Endometrial cancer

PFKFB4 promotes endometrial cancer by regulating glycolysis through SRC‑3 phosphorylation

The present study aimed to investigate the role of 6‑phosphofructo‑2‑kinase/fructose‑2,6‑biphosphatase 4 (PFKFB4) in endometrial cancer cells and to explore its potential molecular mechanisms. PFKFB4 expression in endometrial cancer tissues was detected by immunohistochemistry. Cell Counting Kit‑8, Transwell assays and flow cytometry were used to detect cell proliferation, invasion and apoptosis in endometrial cancer cells after PFKFB4 knockdown. An enzyme‑linked immunosorbent assay was used to detect the glucose and lactic acid contents. Western blotting was performed to detect the levels of glycolysis‑related enzymes, steroid receptor coactivator‑3 (SRC‑3), and phosphorylated SRC‑3. In vivo experiments were performed to investigate the tumorigenic potential of PFKFB4. PFKFB4 expression was upregulated in endometrial cancer tissues compared with that in normal controls, and its upregulation was positively correlated with the depth of myometrial invasion, lymph node metastasis, surgical pathological stage and vascular invasion. PFKFB4 knockdown significantly inhibited proliferation and invasion, increased apoptosis, and decreased oxygen consumption and lactic acid production in endometrial cancer cells. PFKFB4 knockdown decreased SRC‑3 phosphorylation. After simultaneous PFKFB4 knockdown and SRC‑3 overexpression in cancer cells, oxygen consumption, lactic acid production, and glycolysis‑related protein expression were increased compared with those in control cells. PFKFB4 knockdown inhibited tumor proliferation, apoptosis and the expression of Ki‑67. PFKFB4 may regulate glycolysis in endometrial cancer cells by targeting SRC‑3, thus promoting endometrial cancer progression.

Skull Base Metastasis of Uterine Carcinosarcoma Mimicking Primary Carcinoma of the Middle Ear

ABSTRACT

Uterine carcinosarcoma is a rare type of endometrial carcinoma with poor prognosis. A bone metastasis to the skull base is extremely scarce in uterine carcinosarcoma. A 54-year-old woman with uterine carcinosarcoma complained of right ear otorrhea and otalgia. 18 F-FDG PET/CT presented an increased FDG uptake at the right middle ear involving the mastoid process and external acoustic meatus. Primary carcinoma of the middle ear was considered according to clinical symptoms and PET manifestation. However, the skull base metastasis from uterine carcinosarcoma was pathologically confirmed. The rare metastasis from uterine carcinosarcoma should be differentiated from primary carcinoma of the middle ear.

Association of peripheral monocytic myeloid-derived suppressor cells with molecular subtypes in single-center endometrial cancer patients receiving carboplatin + paclitaxel/avelumab (MITO-END3 trial)

The MITO-END3 trial compared carboplatin and paclitaxel (CP) with avelumab plus carboplatin and paclitaxel (CPA) as first-line treatment in endometrial cancer (EC) patients and demonstrated a significant interaction between avelumab response and mismatch repair status. To investigate prognostic/predictive biomarker, 29 MITO-END3-EC patients were evaluated at pretreatment (B1) and at the end of CP/CPA treatment (B2) for peripheral myeloid-derived suppressor cells (MDSC) and Tregs. At B2, effector Tregs frequency was significantly higher in patients treated with CPA as compared to CP (p = 0.038). Both treatments (CP/CPA) induced significant decrease in peripheral M-MDSC (- 5.41%) in TCGA 2-MSI-high as compared to TCGA-category 4 tumors (p = 0.004). In accordance, both treatments induced M-MDSCs (+ 5.34%) in MSS patients as compared to MSI-high patients (p = 0.001). Moreover, in a subgroup of patients, primary tumors were highly infiltrated by M-MDSCs in MSS as compared to MSI-high ECs. A post hoc analysis displayed higher frequency of M-MDSCs (p = 0.020) and lower frequency of CD4+ (p < 0.005) at pretreatment in EC patients as compared to healthy donors. In conclusion, the peripheral evaluation of MDSCs and Tregs correlated with molecular features in EC treated with CP/CPA and may add insights in identifying EC patients responder to first-line chemo/chemo-immunotherapy.

Surgical Management of Endometrial Intraepithelial Neoplasia at Military Treatment Facilities: A Multicenter Retrospective Study

INTRODUCTION

Endometrial intraepithelial neoplasia (EIN), also known as atypical endometrial hyperplasia (AEH), is a precursor lesion of endometrial carcinoma (EC). In endometrial cancer patients, lymph node assessment with biopsy during hysterectomy is part of surgical staging. However, routine lymph node assessment for EIN is inconsistently utilized. This study aims to investigate the surgical management of EIN in the military to inform best-practice guidelines tailored for the Military Health System to avoid delays in care, manage cost, ensure military readiness and optimize clinical outcome.

MATERIALS AND METHODS

We performed a retrospective chart review of patients with EIN treated at 2 military treatment facilities over a 10-year period between July 1, 2013 and July 1, 2023. Pathology reports were queried to identify patients with a preoperative diagnosis of EIN. Patients not surgically managed were excluded. Statistical analysis was performed using chi-squared test and Wilcoxon rank-sum test. Independent associations were investigated using logistic regression modeling.

RESULTS

There were 95 evaluable patients with an EIN diagnosis, including 43 (45.3%) patients upstaged to EC based on final pathology (95% CI: 35.0-55.8). Older patients diagnosed with EIN ≥65 years old and those with endometrial thickness ≥15 mm exhibited the highest risk for upstaging EIN to an EC diagnosis. Of the 50 patients who underwent lymph node assessment, none had positive lymph nodes. Patients diagnosed with EIN via hysteroscopy vs. an endometrial biopsy had the lowest risk of being upstaged to EC.

CONCLUSIONS

Upstaging from EIN to EC occurred in 45.3% of the 95 patients emphasizing the value of performing surgicopathologic staging in this setting. In contrast, none of the 50 EIN patients who underwent lymph node resection had positive lymph nodes indicating morbidity risk with low likelihood of clinical benefit. We identified risk factors for upstaging to EC, including age ≥65 years and endometrial thickness ≥15 mm, and confirmed the diagnostic superiority of hysteroscopy. These findings have informed clinical practice guideline recommendations for the surgical management of EIN in the Military Health System.

Regional differences in the disease burden and attributable risk factors of female cancers

The aim was to assess the differences in the burden and risk factors of female cancers among women aged 20-94 years across regions and countries, in order to provide a reference for formulating tailored interventions. The study analyzed the incidence, deaths, and disability-adjusted life years (DALYs) using data from the Global Burden of Disease 2021 study. Age-period-cohort model evaluated the effects of the age, period, and cohort on the burden, and negative binomial regression explored the association of the socio-demographic index (SDI) with the burden. From 1990 to 2021, regional and national incidence, deaths, and DALYs of female cancers varied markedly. Overall, SDI was significantly positively associated with the incidence of female cancers, except for cervical cancer (with a negative relationship). High body-mass index as the leading risk factor of uterine cancer contributed to the higher burden, such as in the USA and higher SDI regions. Diet high in red meat, unsafe sex, and high body-mass index were the leading risk factors for breast cancer, cervical cancer, and uterine cancer, respectively; however, other socioeconomic and cultural factors should be considered, such as in the rural areas of China and lower SDI regions. A slightly increasing trend in the burden of breast cancer in the recent birth cohorts indicated the effect of generational experiences. The disease burden of female cancers has increased and varies with SDI levels and regions. The findings provide new insights into the development of targeted preventive measures for the specific region from the perspective of social and cultural context.

Immune microenvironment and molecular mechanisms in endometrial cancer: implications for resistance and innovative treatments

This review provides a systematic overview of the molecular mechanisms of endometrial cancer and its drug resistance, particularly involving the aberrant activation of some key signaling pathways. These molecular mechanisms significantly affect the therapeutic outcome of endometrial cancer by promoting tumor cell proliferation, anti-apoptosis, and drug resistance. The article also analyzes the critical role of the immune microenvironment in cancer drug resistance, focusing on the impact of immune cells, immune checkpoints, and hypoxic metabolic reprogramming on anticancer therapies. In recent years, immunotherapy and individualized therapy have shown promising clinical outcomes, especially in advanced endometrial cancer. This article summarizes recent advances in related therapeutic strategies and proposes emerging therapeutic strategies by targeting key pathways and modulating the immune microenvironment to overcome drug resistance and improve patient prognosis.

Engineered Endometrial Clear Cell Cancer-on-a-Chip Reveals Early Invasion-Metastasis Cascade of Cancer Cells

Endometrial clear cell cancer (ECCC) is an extremely rare and highly malignant subtype of endometrial cancer. For most ECCC patients, cancer metastasis is the major cause of death. To date, due to the complexity of cancer evolution and the small number of cases, the metastasis of ECCC at the early stage remains largely unknown. Herein, we modeled the early invasion-metastasis cascade of ECCC by coculturing the ECCC patient-derived tumor cells (PDTCs) and primary human vascular endothelial cells on a microfluidic chip. With the chip, we for the first time replicated the dynamic migration of PDTCs into the surrounding stroma, including the intravasation and extravasation of PDTCs through the capillaries/microvessels, and presented the changes in the morphology and permeability of capillaries, with the decreased diameter and the increased permeability after cancer metastasis. We found that PDTCs were more invasive than the common endometrial adenocarcinoma cells. In addition, we preliminarily explored the inhibition of drugs on the early PDTC infiltration. This study provides new ideas for better understanding of ECCC evolution.

