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Abu-Rustum N, Yashar C, Arend R, Barber E, Bradley K, Brooks R, Campos SM, Chino J, Chon HS, Chu C, Crispens MA, Damast S, Fisher CM, Frederick P, Gaffney DK, Giuntoli R, Han E, Holmes J, Howitt BE, Lea J, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Podoll M, Salani R, Schorge J, Siedel J, Sisodia R, Soliman P, Ueda S, Urban R, Wethington SL, Wyse E, Zanotti K, McMillian NR, Aggarwal S. Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2023; 21:181-209. [PMID: 36791750 DOI: 10.6004/jnccn.2023.0006] [Citation(s) in RCA: 83] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.
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Affiliation(s)
| | | | | | - Emma Barber
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Susana M Campos
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | | | | | | | | | | | | | | | | | | | | | - Jordan Holmes
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | | | - Jayanthi Lea
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Larissa Nekhlyudov
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | | | | | - John Schorge
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Rachel Sisodia
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | | | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | - Kristine Zanotti
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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Narasimhulu DM, Block MS, Weaver AL, McGree M, Kumar A, Langstraat C, Petersen I, Mariani A, Glaser G. Sequencing chemotherapy before radiotherapy for women with stage IIIC endometrial cancer. Int J Gynecol Cancer 2021; 31:702-708. [PMID: 33771845 DOI: 10.1136/ijgc-2020-002158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE It is unclear how to best sequence adjuvant chemotherapy and radiotherapy for advanced endometrial cancer. We studied the outcomes for women treated with chemotherapy before radiotherapy in a chemotherapy-first (chemotherapy for 6 cycles followed radiotherapy) or 'sandwich' approach (chemotherapy for 3 cycles followed by radiotherapy and subsequently chemotherapy for 3 cycles). METHODS Women with stage IIIC endometrial cancer and no gross residual disease treated with chemotherapy before radiotherapy between April 2003 and April 2016 were included. The Kaplan-Meier method was used to estimate recurrence and survival. We performed a meta-analysis of endometrial cancer trials comparing chemotherapy and radiotherapy versus radiotherapy alone. RESULTS A total of 102 patients were included. The mean (SD) age was 63.8 (10.6) years; 84 patients received the chemotherapy-first approach and 18 patients received the 'sandwich' approach. Pelvic and para-aortic nodes were removed in 99% and 88.2%, respectively. Among all the patients, we observed 1 pelvic (1%), 1 para-aortic (1%), and 5 vaginal (4.9%) recurrences. At 3 years, for the 'sandwich' and chemotherapy-first approaches, the vaginal recurrence was 11.8% and 4.2%, pelvic recurrence was 0% and 1.5%, para-aortic recurrence was 0% and 1.2%, distant recurrence was 42.9% and 24.4%, and overall survival was 70.3% and 81.7%, respectively. With 'chemotherapy before radiotherapy' 94.9% completed 4+ chemotherapy cycles (vs 71-90% reported in the literature for 'radiotherapy before chemotherapy'). In a meta-analysis of endometrial cancer trials, distant recurrence rates were reduced with 4+ chemotherapy cycles but not with 3 cycles (p=0.01). CONCLUSION Chemotherapy before radiation sequencing for stage IIIC endometrial cancer was associated with a high proportion of patients completing 4+ chemotherapy cycles and low locoregional lymphatic recurrence rate, despite delaying radiotherapy until after 3-6 cycles of chemotherapy and not administering concurrent cisplatin.
