Direct Comparison of Logistic Regression and Recursive Partitioning to Predict Lymph Node Metastasis in Endometrial Cancer

Predictive models for lymph node metastasis in endometrial cancer: A systematic review and bibliometric analysis

BACKGROUND

Lymph node metastasis is associated with a poorer prognosis in endometrial cancer.

OBJECTIVE

The objective was to synthesize and critically appraise existing predictive models for lymph node metastasis risk stratification in endometrial cancer.

DESIGN

This study is a systematic review.

DATA SOURCES AND METHODS

We searched the Web of Science for articles reporting models predicting lymph node metastasis in endometrial cancer, with a systematic review and bibliometric analysis conducted based upon which. Risk of bias was assessed by the Prediction model Risk Of BiAS assessment Tool (PROBAST).

RESULTS

A total of 64 articles were included in the systematic review, published between 2010 and 2023. The most common articles were "development only." Traditional clinicopathological parameters remained the mainstream in models, for example, serum tumor marker, myometrial invasion and tumor grade. Also, models based upon gene-signatures, radiomics and digital histopathological images exhibited an acceptable self-reported performance. The most frequently validated models were the Mayo criteria, which reached a negative predictive value of 97.1%-98.2%. Substantial variability and inconsistency were observed through PROBAST, indicating significant between-study heterogeneity. A further bibliometric analysis revealed a relatively weak link between authors and organizations on models predicting lymph node metastasis in endometrial cancer.

CONCLUSION

A number of predictive models for lymph node metastasis in endometrial cancer have been developed. Although some exhibited promising performance as they demonstrated adequate to good discrimination, few models can currently be recommended for clinical practice due to lack of independent validation, high risk of bias and low consistency in measured predictors. Collaborations between authors, organizations and countries were weak. Model updating, external validation and collaborative research are urgently needed.

REGISTRATION

None.

The value of machine learning in preoperative identification of lymph node metastasis status in endometrial cancer: a systematic review and meta-analysis

Background

The early identification of lymph node metastasis status in endometrial cancer (EC) is a serious challenge in clinical practice. Some investigators have introduced machine learning into the early identification of lymph node metastasis in EC patients. However, the predictive value of machine learning is controversial due to the diversity of models and modeling variables. To this end, we carried out this systematic review and meta-analysis to systematically discuss the value of machine learning for the early identification of lymph node metastasis in EC patients.

Methods

A systematic search was conducted in Pubmed, Cochrane, Embase, and Web of Science until March 12, 2023. PROBAST was used to assess the risk of bias in the included studies. In the process of meta-analysis, subgroup analysis was performed according to modeling variables (clinical features, radiomic features, and radiomic features combined with clinical features) and different types of models in various variables.

Results

This systematic review included 50 primary studies with a total of 103,752 EC patients, 12,579 of whom had positive lymph node metastasis. Meta-analysis showed that among the machine learning models constructed by the three categories of modeling variables, the best model was constructed by combining radiomic features with clinical features, with a pooled c-index of 0.907 (95%CI: 0.886-0.928) in the training set and 0.823 (95%CI: 0.757-0.890) in the validation set, and good sensitivity and specificity. The c-index of the machine learning model constructed based on clinical features alone was not inferior to that based on radiomic features only. In addition, logistic regression was found to be the main modeling method and has ideal predictive performance with different categories of modeling variables.

Conclusion

Although the model based on radiomic features combined with clinical features has the best predictive efficiency, there is no recognized specification for the application of radiomics at present. In addition, the logistic regression constructed by clinical features shows good sensitivity and specificity. In this context, large-sample studies covering different races are warranted to develop predictive nomograms based on clinical features, which can be widely applied in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023420774.

Tumor diameter as a predictor of lymph node involvement in endometrioid type endometrial adenocarcinomas

AIM

To analyze the risk factors of lymph node involvement in pure endometrioid type endometrial cancer and assess factors that necessitate lymphadenectomy.

METHODS

Patients who had been operated on due to endometrial cancer and whose final pathology was reported as pure endometrioid carcinoma between January 2014 and January 2020 were assessed. Hysterectomy, bilateral salpingo-oophorectomy, and systematic lymphadenectomy were performed in all patients. All specimens were reported by expert gynecopathologists.