SIM2, associated with clinicopathologic features, promotes the malignant biological behaviors of endometrial carcinoma cells

BACKGROUND

Endometrial carcinoma (EC) poses a significant threat to women's health. Identifying effective prognostic biomarkers and therapeutic targets is essential for improving survival rates in EC patients. This study aimed to identify key regulators involved in EC progression and investigate the biological functions of SIM bHLH transcription factor 2 (SIM2) in EC.

METHODS

Gene expression profiles and clinical data from EC and control samples were retrieved from the TCGA and GEO databases. Differential expression analysis and weighted gene co-expression network analysis (WGCNA) were used to identify genes associated with EC tumorigenesis and progression. The least absolute shrinkage and selection operator (LASSO) method was applied to further screen prognostic genes and construct a prognostic risk model. The expression and biological function of SIM2 were analyzed using the GEPIA, HPA, and LinkedOmics databases. SIM2 knockdown and overexpression models were established in EC cell lines, and their function was validated through qRT-PCR, CCK-8, flow cytometry, and western blot. Additionally, an in vivo lung/liver metastasis model was employed to further validate the cancer-promoting properties of SIM2 in EC.

RESULTS

WGCNA identified 343 EC-related genes. Cox regression analysis and LASSO were further applied to identify 13 prognostic genes, leading to the development of a robust prognostic risk model that effectively predicted EC patients' clinical outcomes. Significant differences in the tumor immune microenvironment were observed between the high- and low-risk groups. Among these 13 genes, SIM2 was significantly overexpressed in EC tissues, and its high expression was associated with poor prognosis in EC patients. SIM2 depletion inhibited EC cell viability, induced cell cycle arrest, and promoted apoptosis. Additionally, SIM2 knockdown increased the expression of cleaved caspase-3 and reduced the levels of Cyclin D1 and CDK4 proteins, while SIM2 overexpression showed the opposite effects. In vivo, silencing SIM2 notably suppressed the metastatic potential of EC cells.

CONCLUSION

SIM2 serves as both a biomarker and a therapeutic target for EC diagnosis and prognosis prediction, which positively modulates the malignant phenotypes of EC cells.

Oroxylin A may promote cell apoptosis and inhibit epithelial-mesenchymal transition in endometrial cancer, associated with the ERβ/PI3K/AKT pathway

Endometrial cancer (EC) is a prevalent gynecological cancer worldwide, often associated with poor prognosis after recurrence or metastasis. Oroxylin A (OA) is an active flavonoid compound with a strong anti-tumor function. However, the effects of OA on EC remain unknown. In this study, we planned to investigate the anti-EC effects of OA and explore its mechanisms. Five cell lines were used for in vitro experiments, and female BALB/c nude mice were applied for xenograft experiments. The cytotoxicity and experimental concentration of OA were detected by CCK-8. Wound healing, transwell, and colony formation assays were used to evaluate the anti-metastatic and anti-proliferative activities of OA on EC cells. TUNEL assay and flow cytometry were applied for the evaluation of apoptosis. Network pharmacology was used to explore potential targets, and molecular dynamics simulations and dockings were applied for the quantification of binding energy, and stability of OA. RT-qPCR, WB, and immunofluorescence were applied for the detection of localization and expression of correlated markers. The results showed that OA notably inhibited the proliferation, migration, and invasion of Ishikawa cells. Meanwhile, in vivo Ishikawa xenograft assays demonstrated that OA notably inhibited growth and promoted apoptosis of EC. Mechanistically, after treatment with OA, the expressions of Cleaved Caspase-3, BAX, E-cadherin, and ERβ were increased, while the expressions of Bcl-2, Vimentin, N-cadherin, MMP2, MMP9, PI3K and phospho-AKT (Ser473) were decreased. Therefore, OA may exhibit significant anti-EC effects by regulating the ERβ/PI3K/AKT pathway to promote apoptosis and inhibit epithelial-mesenchymal transition (EMT).

TRIM22 governs tumorigenesis and protects against endometrial cancer-associated cachexia by inhibiting inflammatory response and adipose thermogenic activity

BACKGROUND

Endometrial cancer (EC) is one of the most common cancers in women, with a short overall survival and poor prognosis. Besides the biologically aggressive EC properties, Cancer-associated cachexia is the main factor. However, the detailed mechanism underlying EC-related cachexia and its harmful effects on EC progression and patient prognosis remains unclear.

METHODS

For clinical specimen and the vitro experiment, we detected TRIM22 expression level, EC patients' survival time, EC cell functional change, and adipose thermogenic changes to identify the function of TRIM22 in EC progression, EC-associated cachexia, and their molecular mechanisms. Then, for the vivo experiment, we exploited the xenografts in mice to identify the function of TRIM22 again, and to screen the drug therapeutic schedule.

RESULTS

Herein, we demonstrated that TRIM22 inhibited EC cell growth, invasion, and migration. Interleukin (IL)-6 mediated brown adipose tissue activation and white adipose tissue browning which induced EC-related cachexia. TRIM22 suppressed the EC cells' secretion of IL-6, and IL-6 mediated EC-related cachexia. Mechanistically, TRIM22 inhibited EC progression by suppressing the nucleotide-binding oligomerization domain 2(NOD2)/nuclear factor-kappaB (NF-κB) signaling pathway, with the purpose of impeding the production of IL-6. Moreover, we revealed that TRIM22 inhibited EC-associated cachexia by suppressing the IL-6/IL-6 receptor (IL-6R) signaling pathway. Therapeutically, we demonstrated that combination treatment with a TRIM22 inducer (progesterone) and a thermogenic inhibitor (IL-6R antibody) synergistically augmented the antitumor efficacy of carbotaxol (carboplatin and paclitaxel), in vivo.

CONCLUSION

Our data reveals that TRIM22-EC-IL-6-cachexia cross-communication has important clinical relevance and that the use of combined therapy holds great promise for enhancing the efficacy of anti-ECs. (Fig. graphical abstract).

MTA1-DT promotes endometrial cancer growth by modulating G2/M-related gene transcription via PURα

In recent years, patients with early endometrial cancer (EC) can achieve a good prognosis through surgery. However, advanced and recurrent cases have still posed significant therapeutic challenges. This study aimed to investigate the biological function of long non-coding RNAs (lncRNAs) in EC and elucidate its underlying molecular mechanism. Through quantitative reverse transcription polymerase chain reaction (RT-qPCR) analysis, functional assays in cell lines, and bioinformatics approaches, we identified lncRNA MTA1-DT as a novel oncogenic factor in EC progression. RNA-seq and RT-qPCR analysis demonstrated that MTA1-DT was significantly upregulated with a 5-fold increase in EC cell lines compared to normal controls. Functional studies revealed that MTA1-DT promoted cell proliferation and migration. Mechanistically, we demonstrated that MTA1-DT physically interacted with purine-rich element binding protein-alpha (PURα) and facilitated its nuclear translocation, thereby enhancing its transcription factor activity. This nuclear accumulation of PURα promoted the transcription of downstream G2/M related genes, particularly EGF, leading to accelerated tumor growth. Thus, these results indicate that MTA1-DT exerts its oncogenic effects in EC through regulation of the cell cycle. Our findings establish MTA1-DT as a promising therapeutic target for EC treatment and provide new insights into the molecular mechanisms underlying EC progression.

Deciphering the mysteries of MEG3 LncRNA and its implications in genitourinary cancers

Maternally expressed gene 3 (MEG3), a long non-coding RNA, plays a pivotal role in various biological processes, including tumorigenesis. Aberrant expression of MEG3 has been implicated in several cancers, including genitourinary malignancies. This comprehensive review explores the multifaceted functions of MEG3 in the context of genitourinary cancers through unravelling the molecular mechanisms underlying the influence of MEG3 on cellular proliferation, apoptosis, invasion, and metastasis. Additionally, we discuss the potential clinical implications of MEG3 as a biomarker and therapeutic target in genitourinary cancers. By unraveling the intricate role of MEG3 in these biological processes, this review aims to contribute to the development of novel strategies for the diagnosis and treatment of genitourinary malignancies.

Identifying risk factors for postoperative complications following staging surgery for endometrial cancer

INTRODUCTION

Endometrial cancer is the most prevalent gynecologic malignancy, with increasing incidence primarily due to aging, obesity, and diabetes. Surgical staging, a gold standard treatment involving total hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node biopsy, presents various postoperative complications influencing patient outcomes and healthcare costs. This study aims to identify risk factors associated with short term postoperative complications following staging surgery for endometrial cancer.

METHODS

A retrospective cohort study conducted at a single university-affiliated medical center from January 2016 to December 2022. Data were extracted from electronic medical records, including patient demographics and comorbidities, surgical data including intraoperative complications, tumor histology and surgical outcomes. A composite adverse post operative outcome was defined, including need for post-operative blood transfusion, antibiotic treatment, Intensive care unit (ICU) admission, prolonged hospitalization, and 30-day readmission rates.

RESULTS

Among 495 patients, 34.3 % experienced at least one postoperative complication. Significant factors associated with complications included age over 65, ASA score >2, pathologic grade 3 tumours, and non-minimally invasive surgical approaches. Prolonged operative time (>75th percentile) and intraoperative complications also correlated with increased risk. Conversely, higher preoperative haemoglobin levels were protective against complications.

