ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up

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.

Single-cell sequencing reveals the role of aggrephagy-related patterns in tumor microenvironment, prognosis and immunotherapy in endometrial cancer

Background

As a type of autophagy, aggrephagy degrades the aggregation of misfolded protein in cells and plays an important role in key genetic events for various cancers. However, aggrephagy functions within the tumor microenvironment (TME) in endometrial cancer (EC) remain to be elucidated.

Methods

A total of 36,227 single cells from single-cell RNA-seq data derived from five EC tumor samples were comprehensively analyzed using a nonnegative matrix factorization (NMF) algorithm for 44 aggrephagy-related genes. Bulk RNA-seq cohorts from public repositories were utilized to assess the prognostic value of aggrephagy-related TME clusters and predict immune checkpoint blockade immunotherapeutic response in EC.

Results

Fibroblasts, macrophages, CD8+T cells, and lymphatic endothelial cells were categorized into two to five aggrephagy-related subclusters, respectively. CellChat analysis showed that the aggrephagy-related subtypes of TME cells exhibited extensive interactions with tumor epithelial cells, particularly for macrophages. Moreover, aggrephagy regulators may be significantly associated with the pseudotime trajectories of major TME cell types as well as the clinical and biological features of EC. Bulk-seq analysis showed that these aggrephagy-related subclusters had significant predictive value for the survival and immune checkpoint blockade response in EC patients. Notably, immunohistochemical staining results manifested that the TUBA1A+ macrophage subtype was linked to less lymph node metastasis and longer survival, which were consistent with the bioinformatics analysis findings.

Conclusions

This study provided a novel view of aggrephagy signaling in the EC tumor microenvironment, and intervention of aggrephagy was expected to improve the survival rate of EC patients.

Mark3 a Prognostic Marker for the Endometrial Cancer

Introduction: Endometrial cancer (EC) is one of the most common gynecologic cancers, with an increasing incidence due to variables such as aging and lifestyle changes. Current biomarkers exhibit limited prognostic value, despite advancements in understanding their molecular basis, underscoring the necessity for new molecular markers. Microtubule affinity-regulating kinase 3 (MARK3) has been identified as a potential candidate owing to its established prognostic significance in various cancers; however, its function in endometrial cancer (EC) is not yet well understood. Methods: This study investigates the function of MARK3 in endometrial cancer through the analysis of Ishikawa and HEC-1B cell lines. A series of assays were conducted, including colony formation, CCK-8 viability, EDU proliferation assays, scratch wound healing tests, and Transwell migration assays, to investigate the effects of MARK3 overexpression. We conducted RT-qPCR, Western blot, and immunofluorescence assays to evaluate the molecular mechanisms influencing cell proliferation and migration. Bioinformatics analysis utilized publicly available datasets to examine the gene enrichment and co-expression networks. Results: The overexpression of MARK3 markedly reduced colony formation in both Ishikawa (p = 0.0039) and HEC-1B (p = 0.0014) cell lines. Furthermore, the overexpression of MARK3 led to decreased cell viability, as demonstrated by the EDU assay results (Ishikawa-OE p = 0.0302; HEC-OE p = 0.0037). The molecular analysis supported these findings, indicating an increase in phosphorylated AKT (pAKT), thereby suggesting MARK3's role in regulating cell survival pathways. Gene enrichment analysis revealed pathways associated with cell cycle regulation and apoptosis, whereas co-expression analysis pinpointed critical interacting genes that may play a role in EC progression. Conclusions: MARK3 is essential in the regulation of cell proliferation and migration in endometrial cancer, positioning it as a potential prognostic biomarker and therapeutic target. This study represents the inaugural investigation into the functional role of MARK3 in endothelial cell progression, thereby enhancing our comprehension of its mechanistic influence on cancer biology and its implications for personalized therapy. Bioinformatics analysis reinforces the relevance of MARK3 in endometrial cancer, offering new insights into its clinical significance.

Fertility-Sparing Treatments in Endometrial Cancer: A Comprehensive Review on Efficacy, Oncological Outcomes, and Reproductive Potential

Endometrial cancer (EC) affects 3-14% of women under 40 who wish to preserve their fertility. The standard treatment for EC is a hysterectomy with salpingo-oophorectomy. However, for those desiring fertility preservation, oral progestogens such as medroxy-progesterone acetate (MPA) or megestrol acetate (MA) are the most common therapies in Fertility-Sparing Treatment (FST). Other treatments include gonadotropin-releasing hormone agonist (GnRHa), levonorgestrel-releasing intrauterine system (LNG-IUS), and metformin plus progestin. This comprehensive review evaluates the best FST options for women with reproductive potential. PubMed, EMBASE, and Scopus were searched in June 2023 using specific keywords. Studies included in the review focused on patients with EC undergoing FST, with outcomes such as complete response rate (CRR), recurrence rate (RR), pregnancy rate (PR), and live birth rate. Eighteen studies met the inclusion criteria, involving 23,976 patients. In only-oral progestin trials, CRR ranged from 18% to 100%; RR ranged from 0% to 81.8%; Death Rate ranged from 0% to 3.6%. In studies combining oral progestin with LNG-IUS, CRR ranged from 55% to 87.5%; RR ranged from 0% to 41.7%; Death Rate was 0%. Most patients with Stage IA EC received MPA or MA. Fertility-related outcomes were reported in 15 studies. PR ranged from 4 to 44 patients in trials involving only oral progestins. When combining oral progestin with LNG-IUS, PR ranged from 1 to 46 patients. Progestin therapy, including oral MPA and MA, is considered safe and effective, with limited evidence supporting the use of LNG-IUS.

A Deeper Look at Office Hysteroscopy in Asymptomatic Postmenopausal Patients: Indications and Outcomes of 822 Cases

STUDY OBJECTIVE

This study aims to assess the prevalence of malignancy and other endometrial pathologies in asymptomatic postmenopausal women referred for office hysteroscopy (OH), identify main referral indications, and assess their relationship with the risk of malignancy. Secondary objectives included evaluating the association between ultrasound variables and malignancy risk and assessing procedure validity, which encompasses duration, feasibility, and patient comfort during OH.

DESIGN

Retrospective analysis.

SETTING

The study was conducted at the Department of Gynecology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Slovenia's largest tertiary care center.

PARTICIPANTS

The cohort consisted of 822 asymptomatic postmenopausal women referred for OH, excluding those with postmenopausal bleeding within the last year.

INTERVENTIONS

Participants underwent OH with or without biopsy.

MEASUREMENTS AND MAIN RESULTS

The main indication for hysteroscopy was ultrasound abnormalities alone, with remaining indications including a combination of ultrasound and clinical findings. Among the cohort, 97.4% exhibited benign findings, while 2.6% were diagnosed with cancer or precancerous lesions. The analysis revealed that patients with indications based on ultrasound and clinical findings suggestive of malignancy had a higher risk of malignancy compared to those with ultrasound alone. In 387 patients with documented ultrasound variables, inhomogeneous endometrial appearance (OR: 8.2, 95% CI: 2.4-27.9, p < .001) and significant liquid content within the uterine cavity (OR: 10.2, 95% CI: 3.6-28.9, p < .001) exhibited strong associations with malignancy. Analysis of the procedure revealed a high feasibility rate (87.8%), with a median duration of 13.7 minutes and a median Visual Analog Scale pain score after the procedure of 3/10.

CONCLUSION

The prevalence of endometrial cancer and precancerous lesions in asymptomatic postmenopausal patients is likely low, with most intrauterine pathologies being benign. Our study demises the utility of routine endometrial surveillance for this population in the absence of specific risk factors. A holistic approach, considering individualized assessments and factors beyond endometrial thickness, is crucial in interpreting ultrasonic findings.

The tipping point: Key oncologic imaging findings resulting in critical changes in the management of malignant genitourinary and gynecological tumors

OBJECTIVE

The purpose of this article is to review the staging systems for common malignant genitourinary and gynecological tumors, including renal cell carcinoma, urinary bladder carcinoma, as well as cervical, endometrial, and ovarian carcinoma, and to highlight the key imaging findings ("tipping points") that may alter patient management algorithms based on radiological staging.

CONCLUSION

There are identifiable imaging features for the common genitourinary and gynecological malignancies, including the size of the primary tumor, tumor extension, invasion of adjacent structures, lymph node involvement, and distant metastasis, which provide important prognostic information and determine patient management. Radiologists must be aware of these imaging findings ("tipping points") when interpreting staging examinations.

Serum CA125 levels in the context of ProMisE molecular classification provides pre-operative prognostic information that can direct endometrial cancer management

OBJECTIVE

Previous research suggests serum CA125 reflects extra-uterine disease in patients with endometrial carcinoma (EC). Our objective was to determine if CA125 can identify patients with extra-uterine and/or nodal metastases, the association of this biomarker with EC molecular subtype, and to explore an optimal cutoff in this context.

