A suggested modification to FIGO stage I endometrial cancer

Evaluation of prognostic significance of lymphovascular space invasion in early stage endometrial cancer: a systematic review and meta-analysis

Background

Studies evaluating the prognostic significance of lymphovascular space invasion (LVSI) in early stage endometrial cancer (EC) are conflicting.

Objectives

To evaluate whether LVSI identified in stage I EC is associated with worse survival.

Search strategy

A comprehensive literature search of three databases (Embase, PubMed, and Cochrane) was performed up to April 30th 2023.

Selection criteria

Cohort studies that have evaluated the relationship between LVSI and prognosis in patients with stage I EC were included.

Data collection and analysis

Two authors independently assessed the studies for inclusion, extracted the data of recurrence and survival, and conducted meta-analysis using random effects model. Heterogeneity was evaluated by I2 test.

Main results

A total of 15 studies involving 6,705 patients were included in the meta-analysis. The overall pooled rate of LVSI was 14% [95% confidence interval (CI) CI 0.09-0.18] in stage I EC. LVSI was significantly associated with a higher risk of recurrence [odds ratio (OR) = 2.79, 95%CI 2.07-3.77], reduced overall survival (OS) [hazard ratio (HR)=5.19, 95%CI 3.33-8.07] and recurrence free survival (RFS) [HR = 5.26, 95%CI 3.45-8.02] in stage I EC patients. Similarly, LVSI was associated with an increased risk of recurrence [OR= 3.10, 95%CI 2.13-4.51], decreased OS [HR=5.52, 95%CI 2.16-14.09] and RFS [HR = 4.81, 95%CI 2.34-9.91] in stage IA grade 1 or 2 endometrioid carcinoma patients.

Conclusion

The presence of LVSI in stage I EC and in stage IA, grade 1 or 2 endometrioid carcinoma is associated with an increased risk of recurrence, lower OS and RFS.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier 42023425231.

Personalized Sentinel Node Mapping in Endometrial Cancer by the Indocyanine Green Implementation as Single Tracer: A Case Control Study

The main objective was to analyze the rate of bilateral sentinel lymph node (SLN) detection in endometrial cancer using indocyanine green (ICG) as a unique tracer compared to Technetium99 + ICG. As secondary objectives, we analyzed the drainage pattern and factors that might affect the oncological outcomes. A case-control ambispective study was carried out on consecutive patients at our center. Data on the SLN biopsy with ICG collected prospectively were compared to retrospective data on the use of a double-tracer technique including Technetium99 + ICG. In total, 194 patients were enrolled and assigned to both groups, in which the group with both tracers (controls) included 107 (54.9%) patients and the ICG-alone group (cases) included 87 (45.1%) patients. The rate of bilateral drainage was significantly higher in the ICG group (98.9% vs. 89.7%; p = 0.013). The median number of nodes retrieved was higher in the control group (three vs. two nodes; p < 0.01). We did not find survival differences associated with the tracer used (p = 0.85). We showed significant differences in terms of disease-free survival regarding the SLN location (p < 0.01), and obturator fossa retrieved nodes showed better prognosis compared to external iliac. The use of ICG as a single tracer for SLN detection in endometrial cancer patients seemed to obtain higher rates of bilateral detection with similar oncological outcomes.

Use of clinicopathological factors to predict prognosis of fertility-sparing treatment for endometrial endometrioid carcinoma and atypical hyperplasia