RESULTS

The lymph node positivity rate was 14.4%. When the study population was classified according to the Mayo risk criteria; lymph node involvement in the low-risk and high-risk groups was 9.1% and 14.8%, respectively and there was no statistically difference (p > 0.05). The median of tumor size and the rate of deep myometrial invasion, lymphovascular space invasion, adnexal involvement, FIGO grade 3 tumor were found significantly higher in the positive lymph node group in univariate analysis. In the receiver operating characteristic curve analysis, the cut-off value of the tumor diameter was determined as 47.5 mm (sensitivity 85%, specificity 62%). Every 10 mm increase in tumor diameter increased the risk of lymph node involvement 10 times.

CONCLUSION

This study defined that the tumor diameter is an independent predictor for lymphatic dissemination. In the future, it could be shown that even with new modeling based on tumor diameter, lymphadenectomy or adjuvant radiotherapy requirements would be reevaluated.

The Perspectives of Fertility Preservation in Women with Endometrial Cancer

Simple Summary

Endometrial cancer is a common gynecological malignant disease. Its incidence in women of reproductive age in developed countries is increasing. The standard treatment is surgical in the form of hysterectomy and bilateral salpingo-oophorectomy, which has a significant impact on the quality of women’s lives and precludes further fertility. Conservative management to preserve reproductive function and delay final surgery can today be considered in carefully selected women. We analyze the current approaches to select appropriate candidates and current medical regimens for fertility sparing management. We elaborate on the future perspectives of management. With better characterization of the disease and implementation of molecular biomarkers, more women should be able to benefit from conservative approaches to management of endometrial cancer.

Abstract

Endometrial cancer is the most common gynecological cancer in developed countries. The disease is diagnosed with increasing frequency in younger women, commonly also in their reproductive age. The standard treatment of endometrial cancer is surgical in the form of hysterectomy and bilateral salpingo-oophorectomy, and this precludes future fertility in younger women. The current challenge is to identify the group of women with endometrial cancer and low-risk features that would benefit from more conservative treatment options. More focus in management needs to be aimed towards the preservation of quality of life, without jeopardizing oncological outcomes. In this review, we analyze the current approaches to identification of women for conservative management and evaluate the success of different medical options for treatment and surgical techniques that are fertility sparing. We also elaborate on the future perspectives, focusing on the incorporation of molecular characterization of endometrial cancer to fertility preservation algorithms. Future studies should focus specifically on identifying reliable clinical and molecular predictive markers in this group of young women. With improved knowledge and better risk assessment, the precision medicine is the path towards improved understanding of the disease and possibly widening the group of women that could benefit from treatment methods preserving their fertility.

Lymph node metastasis probability in young patients eligible for conservative management of endometrial cancer

OBJECTIVE

Endometrial cancer (EC) is a rare condition in young women. The objective of this study was to evaluate the risk of pelvic lymph node (LN) metastasis in young women with EC who are candidates for conservative management.

METHODS

Using the SEER database, a population-based analysis was conducted to identify women <45 years with grade 1, 2, or 3 endometrioid adenocarcinoma stage IA (FIGO 2009) who underwent pelvic lymphadenectomy with at least ten LNs removed. The LN macrometastases rate based on conventional histological diagnosis was analyzed according to tumor grade and myometrial invasion (MI) on final histology.

RESULTS

A cohort of 1284 women was analyzed. The LN metastasis rates were: 2/414 (0.5%) grade 1 EC without MI, 5/239 (2.1%) grade 2 or 3 EC without MI, 5/308 (1.6%) grade 1 EC with MI, and 14/323 (4.3%) grade 2 or 3 EC with MI. Tumor size was not correlated with LN metastasis probability.

CONCLUSIONS

Young patients eligible for conservative management have a low rate of LN macrometastasis, especially in stage IA without MI grade 1 EC. A systematic lymphadenectomy should not be performed in these patients. Prospective study evaluating the sentinel LN mapping in conservative management of EC could be performed to assess the LN micrometastasis rate.

Predictors of treatment response in a web-based intervention for cannabis users

BACKGROUND

Trials demonstrate the effectiveness of web-based interventions for cannabis-related disorders. For further development of these interventions, it is of vital interest to identify user characteristics which predict treatment response.

METHODS

Data from a randomized factorial trial on a web-based intervention for cannabis-users (n = 534) was reanalyzed. As potential predictors for later treatment response, 31 variables from the following categories were tested: socio-demographics, substance use and cognitive processing. The association of predictors and treatment outcome was analyzed using unbiased recursive partitioning and represented as classification tree. Predictive performance of the tree was assessed by comparing its cross-validated results to models derived with all-subsets logistic regression and random forest.

