Women at extreme risk for obesity-related carcinogenesis: Baseline endometrial pathology and impact of bariatric surgery on weight, metabolic profiles and quality of life

Does weight loss in women with obesity induce regression of endometrial hyperplasia? A systematic review

Obesity is a leading risk factor for endometrial cancer and its precursor, endometrial hyperplasia (EH). Currently, weight loss is recommended for people with EH and obesity, but evidence to guide weight management as primary or adjunctive therapy is limited. This systematic review aims to assess the role of weight loss in inducing histopathological regression of EH in women with obesity. A systematic search of Medline, PubMed, Embase and The Cochrane Library databases was conducted in January 2022. Studies reporting on participants with EH who underwent weight loss interventions, incorporating comparisons of pre- and post-intervention histology, were included. Studies were limited to those published in English with full text available. Six studies met the inclusion criteria, all of which reported outcomes after bariatric surgery. Three studies reported outcomes for the same group of participants, therefore only one outcome set was included. Pre-operative endometrial biopsy results were available for 167 women, and 81 had post-operative biopsies reported. Nineteen women (11.4% of those biopsied) had EH pre-operatively; 17 underwent repeat sampling post-operatively. Twelve (71%) had complete histological resolution, 1 (6%) had partial regression from complex hyperplasia to simple hyperplasia, 1 (6%) had persistent atypical hyperplasia, and 3 (18%) had persistent simple hyperplasia. One patient with a normal pre-intervention biopsy had simple hyperplasia post-operatively. Due to poor quality and overall scarcity of data, the role of weight loss in the primary or adjunctive treatment of EH is unknown. Future studies should prospectively assess weight loss modalities and targets, as well as use of concurrent therapies.

The impact of microbially modified metabolites associated with obesity and bariatric surgery on antitumor immunity

Obesity is strongly associated with the occurrence and development of many types of cancers. Patients with obesity and cancer present with features of a disordered gut microbiota and metabolism, which may inhibit the physiological immune response to tumors and possibly damage immune cells in the tumor microenvironment. In recent years, bariatric surgery has become increasingly common and is recognized as an effective strategy for long-term weight loss; furthermore, bariatric surgery can induce favorable changes in the gut microbiota. Some studies have found that microbial metabolites, such as short-chain fatty acids (SCFAs), inosine bile acids and spermidine, play an important role in anticancer immunity. In this review, we describe the changes in microbial metabolites initiated by bariatric surgery and discuss the effects of these metabolites on anticancer immunity. This review attempts to clarify the relationship between alterations in microbial metabolites due to bariatric surgery and the effectiveness of cancer treatment. Furthermore, this review seeks to provide strategies for the development of microbial metabolites mimicking the benefits of bariatric surgery with the aim of improving therapeutic outcomes in cancer patients who have not received bariatric surgery.

Glucose metabolic reprogramming and its therapeutic potential in obesity-associated endometrial cancer

Endometrial cancer (EC) is a common gynecological cancer that endangers women health. Although substantial progresses of EC management have been achieved in recent years, the incidence of EC still remains high. Obesity has been a common phenomenon worldwide that increases the risk of EC. However, the mechanism associating obesity and EC has not been fully understood. Metabolic reprogramming as a remarkable characteristic of EC is currently emerging. As the primary factor of metabolic syndrome, obesity promotes insulin resistance, hyperinsulinemia and hyperglycaemia. This metabolic disorder remodels systemic status, which increases EC risk and is related with poor prognosis. Glucose metabolism in EC cells is complex and mediated by glycolysis and mitochondria to ensure energy requirement. Factors that affect glucose metabolism may have an impact on EC initiation and progression. In this study, we review the glucose metabolic reprogramming of EC not only systemic metabolism but also inherent tumor cell metabolism. In particular, the role of glucose metabolic regulation in malignant properties of EC will be focused. Understanding of metabolic profile and glucose metabolism-associated regulation mechanism in EC may provide novel perspective for treatment.

Metabolic disorders sensitise endometrial carcinoma through endoplasmic reticulum stress

BACKGROUND

Metabolic disorder is considered a well-established risk factor for endometrial carcinoma (EC). However, the mechanism remains unclear. Insulin resistance and excessive flux of free fatty acids serve as fundamental pathogenic factors in metabolic disorders, including obesity and type 2 diabetes. The aim of this study was to test the correlation between insulin resistance and dyslipidaemia in EC and to determine the effect of insulin and saturated fatty acids on EC cells.

METHODS

A retrospective study on the medical records of patients with EC and RNA-seq from the TCGA database analysed with edgR and Gene Ontology (GO) were used to assess the correlation of dyslipidaemia and diabetes as well as obesity. Crystal violet assays and CCK-8 assays were used to detect the proliferation of EC cells, and Annexin V-PI was used to examine apoptosis. Transient changes in mitochondrial Ca²⁺ and reactive oxygen species (ROS) were monitored via confocal microscopy. DNA damage was assessed by comet assays. Changes in signalling pathways were detected via phospho-kinase array. western blotting was used to assess the molecular changes in endoplasmic reticulum (ER) stress and DNA damage.

RESULTS

We found that glucose metabolism disorders accompanied dyslipidaemia in patients with EC. As a key regulator of glucose metabolism disorders, insulin promoted DNA damage, ROS and Ca²⁺ homoeostasis imbalance in a panel of established EC cell lines. Interestingly, excessive insulin boosted saturated fatty acid-induced pro-apoptotic effects in EC cells. Furthermore, our data showed that insulin synergised with saturated fatty acids to activate the mechanistic target of rapamycin kinase/70 kDa ribosomal protein S6 kinase (mTOR/p70S6K) pathway and ER stress, resulting in Ca²⁺ release from ER and unfolded protein response (UPR) activation, which contributed to combined insulin and saturated fatty acid treatment-induced apoptosis and tumour progression.

CONCLUSIONS

Our data are the first to illustrate that impaired glucose metabolism accelerates dyslipidaemia-promoted EC progression, which is attributed to hyperinsulinaemia and saturated fatty acid-induced Ca²⁺ dyshomoeostasis and UPR activation in EC cells via ER stress.