The incidence of endometrial endometrioid carcinoma (EEC) has been gradually increasing over the past decade. Fertility-sparing therapy with progestin is a treatment option for EEC or endometrial atypical hyperplasia (AH). The present study evaluated the role of numerous prognostic factors following fertility-sparing therapy for EEC or AH. Furthermore, the present study assessed the strength of various clinicopathological indicators for the prediction of treatment efficacy. A retrospective analysis was performed of patients with EEC and AH who received fertility-sparing therapy between August 2013 and September 2021 at Peking University People's Hospital (Beijing, China). Endometrial specimens were obtained from each patient after 3 months of treatment and at the end of the fertility-sparing therapy, before treatment efficacy and prognosis were evaluated using the χ² test. Furthermore, the protein expression levels of EEC biomarkers, such as estrogen receptor (ER), progesterone receptor (PR), paired box 2 (PAX2), PTEN and p53 were assessed using immunohistochemistry. The overall complete response (CR) rate of fertility-sparing treatment in the EEC group was 67.39% (31/46), whereas that in the AH group was 86.49% (32/37). The difference between the CR rates in the EEC and AH groups was statistically significant (P<0.05). There was no association between prognosis after treatment and ER, PAX2, PTEN or Ki-67 expression in the initially untreated AH or EEC groups. However, tissues with >50% positive PR expression were demonstrated to have a higher CR rate compared with those with ≤50% positive PR expression in both the EEC and AH groups. Furthermore, the PAX2-positive group tended to demonstrate higher CR rates compared with the PAX2-negative group in the patients with EEC. In conclusion, these data suggested that fertility-sparing therapy is effective for patients with EEC and AH who wish to remain fertile after treatment. Specifically, in the AH group, a higher proportion of patients achieved a CR whilst also achieving this more rapidly. Furthermore, PR was demonstrated to be a useful marker for the evaluation of EEC and AH.

Cancer of the corpus uteri: 2021 update

Endometrial cancer is the most common gynecological malignancy in high‐ and middle‐income countries. Although the overall prognosis is relatively good, high‐grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Since The Cancer Genome Atlas defined four molecular subgroups of endometrial cancers, the molecular factors are increasingly used to define prognosis and treatment. Standard treatment consists of hysterectomy and bilateral salpingo‐oophorectomy. Lymphadenectomy (and increasingly sentinel node biopsy) enables identification of lymph node‐positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant therapy is used for Stage I–II patients with high‐risk factors and Stage III patients; chemotherapy is especially used in non‐endometrioid cancers and those in the copy‐number high molecular group characterized by TP53 mutation. In advanced disease, a combination of surgery to no residual disease and chemotherapy with or without radiotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease‐free interval.

The latest state‐of‐the‐art treatment for endometrial cancer is described, incorporating the most recent new data that influence its clinical management.

Molecular characterization in the prediction of disease extent in endometrial carcinoma

OBJECTIVE

Patients with endometrial carcinoma are usually triaged to staging lymphadenectomy selectively based on estimated risk of lymphatic spread. The risk is generally assessed by the presence of uterine risk factors, but their preoperative and intraoperative identification remain a challenge. The objective of this study was to assess the capability of molecular classification, described by The Cancer Genome Atlas (TCGA), to predict the stage of endometrial carcinoma.

STUDY DESIGN

Sequencing of polymerase-ε (POLE) and immunohistochemistry of mismatch repair (MMR) proteins and p53 were performed to stratify endometrial carcinomas into subgroups of POLE exonuclease domain mutation (EDM), MMR deficiency, abnormal p53 (p53 abn) and 'no specific molecular profile' (NSMP). NSMP was the reference subgroup for comparisons. Associations of molecular subgroups and uterine risk factors with stage were examined in univariable and multivariable analyses.

RESULTS

Six hundred and four patients were included in the study. None of the POLE EDM tumours extended beyond the uterine cervix. In an unadjusted analysis, p53 abn was associated with increased risk for stage IIIC-IV disease [odds ratio (OR) 4.6, 95% confidence interval (CI) 2.3-9.2; p < 0.0005]. When controlling for uterine risk factors (histotype and grade, depth of myometrial invasion, tumour size, lymphovascular space invasion), p53 was not an independent predictor of advanced disease. In contrast, POLE EDM independently predicted local disease (OR 0.12, 95% CI 0.015-0.99; p = 0.049 for stage II-IV cancer). Of the molecular subgroups, p53 abn was most strongly associated with the presence of high-risk uterine factors (ORs between 2.2 and 19; p ≤ 0.010).

CONCLUSION

Of the TCGA-based molecular subgroups, POLE EDM independently predicted early-stage endometrial carcinoma. Although p53 abn was not an independent predictor of advanced disease, its association with uterine risk factors could allow utilization of molecular data in deciding the type of staging surgery if knowledge of uterine factors is deficient.