CONCLUSION

The findings emphasize the importance of recognizing risk factors such as advanced age, elevated ASA scores, and specific tumor characteristics to enhance preoperative assessments and surgical planning. By tailoring surgical approaches and optimizing patient preparation, healthcare providers may improve postoperative outcomes and reduce complications for patients undergoing staging surgery for endometrial cancer.

Experience of healthcare discrimination reported by individuals with a history of gynecologic cancer in the All of Us research program

Objective

We aimed to describe prevalence of healthcare discrimination in All of Us participants with a history of gynecologic cancer and compare patient experiences of discrimination by gynecologic cancer type.

Methods

We analyzed survey data of participants with a history of gynecologic cancer in the All of Us Research Program. Cancer status was defined using self-report or electronic health record documentation. Healthcare discrimination was measured by the Discrimination in Medical Settings (DMS) Scale. Potential confounders were self-reported (cigarette use, sexual orientation, gender, race, ethnicity, income, education, and age) and physical measurement (body mass index). We report associations between gynecologic cancer site (cervical, ovarian, uterine, vaginal or vulvar, more than one) and DMS scores using multivariable logistic regression.

Results

Of 2,195 participants, 1,001 had cervical, 579 uterine, 419 ovarian, 30 vaginal/vulvar, and 166 more than one gynecologic cancer. Most (76.5%) reported experiencing any healthcare discrimination, and 45.0% reported frequent healthcare discrimination. Those with a history of cervical cancer (52%, OR: 1.80, 95% CI: 1.42, 2.28) and multiple cancers (47.8%, OR: 1.53, 95% CI: 1.05, 2.21) had higher odds of frequently reporting discrimination than those with a history of ovarian cancer (37.5%) in the unadjusted model. The relationship observed remained but was attenuated in the adjusted model (Cervical OR: 1.35, 95% CI: 1.04, 1.75; Multiple OR: 1.35 95% CI: 0.91, 2.00).

Conclusions

Healthcare discrimination was reported across cancer types. Individuals with a history of cervical or multiple gynecologic malignancies reported frequent healthcare discrimination more often than those with other gynecologic cancers.

The tumor suppressor role and epigenetic regulation of 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in cancer and tumor microenvironment (TME)

Oxidative stress and inflammation may initiate carcinogenesis and facilitate metastasis via activation of pro-inflammatory signaling network. The side product of arachidonic acid processing by cyclooxygenase-2 (COX-2), the prostaglandin E2 (PGE2), plays a key role in various metabolic disorders and during inflammation-mediated tumorigenesis. It has been demonstrated that PGE2 increases the proliferation, migration, invasion, metastasis, and resistance of cancer cells to apoptosis and other forms of programmed cell death. The expression level of PGE2 metabolizing enzyme 15-hydroxyprostaglandin dehydrogenase (15-PGDH) is often decreased in various malignancies. However, the role of 15-PGDH and PGE2 in the regulation of carcinogenesis remains controversial. Numerous cancer cell lines and mouse models have demonstrated the role of 15-PGDH as a tumor suppressor. Downregulation of 15-PGDH increased cancer cell proliferation, migration, anchorage independent growth, colony formation while overexpression reversed these effects, by inducing apoptosis and cell cycle arrest in vitro and in vivo. The expression of 15-PGDH is regulated by various mechanisms, including (a) epigenetic alterations (methylation of promoter region, histone deacetylases, microRNAs (miR-21, miR-26a/b, miR-106b-5p, miR-146b-3p, miR-155, miR-218-5p, and miR-620)); and (b) dysregulated oxidative stress and associated mediators (elevated levels of growth factors and proinflammatory cytokines (such as IL1β and TNFα)). Several transcription factors, such as HNF3β, β-catenin, Snail, Slug, can bind to 15-PGDH promoter region and downregulate the enzyme expression. In contrast, the expression of 15-PGDH can be upregulated by several anti-inflammatory cytokines and anti-cancer agents, such as IL10 and vitamin D. The functional activity of 15-PGDH protein can be modulated by signaling effectors and oxidative stress, including increased production of reactive oxygen species (ROS). However, the role of oxidative stress regulator protein, i.e., nuclear factor erythroid 2-related factor 2 (Nrf2), in the control of 15-PGDH expression remains unclear. This article provides insights and comprehensive overview of the tumor suppressor role of 15-PGDH in various cancers. Epigenetic and post-translational mechanisms regulating 15-PGDH expression and the role of novel ROS-Nrf2-15-PGDH axis were discussed and accented as potential drug targets.

Preoperative risk stratification of early-stage endometrial cancer assessed by multimodal magnetic resonance functional imaging

Endometrial cancer is a common disease in women. Stratifying the risk of early-stage endometrial cancer can aid in personalized treatment for patients. Risk stratification is primarily based on tumor grade, histological type, lymph node metastasis, and depth of myometrial invasion. Multimodal magnetic resonance functional imaging (including DCE-MRI, DWI, IVIM, DTI, DKI) has significant value in assessing the extent of myometrial and cervical infiltration, extrauterine involvement range, determining lymph node metastasis and tumor size. This article provides a brief overview of these techniques.

Methods of surgical quality assurance in cervical and endometrial cancer trials: a systematic review and meta-analysis

Surgery quality in gynecology oncology trials varies, potentially biasing results. This systematic review examines methods for assuring surgical quality in multi-center gynecologic oncology trials and the impact on patient outcomes. A systematic search (2000-2023) was conducted in Medline, Embase, and Web of Science. Multi-center randomized controlled trials reporting on surgical endometrial and cervical cancer trials and lymph node harvest, short-term mortality, or conversion rate were included. Studies were assessed using a 10-point checklist to determine surgical quality. This was used to assess the association with variation in lymph node harvest, post-operative mortality, and conversion rate. Overall, 5963 titles and abstracts were screened for their eligibility and 10 studies reporting on 22 surgical-only arms were included for further analysis. The total number of included patients was 7434 from 366 centers. Analysis showed that standardization of surgical approach (β = -6.6, 95%, p = .043), standardization of the extent of lymphadenectomy (β = -2.432, p = .004), video assessment pre-trial (β = -3.492, p = .04) and monitoring of data including clinical outcome measures (β = -4.018, p = .009) were significantly associated with reducing variation in lymph node harvest. It also showed that standardization of the extent of lymphadenectomy (β = -0.718, p < .001) and pre-trial case/procedure volume assessment (β = -0.531, p = .049) were significantly associated with reducing short-term mortality. The regression model showed standardization of the extent of lymphadenectomy (β = -3.123, p = .034) was significantly associated with reducing conversion rate. In conclusion, the heterogeneity of surgical quality measures showed that there is no clear consensus on the approach to delivering surgical quality assurance in gynecology oncology trials. The analysis in this evidence synthesis has shown a potential association between different aspects of surgical quality assurance and clinical outcomes. Further research is required to develop a framework ensuring surgical quality deliverance in gynecology oncology trials.

Knockdown of HSF1 inhibits invasion, metastasis, and proliferation of endometrial carcinoma cells while promoting apoptosis

BackgroundHeat shock factor 1 (HSF1), the principal transcriptional regulator of cellular stress responses, has been exhibited to play a role in the progression of various human cancer types. However, the function of HSF1 in endometrial cancer (EC) has not yet been evaluated.ObjectiveThis study examined the expression and role of HSF1 in EC.MethodsImmunohistochemistry was performed to explore HSF1 level in 135 endometrial tissue specimens. The relationship between HSF1 level and EC patients' clinicopathological characteristics was analyzed. Quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and Western blotting were employed to explore HSF1 expression level in tissues in vitro. Small interfering RNA (siRNA) was employed to suppress HSF1 expression level. The invasion and migration capacities were evaluated using transwell and wound healing assays. Cell cycle arrest and apoptosis were assessed by flow cytometric analysis.ResultsEC tissues exhibited higher HSF1 expression level compared with normal endometrial and atypical endometrial hyperplasia tissues. High HSF1 expression level was associated with histological grade, muscular invasion, lymph node metastasis, and estrogen receptor (ER) expression level in EC tissues and cells. Kaplan-Meier analysis indicated that EC patients with elevated HSF1 expression level had poorer overall survival. Knockdown of HSF1 in EC cells resulted in cell cycle arrest, increased apoptosis, and inhibited EC cell proliferation, invasion, and migration.ConclusionThe results demonstrated that HSF1 could function as an oncogene in EC. HSF1 could play a notable role in EC progression. HSF1 may be a potential molecular target for both the treatment and prognosis of patients with EC.

A Single Arm Pilot Observational Study to Evaluate the Safety and Feasibility of a Pre-Operative Very Low Calorie Diet in Severely Obese Patients With Endometrial Cancer

BACKGROUND

Pre-operative very low calorie diets (VLCDs) can achieve rapid and safe weight loss, yet no studies have evaluated VLCDs in the severely obese endometrial cancer population prior to surgery. Our aim was to evaluate the safety and feasibility of a 4-6 week pre-operative nutritional intervention with the Optifast VLCD prior to surgery in patients with clinical stage 1, Grade 1 endometrioid endometrial adenocarcinoma and a body mass index ≥ 35 kg/m2.

