PET-CT scan in the preoperative workup of early stage intermediate- and high-risk endometrial cancer

Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment

INTRODUCTION/BACKGROUND

Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC.

METHODOLOGY

From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard).

RESULTS

Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV.

CONCLUSION

HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.

Beyond Sentinel Lymph Node: Outcomes of Indocyanine Green-Guided Pelvic Lymphadenectomy in Endometrial and Cervical Cancer

BACKGROUND

The aim of our study was to compare the number of lymph nodes removed during indocyanine green (ICG)-guided laparoscopic/robotic pelvic lymphadenectomy with standard systematic lymphadenectomy in endometrial cancer (EC) and cervical cancer (CC).

METHODS

This is a multicenter retrospective comparative study (Clinical Trial ID: NCT04246580; updated on 31 January 2023). Women affected by EC and CC who underwent laparoscopic/robotic systematic pelvic lymphadenectomy, with (cases) or without (controls) the use of ICG tracer injection within the uterine cervix, were included in the study.

RESULTS

The two groups were homogeneous for age (p = 0.08), Body Mass Index, International Federation of Gynaecology and Obstetrics (FIGO) stages (p = 0.41 for EC; p = 0.17 for CC), median estimated blood loss (p = 0.76), median operative time (p = 0.59), and perioperative complications (p = 0.66). Nevertheless, the number of lymph nodes retrieved during surgery was significantly higher (p = 0.005) in the ICG group (n = 18) compared with controls (n = 16).

CONCLUSIONS

The accurate and precise dissection achieved with the use of the ICG-guided procedure was associated with a higher number of lymph nodes removed in the case of systematic pelvic lymphadenectomy for EC and CC.

Influence of uterine manipulator use on the incidence of lymphovascular propagation in the treatment of endometrial cancer

BACKGROUND

Endometrial cancers are among the epithelial malignancies of the lining of the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI) is considered a risk factor for the course of the disease.

MATERIAL AND METHODS

We evaluated 170 female patients. Our primary objective was to find any difference in the incidence of LVSI in female patients treated with and without an intrauterine manipulator. In addition, we analyzed the effect of the type of intrauterine manipulator used on the incidence of LVSI, tumor grading, myometrial invasion, and the method of obtaining primary histology with regard to the incidence of LVSI.

RESULTS

Using a manipulator during surgery was not associated with LVSI (with a manipulator vs. without, 11.5 vs. 21.7%; OR 1.8; 95% CI 0.73-4.39; p = 0.199). However, the method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (p-value = 0.011).

CONCLUSIONS

In our study, we did not confirm the effect of a uterine manipulator on the possible increase of LVSI positive cases. The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Trail registration: Trail is registered in ClicincalTrails.gov with identifier: NCT05261165.

Resection of inferior vena cava, abdominal aorta, bilateral common iliac arteries, and bilateral partial external iliac arteries with artificial vessel replacement during radical endometrial cancer surgery: a case report

BACKGROUND

Endometrial carcinoma (EC) is a common malignant tumor of the female reproductive system, often accompanied by lymph node metastasis. Artificial vascular implantation is a common surgical treatment for mediastinal tumors and abdominal aortic aneurysms but is rarely used in gynecological surgery.

CASE PRESENTATION

A 54-year-old female patient was first admitted to the hospital in January 2018 due to "irregular vaginal bleeding over 3 months". CT showed a mass in the uterine cavity, and several swollen lymph nodes in the retroperitoneum and pelvic cavity. The initial diagnosis was an endometrial malignant tumor. We performed radical endometrial cancer surgery with parallel resection of inferior vena cava, abdominal aorta, bilateral common iliac arteries, bilateral external iliac arteries, and artificial vessel replacement, which was successful, with good postoperative recovery and no lesion progression at 3 years postoperative follow-up.

CONCLUSION

This is an early case of gynecological clinical use of prostheses. Through multidisciplinary cooperation, the surgical resection rate of patients with EC in radical surgery was improved without serious fatal complications and achieved a high long-term postoperative survival rate.