RESULTS

Goal commitment (p < .001), the extent of self-reflection (p < .001), the preferred effect of cannabis (p = .005) and initial cannabis use (p = .015) significantly differentiate between successful and non-successful participants in all three analysis methods. The predictive accuracy of all three models is comparable and modest.

CONCLUSIONS

Participants who commit to quit using cannabis, who at least have moderate levels of self-reflection and who prefer mild intoxicating effects were most likely to respond to treatment. To predict treatment response on an individual level, the classification tree should only be used as one of several sources of information.Trial registration: http://www.isrctn.com/ISRCTN99818059.

A Refined Staging Model for Resectable Pancreatic Ductal Adenocarcinoma Incorporating Examined Lymph Nodes, Location of Tumor and Positive Lymph Nodes Ratio

Background: Nodal status and tumor site are prognostic factors for resectable pancreatic ductal adenocarcinoma (PDAC). Parameters for nodal status are diverse, and the number of examined lymph nodes (eNs) needed for good prognosis are uncertain. We try to modify staging system of resectable PDAC with parameters mentioned above by recursive partitioning analysis.

Methods: Patients from the Surveillance, Epidemiology, and End Results (SEER) database were divided into training cohort and internal validation cohort, randomly. PDAC patients from Sun Yat-sen University Cancer Center were regarded as external validation cohort. The training cohort was used to refine staging model by recursive partitioning analysis, while the internal validation cohort and the external validation cohort were applied to assess discriminatory capacity of staging model. For parameters included in the modified model, their effects were studied.

Results: The number of eNs, tumor site and tumor size were risk factors for positive nodal status. Lymph nodes ratio (LNR), tumor site, eNs and T stages of 8^th the American Joint Committee on Cancer (AJCC) were selected to develop a refined model, dividing patients into 5 groups of different outcomes, preceding 8^th AJCC classification. Besides, we found that (1) for small PDAC (diameter < 1cm), lymph node metastasis was rarely found; (2) enough eNs were needed to ensure better prognosis of node-negative patients; (3) tumors in the head of pancreas were prone to lymph nodes metastasis; (4) for node-positive patients, LNR was a better nodal parameter compared to positive lymph nodes (pNs).

Conclusion: Our improved staging system helps to illuminate the interactions among tumor site, size and eNs.

Impact of Conservative Managements in Young Women With Grade 2 or 3 Endometrial Adenocarcinoma Confined to the Endometrium

OBJECTIVES

The aim of this study was to evaluate the impact of ovarian and/or uterine preservation in young patients with grade 2 or 3 endometrial adenocarcinoma confined to the endometrium.

METHODS/MATERIALS

A population-based analysis was conducted. The SEER'17 Database was used to identify women younger than 45 years with grade 2 or 3 endometrial adenocarcinoma confined to the endometrium from 1983 to 2012. A cohort of 1106 women was included: 849 underwent hysterectomy with bilateral adnexectomy, 96 underwent hysterectomy with ovarian preservation, and 49 underwent uterine preservation. The demographics and survival rates according to the type of treatment administered were compared.

RESULTS

The 5-year overall survival probabilities were 94.8% (95% confidence interval [CI], 92.8-96.2), 93.8% (95% CI, 85.8-97.4), and 78.2% (95% CI, 62.1-88.1) for patients who underwent hysterectomy with bilateral adnexectomy, ovarian preservation, and uterine preservation, respectively (P < 0.001).The 5-year cancer-related survival probabilities were 99.3% (95% CI, 98.6-99.9), 98.9% (95% CI, 96.9-99.9), and 86.2% (95% CI, 75.7-98.2) for patients who underwent hysterectomy with bilateral adnexectomy, ovarian preservation, and uterine preservation, respectively (P < 0.001).Patients who received uterine conservation had lower disease-specific (adjusted hazard ratio [aHR], 15.8 95% CI, 5.5-45.2) and overall survival probabilities (aHR, 6.6; 95% CI, 3.3-13.4) than did patients who underwent hysterectomy with or without oophorectomy. Ovarian conservation was not associated with decreased disease-specific (aHR, 1.45; 95% CI, 0.31-6.71) or overall (aHR, 0.58; 95% CI, 0.17-1.90) survival.

CONCLUSIONS

Ovarian preservation has no impact on survival probability in patients with grade 2 or 3 endometrial cancer confined to the endometrium. On the contrary, physicians and patients should be aware of the worse prognosis associated with uterine preservation.