METHODS

This was an investigator-initiated single-arm prospective observational study. Co-primary endpoints were safety and feasibility. Secondary endpoints were changes in anthropometric measures, blood pressure, biochemistry, perioperative complications, length of stay and final tumour stage. Tolerability and compliance of the VLCD were assessed by fortnightly questionnaires and urinary ketones.

RESULTS

Twenty-eight patients were enrolled, of which 25 underwent the intervention. 22/25 patients (88%) completed at least 4 weeks of Optifast. Mean (SD) age was 56.4 (6.3) years, and mean body mass index (BMI) was 45.2 (7.1) kg/m2. Significant decreases in weight (mean 8.2 kg [3.6]), BMI (mean 3.1 kg/m2 [1.3]), waist and hip circumference (mean 5.7 [6.5] and 4.5 cm [4.1], respectively), and diastolic blood pressure (10 mmHg [14.1]) were observed (p < 0.001 for all). One patient had a flare of gout. All patients had laparoscopic surgery without adverse events. Optifast was considered acceptable, and compliance was 40% to 61.9%. Eighty-eight percent (22/25) of patients had FIGO 2009 Stage 1A Grade 1 endometrioid endometrial adenocarcinoma on final staging.

CONCLUSIONS

A 4-6 week pre-operative VLCD in severely obese clinically low-risk endometrial cancer patients appears safe, feasible and well tolerated.

Immune checkpoint inhibitor restores daily function in patient with microsatellite instability (MSI)-high advanced endometrial cancer and poor performance status

The immune checkpoint system suppresses T-cell activity. Unlike cytotoxic anticancer drugs that directly kill cells, immune checkpoint inhibitors (ICIs) are generally safer by stimulating tumor immunity. However, most clinical trials require patients to have a better performance status (PS), leaving limited evidence for those with poorer PS. In practice, patients may be classified with poor PS due to tumor-induced pain and motor dysfunction, even if major organs remain functional. Real-world data on non-small cell lung cancer has shown no safety difference between patients with PS 3/4 and those with lower PS. Approximately 20-30% of endometrial cancer cases show microsatellite instability-high (MSI-high), the highest among common malignancies. A 46-year-old patient with advanced, recurrent endometrial cancer resistant to standard chemotherapy, and PS of 4 from severe pelvic pain, was diagnosed with MSI-high. Pembrolizumab was initiated and continued for 19 courses, after which lesions had disappeared or calcified, leading to drug discontinuation. Now, 4 and a half years post-treatment, she has regained independent mobility and returned to work, and her PS has improved to approximately 1. Side effects included Grade 2 or lower thyroiditis, hypothyroidism, and hypoadrenalism, manageable with hormone replacement therapy and temporary pembrolizumab suspension. This case underscores the need to test for MSI-high/mismatch repair deficiency in endometrial cancer and to consider ICI therapy in patients with poor PS but no major organ dysfunction. In such cases, ICI can rapidly improve overall condition, a phenomenon known as a Lazarus-type response, as seen in other cancers such as non-small cell lung cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13691-025-00752-3.

Hysteroscopic endometrial laser ablation - A novel approach for palliative management of endometrial cancer in inoperable patients

Background

Endometrial cancer, the most common gynecologic malignancy in developed nations, poses substantial treatment challenges, particularly in patients with significant comorbidities or advanced obesity.

Purpose

This manuscript introduces an innovative method that employs awake hysteroscopic endometrial laser ablation (HEA) as a palliative treatment for patients with endometrial cancer who were either inoperable or medically unfit to undergo general or regional anaesthesia for conventional therapies.

Methods

A retrospective evaluation of patients diagnosed with endometrial cancer at a tertiary center from 2019 to 2024, focusing on those with symptomatic uterine bleeding, who failed previous treatment options and could not undergo surgical or standard palliative interventions due to high surgical risk.

Results

In our study, three patients (n = 3) with severe medical conditions-high BMI and poor performance status-underwent awake HEA using a vaginoscopic approach, treating symptomatic vaginal bleeding effectively. The procedure allowed for rapid treatment, minimal recovery time, and enhanced quality of life. Histological analyses post-ablation indicated satisfactory outcomes, contributing to symptom relief and stabilization of patients' conditions.

Conclusion

Our findings highlight the potential of conscious HEA as a palliative management strategy in high-risk patient populations, emphasizing its role when conventional therapies fail. This study underscores the importance of personalized treatment plans and multidisciplinary approaches in managing endometrial cancer, paving the way for further research into the safety and efficacy of HEA in similar cohorts.

The prognostic value of tumor microenvironment in endometrioid type endometrial cancer: Effect of CD44 on oncologic outcome

OBJECTIVES

The study aimed to evaluate the expression of CD44, CD47, interleukin-1 (IL-1), and tumor necrosis factor alpha (TNF-α) in immunohistochemically stained (IHS) samples from endometrioid endometrial cancer (EEC) and to examine their correlation with clinicopathologic parameters.

METHODS

IHS was used to assess CD44, CD47, IL-1, and TNF-α expression in 53 EEC samples. Immunostaining was scored as negative (-), slightly positive (+), moderately positive (++), or strongly/diffuse positive (+++). The prognostic value of these markers was analyzed in relation to clinicopathologic features, including survival.

RESULTS

In endometrial cancer tissues, positivity rates were CD44 (81%), CD47 (81%), TNF-α (40.5%), and IL-1 (42.9%). Strong and diffuse CD44 staining was associated with improved survival and linked to endocervical invasion and stage. Patients with slightly positive CD47 had significantly higher rates of pelvic and para-aortic lymph node metastases. Strong TNF-α staining correlated with grade 3 EEC, while slightly positive IL-1 staining was associated with increased endocervical invasion. No significant correlation was found between CD47, IL-1, and TNF-α expression and survival.

CONCLUSION

CD44 and CD47 were positive in most EEC specimens. CD44 expression was the only marker significantly correlated with overall survival and recurrence. TNF-α showed a positive correlation with high-grade tumors, and IL-1 staining was inversely associated with endocervical invasion. These findings suggest that CD44 is a prognostic marker for survival, while TNF-α and IL-1 may have indirect prognostic roles in EEC.

Unus Pro omnibus, omnes Pro uno: a commentary on the eternal dilemma of endometrial cancer screening in postmenopausal asymptomatic women. Is it time to team up?

INTRODUCTION

The diagnostic workflow for endometrial carcinoma in postmenopausal asymptomatic women remains an ongoing dilemma. Whereas an ultrasonographic endometrial thickness greater than 4.0 or 5.0 mm is adequate for warranting further investigations in women with postmenopausal vaginal bleeding, there is still no unanimous consensus on what the ideal endometrial thickness cut-off should be, justifying additional inspection through endometrial sampling when bleeding is absent.

METHODS

A comprehensive overview of the most recent literature to summarize the clinical pathway necessary for the diagnostic assessment of a postmenopausal asymptomatic woman with increased ultrasonographic endometrial thickness.

RESULTS

An endometrial thickness cut-off between 3.0 and 5.9 mm seems to show the lowest specificity while also reducing the chances of missing malignancy. If endometrial thickness can be a valid starting point, a careful evaluation of the other ultrasonographic endometrial features and a thorough scrutiny of patients' risk factors are pivotal to standardizing the diagnostic process while avoiding overtreatment. Although preventing unnecessary procedures is crucial, stratifying the risk and proceeding with further investigations (preferably through outpatient or office hysteroscopically-guided targeted biopsies) should be the goal.

CONCLUSIONS

Closer collaboration between different fields of medicine (ultrasonography, hysteroscopy, and oncology) is strongly encouraged to facilitate early diagnosis of asymptomatic postmenopausal women at risk of developing endometrial malignancy.

State of the art endocrine treatments for patients diagnosed with endometrial cancer in 2025

PURPOSE OF REVIEW

Endometrial cancer (EC) is rising in incidence, particularly in younger, premenopausal women, due to increasing rates of obesity and delayed childbearing. This review evaluates current and emerging endocrine therapies, with a focus on fertility-preserving approaches for early-stage EC and treatment options for advanced or recurrent disease.

RECENT FINDINGS

Fertility-sparing endocrine therapies, such as medroxyprogesterone acetate, megestrol acetate, and levonorgestrel-releasing intrauterine devices, achieve high response rates but carry recurrence risks. Biomarkers, including progesterone receptor status and molecular subtyping, are improving patient selection and outcomes. In advanced EC, single-agent and combination endocrine therapies with agents like selective estrogen receptor modulators, selective estrogen receptor down-regulators (SERDs), and aromatase inhibitors show efficacy, especially in hormone receptor-positive disease. Newer agents, including next-generation SERDs and proteolysis-targeting chimeras, hold potential for treating resistant cases.

SUMMARY

Endocrine therapy offers a well tolerated alternative to chemotherapy in selected EC patients, particularly those with hormone-sensitive tumors. Advances in molecular profiling and the development of novel endocrine agents are refining treatment strategies, supporting endocrine therapy's continued role in managing EC across various stages.

The Node Reporting and Data System (Node-RADS) for standardized MRI evaluation of lymph nodes in endometrial cancer, integrated with clinicopathological and molecular data

OBJECTIVES

To evaluate the diagnostic performance of Node-RADS score using magnetic resonance imaging (MRI) in predicting lymph node involvement (LNI) in patients with endometrial cancer (EC). Additionally, the applicability of the Node-RADS score was evaluated by three readers with different levels of experience in pelvic imaging. Finally, this study investigated the correlation between the Node-RADS score and the extent of myometrial invasion, histological type, lympho vascular invasion (LVI) and molecular subtype.