A novel association between Bmi-1 protein expression and the SUVmax obtained by 18F-FDG PET/CT in patients with gastric adenocarcinoma

This study aimed to examine B-cell-specific Moloney murine leukemia virus integration site 1 (Bmi-1) in gastric adenocarcinoma (GAC) and its association with the maximal standard uptake value (SUVmax) of preoperative fluorine-18-fludeoosyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT). Clinicopathological data were retrospectively collected from 60 primary GAC patients. The Bmi-1 protein expression in GAC and adjacent noncancerous tissues was examined by immunohistochemistry and western blot analysis. Pearson's correlation analysis was conducted to assess the correlation between Bmi-1 expression and the SUVmax. The Bmi-1 protein levels were significantly greater in GAC versus noncancerous tissues, and higher Bmi-1 was significantly correlated with a lower degree of tumor differentiation, higher tumor stages, more lymph node metastasis, and depth of invasion. The SUVmax value was significantly correlated with the T stage, N stage, and clinical stage, but not with age, gender, tumor size, histological differentiation degree, or Lauren classification. Moreover, a significant positive correlation between Bmi-1 and SUVmax was observed in GAC tissues. In conclusion, our findings demonstrate a novel correlation between Bmi-1 and preoperative SUVmax in GAC patients who did not receive radiotherapy, chemotherapy, or targeted treatment before surgery, and both are positively correlated with unfavorable prognostic factors and a higher grade of malignancy.

Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer in Childbearing Age Women

Total hysterectomy and bilateral adnexectomy is the standard treatment for atypical endometrial hyperplasia and early-stage endometrial cancer. However, the recommended surgical treatment precludes future pregnancy when these conditions are diagnosed in women in their fertile age. In these patients, fertility-sparing treatment may be feasible if the desire for childbearing is consistent and specific conditions are present. This review summarizes the available evidence on fertility-sparing management for atypical endometrial hyperplasia and early-stage endometrial cancer. Historically, oral progestins have been the mainstay of conservative management for atypical endometrial hyperplasia and stage IA endometrioid endometrial cancer with no myometrial invasion, although there is no consensus on dosage and treatment length. Intrauterine progestin therapy has proved a valid alternative option when oral progestins are not tolerated. GnRH analogs, metformin, and hysteroscopic resection in combination with progestins appear to increase the overall efficacy of the treatment. After a complete response, conception is recommended; alternatively, maintenance therapy with strict follow-up has been proposed to decrease recurrence. The risk of disease progression is not negligible, and clinicians should not overlook the risk of hereditary forms of the disease in young patients, in particular, Lynch syndrome. Hysterectomy is performed once the desire for childbearing desire has been established. The conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer is feasible, provided a strong desire for childbearing and permitting clinical–pathological conditions. However, patients must be aware of the need for a strict follow-up and the risk of progression with a possible consequent worsening of the prognosis. More homogenous and well-designed studies are necessary to standardize and identify the best treatment and follow-up protocols.

Contemporary Fertility-Sparing Management Options of Early Stage Endometrioid Endometrial Cancer in Young Nulliparous Patients

Incidence of endometrial cancer (EC) has been increasing in recent years, especially in high-income countries. The disease commonly affects peri- and postmenopausal women; however, about 5% of women are diagnosed with EC in their reproductive age. Due to both the increasing incidence of EC among reproductive age women and trends to delayed childbearing, fertility-sparing treatment for young patients with EC has become extremely important for researchers and practitioners. Because the classic treatment with total hysterectomy and bilateral saplingo-oophorectomy is not an appropriate approach for young women demanding fertility preservation, several fertility-sparing options have been developed and summarized in this review. Utilization of different medications and their combination (progestagens, gonadotropin releasing hormones analogues, and metformin in different formulations) are tested and found as efficient for fertility-sparing treatment. New minimally invasive surgical techniques, combined with progestagens, are also confirmed as valuable. There are many novel conservative and surgical treatment approaches under investigation. Assuming that molecular biomarkers can be both diagnostic and prognostic to assist in prediction of response to a certain therapy, prognostic risk groups' stratification along with specific biomarkers' identification will ensure low recurrence and decrease mortality rates in young women with EC.

