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Ji J, Cheng X, Du R, Xie Y, Zhang Y. Advances in research on autophagy mechanisms in resistance to endometrial cancer treatment. Front Oncol 2024; 14:1364070. [PMID: 38601753 PMCID: PMC11004244 DOI: 10.3389/fonc.2024.1364070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024] Open
Abstract
Administering medication is a crucial strategy in improving the prognosis for advanced endometrial cancer. However, the rise of drug resistance often leads to the resurgence of cancer or less-than-ideal treatment outcomes. Prior studies have shown that autophagy plays a dual role in the development and progression of endometrial cancer, closely associated with drug resistance. As a result, concentrating on autophagy and its combination with medical treatments might be a novel approach to improve the prognosis for endometrial cancer. This study explores the impact of autophagy on drug resistance in endometrial cancer, investigates its core mechanisms, and scrutinizes relevant treatments aimed at autophagy, aiming to illuminate the issue of treatment resistance in advanced endometrial cancer.
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Affiliation(s)
- Jingjing Ji
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Nantong, China
- Research Central of Clinical Medicine, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Xi Cheng
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Nantong, China
- Research Central of Clinical Medicine, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Rong Du
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Nantong, China
- Research Central of Clinical Medicine, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuanyuan Xie
- Research Central of Clinical Medicine, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuquan Zhang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Nantong, China
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Qin ZJ, Wang YS, Chen YL, Zheng A, Han L. Evaluation of prognostic significance of lymphovascular space invasion in early stage endometrial cancer: a systematic review and meta-analysis. Front Oncol 2024; 13:1286221. [PMID: 38273843 PMCID: PMC10808564 DOI: 10.3389/fonc.2023.1286221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
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.
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Affiliation(s)
- Zhao-juan Qin
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Yi-si Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Ya-li Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Ai Zheng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Ling Han
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
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Miao M, Zhu Y, Wang L, Miao Y, Li R, Zhou H. A nomogram for predicting recurrence in endometrial cancer patients: a population-based analysis. Front Endocrinol (Lausanne) 2023; 14:1156169. [PMID: 38027107 PMCID: PMC10661936 DOI: 10.3389/fendo.2023.1156169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Endometrial cancer recurrence is one of the main factors leading to increased mortality, and there is a lack of predictive models. Our study aimed to establish a nomogram predictive model to predict recurrence in endometrial cancer patients. Method Screen 517 endometrial cancer patients who came to Nanjing Drum Tower Hospital from 2008 to 2018. All these data are listed as the training group, and then 70% and 60% are randomly divided into verification groups 1 and 2. Univariate, Multivariate logistic regression, stepwise regression were used to select variables for nomogram. Nomogram identification and calibration were evaluated by concordance index (c-index), area under receiver operating characteristic curve (AUC) over time and calibration plot Function. By decision curve analysis (DCA), net reclassification index (NRI), integrated discrimination improvement (IDI), we compared and quantified the net benefit of nomogram and ESMO-ESGO-ESTRO model-based prediction of tumor recurrence. Results A nomogram predictive model of endometrial cancer recurrence was established with the eight variables screened. The c-index (for the training cohort and for the validation cohort) and the time-dependent AUC showed good discriminative power of the nomogram. Calibration plots showed good agreement between nomogram predictions and actual observations in both the training and validation sets. Conclusions We developed and validated a predictive model of endometrial cancer recurrence to assist clinicians in assessing recurrence in endometrial cancer patients.