METHODS

Out of 108 cases, 82 patients with histologically confirmed locally advanced EC met the inclusion criteria for retrospective analysis. LNI risk was assessed for each pelvic lymph node station using a Node-RADS score (1-5). Diagnostic accuracy was determined by comparing scores to histologic findings, considered as the gold standard. Three independent readers with different experience levels assigned scores.

RESULTS

The Node-RADS score strongly correlated with histologically confirmed LNI (AUC: 0.832). A cutoff of Node-RADS ≥ 3 optimally detected metastatic lymph nodes, with 85.71 % sensitivity and 76.47 % specificity. Interobserver agreement was high, with κ values of 0.86 (senior vs. junior reader 1) and 0.70 (senior vs. junior reader 2). A significant positive correlation was found between Node-RADS score and myometrial invasion as well as LVI.

CONCLUSION

Node-RADS score is a reliable, standardized tool for assessing LN stations and enhancing diagnostic accuracy in locoregional staging of EC.

FOXA1-mediated transcription of MFAP2 facilitates cell growth, metastasis and cisplatin resistance in uterine corpus endometrial carcinoma

Microfibril-associated protein 2 (MFAP2) has been confirmed to be an oncogene to participate in regulating the progression of many cancers. However, its role and mechanism in the development of uterine corpus endometrial carcinoma (UCEC) are still unclear. The mRNA and protein levels of MFAP2 and forkhead box A1 (FOXA1) were determined using qRT-PCR and western blot. Cell proliferation, apoptosis, migration, invasion and cisplatin resistance were detected by colony formation assay, EdU assay, flow cytometry, transwell assay and CCK8 assay. Xenograft tumor models were constructed to explore the effect of MFAP2 knockdown on UCEC tumorigenesis and cisplatin resistance in vivo. The interaction between FOXA1 and MFAP2 promoter was evaluated by ChIP assay and dual-luciferase reporter assay. MFAP2 was upregulated in UCEC tissues and cells. Silencing of MFAP2 repressed UCEC cell growth, metastasis and cisplatin resistance in vitro, as well as reduced tumorigenesis in vivo. In terms of mechanism, FOXA1 bound to MFAP2 promoter region to increase its expression. FOXA1 knockdown could inhibit UCEC cell growth, metastasis and cisplatin resistance. Moreover, FOXA1 promoted growth, metastasis and cisplatin resistance in UCEC cells via enhancing MFAP2 expression. FOXA1-activated MFAP2 might contribute to the growth, metastasis and cisplatin resistance of UCEC cells, providing a novel target for UCEC treatment.

Therapeutically targeting endometrial cancer in preclinical models by ICAM1 antibody-drug conjugates

OBJECTIVE

The incidence of mortality and morbidity from endometrial cancer (EC) is increasing annually, and there is a paucity of effective targeted therapies for the condition. Antibody-drug conjugates (ADCs) represent a promising approach to tumor-targeted therapy. In this study, we aim to identify a novel molecular target for the preclinical development of EC-targeted ADCs.

METHODS

Through quantitative and unbiased bioinformatics analyses intercellular adhesion molecule-1 (ICAM1) was identified as a potential cell membrane target. Two ADCs, ICAM1-MMAE and ICAM1-DXd, were subsequently developed by conjugating ICAM1 monoclonal antibodies with microtubule inhibitors and DNA topoisomerase inhibitors, respectively. The preclinical efficacy and biosafety of these ICAM1 ADCs were validated in both in vitro and in vivo models. Furthermore, transcriptomic analysis was conducted to elucidate the therapeutic effects of the ICAM1 ADCs.

RESULTS

Quantitative flow screening and bioinformatics analyses revealed significant overexpression of ICAM1 in EC. ICAM1-MMAE and ICAM1-DXd were developed using clinically effective linkers and payloads. In preclinical models, ICAM1 ADCs showed superior antitumor efficacy compared to standard chemotherapy, achieving sustained tumor regression with an excellent safety profile in both subcutaneous and orthotopic xenograft models. Transcriptomic analysis further revealed that ICAM1-DXd potently activated tumor immunity.

CONCLUSIONS

ICAM1 was identified as a promising cell membrane protein target for ADC development in EC. As-synthesized ICAM1 ADCs demonstrated potent antitumor activity, favorable biosafety profiles in vitro and in vivo, and the ability to activate tumor immunity. These findings support the potential of ICAM1 ADCs as a therapeutic strategy and warrant further investigation in clinical studies.

Excess heme orchestrates progesterone resistance in uterine endometrial cancer through macrophage polarization and the IL-33/PAX8/PGR axis

Progesterone is an important drug for hormone therapy in uterine endometrial cancer (UEC). However, the therapeutic efficacy of progestogen is often limited by resistance, and the underlying mechanism remains unknown. In this study, we observed heme metabolism is more active in progesterone-insensitive patients. Heme induced macrophages (Mφs) bias towards M2-like phenotype and downregulated the expression of IL-33, resulting in increased levels of Paired box gene 8 (PAX8). Further study showed PAX8 inhibited the transcriptional activity of PGR by binding to the PGR promoter region. In addition, PGR can also act as a transcriptional factor to regulate the transcription of autophagy-related gene 7 (ATG). Low expression of PGR decreases the transcriptional activity of ATG7 promoter, which decreases cell autophagy and promotes the progression of UEC. Overall, this study reveals the important interaction between heme metabolism, IL-33 and PGR in progesterone-insensitive UEC, and is promising to provide new therapeutic targets for overcoming progesterone resistance.

Different Patterns of the Relationship Between Gynecological Malignancy and Obesity Index: A Nationwide Retrospective Cohort Study in Korea

BACKGROUND

In Korea, the patterns of prevalence of gynecological cancers have shifted due to rising obesity-related cancer cases. We evaluated the associations of body mass index (BMI) and waist circumference (WC) with the risk of gynecological malignancy in Korean women.

METHODS

Using National Health Insurance Service cohort data, we analyzed 365,581 participants among the 1,999,980 women aged ≥ 19 years who underwent health check-ups at the baseline year 2009-2010, excluding those who died, those with prior cancer diagnoses, underwent hysterectomy and/or salpingo-oophorectomy before the index date (January 1st, 2011), or missing/outliers BMI and WC values. Follow-up extended to December 31st, 2021, evaluating the incidences of endometrial, ovarian, and cervical cancer. The hazard ratios (HRs) and 95% confidence intervals (CIs) for each gynecological malignancy according to BMI and WC were calculated using Cox proportional hazard regression.

RESULTS

Among the 365,581 participants, 898, 1,268, and 873 cases of endometrial, ovarian, and cervical cancer occurred, respectively. HRs (95% CIs) for endometrial cancer were 1.37 (1.15-1.63), 1.63 (1.38-1.94), and 3.64 (2.81-4.70) for BMIs of 23.0-24.9, 25.0-29.9, and ≥ 30 kg/m² compared to BMI of 18.5-22.9 kg/m² (P for trend < 0.001). HRs (95% CIs) for ovarian cancer were 1.16 (1.00-1.33), 1.19 (1.03-1.37), and 1.49 (1.12-1.98) for BMIs of 23.0-24.9, 25.0-29.9, and ≥ 30 kg/m² compared to BMI of 18.5-22.9 kg/m² (P for trend = 0.002). No significant association was found between BMI and the risk for cervical cancer (P for trend = 0.266). HRs (95% CIs) for endometrial cancer were 1.35 (1.09-1.66), 1.41 (1.14-1.74), and 1.90 (1.55-2.34) for the 2nd, 3rd, and 4th quartiles of WCs compared to the 1st quartile (P for trend <0.001). Ovarian cancer tended to increase and cervical cancer tended to decrease as WC increased (P for trend = 0.035 for ovarian cancer, P for trend = 0.034 for cervical cancer).

CONCLUSION

In Korean women, the risks of endometrial and ovarian cancers increased significantly from the pre-obese level as BMI and WC increased, while cervical cancer risk tended to increase as WC decreased. Management of obesity should be reinforced for the prevention of obesity-related gynecological cancers, considering the increasing incidence of these cancers among Korean women.

Expression and prognosis of NR3C1 in uterine corpus endometrial carcinoma based on multiple datasets

Uterine corpus endometrial carcinoma (UCEC), a prevalent malignancy in the female reproductive system, has witnessed a 30% increase in recent year. Recognizing the significance of early treatment in reducing patient mortality, the identification of potential biomarkers for UCEC plays a crucial role in early diagnosis. This study was to identify key genes associated with UCEC utilizing the Gene Expression Omnibus database, followed by validating their prognostic value across multiple databases. Analysis of four UCEC databases (GSE17025, GSE36389, GSE63678, GSE115810) yielded 72 co-expressed genes. KEGG and GO enrichment analyses revealed their involvement in physiological processes such as transcriptional misregulation in cancer. Constructing a protein-protein interaction network for these 72 genes, the top 10 genes with significant interactions were identified. Survival regression analysis highlighted NR3C1 as the gene with a substantial impact on UCEC prognostic outcomes. Differential expression analysis indicated lower expression of NR3C1 in UCEC compared to normal endometrial tissue. Cox regression analysis, performed on clinical datasets of UCEC patients, identified clinical stage III, clinical stage IV, age, and NR3C1 as independent prognostic factors influencing UCEC outcomes. The LinkedOmics online database revealed the top 50 positively and negatively correlated genes with NR3C1 in UCEC. Subsequent investigations into the relationship between NR3C1 and tumor-infiltrating immune cells were conducted using R software. Gene set enrichment analysis provided insights into NR3C1-related genes, showing enrichment in processes such as Ribosome, Oxidative phosphorylation in UCEC. Collectively, these comprehensive analyses suggest that NR3C1 may serve as a potential biomarker indicating the prognosis of UCEC.