Extraperitoneal laparoscopy for para-aortic lymphadenectomy in endometrial carcinoma staging: an approach with higher efficiency

Background

Removing more inframesenteric nodes is not only significantly increases the likelihood of finding metastasis for endometrial cancer, but also can add survival advantage. As most patients diagnosed with endometrial cancer are overweight or obesity, a high efficiency approach is important. Aim of this study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and laparotomic para-aortic lymphadenectomy in endometrial carcinoma staging.

Methods

We retrospectively reviewed data of all patients diagnosed with primary endometrial carcinoma who were treated at the Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center from 1 January 2017 to 31 December 2019. The numbers of para-aortic lymph nodes, surgical time, complications, blood loss and hospital stay were compared. The patients’ medical records and pathological reports were carefully reviewed. Statistical significance was defined as p < 0.05.

Results

We retrospectively compared patients who underwent extraperitoneal laparoscopy (Group E, n = 20), transperitoneal laparoscopy (group T, n = 21), and laparotomy (group L, n = 135). The median number of para-aortic lymph nodes was significantly higher in group E than in groups T and L (9.5, 5, and 6, respectively; p = 0.004 and 0.0004, respectively). All patients in group E underwent successfully dissection to the renal vessel level. The median operation time was significantly shorter in group L than in groups T and E (94, 174, and 233 min, respectively; p < 0.0001). The median estimated blood loss volume was higher in group L than in groups T and E (200, 100, and 142.5 ml, respectively; all comparisons p < 0.001), and the length of hospital stay was significantly longer in group L than in Groups T and E (6, 5, and 6 days, respectively; all comparisons p < 0.001).

Conclusion

The extraperitoneal laparoscopic approach for staging endometrial carcinoma harvested higher numbers of para-aortic lymph nodes which could be considered for endometrial carcinoma staging, especially for para-aortic lymph node harvest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02416-x.

Pipelle endometrial sampling success rates in Kazakhstani settings: results from a prospective cohort analysis

The aim of this study was to evaluate the feasibility of Pipelle endometrial sampling and to explore factors influencing Pipelle success rate in the clinical settings of Kazakhstan. This prospective analysis included 87 patients who had undergone Pipelle biopsy due to medical indications for endometrial sampling. We analysed physician and patient-related factors potentially influencing the success rate of this method. Pipelle endometrial biopsy overall success rate was 82.76%. The indications for the procedure and patients' age were key factors influencing Pipelle sampling success (p < .001). The success rate was the highest in the group with abnormal uterine bleeding as a biopsy indication in the reproductive age group (93.19%; p < .001).Pipelle biopsy was found to be an acceptable option for endometrial sampling in our clinical setting; at the same time, physicians should consider the potential influencing factors on its success rate like indications for the procedure, BMI and patients' age as well as their menopausal status. In order to provide precise future directions, there is a need to study a larger number of patients.IMPACT STATEMENTWhat is already known on this subject? Compared to dilation and curettage sampling conducted in the operation room, Pipelle endometrial sampling is relatively inexpensive, associated with less morbidity, safe, accurate, and can be performed in an office setting.What do the results of this study add? This is the first prospective data analysis about Pipelle endometrial sampling in Kazakhstani population.What are the implications of these findings for clinical practice and/or further research? Enabling the timely diagnosis of current endometrial pathology, Pipelle endometrial sampling approach may have an important impact on healthcare safety and efficiency, and improve overall treatment outcomes and the quality of life of Kazakhstani population if used consistently.

