Positive peritoneal cytology is highly predictive of prognosis and relapse patterns in stage III (FIGO 2009) endometrial cancer

The comparison of pure uterine serous carcinoma and mixed tumor with serous component: a single-institution review of 91 cases

BACKGROUND

Pure uterine serous carcinoma (p-USC) and mixed tumors with serous component (m-USC) are aggressive subtypes of endometrial cancer associated with high mortality rates. This retrospective study aimed to compare clinicopathologic features and outcomes of p-USC and m-USC in a single center.

METHODS

This study retrospectively reviewed patients diagnosed with USC at Peking University People's Hospital between 2008 and 2022. T-tests and chi-square tests were used to compare clinicopathological characteristics between p-USC and m-USC. Kaplan-Meier survival curve and Cox regression analysis were used to analyze the impact of clinical and pathological variables on OS and PFS.

RESULTS

Among the 91 patients who underwent surgery, 65.9% (n = 60) were p-USC, and 34.1% (n = 31) were m-USC. Patients with p-USC had earlier menopause (P = 0.0217), a lower rate of progesterone receptor(PR) expression (P < 0.001), and were more likely to have positive peritoneal cytology (P = 0.0464). After a median follow-up time of 40 months, 28 (46.7%) p-USC and 9 (29%) m-USC patients had progression disease, 18 (30%) and 8 (25.8%) patients died of their disease. 5-year PFSR were 51.2% and 75.3%, respectively, and 5-year OS rates were 66% and 67.4%. Kaplan-Meier survival analysis showed that p-USC was more likely to relapse than m-USC (P = 0.034), but there was no significant difference in OS. Cox regression analysis showed that lymph node metastasis and surgical approach were risk factors for OS, and myoinvasion depth ≥ 1/2 was an independent risk factor for PFS.

CONCLUSIONS

p-USC was more likely to relapse than m-USC, but there was no significant difference in OS between the two subtypes.

Prognostic significance of positive peritoneal cytology in endometrial carcinoma based on ESGO/ESTRO/ESP risk classification: A multicenter retrospective study

OBJECTIVE

This study aimed to determine the prognostic significance of positive peritoneal cytology (PC) on endometrial carcinoma (EC) patients under the ESGO/ESTRO/ESP risk classification.

METHODS

This study retrospectively analyzed EC patients from 27 medical centers in China from 2000 to 2019. Patients were divided into three ESGO risk groups: low-risk, intermediate-risk and high-intermediate risk, and high-risk groups. The covariates were balanced by using the propensity score-based inverse probability of treatment weighting (PS-IPTW). The prognostic significance of PC was assessed by Kaplan-Meier curves and multivariate Cox regression analysis.

RESULTS

A total of 6313 EC patients with PC results were included and positive PC was reported in 384 women (6.1%). The multivariate Cox analysis in all patients showed the positive PC was significantly associated with decreased PFS (hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.55-3.13, P < 0.001) and OS (HR 2.25, 95% CI 1.49-3.40, P < 0.001),and the Kaplan-Meier curves also showed a poor survival in the intermediate and high-intermediate risk group (5-year PFS: 75.5% vs. 93.0%, P < 0.001; 5-year OS: 78.3% vs. 96.4%, P < 0.001); While in the low-risk group, there were no significant differences in PFS and OS between different PC status (5-year PFS: 93.1% vs. 97.3%, P = 0.124; 5-year OS: 98.6% vs. 98.2%, P = 0.823); in the high-risk group, significant difference was only found in PFS (5-year PFS: 62.5% vs. 77.9%, P = 0.033).

CONCLUSION

Positive PC was an adverse prognostic factor for EC, especially in the intermediate and high-intermediate risk patients. Gynecologic oncologists should reconsider the effect of positive PC on different ESGO risk groups.

Significance of positive peritoneal cytology for recurrence and survival in patients with endometrial cancer

AIM

This study aims to examine the association between malignant peritoneal cytology and prognosis in women with endometrial cancer.

METHODS

We retrospectively analyzed the records of patients with endometrial cancer who underwent surgery with intraoperative peritoneal cytology at our hospital between January 1988 and December 2012. All results were reclassified according to the 2009 International Federation of Gynecology and Obstetrics (FIGO) system, and the relation between intraoperative peritoneal cytology results and recurrence and prognosis was examined.

