Quantitative assessment of lymph vascular space invasion (LVSI) provides important prognostic information in node-negative breast cancer

Intrauterine manipulator during hysterectomy for endometrial cancer: a systematic review and meta-analysis of oncologic outcomes

OBJECTIVE

This study aimed to assess the effects on oncologic outcomes of intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer.

DATA SOURCES

A systematic literature search was performed by an expert librarian in multiple electronic databases from inception to January 31, 2023.

STUDY ELIGIBILITY CRITERIA

We included all studies in the English language that compared oncologic outcomes (recurrence-free, cause-specific, or overall survival) between endometrial cancer patients who underwent total laparoscopic or robotic hysterectomy for endometrial cancer with vs without the use of an intrauterine manipulator. Studies comparing only peritoneal cytology status or lymphovascular space invasion were summarized for completeness. No selection criteria were applied to the study design.

METHODS

Four reviewers independently reviewed studies for inclusion, assessed their risk of bias, and extracted data. Pooled hazard ratios with 95% confidence intervals were estimated for oncologic outcomes using the random effect model. Heterogeneity was quantified using the I2 tests. Publication bias was assessed by funnel plot and Egger test.

RESULTS

Out of 350 identified references, we included 2 randomized controlled trials and 12 observational studies for a total of 14 studies and 5,019 patients. The use of an intrauterine manipulator during hysterectomy for endometrial cancer was associated with a pooled hazard ratio for recurrence of 1.52 (95% confidence interval, 0.99-2.33; P=.05; I2=31%; chi square P value=.22). Pooled hazard ratio for recurrence was 1.48 (95% confidence interval, 0.25-8.76; P=.62; I2=67%; chi square P value=.08) when only randomized controlled trials were considered. Pooled hazard ratio for overall survival was 1.07 (95% confidence interval, 0.65-1.76; P=0.79; I2=44%; chi square P value=.17). The rate of positive peritoneal cytology or lymphovascular space invasion did not differ using an intrauterine manipulator.

CONCLUSION

Intrauterine manipulator use during hysterectomy for endometrial cancer was neither significantly associated with recurrence-free and overall survival nor with positive peritoneal cytology or lymphovascular space invasion, but further prospective studies are needed.

Morphologic Pattern, Frequency, and Spatial Distribution of Lymphovascular Invasion Foci in Radical Prostatectomy Specimens

Introduction. Lymphovascular invasion (LVI) is an adverse pathological finding in radical prostatectomy (RP) specimens associated with increased risk of metastatic disease. Its variable incidence may be attributed to underreporting. We characterized the location, quantity, and morphology of LVI foci in RP specimens and assessed the relationship between LVI and cribriform and intraductal carcinoma and metastatic risk. Methods. Two pathologists reviewed retrospectively 54 RP specimens reported as positive for LVI. Ambiguous cases were confirmed by immunostaining for ERG, CD31 and D2-40. Results. In 4/54 (7.4%), LVI could not be confirmed. Main mimickers of LVI were retraction artifact and dislodged tumor cells. Based on our review, the most important criteria to distinguish LVI from its mimickers were a corrugated lining of vascular spaces, endothelial nuclei bulging into the lumen, and presence of proteinaceous material. The LVI frequency per case ranged from 1 to 109 (median 7.5). In 47/50 (94%) cases with LVI, the associated carcinoma comprised cribriform pattern and/or intraductal carcinoma. The most common morphology of LVI foci was cribriform, occurring in 43/50 specimens, representing 469/843 (56%) of LVI foci. Most LVI foci were intraprostatic and located at the carcinoma-stroma interface. Particularly the risk of bone metastases during follow-up was independently associated with higher frequency of LVI foci (P = .009). Conclusions. The detailed description of prostatic LVI, and awareness of their predominant location and morphology may help its identification and improve the diagnostic accuracy of LVI in pathology reporting. The clinical impact of LVI quantification in prostate cancer needs validation by further studies.