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Affiliation(s)
- Mengdan Miao
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
- Department of Gynecology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Yanping Zhu
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Lulu Wang
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Yifei Miao
- Department of Gynecology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Rong Li
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Huaijun Zhou
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
- Department of Gynecology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
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Oliver-Perez MR, Padilla-Iserte P, Arencibia-Sanchez O, Martin-Arriscado C, Muruzabal JC, Diaz-Feijóo B, Cabrera S, Coronado P, Martín-Salamanca MB, Pantoja-Garrido M, Marcos-Sanmartin J, Cabezas-López E, Lorenzo C, Beric D, Rodriguez-Hernandez JR, Roldan-Rivas F, Gilabert-Estelles J, Sanchez L, Laseca-Modrego M, Tauste-Rubio C, Gil-Ibañez B, Tejerizo-Garcia A. Lymphovascular Space Invasion in Early-Stage Endometrial Cancer (LySEC): Patterns of Recurrence and Predictors. A Multicentre Retrospective Cohort Study of the Spain Gynecologic Oncology Group. Cancers (Basel) 2023; 15:cancers15092612. [PMID: 37174081 PMCID: PMC10177148 DOI: 10.3390/cancers15092612] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
The main aim is to compare oncological outcomes and patterns of recurrence of patients with early-stage endometrioid endometrial cancer according to lymphovascular space invasion (LVSI) status. The secondary objective is to determine preoperative predictors of LVSI. We performed a multicenter retrospective cohort study. A total of 3546 women diagnosed with postoperative early-stage (FIGO I-II, 2009) endometrioid endometrial cancer were included. Co-primary endpoints were disease-free survival (DFS), overall survival (OS), and pattern of recurrence. Cox proportional hazard models were used for time-to-event analysis. Univariate and multivariate logistical regression models were employed. Positive LVSI was identified in 528 patients (14.6%) and was an independent prognostic factor for DFS (HR 1.8), OS (HR 2.1) and distant recurrences (HR 2.37). Distant recurrences were more frequent in patients with positive LVSI (78.2% vs. 61.3%, p < 0.01). Deep myometrial invasion (OR 3.04), high-grade tumors (OR 2.54), cervical stroma invasion (OR 2.01), and tumor diameter ≥ 2 cm (OR 2.03) were independent predictors of LVSI. In conclusion, in these patients, LVSI is an independent risk factor for shorter DFS and OS, and distant recurrence, but not for local recurrence. Deep myometrial invasion, cervical stroma invasion, high-grade tumors, and a tumor diameter ≥ 2 cm are independent predictors of LVSI.
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Affiliation(s)
- M Reyes Oliver-Perez
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 12 de Octubre Research Institute (i+12), 28041 Madrid, Spain
| | - Pablo Padilla-Iserte
- Department of Gynaecologic Oncology, La Fe University and Polytechnic Hospital, 46026 Valencia, Spain
| | - Octavio Arencibia-Sanchez
- Department of Gynecologic Oncology, University Hospital Materno-Infantil de Canarias, 35016 Las Palmas de Gran Canaria, Spain
| | - Cristina Martin-Arriscado
- Scientific Support Unit, Hospital Universitario 12 de Octubre, 12 de Octubre Research Institute (i+12), 28041 Madrid, Spain
| | - Juan Carlos Muruzabal
- Department of Gynecologic Oncology, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - Berta Diaz-Feijóo
- Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Universitat de Barcelona, 08036 Barcelona, Spain
| | - Silvia Cabrera
- Gynecologic Oncology Unit, Gynecology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Pluvio Coronado
- Women's Health Institute of the Hospital Clínico San Carlos, IdISSC, School of Medicine, Complutense University Madrid, 28040 Madrid, Spain