Endometrial Hyperplasia

The objectives of this Clinical Expert Series on endometrial hyperplasia are to review the etiology and risk factors, histologic classification and subtypes, malignant progression risks, prevention options, and to outline both surgical and nonsurgical treatment options. Abnormal uterine and postmenopausal bleeding remain the hallmark of endometrial pathology, and up to 10-20% of postmenopausal bleeding will be either hyperplasia or cancer; thus, immediate evaluation of any abnormal bleeding with either tissue procurement for pathology or imaging should be undertaken. Although anyone with a uterus may develop atypical hyperplasia, also known as endometrial intraepithelial neoplasia (EIN), genetic predispositions (eg, Lynch syndrome), obesity, chronic anovulation, and polycystic ovarian syndrome all markedly increase these risks, whereas use of oral contraceptive pills or progesterone-containing intrauterine devices will decrease the risk. An EIN diagnosis carries a high risk of concomitant endometrial cancer or eventual progression to cancer in the absence of treatment. The definitive and curative treatment for EIN remains hysterectomy; however, the obesity epidemic, the potential desire for fertility-sparing treatments, the recognition of varying rates of malignant transformation, medical comorbidities, and an aging population all may factor into decisions to employ nonsurgical treatment modalities.

Gut Microbes in Gynecologic Cancers: Causes or Biomarkers and Therapeutic Potential

The human intestine is home to a variety of microorganisms. In healthy populations, the intestinal flora shares a degree of similarity and stability, and they have a role in the metabolism, immunological response, and physiological function of key organs. With the rapid advent of high-throughput sequencing in recent years, several researchers have found that dysbiosis of the human gut microflora potentially cause physical problems and gynecological malignancies among postmenopausal women. Besides, dysbiosis hinders tumor treatment. Nonetheless, the importance of maintaining homeostatic gut microbiota and the effective use of probiotics in the treatment of gynecological malignancies should not be disregarded. Moreover, intestinal flora regulation and the involvement of probiotics as well as associated biologically active substances in gynecological malignancies could be an adjuvant treatment modality related to surgery and chemoradiotherapy in the future. Herein, this article aims to review the potential relationship between gut microorganisms and postmenopausal status as well as gynecologic malignancies; then the relationship between gut microbes and early screening as well as therapeutic aspects. Also, we describe the role of probiotics in the prevention, treatment, and prognosis of gynecologic malignancies.

Perinatal outcomes after bariatric surgery

BACKGROUND

Bariatric surgery is a widely used treatment option for obesity that often provides long-term weight control and health benefits. Although a growing number of women are becoming pregnant after bariatric surgery, only a few population-based studies have assessed the impact thereof on perinatal outcomes.

OBJECTIVE

This study aimed to examine the association between bariatric surgery and adverse perinatal outcomes in pregnant women and to examine whether the risk for adverse perinatal outcomes is modified by the postsurgery weight, gestational weight gain, type of bariatric surgery, timing of pregnancy after bariatric surgery, and maternal comorbidities.

STUDY DESIGN

A retrospective cohort study was performed with the use of the Bariatric Surgery Registry and hospital inpatient and outpatient physician encounter records. The International Classification of Diseases, Ninth and Tenth Revision codes from hospitalizations during pregnancy and infant birth records were used to ascertain the outcomes of interest. Women eligible for BS who delivered at ≥20 weeks of gestation (n=20,213) at Kaiser Permanente Southern California hospitals (January 1, 2007 to December 31, 2018) were included in the study. Adjusted odds ratios were derived from logistic regression models with inverse probability of treatment weighting to adjust for confounding using propensity scores.

RESULTS

Bariatric surgery was associated with a reduction in the risks for gestational diabetes (adjusted odds ratio, 0.60; 95% confidence interval, 0.53-0.69; P<.001), preeclampsia (adjusted odds ratio, 0.53; 95% confidence interval, 0.46-0.61; P<.001), chorioamnionitis (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63; P<.001), cesarean delivery (adjusted odds ratio, 0.65; 95% confidence interval, 0.59-0.72; P<.001), large for gestational age neonate (adjusted odds ratio, 0.23; 95% confidence interval, 0.19-0.29; P<.001), macrosomia (adjusted odds ratio, 0.24; 95% confidence interval, 0.19-0.30; P<.001), and neonatal intensive care unit admission (adjusted odds ratio, 0.70; 95% confidence interval, 0.61-0.81; P<.001). However, bariatric surgery was also associated with a significantly increased risk for small for gestational age neonates (adjusted odds ratio, 2.46; 95% confidence interval, 2.16-2.79; P<.001). The risk for the adverse outcomes is independent of the time interval between the surgery and subsequent pregnancy.

CONCLUSION

These data suggest that there are many pregnancy outcome benefits for women with severe obesity who undergo bariatric surgery; however, women who have undergone bariatric surgery before pregnancy should be monitored closely to reduce the risk for small for gestational age neonates and postpartum hemorrhage.

Short-term changes in the serum metabolome after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

INTRODUCTION

Bariatric surgery is known to be the most effective treatment for weight loss in obese patients and for the rapid remission of obesity-related comorbidities. These short-term improvements result from not only limited digestion or absorption but also dynamic changes in metabolism throughout the whole body. However, short-term metabolism studies associated with bariatric surgery in Asian individuals have not been reported.

OBJECTIVES

The aim of this study was to investigate the short-term metabolome changes in the serum promoted by laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) and to determine the underlying mechanisms that affect obesity-related comorbidities.

METHODS

Serum samples were collected from Korean patients who underwent RYGB or SG before and 4 weeks after the surgery. Metabolomic and lipidomic profiling was performed using UPLC-Orbitrap-MS, and data were analyzed using statistical analysis.

RESULTS

Metabolites mainly related to amino acids, lipids (fatty acids, glycerophospholipids, sphingolipids, glycerolipids) and bile acids changed after surgery, and these changes were associated with the lowering of risk factors for obesity-related diseases such as nonalcoholic fatty liver disease (NAFLD), type 2 diabetes (T2D) and atherosclerosis. Interestingly, the number of significantly altered metabolites related to the lipid metabolism were greater in SG than in RYGB. Furthermore, the metabolites related to amino acid metabolism were significantly changed only after SG, whereas bile acid changed significantly only following RYGB.