METHODS

We assessed the association of CA125 levels with clinicopathologic and outcomes data on a cohort of 1107 molecularly classified EC.

RESULTS

Abnormal CA125 (>35kU/L) was associated with higher stage and lymph node metastases (LNM) in all EC and in each molecular subtype on univariate (p < 0.01) and multivariate (p < 0.05) analyses. POLEmut had the lowest median CA125 level and proportion of CA125 abnormal patients, and p53abn the highest proportion (p < 0.001). CA125 > 35 kU/L had a sensitivity of 0.82, specificity 0.53, positive-predictive-value 0.92, and negative-predictive-value 0.31 for LNM, with similar values for stage>I. CA125 > 35 kU/L was associated with worse overall (OS), disease-specific (DSS), and progression-free survival (PFS) in all EC, p53abn (OS, DSS, PFS), NSMP (OS, DSS), and MMRd (OS, DSS) subtypes. CA125 > 35 kU/L demonstrated a relative risk (RR) of 2.50 with presence of stage III/IV disease (p < 0.001) and RR 18.4 for the presence of synchronous endometrial and ovarian carcinomas (SEOC)/co-existing adnexal malignancies (CAM) (p < 0.001). An exploratory cut point, optimized for correlation with DSS (CA125 > 24 kU/L) show similar association with clinical parameters and survival outcome.

CONCLUSIONS

CA125 levels are associated with molecular subtype, stage>I disease, and SEOC/CAM. CA125 remains a useful clinical tool in the triage of EC in the era of molecular classification.

Patient-initiated follow-up in low-risk endometrial cancer after surgery: a systematic review

OBJECTIVE

To evaluate the impact of patient-initiated follow-up in surgically treated early-stage endometrial cancer on quality of life, survival, and health care costs in patients with low-risk early-stage endometrial cancer.

METHODS

We searched the Cochrane Centre Register of Controlled trials, MEDLINE, Embase, LILACS, and CINAHL databases up to August 24, 2024. Inclusion criteria were randomized controlled trials, cohort studies, and observational studies that included women aged >18 years with stage 1A, grade 1 and 2 endometrial cancers, as per the International Federation of Gynecology and Obstetrics 2009 staging criteria, who underwent surgery as their primary treatment and did not require adjuvant therapy. Included studies were those that assessed the impact of patient-initiated follow-up in low-risk endometrial cancer. The primary outcome was quality of life. The secondary outcomes were overall survival, cancer-specific survival, recurrence-free survival, cost/health care utilization, and adverse events. Data were extracted and the evidence were synthesized.

RESULTS

A total of 6 studies with a total of 1081 participants matched the selection criteria and were included. There was 1 multi-center randomized controlled trial and 5 cohort studies. Patient-initiated follow-up had no impact on fear of cancer recurrence in 1 study, and the quality of life, assessed in 2 studies, was acceptable. In 5 studies that included 853 patients and a median follow-up between 10 and 60.7 months, there were 22 recurrences and the overall survival was 93% to100%.

CONCLUSION

Patient-initiated follow-up may be a viable mode of surveillance for patients with low-risk endometrial cancer and appears to have little impact on quality of life. Evidence for the impact of patient-initiated follow-up on survival on this patient population is lacking. Large, randomized controlled trials are needed to assess long-term outcomes.

Different surgical methods of hysterectomy for the management of endometrial cancer: a systematic review and network meta-analysis

Background

Emerging surgical methods are utilized to treat endometrial cancer. The study aimed to assess the efficacy and safety of four common surgical methods of hysterectomy.

Methods

We systematically searched the PubMed, Cochrane Library databases, Medline, EMBASE and Web of Science from their inception until April 30, 2024. We used hazard ratios (HR) for overall survival (OS) and disease-free (DFS), odds ratios (OR) for categorical outcomes, and mean differences (MD) for continuous outcomes with 95% confidence intervals. These were pooled in Bayesian network meta-analysis models. The surface under the cumulative ranking curve (SUCRA) was used to illuminate the probability that each method would be the best for each outcome.

Results

Thirty studies comprising 13446 patients were included. Robotic hysterectomy (RH) retrieved fewer pelvic lymph nodes than open hysterectomy (OH). OH showed a significantly higher postoperative complication rate than laparoscopic hysterectomy (LH) and RH. LH had a higher intraoperative complication rate than OH. According to SUCRA values, OH ranked the highest in the number of retrieved pelvic lymph nodes (0.89), intraoperative complications (0.73), and operative time (0.97). LH ranked the highest in DFS (0.81) and overall survival (OS) (0.87). RH ranked the highest in the postoperative complications (0.95). Laparoscopic-assisted vaginal hysterectomy (LAVH) ranked the highest in number of retrieved para-aortic lymph nodes (0.72).

Conclusions

There are no significant differences among the four surgical methods in DFS or OS. The use of uterine manipulators does not affect prognosis. OH is the best method for shortening operative time, dissecting the pelvic lymph nodes and controlling intraoperative complications. LH and LAVH have an advantage in para-aortic lymph node dissection. Besides, LH has the best advantage in DFS and OS. RH has advantages in controlling surgical complications.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024529974.

Evaluation of One Step Nucleic Acid Amplification for detection of lymph node metastases compared to histopathological ultrastaging in women with endometrial cancer: a protocol for a diagnostic accuracy study

BACKGROUND

This is a multicentre, European, prospective trial evaluating the diagnostic accuracy of One Step Nucleic Acid Amplification (OSNA) compared to sentinel lymph nodes histopathological ultrastaging in endometrial cancer patients.

METHODS

Centres with expertise in sentinel lymph node mapping in endometrial cancer patients in Europe will be invited to participate in the study. Participating units will be trained on the correct usage of the OSNA RD-210 analyser and nucleic acid amplification reagent kit LYNOAMP CK19 E for rapid detection of metastatic nodal involvement, based on the cytokeratin 19 (CK19) mRNA detection. Endometrial cancer patients ≥ 18 years listed for surgical treatment with sentinel lymph node mapping, with no history of other types of cancer and who provide a valid written consent will be considered potentially eligible for the study. However, they will only be enrolled if a successful sentinel lymph node mapping is retrieved. Each node will be processed according to the study protocol and assessed by both OSNA and ultrastaging.

DISCUSSION

The accuracy of OSNA (index test) will be assessed against sentinel lymph node histopathological ultrastaging (reference test). This European study has the potential to be the largest study on the use of OSNA in endometrial cancer to date. OSNA could represent a modern diagnostic alternative to sentinel lymph node ultrastaging with the added benefits of standardisation and fast results.

TRIAL REGISTRATION

The study was registered in the German Clinical Trial Register - Nr. DRKS00021520, registration date 25th of May 2020, URL of the trial registry record: https://drks.de/search/en/trial/DRKS00021520 .

Impacts of Postoperative Adjuvant Therapies on the Survival of Women with High-Risk Early-Stage Endometrial Cancer: A Cohort Study

Background/Objectives: The survival outcomes according to postoperative adjuvant therapeutic strategy in women with high-risk early-stage endometrial cancer (EEC) have not been clearly compared. This study examined the impacts of various postoperative adjuvant therapies on the survival of women with high-risk EEC. Methods: Korean Health Insurance Review and Assessment Service data related to Korean cancer registration data were used. The data of 1341 women who met the eligibility criteria for high-risk EEC were selected. The overall survival (OS) after the women had received various postoperative adjuvant therapies was analyzed. Results: The mean age of the women was 58.2 ± 10.3 years, and they were followed up for 5.9 ± 4.0 years. When compared with primary surgery alone, the OS was similar in the women who had received adjuvant external beam radiation therapy (EBRT) ± vaginal brachytherapy (VB), adjuvant VB alone, adjuvant chemotherapy, or adjuvant hormone therapy in combination with primary surgery, but the OS was significantly lower in the women who had received adjuvant chemoradiotherapy combined with primary surgery (HR 3.083; 95% CI 1.311-7.247; p = 0.010). In addition, compared to adjuvant EBRT ± VB, the OS was significantly lower in the group given adjuvant radiotherapy after chemotherapy (HR 11.87; 95% CI 4.595-30.664; p < 0.001), but the OS was similar in the women who had received adjuvant VB alone, adjuvant concurrent chemoradiotherapy, or adjuvant chemotherapy after radiotherapy. Conclusions: Except for adjuvant radiotherapy after chemotherapy, postoperative adjuvant therapies have similar impacts on the survival of women with high-risk EEC.