| | | | - Manuel Pantoja-Garrido
- Department of Gynecology and Obstetrics, University Hospital Virgen Macarena, 41009 Sevilla, Spain
| | - Josefa Marcos-Sanmartin
- Departments of Obstetrics and Gynecology, Dr. Balmis General University Hospital, 03010 Alicante, Spain
- Department of Public Health, Miguel Hernandez University, Sant Joan D'Alacant, 03550 Alicante, Spain
- Institute for Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain
| | - Elena Cabezas-López
- Department of Gynecologic Oncology, University Hospital Ramón y Cajal, 28034 Madrid, Spain
| | - Cristina Lorenzo
- Department of Obstetrics and Gynecology, Hospital Nuestra Señora de la Calendaria, 38010 Santa Cruz de Tenerife, Spain
| | - Duska Beric
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrevieja, 03186 Alicante, Spain
| | | | - Fernando Roldan-Rivas
- Department of Obstetrics and Gynaecology, Clinico Lozano Blesa Hospital, 50009 Zaragoza, Spain
| | - Juan Gilabert-Estelles
- Department of Pediatrics, Obstetrics and Gynecology, University General Hospital of Valencia, 46014 Valencia, Spain
| | - Lourdes Sanchez
- Department of Gynecology and Obstetrics, University General Hospital of Ciudad Real, 13005 Ciudad Real, Spain
| | - Maria Laseca-Modrego
- Department of Gynecologic Oncology, University Hospital Materno-Infantil de Canarias, 35016 Las Palmas de Gran Canaria, Spain
| | - Carmen Tauste-Rubio
- Department of Gynecologic Oncology, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - Blanca Gil-Ibañez
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 12 de Octubre Research Institute (i+12), 28041 Madrid, Spain
| | - Alvaro Tejerizo-Garcia
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 12 de Octubre Research Institute (i+12), 28041 Madrid, Spain
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Yarandi F, Shirali E, Akhavan S, Nili F, Ramhormozian S. The impact of lymphovascular space invasion on survival in early stage low-grade endometrioid endometrial cancer. Eur J Med Res 2023; 28:118. [PMID: 36915143 PMCID: PMC10012545 DOI: 10.1186/s40001-023-01084-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/03/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND The lymphovascular space invasion (LVSI) is suggested as a prognostic factor for endometrial cancer in many studies, but it has not yet been employed in FIGO staging system. The present study was aimed to evaluate the impact of LVSI on survival in patients with early stage endometrioid endometrial cancer. METHODS This retrospective cohort was conducted on early stage endometrial cancer patients who underwent surgical staging [total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO)] and omental biopsy at Referral Teaching Hospitals of Tehran from 2005 to 2021. Patient's age, menopause status, tumor grade, tumor size, depth of myometrial invasion, LVSI and lower segment involvement were recorded. Data were analyzed with SPSS 22. RESULTS 415 patients with stage I and grade 1-2, endometrioid endometrial cancer were analyzed. 100 patients (24.1%) were LVSI-positive. 3-year and 5-year survival rates were 97.1% and 88.9%, respectively. Recurrence occurred in 53 patients (12.8%). 3-year overall survival rates in LVSI-negative and LVSI-positive were 98.7% and 92%. These rates for 5-year survival were 92.1% and 79%, respectively. Recurrence rates in LVSI-negative were 8.9% while it was 25% in LVSI-positive cases. Multivariate analysis showed that LVSI has significant correlation with 3-year and 5-year overall survival rates. CONCLUSIONS LVSI in early stage endometrial cancer significantly and independently influences 3-year and 5-year survival rates and acts as a strong prognostic factor in these patients. LVSI should be implemented in endometrial cancer staging systems due to its significant correlation with cancer recurrence rates and 5-year survival rates.