Fine particulate matter components and reproductive hormones in female adults: A 15-year longitudinal cohort study

BACKGROUND

Few cohort studies have evaluated the long-term impacts of ambient fine particulate matter (PM2.5) and its components on reproductive hormone levels in female adults.

METHODS

We conducted a 15-year retrospective cohort study in Taiwan between 2003 and 2017. The two-year average concentrations of PM2.5 and its components, including sulfate (SO42-), nitrate (NO3-), ammonium (NH4+), organic matter (OM), and black carbon (BC), were assessed at each participant's addresses. Linear mixed models were used to examine the associations of PM2.5 and its components with reproductive hormones, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), estradiol (E2), and prolactin (PRL). Stratified analyses were conducted to identify vulnerable populations.

RESULTS

17,152 female adults were included. Each interquartile range (IQR: 3.545 μg/m3) increase in PM2.5 was associated with a 0.585 mIU/mL [95% confidence interval (CI): 0.190-0.980] increase in FSH levels. Among the five components of PM2.5, BC had the strongest positive association [each IQR (0.272 μg/m3) increase was associated with a 0.863 mIU/mL (95% CI: 0.476-1.250) increase in FSH levels], followed by OM, SO42-, and NH4+. Similar associations were found for LH, with a 0.483 mIU/mL (95% CI: 0.225-0.742) and 0.684 mIU/mL (95% CI: 0.431-0.938) increase in LH levels per IQR increase in PM2.5 and BC, respectively. The pollutants were marginally associated with decreased E2 levels and increased PRL levels. Non-linear associations between PM2.5 and its components and the levels of FSH, LH, E2, and PRL were observed. These pollutants were also positively associated with T levels among young adults. Post-menopausal women were more susceptible to the chronic impacts of PM2.5 and its components.

CONCLUSION

Our study highlighted the adverse impacts of long-term exposure to PM2.5 components on hormonal homeostasis, revealing the biological mechanism of air pollution-reproductive health associations in females. Implementing stringent control of air pollution levels can benefit reproductive health in female adults, even in moderately polluted regions.

Quality indicators for endometrial cancer care in Japan

OBJECTIVE

The incidence and mortality rates of endometrial cancer are increasing globally, including in Japan. Quality of cancer care is promoted through guideline adherence. This study aimed to establish quality indicators (QIs) for endometrial cancer and explore the factors contributing to treatment nonadherence.

METHODS

QIs and pattern-of-care indicators (PCIs) were developed using the Research and Development/University of California Los Angeles modified Delphi method. QIs reflect desirable healthcare patterns, whereas PCIs address treatment areas with lacking evidence. Data from the Hospital-Based Cancer Registry and Diagnosis Procedure Combination Survey were used. Patients diagnosed or treated between January 1 and December 31, 2020 were included. The reasons for nonadherence were collected. Logistic regression was used to analyze the factors influencing adherence, including age, body mass index, comorbidities, facilities, and recurrence risk.

RESULTS

Of the 35 proposed QI candidates, 8 QIs and 9 PCIs were selected, predominantly focusing on surgical aspects. Adherence rates varied, with peritoneal lavage cytology being the highest (93.1%), and postoperative hormone replacement therapy (HRT) for patients aged <45 years being the lowest (30.9%), when focusing on process indicators. Reasons for nonadherence included patient preference and medical comorbidities as significant factors. Multivariate analysis highlighted age, clinical stage, and Barthel index as significant contributors to nonadherence.

CONCLUSION

We developed QIs to comprehensively assess endometrial cancer treatment. Adherence rates are favorable; however, HRT has a low adherence rate. Factors leading to nonadherence include advanced age and incomplete activities of daily living, particularly in advanced stages.

From diagnosis to therapy: The role of LncRNA GAS5 in combatting some cancers affecting women

Long non-coding RNAs (lncRNAs) are a collection of non-coding RNA molecules that consist of more than 200 nucleotides. In human malignancies, these lncRNAs exhibit abnormal expression patterns and play a significant role in either suppressing or promoting tumor growth. They achieve this by modulating various functions and mechanisms within cancer cells, including proliferation, invasion, metastasis, apoptosis, and resistance to different therapeutic approaches. The downregulation of long non-coding RNA growth arrest‑specific transcript 5 (GAS5) has been observed in multiple tumor types, indicating its role as a tumor suppressor in cancer. GAS5 exhibits interactions with various proteins, DNA, and microRNAs (miRNAs), leading to the upregulation of several mRNAs encoding suppressor proteins like PTEN. Consequently, this upregulation inhibits tumor growth. In this review, we have examined the existing literature concerning the expression of GAS5 and its diagnostic significance in female tissue-specific cancers, including breast, cervical, ovarian, and endometrial cancers. Additionally, we have explored its interactions with different miRNAs and its impact on cancer progression and resistance to therapy in these malignancies.

CPA4 overexpression correlates with poor prognosis and tumor progression in endometrial cancer

BACKGROUND

The rise in endometrial cancer rates globally calls for advanced diagnostic methods and new biomarkers. CPA4, known for its role in cancer development, has not yet been studied in relation to endometrial cancer, making it a promising research avenue.

METHODS

We analyzed CPA4's mRNA expression using data from TCGA and GEO databases and validated these findings with 116 clinical samples through immunohistochemical analysis. The Ishikawa and Hec-1-A cell lines were used to examine CPA4's functionality. In addition, we conducted correlation analysis, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Gene Set Enrichment Analysis (GSEA), and survival analysis to understand CPA4's role in endometrial cancer prognosis. A nomogram model was developed for clinical prognostic predictions.

RESULTS

CPA4 is significantly overexpressed in endometrial cancer, correlating with tumor progression and poor prognosis. Overexpression is linked to crucial functions, such as mitosis and cell cycle. Reducing CPA4 in cell lines inhibited tumor growth and spread. Kaplan-Meier plots and Cox regression analysis confirmed CPA4's significance in prognosis, with our predictive model showing high accuracy.

CONCLUSIONS

CPA4 emerges as a vital biomarker for diagnosing and prognosing endometrial cancer, presenting a novel pathway for research and clinical application. The study highlights its potential as a clinical tool, paving the way for improved patient management and treatment strategies in endometrial cancer.

The qualitative and quantitative characteristics of serous endometrial carcinoma on MRI: applying a novel nomogram for predicting an aggressive histological type

Objectives

To comprehensively describe MRI characteristics of serous endometrial carcinoma (SEC) and distinguish SEC from endometrioid endometrial carcinoma (EEC).

Methods

We retrospectively recruited 62 patients from a tertiary center with pathologically proven endometrioid cancers (37 SEC and 25 EEC) as the training set. MRI image interpretation was blindly interpreted by two experienced radiologists with consensus reading. Both qualitative and quantitative characteristics on MRI were recorded case by case. Histological findings were retrieved from the hospital information system. Fifty-four samples (27 SEC and 27 EEC) from the external hospital were treated as the testing set.

Results

The qualitative MRI characteristics had no statistical difference between the SEC and EEC groups in the training set. SEC more often invaded the deep myometrium than EEC (p = 0.03). The signal intensity (SI)T2Ratio, SIcontrastRatio, LesionareaRatio, and VolumeareaRatio in the SEC group were 1.35 ± 0.36, 0.77 ± 0.18, 0.25 ± 0.24, and 0.22 ± 0.26, respectively. The SIT2Ratio, SIcontrastRatio, and VolumeareaRatio showed statistically significant differences between SEC and EEC (p < 0.05). The highest discriminative index for distinguishing SEC from EEC was SIcontrastRatio with an area under the curve (AUC) of 0.7533 (95% CI: 0.627-0.878). A predictive nomogram achieved an AUC of 0.814 (95% CI: 0.614-0.968), a sensitivity of 1.0, and a specificity of 0.60 in the testing set.

Conclusions

This study developed and validated a nomogram model to predict SEC patients based on clinical and quantitative MRI features, which can be used in distinguishing SEC from EEC.

Differential gene expression in uterine endometrioid cancer cells and adjusted normal tissue

Endometrial cancer is a significant public health concern with rising incidence rates globally. Understanding the molecular mechanisms underlying this disease is crucial for developing effective therapeutic strategies. Our study aimed to characterize transcriptional changes in endometrial cancer tissues compared to adjusted healthy tissue. Using RNA sequencing, we identified 2483 differentially expressed genes (DEGs), including protein-coding genes, long non-coding RNAs (lncRNAs), and microRNAs (miRNAs). Notably, several known cancer-related genes were differentially expressed, such as MYC, AKT3, CCND1, and CDKN2A. Pathway analysis revealed significant alterations in cell cycle regulation, several signaling pathways, and metabolic processes. These findings provide valuable insights into the molecular pathways dysregulated in endometrial cancer. Our results may contribute to the development of novel therapeutic targets and biomarkers for this disease.