RESULTS

Of the 908 patients analyzed, 205 (22.6%) had positive peritoneal cytology. Patients with positive peritoneal cytology had significantly lower rates of recurrence-free survival (RFS) and overall survival (OS) than those in the negative cytology group (both p < 0.001). Subgroup analysis of patients with FIGO stage I/II showed significantly lower RFS in the positive-cytology group (p = 0.005), but there was no significant difference in OS (p = 0.637). In the patients with FIGO stage III/IV or patients classified as "high risk," the RFS and OS were significantly lower in the positive-cytology group (both p < 0.001). Cox regression analysis identified positive peritoneal cytology as a significant predictor of recurrence in patients with FIGO stage I/II disease.

CONCLUSIONS

Patients with positive peritoneal cytology for endometrial cancer have a high risk of recurrence, regardless of histopathologic type or FIGO stage. Peritoneal cytology has already been removed from the 2009 FIGO classification of endometrial cancer, but it may deserve reconsideration.

Prognostic significance of positive peritoneal cytology in endometrial cancer patients

Although peritoneal cytology has been shown to be an independant predictor of survival in endometrial cancer, the present international federation of gynaecology and obstetrics (FIGO) staging system does not involve it for risk stratification. This work aimed to assess the prognostic importance of PPC (positive peritoneal cytology) in endometrial cancer patients. The medical profiles of uterine carcinoma patients were reviewed who were referred to Khatam-al- Anbia and Bahman hospital within 2010-2019. The factors possibly affecting peritoneal fluid cytology in all patients were analysed. There was a considerable association between survival and the number of lymph nodes involvement (95% CI = 2.5 - 12.51, OR = 5.59, p < .001), stage 3 (95% CI = 2.95-22.10, OR = 7.12, p < .001), stage IV (95% CI = 2.14 - 30.09, OR = 8.04, p < .001), Grade (95% CI = 4.4-47.7, OR = 14.54, p < .001). Positive peritoneal cytology was revealed in our study, as an independent prognostic factor in patients with endometrial cancer. Impact statementWhat is already known on this subject? Peritoneal cytology is one of the independent risk factors for poor survival for endometrial cancer, but international federation of gynaecology and obstetrics (FIGO) staging system does not involve it for risk stratification.What do the results of this study add? Positive peritoneal cytology was revealed in our study, as an independent prognostic factor in patients with endometrial cancer.What are the implications of these findings for clinical practice and/or further research? It is recommended peritoneal cytology for future FIGO staging reviews. Till now, peritoneal washings need to be still regarded as a key part for precise risk-stratification.

Prognosis and adjuvant chemotherapy for patients with positive peritoneal cytology in stage IA endometrial cancer

This study evaluated the influence of positive peritoneal cytology (PPC) on the prognosis of patients with stage IA endometrial cancer, and the usefulness of adjuvant chemotherapy in their treatment. We retrospectively analyzed the data of patients with stage IA endometrial cancer admitted in our hospital between 2005 and 2015. Among 989 patients who underwent peritoneal cytology, 135 (13.7%) had PPC. Multivariate analysis extracted several independent risk factors for recurrence in stage IA patients, including those with PPC. Adjuvant chemotherapy did not cause a significant difference in the 5-year relapse-free survival rate in patients with PPC (p = 0.78). Similarly, the 5-year recurrence-free survival rate with or without chemotherapy was not different among type II cancer patients (p = 0.11). However, the baseline risk of 5-year relapse-free survival without chemotherapy in patients with PPC and type II was very low (66.7%). While PPC was an independent risk factor for recurrence in stage IA endometrial cancer, adjuvant chemotherapy did not influence the survival rate in patients with PPC. While it is controversial whether adjuvant chemotherapy should be administered in stage IA uterine cancer with only PPC as a prognostic factor, it should be considered for early-stage patients who have multiple risk factors for recurrence.

Ovarian metastasis risk factors in endometrial carcinoma: A systematic review and meta-analysis

OBJECTIVE

To investigate the incidence of ovarian metastasis in endometrial carcinoma (EC) and analyze its risk factors and provide a theoretical basis for whether retention of the ovary in patients with EC.

