purpose of this study was to investigate the prognostic value of lymph node ratio (LNR) in women with stage IIIC endometrioid endometrial cancer (EC).

Methods

A multicenter, retrospective department database review was performed to identify patients with stage IIIC pure endometrioid EC at 6 gynecologic oncology centers in Turkey. A total of 207 women were included. LNR, defined as the percentage of positive lymph nodes (LNs) to total nodes recovered, was stratified into 2 groups: LNR1 (≤0.15), and LNR2 (>0.15). Kaplan-Meier method was used to generate survival data. Factors predictive of outcome were analyzed using Cox proportional hazards models.

Results

One hundred and one (48.8%) were classified as stage IIIC1 and 106 (51.2%) as stage IIIC2. The median age at diagnosis was 58 (range, 30–82) and the median duration of follow-up was 40 months (range, 1–228 months). There were 167 (80.7%) women with LNR ≤0.15, and 40 (19.3%) women with LNR >0.15. The 5-year progression-free survival (PFS) rates for LNR ≤0.15 and LNR >0.15 were 76.1%, and 58.5%, respectively (p=0.045). An increased LNR was associated with a decrease in 5-year overall survival (OS) from 87.0% for LNR ≤0.15 to 62.3% for LNR >0.15 (p=0.005). LNR >0.15 was found to be an independent prognostic factor for both PFS (hazard ratio [HR]=2.05; 95% confidence interval [CI]=1.07–3.93; p=0.03) and OS (HR=3.35; 95% CI=1.57–7.19; p=0.002).

Conclusion

LNR seems to be an independent prognostic factor for decreased PFS and OS in stage IIIC pure endometrioid EC.

Does post-operative radiochemotherapy improve survival in high-grade endometrial cancer patients? Results of a population-based cohort analysis of a cancer registry

PURPOSE

Adjuvant treatment of high-grade endometrial cancer varies greatly due to the lack of definitive results from controlled randomized trials on the subject. In a retrospective study, we sought to investigate the influence of post-operative radio-, chemo, and radiochemotherapy on survival time and recurrence rates among high-grade endometrial cancer patients.

METHODS

284 high-grade endometrial cancer patients (FIGOI-III, or unknown classification) diagnosed between 1998 and 2015 were retrospectively analyzed. All patients underwent surgery. Overall survival (OS), recurrence-free survival (RFS), and recurrence rates were compared for post-operative treatment modalities of radiotherapy alone (RT), chemotherapy alone (CTX), radiochemotherapy (RCT), and observation (OBS).

RESULTS

Post-operative RCT and RT resulted in a significantly improved 5-year OS of 94.1% (HR 0.104, CI 0.013-0.809) and 62.1% (HR 0.615, CI 0.390-0.969), respectively, compared to 43.6% for OBS. CTX did not significantly improve OS leading to a 5-year OS of 56.5% (HR 0.783, CI 0.224-2.740). 5-year recurrence rate was lowest for patients treated with RCT (5.3%). 5-year RFS was 94.1% for the RCT group and proved to be significantly superior to 58.8% for RT (HR 9.034, CI 1.184-68.948), 56% for CTX (HR 12.738, CI 1.337-121.346), and 37.4% for OBS (HR 16.407, CI 2.127-126.575), respectively. In comparison with OBS, RT alone resulted in a significant improvement in RFS (HR 0.551, CI 0.354-0.856).

CONCLUSIONS

Our retrospective population-based study indicates a survival benefit from treating high-grade endometrial cancer with post-operative RCT. Randomized controlled trials are needed to minimize potential confounding parameters and further clarify the subject.

Evolving Roles of Histologic Evaluation and Molecular/Genomic Profiling in the Management of Endometrial Cancer

Endometrial cancers are the most common gynecologic malignancies. The staging of endometrial cancer has evolved from a clinical-based system to a comprehensive surgical-pathologic approach that allows for better risk stratification and treatment planning. Over the past few years, use of NCCN's sentinel lymph node (SLN) mapping algorithm for the surgical staging of endometrial cancer has gained significant acceptance and is now commonly applied in many practices. However, pathologic evaluation of prognostic factors is beset by challenges, including the reproducibility of histologic classification and FIGO's grading, as well as the questionable clinical significance of low-volume tumor in SLNs. With the revelation of major genomic classes of endometrial cancer comes the potential for improved, reproducible, and prognostically relevant classification schemes, which integrate traditional pathologic parameters with genomic findings, to aid in treatment decisions. Pathologic identification of new variants of endometrial cancer, such as undifferentiated carcinoma, continues to advance the phenotypic spectrum of these tumors, spurring genomic and functional studies to further characterize their mechanistic underpinnings and potentially reveal new avenues for treatment. In the era of precision medicine, pathologic assessment of biomarkers (eg, mismatch repair proteins) and recognition of phenotypes that are amenable to specific targeted therapies (such as POLE-mutated tumors) have become integral to the management of women with endometrial carcinoma.