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Affiliation(s)
- Fariba Yarandi
- Department of Gynecologic Oncology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Shirali
- Department of Gynecologic Oncology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Setare Akhavan
- Department of Gynecologic Oncology, Vali-Asr Hospital, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex (IKHC), Tehran, Iran
| | - Fatemeh Nili
- Department of Pathology, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Sara Ramhormozian
- Department of Gynecologic Oncology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Simvastatin Inhibits Endometrial Cancer Malignant Behaviors by Suppressing RAS/Mitogen-Activated Protein Kinase (MAPK) Pathway-Mediated Reactive Oxygen Species (ROS) and Ferroptosis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:6177477. [PMID: 36276874 PMCID: PMC9586725 DOI: 10.1155/2022/6177477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/09/2022] [Accepted: 09/29/2022] [Indexed: 12/03/2022]
Abstract
This paper was designed to explore the function of simvastatin as a chemotherapeutic drug on the endometrial cancer (EC) cell proliferation, invasion, and ferroptosis. Firstly, a number of in vitro experiments were conducted to determine the impact of different treatments of simvastatin on the Ishikawa cell invasion, proliferation, and colony formation. The concentration of DCFH-DA-labeled reactive oxygen species (ROS) in cells was assessed by flow cytometry. Enzyme-linked immunosorbent assay (ELISA) was performed to examine the intracellular contents of Fe2+, malondialdehyde (MDA), and glutathione (GSH). Additionally, Western blot was utilized to measure the expression level of RAS/mitogen-activated protein kinase (MAPK)-related proteins and ferroptosis-related proteins in cells. The results showed that simvastatin at 10 μM and 15 μM apparently suppressed the proliferation of Ishikawa cells, colony formation, and invasion ability of Ishikawa cells, and upregulated the level of MDA and ROS, but downregulated the level of GSH. Besides, 10 μM and 15 μM of simvastatin promoted cell ferroptosis (up-regulation of Fe2+ and TRF 1 protein level; down-regulation of SLC7A11 and FPN protein level) and lowered the RAS, p-MEK, and ERK protein level. Furthermore, experiments also revealed that the inhibitory effects of simvastatin on Ishikawa cell proliferation, colony formation, and invasion, as well as the promoting effects on oxidation and ferroptosis were reversed. All in all, simvastatin reduces the RAS/MAPK signaling pathway to inhibit Ishikawa cell proliferation, colony formation, and invasion, and promote cell oxidation and ferroptosis. This paper demonstrates the potential of simvastatin as a new anticancer drug for EC.
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Nasioudis D, Oh J, Ko EM, Haggerty AF, Cory L, Giuntoli Ii RL, Kim SH, Morgan MA, Latif NA. Adjuvant chemotherapy for stage I high-intermediate risk endometrial carcinoma with lymph-vascular invasion. Int J Gynecol Cancer 2022; 32:ijgc-2022-003496. [PMID: 35649658 DOI: 10.1136/ijgc-2022-003496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The goal of this study was to evaluate if addition of adjuvant chemotherapy to radiation therapy improves overall survival in patients with high-intermediate risk stage I endometrial carcinoma with lymphovascular invasion. METHODS Patients diagnosed between January 2010 and December 2015 with FIGO (International Federation of Gynecology and Obstetrics) stage I endometrioid endometrial carcinoma with lymphovascular invasion who underwent hysterectomy with lymphadenectomy and met the GOG-99 criteria for high-intermediate risk were identified in the National Cancer Database. Patients who received adjuvant radiotherapy with or without adjuvant chemotherapy (administered within 6 months of surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared with the log-rank test following stratification by type of radiation treatment. A Cox model was constructed to control for a priori selected confounders. RESULTS A total of 2881 patients who met the inclusion criteria were identified; 2417 (83.9%) patients received radiation therapy alone while 464 (16.1%) received chemoradiation. Rate of adjuvant chemotherapy administration was comparable between patients who received vaginal brachytherapy alone (16.2%), and external beam radiation therapy (with or without vaginal brachytherapy) (15.8%), p=0.78. Rate of chemoradiation was higher for patients with grade 3 (28.8%) tumors compared with those with grade 2 (9.9%) and grade 1 (8.3%) tumors, p<0.001. After controlling for confounders for patients receiving external beam radiation, addition of chemotherapy was not associated with improved overall survival (HR 0.90, 95% CI 0.56 to 1.46). For patients receiving vaginal brachytherapy addition of chemotherapy was associated with better overall survival (HR 0.644, 95% CI 0.45 to 0.92). Benefit was limited to patients with grade 3 tumors, p=0.026; 4-year overall survival rate was 81.1% versus 74.9%. CONCLUSIONS In patients with high-intermediate risk FIGO stage I endometrioid endometrial carcinoma and lymphovascular invasion, addition of chemotherapy to radiation therapy was associated with a survival benefit for patients with grade 3 tumors receiving vaginal brachytherapy.