CONCLUSION

These differences could result from anatomical differences between the two surgeries and could be related to the gut microbiota. This study provides crucial information to expand the knowledge of the common but different molecular mechanisms involved in obesity and obesity-related comorbidities affected by each bariatric procedure.

Metabolomics in Bariatric Surgery: Towards Identification of Mechanisms and Biomarkers of Metabolic Outcomes

Bariatric surgery has been widely performed for the treatment of obesity and type 2 diabetes. Efforts have been made to investigate the mechanisms underlying the metabolic effects achieved by bariatric surgery and to identify candidates who will benefit from this surgery. Metabolomics, which includes comprehensive profiling of metabolites in biological samples, has been utilized for various disease entities to discover pathophysiological metabolic pathways and biomarkers predicting disease progression or prognosis. Over the last decade, metabolomic studies on patients undergoing bariatric surgery have identified significant biomarkers related to metabolic effects. This review describes the significance, progress, and challenges for the future of metabolomics in the area of bariatric surgery.

An ecological evaluation of the increasing incidence of endometrial cancer and the obesity epidemic

BACKGROUND

The prevalence of obesity has increased significantly in recent decades, particularly among younger women, and is a known risk factor for endometrial cancer.

OBJECTIVE

This study aimed to evaluate the trend in the prevalence of obesity and the incidence of type I endometrial cancer over time in various age categories to determine whether an ecological relationship exists.

STUDY DESIGN

Data from the Surveillance, Epidemiology, and End Results Program and the National Health and Nutrition Examination Survey were used. The overall trend in the incidence of type 1 endometrial cancer and prevalence of obesity were observed over time from 1988 to 2016 and further categorized by age group (<45, 45-54, and ≥55 years).

RESULTS

The prevalence of obesity has increased for all women, but most significantly for women younger than 45 years with a 16.3% increase among women aged 20 to 34 years and a 17.9% increase for women aged 35 to 44 years. The incidence of endometrial cancer has also increased across all age categories, and although it has increased in patients younger than 45 years by more than 14-fold (from <0.1 per 100,000 in 1988 to 1.4 per 100,000 in 2016), a more pronounced increase of 63-fold and 50-fold was observed among women aged 45 to 54 years (0.2 per 100,000 in 1988 to 12.6 per 100,000 in 2016) and women aged 55 years and older (from 0.6 per 100,000 in 1988 to 30 per 100,000 in 2016), respectively. The mean age of women diagnosed as having endometrial cancer also decreased from 64.1 years from 1988 to 1990 to 61.0 years from 2014 to 2016.

CONCLUSION

The prevalence of obesity has increased significantly in women of all ages. This increase, particularly among women aged <45 years, occurred simultaneously with an increase in the incidence of endometrial cancer in young women, with an even more pronounced increase among women aged ≥45 years.

Fertility-Sparing Treatment for Atypical Endometrial Hyperplasia and Endometrial Cancer: A Cochrane Systematic Review Protocol

INTRODUCTION

Endometrial cancer is the fifth most common cancer in women and atypical endometrial hyperplasia is a precancerous lesion. Obesity is an important risk factor for endometrioid endometrial adenocarcinoma and endometrial hyperplasia. Progesterone is recommended as first-line treatment in endometrial cancer or atypical endometrial hyperplasia in women who wish to preserve fertility, but optimal treatment schedules have not been defined. Metformin or bariatric surgery may also be useful in these women. The effectiveness and safety of fertility-preserving treatments being used for women with atypical endometrial hyperplasia and stage IA grade 1 endometrial cancer is unclear. Therefore, the systematic review aims to determine this point.

METHODS

We will search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registers, conference proceedings, abstracts, cooperative trial groups and reference lists. We will include randomised controlled trials (RCTs) that compare fertility-preserving therapy including orally administered progesterone versus a levonorgestrel-releasing intrauterine system (IUS), metformin, other pharmacological interventions or bariatric surgery, and any of these interventions with womb-removing surgery. Quasi-randomised trials, non-randomised trials and cohort studies will be included. Two review authors will independently assess study eligibility and risk of bias and extract data. The primary outcomes are complete pathologic response and live birth rate. Secondary outcomes include overall survival, progression-free survival, pregnancy rate, need for hysterectomy, adverse events, psychological symptoms and quality of life.

PLANNED OUTCOMES

This review aims to clarify the effectiveness and risks of fertility-preserving treatments, including complete pathologic response rate, live birth rates, need for surgical treatment, adverse events, psychological symptoms and quality of life. The broad scope of the review includes the use of progesterone, metformin to reverse insulin resistance, and bariatric surgery or operative hysteroscopy.

RESULTS

The results may help to determine the optimal fertility-sparing treatment in endometrial cancer and atypical endometrial hyperplasia.

SYSTEMATIC REVIEW REGISTRATION

Prospero 2019 number CRD42019145991.

Preoperative Factors of Endometrial Carcinoma in Patients Undergoing Hysterectomy for Atypical Endometrial Hyperplasia

OBJECTIVE

To identify clinicopathological preoperative factors associated with concurrent endometrial carcinoma in patients undergoing surgical management of atypical endometrial hyperplasia.

METHODS

The records of all patients who underwent hysterectomy for preoperatively diagnosed atypical endometrial hyperplasia at a tertiary care hospital from April 2017 to April 2020 were retrospectively reviewed. Clinicopathological characteristics of patients were extracted. Patients who did not undergo hysterectomy or who had evidence of simple hyperplasia or carcinoma on initial biopsy were excluded. Univariate analysis was performed. A multivariate regression model for progression to endometrial carcinoma was developed.

RESULTS

A total of 126 patients were included. Of these patients, 19 (15.1%) had a final diagnosis of endometrial carcinoma, whereas 86 (68.2%) retained the diagnosis of atypical endometrial hyperplasia and 21 (16.7%) were found to have no residual atypical endometrial hyperplasia. The odds of a patient being diagnosed with endometrial carcinoma were 6.1 times higher (95% CI 1.32-27.68) if they had an endometrial stripe thickness >1.1 cm and 13.5 times higher (95% CI 3.56-51.1) if there was histological suspicion of carcinoma. The odds of a patient being diagnosed with endometrial carcinoma were significantly lower if the patient had an initial diagnosis of atypical endometrial hyperplasia in a polyp (OR 0.07; 95% CI 0.02-0.34).