Improved Outcome of High-Grade, Early 1-Stage Endometrioid Endometrial Carcinoma With Adjuvant Chemotherapy and Radiotherapy: Comparison of 2 Treatment Strategies

OBJECTIVE

Patients with high-grade endometrioid endometrial carcinoma have a high risk of recurrence, even in early stage. To determine the benefit of a more aggressive adjuvant treatment approach, different treatment strategies of 2 referral centers were compared.

MATERIALS AND METHODS

Outcome of all patients with International Federation of Gynecology and Obstetrics IB and II high-grade endometrioid endometrial carcinoma treated between 2008 and 2012, at the Gynecological Oncology Center South (GOCS) were compared with patients treated at the British Columbia Cancer Agency (BCCA). All patients underwent primary surgical treatment. Adjuvant treatment consisted of radiotherapy dependent on final pathology (GOCS), or adjuvant chemotherapy and pelvic radiotherapy (BCCA).

RESULTS

A total of 116 patients were treated at the GOCS (n = 61) and BCCA (n = 55). Patient cohorts were comparable for clinicopathological factors, except for age at diagnosis and lymphadenectomy. Radiotherapy was applied in 70.5% at the GOCS compared with 100% at the BCCA. All BCCA patients received chemotherapy compared with 3.3% at GOCS. The BCCA treatment strategy resulted in a significant reduced recurrence rate when compared with GOCS, 10.9% and 36.1%, respectively. There was no significant difference in the recurrence rate between patients with (n = 48) and without a lymphadenectomy (n = 68). Yet, numbers are relatively low. Because most recurrences were distant 78.6% (22/28), adjuvant chemotherapy resulted in reduced disease-related mortality.

CONCLUSIONS

Adjuvant chemotherapy and radiotherapy in early-stage high-grade endometrioid endometrial carcinoma results in improved disease-specific and overall survival compared to radiotherapy alone. Yet, due to the relatively low numbers, validation of these findings is needed in large prospective trials.

Uterine Clear Cell Carcinoma: Does Adjuvant Chemotherapy Improve Outcomes?

OBJECTIVES

Women with uterine clear cell carcinoma (UCCC) are at high risk of relapse. Adjuvant chemotherapy (CT) is often recommended, although its effectiveness remains controversial. Our objective was to evaluate treatment-related outcomes of patients with UCCC, particularly those treated with adjuvant CT.

METHODS

In this retrospective cohort study, patients diagnosed with UCCC at 2 academic cancer centers from 2000 to 2014 were included. Clinical, surgical, and pathological data were collected. Survival estimates were obtained using the Kaplan-Meier method and compared by log rank test. Multivariable analysis was used to determine the effect of CT and radiation therapy (RT) on overall survival (OS) and progression-free survival (PFS).

RESULTS

We included 146 patients with UCCC, with a median follow-up of 27 months (range, 1-160). Ninety-five (65%) patients presented with stage I to II disease and 51 (35%) with stage III to IV disease. Forty-six percent of patients with clinical stage I were upstaged after surgery: 29% were upstaged to stages III and IV. Thirty-one percent of patients with early-stage disease and 70% with advanced-stage received CT. Among recurrences, the majority had distant relapse in both early-stage (61.5%) and advanced-stage (96.3%) diseases. In both patients with early-stage and advanced-stage diseases, adjuvant CT did not improve OS or PFS. On multivariate analysis, CT was not a significant factor associated with improved PFS (hazard ratio [HR], 1.37; 95% confidence interval [CI], 0.69-2.71; P = 0.37) or OS (HR, 0.58; 95% CI, 0.24-1.38; P = 0.22), whereas RT was associated with improved PFS (HR, 0.51; 95% CI, 0.29-0.90; P = 0.02) and OS (HR, 0.19; 95% CI, 0.09-0.42; P < 0.001).

CONCLUSIONS

The high rate of upstaging after surgery highlights the importance of lymph node assessment. The high rate of distant recurrence questions the effectiveness of current CT regimens and warrants the development of novel systemic approaches. The role of adjuvant RT deserves further study.

Omental Biopsy for Surgical Staging of Uterine Serous Carcinoma

OBJECTIVES

The aims of this study were to determine the role of omental sampling in staging of uterine serous carcinoma (USC) and to evaluate its impact on patient outcomes.

MATERIALS AND METHODS

A retrospective study of 106 women with USC who underwent primary surgery between 2005 and 2014 was done. Overall survival, disease-free survival, and progression and recurrence patterns were studied in 84 patients with follow-up over 1 year. Diagnostic characteristics were evaluated for preoperative imaging and operative findings. Univariate and multivariate analyses were performed to evaluate risk factors for omental metastasis. Survival curves were used to compare omental sampling status and the presence of omental metastasis.