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Affiliation(s)
- Dimitrios Nasioudis
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinhee Oh
- Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Emily M Ko
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashley F Haggerty
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori Cory
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert L Giuntoli Ii
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah H Kim
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark A Morgan
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nawar A Latif
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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The Pattern of Recurrence in Carcinoma Endometrium. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00595-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The Prediction of Recurrence in Low-Risk Endometrial Cancer: Is It Time for a Paradigm Shift in Adjuvant Therapy? Reprod Sci 2021; 29:1068-1085. [DOI: 10.1007/s43032-021-00565-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
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10
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Reshko LB, Gaskins JT, Dryden SM, Metzinger DS, Todd SL, Eldredge-Hindy HB, Silva SR. Role of adjuvant chemotherapy in patients with FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma treated with surgery and post-operative radiotherapy. Int J Gynecol Cancer 2021; 31:694-701. [PMID: 33741653 DOI: 10.1136/ijgc-2021-002380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The optimal treatment of patients with FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma remains unknown. OBJECTIVE To compare overall survival following treatment with a hysterectomy and adjuvant radiotherapy with or without chemotherapy in this group of patients. METHODS Patients diagnosed between January 2004 and January 2016 with FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma treated with hysterectomy and postoperative radiotherapy with or without adjuvant concurrent chemotherapy were identified in the National Cancer Database. Overall survival was assessed with Kaplan-Meier curves. A Cox model was constructed to evaluate survival after controlling for confounding variables. A logistic regression model was used to reveal predictors of chemotherapy use. RESULTS A total of 2173 patients were included. The receipt of chemotherapy was associated with an increased 5-year overall survival from 67.6% to 75.6% (p=0.0313). This association trended toward statistical significance on multivariate analysis (adjusted HR (aHR) 0.80; 95% CI 0.63 to 1.01; p=0.0653). Other factors associated with improved survival were undergoing a lymphadenectomy, absence of lymphovascular space invasion, younger age, smaller tumor size, non-black race, and absence of comorbidities. Patients who underwent brachytherapy, had lymphovascular space invasion, were younger, were diagnosed in the more recent years, and were treated in higher volume centers were more likely to receive adjuvant chemotherapy. CONCLUSION Adjuvant chemotherapy and radiation therapy were associated with an increase in survival in patients with FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma compared with those treated with adjuvant radiotherapy alone.
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Affiliation(s)
- Leonid B Reshko
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Jeremy T Gaskins
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Sara M Dryden
- Department of Medical Education, University of Louisville, Louisville, Kentucky, USA
| | - Daniel S Metzinger
- Department of Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Sarah L Todd
- Department of Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Harriet B Eldredge-Hindy
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott R Silva
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA
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Tam C, Rao S, Waye MMY, Ng TB, Wang CC. Autophagy signals orchestrate chemoresistance of gynecological cancers. Biochim Biophys Acta Rev Cancer 2021; 1875:188525. [PMID: 33600824 DOI: 10.1016/j.bbcan.2021.188525] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/14/2022]
Abstract
Gynecological cancers are characterized by a high mortality rate when chemoresistance develops. Autophagy collaborates with apoptosis and participates in homeostasis of chemoresistance. Recent findings supported that crosstalk of necrotic, apoptotic and autophagic factors, and chemotherapy-driven hypoxia, oxidative stress and ER stress play critical roles in chemoresistance in gynecological cancers. Meanwhile, current studies have shown that autophagy could be regulated by and cooperate with metabolic regulator, survival factors, stemness factors and specific post-translation modification in chemoresistant tumor cells. Meanwhile, non-coding RNA and autophagy crosstalk also contribute to the chemoresistance. Until now, analysis of individual autophagy factors towards the clinical significance and chemoresistance in gynecological cancer is still lacking. We suggest comprehensive integrated analysis of cellular homeostasis and tumor microenvironment to clarify the role of autophagy and the associated factors in cancer progression and chemoresistance. Panel screening of pan-autophagic factors will pioneer the development of risk models for predicting efficacy of chemotherapy and guidelines for systematic treatment and precision medicine.