CONCLUSION

Our results suggest that an endometrial stripe thickness >1.1 cm, a histological suspicion of carcinoma on preoperative pathology, and the absence of polyp involvement on initial diagnosis are the strongest predictors of endometrial carcinoma at the time of hysterectomy in patients with atypical endometrial hyperplasia.

Endometrial biomarkers in premenopausal women with obesity: an at-risk cohort

BACKGROUND

Obesity is a well-known risk factor for endometrial cancer, but the mechanisms of obesity-related carcinogenesis are not well defined, particularly for premenopausal women. With the continuing obesity epidemic, increases in the incidence of endometrial cancer and a younger age of diagnosis are often attributed to a hyperestrogenic state created by hormone production in adipose tissue, but significant knowledge gaps remain. The balance of estrogen-responsive signals has not been defined in the endometrium of premenopausal women with obesity, where obesity may not create hyperestrogenism in the context of ovaries being the primary source of estrogen production. Obesity is associated with a state of low-grade, chronic inflammation that can promote tumorigenesis, and it is also known that hormonal changes alter the immune microenvironment of the endometrium. However, limited research has been conducted on endometrial immune-response changes in women who have an increased risk for cancer due to obesity.

OBJECTIVE

Endometrial estrogen-regulated biomarkers, previously shown to be dysregulated in endometrial cancer, were evaluated in a cohort of premenopausal women to determine if obesity is associated with differences in the biomarker expression levels, which might reflect an altered risk of developing cancer. The expression of a multiplexed panel of immune-related genes was also evaluated for expression differences related to obesity.

STUDY DESIGN

Premenopausal women with a body mass index of ≥30 kg/m² (n=97) or a body mass index of ≤25 kg/m² (n=33) were prospectively enrolled in this cross-sectional study, which included the assessment of serum metabolic markers and a timed endometrial biopsy for pathologic evaluation, hormone-regulated biomarker analysis, and immune response gene expression analysis. Medical and gynecologic histories were obtained. Endometrial gene expression markers were also compared across the body mass index groups in a previous cohort of premenopausal women with an inherited cancer risk (Lynch syndrome).

RESULTS

In addition to known systemic metabolic differences, histologically normal endometria from women with obesity showed a decrease in gene expression of progesterone receptor (P=.0027) and the estrogen-induced genes retinaldehyde dehydrogenase 2 (P=.008), insulin-like growth factor 1 (P=.016), and survivin (P=.042) when compared with women without obesity. The endometrial biomarkers insulin-like growth factor 1, survivin, and progesterone receptor remained statistically significant in multivariate linear regression models. In contrast, women with obesity and Lynch syndrome had an increased expression of insulin-like growth factor 1 (P=.017). There were no differences in endometrial proliferation, and limited endometrial immune differences were observed.

CONCLUSION

When comparing premenopausal women with and without obesity in the absence of endometrial pathology or an inherited cancer risk, the expression of the endometrial biomarkers does not reflect a local hyperestrogenic environment, but it instead reflects a decreased cancer risk profile that may be indicative of a compensated state. In describing premenopausal endometrial cancer risk, it may be insufficient to attribute a high-risk state to obesity alone; further studies are warranted to evaluate individualized biomarker profiles for differences in the hormone-responsive signals or immune response. In patients with Lynch syndrome, the endometrial biomarker profile suggests that obesity further increases the risk of developing cancer.

Obese endometrial cancer survivors' perceptions of weight loss strategies and characteristics that may influence participation in behavioral interventions

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Endometrial cancer (EC) survivors have attempted many methods to lose weight.

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EC survivors rarely choose bariatric surgery, physical therapy, or psychologic support services to lose weight.

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EC survivors without recurrence were more likely to enroll in a weight loss intervention trial than those with recurrence.

We aimed to evaluate obese endometrial cancer (EC) survivors' perceptions of weight loss barriers and previously attempted weight loss methods and to identify characteristics that predicted willingness to enroll in a behavioral intervention trial. We administered a 27-question baseline survey at an academic institution to EC survivors with body mass index ≥ 30 kg/m². Survivors were asked about their lifestyles, previous weight loss attempts, perceived barriers, and were offered enrollment into an intervention trial. Data was analyzed using Fisher’s Exact, Kruskal-Wallis, and univariate and multivariate regressions. 155 of 358 (43%) eligible obese EC survivors were surveyed. Nearly all (n = 148, 96%) had considered losing weight, and 77% (n = 120) had tried two or more strategies. Few had undergone bariatric surgery (n = 5, 3%), psychologic counseling (n = 2, 1%), or met with physical therapists (n = 9, 6%). Lower income was associated with difficulty in accessing interventions. Survivors commented that negative self-perceptions and difficulties with follow-through were barriers to weight loss, and fear of complications and self-perceived lack of qualification were deterrents to bariatric surgery. 80 (52%) of those surveyed enrolled in the trial. In a multivariate model, adjusting for race and stage, survivors without recurrence were 4.3 times more likely to enroll than those with recurrence. Most obese EC survivors have tried multiple strategies to lose weight, but remain interested in weight loss interventions, especially women who have never experienced recurrence. Providers should encourage weight loss interventions early, at the time of initial diagnosis, and promote underutilized strategies such as psychological counseling, physical therapy, and bariatric surgery.

The risk of female-specific cancer after bariatric surgery in the state of New York

BACKGROUND

Obesity is a known risk factor for many cancers. Although bariatric surgery has been associated with a decrease in the risk of developing cancer, data on the effect of bariatric surgery on female-specific cancers are limited. This study aimed to assess the impact of bariatric interventions on the development of endometrial, ovarian and breast cancer.

METHODS

The New York Statewide Planning and Research Cooperative System database was used to identify all female patients without a pre-existing cancer diagnosis who had a diagnosis of obesity between 2006 and 2012. The risk of having female-specific cancer diagnosis in patients who underwent bariatric surgery were compared with those who had no bariatric interventions using multivariable proportional sub-distribution hazard regression analysis. Subsequent cancer diagnoses were followed up to 2016.