RESULTS

Of the 106 patients, 66 underwent surgical staging with omental biopsy (54; 82%) or omentectomy (12, 18%). Eight (12%) patients had metastatic disease in the omental samplings. All 6 patients with macrometastasis had visible lesions or palpable nodules and preoperative computed tomography (CT) was suspicious in 3. In 2 (3%) patients, omentum was not suspicious on CT or intraoperatively but had micrometastases. The negative predictive value regarding the staging CT scan was 92% and of the operative findings was 97%. On multivariate analysis, no variable was associated with omental involvement. Disease progressed or recurred in 40 (48%) patients. The most frequent sites of recurrence or progression were the omentum (23; 27%), peritoneum (26; 31%), pelvis (15, 18%), lung (15, 18%), and liver (12, 14%). Comparing the groups with or without omental assessment, no significant difference was found regarding progression and recurrence patterns, overall survival, and disease-free survival.

CONCLUSIONS

Omental involvement in USC upstages patients to stage IV disease and traditional risk factors fail to predict extrauterine disease. Although omental sampling does not influence disease progression or survival, a comprehensive intraoperative evaluation of the omentum is advised as most cases have grossly visible lesions.

Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy for Patients with Peritoneal Metastases from Endometrial Cancer

Background

More information is needed for selection of patients with peritoneal metastases from endometrial cancer (EC) to undergo cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

This study analyzed clinical, pathologic, and treatment data for patients with peritoneal metastases from EC who underwent CRS plus HIPEC at two tertiary centers. The outcome measures were morbidity, overall survival (OS), and progression-free survival (PFS) during a median 5 year follow-up period. Uni- and multivariate analyses were performed to identify significant factors related to outcome.

Results

A total of 33 patients met the inclusion criteria and completed the follow-up period. At laparotomy, the median peritoneal cancer index (PCI) was 15 (range 3–35). The CRS procedure required a mean 8.3 surgical procedures per patient, and for 22 patients (66.6%), a complete cytoreduction was achieved. The mean hospital stay was 18 days, and major morbidity developed in 21% of the patients. The operative mortality was 3%. When surgery ended, HIPEC was administered with cisplatin 75 mg/m² for 60 min at 43 °C. During a median follow-up period of 73 months, Kaplan–Meier analysis indicated a 5 year OS of 30% (median 33.1 months) and a PFS of 15.5% (median 18 months). Multivariate analysis identified the completeness of cytoreduction (CC) score as the only significant factor independently influencing OS. Logistic regression for the clinicopathologic variables associated with complete cytoreduction (CC0) for patients with metachronous peritoneal spread from EC who underwent secondary CRS plus HIPEC identified the PCI as the only outcome predictor.

Conclusions

For selected patients with peritoneal metastases from EC, when CRS leaves no residual disease, CRS plus HIPEC achieves outcomes approaching those for other indications such as colon and ovarian carcinoma.

Evaluation of unusual and highly aggressive variant of endometrium cancer: nonendometrioid endometrium carcinoma of the uterus

AIMS

To evaluate the survival and treatment outcomes of patients with nonendometrioid endometrium carcinoma after postoperative radiotherapy.

METHODS

The records of 94 patients treated with postoperative radiotherapy (RT) between January 2005 and December 2011 were retrospectively reviewed. Postoperative RT was delivered with a dose of 45-50.4 Gy with 1.8 Gy daily fractions and brachytherapy was added to external RT for 62 patients with a dose of 3 × 6 Gy. Median follow-up time was 35 months (range 6-95 months).

RESULTS

Median age was 63 years (range 43-83 years) and lymph node metastasis (LNM) was positive in 15 (16.0%) patients. The stage distribution of the patients was as follows: stage I, 58 (61.7%); stage II, 16 (17.0%); stage III, 18 (19.1%); stage IV, 2 (2.2%). Five-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) rates were 92.3%, 68.2%, and 78.6%, respectively. In univariable analysis, it was determined that the factors affecting OS rates were stage (p = 0.003), presence of LNM (p = 0.003), and presence of lymphovascular space invasion (LVSI) (p = 0.007); factors affecting DFS rates were stage (p = 0.019), presence of LVSI (p = 0.002), and having LNM (p = 0.049); and the factor affecting LRC rates was tumor size (>5 cm) (p = 0.011). In subgroup analyses, among all stage I patients, the DFS rates were lower for those with histologic grade 3 tumors and more than ½ myometrial invasion.

CONCLUSIONS

Due to its rarity, the prognostic factors and outcomes of nonendometioid endometrium carcinoma are not fully understood. In our analysis, stage, LNM, and presence of LVSI were found to be the most important prognostic factors. In order to tailor the optimal treatment strategy, prospective studies are needed.

Prognostic factors and treatment outcomes in surgically-staged non-invasive uterine clear cell carcinoma: a Turkish Gynecologic Oncology Group study

OBJECTIVE

To assess the prognosis of surgically-staged non-invasive uterine clear cell carcinoma (UCCC), and to determine the role of adjuvant therapy.

METHODS

A multicenter, retrospective department database review was performed to identify patients with UCCC who underwent surgical treatment between 1997 and 2016 at 8 Gynecologic Oncology Centers. Demographic, clinicopathological, and survival data were collected.