Multiparametric MRI-Based Radiomics Nomogram for Predicting Lymphovascular Space Invasion in Endometrial Carcinoma

BACKGROUND

Lymphovascular space invasion (LVSI) of endometrial carcinoma (EMC) is one of the important prognostic factors, which is not usually visible subjectively. Therefore, clinicians lack imaging-based evidence about LVSI for preoperative treatment decision-making.

PURPOSE

To develop a multiparametric MRI (mpMRI)-based radiomics nomogram for predicting LVSI in EMC and provide decision-making support to clinicians.

STUDY TYPE

Retrospective.

POPULATION

In all, 144 patients with histologically confirmed EMC, 101 patients in a training cohort, and 43 patients in a test cohort.

FIELD STRENGTH/SEQUENCE

T₂ WI, contrast enhanced-T₁ WI, and diffusion-weighted imaging (DWI) at 3.0T MRI.

ASSESSMENT

Tumors were independently segmented images by two radiologists. Two pathologists reviewed the tissue specimens of the tumors to identify the existence of LVSI in consensus.

STATISTICAL TESTS

The intraclass correlation coefficient was used to test the reliability and least absolute shrinkage and selection operator (LASSO) regression for features selection and then developed a radiomics signature named Rad-score. A nomogram was developed in the training cohort. The diagnostic performance of the nomogram model was assessed by area under the curve (AUC) of the receiver operator characteristic (ROC) in the training and test cohort, respectively.

RESULTS

LVSI was identified in 32 patients (22.2%). Older age and high grade were correlated with LVSI at univariate analysis. There were five radiomics features that were identified as independent risk factors for LVSI by LASSO regression. Based on age, grade, and Rad-score, the AUC values of the nomogram model to predict LVSI in the training and test cohort were 0.820 (95% confidence interval [CI]: 0.725, 0.916; sensitivity: 82.6%, specificity: 72.9%), 0.807 (95% CI: 0.673, 0.941; sensitivity: 77.8%, specificity: 78.6%), respectively.

DATA CONCLUSION

The radiomic-based machine-learning model using a nomogram algorithm achieved high diagnostic performance for predicting LVSI of EMC preoperatively, which could enhance risk stratification and provide support for therapeutic decision-making.

LEVEL OF EVIDENCE

2.

TECHNICAL EFFICACY STAGE

3. J. Magn. Reson. Imaging 2020;52:1257-1262.

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

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

Prognostic significance of lymphovascular space invasion in low-risk endometrial cancer

Objective

The purpose of this study was to assess the prognostic significance of lymphovascular space invasion in women with low-risk endometrial cancer.

Methods

A dual-institutional, retrospective department database review was performed to identify patients with ‘low-risk endometrial cancer’ (patients having <50% myometrial invasion with grade 1 or 2 endometrioid endometrial cancer according to their final pathology reports) at two gynecologic oncology centers in Ankara, Turkey. Demographic, clinicopathological and survival data were collected.

Results

We identified 912 women with low-risk endometrial cancer; 53 patients (5.8%) had lymphovascular space invasion. When compared with lymphovascular space invasion-negative patients, lymphovascular space invasion-positive patients were more likely to have post-operative grade 2 disease (p<0.001), deeper myometrial invasion (p=0.003), and larger tumor size (p=0.005). Patients with lymphovascular space invasion were more likely to receive adjuvant therapy when compared with lymphovascular space invasion-negative women (11/53 vs 12/859, respectively; p<0.001). The 5-year recurrence-free survival rate for lymphovascular space invasion-positive women was 85.5% compared with 97.0% for lymphovascular space invasion-negative women (p<0.001). The 5-year overall survival rate for lymphovascular space invasion-positive women was significantly lower than that of lymphovascular space invasion-negative women (88.2% vs 98.5%, respectively; p<0.001). Age ≥60 years (HR 3.13, 95% CI 1.13 to 8.63; p=0.02) and positive lymphovascular space invasion status (HR 6.68, 95% CI 1.60 to 27.88; p=0.009) were identified as independent prognostic factors for decreased overall survival.

Conclusions

Age ≥60 years and positive lymphovascular space invasion status appear to be important prognostic parameters in patients with low-risk endometrial cancer who have undergone complete surgical staging procedures including pelvic and para-aortic lymphadenectomy. Lymphovascular space invasion seems to be associated with an adverse prognosis in women with low-risk endometrial cancer; this merits further assessment on a larger scale with standardization of the lymphovascular space invasion in terms of presence/absence and quantity.