The value of prognostic ultrasound features of breast cancer in different molecular subtypes with a focus on triple negative disease

The ultrasound (US) features of breast cancer have recently been shown to have prognostic significance. We aim to assess these features according to molecular subtype. 1140 consecutive US visible invasive breast cancers had US size and mean stiffness by shearwave elastography (SWE) recorded prospectively. Skin thickening (> 2.5 mm) overlying the cancer on US and the presence of posterior echo enhancement were assessed retrospectively while blinded to outcomes. Cancers were classified as luminal, triple negative (TN) or HER2 + ve based on immunohistochemistry and florescent in-situ hybridization. The relationship between US parameters and breast cancer specific survival (BCSS) was ascertained using Kaplan–Meier survival curves and ROC analysis. At median follow-up 6.3 year, there were 117 breast cancer (10%) and 132 non-breast deaths (12%). US size was significantly associated with BCSS all groups (area under the curve (AUC) 0.74 in luminal cancers, 0.64 for TN and 0.65 for HER2 + ve cancers). US skin thickening was associated most strongly with poor prognosis in TN cancers (53% vs. 80% 6 year survival, p = 0.0004). Posterior echo enhancement was associated with a poor BCSS in TN cancers (63% vs. 82% 6 year survival, p = 0.02). Mean stiffness at SWE was prognostic in the luminal and HER2 positive groups (AUC 0.69 and 0.63, respectively). In the subgroup of patients with TN cancers receiving neo-adjuvant chemotherapy posterior enhancement and skin thickening were not associated with response. US skin thickening is a poor prognostic indicator is all 3 subtypes studied, while posterior enhancement was associated with poor outcome in TN cancers

Role of uterine manipulator during laparoscopic endometrial cancer treatment

Endometrial cancer (EC) is the most frequent gynecologic malignancy with 61,000 new cases diagnosed per year in the USA. Gynecologic Oncology Group (GOG) LAP2 randomized study demonstrated a superimposable 5-year overall survival between laparotomic and laparoscopic approaches in EC treatment. In this context the uterine manipulator (UM) represents a valuable tool in order to increase the ergonomics of surgical gesture during a laparoscopic total hysterectomy. Despite the proven safety of the minimally invasive approach in EC treatment, neither the indication whether to use or not, nor the recommendation concerning a specific type of UM are provided by international guidelines. This narrative review aims to collect all the main findings in the literature about UM use to investigate its safety in EC patients. Based on the analysis of the literature research, the main results were categorized into two manipulator-related problems: the iatrogenic LVSI, and the retrograde tumor spillage. LVSI is defined as the presence of tumor cells within an endothelium-lined space. An electronic search was performed using the following keywords: 'uterine manipulator', and 'endometrial cancer'. The electronic database search provided a total of 93 studies. Of whom, 12 case reports, 5 studies not in English language, and 65 works not fitting the review scope were excluded from the analysis. Eleven studies were considered eligible for the purpose of the study. The most recent studies have highlighted the safety of the uterine manipulator in the early-stage EC laparoscopic treatment. All types of manipulators are considered to be fairly safe but its application should be tailored according to tumor dimension and grade of myometrial infiltration.

Associations between the ultrasound features of invasive breast cancer and breast cancer specific survival

AIM

To assess whether ultrasound features of breast cancer are associated with breast cancer specific survival (BCSS).

MATERIALS AND METHODS

Within a single breast service, data was collected prospectively (April 2010-April 2012) from 319 consecutive women (mean age 63 years) with 335 ultrasound-visible invasive breast cancers. Ultrasound features were evaluated retrospectively from the recorded images according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon by a radiologist blinded to outcomes. Survival and cause of death were ascertained from local and national sources. Kaplan-Meier survival curves were generated, and statistical significance tested using the log-rank test.

RESULTS

Mean follow-up in those alive was 80.9 months. Thirty breast cancer deaths and 45 non-breast cancer deaths occurred. Five-year BCSS in the presence of distal acoustic enhancement was 76% compared to 88%, 96%, and 100% for those with distal shadowing, no distal effect or combined effect respectively (p<0.0002). Patients with sonographic skin involvement had 73% 5-year BCSS compared to 92% for no skin involvement (p<0.0001). Focal oedema was associated with 56% 5-year BCSS compared to 89% for those without (p=0.0002). A significant association was demonstrated between ultrasound tumour size and BCSS (p<0.0001). At multivariate analysis, skin changes, distal enhancement, and focal oedema maintained prognostic significance.

CONCLUSION

Distal enhancement, focal oedema, and skin involvement have strong associations with breast cancer death. These factors could be taken into account, along with lesion size and other commonly used preoperative prognostic features, when considering management of women with breast cancer.