RESULTS

A total of 232 women with UCCC were identified. Of these, 53 (22.8%) had surgically-staged non-invasive UCCC. Twelve patients (22.6%) were upstaged at surgical assessment, including a 5.6% rate of lymphatic dissemination (3/53). Of those, 1 had stage IIIA, 1 had stage IIIC1, 1 had stage IIIC2, and 9 had stage IVB disease. Of the 9 women with stage IVB disease, 5 had isolated omental involvement indicating omentum as the most common metastatic site. UCCC limited only to the endometrium with no extra-uterine disease was confirmed in 41 women (73.3%) after surgical staging. Of those, 13 women (32%) were observed without adjuvant treatment whereas 28 patients (68%) underwent adjuvant therapy. The 5-year disease-free survival rates for patients with and without adjuvant treatment were 100.0% vs. 74.1%, respectively (p=0.060).

CONCLUSION

Extra-uterine disease may occur in the absence of myometrial invasion (MMI), therefore comprehensive surgical staging including omentectomy should be the standard of care for women with UCCC regardless of the depth of MMI. Larger cohorts are needed in order to clarify the necessity of adjuvant treatment for women with UCCC truly confined to the endometrium.

Distinct molecular landscapes between endometrioid and nonendometrioid uterine carcinomas

Endometrial carcinoma (EC) is traditionally characterized as endometrioid and nonendometrioid based on histopathologic phenotypes. Molecular-based classifications have been proposed, but are not widely implemented. Herein we examine molecular profiles between EC histologic subtypes. 3133 ECs were submitted between March 2011 and July 2014: 1634 Type I and 1226 Type II. In situ hybridization and immunohistochemistry were used to assess copy number and protein expression of selected genes. Sequenced variants in 47 genes were analyzed using the Illumina TruSeq Amplicon Cancer Panel. Type II EC included 628 cases of uterine serous cancer (USC), 136 cases of clear cell (CC), 361 cases of carcinosarcoma (CS), 38 cases of mucinous, and 36 cases of squamous cell. PI3K/Akt/mTOR pathway was most frequently dysregulated within Type I and mucinous histologies, least altered in CS and squamous. PD-L1 expression was highest in mucinous, absent in squamous. ER/PR expression was common in Type II, most frequent in USC, mucinous, and squamous. Receptor tyrosine kinase was frequently dysregulated in Type II disease: HER2 amplification highest in USC and CC, EGFR mutations exclusively seen in mucinous EC, KRAS mutations common in mucinous, squamous, and Type I, and c-MET overexpression high in CC and mucinous. BRCA1 and BRCA2 were most frequently mutated in CS. Grade 3 EC shares features of G1 tumor and Type II disease, most notably resembling CS. Endometrial carcinomas are a molecularly heterogeneous group of tumors. A histology-based molecular map can identify rational targets to optimize treatment and guide future clinical trials.

Role of diffusion-weighted MRI in the differential diagnosis of endometrioid and non-endometrioid cancer of the uterus

Background Many publications have examined the relationship between apparent diffusion coefficient (ADC) values and tumor grade in endometrial cancer. Nevertheless, none were designed to evaluate according to the histopathological type of endometrioid and non-endometrioid tumors. Purpose To evaluate the role of diffusion-weighted imaging (DWI) in the differential diagnosis of endometrioid and non-endometrioid cancer of the uterus, by comparing them with contrast-enhanced magnetic resonance imaging (MRI) findings. Material and Methods Institutional review board approval and informed consent were obtained. The MRI findings of 63 patients with endometrial cancer were retrospectively evaluated and divided into four groups: Grades I, II, and III endometrioid tumors, and non-endometrioid tumors. ADC values, DWI quotients ( b = 1000 s/mm²), and post-contrast signal intensities between lesions and the myometrium (b1000q-Cq values) were evaluated. The one-way-ANOVA, student's t-test, Kruskal-Wallis test, and receiver operating characteristic (ROC) analysis were used for statistical evaluation. Results Mean ADC values were 0.86 ± 0.14 in Grade I, 0.80 ± 0.7 in Grade II, 0.71 ± 0.14 in Grade III for endometrioid tumors, and 0.70 ± 0.12 in non-endometrioid tumors. There was a significant difference in ADC values between Grade I and Grade III ( P = 0.006), and non-endometrioid tumors ( P = 0.003). The difference was also significant between Grades I + II and Grade III ( P = 0.009), and non-endometrioid tumors ( P = 0.004). Besides, there was a significant difference between endometrioid and non-endometrioid tumors ( P = 0.022). However, when considering b1000q (F = 0.640, P = 0.593) and Cq (χ²= 6.233; P = 0.101), no significant difference was detected among the groups. Conclusion The difference in ADC values between the endometrioid and non-endometrioid tumors was statistically significant. However, the difference in DWI and contrast-enhancement findings were not statistically significant. Furthermore, the mean ADC values had an inverse relationship with tumor grade in the endometrioid cancer group.