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Affiliation(s)
- Chit Tam
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China.
| | - Shitao Rao
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China; School of Medical Technology and Engineering, Fujian Medical University, Fujian, China
| | - Mary Miu Yee Waye
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Tzi Bun Ng
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China; School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China; Reproduction and Development Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
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12
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Substantial lymphovascular space invasion predicts worse outcomes in early-stage endometrioid endometrial cancer. Brachytherapy 2021; 20:527-535. [PMID: 33485810 DOI: 10.1016/j.brachy.2020.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Substantial as opposed to focal or no lymphovascular space invasion (LVSI) is proposed as an independent adverse prognostic factor in patients with early-stage endometrioid endometrial cancer (EEC). We reviewed outcomes of patients treated with adjuvant vaginal brachytherapy (VB) alone in a single institution, stratified by LVSI extent. METHODS AND MATERIALS Retrospective review identified Stage I-II EEC patients receiving VB alone from 2010 to 2017. Extent of LVSI was reported as none, focal, or substantial. Kaplan-Meier estimates and Log-Rank test were used to determine significance between variables. Cox proportional hazards model was used for multivariate analyses. RESULTS In total, 325 patients were identified with a median follow-up of 35 (23-48) months. LVSI was found in 112 patients with extent reported in 78, 45 (58%) had focal, and 33 (42%) substantial LVSI. Estimated disease-free survival for those with substantial LVSI was 73 (57-94)%, focal LVSI 89 (79-100)%, and no LVSI 94 (90-98)% at 48 months (p = 0.012). On multivariate analyses substantial LVSI was the only risk factor predictive of pelvic [HR substantial vs no: 7.2 (1.0-51.6); p = 0.048] and distant failure [HR substantial vs no: 4.4 (1.2-16.3); p = 0.027]. Both high-grade disease [HR 3 vs 1: 5.5 (1.2-25.6); p = 0.031] and extent of LVSI [HR substantial vs no: 4.4 (1.7-11.4); p = 0.002] predicted for worse disease-free survival. DISCUSSION Substantial LVSI was the strongest adverse prognostic factor for pelvic and distant failure in this cohort of EEC patients receiving adjuvant VB alone, suggesting this subset may benefit from additional adjuvant therapy. This study underscores the importance of quantifying LVSI extent in EEC.
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Tortorella L, Restaino S, Zannoni GF, Vizzielli G, Chiantera V, Cappuccio S, Gioè A, La Fera E, Dinoi G, Angelico G, Scambia G, Fanfani F. Substantial lymph-vascular space invasion (LVSI) as predictor of distant relapse and poor prognosis in low-risk early-stage endometrial cancer. J Gynecol Oncol 2021; 32:e11. [PMID: 33470061 PMCID: PMC7930448 DOI: 10.3802/jgo.2021.32.e11] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/08/2020] [Accepted: 12/05/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE The aim of this study is to analyze the prognostic role of lymph-vascular space invasion (LVSI), evaluated in a semi-quantitative fashion on prognosis of early stage, low risk endometrial cancer (EC). METHODS We enrolled patients who underwent surgery for endometrial cancer between 2003 and 2018 in two referral cancer center. All patients had endometrioid EC, G1-G2, with myometrial invasion <50%, and no lymph-node involvement. LVSI was analyzed in a semi-quantitative way, according to a 3-tiered scoring system in absent, focal and substantial. RESULTS Among 524 patients, any positive LVSI was found in 57 patients (10.9%) with focal LVSI (n=35, 6.7%) and substantial LVSI (n=22, 4.2%). Substantial LVSI was associated to higher rate of G2 (p<0.001), myometrial infiltration (p=0.002) and greater tumor dimensions (p=0.014). Patients with substantial LVSI were more likely to receive adjuvant treatment (6.6% vs. 52.6%, p<0.001). The 5-year OS was 99.5% in patients with absent LVSI and 70.6% in those with substantial LVSI (p<0.001). The 5-year disease free survival (DFS) was 93.6% in patients with absent LVSI and 56.5% in those with substantial LVSI (p<0.001). The rate of distant failures increased from 1.8% for absent LVSI to 22.7% for substantial LVSI (p=0.002). In univariate analysis substantial LVSI was the strongest predictor of poor overall survival (hazard ratio [HR]=11.9, p=0.001). Multivariate analysis showed that substantial LVSI was an independent predictive factor of both recurrence (HR=5.88, p=0.001) and distant failure (HR=10.6, p=0.006). CONCLUSIONS Substantial LVSI represents the strongest independent risk factor for decreased survival and distant relapse, indicating a role for potential hematogenous dissemination.