RESULTS

We identified 55,781 and 247,102 obese female patients who had and did not have bariatric surgery, respectively. The overall incidence of female-specific cancer was 2.69% and 2.09% for the non-surgery and surgery groups, respectively (p < 0.0001). Surgery patients were less likely to develop female-specific cancers [hazard ratio (HR) 0.78; 95% CI 0.73-0.83; p < 0.0001]. Patients undergoing Roux-en-Y gastric bypass had a lower risk of developing female-specific cancer than laparoscopic sleeve gastrectomy (HR 0.66; 95% CI 0.51-0.87; p = 0.0056) and laparoscopic adjustable gastric banding (HR 0.83; 95% CI 0.69-0.99; p = 0.0056) patients.

CONCLUSIONS

Patients undergoing bariatric surgery have a lower incidence of endometrial, female breast and ovarian cancer than non-surgery obese patients. These data suggest that bariatric interventions may reduce the risk of female-specific cancers.

Amino Acid Metabolites and Slow Weight Loss in the Early Postoperative Period after Sleeve Gastrectomy

Background: Profiles of amino acid metabolites (AAMs) have been linked to obesity and energy homeostasis. We investigated whether baseline obesity-related AAMs were associated with weight status in the early postoperative period after sleeve gastrectomy. Methods: In this prospective, single-arm, longitudinal study, 27 bariatric patients underwent sleeve gastrectomy. Twenty obesity-related AAMs were comprehensively quantified prior to surgery, and slow weight loss was defined as the lowest 40% of the percentage excess weight loss (%EWL) at three and six months postoperatively. Linear regression models were used to assess the association between baseline obesity-related AAMs and %EWL, and receiver operating characteristic curves were assessed. Results: Isoleucine and metabolites from the serotonin pathway were significantly associated with the %EWL at three and six months after sleeve gastrectomy. Among the metabolites identified to be significant in the regression analyses, serotonin (area under receiver operating characteristic curves (AUROC): 0.79, 95% confidence interval (CI): 0.59–0.97) and serotonin/5-hydroxytryptophan ratio (AUROC: 0.80, 95% CI: 0.58–1.00) showed superior performance in predicting slow weight loss six months after sleeve gastrectomy. Conclusions: Our findings underscore the importance of baseline AAM profiles, especially serotonin and serotonin/5-hydroxytryptophan ratio, in predicting slow weight loss in the early postoperative period after sleeve gastrectomy.

Fecal metagenomics and metabolomics reveal gut microbial changes after bariatric surgery

BACKGROUND

Evidence from longitudinal patient studies regarding gut microbial changes after bariatric surgery is limited.

OBJECTIVE

To examine intraindividual changes in fecal microbiome and metabolites among patients undergoing Roux-en-Y gastric bypass or vertical sleeve gastrectomy.

SETTING

Observational study.

METHODS

Twenty patients were enrolled and provided stool samples before and 1 week, 1 month, and/or 3 months after surgery. Shallow shotgun metagenomics and untargeted fecal metabolomics were performed. Zero-inflated generalized additive models and linear mixed models were applied to identify fecal microbiome and metabolites changes, with adjustment for potential confounders and correction for multiple testing.

RESULTS

We enrolled 16 women and 4 men, including 16 white and 4 black participants (median age = 45 years; presurgery body mass index = 47.7 kg/m²). Ten patients had Roux-en-Y gastric bypass, 10 had vertical sleeve gastrectomy, and 14 patients provided postsurgery stool samples. Of 47 samples, median sequencing depth was 6.3 million reads and 1073 metabolites were identified. Microbiome alpha-diversity increased after surgery, especially at 3 months. Significant genus-level changes included increases in Odoribacter, Streptococcus, Anaerotruncus, Alistipes, Klebsiella, and Bifidobacterium, while decreases in Bacteroides, Coprocosccus, Dorea, and Faecalibacterium. Large increases in Streptococcus, Akkermansia, and Prevotella were observed at 3 months. Beta-diversity and fecal metabolites were also changed, including reduced caffeine metabolites, indoles, and butyrate.

CONCLUSIONS

Despite small sample size and missing repeated samples in some participants, our pilot study showed significant postsurgery changes in fecal microbiome and metabolites among bariatric surgery patients. Future large-scale, longitudinal studies are warranted to investigate gut microbial changes and their associations with metabolic outcomes after bariatric surgery.

Cancer Risk After Bariatric Surgery in a Cohort Study from the Five Nordic Countries

PURPOSE

Obesity increases the risk of several cancers, but the influence of bariatric surgery on the risk of individual obesity-related cancers is unclear. This study aimed to assess the impact of bariatric surgery on cancer risk in a multi-national setting.

MATERIALS AND METHODS

This cohort study included all adults with an obesity diagnosis identified from national patient registries in all Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) from 1980 to 2012. Cancer risk in bariatric surgery patients was compared with non-operated patients with obesity. Multivariable Cox regression provided adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Age, sex, calendar year, country, length of follow-up, diabetes, chronic obstructive pulmonary disease and alcohol-related diseases were evaluated as confounders.

RESULTS

Among 482,572 participants with obesity, 49,096 underwent bariatric surgery. Bariatric surgery was followed by a decreased overall cancer risk in women (HR 0.86, 95% CI 0.80-0.92), but not in men (HR 0.98, 95% CI 0.95-1.01). The risk reduction was observed only within the first five post-operative years. Among specific tumours, HRs decreased for breast cancer (HR 0.81, 95% CI 0.69-0.95), endometrial cancer (HR 0.69, 95% CI 0.56-0.84) and non-Hodgkin lymphoma (HR 0.64, 95% CI 0.42-0.97) in female bariatric surgery patients, while the risk of kidney cancer increased in both sexes (HR 1.44, 95% CI 1.13-1.84).

CONCLUSION

Bariatric surgery may decrease overall cancer risk in women within the first five years after surgery. This decrease may be explained by a decreased risk of breast and endometrial cancer and non-Hodgkin lymphoma in women.