Honing the classification of high-risk endometrial cancer with inclusion of lymphovascular space invasion

OBJECTIVES

The purpose of this study was to analyse the clinical impact of LVSI status in a large French multicentre cohort of women with high-risk ECs according to the ESMO classification.

METHODS

Data of 258 women with high-risk EC who received primary surgical treatment between January 2001 and December 2012 were abstracted from prospective multicentre database. The end points were the recurrence and the lymph node metastasis (LNM) rates. Recurrence free survival (RFS) and overall survival (OS) were analyzed.

RESULTS

The recurrence and LNM rates in the whole population were 32.9% and 34.5%, respectively. The median follow-up and initial recurrence times were 27 (range: 1-151) and 23.5 (range: 1-151) months, respectively. The respective 3-year RFS rates according to the LNM and LVSI status were, 78.3% (95% CI, 70.1-87.3), 53.7% (95% CI, 40.8-70.6), 65.5% (95% CI, 46.1-93.2), 43.5% (95% CI, 30.3-62.3) for women with no LN metastasis/no LVSI; no LN metastasis/LVSI present; LN metastasis/no LVSI; LN metastasis/LVSI present, respectively (p = 0.0005).

CONCLUSIONS

LVSI status remains a strong prognostic factor in high-risk ECs associated with a higher recurrence rate and lower RFS and OS whatever the histological type and lymph node status. It could thus be considered in future trials to guide decision-making about adjuvant therapy in high-risk ECs.

Bokhman Redux: Endometrial cancer "types" in the 21st century

In 1983 Jan V. Bokhman, M.D. published a landmark paper entitled "Two Pathogenetic Types of Endometrial Carcinoma" in which an enduring dualistic view of endometrial cancer was first proposed. "Type I" cancers are thought to represent estrogen driven mostly low grade endometrioid tumors strongly associated with obesity and other components of the metabolic syndrome. "Type II" cancers represent higher grade non-endometrioid tumors for which the latter associations are less significant. Basic tenets of this dichotomy including significant prognostic differences have been abundantly confirmed by later literature. The construct has in turn contributed a useful framework for decades of teaching and scientific advancement across disciplines. However, recent large epidemiologic studies indicate a more complex web of risk factors with obesity and hormones likely playing an important role across the entire endometrial cancer histologic and clinical spectrum. Moreover, high quality molecular data and refinements in pathologic classification challenge any simplistic classification of endometrial cancer. For example, the Cancer Genome Atlas (TCGA) recently defined four clinically distinct endometrial cancer types based on their overall mutational burden, specific p53, POLE and PTEN mutations, microsatellite instability and histology. Additionally, new histologic categories with clear prognostic implications have been accepted and it is becoming evident from an epidemiologic point of view that metabolic factors may play an important role in endometrial cancer overall. While Bokhman's intuitive dualistic model remains relevant when working with large registries and databases lacking granular information; most other efforts should integrate clinical, pathological and molecular specifics into more nuanced classifications.

SLUG expression is an indicator of tumour recurrence in high-grade endometrial carcinomas

AIMS

To investigate how SNAIL and SLUG were involved in the nature of high-grade endometrial carcinomas (grade 3 endometrioid carcinoma, serous carcinoma and clear cell carcinoma), we analysed the correlation of their expression status with clinicopathological characteristics and evaluated their prognostic significance.

METHODS AND RESULTS

We performed immunohistochemical staining in 52 high-grade endometrial carcinomas. Expression status of SNAIL and SLUG was classified into a high expression (positive in more than 50% of the tumour cells) and a low expression. Thirteen cases (25%) showed a high expression of SLUG, whereas all 52 cases showed a low expression of SNAIL. High expression of SLUG was correlated significantly with tumour recurrence (P = 0.0203) and aberrant p53 expression (P = 0.000559). Overall survival was worse in patients with high SLUG expression at all stages (P = 0.0327) and in those who underwent adjuvant therapy (P = 0.00963). Among the patients with complete tumour resection, high SLUG expression was associated with worse recurrence-free survival (RFS) in the patients at all stages (P = 0.00264), at stages III/IV (P = 0.0146), and who underwent adjuvant therapy (P = 0.000743). SLUG expression was identified as an independent factor of RFS by multivariate analysis (hazard ratio 5.938, 95% confidence interval 1.251-28.18, P = 0.025).

CONCLUSIONS

SLUG expression could be correlated with TP53 mutational status and could be involved in therapeutic resistance resulting in tumour recurrence. A high expression level of SLUG can be an indicator of recurrence and a therapeutic target for long-term remission in high-grade endometrial carcinomas.

The Role of Steroid Sulfatase as a Prognostic Factor in Patients with Endometrial Cancer

PURPOSE

The aim of the study was to determine steroid sulfatase (STS) expression in endometrial cancer patients and its correlation with disease prognosis.

MATERIALS AND METHODS

We conducted a retrospective study in 59 patients who underwent surgery with histologically confirmed endometrial cancer from January 2000 to December 2011 at Hanyang University Hospital. Immuno-histochemical staining of STS was performed using rabbit polyclonal anti-STS antibody.