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Affiliation(s)
| | - Matthew S Block
- Department of Medical Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Amy L Weaver
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Amanika Kumar
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Carrie Langstraat
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ivy Petersen
- Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Sequencing of Adjuvant Chemoradiation for Advanced Stage Endometrial Cancer. Am J Clin Oncol 2020; 43:755-761. [DOI: 10.1097/coc.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liang Y, Lin B, Ye Z, Chen S, Yu H, Chen C, Zhang X, Zhou K, Zeng J. Triple-high expression of phosphatase and tensin homolog (PTEN), estrogen receptor (ER) and progesterone receptor (PR) may predict favorable prognosis for patients with Type I endometrial carcinoma. J Cancer 2020; 11:1436-1445. [PMID: 32047550 PMCID: PMC6995374 DOI: 10.7150/jca.33720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 11/19/2019] [Indexed: 01/30/2023] Open
Abstract
Endometrial carcinoma (EC) is the most common malignant tumors in female derived from the endometrial epithelium. Several previous studies have described estrogen receptors (ER), progesterone Receptor (PR) and phosphatase and tensin homolog (PTEN) are associated with clinicopathological factors and prognosis in EC patients. However, during EC patients follow-up, we found that some EC patients with down-regulation of PTEN, but up-regulation of ER or PR , and some EC patients with down-regulation of ER or PR, but up-regulation of PTEN also had a poor prognosis. Therefore, to reveal the prognosis of EC patients with different phenotypes based on PTEN, ER and PR expression, 120 cases formalin-fixed paraffin-embedded EC tissues and 543 cases uterine corpus endometrial carcinoma (UCEC) patients from the cancer genome atlas (TCGA) UCEC datasets were analyzed. Results showed that EC tissues can be classified to PTENLERLPRL, PTENHERLPRL, PTENHERHPRH, PTENLERHPRH, PTENHERHPRL, PTENHERLPRH, and PTENLERHPRL phenotypes basing on IHC analysis. Additionally, EC patients with PTENLERLPRL showed high malignancy, while patients with PTENHERHPRH showed low malignancy. Therefore, combined detection of PTEN, ER, PR may help identify a small subset of EC with more aggressive behavior and may aid in risk stratification.
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Affiliation(s)
- Yanfang Liang
- Department of Pathology, Dongguan Hospital Affiliated to Medical College of Jinan University, The Fifth People's Hospital of Dongguan, Dongguan 523905, China
| | - Bihua Lin
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Ziyu Ye
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Shasha Chen
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Haibo Yu
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Can Chen
- Department of Pathology, Dongguan Hospital Affiliated to Medical College of Jinan University, The Fifth People's Hospital of Dongguan, Dongguan 523905, China
| | - Xin Zhang
- Clinical Experimental Center, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen 529030, China
| | - Keyuan Zhou
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Jincheng Zeng
- Dongguan Key Laboratory of Medical Bioactive Molecular Developmental and Translational Research, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong Medical University, Dongguan, Guangdong 523808, China
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Adjuvant chemoradiotherapy versus radiotherapy alone in high-risk endometrial cancer: A systematic review and meta-analysis. Gynecol Oncol 2018. [PMID: 29530332 DOI: 10.1016/j.ygyno.2018.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefits of adjuvant chemoradiotherapy (CRT) for high-risk endometrial cancer (HREC) in International Federation of Gynecology and Obstetrics (FIGO) stages I-III remain controversial. A systematic review and meta-analysis was conducted to evaluate the clinical effectiveness and safety of postoperative CRT over radiotherapy (RT) alone, exclusively for patients with HREC for the following key endpoints: overall survival (OS), progression-free survival (PFS), the local recurrence rate, the distant metastasis rate, cancer-specific survival (CSS), grade III/IV acute and late toxicities, and the small bowel obstruction rate. METHODS Five databases, namely, PubMed, EMBASE, Cochrane Library, Web of Science and ClinicalTrials.gov, were systematically explored and supplemented by manual searching to identify relevant studies published before Dec 9, 2017. Only prospective randomized controlled trials (RCTs) conducted for HREC comparing CRT and RT alone after surgery were included. All statistical analyses were performed using RevMan Version 5.3 software. RESULTS Six eligible trials involving 2105 patients were identified for the final meta-analysis (CRT: n = 1064; RT: n = 1041). No statistically significant differences were evident between the CRT and RT groups regarding OS (n = 2105, RR = 1.02, 95% CI 0.98-1.06, P = 0.40). Additionally, no differences were apparent in terms of the local recurrence rate (n = 690, RR = 0.48, 95% CI 0.19-1.18, P = 0.11) or distant metastasis rate (n = 1445, RR = 0.94, 95% CI 0.72-1.23, P = 0.67). However, CRT significantly prolonged overall five-year PFS (80.2% vs. 74.5%, +5.7%; RR = 1.08, P = 0.005) and five-year CSS (86.1% vs. 79.0%, +7.1%; RR = 1.09, P = 0.03). A higher incidence of grade III/IV toxicities (P < 0.00001) was evident with CRT, while grade III/IV late toxicities and the small bowel obstruction rate were not significantly different between the two groups. CONCLUSIONS For patients with endometrial cancers with stage I-III risk factors, adjuvant CRT can significantly improve PFS and CSS compared with RT. With the exception of increased acute toxicities, CRT is well accepted and tolerated in HREC patients.