The Role of Hyperglycemia in Endometrial Cancer Pathogenesis

Endometrial cancer is one of the most common cancers in women worldwide and its incidence is increasing. Epidemiological evidence shows a strong association between endometrial cancer and obesity, and multiple mechanisms linking obesity and cancer progression have been described. However, it remains unclear which factors are the main drivers of endometrial cancer development. Hyperglycemia and type 2 diabetes mellitus are common co-morbidities of obesity, and there is evidence that hyperglycemia is a risk factor for endometrial cancer independent of obesity. This review aims to explore the association between hyperglycemia and endometrial cancer, and discuss the evidence supporting a role for increased glucose metabolism in endometrial cancer and how this phenotype may contribute to endometrial cancer growth and progression. Finally, the potential role of blood glucose lowering strategies, including drugs and bariatric surgery, for the treatment of this malignancy will be discussed.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.

Overall and Estrogen Receptor-Positive Breast Cancer Incidences Are Decreased Following Bariatric Surgery

INTRODUCTION

Bariatric surgery treats morbid obesity resulting in long-lasting weight loss. Elevated body mass index (BMI) increases breast cancer risk. We hypothesized that patients undergoing bariatric surgery would have decreased overall and estrogen receptor (ER)-positive breast cancer incidences compared to a propensity-matched non-surgical cohort.

METHODS

The bariatric population included all female patients who underwent weight loss surgery at a single institution from 1985 to 2015. Patients from all outpatient visits were propensity score matched 1:1 with bariatric patients using BMI, comorbidities, demographics, and insurance status. The primary outcome was breast cancer incidence. Univariate analyses compared the groups.

RESULTS

A total of 4860 patients were included, with 2430 in both groups. Median follow-up time from date of surgery or morbid obesity diagnosis was 5.7 years. There were no differences in age or comorbidities aside from gastroesophageal reflux disease. Seventeen (0.7%) patients in the surgery group were subsequently diagnosed with breast cancer versus 32 (1.3%) in the non-surgery group (p = 0.03). The non-surgery group had more ER-positive tumors [4 (36.4%) vs. 22 (71.0%); p = 0.04].

CONCLUSION

Female patients who underwent bariatric surgery were less frequently diagnosed with any breast cancer and ER-positive breast cancer versus a propensity-matched cohort suggesting a possible oncologic benefit to weight loss surgery.

Does Bariatric Surgery Affect the Incidence of Endometrial Cancer Development? A Systematic Review

Obesity has been linked to an increased prevalence in multiple cancers. Studies have suggested a reduction in the overall risk of cancer after bariatric surgery. We reviewed the evidence for bariatric surgery reducing the risk of endometrial cancer. Data was extracted from PubMed, EMBASE, and Medline to perform a systematic review. Thirty-one full text articles were identified from 265 abstracts. Nine observational studies were relevant to endometrial cancer. In the five controlled studies, 462 of 113,032 (0.4%) patients receiving bariatric surgery versus 11,997 of 848,864 (1.4%) controls developed endometrial cancer, odds ratio of 0.317 (95% CI 0.161 to 0.627) using random effects model (P < 0.001). Bariatric surgery seems to reduce the risk of endometrial cancer; however, more research is required.

Obese and Non-obese Polycystic Ovarian Syndrome: Comparison of Clinical, Metabolic, Hormonal Parameters, and their Differential Response to Clomiphene

OBJECTIVE

To study the clinical, metabolic, hormonal parameters, and differential response to clomiphene among the obese and non-obese PCOS (polycystic ovarian syndrome).

DESIGN

Prospective observational study.

SETTING

Infertility OPD, a government hospital.

SAMPLE SIZE

About 164 women with PCOS-related infertility.

STUDY GROUPS

Obese PCOS group [body mass index (BMI) ≥23 kg/m²) and non-obese PCOS group (BMI <23 kg/m²).

RESULTS

Of the total 164 PCOS women, 124 (75.61%) were in the obese group with BMI ≥23 kg/m² and 40 (24.39%) were in the non-obese PCOS group. The prevalence of menstrual irregularity, hypertension, insulin resistance (IR), metabolic syndrome, endometrial hyperplasia, and clomiphene resistance in the PCOS women were 82.34%, 3.66%, 59.76%, 24.39%, 7.93%, and 53.7%, respectively. The Ferriman-Gallwey score, menstrual irregularity, IR [fasting insulin and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR)], metabolic syndrome, deranged lipid profile, and clomiphene resistance were statistically more common in the obese PCOS group (P < 0.05). Hypertension, deranged blood sugar profile, testosterone, androstenedione levels, and endometrial hyperplasia were more common in obese PCOS group but the results were not statistically significant. No significant differences were found in the luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH-FSH ratio, and 17-hydroxyprogesterone (17-OHP) levels between the two groups.

CONCLUSION

Obese PCOS have a higher risk of adverse outcomes like hypertension, IR, metabolic syndrome, and endometrial hyperplasia. So, targeting obesity in PCOS women will not only help to prevent adverse outcomes but also improve responsiveness to clomiphene citrate.

The impact of obesity and bariatric surgery on circulating and tissue biomarkers of endometrial cancer risk

Obesity is the strongest risk factor for endometrial cancer (EC). To inform targeted screening and prevention strategies, we assessed the impact of obesity and subsequent bariatric surgery-induced weight loss on endometrial morphology and molecular pathways implicated in endometrial carcinogenesis. Blood and endometrial tissue were obtained from women with class III-IV obesity (body mass index ≥40 and ≥50 kg/m2 , respectively) immediately prior to gastric bypass or sleeve gastrectomy, and at two and 12 months' follow up. The endometrium underwent pathological examination and immunohistochemistry was used to quantify proliferation (Ki-67), oncogenic signaling (PTEN, pAKT, pERK) and hormone receptor (ER, PR) expression status. Circulating biomarkers of insulin resistance, reproductive function and inflammation were also measured at each time point. Seventy-two women underwent bariatric surgery. At 12 months, the mean change in total and excess body weight was -32.7 and -62.8%, respectively. Baseline endometrial biopsies revealed neoplastic change in 10 women (14%): four had EC, six had atypical hyperplasia (AH). After bariatric surgery, most cases of AH resolved (5/6) without intervention (3/6) or with intrauterine progestin (2/6). Biomarkers of endometrial proliferation (Ki-67), oncogenic signaling (pAKT) and hormone receptor status (ER, PR) were significantly reduced, with restoration of glandular PTEN expression, at 2 and 12 months. There were reductions in circulating biomarkers of insulin resistance (HbA1c, HOMA-IR) and inflammation (hsCRP, IL-6), and increases in reproductive biomarkers (LH, FSH, SHBG). We found an unexpectedly high prevalence of occult neoplastic changes in the endometrium of women undergoing bariatric surgery. Their spontaneous reversal and accompanying down-regulation of PI3K-AKT-mTOR signaling with weight loss may have implications for screening, prevention and treatment of this disease.