Co-existent abdominoperitoneal tuberculosis with endometrial cancer: A diagnostic and surgical challenge

The presence of abdominoperitoneal tuberculosis (APTB) complicates the diagnosis, staging and management of endometrial cancer. Lymph node involvement in APTB may mimic metastatic lymphadenopathy in patients with endometrial cancer. To our knowledge, there have only been 2 previous case reports on this topic. We will describe 3 cases of endometrial cancer co-existing with APTB. The 1st case is a 57-year-old female who underwent elective total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLHBSO) and bilateral pelvic lymph node dissection (PLND). The final diagnosis is Stage 3C1 endometrial endometroid carcinoma with mucinous differentiation. The 2nd case is a 70-year-old female with who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) and PLND. The final diagnosis is a Stage 1A endometrioid adenocarcinoma. The 3rd case is a 63-year-old female who underwent TAHBSO and PLND and the final diagnosis was a mixed high-grade serous (90%) and endometrioid (10%) carcinoma of the endometrium. In these cases, the importance of surgical staging is emphasised to accurately stage endometrial cancer. Moreover, thorough peri-operative optimisations by a multi-disciplinary team are essential to improve the outcomes of surgery.

Molecular Basis of Endometriosis and Endometrial Cancer: Current Knowledge and Future Perspectives

The human endometrium is a unique tissue undergoing important changes through the menstrual cycle. Under the exposure of different risk factors in a woman's lifetime, normal endometrial tissue can give rise to multiple pathologic conditions, including endometriosis and endometrial cancer. Etiology and pathophysiologic changes behind such conditions remain largely unclear. This review summarizes the current knowledge of the pathophysiology of endometriosis and its potential role in the development of endometrial cancer from a molecular perspective. A better understanding of the molecular basis of endometriosis and its role in the development of endometrial pathology will improve the approach to clinical management.

Prediction of Myometrial Invasion in Stage I Endometrial Cancer by MRI: The Influence of Surgical Diagnostic Procedure

Simple Summary

Fertility sparing treatment can be considered for young women with clinical stage 1A endometrial cancer (EC) without myometrial invasion (MI). Surgical diagnostic procedures (SDP) were needed to make diagnosis of EC, but different extents of SDP including diagnostic hysteroscopic biopsy (DHB, group 1), operative hysteroscopic partial resection (OHPR, group 2), operative hysteroscopic complete resection (OHCR, group 3), and cervical dilatation and fractional curettage (D&C, group 4) may affect the accuracy of MI assessment by magnetic resonance imaging (MRI) after SDP. Here, we retrospectively review those initially diagnosed with stage 1A EC and compare MI status on MRI reports and final histopathology of hysterectomy. We found that the MRI accuracy of MI was better in patients with EC diagnosed with D&C. Three diagnostic procedures using hysteroscopy might interfere with the diagnostic power of MI on MRI. Thus, D&C for diagnosis of EC and further hysteroscopic complete resection with hormone as a fertility sparing treatment for those confirmed as stage 1A without MI from MRI may be a choice in the future.

Abstract

Young women with endometrial cancer (EC) can choose fertility-sparing treatment for stage 1A disease without myometrial invasion (MI). The surgical diagnostic procedure (SDP) may affect the accuracy of magnetic resonance imaging (MRI) to assess MI. Here, we evaluated different SDP and compared the MI on MRI results with further pathologic results after hysterectomy. We retrospectively collected data on 263 patients with clinical stage IA EC diagnosed between January 2013 and December 2015. Patients were classified into four groups based on SDP, including diagnostic hysteroscopic biopsy (DHB, group 1), operative hysteroscopic partial resection (OHPR, group 2), operative hysteroscopic complete resection (OHCR, group 3), and cervical dilatation and fractional curettage (D&C, group 4). The sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value of MRI to assess MI were 73.1%, 46.7%, 63.9%, 71.8%, and 48.3%, respectively. Three hysteroscopic procedures (groups 1 to 3) had a trend with a higher odds ratio of discrepancy between MRI and histopathology (p = 0.068), especially in group 2 (odds ratio 2.268, p = 0.032). Here, we found MRI accuracy of MI was better in patients with EC diagnosed with D&C. Three diagnostic procedures using hysteroscopy might interfere with the diagnostic power of MI on MRI.