Physical activity and lower extremity lymphedema among endometrial cancer survivors: A population-based cross-sectional study

OBJECTIVE

The aims of this cross-sectional study were to describe the prevalence of self-reported lower extremity lymphedema (LEL) by different physical activity (PA) levels and to examine if higher levels of PA are associated with lower odds of self-reported LEL among endometrial cancer survivors.

METHODS

Women treated for assumed early-stage endometrial cancer between 2006 and 2021 were invited to complete the Lower Extremity Lymphedema Screening Questionnaire (LELSQ) and the Physical Activity Frequency, Intensity, and Duration (PAFID) questionnaire. Responses of PAFID were converted into metabolic equivalent of task minutes per week (MET-min/week), and participants were categorized into different PA levels: meeting (≥500 MET-min/week) versus not meeting PA guidelines; low active (<500 MET-min/week), active (500-1000 MET-min/week), and high active (>1000 MET-min/week); and PA quartiles.

RESULTS

Among 1077 included, the prevalence of LEL was 48 %, 32 %, and 32 % among the low active, active, and high active survivors, respectively. Compared to the low active, the active survivors had 40 % lower odds of LEL (OR 0.60, 95 % CI 0.44-0.81), but no further reduction was observed among the high active survivors (OR 0.71, 95 % CI 0.47-1.06). According to PA quartiles, higher PA levels were associated with lower odds of LEL, but not in a linear dose-response way.

CONCLUSION

Findings suggest that regular PA according to the current PA guidelines is associated with decreased the odds of self-reported LEL among endometrial cancer survivors; however, causality of association needs to be verified in a longitudinal setting.

Diagnostic value of contrast-enhanced ultrasound for the depth of myometrial infiltration in early endometrial cancer: a meta-analysis

Objectives

Globally, endometrial cancer (EC) is currently one of the most common gynecologic malignancies among females. Preoperative infiltration depth analysis is important for disease progression and prognostic impact. This study aimed to evaluate the diagnostic value of contrast-enhanced ultrasound (CEUS) in the infiltration depth analysis of EC.

Method

Electronic databases PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP were searched for more extensive literature on CEUS in the diagnosis of myometrial infiltration in EC patients up to March 29, 2024. Cochran Q and I² were used to assess the heterogeneity of eligible studies. Sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were analyzed for each clinical outcome using a bivariate random effects model. Summary receiver operating characteristic (SROC) curves were also generated.

Results

In total, 23 papers with 1247 EC patients were included in the meta-analysis. The SEN, SPE, PLR, NLR, and DOR for the diagnosis of deep myometrial infiltration (DMI) of EC using CEUS were 0.84 [95% confidence interval (CI): 0.79, 0.89], 0.92 (95%CI: 0.90, 0.94), 11.05 (95%CI: 8.00, 15.25), 0.17 (95%CI: 0.12, 0.23), and 64.91 (95%CI: 37.11, 113.52), respectively. The area under the curve (AUC) was 0.95 (95%CI: 0.93, 0.97). For the diagnosis of superficial myometrial invasion (SMI) of EC by CEUS, the SEN, SPEN, PLR, NLR, DOR and AUC were 0.91 (95%CI: 0.85, 0.95), 0.80 (95%CI: 0.64, 0.90), 4.55 (95%CI: 2.34, 8.85), 0.11 (95%CI: 0.06, 0.21), 41.40 (95%CI: 12.14, 141.13), and 0.94 (95%CI: 0.91, 0.95), respectively.

Conclusion

CEUS might be a reliable and practical technique for EC myometrial infiltration diagnosis. More clinical data and studies are still needed to confirm these results in the future.

A randomized phase II/III study of paclitaxel/carboplatin/metformin versus paclitaxel/carboplatin/placebo as initial therapy for measurable stage III or IVA, stage IVB, or recurrent endometrial cancer: An NRG oncology/GOG study

INTRODUCTION

We evaluated the efficacy of the addition of the anti-diabetic drug metformin to standard-of-care paclitaxel and carboplatin (PC) in patients with advanced and recurrent endometrial cancer (EC).

METHODS

In this phase II/III trial, EC patients with chemotherapy-naïve stage III/IVA (with measurable disease) and stage IVB or recurrent (with or without measurable disease) disease were randomly assigned to PC/metformin (850 mg BID) versus PC/placebo. Metformin or placebo was continued as maintenance therapy after completion of PC until disease progression. The primary endpoint of phase II was progression-free survival (PFS). The primary endpoint of phase III was overall survival (OS). Secondary endpoints were objective response, duration of response, and toxicity.

RESULTS

From 3/17/2014 to 12/22/2017, 448 patients were randomized to phase II/III studies, and the data were frozen for interim analysis. The phase II study deemed metformin worthy of further investigation in the phase III study. The interim phase III analysis stopped accrual for futility on 2/1/2018. The addition of metformin to PC had a slightly higher hazard of death compared to the PC regimen (HR = 1.088; 90% CI 0.803 to 1.475), which was sufficient to close the study early. The PFS had (HR = 0.814; 90% CI 0.635 to 1.043). At a median follow-up of 10 months and 121 deaths, median OS was not determined and 28 months, on PC/placebo and PC/metformin, respectively.

CONCLUSION

The hazard ratios for PFS and OS endpoints was not sufficiently decreased with the addition of metformin to PC to justify continuing the trial.

Establishment and validation of a prognostic nomogram for overall survival in type II endometrial carcinoma patients

This study aimed to develop and validate a nomogram model to predict overall survival (OS) in patients with type II endometrial carcinoma (EC). Data from patients with confirmed type II EC enrolled between 2010 and 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly allocated to training and validation groups in a 7:3 ratio. Univariable and multivariable analyses were performed to identify independent prognostic risk factors, which were included in constructing the nomogram model. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to assess the prediction accuracy and clinical utility of the nomogram model. The effects of different variables on survival probability were analyzed using the Kaplan-Meier method. A total of 3,933 eligible patients with type II EC were identified and included in this study. Independent risk factors for type II EC were found to be race, tumor size, histology, grade, T stage, N stage, M stage, examination of para-aortic lymph nodes, examination of pelvic lymph nodes, surgery, lung metastasis, radiation therapy, and chemotherapy. A prognostic nomogram was constructed based on these variables. The C-index for the training cohort was 0.791 (95% CI 0.780-0.802) and for the validation cohort was 0.798 (95% CI 0.778-0.818). The ROC curve demonstrated good prediction accuracy. The calibration curve indicated strong agreement between predicted and actual values. The DCA showed that the nomogram model has significant clinical utility and potential. This study developed a survival prediction model for patients with type II EC to assist clinicians in evaluating prognostic factors, predicting OS, and determining appropriate treatment protocols to improve patient outcomes.

The Histomorphology to Molecular Transition: Exploring the Genomic Landscape of Poorly Differentiated Epithelial Endometrial Cancers

The peremptory need to circumvent challenges associated with poorly differentiated epithelial endometrial cancers (PDEECs), also known as Type II endometrial cancers (ECs), has prompted therapeutic interrogation of the prototypically intractable and most prevalent gynecological malignancy. PDEECs account for most endometrial cancer-related mortalities due to their aggressive nature, late-stage detection, and poor response to standard therapies. PDEECs are characterized by heterogeneous histopathological features and distinct molecular profiles, and they pose significant clinical challenges due to their propensity for rapid progression. Regardless of the complexities around PDEECs, they are still being administered inefficiently in the same manner as clinically indolent and readily curable type-I ECs. Currently, there are no targeted therapies for the treatment of PDEECs. The realization of the need for new treatment options has transformed our understanding of PDEECs by enabling more precise classification based on genomic profiling. The transition from a histopathological to a molecular classification has provided critical insights into the underlying genetic and epigenetic alterations in these malignancies. This review explores the genomic landscape of PDEECs, with a focus on identifying key molecular subtypes and associated genetic mutations that are prevalent in aggressive variants. Here, we discuss how molecular classification correlates with clinical outcomes and can refine diagnostic accuracy, predict patient prognosis, and inform therapeutic strategies. Deciphering the molecular underpinnings of PDEECs has led to advances in precision oncology and protracted therapeutic remissions for patients with these untamable malignancies.

Ultrasound in endometrial cancer: evaluating the impact of pre-surgical staging

Preoperative staging in endometrial cancer has recently been implied as an important factor in accurately selecting low-risk cases, ultimately avoiding unnecessary lymph node debulking. Transvaginal ultrasound seems promising in clinical staging as it offers the possibility to assess the depth of myometrial infiltration and cervical stromal invasion. This commonly available, non-invasive, and low-cost modality serves as an accurate alternative to MRI, especially in middle- and low-income countries, where MRI may not be promptly available and cost is an important issue. This review aims to summarize the progressive role of clinical implementation of pelvic ultrasonography in the locoregional staging of endometrial carcinoma and to compare its accuracy with other preoperative methods.