METHODS

A systematic search using synonyms of 'ovarian cancer' and 'metastasis' was conducted in PubMed, Cochrane database, Embase, Google Scholar, and WOS database. Meta-analysis was performed on 7 included studies, comprising 4281 clinical-stage I-IV EC patients. Studies were assessed using the Newcastle-Ottawa Scale (NOS) criteria. Odds risks (OR) and 95% confidence intervals (CI) were calculated using an inverse variance weighted random-effects model.

RESULTS

The ovarian metastasis risk of EC was significantly higher for patients with myometrial invasion >1/2 (OR = 18.19, 95% CI 5.34 to 61.96 compared to myometrial invasion ≤1/2), any pelvic lymph node invasion (PLNI) (OR = 5.41, 95% CI 2.60-10.97 compared to without PLNI), G3 pathological grade (OR = 2.66, 95%CI 1.35-5.24 compared to G1-G2), non-endometrioid pathological type (OR = 6.46, 95% CI 3.25 to 12.83 compared to endometrioid), lymphatic vascular space invasion (LVSI) (OR = 6.46, 95% CI 3.25 to 12.83 compare to without LVSI), age >45 (OR = 2.01, 95% CI 0.29 to 14.11 compared to age ≤45), and cervical invasion (OR = 4.12, 95% CI 1.87 to 9.08 compared to without cervical invasion).

CONCLUSION

About 4.95% of EC patients develop ovarian metastasis. Age >45, myometrial invasion >1/2, cervical invasion, PLNI, pathological type, G3 pathological grade, and LVSI were the high-risk factors for ovarian metastasis of EC. Ovarian preservation should be carefully selected for patients with EC, and preoperative and intraoperative evaluations should be entirely performed.

Re-thinking the prognostic significance of positive peritoneal cytology in endometrial cancer

BACKGROUND

Whether abnormal peritoneal cytology (PC) is an independent prognostic factor in endometrial cancer (EC) remains controversial. This study aimed to re-think the prognostic significance of PC in not only all EC patients but also in various subgroups with similar clinicopathological and biological characteristics.

METHODS

EC patients who underwent primary surgery of at least a hysterectomy and were pathologically diagnosed with EC in four hospitals affiliated with the Jikei University School of Medicine were retrospectively reviewed. The prognostic significance of PC was evaluated with univariate and multivariate analyses in the entire cohort and subgroups stratified by surgical stages (early/advanced stages), tumor types (types 1/2), and risk classifications (low/intermediate/high).

RESULTS

Of 1963 EC cases, 1616 met the inclusion criteria. Positive PC was identified as an adverse prognostic factor in analyses of all EC cases and in all subgroup analyses stratified by surgical stages and tumor types. In survival curve comparisons, the progression-free survival (PFS) and disease-specific survival in early-stage patients with positive PC were clearly located between those of stage II patients with negative PC and stage III patients. In the subgroup analyses stratified by risk classification in early-stage EC, positive PC was related to poorer PFS in the intermediate- and high-risk groups but not in the low-risk group.

CONCLUSION

PC status was an independent prognostic factor of EC in all stages and tumor types. Early PC-positive cases, except for the low-risk group, may be recommended for upstaging and should be carefully managed compared with PC-negative cases.

Evaluation of pelvic washing specimens in patients with endometrial cancer: Cytomorphological features, diagnostic agreement, and pathologist experience

BACKGROUND

Pelvic washings for patients with endometrial cancer is recommended but not used for staging. The International System for Reporting Serous Fluid Cytology (TIS) has standardized diagnostic categories, but the criteria remain incomplete. The 3 primary goals of this study were to 1) investigate features that distinguish atypical/indeterminate from malignant specimens, 2) measure the level of agreement between chart and reviewer diagnoses, and 3) determine whether the number of years in practice had an effect on the diagnoses rendered.

METHODS

Pelvic washings and surgical pathology specimens for 52 patients with a chart diagnosis of atypical/indeterminate, suspicious, or malignant cytology and 52 age-matched controls with a negative chart diagnosis were included, reviewed blindly by 2 cytopathologists, and assigned a study diagnosis. Morphologic features were assessed. Agreement between original chart diagnoses and reviewer diagnoses were assessed as well as effect of years in practice.