Cancer of the corpus uteri

Endometrial cancer is the most common gynecological malignancy in high-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Standard treatment consists of hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy (with ongoing studies of sentinel node biopsy) enables identification of lymph node positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant radiotherapy is used for Stage I-II patients with high-risk factors and Stage III lymph node negative patients. In advanced disease, a combination of surgery to no residual disease and chemotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease-free interval.

Prognostic Significance of Lymphovascular Space Invasion in the Absence of Lymph Node Metastases in Early-Stage Endometrial Cancer

Objective

Lymphovascular space invasion (LVSI) has been defined as a significant adverse prognostic factor in early-stage endometrial cancer, primarily because of its high association with nodal metastases. This study aimed to determine if LVSI provides any prognostic significance in pathologic node-negative surgically staged (T1N0) endometrial cancer patients.

Methods/Materials

This retrospective cohort study included all patients with pathologic stage T1N0 endometrial carcinoma treated at The Ottawa Hospital Cancer Centre from 1998 to 2007. Patient demographics, pathologic findings, treatment, and outcome data were collected. Univariate and multivariate cox regression modeling was used to assess significance and adjust for demographic and histopathologic covariates. Kaplan-Meier curves were used to estimate the 5-year overall and recurrence-free survival.

Results

Our study included 400 pathologic stage T1N0 patients who received an initial total hysterectomy and bilateral salpingo-oophorectomy with lymphadenectomy. The median age at diagnosis was 62 years, and the median follow-up was 66 months. Fifty-four patients (13.5%) had a positive LVSI status, and 346 (86.5%) had a negative LVSI status. The 5-year overall survival was 97.3% in patients without LVSI and 90.9% in those with LVSI (P < 0.001). The 5-year recurrence-free survival was 95.2% in patients without LVSI and 85.9% in those with LVSI (P = 0.006). Univariate analysis identified grade, stage, and LVSI as the covariates significantly associated with time to recurrence, and identified age, grade, stage, and LVSI to be significantly associated with overall survival. There were no significant covariates for recurrence-free survival by multivariate analysis, and only age and LVSI were significant for overall survival.

Conclusions

Lymphovascular space invasion is an overall poor prognostic factor in T1N0 endometrial cancer. After adjusting for other factors, LVSI remains an independent risk factor for worse overall survival. Therefore, estimation of overall survival in patients with early-stage, node-negative endometrial cancer should take into account LVSI status.

Retrospective Analysis of Intravaginal Brachytherapy in Adjuvant Treatment of Early Endometrial Cancer

The aim of this study was to determine the role of adjuvant endovaginal brachytherapy HDR (High Dose Rate) or observation, as well as identification of risk factors of tumor recurrence. The study included 178 women after radical hysterectomy. All patients belonged to the group of low- and medium-risk stage I FIGO. Analysis consisted of 3-, 5-, and 10-year OS, DFS, and LRFS in both groups. Follow-up was more than 6.5 years. The 5-OS, 5-DFS, and 5-LRFS were 93%, 96%, and 98% in the treated group and 95%, 94%, and 96% in the observed group, respectively. These differences were not statistically significant. There was a statistically significant difference in 5-OS in the treated group, between low- and medium-risk subgroups (100% versus 87.55%, p = 0.018). There was a better prognosis among the patients with FIGO IA compared to FIGO IB (5-DFS, 97 versus 86%, p = 0.047). Among the risk factors, there were only statistically significant differences in the 5-OS, between the ages of ≤ 70 years and >70 years. Use of brachytherapy may affect the reduction in the number of local recurrences at the vaginal stump (6% versus 2%). This is particularly noticeable in the low-risk subgroup (9% versus 0%).

Lymphovascular Space Invasion for Endometrial Cancer: Undertreatment and Overtreatment Risks: A Survey of the Spanish Gynecologic Oncology Group

OBJECTIVE

The purpose of this study is to asses the impact of lymphovascular space invasion (LVSI) present in early-stage endometrial cancer, regarding its therapeutic management and prognosis knowledge, based on a survey among Spanish oncologic gynecologist.