Palbociclib plus letrozole in estrogen receptor-positive advanced/recurrent endometrial cancer: Double-blind placebo-controlled randomized phase II ENGOT-EN3/PALEO trial

PURPOSE

The CDK4/6 inhibitor palbociclib inhibits cyclin A, which is overexpressed in endometrial cancer. Combining palbociclib with endocrine therapy improves efficacy in hormone receptor-positive breast cancer. We investigated palbociclib combined with endocrine therapy for estrogen receptor-positive advanced/recurrent endometrial cancer.

PATIENTS AND METHODS

This placebo-controlled double-blind, randomized phase II screening trial (NCT02730429) enrolled women with measurable/evaluable estrogen receptor-positive endometrioid endometrial cancer that was primary metastatic or had relapsed after ≥1 prior systemic therapy. Patients were randomized in a 1:1 ratio, stratified by number of prior chemotherapy lines, measurable versus evaluable non-measurable disease, and prior medroxyprogesterone/megestrol acetate treatment, to receive oral letrozole 2.5 mg on days 1-28 plus either oral palbociclib 125 mg or placebo on days 1-21, repeated every 28 days until disease progression or unacceptable toxicity. The primary end point was investigator-assessed progression-free survival (PFS).

RESULTS

Among 77 patients randomized between February 16, 2017, and December 21, 2018, 73 were treated (36 with palbociclib-letrozole, 37 with placebo-letrozole). Median follow-up was 21.9 (95 % CI, 16.7 to 22.3) months. Median PFS was 8.3 (95 % CI, 4.6 to 11.2) versus 3.1 (95 % CI, 2.7 to 6.8) months, respectively. In a landmark analysis at 12 months the PFS hazard ratio was 0.57 (95 % CI, 0.32 to 0.99; P = .044). Grade ≥ 3 adverse events were more common with palbociclib-letrozole (67 %) than placebo-letrozole (30 %), most commonly neutropenia (44 % v 0 %, respectively).

CONCLUSION

These results support a potential role of the palbociclib-letrozole combination as treatment for hormone receptor-positive advanced/recurrent endometrial cancer. Based on these encouraging results, phase III evaluation of letrozole combined with a CDK4/6 inhibitor is planned.

CLINICAL TRIAL INFORMATION

NCT02730429.

Prognostic factors and survival outcomes of immunohistochemically detection based-molecular subtypes of endometrial cancer-analysis of 576 clinical cases

OBJECTIVE

The study aimed to identify distinct molecular subtypes of endometrial cancer (EC) by immunohistochemistry and to analyze their pathological characteristics, independent prognostic factors, and patient survival outcomes for potential clinical applications.

METHOD

576 patients with preoperative EC confined to the uterus were divided into three subgroups based on the immunohistochemical detection method: MMR-deficiency (MMRd), P53 wild type (P53wt) and P53 abnormal (P53abn). These subgroups were retrospectively analyzed, and their pathological characteristics, prognostic factors and survival outcomes were compared.

RESULTS

We identified 401 (69.6%), 123 (21.4%), and 52 (9%) cases of P53wt, MMRd, and P53abn subgroups, respectively. A significant difference was observed in the median age of onset, tumor stage, high-grade tumor differentiation, non-endometrioid carcinoma, myometrial invasion, lymphovascular invasion, the incidence of lymph node metastasis postoperative, and expression of ER and PR receptors among the three groups. Pathological type, lymphovascular invasion, ER and PR expression were identified as independent prognostic factors for disease-free survival (DFS). Additionally, pathological type, lymphovascular invasion, myometrial invasion, and PR expression were recognized as independent prognostic factors for overall survival (OS) in the study cohort. However, the survival outcome for P53abn was the worst, with lymphovascular invasion identified as an independent prognostic factor for DFS. Lymph node status, FIGO stage, and ER expression were identified as independent prognostic factors for OS.

CONCLUSION

The study concludes that immunohistochemical detection-based subtyping of EC holds clinical practicality and can be employed to explore both pathological and clinical prognoses for EC patients.

Ladies project: large database in endometrial cancers for a personalized treatment

PURPOSE

To compare Italian use with current international guidelines and to evaluate oncological outcomes and toxicity patterns of adjuvant radiation therapy (RT) for endometrial cancer (EC) in Italian women.

MATERIALS AND METHODS

To conduct a retrospective multicentre Italian study a large database was set up. Inclusion criteria were: accrual between 2010 and 2020, treatment with surgery, post-operative external beam RT (EBRT) and/or interventional radiotherapy (IRT) associated or not with adjuvant chemotherapy. Oncological outcomes, acute and late toxicities were analysed according to RT schedule and risk group.

RESULTS

A total of 1848 patients, from 16 Italian RT centres were enrolled (median age 65 years, range 27-88). All patients received post-operative RT associated with chemotherapy in 31%. Patients were stratified on the basis of standard risk factors (Bosse et al. in Eur J Cancer 51:1742-50, 2015). After merging intermediate and high-intermediate risk classes into one intermediate group and including advanced and oligometastatic disease in the high-risk group, the low-risk group encompassed 124 patients, the intermediate-risk 1140, and the high risk 576. No low-risk patient developed local relapse (LR). Multivariate analysis showed that intermediate risk patients had a 2.5-fold increased risk of LR if treated with IRT alone vs EBRT-IRT boost. RT schedule did not impact significantly on LR in high risk patients. All acute toxicity parameters were highest in patients who received EBRT with simultaneous integrated boost (EBRT-SIB) and lowest in patients who received only IRT (p < 0.0001). Late toxicity was highest patients who received EBRT-SIB and lowest in those who were given EBRT with sequential boost (p < 0.0001).

CONCLUSIONS

This retrospective study showed that Italian administration of adjuvant RT for EC is in accordance with current international guidelines. IRT alone for low-risk patients and EBRT associated with vaginal IRT remain standard adjuvant approaches for EC.

Surgical outcomes of single-port vs multi-port laparoscopic hysterectomy for endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the surgical outcomes in patients with endometrial cancer who underwent either single-port laparoscopic hysterectomy (SPLH) or multi-port laparoscopic hysterectomy (MPLH).

METHODS

We conducted a systematic literature search from the earliest records available up to May 2023. The databases searched included PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library.

RESULTS

A total of 12 studies were included in the analysis. Both the SPLH and MPLH groups had similar operative times (MD = -4.27, 95% CI [-35.75, 27.22], p = 0.98), conversion rates (odds ratio [OR] = 1.43, 95% CI [0.57, 3.59], p = 0.44), blood transfusion rates, intraoperative complications (bladder injury, bowel injury, and vascular injury), and postoperative complications (umbilical hernia, fever, fistula, lymphocyst, and wound-related issues). However, the SPLH group showed significant advantages in certain areas. There was a notable reduction in estimated intraoperative blood loss (EBL) compared to the MPLH group (mean difference [MD] = -23.80, 95% CI [-42.99, -4.62], p = 0.02) and a shorter hospital stay duration (MD = -0.33, 95% CI [-0.46, -0.20], p < 0.00001). Although there was some debate about postoperative pain, SPLH tended to have more favorable outcomes. Despite these advantages, the SPLH group was less efficient in para-aortic lymph node clearance compared to the MPLH group (MD = -0.96, 95% CI [-1.57, -0.35], p = 0.002). No significant differences were observed in overall lymph node dissection (MD = -0.91, 95% CI [-2.52, 0.70], p = 0.27) and pelvic lymph node dissection (MD = -1.22, 95% CI [-3.82, 1.27], p = 0.36) between the two groups. Additionally, both groups showed similar therapeutic results, with no significant differences in overall survival (OS) and progression-free survival (PFS).

CONCLUSION

SPLH and MPLH techniques are equally effective in treating endometrial cancer, with both showing low rates of surgical complications with similar rates of surgical complications and therapeutic outcomes. However, SPLH offers additional benefits, including smaller incisions, reduced estimated intraoperative blood loss, and shorter hospital stays, making it an increasingly popular option for treating endometrial cancer.

Endometrial cancer in the elderly: Characteristics, prognostic and risk factors, and treatment options

Endometrial cancer incidence and related mortality are on the rise due to aging demographics. This population often presents with unfavorable features, such as myometrial invasion, non-endometrioid histology, high-grade tumors, worse prognosis, etc. The role of age as an independent prognostic factor is still debated, and screening tools addressing frailty emerge as pivotal in guiding treatment decisions; however, they are still underutilized. Treatment disparities are evident in the case of older patients with endometrial cancer, who frequently receive suboptimal care, hindering their survival. Radiotherapy and minimally invasive surgical approaches could be performed in older patients. Data on chemotherapy and immunotherapy are scarce, but their potential remains promising and data are being gathered by recent trials, contingent on optimal patient selection through geriatric assessments. Overall, we recommend personalized, screening tool-guided approaches, adherence to guideline-recommended treatments, and inclusion of older people in clinical trials to help identify the best course of treatment.