RESULTS

The overall cellularity in cell block (CB) slides for the malignant category was significantly increased compared with the atypical/indeterminate category (P < .0001). In addition, the number of atypical groups in ThinPrep for malignant washings was significantly increased compared with the atypical category (P < .001) and the negative and suspicious categories (P < .0001) in the CB. Overall agreement between the original and adjudicated diagnoses was high (γ = 0.983). There was no significant difference between diagnoses rendered and years in practice.

CONCLUSION

The overall cellularity and number of atypical cells can be used to distinguish between malignant and atypical pelvic washing specimens. There is high reproducibility in the diagnostic categories and high agreement among pathologists, regardless of practice experience. These findings can help refine the criteria for TIS.

The prognostic significance of positive peritoneal cytology in endometrial cancer and its correlations with L1-CAM biomarker

BACKGROUND

The aim of this study was to evaluate the prognostic role of positive peritoneal cytology (PPC) in a cohort of patients with endometrial cancer (EC). The secondary objective was to correlate the PPC and the expression of L1CAM in a group of patients with recurrence endometrial disease.

METHODS

All women diagnosed with EC and who performed a peritoneal cytology at "Regina Elena" National Cancer Institute of Rome from 2001 to 2013 were included in the study. Patients were divided into two groups according to positivity at peritoneal cytology. Moreover, patients with a recurrence disease and whose a tissue microarray (TMA) tumor sample was available underwent a L1CAM analysis.

RESULTS

Seven hundred sixty six patients underwent to EC staging in our Institute: 696 (90.8%) with negative and 70 (9.2%) with positive cytology. Five-year recurrence rate was higher in women with PPC (46.9% vs 18.4%, p = 0 < 0.0001) and, in particular, distant recurrence (86.7% vs 53.4%, p = 0.03). Moreover, we found an interesting pattern of recurrence disease in the group of early stage of EC with NPC and positive L1CAM.

CONCLUSIONS

Our results support the data that PPC may be a potential prognostic factor in early EC, due to its significant association with other risk factors and its significant influence on survival. Our findings confirm the need for large studies that point out the role of PPC and new prognostic factors, including biomarkers as L1CAM.

An elevated preoperative serum calcium level is a significant predictor for positive peritoneal cytology in endometrial carcinoma

Objective

To evaluate preoperative serum calcium concentration and investigate the association between calcium level and positive peritoneal cytology in endometrial carcinoma (EC).

Methods

A total of 510 patients who were diagnosed with EC and had surgery were initially enrolled in this study at Peking University People’s Hospital between January 2012 and December 2016. Clinical characteristics and preoperative serum calcium, albumin, carbohydrate antigen (CA)125, CA19-9, carcinoembryonic antigen (CEA) were extracted from patient records and evaluated according to postoperative peritoneal cytology. Predictive factors were assessed with Cox univariate and multivariate analyses. Factors selected from multivariate analysis results were used to build a predictive model.

Results

A total of 510 patients are identified in our database and 444 patients who fulfilled inclusion and exclusion criteria are included in this study. Univariate analysis revealed that ionized calcium concentration was closely related to positive peritoneal cytology, tumor grade and lymph-vascular space invasion (LVSI). Moreover, peritoneal cytology was significantly associated with hypertension, tubal ligation, serum CA125, CA19-9, CEA and ionized calcium level. Multivariate analysis revealed that albumin-adjusted calcium level, CA125 and tubal ligation were independent predictive factors of positive peritoneal cytology (P<0.05). A combination of ionized calcium level with the other two indexes yielded significantly great area under the curve (AUC=0.824).

Conclusions

This study enhanced the value of preoperative ionized calcium level. We also identified several potential biomarkers to predict positive peritoneal cytology in EC patients before surgery.

The Clinical Features of Recurrent Endometrial Cancer in Japan: Chemotherapy Instead of Radiotherapy as Postoperative Adjuvant Treatment

Objective

Chemotherapy is a standard adjuvant treatment after primary surgery for endometrial cancer in Japan. We aimed to characterize the clinical features of recurrent endometrial cancer (REC) patients in Japan.