METHODS/MATERIALS

Between October and November 2014, the Young Spanish Onco-gynecologist Group carried out a survey to perform a cross-sectional study about the management of LVSI. All active members in the oncology field of the Spanish Society of Gynecology and Obstetrics were invited to participate in the survey.

RESULTS

Most respondents consider LVSI a bad prognosis factor for endometrial cancer (66%) and also consider that it should be included in the International Federation of Gynecology and Obstetrics classification (56%). Seventy-five percent of all gynecologists did not modify their surgical treatment. Regarding follow-up, 38% of the respondents do not change their surveillance, 28% modify it, and 31% reported any change only with additional factors. Forty-seven percent of respondents advise systemic treatment with chemotherapy.Data were dichotomized between less than or equal to 20 versus greater than 20 years of OB-GYN specialist and less than or equal to 5 versus greater than 5 years of main dedication to gynecology oncology, but it was not possible to show any significant differences among the groups. The response rate (34 individuals) was too low to expect any significant differences.

CONCLUSIONS

Results suggest that LVSI remains a controversial issue in the management of patients with endometrial cancer. Acquiring a deeper knowledge and uniform criteria could avoid the risk of undertreatment and overtreatment in this group of patients with early-stage endometrial cancer. The identification of vascular pseudoinvasion is recommended, although the clinical and prognostic implications still need to be determined.

Survey of Current Practice Patterns in the Treatment of Early-Stage Endometrial Cancer

OBJECTIVES

Our aim was to assess current surgical practices and use of adjuvant therapy in the treatment of FIGO (International Federation of Gynecology and Obstetrics) stage I endometrioid endometrial cancer.

METHODS

A 19-question survey was developed and sent to all Society of Gynecologic Oncologist members by e-mail. Data were collected anonymously using Internet-based survey software. Respondents were asked questions regarding preoperative evaluation, surgical approach, lymph node dissection (LND), and adjuvant therapy.

RESULTS

A total of 1399 surveys were distributed, 320 (23%) members completed the survey. Ninety-seven percent of respondents were gynecologic oncologists or fellows, and 87% treat 30 or more endometrial cancer patients yearly. Respondents were more likely to order preoperative tests such as computed tomography abdomen/pelvis and CA-125 for biopsy-proven grade 3 disease versus grade 1 (82% vs 29%). Robot-assisted laparoscopy was the preferred surgical approach (66%), followed by conventional laparoscopy (21%). Twenty-six percent of respondents perform LND in all cases. Forty-eight percent describe their LND as complete, to the level of the inferior mesenteric artery. Adjuvant therapy was recommended more often with increasing myometrial invasion, tumor grade, and lymphovascular space invasion. Vaginal brachytherapy was the most commonly recommended adjuvant therapy for stage IA. For stage IB, grade 3, positive lymphovascular space invasion disease, respondents were more likely to combine vaginal brachytherapy with external beam radiotherapy and/or chemotherapy. Older patients were more likely to have adjuvant therapy in earlier stages of disease than younger patients.

CONCLUSIONS

Our findings demonstrate that respondents are individualizing care based on preoperative, intraoperative, and pathologic findings. As expected, adjuvant treatment is recommended for patients with higher stage and grade disease. Robot-assisted hysterectomy and chemotherapy are now commonly used in the management of this disease. We anticipate that new trends will continue to emerge as results from additional studies become available.

L1 Cell Adhesion Molecule as a Predictor of Disease-Specific Survival and Patterns of Relapse in Endometrial Cancer

Objective

The aim was to study the association of L1 cell adhesion molecule (L1CAM) expression with the outcome of patients with endometrial cancer, especially with regard to conventional risk variables, and to compare the patterns of relapse in L1CAM-positive and -negative cancers.

Methods

This was a retrospective study of 805 women. The Kaplan–Meier method and univariate and multivariate Cox regression models were applied for survival analyses. Missing data were replaced using multiple imputation. The median follow-up time was 51 months (range, 1–98).