Tumor biomarkers HE4 and CA125 alongside enhanced computed tomography imaging in assessing lymph node metastasis in endometrial cancer

The impact of HE4 and CA125 on lymph node metastasis in endometrial cancer and evaluate the diagnostic effectiveness of these biomarkers when combined with enhanced CT imaging to predict lymph node metastasis. The objective is to examine how HE4 and CA125 influence lymph node metastasis and to assess their diagnostic utility when paired with enhanced CT imaging to predict lymph node involvement in endometrial cancer. The study included 326 patients who underwent surgery for endometrial cancer (experimental group), alongside 98 individuals without cancer (control group). A retrospective analysis was carried out to assess the diagnostic efficacy of HE4 and CA125, in combination with enhanced CT, for predicting lymph node metastasis. Levels of HE4 and CA125 were measured and compared between the experimental and control groups, as well as within the lymph node-positive and -negative groups. Significant variations in HE4 and CA125 levels were found between the endometrial cancer and control groups, and between lymph node-positive and -negative subgroups within the endometrial cancer cohort (p < 0.001). The AUC for HE4 was 0.73 (p < 0.001) in premenopausal and 0.578 (p = 0.164) in postmenopausal groups. For CA125, the AUC was 0.81 (p < 0.001) in premenopausal and 0.671 (p = 0.002) in postmenopausal groups. Cut-off concentrations to predict lymph node metastasis: Premenopausal - HE4 = 52.95 pmol/l, CA125 = 69.45 U/ml; Postmenopausal - HE4 = 69.15pmol/l, CA125 = 21.45 U/ml. Combining enhanced CT imaging with HE4 and CA125 improved diagnostic accuracy compared to individual tests. In conclusion, the study offers valuable insights into the potential usefulness of HE4 and CA125, in conjunction with enhanced CT imaging, for diagnosing and predicting lymph node metastasis in patients with endometrial cancer.

Now or Later? The Role of Neoadjuvant Treatment in Advanced Endometrial Cancer: A Systematic Review

Background: Endometrial cancer (EC) is, nowadays, the most frequent gynecological malignancy worldwide. The main treatment approach for EC is surgery, especially for early-stage tumors. For advanced EC, chemotherapy (CT) with carboplatin and paclitaxel is the standard treatment, especially for women with metastatic or recurrent disease. The present systematic review aimed to establish whether neoadjuvant treatment regimens with CT and/or radiotherapy (RT) lead to better survival outcomes compared to upfront surgery in advanced EC. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, through the string "(("Endometrial Neoplasms"[Mesh]) AND "Hysterectomy"[Mesh]) AND "Radiotherapy"[Mesh] AND Chemotherapy", the selection of articles was made. A quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). The studies included patients with EC with survival and recurrence outcomes-patients treated with upfront surgery or neoadjuvant CT ± External Beam Radiation Therapy (EBRT) or CT ± Brachytherapy (BT). Results: According to the selected evidence in the scientific literature, the 5-year DFS was 21.3% for upfront surgery and ranged from 42 to 73% for neoadjuvant chemotherapy. Also, the 5-year OS was 6.2 to 49.7% with upfront surgery and 15.5 to 100% for neoadjuvant schemes. None of the studies dedicated to surgery reported the 5-year Recurrence Rate (RR), while in the neoadjuvant treatments, it ranged from 27 to 64.7%. Conclusions: The literature's paucity of data makes it difficult to compare neoadjuvant therapy regimens with upfront surgery in advanced endometrial carcinoma. Nevertheless, the current data show more encouraging results for the neoadjuvant treatment group.

Endometrial Cancer: Analysing Patterns of Recurrence and Real-Life Outcome Data Using the 2020 ESGO-ESTRO-ESP Risk Stratification System

AIMS

To evaluate patterns of recurrence and explore the prognostic differences between the 2018 FIGO staging system and the 2020 ESGO-ESTRO-ESP risk stratification system of endometrial cancer with an emphasis on early-stage disease.

BACKGROUND

The incidence of endometrial cancer has risen by around 60% since the 90's. It is projected that by 2035 endometrial cancer will be the sixth most common cause of cancer-related death amongst females.

METHODS

This was a retrospective cohort study which included patients treated between 2010 and 2017. Primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meyer survival analysis was used to assess OS and RFS across different risk groups. Cox proportional hazards regression was used to evaluate prognostic risk factors implicated in recurrence. Different recurrence patterns across the subgroups were analysed with Pearson's chi-square test.

RESULTS

The study included 692 patients with a recurrence rate of 14.9%. The median time to recurrence was 17.1 months (IQR:8.8-28.4). The mean OS varied between 97.2 months in the low-risk group to 63.1 months in the high-risk group (p < 0.001). Mean RFS was 96.1 in the low-risk group and 58.9 in the high-risk group (p < 0.001). RFS was predicted by the following factors; high risk group (OR=3.87; p = 0.041), LVSI (OR=2.54, p = 0.005), carcinosarcoma (OR=2.20, p = 0.021) and serous subtype (OR=1.91, p = 0.01). Logistic regression was used to evaluate risk factors for loco-regional and distant recurrence. Patients in the low-risk group were less likely to have distant recurrence (OR=0.08, p = 0.004). Similarly, negative LVSI and Grade 1 cancers were associated with decreased risk of distant recurrence (OR=0.34, p = 0.006 and OR=0.33, p = 0.007, respectively). There were no significant risk factors for loco-regional recurrence.

CONCLUSIONS

The 2020 ESGO-ESTRO-ESP risk stratification provides accurate estimates of recurrence risk and survival. Those treated in line with current guidance have significantly better outcomes.

Comparing oncological outcomes of robotic versus open surgery in the treatment of endometrial cancer

PURPOSE

Robotic surgery has been incorporated in the treatment of endometrial cancer, with evidence suggesting that minimal access surgery offers advantages over laparotomy including less blood loss, lower rate of perioperative complications, and accelerated postoperative recovery. The laparoscopic approach to cervical cancer (LACC) study has recently demonstrated inferior survival outcomes in cervical cancer patients treated with minimal access surgery including robotic surgery. It is, therefore, imperative that further evaluation of the latter in endometrial cancer is performed.

METHODS

A retrospective analysis of clinical data was performed. We compared two different types of surgery performed for the treatment of FIGO stage 1 to 3 endometrial cancer; open surgery performed in the years 2013-2015 vs robotic surgery performed in 2017-2019, after the implementation of the robotic program in our institution. Main outcome measures were recurrence-free survival and overall survival, with secondary outcomes including surgical morbidity and postoperative recovery.

RESULTS

We compared 123 patients who had open surgery with 104 patients who underwent robotic surgery. One case from the second group was converted to open surgery due to the inability to complete it robotically. After a median follow-up of 68 months, there was no difference in recurrence-free survival or overall survival between the two groups. Length of stay after an operation was significantly different with mean hospital stay of 1.6 days after robotic surgery and 5 days after open surgery (p = 0.001). No significant difference was identified in the rate of complications (p = 0.304).

CONCLUSION

Our analysis has demonstrated that robotic surgery offers better perioperative outcomes without compromising the oncological safety.

Prognostic values of tumor size and location in early stage endometrial cancer patients who received radiotherapy

OBJECTIVE

To investigate the correlation between tumor size, tumor location, and prognosis in patients with early-stage endometrial cancer (EC) receiving adjuvant radiotherapy.

METHODS

Data of patients who had been treated for stage I-II EC from March 1999 to September 2017 in 13 tertiary hospitals in China was screened. Cox regression analysis was performed to investigate associations between tumor size, tumor location, and other clinical or pathological factors with cancer-specific survival (CSS) and distant metastasis failure-free survival (DMFS). The relationship between tumor size as a continuous variable and prognosis was demonstrated by restricted cubic splines. Prognostic models were constructed as nomograms and evaluated by Harrell's C-index, calibration curves and receiver operating characteristic (ROC) curves.

RESULTS

The study cohort comprised 805 patients with a median follow-up of 61 months and a median tumor size of 3.0 cm (range 0.2-15.0 cm). Lower uterine segment involvement (LUSI) was found in 243 patients (30.2%). Tumor size and LUSI were identified to be independent prognostic factors for CSS. Further, tumor size was an independent predictor of DMFS. A broadly positive relationship between poor survival and tumor size as a continuous variable was visualized in terms of hazard ratios. Nomograms constructed and evaluated for CSS and DMFS had satisfactory calibration curves and C-indexes of 0.847 and 0.716, respectively. The area under the ROC curves for 3- and 5-year ROC ranged from 0.718 to 0.890.

CONCLUSION

Tumor size and LUSI are independent prognostic factors in early-stage EC patients who have received radiotherapy. Integrating these variables into prognostic models would improve predictive ability.