Integrating Bioinformatics and Experimental Validation to Identify Mitochondrial Permeability Transition-Driven Necrosis-Related lncRNAs that can Serve as Prognostic Biomarkers and Therapeutic Targets in Endometrial Carcinoma

Endometrial carcinoma (EC) is a common malignant tumor in women with high mortality and relapse rates. Mitochondrial permeability transition (MPT)-driven necrosis is a novel form of programmed cell death. The MPT-driven necrosis related lncRNAs (MRLs) involved in EC development remain unclear. We aimed to predict the outcomes of patients with EC by constructing a novel prognostic model based on MRLs and explore potential molecular functions. A risk prognostic model was developed utilizing multi-Cox regression in conjunction with the Least Absolute Shrinkage and Selection Operator (LASSO) regression algorithm, which was based on MRLs. The predictive efficacy of the model was evaluated through receiver operating characteristic (ROC) curve analysis, as well as nomogram and concordance index (C-index) assessments. Patients were categorized into high- and low-risk groups based on their median risk scores. Notably, the high-risk group exhibited significantly poorer overall survival (OS) outcomes. Gene ontology (GO) and Gene set enrichment analysis (GSEA) demonstrated that Hedgehog and cell cycle pathways were enriched in the high-risk group. Tumor Immune Dysfunction and Exclusion (TIDE) displayed that patients in the high-risk group showed a high likelihood of immune evasion and less effective immunotherapy. A significant disparity in immune function was also observed between two groups. Based on the nine-MRLs, drug sensitivity analysis identified several anticancer drugs with potential efficacy in prognosis. Meanwhile, the results demonstrated that OGFRP1 plays a carcinogenic role by affecting mitochondrial membrane permeability in EC. Therefore, the risk model constructed by nine MRLs could be used to predict the clinical outcomes and therapeutic responses in patients with EC effectively.

[Endometrial cancer]

Novel developments in the diagnosis and treatment of endometrial cancer will likely improve the prognosis of early, advanced and recurrent tumors. Molecular pathology currently classifies endometrial carcinoma into 4 molecular subtypes with prognostic significance. POLE mutated tumors, amounting to about 7% of all endometrial cancer cases, dubbed "ultra-mutated", have an excellent prognosis in early stages - even without adjuvant therapy. Mismatch repair deficient (MMRd) tumors are called "hypermutated" and have an intermediate prognosis in early stages. In advanced stages, they are highly sensitive to immune checkpoint inhibitors which are an integral part of their treatment. The tumors with "no specific molecular profile" have a prognosis that is similar to MMRd endometrial cancers. Finally, TP53 mutated cancers have a dismal prognosis, and aggressive adjuvant therapy is indicated. The 2023 FIGO classification recognizes for the first time the prognostically favorable synchronous endometrial and ovarian carcinomas, the importance of lymph node metastases depending on size and pattern, and the relevance of peritoneal involvement inside versus outside the pelvis. In metastatic disease, in mismatch repair proficient cases, the combination of carboplatin and paclitaxel chemotherapy with durvalumab has been recently approved as first line therapy in the European Union, followed by maintenance therapy with the PARP inhibitor olaparib, in combination with durvalumab. For MMRd tumors, several immune checkpoint inhibitors in combination with chemotherapy or as monotherapy have been approved in recent years. Tumors that are overexpressing Her2/neu have an additional treatment option with trastuzumab.

Socioeconomic marginalization is associated with delayed medical consultation among endometrial cancer patients presenting with postmenopausal bleeding

OBJECTIVE

The key presenting symptom of endometrial cancer is abnormal uterine bleeding, most commonly postmenopausal bleeding (PMB), which facilitates early-stage diagnosis. This study aimed to investigate factors influencing delayed medical consultation for PMB, and particularly its association with social determinants.

METHODS

This is a retrospective study that included endometrial cancer patients receiving care in a gynecologic oncology department of a tertiary medical center who presented with PMB. Demographic and oncologic data was collected from the electronic medical charts. Israeli bureau of statistics data was used to assess community socioeconomic index, based on address. Women seeking consultation more than 1 month after experiencing PMB were compared to those seeking earlier care.

RESULTS

Two hundred ninety-five women were included in the study. One hundred seventy-three sought care after less than 1 month of PMB (early presenters) and 122 sought care after more prolonged PMB (late presenters). Late presenters were more likely to be socioeconomically marginalized (odds ratio [OR], 1.8; P = 0.018), higher body mass index (OR, 1.040; P = 0.022), and greater parity (OR, 1.170; P = 0.032). Socioeconomic marginalized patients experienced a 7-day longer delay from diagnosis to surgery compared to their privileged counterparts (59 vs 52 d, P = 0.022).

CONCLUSIONS

Among women with endometrial cancer, longer duration of PMB before first seeking medical consultation is associated with socioeconomic marginalization. This highlights the need for targeted interventions to minimize delays in diagnosis and treatment initiation among patients from marginalized communities.

Weight Management for Fertility-Preservation Therapy in Endometrial Cancer: Opportunities and Challenges

PURPOSE OF REVIEW

Obesity is increasingly recognized as a significant factor impacting the outcomes of fertility-preserving therapies for endometrial cancer (EC). This review explores the effects of glycolipid metabolism on EC and its relationship with body weight. We will examine how excess body weight influences the effectiveness of fertility-preserving treatments and discuss potential mechanisms for effective weight management. Additionally, the review highlights the importance of comprehensive weight management as an adjunct strategy to enhance the efficacy of fertility-preserving interventions, providing insights into how to integrate metabolic health into clinical treatment protocols.

RECENT FINDINGS

Weight management can modify the tumor microenvironment by depriving the tumor of nutrients, whereas exercise can enhance immunity, potentially leading to tumor cell death. In addition, progesterone therapy may impede the proliferation of EC cells. Comprehensive weight management can serve as an essential adjuvant treatment for patients undergoing fertility-preserving therapies for EC. In this review, we highlight that comprehensive weight management can serve as a crucial adjuvant treatment for patients undergoing fertility-preserving therapies for endometrial cancer. Targeting glycolipid metabolism and addressing adiposity can improve hormonal balance, reduce inflammation, and enhance fertility outcomes. Further research is necessary to establish specific protocols and evaluate the effectiveness of these strategies in clinical practice.

Updates and controversies in the management of uterine serous carcinoma and uterine carcinosarcoma

Uterine serous carcinoma and uterine carcinosarcoma are among the rarest but most lethal endometrial cancer sub-types, accounting for 15% of all cases, and are responsible for more than 50% of related deaths. These malignancies are distinguished by a high likelihood of metastasis and multisite recurrence, making them biologically different from other endometrial cancer sub-types. This review aims to analyze the existing evidence regarding molecular classification, new biomarkers, and innovative treatment approaches for these high-risk tumors. Herein, we explored the role of biomarkers, including HER2, TP53, and mismatch repair deficiency/microsatellite instability hypermutated and their influence on treatment strategies, surveillance approaches, the potential role of circulating tumor deoxyribonucleic acid, novel precision-based treatment options, and disparate survival outcomes for non-Hispanic Black and other underserved minority patients, along with strategies to improve outcomes for these patients. Substantial progress has been made in the last 5 years, prompting the following question: What lies ahead in the next 5 years? Our current understanding of uterine serous carcinoma and carcinosarcoma underscores the necessity of continuing to prioritize biomarker-driven therapies and the development of novel treatments through clinical trials while integrating these new strategies with traditional approaches, such as surgical resection and cytotoxic chemotherapy.

Efficacy of PD-(L)1 inhibition in the treatment of endometrial cancer across molecular classes: a systematic review and meta-analysis

OBJECTIVE

PD-(L)1 inhibitors have shown benefit in mismatch repair-deficient (MMRd) endometrial cancer. However, their efficacy in mismatch repair-proficient endometrial cancer (comprising POLE-mutated (POLEmut), p53-abnormal (p53abn), and no-specific-molecular-profile (NSMP) molecular classes) remains unclear. This systematic review and meta-analysis evaluated the efficacy of PD-(L)1 inhibitors, as monotherapy or combined with chemotherapy, across the 4 molecular classes.

METHODS

Systematic searches were conducted across Embase, PubMed, Cochrane, and Web of Science, with manual searches of reference lists and conference websites. A total of 7 reports on 5 clinical trials were identified, with 3 included in the meta-analysis. Overall survival and progression-free survival were assessed.

RESULTS

In patients with primary advanced or recurrent MMRd endometrial cancer (n=215), adding a PD-(L)1 inhibitor to platinum-based chemotherapy significantly improved overall (HR 0.36, 95% CI 0.21 to 0.62) and progression-free survival (HR 0.35, 95% CI 0.23 to 0.53). In patients with p53abn endometrial cancer, no significant benefits in overall (HR 0.91, 95% CI 0.26 to 3.22; n=135) or progression-free survival (HR 0.84, 95% CI 0.41 to 1.70; n=326) were observed, but both were affected by significant heterogeneity. In patients with NSMP endometrial cancer, a significant benefit was observed for progression-free survival (HR 0.73, 95% CI 0.57 to 0.95; n=373), but no overall survival benefit (HR 0.93, 95% CI 0.63 to 1.39; n=242). Insufficient data were available for patients with POLEmut endometrial cancer (n=12), with no events reported in 2 of 3 clinical trials comprising the majority of patients (n=11).

CONCLUSIONS

PD-(L)1 inhibition demonstrated significant efficacy in patients with advanced or recurrent MMRd endometrial cancer. In NSMP endometrial cancer, adding a PD-(L)1 inhibitor to platinum-based chemotherapy showed potential benefit, whereas in p53abn endometrial cancer, such benefit was not found. POLEmut endometrial cancer, although rare in recurrent or metastatic settings, was associated with a favorable prognosis, regardless of treatment. These findings underscore the relevance of the molecular classification of endometrial cancer and highlight the importance of prioritizing molecular analyses in clinical trials to guide personalized PD-(L)1 inhibition strategies.