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Oncologic Outcomes After Adjuvant Radiotherapy for Stage II Endometrial Carcinoma: A Korean Radiation Oncology Group Study (KROG 14-10). Int J Gynecol Cancer 2018; 27:1387-1392. [PMID: 28604455 DOI: 10.1097/igc.0000000000001030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the survival, patterns of failure, and prognostic factors in patients with stage II endometrial carcinoma treated with adjuvant radiotherapy. METHODS We reviewed the medical records of patients who underwent total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection followed by adjuvant radiotherapy in 10 participating hospitals of the Korean Radiation Oncology Group. Most patients received adjuvant external beam radiation therapy, with a median dose of 50.4 Gy; approximately 50% of these patients received an additional brachytherapy boost, with a median dose of 18 Gy. Adjuvant chemotherapy was administered to 19 patients. RESULTS A total of 122 patients were examined. Over a median follow-up period of 62.7 months (range, 1.9-158.8 months), the 5-year overall survival (OS) and disease-free survival rates were found to be 91.1% and 85.1%, respectively. Recurrence was observed in 14 patients (11.5%), including 3 with local recurrence and 11 with distant metastases as the first site of recurrence. Univariate analysis indicated that lymphovascular invasion was related to an unfavorable OS. An age of 60 years or above, histologic grade 3, and lymphovascular invasion were identified as risk factors for OS. Because there were several risk factors related to OS, we assigned patients to a high-risk group (defined as cases with ≥1 risk factors) and a low-risk group. The 5-year OS rate of the high-risk group was significantly inferior to that of the low-risk group (82.9% vs 100%, P = 0.003). CONCLUSIONS The high-risk group had a significantly poorer survival rate than the low-risk group, and distant metastasis was the main pattern of recurrence, thus indicating that further adjuvant chemotherapy should be considered in high-risk patients.
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Lee YC, Lheureux S, Oza AM. Treatment strategies for endometrial cancer: current practice and perspective. Curr Opin Obstet Gynecol 2017; 29:47-58. [PMID: 27941361 DOI: 10.1097/gco.0000000000000338] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Endometrial cancer incidence is increasing in North America and is a major cause of morbidity and mortality in women. We review recent literature published on treatment of endometrial cancer and highlight areas of active interest. RECENT FINDINGS There has been movement toward minimal invasive surgery at diagnosis; lymph node staging remains controversial and continues to be investigated. Progress has been made to establish consensus on endometrial cancer risk classification to promote consistency for future trial design. Molecular characterization of endometrial cancer and its integration into clinicopathological profiling to develop predictive biomarkers for treatment selection are active areas of research. Optimal adjuvant treatment strategy in high-risk endometrial cancer remains to be defined with recognition of treatment-related toxicity. Despite encouraging results in drug development for treatment of advanced/recurrent endometrial cancer, no targeted therapies beyond hormonal therapy are approved. There is an urgent need for scientifically validated therapy with predictive biomarkers. SUMMARY Our understanding of endometrial cancer has evolved through improvements in molecular biology, allowing improved definition of target-specific therapies. The precise role and sequence of conventional and targeted therapies, including immunotherapy, will require careful attention to the design of clinical trials with translational emphasis to allow the discovery, validation, and implementation of predictive biomarkers into clinical care.