Immune Subtypes and Characteristics of Endometrial Cancer Based on Immunogenes

Purpose

The aim of this study was to explore the immune subtypes of endometrial cancer (EC) and its characteristics by immunogenes from the perspective of multidimensional genomics (multi-omics).

Patients and Methods

Immune subtypes were carried out using an unsupervised non-negative matrix factorization clustering (NMF) method and their characteristics were analysed. Key genes were identified using random forest analysis. A predictive model for immune subtypes and their clinical prognosis were constructed. The relationship between immune subtypes and molecular subtypes was investigated.

Results

Two immune subtypes C1 and C2 were available. C2 patients were younger, less graded, had significantly higher immune cell infiltration, immune checkpoint expression, tumor neoantigens, tumor mutation load than C1 (P<005). S100A9, CD3D, CD3E, HLA-DRB1 and IL2RB were the key genes with significant survival outcomes. S100A9 expression was lower in C2 than C1, and IL2RB, HLA-DRB1, CD3E and CD3D expression was higher than C1 (P<0.05). The predictive accuracy of five key genes for immune subtypes was good, with a Receiver operating characteristic of 0.941. The incidence of TP53abn type in C2 was significantly lower than that of C1, and the incidence of POLE type was significantly higher than that of C1 (P<0.0001).

Conclusion

EC can be divided into two immune subtypes based on immunogenes. Low expression of S100A9 and high expression of IL2RB, HLA-DRB1, CD3E, and CD3D suggest sensitivity to immunotherapy and a good prognosis.

Accuracy of intraoperative frozen section in surgical staging of endometrial cancer

Objective

This study evaluates the role of frozen section (FS) in determining the extent of disease during surgery.

Materials and methods

This study retrospectively analyzed a cohort of patients diagnosed with endometrioid-type endometrial cancer between 2019 and 2022 who underwent surgical intervention. The frozen section (FS) results were compared with the final pathology reports, focusing on tumor grade, depth of myometrial invasion, cervical involvement, and tumor diameter.

Results

The final analysis included 187 patients. The predictive accuracy of FS in determining PS results was 85.6 % for endometrioid histology, 95.7 % for grade 3 tumors, 90.2 % for depth of myometrial invasion, 89.7 % for cervical involvement, and 95.9 % for tumor diameter. Notably, 9.8 % of cases initially classified as grade 1 intraoperatively were upgraded with the final pathology. Similarly, 6.3 % of grade II cases were upgraded, while 60.4 % were downgraded.

Conclusion

Our study highlights the effectiveness of FS as a dependable tool for assessing endometrial carcinomas and guiding surgical staging decisions. By utilizing FS, the risk of unnecessary surgeries and associated morbidity in patients can be reduced.

Limited utility of subendometrial enhancement in assessing the interface between the endometrium and myometrium

This study was conducted to re-evaluate the utility of subendometrial enhancement (SEE) in assessing the interface between the endometrium and myometrium. In total, 110 women who underwent pelvic magnetic resonance imaging (MRI) for non-endometrial gynecologic diseases were enrolled in this prospective study. Two radiologists independently assessed the presence or absence of subendometrial enhancement (SEE) on dynamic contrast-enhanced (CE) MRI. A subgroup analysis was performed to evaluate the impact of menstrual status on the detection of SEE. Identified areas of SEE were rated using a 4-point Likert scale to determine their reliability in assessing the interface between the endometrium and myometrium. SEE was identified in 44.5% (49/110) of cases by radiologist 1 and in 39.1% (43/110) by radiologist 2. A subgroup analysis indicated no significant differences in the detection of SEE based on menstrual status. The identified areas of SEE were deemed reliable for assessing the interface between the endometrium and myometrium in 24.5% (12/49) of the cases evaluated by radiologist 1 and in 32.6% (14/43) of those evaluated by radiologist 2. Among the 110 women studied, reliable areas of SEE for assessing the interface between the endometrium and myometrium were observed in 10.9% (n = 12) by radiologist 1 and 12.7% (n = 14) by radiologist 2. The evaluation of SEE using dynamic CE MRI may be limited in its ability to assess the interface between the endometrium and myometrium.

Vaginal and pelvic recurrences and salvage treatments in a cohort of Danish endometrial cancer patients not given adjuvant radiotherapy

OBJECTIVE

In Denmark, adjuvant radiotherapy has gradually been omitted after surgery in endometrial cancer. This study analyses the impact of this strategy on patterns of recurrence and outcome after salvage radiotherapy. Moreover, the potential effect of adjuvant radiotherapy is estimated in the non-low-risk cohort.

METHODS

The cohort included 3723 consecutive Danish patients with endometrial cancer who had radical surgery without adjuvant treatment (2005-2012). The patients were divided into low-risk (stage 1A, endometrioid, grades 1, 2 and no lymph-vascular space invasion) and non-low-risk. Crude/actuarial recurrence rates evaluated the number of patients who might have benefited from additional adjuvant radiotherapy.

RESULTS

Within 9 years' observation time using crude recurrence rates, 13.4% recurred.The rate of isolated vaginal recurrences was 2.9% in low-risk compared with 6.7% in non-low-risk patients. Isolated pelvic recurrences were 0.8% in low-risk compared with 2.1% in non-low-risk patients. In all, 15.8% of non-low-risk patients died from endometrial cancer, mainly due to primary or secondary non-local recurrences (a later non-local recurrence after a primary isolated local recurrence). Only 0.6% and 1.1% of all non-low-risk patients died from an isolated vaginal or pelvic recurrence, respectively. In all, 86% of all patients with an isolated vaginal recurrence were treated with curative intent. Of these, 72% were given radiotherapy with a local control rate of 91% (crude rate). However, even though only 5.8% died of an unsuccessfully treated isolated vaginal recurrence after curative intended radiotherapy, 23.1% died from a secondary non-local recurrence, while 22.3% died from other causes.

CONCLUSION

The Danish strategy of omitting adjuvant radiotherapy is safe. Adjuvant external beam radiotherapy may have prevented isolated local recurrences in 8.7% of the Danish non-low-risk patients, but a majority of these patients were salvaged by curative radiotherapy with 91% and 70% crude local control rates for isolated vaginal and isolated pelvic recurrences, respectively.

The impact of estrogen receptor and L1 cell adhesion molecule expression on endometrial cancer outcome correlates with clinicopathological risk group and molecular subgroup

OBJECTIVE

To assess the risk stratification of clinicopathologically and molecularly classified endometrial cancer based on estrogen receptor (ER) and L1 cell adhesion molecule (L1CAM) expression.

METHODS

This was a retrospective study of patients who underwent primary treatment at a single tertiary center. Carcinomas were classified into 5 clinicopathological risk groups, as per European guidelines. Immunohistochemistry and polymerase-ϵ sequencing were conducted for molecular classification and determination of ER and L1CAM expression.

RESULTS

Data from 1044 patients were analyzed. The median follow-up was 67.5 months. In univariable analyses, ER expression correlated with improved disease-specific survival (DSS) in the "no specific molecular profile" (NSMP) (P < 0.001) and mismatch repair deficient (MMRd) (P = 0.002) subgroups. Negative L1CAM expression was associated with enhanced DSS in the NSMP subgroup alone (P < 0.001). ER (hazard ratio [HR] 0.18), but not L1CAM, exhibited prognostic significance within NSMP when controlling for parameters available at the time of diagnosis (tumor histotype, grade, age). ER and L1CAM were not independently associated with DSS within NSMP when controlling for parameters available after surgery (clinicopathological risk groups, age, adjuvant therapy). However, in high-risk-advanced-metastatic cases, both ER (HR 0.26) and L1CAM (HR 3.9) independently correlated with DSS. Similarly, within MMRd, ER was associated with improved DSS in high-risk-advanced-metastatic carcinomas (HR 0.42).

CONCLUSION

The prognostic significance of ER and L1CAM varies across clinicopathological risk groups and molecular subgroups of endometrial cancer. Notably, risk assessment for high-risk-advanced-metastatic NSMP and MMRd subtype carcinomas can be refined by ER status.

The mechanism of L1 cell adhesion molecule interacting with protein tyrosine kinase 2 to regulate the focal adhesion kinase-growth factor receptor-bound protein 2-son of sevenless-rat sarcoma pathway in the identification and treatment of type I high-risk endometrial cancer

Objective

The objective of this study was to investigate how L1 cell adhesion molecule (L1CAM) interacting with protein tyrosine kinase 2 (PTK2) affects endometrial cancer (EC) progression and determine its association with the focal adhesion kinase (FAK)-growth factor receptor-bound protein 2 (GRB2)-son of sevenless (SOS)-rat sarcoma (RAS) pathway. EC is a female cancer of major concern in the world, and its incidence has increased rapidly in recent years. L1CAM is considered a reliable marker of poor prognosis in patients with EC.