The diagnostic value of human epididymis protein 4 for endometrial cancer is moderate

Human epididymis protein 4 (HE4) has been used as a biomarker of endometrial cancer (EC) in clinical practice. However, there remains a lack of systemic research on the critical values of HE4 for diagnosing different clinical stages and pathological types of EC. This study investigated the accuracy of human epididymis protein 4 (HE4) in the diagnosis of EC. Patients who were hospitalized for a chief complaint of abnormal vaginal hemorrhage at Xinjiang Uyghur Autonomous Region People's Hospital between 2014 and 2019 were consecutively included. Pathological biopsy confirmed the diagnosis of EC; there were a total of 136 EC patients and 127 non-EC patients. The accuracy of HE4 in the diagnosis of EC was assessed with SPSS software. The accuracy of HE4 for diagnosing different clinical stages and pathological types of EC was also explored. The critical value of HE4 for endometrial cancer was 52.40 mmol/L, with a sensitivity of 57.35% and a specificity of 76.38%. For different stages of EC, the critical value was 36.9 mmol/L, and the sensitivity and specificity were 28% and 87.39%, respectively. For different pathological types, the critical value was 30.60 mmol/L, and the sensitivity and specificity were 93.85% and 33.33%, respectively. The diagnostic value of HE4 for EC is moderate, and the serum HE4 level cannot reflect the stage and type of EC.

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient’s lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.

Fertility issue in early stage endometrial cancer patients

Endometrial cancer (EC) is the most common cancer of the female reproductive system in developed countries. The incidence of EC has been increasing in young women. Approximately 4% of cases are aged <40 years. These young women may wish to delay therapy until after they have children. Common complaints in patients with EC include irregular vaginal bleeding, pelvic pain, and enlarged uterus. Imaging techniques such as transvaginal ultrasound (TVUS) or magnetic resonance imaging (MRI) can be utilized in detecting EC. Although the recommended treatment of EC is hysterectomy and bilateral salpingo-oophorectomy with or without systemic lymph node dissection, loss of reproductive function is the primary limiting factor of this surgical approach. Some studies have reported favorable results with high-dose oral progestins or levonorgestrel-releasing intrauterine system or hysteroscopic tumor resection followed by treatment with high-dose oral progestins. The most widely utilized medical treatment regimens are medroxyprogesterone acetate (MPA) 250–600 mg/day or megestrol acetate (MA) 160–480 mg/day. However, there is still a lack of evidence to establish the optimal dose and duration of progestin treatment. Patients with complete remission (CR) who wish to conceive must be encouraged, and referral to a fertility clinic should be offered as soon as possible. The key aspect of fertility-sparing management in women with EC appears to be the selection of appropriate candidates. Owing to the rarity of this condition, management may often be suboptimal. The aim of this review is to assess the current approaches to management of young women with EC who wish to preserve their fertility.

Preoperative assessment of endometrial cancer

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.

Impact of endometrial sampling technique and biopsy volume on the diagnostic accuracy of endometrial cancer

BACKGROUND

Histotype and tumor grading of endometrial cancer are the most important factors that have to be assessed by preoperative endometrial sampling, and their concordance with the final surgical and definitive histological findings is of paramount importance. We aim to compare histotype and tumor grading concordance of various endometrial sampling techniques (ESTs) and to investigate the role of endometrial volume biopsy.

METHODS

We performed a retrospective analysis of patients with apparent early stage endometrial cancer collecting demographic, clinical data, type of EST, pathological characteristics of endometrial biopsies and final specimens. We classified ESTs as dilation and curettage (D&C), diagnostic hysteroscopy with D&C, outpatient hysteroscopy and operative hysteroscopy with or without D&C. Diagnostic and operative hysteroscopy were performed with Bettocchi's 5 mm hysteroscope. We evaluated concordance for histotype, and tumor grading, and we performed subgroup analysis based on the technique and final tumor grading. Concordance was classified from good, moderate, sufficient, fair, poor and none using Cohen k-statistic. Finally, we investigated the existence of independent risk factors for discordant tumor grading using multivariate binary logistic regression.