Results

One hundred twenty-one (15.0%) cases were L1CAM positive. L1CAM positivity was associated with high stage (I vs II–IV) (odds ratio [OR], 2.3), lymph node involvement (OR, 2.9), poor differentiation (OR, 6.1), non-endometrioid histology (OR, 9.9), lymphovascular space invasion (OR, 2.8), cervical stromal invasion (OR, 1.8), positive peritoneal cytology (OR, 4.1), and age older than 65 years (OR, 2.8). The frequencies of deep myometrial invasion (50% or deeper), tumor size 2 cm or greater, and body mass index 30 kg/m2 or greater were not significantly different between L1CAM-positive and -negative cases. L1CAM predicted poor disease-specific survival in endometrioid (P < 0.0001) but not in non-endometrioid carcinomas (P = 0.934). The negative impact of L1CAM on outcome was confirmed in a Cox multivariate disease-specific survival analysis. Univariate survival analyses in the different ESMO–ESGO–ESTRO endometrial cancer risk groups showed an association between L1CAM positivity and poor outcome in intermediate (hazard ratio, 12) and high-risk advanced metastatic (hazard ratio, 2.0) groups. Extra-abdominal relapses were more frequent in L1CAM-positive (13.2%) than L1CAM-negative (1.9%) stage I endometrioid carcinomas (P < 0.0001), whereas other site-specific relapses in local cancers were L1CAM independent.

Conclusions

L1CAM is associated with the occurrence of poor prognostic variables and predicts advanced disease in endometrial cancer. L1CAM predicts extra-abdominal relapses and poor survival in endometrioid endometrial cancer, but seems not to be a prognostic factor in non-endometrioid carcinomas.

External validation of non-imaging models for predicting distant metastasis in patients with endometrial cancer

OBJECTIVE

To evaluate two non-imaging models designed to predict distant metastasis (stages IIIC-IV) in endometrial carcinoma (EC). Both used preoperative histological and biological findings. One used primary tumoral size, the other did not.

METHODS

374 patients operated on for EC by hysterectomy and at least bilateral pelvic lymphadenectomy were included. Patient's characteristics, preoperative histological, biological findings and primary tumoral size were used to calculate for each patient two scores (one for each model) for distant metastasis. The accuracy of the models was evaluated in terms of areas under the receiver operating characteristic curves (AUCs), rates of false negatives, and number of patients in the group at low risk to predict stages IIIC-IV.

RESULTS

309 and 65 patients had FIGO stages IA-IIIB and IIIC-IV respectively. Thrombocytosis and leukocytosis were not significantly different between patients who had distant metastasis and those who did not. CA125 serum level was significantly higher in patients who had distant metastasis (71.2 vs 32.0U/mL, p<0.001). High-risk preoperative histology and primary tumor diameter >3cm were more frequently observed in patients who had distant metastasis (55.4% and 39.9%, p=0.02 and 21.3% and 8.5%, p=0.003). The AUC were 0.65 [0.63-0.67] and 0.68 [0.63-0.67] with 54% and 93.4% sensitivity, 64% 19.1% specificity. Two hundred and twenty nine patients (61.2%) and 62 (17.0%) were classified as low risk; among them, 30 patients (13.2%) and 4 (6.4%) had final stage IIIC or IV.

CONCLUSION

Both models turned out to have a low discrimination power in our population. However, the score using primary tumoral size permits to identify a subgroup of patients in whom metastatic probability is low and lymphadenectomy unnecessary. Preoperative CA125 level, histological findings and primary tumoral size remain prognostic factors of stages IIIC-IV and should be included in predictive models.

[How were used recommendations for endometrial carcinoma? Britain retrospective study]

OBJECTIVE

To assess the use of French Cancer Institute recommendations for the diagnosis and treatment of endometrial cancer.

METHODS

Retrospective observational study involving 137 patients with endometrial cancer between 2011 and 2013.

RESULTS

Both MRI and pathological assessment with correct report as recommended were used for 66.4% of patients with endometrial cancer. For patients with correct preoperative assessment, 44.9% of patients were uncorrectly classified and upgraded on final pathological analysis of hysterectomy concerning lymph node involvement risk. These patients did not have confident surgical assessment, according this risk.

CONCLUSION

To improve relevance of preoperative assessment in endometrial cancer, radiological and pathological expertise is required. However, even performed optimally, preoperative assessment does not allow correct risk stratification of lymph node involvement in endometrial cancer. This ineffective stratification leads to propose sentinel lymph node biopsy with hysterectomy in case of preoperative low risk endometrial cancer assessment.