Material and Methods

A single-center and prospective study was conducted using data from the Cancer Genome Atlas and samples from normal and EC tissues to explore the differential expression of L1CAM. Additional experimental models included human immortalized endometrial epithelium cells (hEECs) and EC cell lines such as KLE, RL95-2, and Ishikawa. L1CAM expression was regulated using lentiviruses designed for either overexpression or interference, and PTK2/focal adhesion kinase (FAK) signaling was inhibited with PF431396. Transfected KLE cells were injected into mice, and tumor growth was monitored over 14 days. Cellular proliferation and survival were assessed using cell counting kit, colony formation, and terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate (dUTP) nick-end labeling assays. Metastatic behavior was evaluated through Transwell assays for cell migration and invasion. The expression levels of matrix metallopeptidase (MMP) 2 and MMP9 were determined by Western blot. In addition, the activation of the FAK-GRB2-SOS-RAS pathway was examined by assessing the protein levels of FAK, GRB2, SOS, and RAS.

Results

There was a significant difference in L1CAM expression between EC tumor tissues and normal tissues, and L1CAM messenger RNA (1.85-fold) and L1CAM protein (2.59-fold) were significantly more expressed in EC tissues (P < 0.01) than in normal tissues. The tumor growth of L1CAM overexpressing EC cells was faster than that of negative control EC cells (6.43 fold; P < 0.001). L1CAM promoted the expression of FAK (1.43-2.72-fold; P < 0.001); enhanced EC cell proliferation (P < 0.01), survival and motility (P < 0.001), migration (P < 0.001), and invasion (P < 0.001); and activated the FAK-GRB2-SOS-RAS pathway, all of which were reversed when FAK expression was not upregulated (P < 0.001).

Conclusion

By upregulating PTK2 and its encoded protein FAK, L1CAM was found to promote tumor progression and increase the activation of the FAK-GRB2-SOS-RAS pathway. These findings establish L1CAM and PTK2 as reference genes for poor prognostic prediction in EC and as targets for EC therapy, providing a valuable basis for distinguishing between benign and malignant endometrial conditions and justifying the necessity of targeted therapeutic approaches.

Combining demographic data and transvaginal ultrasonography: a predictive model for endometrial carcinoma in postmenopausal patients

BACKGROUND

Although clinical guidelines exist for diagnosing abnormal uterine bleeding, there is a significant lack of agreement on the best management strategies for women presenting with symptom, particularly in diagnosing endometrial cancer. This study aimed to develop a preoperative risk model that utilizes demographic factors and transvaginal ultrasonography of the endometrium to assess and predict the risk of malignancy in females with endometrial cancer.

METHODS

In this retrospective study, a logistic regression model was developed to predict endometrial carcinoma using data from 356 postmenopausal women with endometrial lesions and an endometrial thickness (ET) of 5 mm or more. These patients had undergone transvaginal ultrasonography prior to surgery, with findings including 247 benign and 109 malignant cases. The model's predictive performance was evaluated using receiver operating characteristic (ROC) curve analysis and compared with post-surgical pathological diagnoses.

RESULTS

Our model incorporates several predictors for endometrial carcinoma, including age, history of hypertension, history of diabetes, body mass index (BMI), duration of vaginal bleeding, endometrial thickness, completeness of the endometrial line, and endometrial vascularization. It demonstrated a strong prediction with an area under the curve (AUC) of 0.905 (95% CI, 0.865-0.945). At the optimal risk threshold of 0.33, the model achieved a sensitivity of 82.18% and a specificity of 92.80%.

CONCLUSIONS

The established model, which integrates ultrasound evaluations with demographic data, provides a specific and sensitive method for assessing and predicting endometrial carcinoma.

The Interplay between Oxidative Stress and Sphingolipid Metabolism in Endometrial Cancer

Endometrial cancer is one of the most common malignancies in women. Sphingolipids, a group of lipids, play a key role in cancer biology. Cancer cells often exhibit abnormal redox homeostasis characterized by elevated levels of reactive oxygen species (ROS). Emerging evidence suggests that ceramides are involved in inhibiting proliferation and inducing apoptosis through ROS production. However, there is no data on the relationship between sphingolipid metabolism and oxidative status in endometrial cancer. The present study aims to assess the content of individual sphingolipids and oxidative status in healthy women and those with endometrial cancer. Sphingolipid analysis was performed using mass spectrometry. Total oxidative status (TOS) and total antioxidant capacity (TAC) were assessed colorimetrically. Our results showed a significant increase in the levels of all measured sphingolipids in cancer tissues compared to healthy endometrium. Additionally, a significant decrease in the S1P/ceramide ratio (sphingolipid rheostat) was observed in cancer patients, particularly for C14:0-Cer, C16:0-Cer, C18:1-Cer, C22:0-Cer, and C24:0-Cer. Furthermore, increased TOS and decreased TAC were found in cancer patients compared to healthy women. Significant correlations were observed between the levels of individual sphingolipids and oxidative status, with the strongest correlation noted between C22:0-Cer and TOS (r = 0.64). We conclude that endometrial cancer is characterized by profound changes in sphingolipid metabolism, contributing to oxidative dysregulation and tumor progression.

Efficacy of drugs treatment in patients with endometrial hyperplasia with or without atypia: A systematic review and network meta-analysis

BACKGROUND

Endometrial hyperplasia (EH) is a hyperplastic endometrial lesion with irregular gland size, increased glands, and increased glandular interstitial ratio. During follow-up, some EH progressed further to endometrial cancer. It is crucial to provide timely treatment for EH and improve the overall prognosis of EH patients.

METHODS

We searched the PubMed, ClinicalTrials.gov., and Embase databases for studies published from their inception to March 31, 2023. The methodological quality of each study was evaluated in accordance with the Cochrane Collaboration's tool for assessing the risk of bias. The RevMan5.3 software provided by the Cochrane Collaboration was used for direct meta-analysis statistical analysis; and the relative risk and 95% confidence interval along with the mean difference and 95% confidence interval, were used as evaluation indexes.

RESULTS

We included 21 randomized controlled trials involving a total of 2276 women with EH, 6 studies were of high quality, and 15 were of moderate quality. The blinding of subjects and intervention providers was identified as the main source of potential bias. Six interventions were addressed in the network meta-analysis: medroxyprogesterone acetate (MPA), plus metformin, norethisterone (NET), levonorgestrel-releasing intrauterine system (LNG-IUD), megestrol acetate, and other drugs. In the direct meta-analysis, we found the probability of endometrial complete regression (CR) in the LNG-IUD group to be significantly higher than those in the NET. In the network meta-analysis, we found the probability of CR in the NET group to be significantly lower than those in the MPA and plus metformin groups, the probability of CR in the LNG-IUD group to be significantly higher than those in the NET, the probability of CR in the other drugs group to be significantly higher than those in the LNG-IUD. The NET group had the lowest incidences of endometrial complete regression, plus metformin could have a better outcome.

CONCLUSION

According to the 21 randomized controlled trials included in this study, MPA is the most effective for EH endometrial outcome when applied as a single agent, while the combination of metformin can achieve a more significant effect.

Advantages of Robotic Surgery for Patients of Reproductive Age with Endometrial Cancer

This review presents current knowledge on the surgical treatment of endometrial cancer in young patients. Endometrial cancer is the most common gynecological cancer in Europe. Higher morbidity is correlated with obesity, hypertension and diabetes, which are growing worldwide. However, endometrial cancer at an early age is very rare. The first line of treatment for this cancer is radical hysterectomy, which is controversial in young women. There is an alternative method of fertility-sparing treatment. However, there is a group of young patients for whom surgical treatment is recommended. According to European guidelines, minimally invasive surgery is recommended for endometrial cancer. The aim of the study was to present the advantages of robotic surgery for endometrial cancer detected at a young age. The procedure of radical treatment with robot-assisted laparoscopy is more precise. Better visualization and stabilization of instruments allow a shorter procedure time, a brief hospital stay and fewer complications. Quality of life may be at a similar level. Incisions after trocars are painless and more esthetic than a classical wound. Bilateral adnexectomy in endometrial cancer depends on age, molecular status of the cancer, stage, genetic risk factors and individual decision. Conclusions: Robotic surgery seems to be a better surgical method for endometrial cancer in younger patients.

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region

INTRODUCTION

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety.

MATERIAL AND METHODS

This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05.

RESULTS

Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common.

CONCLUSIONS

The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Artefacts in Hysterectomies with a Special Focus on Vascular Pseudoinvasion

BACKGROUND

Since the advent of laparoscopic hysterectomy, several studies have described artefacts, such as vascular pseudoinvasion, constituting potential pitfalls in the histological evaluation of these specimens. The use of an intrauterine manipulator is often suggested as the factor creating these artefacts.