Performance of CT-based radiomics in diagnosis of superior mesenteric vein resection margin in patients with pancreatic head cancer

OBJECTIVES

To accurately identify the relationship between a portal radiomics score (rad-score) and pathologic superior mesenteric vein (SMV) resection margin and to evaluate the diagnostic performance in patients with pancreatic head cancer.

MATERIALS AND METHODS

A total of 181 patients with postoperatively and pathologically confirmed pancreatic head cancer who underwent multislice computed tomography within one month of resection between January 2016 and December 2018 were retrospectively investigated. For each patient, 1029 radiomics features of the portal phase were extracted, which were reduced using the least absolute shrinkage and selection operator (LASSO) logistic regression algorithm. Multivariate logistic regression models were used to analyze the association between the portal rad-score and SMV resection margin.

RESULTS

Patients with negative (R0) and positive (R1) margins accounted for 70.17% (127) and 29.83% (54) of the cohort, respectively. The rad-score was significantly associated with the SMV resection margin status (p < 0.05). Multivariate analyses confirmed a significant and independent association between the portal rad-score and SMV resection margin (OR 4.62; 95% CI 2.19-9.76; p < 0.0001). The portal rad-score had high accuracy (area under the curve = 0.750). The best cut point based on maximizing the sum of sensitivity and specificity was - 0.741 (sensitivity = 64.8%; specificity = 74.0%; accuracy = 71.3%). Decision curve analysis indicated the clinical usefulness of radiomics score.

CONCLUSIONS

The portal rad-score is significantly associated with the pathologic SMV resection margin, and it can accurately and noninvasively predict the SMV resection margin in patients with pancreatic cancer.

Reproducibility of lymphovascular space invasion (LVSI) assessment in endometrial cancer

Aims

Lymphovascular space invasion (LVSI) in endometrial cancer (EC) is an important prognostic variable impacting on a patient's individual recurrence risk and adjuvant treatment recommendations. Recent work has shown that grading the extent of LVSI further improves its prognostic strength in patients with stage I endometrioid EC. Despite this, there is little information on the reproducibility of LVSI assessment in EC. Therefore, we designed a study to evaluate interobserver agreement in discriminating true LVSI from LVSI mimics (Phase I) and reproducibility of grading extent of LVSI (Phase II).

Methods and results

Scanned haematoxylin and eosin (H&E) slides of endometrioid EC (EEC) with a predefined possible LVSI focus were hosted on a website and assessed by a panel of six European gynaecological pathologists. In Phase I, 48 H&E slides were included for LVSI assessment and in Phase II, 42 H&E slides for LVSI grading. Each observer was instructed to apply the criteria for LVSI used in daily practice. The degree of agreement was measured using the two‐way absolute agreement average‐measures intraclass correlation coefficient (ICC). Reproducibility of LVSI assessment (ICC = 0.64, P < 0.001) and LVSI grading (ICC = 0.62, P < 0.001) in EEC was substantial among the observers.

Conclusions

Given the good reproducibility of LVSI, this study further supports the important role of LVSI in decision algorithms for adjuvant treatment.

Increased risk of poor survival in ovarian cancer patients with high expression of SNAI2 and lymphovascular space invasion

This study is aimed to conduct a meta-analysis to evaluate the prognostic value of lymphovascular space invasion(LVSI) and to explore the potential association of SNAI1 and SNAI2 with LVSI in ovarian cancer. A systematic literature search in PubMed, ISI Web of Science, and Medline was conducted to identify relevant studies assessing the prognostic value of LVSI in ovarian cancer. The main outcomes analyzed were progression free survival/disease free survival and overall survival. TCGA database was used to explore the potential link of SNAI1 and SNAI2 with LVSI status. A total of 11 eligible studies enrolling 1817 patients were included for the meta-analysis. The overall analysis indicated that LVSI presence was associated with shorter duration of survival in ovarian cancer patients. Multivariate analysis indicated that both advanced stage and SNAI2 expression were associated with increased risk of LVSI presence. Survival analysis indicated that tumors with LVSI presence and high SNAI2 expression were significantly correlated with poorer survival when compared to tumors with both LVSI absence and low SNAI2 expression. In conclusion, LVSI presence was associated with worse clinical outcomes in ovarian cancer. Increased expression of SNAI2 and advanced stage were independent risk factors for LVSI presence. Our findings also emphasizes the potential of SNAI2 in promoting lymphovascular spread of ovarian cancer.