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Affiliation(s)
- Yeh C Lee
- Drug Development Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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The Addition of Adjuvant Chemotherapy to Radiation in Early-Stage High-Risk Endometrial Cancer. Int J Gynecol Cancer 2017; 27:912-922. [DOI: 10.1097/igc.0000000000000963] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Multidrug resistance transporter-1 and breast cancer resistance protein protect against ovarian toxicity, and are essential in ovarian physiology. Reprod Toxicol 2017; 69:121-131. [PMID: 28216407 DOI: 10.1016/j.reprotox.2017.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/03/2017] [Accepted: 02/03/2017] [Indexed: 12/14/2022]
Abstract
Ovarian protection from chemotoxicity is essential for reproductive health. Our objective is to determine the role of ATP-dependent, Multidrug Resistance Transporters (MDRs) in this protection. Previously we identified MDR-dependent cytoprotection from cyclophosphamide in mouse and human oocytes by use of MDR inhibitors. Here we use genetic deletions in MDR1a/b/BCRP of mice to test MDR function in ovarian somatic cells and find that mdr1a/b/bcrp-/- mice had significantly increased sensitivity to cyclophosphamide. Further, estrus cyclicity and follicle distribution in mdr1a/b/bcrp-/- mice also differed from age-matched wildtype ovaries. We found that MDR gene activity cycles through estrus and that MDR-1b cyclicity correlated with 17β-estradiol surges. We also examined the metabolite composition of the ovary and learned that the mdr1a/b/bcrp-/- mice have increased accumulation of metabolites indicative of oxidative stress and inflammation. We conclude that MDRs are essential to ovarian protection from chemotoxicity and may have an important physiological role in the ovary.
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Zhang H, Li J, Li G, Wang S. Effects of celastrol on enhancing apoptosis of ovarian cancer cells via the downregulation of microRNA‑21 and the suppression of the PI3K/Akt‑NF‑κB signaling pathway in an in vitro model of ovarian carcinoma. Mol Med Rep 2016; 14:5363-5368. [PMID: 27840916 DOI: 10.3892/mmr.2016.5894] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/22/2016] [Indexed: 11/05/2022] Open
Abstract
Celastrol has previously been used to treat rheumatoid arthritis, bruises, back pain and additional diseases. At present, efficacy studies predominantly focus on the anti‑inflammatory, antioxidative and antitumor effects of celastrol. However, the effect of celastrol on ovarian cancer cells is not fully elucidated. In the present study, the effects of celastrol were investigated in ovarian cancer cells and the mechanisms involved were explored. In OVCAR3 cells, celastrol was observed to suppress cellular proliferation, induce apoptosis and increase caspase‑9 and ‑3 activity in a dose‑ and time‑dependent manner. The expression levels of microRNA‑21 (miRNA‑21) were reduced, in addition to a reduction in the levels of phosphoinositide 3‑kinase (PI3K)/p‑Akt‑NF (NF)‑κB following treatment with celastrol. Notably, reduced expression of miRNA‑21 replicated the effect of celastrol on OVCAR3 cells and inhibited the PI3K/p‑Akt‑NF‑κB signaling pathway in an in vitro model of ovarian carcinoma. To the best of our knowledge this is the first study to indicate that celastrol may represent a potential agent for the treatment of human ovarian carcinoma, via the induction of apoptosis through the downregulation of miRNA‑21 and the PI3K/Akt‑NF‑κB signaling pathway in an in vitro model of ovarian carcinoma.
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Affiliation(s)
- Haiyan Zhang
- Gynaecology Ward‑1, Department of Gynaecology, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Jianhua Li
- Department of Gynaecology Lab, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Guang Li
- Department of Gastrointestinal Surgery, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Surong Wang
- Gynaecology Ward‑3, Department of Gynaecology, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
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