OBJECTIVES

To describe possible artefacts, such as vascular pseudoinvasion, myometrial clefts, and tumor cells in the lumen of the cervix, on the serosa, and in the tubal lumen, and to correlate them with clinical and pathological characteristics.

MATERIAL AND METHODS

This is a retrospective monocentric study of 60 patients having been treated for benign (n = 27, 45%) or malignant (n = 33, 55%) uterine pathologies.

RESULTS

Vascular pseudoinvasion was found in 13 (22%) adenocarcinomas and in one (2%) benign uterine pathology. Clefts within the myometrium were observed in 16 (27%) uteri. Cells in the tubal lumen were observed in six (10%) hysterectomies. True vascular emboli were not correlated with the use of an intrauterine manipulator (p = 0.47) or the type of surgery (p = 0.21). Vascular pseudoinvasion was correlated with the presence of tumor cells in the lumen of the cervix (p = 0.013) and the presence of clefts in the myometrium (p < 0.001), but not with the other factors studied.

CONCLUSIONS

Overall, in our series, we did not observe any statistical association between the use of an intrauterine manipulator and the presence of true emboli or vascular pseudoinvasion during hysterectomy in women with malignant or benign uterine pathologies. Vascular pseudoinvasion was also associated with the presence of other artefacts.

The Use of Photodynamic Therapy in the Treatment of Endometrial Cancer-A Review of the Literature

Endometrial cancer is the most common malignant tumor of the female reproductive system. It develops in the mucous membrane lining the inside of the uterine body-the endometrium, through the abnormal and continuous growth of cancer cells originating from the uterine mucosa. In recent years, there has been a significant increase in the number of cases in European countries. Photodynamic therapy (PDT) is an innovative and dynamically developing medical procedure, useful in the treatment of cancer and non-cancer tissue conditions. The PDT reaction involves the activation of a photosensitizing substance with visible light, which in turn leads to the formation of free oxygen radicals, which contribute to the destruction of the cell. PDT is minimally invasive, has few side effects, and preserves organ anatomy and function. Both diagnostics and photodynamic therapy as modern methods of treatment are becoming more and more popular in many research units around the world. They are most often practiced and tested in in vitro experimental conditions. In clinical practice, the use of PDT is rare. Comprehensive cooperation between scientists contributes to taking steps towards obtaining new, synthetic photosensitizers, directing their physicochemical properties, and showing the impact on a given organism. This review examines the evidence for the potential and usefulness of PDT in the treatment of endometrial cancer. This review highlights that PDT is gaining popularity and is becoming a promising field of medical research.

Preliminary results of adjuvant image-guided vaginal brachytherapy alone for early stage endometrial carcinoma

Objective

This retrospective study evaluated the preliminary outcomes of image-guided vaginal brachytherapy (IG-VBT) in the adjuvant treatment of high intermediate risk endometrial cancer.

Materials and Methods

Data were collected from 48 patients who underwent adjuvant IG-VBT between 2019 and 2022 at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University. The vaginal cuff clinical target volume (CTV-VC) is composed of a 4-mm-thick band around vaginal cylinder at the upper 3 cm of the vaginal cuff. A total dose of 21 Gy in three fractions was delivered to the CTV-VC, and the dose to the bladder and rectum were evaluated. Treatment details, patient characteristics, and outcomes were analyzed. Descriptive statistics were used for analysis, and Kaplan-Meier method was employed for survival analysis.

Results

The mean age was 62 years, with mainly endometrioid carcinoma pathology (96 %). All patients were at stage I, with 87.5 % receiving complete surgical staging. Mean total treatment time was 10 days with mean D90 of CTV-VC was 29.7 Gy, and D2cc of bladder, rectum, and sigmoid were 24.6 Gy, 21.0 Gy, and 7.7 Gy, respectively. At a median follow-up of 37 months, 3-year local control, disease-free survival, and overall survival rates were 100 %, 100 %, and 97.9 %. respectively. Two patients (4.2 %) experienced grade 1-2 gastrointestinal toxicity, while no genitourinary toxicity or serious adverse events were observed.

Conclusions

The preliminary results of IG-VBT in endometrial cancer demonstrated favorable outcomes in terms of vaginal control and toxicity. Further studies with larger cohorts and longer follow-up durations are warranted.

Endometrial cancer treatment and outcomes in Argentina: ECHOS-A real-world study

Objective

Real-world data for patients with endometrial cancer (EC) are limited, particularly in Latin America. We present treatment pattern findings from ECHOS-A - Endometrial Cancer Health Outcomes Study in Argentina.

Materials and methods

A retrospective study using clinical data from privately insured patients with EC diagnosed from 2010 to 2019. Index (diagnosis proxy) was first date of an EC-related health term or treatment. Demographics, clinical characteristics, and FIGO staging were described. Disease progression and survival were assessed until study end, loss to follow-up, or death.

Results

Of 805 patients with EC, 77.4 % (n = 623/805) received any treatment and 22.6 % (n = 182/805) received none. Among those treated, 31.8 % (n = 198/623) had first-line (1L) systemic therapy, and 45.5 % (n = 90/198) proceeded to second-line (2L) therapy. Mean follow-up was 33.6 (SD 31.8) months. Of those receiving any treatment, 87.3 % (n = 544/623) had FIGO stage data (I, 62.9 %; II, 18.6 %; III, 13.6 %; IV, 5.0 %). Treatment by class in 1L and 2L, respectively, were platinum chemotherapy, 73.7 %, 36.7 %; non-platinum chemotherapy, 73.7 %, 62.2 %; immunotherapy, 1.0 %, 11.1 %; hormone therapy, 17.7 %, 26.7 %. Carboplatin/paclitaxel was the most frequent 1L (52.5 %) and 2L (14.4 %) regimen. Mean time to progression was 14.1 (SD 16.3) and 8.8 (SD 8.3) months in 1L and 2L, respectively. Adjusted 1- to 5-year risk of progression/death was 46.5-77.5 % and 65.0-86.2 % in 1L and 2L, respectively.

Conclusions

Approximately one-quarter of patients with EC received no treatment, and approximately two-thirds were not treated with 1L systemic therapy. Efforts to better understand the reasons for these treatment patterns are crucial for improving patient outcomes.

Prognostic Significance of Disseminated Tumor Cells in Bone Marrow for Endometrial Carcinoma Patients

Background: Until now, limited clinical significance had been reported for disseminated tumor cells (DTCs) in gynecologic malignancies. DTCs were previously reported not to be associated with established risk factors, L1CAM immunoreactivity, and outcome in endometrial carcinoma (EC). This study's primary objective was to investigate potential correlations of DTCs in the bone marrow (BM) of EC patients with disease-related survival, and a secondary objective was to evaluate associations between molecular classification of EC and DTCs. Methods: Patients treated for primary EC at Tuebingen University women's hospital between 2003 and 2016 were identified. A total of 402 patients with a complete set of BM cytology, molecular, and clinical data were evaluable. Results: DTC occurrence was distributed equally among all four molecular groups (p = 0.651). DTC positivity was associated with a less favorable disease-free survival (HR: 1.86, 95% CI: 1.03-3.36, p = 0.036) and progression-free survival (HR: 1.86, 95% CI: 1.01-3.44, p = 0.045). Presence of DTCs was associated with a higher frequency of distant disease recurrence (p = 0.017). Conclusions: In line with our previous findings, tumor cell dissemination is not associated with molecular features in our large cohort of primary EC patients. Since DTCs seem to be associated with survival and location of disease recurrence, further studies are needed to decisively define their role in EC survival.

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.

Guideline No. 451: Asymptomatic Endometrial Thickening in Postmenopausal Women

OBJECTIVE

To formulate strategies for clinical assessments for endometrial thickening on ultrasound in a postmenopausal woman without bleeding.

TARGET POPULATION

Postmenopausal women of any age.

OUTCOMES

To reduce unnecessary invasive interventions and investigations in women with asymptomatic endometrial thickening while selectively investigating women at risk for endometrial cancer.

BENEFITS, HARMS, AND COSTS

It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complications. It is also expected to decrease the cost to the health care system by eliminating unnecessary interventions.

EVIDENCE

English language articles from Medline, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1995 to 2022 (e.g., asymptomatic endometrial thickness, endometrial cancer, postmenopausal bleeding, transvaginal ultrasound, endometrial biopsy, cervical stenosis, hormone therapies and the endometrium, tamoxifen, tibolone, aromatase inhibitors). Results were restricted to systematic reviews and meta-analyses, randomized controlled trials/controlled clinical trials, and observational studies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Physicians, including gynaecologists, obstetricians, family physicians, radiologists, pathologists, and internists; nurse practitioners and nurses; medical trainees, including medical students, residents, and fellows; and other providers of health care of the postmenopausal population.