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Affiliation(s)
- Lucia Tortorella
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Stefano Restaino
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Gian Franco Zannoni
- Dipartimento della salute della Donna, del Bambino e di Sanità Pubblica, Area Anatomia Patologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Giuseppe Vizzielli
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Vito Chiantera
- Dipartimento di Ginecologia Oncologica, Università di Palermo, Palermo, Italia
| | - Serena Cappuccio
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Alessandro Gioè
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Eleonora La Fera
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Giorgia Dinoi
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Giuseppe Angelico
- Dipartimento della salute della Donna, del Bambino e di Sanità Pubblica, Area Anatomia Patologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Giovanni Scambia
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italia.
| | - Francesco Fanfani
- Dipartimento della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italia
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Liang M, Wang H, Liu C, Lei T, Min J. LncRNA RUNX1-IT1 is Downregulated in Endometrial Cancer and Binds to miR-21 Precursor to Suppress Its Maturation. Cancer Manag Res 2021; 12:13451-13459. [PMID: 33408517 PMCID: PMC7779314 DOI: 10.2147/cmar.s272165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background RUNX1-IT1 suppresses colorectal cancer and liver cancer, while its role in other cancers is unknown. This study was performed to investigate the role of RUNX1-IT1 in endometrial cancer (EC). Methods EC and paired non-tumor tissues were collected from 62 EC patients, and the expression of RUNX1-IT1, mature miR-21 and miR-21 precursor in these tissue samples were determined by RT-qPCR. Correlations were analyzed by linear regression. Overexpression of RUNX1-IT1 was achieved in EC cells and the expression of mature miR-21 and miR-21 precursor were analyzed by RT-qPCR. CCK-8 assay was used for cell proliferation analysis. Results We found that RUNX1-IT1 was downregulated in EC and inversely correlated with mature miR-21 but not miR-21 precursor. RUNX1-IT1 was predicted to bind with miR-21 precursor. The interaction between them was verified by dual-luciferase activity assay and RNA pull-down assay. In EC cells, overexpression of RUNX1-IT1 downregulated mature miR-21, but not miR-21 precursor. Overexpression of RUNX1-IT1 suppressed the role of miR-21 in increasing cell proliferation. Conclusion RUNX1-IT1 is downregulated in EC and inhibits cancer cell proliferation by suppressing the maturation of miR-21.