RESULTS

Sixteen of the 59 patients (27.1%) were positive for STS expression. Disease free survival (DFS) was 129.83±8.67 [95% confidence interval (CI): 112.84-146.82] months in the STS positive group (group A) and 111.06±7.17 (95% CI: 97.01-125.10) months in the STS negative group (group B) (p=0.92). Overall survival (OS) was 129.01±9.38 (95% CI: 110.63-147.38) months and 111.16±7.10 (95% CI: 97.24-125.07) months for the groups A and B, respectively (p=0.45). Univariate analysis revealed that FIGO stage and adjuvant therapy are significantly associated with DFS and OS. However, in multivariate analysis, FIGO stage and adjuvant therapy did not show any statistical significance with DFS and OS. STS was also not significantly associated with DFS and OS in univariate and multivariate analysis.

CONCLUSION

STS expression was not significantly associated with DFS and OS, despite positive STS expression in 27% of endometrial cancer patients. Therefore, the role of STS as a prognostic factor in patients with endometrial cancer remains unclear and requires further research.

Early-stage Uterine Pure and Mixed Clear Cell Carcinoma: Outcomes and Recurrence With and Without Adjuvant Therapy

OBJECTIVE

Clear cell carcinoma (CCC) of the uterus is a rare but aggressive histology for which the role of adjuvant therapy for stage I-II disease is unclear. Our study investigated outcomes and patterns of failure in these patients.

METHODS

We found 64 cases of CCC, including 26 of pure CCC, 22 mixed with endometrioid adenocarcinoma, and 16 mixed with uterine papillary serous carcinoma. Adjuvant treatment was given to 55%.

RESULTS

Median follow-up was 51.9 months. By Kaplan-Meier estimate, 5-year vaginal recurrence-free survival (RFS) was 91.3%, pelvic RFS was 92.6%, distant metastasis RFS was 81.6%, disease-free survival was 79.6%, and overall survival was 79.7%. Median time to recurrence was 20.7 months (range, 2 to 40.5 mo). Patients treated adjuvantly had higher proportion of stage II disease (40% vs. 6.9% observed, P=0.0031) and 20% (7/35) recurred. There were no significant differences in outcomes by histologic subtypes but numerically more recurrences with uterine papillary serous involvement. By univariate analysis, higher stage, presence of lymphovascular invasion, and lack of lymph node dissection were predictive of worse overall survival. Age 65 years and above was predictive of worse cancer-specific survival. Of 12 who progressed, only 1 was salvaged and 11 died of disease. Of progressors, 10 had documented distant metastasis. Median time from recurrence to death was 4.5 months (range, 0.2 to 21.2 mo).

CONCLUSIONS

Given aggressive and often unsalvageable nature of recurrence, consideration of adjuvant treatment (including chemotherapy and radiation) is warranted for early-stage CCC, particularly for stage II or those with poor prognostic factors.

Treatment related outcomes in high-risk endometrial carcinoma: Canadian high risk endometrial cancer consortium (CHREC)

OBJECTIVE

The lack of randomized clinical data pertaining to optimal surgery and adjuvant treatment in women with high-risk histotypes of endometrial cancer has resulted in selective management based on institutional policies. The objective of this study was to assess differences in treatment strategies and their outcomes among various institutions.

METHOD

High-risk endometrial cancer cases (2000-2012) with corresponding clinicopathologic data were collected from 7 academic cancer centers. Histotypes included grade 3 endometrioid (EC3), serous (ESC), clear cell (CCC) and carcinosarcoma (CS). Associations with overall survival were performed using Cox proportional hazard regression.

RESULTS

1260 patients treated between 2000 and 2012 were included in the study: 398 EC3, 449 ESC, 91 CCC, 236 CS and 83 'other'. The use of adjuvant chemotherapy, adjuvant radiation, and extent of surgical staging were statistically different among the 7 centers (P<0.001). Histotype was independently associated with overall survival (OS) in patients with stage 1 and 2 disease who underwent surgical staging (P=0.0324). Adjuvant radiation was associated with improved OS for EC3 and CCC and adjuvant chemotherapy was associated with improved OS for ESC and CS. There was a high rate of recurrence (17.8% and 21.4%) in completely staged, stage 1A patients with ESC and CS respectively.

CONCLUSION

There exists a wide variation in practice and outcomes for high-risk histotypes of endometrial cancer. The relative impact of adjuvant therapy appears to be histotype dependent and prospective studies examining adjuvant treatment in high-risk histotypes should use caution combining them together.

Mutation spectrum of POLE and POLD1 mutations in South East Asian women presenting with grade 3 endometrioid endometrial carcinomas

OBJECTIVE

Somatic POLE mutations have been found in a subset of endometrioid ECs particularly in FIGO grade 3 tumors while POLD1 mutations are reportedly rare in ECs. While it has been suggested that POLE mutation confers good prognosis, the data remains conflicting. Our study aims to determine the mutation spectrum of somatic and germline POLE and POLD1 gene mutations in South East Asian (SEA) women with FIGO grade 3 endometrioid ECs.