Bariatric surgery after failed conservative management in a morbidly obese patient with endometrial cancer

•Extreme obesity may preclude patients from primary surgical management of endometrial cancer.•Bariatric surgery is a safe and effective method of rapid weight loss in patients with extreme obesity.•Delayed hysterectomy, after weight loss from bariatric surgery, is an option in select patients with endometrial cancer.

POSTOPERATIVE CHANGES IN INTESTINAL MICROBIOTA AND USE OF PROBIOTICS IN ROUX-EN-Y GASTRIC BYPASS AND SLEEVE VERTICAL GASTRECTOMY: AN INTEGRATIVE REVIEW

Introduction:

Studies suggest that weight loss induced by bariatric surgery and the remission of some comorbidities may be related to changes in the microbiota profile of individuals undergoing this procedure. In addition, there is evidence that manipulation of the intestinal microbiota may prove to be a therapeutic approach against obesity and metabolic diseases.

Objective:

To verify the changes that occur in the intestinal microbiota of patients undergoing bariatric surgery, and the impact of the usage of probiotics in this population.

Methods:

Articles published between 2007 and 2017 were searched in Medline, Lilacs and Pubmed with the headings: bariatric surgery, microbiota, microbiome and probiotics, in Portuguese, English and Spanish. Of the 166 articles found, only those studies in adults subjected to either Roux-en-Y gastric bypass or sleeve vertical gastrectomy published in original articles were enrolled. In the end, five studies on the change of intestinal microbiota composition, four on the indirect effects of those changes and three on the probiotics administration on this population were enrolled and characterized.

Conclusion:

Bariatric surgery provides changes in intestinal microbiota, with a relative increase of the Bacteroidetes and Proteobacteria phyla and reduction of Firmicutes. This is possibly due to changes in the gastro-intestinal flux, coupled with a reduction in acidity, in addition to changes in eating habits. The usage of probiotics seems to reduce the gastro-intestinal symptoms in the post-surgery, favor the increase of vitamin B12 synthesis, as well as potentiate weight loss.

Prospective Randomized Biomarker Study of Metformin and Lifestyle Intervention for Prevention in Obese Women at Increased Risk for Endometrial Cancer

Obesity increases risk of endometrial cancer through dysregulation of estrogen and insulin signaling. The primary aim of this study was to evaluate the impact of metformin or lifestyle intervention on endometrial proliferation in postmenopausal obese women. Secondary aims included evaluating obesity-related biomarkers and adverse events experienced. Obese, postmenopausal women with prediabetes were randomized into four groups for a 16-week intervention using a 2 (metformin 1700 mg/day vs. placebo) × 2 (lifestyle intervention vs. no lifestyle intervention) factorial design. Pre- and postintervention endometrial proliferation, anthropometrics, body composition, and serum biomarkers (sex hormones, sex hormone binding globulin, IGF-I, adiponectin, omentin, insulin, glucose, and others) were assessed. Data were analyzed with linear regression models and false-discovery rate correction. Of 576 women approached for the study, 52 attended initial screening, 29 were eligible and randomized, and 26 completed the study. Lifestyle intervention resulted in significant loss of weight (-4.23 kg, P = 0.006) and total fat mass (-3.23 kg, P < 0.001). Participants receiving metformin lost 3.43 kg of weight (P = 0.023), but this was not statistically significant after multiple comparisons adjustment controlling false-discovery rate to 10%. Endometrial proliferation was low at baseline (mean 7.1%) and remained unchanged by 16 weeks, but included substantial variability. Metformin and lifestyle intervention produced minor changes to serum biomarkers. Lifestyle intervention produced the most significant changes in weight and body composition. While it is known that obese postmenopausal women are at increased risk for endometrial cancer, improved biomarkers are needed to stratify risk and test prevention strategies, particularly at the endometrial tissue level. Cancer Prev Res; 11(8); 477-90. ©2018 AACR.

Does Bariatric Surgery Affect the Incidence of Breast Cancer Development? A Systematic Review

We reviewed the evidence for bariatric surgery reducing the risk of breast cancer. Data was extracted from multiple libraries, including PubMed, EMBASE, and Medline, to perform a systematic review. Abstracts were reviewed by two independent reviewers. Thirty-eight full-text articles were identified from 1171 abstracts. Four studies were included for meta-analysis; 114 of 10,533 (1.1%) patients receiving bariatric surgery versus 516 of 20,130 (2.6%) controls developed breast cancer, odds ratio 0.564 (95% CI 0.453 to 0.702) using a fixed effects model (P < 0.001) and odds ratio 0.585 (95% CI 0.247 to 1.386) using a random effects model (P 0.223). Bariatric surgery may reduce the risk of breast cancer. More research is required due to heterogeneity of studies, difficulty in identifying accurate controls, and limited follow-up.

Visceral abdominal fat measured by computer tomography as a prognostic factor for gynecological malignancies?

Introduction

Obesity is associated with increased incidence of ovarian (OC), cervical (CC) and endometrium cancer (EC). However, the impact of body composition (BC) on overall survival (OS), especially of visceral adipose tissue (VAT) is not yet understood.

Methods

In 189 women with gynecological malignancies (31 OC, 104 CC, 54 EC, mean age 62.9y; mean BMI 26.8 kg/m²; median follow-up 30.7months) with routine staging CT-scans at baseline (mean interval: 4.3 months), densitometric quantification of total (TAT), visceral, and subcutaneous-fat-area (SAT), inter-muscular-fat-area (IMFA), and skeletal-muscle-index (SMI) was performed to analyze the impact of BC on survival.