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Affiliation(s)
- Minglin Liang
- Department of Obstetrics and Gynecology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan City, Hubei Province 430022, People's Republic of China
| | - Hongbo Wang
- Department of Obstetrics and Gynecology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan City, Hubei Province 430022, People's Republic of China
| | - Cong Liu
- Department of Obstetrics and Gynecology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan City, Hubei Province 430022, People's Republic of China
| | - Tao Lei
- Department of Obstetrics and Gynecology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan City, Hubei Province 430022, People's Republic of China
| | - Jie Min
- Department of Obstetrics and Gynecology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan City, Hubei Province 430022, People's Republic of China
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15
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Son J, Chambers LM, Carr C, Michener CM, Yao M, Beavis A, Yen TT, Stone RL, Wethington SL, Fader AN, Burkett WC, Richardson DL, Staley AS, Ahn S, Gehrig PA, Torres D, Dowdy SC, Sullivan MW, Modesitt SC, Watson C, Veade A, Ehrisman J, Havrilesky L, Secord AA, Loreen A, Griffin K, Jackson A, Viswanathan A, Ricci S. Adjuvant treatment improves overall survival in women with high-intermediate risk early-stage endometrial cancer with lymphovascular space invasion. Int J Gynecol Cancer 2020; 30:1738-1747. [PMID: 32771986 DOI: 10.1136/ijgc-2020-001454] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Adjuvant therapy in early-stage endometrial cancer has not shown a clear overall survival benefit, and hence, patient selection remains crucial. OBJECTIVE To determine whether women with high-intermediate risk, early-stage endometrial cancer with lymphovascular space invasion particularly benefit from adjuvant treatment in improving oncologic outcomes. METHODS A multi-center retrospective study was conducted in women with stage IA, IB, and II endometrial cancer with lymphovascular space invasion who met criteria for high-intermediate risk by Gynecologic Oncology Group (GOG) 99. Patients were stratified by the type of adjuvant treatment received. Clinical and pathologic features were abstracted. Progression-free and overall survival were evaluated using multivariable analysis. RESULTS 405 patients were included with the median age of 67 years (range 27-92, IQR 59-73). 75.0% of the patients had full staging with lymphadenectomy, and 8.6% had sentinel lymph node biopsy (total 83.6%). After surgery, 24.9% of the patients underwent observation and 75.1% received adjuvant therapy, which included external beam radiation therapy (15.1%), vaginal brachytherapy (45.4%), and combined brachytherapy + chemotherapy (19.1%). Overall, adjuvant treatment resulted in improved oncologic outcomes for both 5-year progression-free survival (77.2% vs 69.6%, HR 0.55, p=0.01) and overall survival (81.5% vs 60.2%, HR 0.42, p<0.001). After adjusting for stage, grade 2/3, and age, improved progression-free survival and overall survival were observed for the following adjuvant subgroups compared with observation: external beam radiation (overall survival HR 0.47, p=0.047, progression-free survival not significant), vaginal brachytherapy (overall survival HR 0.35, p<0.001; progression-free survival HR 0.42, p=0.003), and brachytherapy + chemotherapy (overall survival HR 0.30 p=0.002; progression-free survival HR 0.35, p=0.006). Compared with vaginal brachytherapy alone, external beam radiation or the addition of chemotherapy did not further improve progression-free survival (p=0.80, p=0.65, respectively) or overall survival (p=0.47, p=0.74, respectively). CONCLUSION Adjuvant therapy improves both progression-free survival and overall survival in women with early-stage endometrial cancer meeting high-intermediate risk criteria with lymphovascular space invasion. External beam radiation or adding chemotherapy did not confer additional survival advantage compared with vaginal brachytherapy alone.
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Affiliation(s)
- Ji Son
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura M Chambers
- Division of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Caitlin Carr
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chad M Michener
- Division of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Beavis
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ting-Tai Yen
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca L Stone
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie L Wethington
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda N Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wesley C Burkett
- Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Debra L Richardson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Allison S Staley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susie Ahn
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paola A Gehrig
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diogo Torres
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackenzie W Sullivan
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Susan C Modesitt
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Catherine Watson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Ashley Veade
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jessie Ehrisman
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Amy Loreen
- Department of Obstetrics and Gynecology, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
| | - Kaitlyn Griffin
- Department of Obstetrics and Gynecology, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
| | - Amanda Jackson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
| | - Akila Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Ricci
- Division of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
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