Materials and Methods

We retrospectively reviewed the medical records of 112 REC patients who were primarily treated at 1 of 3 university hospitals in Japan from 2005 to 2012. We analyzed overall survival since the first recurrence (R-OS) in accordance with several factors.

Results

Median patient age was 64 years. The median follow-up period was 48 months. The distributions of cancer stage and histological subtype lacked distinctive features, and most patients had a high risk for recurrence at the time of the primary surgery. Although approximately 78% of patients received adjuvant chemotherapy, 85/112 patients (76%) experienced recurrence within 2 years after the initial treatment ended. For patients receiving adjuvant chemotherapy, regional lymph node (LN) and distant-site recurrence were more frequent (>40%) than vaginal or intra-abdominal recurrence. Median survival and 5-year R-OS were 27 months and 26.1%, respectively. The R-OS was significantly better for patients aged 65 years or older, those with negative peritoneal cytology at the time of primary surgery, those with recurrence within regional LN (eg, pelvic LN or para-aortic LN under the renal vein) and/or vagina, and those who underwent surgery and/or radiotherapy after recurrence. A multivariate analysis indicated that positive peritoneal cytology, a disease-free interval of less than 12 months, recurrent lesions in 2 or 3 areas, and treatment excluding surgery or radiotherapy were independent predictors of poor prognosis after recurrence.

Conclusions

Adjuvant chemotherapy was insufficient to reduce the incidence of distant recurrence. The prognosis of patients recurred within regional LN and/or vagina was significantly better than that of patients with recurrence in other lesions because of treatment with surgery and/or radiotherapy. The disease-free interval was a significant prognostic factor for REC patients.

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.

Prognosis and treatment of positive peritoneal cytology in early endometrial cancer: matched cohort analyses from the National Cancer Database

BACKGROUND

While positive peritoneal cytology is no longer included among the endometrial cancer staging criteria, Federation International de Gynecologie et Obstetrique recommends continued collection of pelvic washings for cytology to produce additional data that may be used to determine the significance of positive cytology for prognosis and treatment of endometrial cancer.

OBJECTIVES

The objectives of the study was to validate that positive cytology is a predictor of decreased survival in early endometrial cancer and to test whether adjuvant chemotherapy for positive cytology is associated with increased survival.

STUDY DESIGN

We performed an observational retrospective cohort analysis of the 2010-2013 National Cancer Database including women with cytology status and Federation International de Gynecologie et Obstetrique stage IA-II endometrial cancer. Overall cohort and matched cohort survival analyses were performed with and without imputation of missing data. We also performed survival analyses of women with positive cytology grouped by chemotherapy exposure. Multivariable Cox proportional-hazards regressions were performed to adjust for possible confounders. A variety of sensitivity analyses, including robustness of results to possible unmeasured confounding, were reported.

RESULTS

A total of 16,851 women including 953 with positive cytology were included. Four-year overall survival was 79.5% (range, 76.2-83.0%) for women with stage I/II with positive cytology vs 92.2% (range, 91.5-92.9%), 83.3% (range, 81.6-84.9%), and 86.8% (range, 85.1-88.5%) for stage IA, IB, and II with negative cytology, respectively (P ≤ .001). Positive cytology was associated with decreased survival (hazard ratio [95% confidence interval], 1.85 [range, 1.54-2.21], P < .001). For women with Federation International de Gynecologie et Obstetrique grade 1/2 endometrioid adenocarcinoma, the hazard of death associated with positive cytology was similar (hazard ratio [95% confidence interval], 1.85 [1.28-2.67], P < .001). Use of adjuvant chemotherapy by women with positive cytology was associated with increased survival (hazard ratio [95% confidence interval], 0.62 [0.40-0.95], P = .03).

CONCLUSION

Positive peritoneal cytology was associated with decreased overall survival of women with Federation International de Gynecologie et Obstetrique stage I/II endometrial cancer, including low-grade endometrioid endometrial cancer. Treatment of women with stage I/II endometrial cancer and positive cytology with adjuvant chemotherapy was associated with increased survival.

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.

Revaluating the survival effects of International Federation of Gynecology and Obstetrics 1988 stage IIIA criteria for endometrial cancer

Objective:

This study aimed to define factors that affected survival in the International Federation of Gynecology and Obstetrics (FIGO) 1988 stage IIIA endometrial cancer (EC).