RESULTS

We collected 148 patients and of these 131 (88.5%) were diagnosed with endometrioid histotype and 65 (44%), 46 (31%) and 37 (25%) respectively with well, moderate and poor differentiated tumors. Atypical hyperplasia (AH) was detected preoperatively in 28 patients (19%). Histotype concordance was fair (k=0.35) and tumor grading concordance was moderate (k=0.45); particularly, concordance was fair in well-differentiated cases (k=0.38); concordance was moderate in moderate- and poor-differentiated cases (k=0.52) and good (k=0.71). Operative hysteroscopy showed moderate concordance for histotype (k=0.41), while grading concordance was fair for G1 (k=0.41), moderate for G2 (k=0.58) and good for G3 (k=0.72), regardless the use of D&C. Preoperative volume biopsy did not impact the concordance of tumor grading, while the adoption of operative hysteroscopy (with or without D&C) decreased the risk of grading discordance in G3 tumors (HR 0.17; 95% CI: 0.03-0.94; P=0.04). Conversely, time elapsed from diagnosis to treatment in well-differentiated tumors increased the risk of discordant results (HR 1.06; 95% CI: 1.02-1.52; P=0.04).

CONCLUSIONS

Operative hysteroscopy demonstrated the best tumor grading concordance, especially in poor-differentiated tumors. The volume of biopsy did not affect the tumor grading concordance.

Lymph node evaluation in endometrial cancer: how did it change over the last two decades?

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and surgery represents the pivotal part of treatment. Hysterectomy and salpingo-oophorectomy allow removing the primary tumor and defining patients at higher risk, who might benefit from adjuvant therapies. Minimally invasive surgery is associated with superior postoperative outcomes and represents a safe and effective approach for surgical staging of EC. The lymph node status evaluation in EC is still a matter of debate. Over the last twenty years much has changed, moving from a full systematic pelvic and paraaortic lymphadenectomy for staging purpose to the removal of the pelvic (with or without paraaortic) lymph nodes only in selected EC classes of risk. Two randomized trials failed to demonstrate survival benefits of lymphadenectomy in case of apparent early stage EC; however, its prognostic role has never been questioned. At present, with the aim of reducing the surgical-related morbidity, sentinel node mapping is emerging as a safe and valid alternative to lymphadenectomy for EC staging, demonstrating high accuracy and an increased detection of lymph nodes metastasis. Here, we performed a review of the most significant studies, which supported the changes in the lymph node status evaluation for EC over the last two decades.

Accuracy of preoperative sampling diagnosis for predicting final pathology in patients with endometrial carcinoma: a review

Endometrial cancer (EC) is the most common gynecologic cancer. The most frequent symptom of this disease is postmenopausal bleeding. Diagnosis of EC must be histologically confirmed, and there are several methods for endometrial sampling to obtain cells or endometrial tissue. The first step in diagnosis should be ultrasound measurement of endometrial thickness, followed by endometrial sampling, which can be performed by office endometrial biopsy, hysteroscopic biopsy, or dilatation and curettage (D&C). The review in this article was carried out to present previously published studies, comprehensively evaluate method performance (i.e., overall accuracy of preoperative sampling in patients with endometrial carcinoma, and overall agreement on grade and histological subtype between preoperative endometrial sampling and final diagnosis), and determine which sampling method is most accurate on the basis of the statistical data in the studies analyzed. From the literature analyzed and examined, it can be concluded that preoperative endometrial sampling is not always the best predictor of final histology in EC and has its limitations. In surgical decisions based only on preoperative sampling, a biopsy should be made with caution, and it is necessary to take other parameters into account. Inadequate grading leads to suboptimal clinical management, mainly in early-stage tumors. This review showed that, although hysteroscopic biopsy was mainly associated with the highest tumor grade agreement, and although D&C showed the highest overall accuracy in detecting endometrial carcinoma, the data do not therefore reliably indicate which method yields the most precise results. The results of this review indicate that further studies on larger samples and with greater statistical power are needed to accurately define the role and type of preoperative sampling methods.