Results

With a mean follow-up of 30.7 months 48 patients had died. We observed no significant differences regarding BMI, the adipose- and muscle-distribution between surviving and deceased women. Univariate analyses revealed no significant BC-parameter with impact on OS, which was confirmed by different multivariate models. A subgroup analysis of OC, CC and EC showed only a protective impact of SMI on survival in the subgroup of CC.

Conclusions

Despite the increased incidence of gynecological malignancies in obese, we found no significant impact of BC including VAT on patient survival. Further studies with larger cohorts are needed to quantify BC and its metabolomic impact regarding treatment and prognosis.

Application of Metabolomics to Study Effects of Bariatric Surgery

Bariatric surgery was born in the 1950s at the University of Minnesota. From this time, it continues to evolve and, by the same token, gives new or better possibilities to treat not only obesity but also associated comorbidities. Metabolomics is also a relatively young science discipline, and similarly, it shows great potential for the comprehensive study of the dynamic alterations of the metabolome. It has been widely used in medicine, biology studies, biomarker discovery, and prognostic evaluations. Currently, several dozen metabolomics studies were performed to study the effects of bariatric surgery. LC-MS and NMR are the most frequently used techniques to study main effects of RYGB or SG. Research has yield many interesting results involving not only clinical parameters but also molecular modulations. Detected changes pertain to amino acid, lipids, carbohydrates, or gut microbiota alterations. It proves that including bariatric surgery to metabolic surgery is warranted. However, many molecular modulations after those procedures remain unexplained. Therefore, application of metabolomics to study this field seems to be a proper solution. New findings can suggest new directions of surgery technics modifications, contribute to broadening knowledge about obesity and diseases related to it, and perhaps develop nonsurgical methods of treatment in the future.

Inhibition of hepatic lipogenesis enhances liver tumorigenesis by increasing antioxidant defence and promoting cell survival

The metabolic pathway of de novo lipogenesis is frequently upregulated in human liver tumours, and its upregulation is associated with poor prognosis. Blocking lipogenesis in cultured liver cancer cells is sufficient to decrease cell viability; however, it is not known whether blocking lipogenesis in vivo can prevent liver tumorigenesis. Herein, we inhibit hepatic lipogenesis in mice by liver-specific knockout of acetyl-CoA carboxylase (ACC) genes and treat the mice with the hepatocellular carcinogen diethylnitrosamine (DEN). Unexpectedly, mice lacking hepatic lipogenesis have a twofold increase in tumour incidence and multiplicity compared to controls. Metabolomics analysis of ACC-deficient liver identifies a marked increase in antioxidants including NADPH and reduced glutathione. Importantly, supplementing primary wild-type hepatocytes with glutathione precursors improves cell survival following DEN treatment to a level indistinguishable from ACC-deficient primary hepatocytes. This study shows that lipogenesis is dispensable for liver tumorigenesis in mice treated with DEN, and identifies an important role for ACC enzymes in redox regulation and cell survival.

Lifestyle changes and the risk of developing endometrial and ovarian cancers: opportunities for prevention and management

Modifiable lifestyle factors, such as obesity, lack of physical activity, and smoking, contribute greatly to cancer and chronic disease morbidity and mortality worldwide. This review appraises recent evidence on modifiable lifestyle factors in the prevention of endometrial cancer (EC) and ovarian cancer (OC) as well as new evidence for lifestyle management of EC and OC survivors. For EC, obesity continues to be the strongest risk factor, while new evidence suggests that physical activity, oral contraceptive pills, and bariatric surgery may be protective against EC. Other medications, such as metformin and nonsteroidal anti-inflammatory drugs, may be protective, and interventional research is ongoing. For OC, we find increasing evidence to support the hypothesis that obesity and hormone replacement therapy increase the risk of developing OC. Oral contraceptive pills are protective against OC but are underutilized. Dietary factors such as the Mediterranean diet and alcohol consumption do not seem to affect the risk of either OC or EC. For EC and OC survivors, physical activity and weight loss are associated with improved quality of life. Small interventional trials show promise in increasing physical activity and weight maintenance for EC and OC survivors, although the impact on long-term health, including cancer recurrence and overall mortality, is unknown. Women's health providers should integrate counseling about these modifiable lifestyle factors into both the discussion of prevention for all women and the management of survivors of gynecologic cancers.

Multi-Strain Probiotics Inhibit Cardiac Myopathies and Autophagy to Prevent Heart Injury in High-Fat Diet-Fed Rats

High-fat diets induce obesity, leading to cardiomyocyte fibrosis and autophagy imbalance. In addition, no previous studies have indicated that probiotics have potential health effects associated with cardiac fibrosis and autophagy in obese rats. This study investigates the effects of probiotics on high-fat (HF) diet-induced obesity and cardiac fibrosis and autophagy in rat hearts. Eight-week-old male Wistar rats were separated randomly into five equally sized experimental groups: Normal diet (control) and high-fat (HF) diet groups and groups fed a high-fat diet supplemented with low (HL), medium (HM) or high (HH) doses of multi-strain probiotic powders. These experiments were designed for an 8-week trial period. The myocardial architecture of the left ventricle was evaluated using Masson's trichrome staining and immunohistochemistry staining. Key probiotics-related pathway molecules were analyzed using western blotting. Abnormal myocardial architecture and enlarged interstitial spaces were observed in HF hearts. These interstitial spaces were significantly decreased in groups provided with multi-strain probiotics compared with HF hearts. Western blot analysis demonstrated that key components of the TGF/MMP2/MMP9 fibrosis pathways and ERK5/uPA/ANP cardiac hypertrophy pathways were significantly suppressed in probiotic groups compared to the HF group. Autophagy balance is very important in cardiomyocytes. In this study, we observed that the beclin-1/LC3B/Atg7 autophagy pathway in HF was increased after probiotic supplementation was significantly decreased. Together, these results suggest that oral administration of probiotics may attenuate cardiomyocyte fibrosis and cardiac hypertrophy and the autophagy-signaling pathway in obese rats.