Material and Methods:

The study included patients with EC who underwent surgery between 1992 and 2013. Patients with adnexal metastases, uterine serosal involvement or positive peritoneal cytology (stage IIIA disease according to the former 1988 FIGO staging system) were selected for further analysis. Clinical and pathologic factors associated with progression-free survival (PFS) were evaluated using univariate and multivariate statistical tests.

Results:

Seventy-seven patients with stage IIIA disease according to the 1988 FIGO staging system were included. The median follow-up was 37 months (range, 1-175 months) and recurrence was detected in 19 patients. Univariate analysis revealed that the presence of uterine serosal invasion and advanced histologic grade (grade 1-2 vs. grade 3) were associated with diminished PFS (p=0.001, p=0.047). The presence of adnexal involvement and positive peritoneal cytology had no statistically significant influence on PFS (p=0.643 and p=0.795, respectively).

Conclusion:

In patients with stage IIIA EC according to the FIGO 1988 staging system, only uterine serosal involvement was related with adverse oncologic outcomes, not adnexal involvement or presence of positive cytology.

Conversion of intraperitoneal cytology during laparoscopic surgery of uterine cancer

INTRODUCTION

The laparoscopic surgery of uterine cancer is an oncological safe treatment option in early stage cancer. However, there are no data about whether laparoscopy can lead to intraperitoneal tumor cell dissemination. We aimed in our study to detect a possible cytological conversion during laparoscopic procedures.

METHODS

In this prospective study, we included all patients receiving laparoscopic treatment at the early stage endometrial and cervical cancer in the Department of Obstetrics and Gynecology at the University of the Saarland and obtained peritoneal wash for cytological examination at the beginning and at the end of laparoscopic surgery. All patients received stage-adjusted operative and adjuvant therapy.

RESULTS

We enrolled 43 patients [endometrial cancer (n = 24) and cervical cancer (n = 19)]. At the beginning of the operation, one patient with endometrial cancer and one patient with cervical cancer showed a positive cytology. One tumor cell conversion from negative to positive cytology during surgery was detected in a patient suffering from endometrial cancer stage FIGO Ia. The median duration of surgery was 191.8 ± 79.3 min. The average time of follow-up was 16.5 ± 10.3 month. At the end of data evaluation at December 2014, two patients (8.6 %) are suffering from recurrent disease, two patients died, none of these patients had a positive cytology. All patients with positive cytology are free of cancer.

CONCLUSION

During laparoscopic surgery of early stage endometrial and cervical cancer, only one conversion of cytology was detected, which proves that laparoscopy does not appear to increase the intraoperative tumor cell dissemination or rate of positive cytological results.

Peritoneal cytology in endometrial cancer

AIMS

To investigate whether positive peritoneal cytology (PPC) has an effect on expected survival in endometrial cancer and to present factors that affect PPC occurrence.

METHODS

Patient chart information of 224 patients who had been treated at the Ankara Oncology Education and Research Hospital due to endometrial cancer between 1996 and 2006 were retrospectively reviewed. Factors that were likely to have an effect on peritoneal fluid cytology in all patients, such as age, histologic type, grade, myometrial invasion, cervical invasion, tumor size, and lymphatic metastasis, were analyzed.

RESULTS

We observed peritoneal cytology, grade, myometrial invasion, cervical stromal invasion, tumor size, and lymphatic metastasis to have a significant effect on survival. Cytology was positive in 20 of 224 patients (8.9%). Statistical analysis revealed a significant effect on PPC occurrence of myometrial invasion, cervical stromal invasion, tumor size, histologic type, and lymphatic metastasis.

CONCLUSIONS

Positive peritoneal cytology has a significant effect on survival in endometrial cancer. Positive peritoneal cytology occurrence is influenced by myometrial invasion, cervical stromal invasion, tumor size, histologic type, and lymphatic metastasis.

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.