METHODS

Forty-seven patients diagnosed with FIGO grade 3 endometrioid EC, diagnosed between 2009 and 2013 were included. Next generation sequencing (NGS) using formalin fixed embedded (FFPE) tissue was utilized to sequence tumor and matched normal tissue. Tumors were also assessed for other clinicopathologic and microsatellite status phenotype. Survival curves for pathogenic somatic POLE mutated and wild-type tumors were estimated by Kaplan-Meier method.

RESULTS

Pathogenic POLE (somatic or germline) and POLD1 (germline) mutations were detected in 29.7% (14/47) and 4.3% (2/47) patients, respectively. Three pathogenic germline mutations; one POLE and two POLD1 mutations were novel. Pathogenic germline and somatic POLE and POLD1 mutations were associated with 100% recurrence free survival. In contrast, among the wild-type POLE and POLD1 patients, 25% (8/32) had recurrence with 15.6% (5/32) subsequently dying of the disease. Somatic POLE-mutated tumors were more commonly associated with microsatellite stable (MSS) ECs (83% vs 49%; p=0.04) and peritumoral lymphocytic infiltration (75% vs 42%; p=0.05). All tumors with tumoral infiltrating lymphocytes exhibited peritumoral lymphocytic infiltrate but not vice versa.

CONCLUSION

Mutations in POLE and POLD1 in SEA women with grade 3 endometrioid ECs are associated with improved recurrence free survival. Notably, germline mutations in either POLE/POLD1 were seen in 8.5% of patients who will require appropriate genetic counseling regarding risk of developing colorectal carcinoma and on the need for additional surveillance for colonic changes. MSS and peritumoral lymphocytic infiltration may be useful histological features for distinguishing POLE mutated grade 3 endometrioid ECs.

Para-aortic and pelvic extended-field radiotherapy for advanced-stage uterine cancer: dosimetric and toxicity comparison between the four-field box and intensity-modulated techniques

BACKGROUND

In patients with advanced-stage endometrial carcinoma (eca), extended-field radiotherapy (efrt) is traditionally delivered by the 3-dimensional conformal (3d-crt) 4-field box technique. In recent years, the use of intensity-modulated radiotherapy (imrt) in gynecologic cancers has increased. We compared the delivery of efrt by the 3d-crt and contemporary imrt techniques.

METHODS

After surgical staging and adjuvant chemotherapy in 38 eca patients, efrt was delivered by either imrt or 3d-crt. Doses to the organs at risk, side effects, and outcomes were compared between the techniques.

RESULTS

Of the 38 eca patients, 33 were stage iiic, and 5 were stage ivb. In the imrt group, maximal doses to rectum, small intestine, and bladder were significantly higher, and mean dose to bladder was lower (p < 0.0001). Most acute gastrointestinal, genitourinary, and hematologic side effects were grade i or ii and were comparable between the groups. In long-term follow-up, only grade 1 cystitis at 3 months was statistically higher in the imrt patients. No grade iii or iv gastrointestinal or genitourinary toxicities were observed. No statistically significant differences in overall and disease-free survival or recurrence rates were observed between the techniques.

CONCLUSIONS

In advanced eca patients, imrt is a safe and effective technique for delivering efrt to the pelvis and para-aortic region, and it is comparable to the 3d-crt 4-field box technique in both side effects and efficacy. For centres in which imrt is not readily available, 3d-crt is a valid alternative.

Canadian high risk endometrial cancer (CHREC) consortium: analyzing the clinical behavior of high risk endometrial cancers

OBJECTIVES

The objective of this study is to analyze the clinical behavior of endometrial carcinomas by high risk(HR) histotype, including stage, overall survival, recurrence free survival and patterns of failure.

METHODS

This is a retrospective multi-institutional cohort study performed at 7 tertiary care centers across Canada between 2000 and 2012 and included: grade 3 endometrioid (EC3), endometrial serous cancer (ESC), clear cell carcinomas (CCC) and carcinosarcoma (CS). Clinicopathological and outcome data was collected.

RESULTS

1260 women with endometrial carcinoma with 1013 having staging procedures were identified; 398 EC3, 449 ESC, 236 CS and 91 CCC. 51.8% had lymphovascular space invasion (LVSI) and 18.5% had omental involvement with a statistically significant difference between tumor types (p=0.0005 and 0.0047 respectively); ESC had a significantly greater rate of omental involvement compared to EC3 (22% to 9%, p=0.0005). Within the entire cohort 49.3% were stage 1, 10.6% were stage 2, 27.4% were stage 3 and 12.7% were stage 4. Overall survival and recurrence free survival were significantly different between histotypes (p<0.0001) with CS having the worst outcome. Overall 31.5% of patients recurred. CS and ESC had a higher distant recurrence rate compared to EC3 (29.6%, 31.0% compared to 16.4%, p=0.0002 and p<0.001).