Endometrial cancer-is our knowledge changing?

In developed countries, endometrial cancer (EC) is the most frequent gynecologic malignancy in postmenopausal women. At the same time, EC has become one of the most common cancers in numerous developing countries, probably influenced by global epidemic of obesity. The majority of patients have low-grade endometrioid cancer with a high 5-year survival rate, but with high-risk EC, the survival rates are still rather low. However, despite intensive research in last decades, our knowledge of the mechanisms, risk factors, diagnosis and treatment have not significantly improved. The standard treatment of all types of EC is still a traditional combination of surgery, irradiation and/or chemotherapy, despite the fact that each of these options is not without having some negative side effects. Despite the fact that on the molecular level, EC is relatively well-studied, but the efforts to transform these findings into either diagnosis or therapies of EC remain elusive. In addition, some research into risk factors involved in the development or progression of EC seems to be more a fishing expedition than a well thought-out approach. The purpose of this review is to summarize the most recent developments in the search for biomarkers and prognostic markers and to discuss the progress in EC treatment.

Sentinel lymph node biopsy in endometrial cancer: state of the art

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.

Aberrant Telomere Length in Circulating Cell-Free DNA as Possible Blood Biomarker with High Diagnostic Performance in Endometrial Cancer

To investigate the diagnostic performance of relative telomere length (RTL) in cell-free DNA (cfDNA) for endometrioid endometrial cancer (EC). We measured RTL in cfDNA of 40 EC patients (65 ± 12 years) and 31 healthy controls (HC) (63 ± 13 years), excluding in both groups other oncologic and severe non-oncologic diseases to limit confounders. Circulating cfDNA was extracted from serum using the QIAamp DNA Blood Mini kit (Qiagen, Hilden, Germany). After the quantitative real-time polymerase chain reaction, telomere repeat copy number to single-gene copy number ratio was calculated. RTL in cfDNA was found to be significantly lower in EC patients than in HC (p < 0.0001). The diagnostic performance of cfDNA RTL was estimated with receiver operating characteristics (ROC) curve analysis, which showed a diagnostic accuracy for EC of 0.87 (95% CI: 0.79-0.95, p < 0.0001). The cutoff cfDNA RTL value of 2.505 (T/S copy ratio) reported a sensitivity of 80.0% (95% CI: 64.35-90.95) and a specificity of 80.65% (95% CI: 62.53-92.55). Significant differences of RTL among EC stages or grades (p = 0.85 and p = 0.89, respectively) were not observed. Our results suggest that cfDNA RTL analysis may be a diagnostic tool for EC detection since the early stage, whilst its diagnostic performance seems unsatisfactory for cancer progression, staging, and grading. However, further studies are needed to confirm these preliminary findings. In particular, future investigations should focus on high-risk patients (such as those with atypical endometrial hyperplasia) that may benefit from this tool, because TL shortening is not specific for EC and is influenced by other oncologic and non-oncologic diseases.

Fertility preservation in endometrial cancer patients: options, challenges and perspectives

Several different approaches have been designed by physicians in order to preserve fertility in younger patients with endometrial carcinoma. There are various options offering different advantages, but hysteroscopic resection of pathologic endometrial tissue with placement of a Levonorgestrel Intrauterine Device has proven to be the most successful in allowing patients to conceive and give birth afterwards. However, conservative treatments should only be considered in patients with low-grade and low-stage endometrial tumours. There are many published studies which have sought out a preferable approach to treating endometrial cancer whilst preserving fertility. However, more research on this matter is needed to allow a better understanding as to which techniques/approaches are optimal. In this review, we will summarise the current available treatment options for endometrial cancer in patients of reproductive age.