Managing Endometrial Cancer: The Role of Pelvic Lymphadenectomy and Secondary Surgery

PURPOSE

In November 2010, the French National Cancer Institute published new guidelines for managing endometrial cancer. Pelvic lymphadenectomy is not indicated for preoperative low-intermediate risk type 1 endometrial cancer, and high-risk patients should undergo secondary surgery with para-aortic lymphadenectomy. This study evaluated these new guidelines with regard to overall survival (OS), relapse-free survival (RFS), and morbidity for patients with low-intermediate risk disease.

METHODS

We evaluated all type 1 endometrial cancer patients with low-intermediate risk of recurrence who were treated from 1 January 1997 through 31 December 2012. All patients were classified according to the 2009 International Federation of Gynecology and Obstetrics staging criteria and the European Society for Medical Oncology.

RESULTS

Overall, 230 patients were included (159 before and 71 after the new guidelines were issued). Pelvic lymphadenectomies were performed before and after the new guidelines in 77.4 and 28.6 % of patients, respectively (p < 0.001). After 2010, eight patients also underwent secondary surgery, which consisted of a para-aortic lymphadenectomy for lymphovascular space invasion (LVSI). This second surgery changed the adjuvant treatment for one patient. OS and RFS were similar between both groups, and no difference in morbidity was observed between the groups. LVSI was an independent factor for OS [hazard ratio (HR) 7.2, 95 % CI 3.1-17; p < 0.001] and RFS (HR 3.7, 95 % CI 1.6-8.5; p < 0.003).

CONCLUSIONS

Fewer pelvic lymphadenectomies in low-intermediate risk patients did not affect OS, RFS, or morbidity, including patients with secondary surgery. We must gather additional data with a longer follow-up period to not only confirm our results but to also fully investigate the paradoxical absence of decreased morbidity that our study has shown.

Extracellular matrix metalloproteinase inducer and matrix metalloproteinase-2 overexpression is associated with loss of hormone receptor expression and poor prognosis in endometrial cancer

Extracellular matrix metalloproteinase inducer (CD147) and matrix metalloproteinase-2 (MMP-2) have been documented in various malignancies. CD147 is a member of the immunoglobulin superfamily, which promotes the production and release of MMPs in mesenchymal cells and tumor cells. MMP-2 has been extensively studied and is considered to be particularly important in cancer invasion and metastasis. However, studies investigating the expression and prognostic value of CD147 in endometrioid endometrial carcinoma (EEC) are limited. The present study analyzed the expression of CD147 and MMP-2 by immunohistochemistry in endometrial tissue samples from 107 patients with EEC and 30 patients with benign uterus myoma. The association between CD147 and MMP-2 expression and clinicopathological characteristics was evaluated. The results showed that the overexpression of MMP-2 was significantly associated with International Federation of Gynecology and Obstetrics stage (P=0.007), depth of invasion (P=0.037) and reduced expression of progesterone receptor (P=0.005). Kaplan-Meier analyses indicated that CD147 overexpression alone (P<0.05 for disease-specific survival) or in combination with MMP-2 (P<0.001 for disease-specific survival) was correlated with adverse prognosis in EEC patients. Multivariate analysis revealed that the combined overexpression of CD147 and MMP-2 was an independent prognostic factor for disease-specific survival (hazard ratio=5.141, P=0.001) in EEC patients. CD147 and MMP-2 overexpression was positively correlated with aggressive phenotypic features in EEC, however it was negatively correlated with hormone receptor expression. The combination of CD147 and MMP-2 overexpression in EEC further distinguished a subgroup of patients with poor prognosis. Thus, the results of present study indicate that the co-expression of CD147 and MMP-2 may be an independent prognostic factor in EEC patients.

The Incidence and Clinical Significance of the Micrometastases in the Sentinel Lymph Nodes During Surgical Staging for Early Endometrial Cancer

Introduction

The status of regional node remains one of the most important factors to guide adjuvant therapy in endometrial cancer (EC). Pelvic recurrence occurs in up to 15% of early EC patients with negative pelvic lymph nodes (LNs). The prognostic significance of detecting micrometastases (μM) in LN is debated. This retrospective case-control study performed in the Oncological Gynecology Department in Lyon between December 1998 and June 2012 reports the incidence and the clinical significance of μM detected during ultrastaging of negative sentinel lymph node (SLN) in EC.