Feasibility, Sensitivity, and Specificity of Postprocedure Peritoneal Cytology

The objective of this study was to determine the feasibility and diagnostic performance of cytopathologic evaluation of postprocedure washings collected after hysterectomy for gynecologic cancer. A total of 92 cases of hysterectomy for malignancy having cytology reports of both pre- and postprocedure washings were retrospectively identified. In all, 98.7% of preprocedure and 99.3% of postprocedure washings (P = 1.00) were satisfactory for cytopathology. Discordance regarding the observation of malignant cells between preprocedure and postprocedure washings was insignificant (P = .267). The sensitivity of postprocedure cytology for detecting malignant cells in cases of positive peritoneal histology was significantly lower than the sensitivity of preprocedure cytology (28.6% vs 57.1%, P = .041), with similar specificities (both 94%). Four patients with endometrial cancer having negative preprocedure peritoneal cytology were discovered to have positive postprocedure cytology. Postprocedure peritoneal cytology is feasible and may benefit patients with early-stage cancer by increasing the detection of microscopic peritoneal metastasis or cancer cell seeding during surgery.

Lymphovascular space invasion in robotic surgery for endometrial cancer

BACKGROUND

Minimally invasive surgery has become a standard treatment for endometrial cancer and offers significant benefits over abdominal approaches. There are discrepant data regarding lymphovascular space invasion (LVSI) and positive peritoneal cytology with the use of a uterine manipulator, with previous small-scale studies demonstrating an increased incidence of these prognostically important events. We sought to determine if there was a higher incidence of LVSI in patients who underwent robot-assisted surgery for endometrial cancer.

METHODS

We performed a single-institution review of medical records for patients who underwent open abdominal or robot-assisted hysterectomy for endometrial cancer over a 24-month period. The following data were abstracted: age, tumor grade and stage, size, depth of invasion, LVSI, and peritoneal cytology. For patients with LVSI, slides were reviewed by 2 pathologists for confirmation of LVSI.

RESULTS

Of 104 patients identified, LVSI was reported in 39 (37.5%) and positive peritoneal cytology in 6 (4.8%). Rates of peritoneal cytology were not significantly different between the 2 groups (odds ratio, 0.55; 95% confidence interval, 0.10-3.17; P=.50). LVSI was reported in significantly fewer robot-assisted hysterectomies than open procedures (odds ratio, 0.39; 95% confidence interval, 0.17-0.92; P=.03). In subgroup analyses restricted to early-stage disease (stage≤II), there was no significant difference in LVSI between open and robot-assisted hysterectomies (odds ratio, 0.64; 95% confidence interval, 0.22-1.85; P=.43).

CONCLUSION

In this retrospective study, we found that use of a uterine manipulator in robot-assisted surgery did not increase the incidence of LVSI.

Factors predicting nodal metastasis in endometrial cancer

PURPOSE

Evaluation of lymph node (LN) metastases in endometrial carcinoma (EC) is an important prognostic factor and a required element of cancer staging. The purpose of this study is to analyze what factors might predict the likelihood of nodal involvement in EC.

METHODS

A retrospective search of our institutional database for hysterectomies with associated LN dissection in women with EC revealed 207 cases between 2005 and 2012. Cases with primary EC, irrespective of histologic subtype, including carcinosarcomas were included in the study, but pure sarcomas were excluded. We evaluated various factors including tumor size (TS; ≤2.0 cm and >2.0 cm), depth of myometrial invasion (DMI; absent, ≤50 %, >50 %), positive pelvic cytology (PPC), cervical stromal invasion (CSI), and lymph-vascular invasion (LVI), to determine which factors correlated with the presence of LN metastasis.

RESULTS

Of the 207 (age = 62.29 ± 10.9, mean ± SD) cases of EC with LN dissection in our study group, 34 (16.42 %) had positive LNs. On univariate analysis, we found that TS (p = 0.04), tumor grade (Grade I and II versus grade III, p < 0.0001), DMI (p < 0.0001), CSI (p < 0.0001), LVI (p < 0.0001), and PPC (p = 0.001) showed statistically significant correlation with LN metastasis. However, on multivariate analysis, only DMI (p = 0.002) and LVI (p = 0.004) independently showed statistically significant correlation with LN metastasis. In addition, 18 (8.7 %) grade I and II (well/moderately differentiated) tumors with TS ≤2.0 cm and <50 % DMI showed no LN metastasis, LVI, CSI, or PPC.

CONCLUSION

We concluded that DMI and LVI were independent factors predictive of LN metastasis.