CONCLUSION

This study is one of the largest clinical cohorts of HR endometrial cancers. We have further clarified the impact of histotype and stage on recurrence and survival, and the high likelihood of distant recurrence. However, the differences are modest and risk prediction models will require additional molecular markers.

Neo-adjuvant chemotherapy for advanced stage endometrial carcinoma: a glimmer of hope in select patients

PURPOSE OF REVIEW

The objective of this review is to conduct a critical appraisal of the published literature on the use of neo-adjuvant chemotherapy followed by interval debulking in the treatment of stage IVb endometrial carcinoma patients.

METHODS

Narrative review of the pertinent literature on the application of neo-adjuvant chemotherapy and interval surgery in the treatment of advanced stage endometrial cancers.

RESULTS

Advanced stage endometrial carcinoma patients are treated by aggressive cytoreduction followed by adjuvant chemotherapy or by chemotherapy alone. The prognosis of patients that cannot undergo surgery is extremely poor. Preoperative reduction of tumor burden by chemotherapy can facilitate surgery in patients previously considered to have an unresectable disease, identify patients with chemo-sensitive tumors that are more likely to benefit from surgery, and enable a less aggressive surgery thus reducing morbidity. However, only 106 cases of neo-adjuvant chemotherapy were documented in the last two decades, majority (76) were described in retrospective case reports and case series. The available data may indicate feasibility of neo-adjuvant treatment in select patients. Compared to patients that had primary surgery, neo-adjuvant setting was associated with improved or equivalent survival and maximal debulking rates and reduced postoperative morbidity.

CONCLUSIONS

Until further progress is reached, consideration can be given to recommending neo-adjuvant chemotherapy followed by interval debulking to patients with poor performance status or those patients who the surgeon believes would have suboptimal debulking if surgery was attempted.

Adjuvant chemotherapy with external beamradiation therapy for high-grade, node-positive endometrial cancer

OBJECTIVE

The objective of this study was to evaluate clinical outcomes including disease-free survival (DFS) and overall survival (OS) for women with node-positive, high-grade adenocarcinoma of the uterus.

METHODS

Database review identified 73 patients with International Federation of Gynecology and Obstetrics stage IIIC 1/2 grade 3 endometrial cancer diagnosed from 1995 to 2009. Study inclusion required total abdominal hysterectomy/bilateral salpingo-oophorectomy and negative chest imaging. Histologic subtypes were endometrioid (22, 30%), papillary serous (20, 27%), clear cell (9, 12%), mixed (21, 29%), and undifferentiated (1, 1%). Adjuvant treatment was chemotherapy with external beam radiation therapy (EBRT) in 55 patients (75%), EBRT alone in 14 (19%), chemotherapy in 2 (3%), and no adjuvant therapy in 2 (3%).

RESULTS

With a median follow-up of 50 months, DFS/OS rates at 5 years were 44%/53%, respectively. Intraperitoneal relapse was more common in patients with positive cytology (30% vs 6%, P = 0.02) and nonendometrioid histology (16% vs 4%, P = 0.3). By histologic subtype, 5-year DFS/OS rates were 59%/82% for grade 3 endometrioid, 25%/30% for serous, 22%/17% for clear cell, and 50%/51% for mixed histology (P = 0.1/P < 0.001). The 5-year DFS/OS rates were 56%/68% for those who received both chemotherapy and EBRT. Among patients treated with adjuvant EBRT, pelvic control was 93%.

CONCLUSIONS

For node-positive, high-grade endometrial cancer, patients with endometrioid and mixed histologic subtypes had better clinical outcomes than did those with serous and clear cell cancers. Distinct patterns of relapse were observed with a greater risk of intraperitoneal failure for nonendometrioid histologic subtypes. Future studies are needed to define the optimal chemotherapy regimen and radiation fields.

Predicting lympho-vascular space invasion in endometrial cancers with mucinous carcinomatous components

OBJECTIVE

To determine the predictors of lympho-vascular space invasion (LVSI) in endometrial cancers which contain mucinous carcinomatous histology.

MATERIALS AND METHODS

Clinical and histopathological data of endometrial carcinomas with a mucinous carcinomatous component diagnosed between January 2007 and January 2014 at the Gynecologic Oncology Department of Zekai Tahir Burak Women's Health Education and Research Hospital were reviewed retrospectively.

RESULTS

Twelve patients (25.5%) were positive for LVSI and 35 (74.5%) patients were negative. Patients with LVSI were mostly staged higher than 1A. Mean age, BMI and parity were not significantly different between patient groups. Larger tumor diameter (≥2 cm) (p=0.04) and elevated Ca125 and Ca-19.9 (p=0.01) levels were significant for predicting LVSI. We also found >1/2 myometrial invasion (p<0.001), cervical stromal involvement (p=0.002) and higher grade (2-3) (p=0.001) significant for predicting LVSI. In multivariate analysis we found only grade significant for predicting LVSI.

CONCLUSIONS

Especially grade of tumor is a crucial factor for determining LVSI in endometrial cancers with mucinous carcinomatous components.