Patients and Methods

Ninety-three patients affected by type I and II EC were submitted to surgery with SLN. Dual-labeling method was used to detect SLN. All the SLNs were subjected to ultrastaging researching μM. The patients with a locoregional or distant relapse represented the case-series (CS). The patients without locoregional or distant recurrences were the case-controls (CC).They were matched (1:2 ratio) according to age, International Federation of Gynecology and Obstetrics stage, and histopathologic features.

Results

Ten patients presenting a relapse represented CS. In the remaining 83 patients without recurrence, 20 CC were individualized. The detection rate of SLN per hemipelvis was of 17 (85%) of 20 hemipelvis and of 33 (82.5%) of 40 hemipelvis for CS and CC, respectively. Two SLN of CS arm were positives at frozen section. One of the 8 patients of CS arm with negative SLNs was positive for μM by immunohistochemistry analysis.

Conclusions

Lymph node status is one of the most important histopathologic features to determine the adjuvant treatment. The SLN technique could be proposed in selected patients affected by early EC. The μM in SLN could be researched and could help to modulate the following treatment. The multicenter study must be performed to clarify the optimal method of research of SLN in EC and the significance of μM in the LN.

Staging for endometrial cancer: The controversy around lymphadenectomy - Can this be resolved?

Endometrial cancer remains the most common malignancy of the female genital tract. Lymph node metastasis is one of the most important prognostic factors, and stratification into pelvic lymph node invasion (stage IIIC1) and para-aortic lymph node invasion (stage IIIC2) improved the predictive value of the 2009 International Federation of Gynecology and Obstetrics (FIGO) classification. Radiological examination methods such as magnetic resonance imaging and positron emission tomography-computed tomography do not have good-enough sensitivity to avoid lymphadenectomy for the assessment of lymph node invasion. Prediction scores are becoming increasingly valuable to exclude lymph node metastasis in low-risk groups, and biomarkers could help to identify patients with high-risk lymph node metastatic probability. The therapeutic role of lymph node dissection remains a matter of debate. Several end points can be considered to evaluate the opportunity of lymphadenectomy in endometrial cancer. First, we compare survival according to the realization, the extent, and the numbers of nodes removed during lymphadenectomy. Second, we assess the opportunity of lymphadenectomy in order to tailor adjuvant treatment modalities. Third, we analyze the surgical complication rate after pelvic lymphadenectomy.

Relevance of sentinel lymph node procedure for patients with high-risk endometrial cancer

OBJECTIVE

While the accuracy of the Sentinel Lymph Node (SLN) procedure has been validated in patients with early-stage endometrial cancer (EC) at low and intermediate risk of recurrence, its relevance for high-risk EC remains unknown. The aim of this study was to evaluate the contribution of SLN biopsy in staging patients with presumed high-risk EC.

METHODS

This retrospective multicenter study, conducted from January 2001 to December 2012, included 180 patients with early-stage EC undergoing SLN biopsy. Detection rate and false negative rate were assessed according to risk groups of recurrence.

RESULTS

SLNs were detected in 159/180 patients (88%) and were bilateral in 63% of cases. Of the 180 patients, 41 (22%) had a positive lymph node. Ultrastaging detected metastases undiagnosed by conventional histology in 17/41 patients (41%). The false negative rate was 6% (9/159); 2.3% in the low/intermediate risk group and 20% in the high-risk group (p = 0.0008). Lymphovascular space invasion (LVSI) was present in 48 patients (27%). Preoperative findings classified 146 patients as ESMO low/intermediate risk (81%) and 34 as high risk (19%). Ten of the 34 patients (29%) in the presumed high-risk group were downstaged on final histology and 5/18 patients (28%) initially diagnosed with type 2 were finally classified as having type 1 EC. Classification was more likely discordant for patients with preoperative type 2 EC (p = 0.03) and in the initial high-risk group (p = 0.02).

CONCLUSIONS

SLN biopsy associated with LVSI status can select which high-risk patients with EC would benefit from comprehensive staging.