SOCIAL MEDIA ABSTRACT

Postmenopausal women often have a thickening of the lining of the uterus found during ultrasound. Without bleeding, an endometrium <11 mm is rarely a serious problem but should be evaluated by a health care provider.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Application of novel algorithm on a retrospective series to implement the molecular classification for endometrial cancer

INTRODUCTION

The study aimed to validate the Betella algorithm, focusing on molecular analyses exclusively for endometrial cancer patients, where molecular classification alters risk assessment based on ESGO/ESTRO/ESP 2020 guidelines.

MATERIALS AND METHODS

Conducted between March 2021 and March 2023, the retrospective research involved endometrial cancer patients undergoing surgery and comprehensive molecular analyses. These included p53 and mismatch repair proteins immunohistochemistry, as well as DNA sequencing for POLE exonuclease domain. We applied the Betella algorithm to our population and evaluated the proportion of patients in which the molecular analysis changed the risk class attribution.

RESULTS

Out of 102 patients, 97 % obtained complete molecular analyses. The cohort exhibited varying molecular classifications: 10.1 % as POLE ultra-mutated, 30.3 % as mismatch repair deficient, 11.1 % as p53 abnormal, and 48.5 % as non-specified molecular classification. Multiple classifiers were present in 3 % of cases. Integrating molecular classification into risk group calculation led to risk group migration in 11.1 % of patients: 7 moved to lower risk classes due to POLE mutations, while 4 shifted to higher risk due to p53 alterations. Applying the Betella algorithm, we can spare the POLE sequencing in 65 cases (65.7 %) and p53 immunochemistry in 17 cases (17.2 %).

CONCLUSION

In conclusion, we externally validated the Betella algorithm in our population. The application of this new proposed algorithm enables assignment of the proper risk class and, consequently, the appropriate indication for adjuvant treatment, allowing for the rationalization of the resources that can be allocated otherwise, not only for the benefit of settings with low resources, but of all settings in general.

Adjuvant Therapy for Endometrial Cancer in the Era of Molecular Classification

Endometrial cancer primarily undergoes surgical intervention, with adjuvant treatments such as external beam pelvic radiotherapy, vaginal brachytherapy, chemotherapy, and combined therapy investigated in randomized trials. Treatment decisions hinge on clinicopathological risk factors. Low-risk cases usually require surgery alone, whereas high-intermediate risk often benefit from adjuvant vaginal brachytherapy for enhanced local control with minimal side effects. Recent trials advocate pelvic radiotherapy for high-risk cases, particularly in Stage I-II tumors with risk factors. Chemoradiation proves advantageous for serous cancers and Stage III disease, improving recurrence-free, and overall survival. Molecular studies, notably the Cancer Genome Atlas project, identified four distinct molecular classes, transcending stages, and histological types. These molecular subtypes exhibit a stronger prognostic impact than histopathological characteristics, heralding a shift toward molecular-integrated diagnostics and treatments. Incorporating molecular factors into adjuvant strategies, including targeted therapies, marks a new paradigm in endometrial cancer management, underpinning ongoing research, and clinical trials. This review outlines current adjuvant approaches, underscores the emergence of molecular-integrated risk profiling, and touches on developments in targeted therapy.

Colombian consensus for the molecular diagnosis of endometrial cancer

Objective: The Cancer Genome Atlas research program (TCGA) developed the molecular classification for endometrial cancer with prognostic and therapeutic utility, which was replaced by the ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) classification by consensus and international guidelines due to its high cost. This article aims to present national recommendations from an expert consensus that allows unification and implementation of the molecular classification for women with endometrial cancer nationwide, with a rational use of resources and technology. Methods: Consensus of 36 experts in clinical oncology, oncological gynecology, pathology, and genetics, with clinical practice in the national territory. The leader group performed a literature review and structuring of questions rated 1 to 9 points. A modified nominal group technique was used. There was a face-to-face meeting with master presentations, deliberative dialogue, and Google Forms (Google LLC, Mountain View, CA, USA) questionnaire voting with analysis and discussion of responses. The non-consensual responses led to a second round of voting. The final manuscript was finally prepared and revised. Results: Seven recommendations were formulated integrating the panelist responses based on evidence, but adjusted to the Colombian context and reality. Recommendation 1. The molecular classification is recommended in all the endometrial cancers using the immunohistochemistry markers as subrogated results from the molecular profile initially proposed in the TCGA classification. Recommendation 2. The sequential test strategy is recommended, starting with the immunohistochemistry markers (p53, MLH1, MSH 2, MSH6, PMS2) simultaneously in all the patients, defining to request POLE (DNA polymerase epsilon) (if available) according to the risk classification based on the surgical piece. Recommendation 3. It is recommended, that the gynecologist oncologist should be the one to request the POLE (if available) according to the final pathology report. This test must be requested for all endometrial cancers stage I-II, except in low risk (stage IA low grade endometrioid histology without linfovascular invasion normal p53) and, stages III-IV without residual disease, without affecting the request of subrogated immunohistochemistry molecular markers upon histology. The consensus proposes that the POLE is requested after the immunohistochemistry and according to the categories in the risk classification established by the 2020 ESGO/ESTRO/ESP guidelines. Recommendation 4. It is recommended to perform immunohistochemistry for hormonal receptors for all women with endometrial cancer and the HER2 in patients with p53abn, simultaneously with the others immunohistochemistry markers. Recommendation 5. It is recommended to perform the immunohistochemistry markers (p53, MLH1, MSH2, MSH6 y PMS2) in an initial endometrial biopsy or curettage when the specimen is adequate and available. In case the initial immunohistochemistry is inconclusive, or there are histological discrepancies between the initial and definitive pathology, it is recommended to repeat the molecular profile in the surgical pathology. The immunohistochemistry markers must be reported in the pathology report according to the CAP (College of American Pathologists) recommendations, independently of the type of sample. Recommendation 6. It is recommended to perform MLH1 promoter methylation testing in patients who exhibit loss of expression of MLH1 in immunohistochemistry whether it is accompanied or not with loss of expression of PMS2. All the patients with deficient MMR (mismatch repair), should be sent for genetic counseling to rule out Lynch syndrome. Recommendation 7. It is recommended to consider the molecular classification in addition to the classical histopathological criteria when making adjuvant judgments, as incorporated by the classification of prognostic groups of the 2020 ESGO/ESTRO/ESP guidelines. Conclusions: It is necessary to implement the molecular classification of endometrial cancer in clinical practice in accordance to the Colombian context, due to its prognostic and probably predictive value. This will enable the characterization of the Colombian population in order to offer individualized guided treatments. This is an academic and nonregulatory document.

Integrating proteomics and explainable artificial intelligence: a comprehensive analysis of protein biomarkers for endometrial cancer diagnosis and prognosis

Endometrial cancer, which is the most common gynaecological cancer in women after breast, colorectal and lung cancer, can be diagnosed at an early stage. The first aim of this study is to classify age, tumor grade, myometrial invasion and tumor size, which play an important role in the diagnosis and prognosis of endometrial cancer, with machine learning methods combined with explainable artificial intelligence. 20 endometrial cancer patients proteomic data obtained from tumor biopsies taken from different regions of EC tissue were used. The data obtained were then classified according to age, tumor size, tumor grade and myometrial invasion. Then, by using three different machine learning methods, explainable artificial intelligence was applied to the model that best classifies these groups and possible protein biomarkers that can be used in endometrial prognosis were evaluated. The optimal model for age classification was XGBoost with AUC (98.8%), for tumor grade classification was XGBoost with AUC (98.6%), for myometrial invasion classification was LightGBM with AUC (95.1%), and finally for tumor size classification was XGBoost with AUC (94.8%). By combining the optimal models and the SHAP approach, possible protein biomarkers and their expressions were obtained for classification. Finally, EWRS1 protein was found to be common in three groups (age, myometrial invasion, tumor size). This article's findings indicate that models have been developed that can accurately classify factors including age, tumor grade, and myometrial invasion all of which are critical for determining the prognosis of endometrial cancer as well as potential protein biomarkers associated with these factors. Furthermore, we were able to provide an analysis of how the quantities of the proteins suggested as biomarkers varied throughout the classes by combining the SHAP values with these ideal models.

ARG1 Is a Potential Prognostic Marker in Metastatic Endometrial Cancer

Endometrial cancer (EC) is the most common gynecologic malignancy. While the majority of patients present with early-stage and low-grade EC and have an excellent prognosis, a subset has metastatic disease at presentation or develops distant recurrence after initial treatment of the primary. However, the lack of prognostic biomarkers for metastatic EC is a critical barrier. Arginase 1 (ARG1) regulates the last step of the urea cycle, and an increase in ARG1 has been correlated as a poor prognostic factor in a variety of cancers. In the present study, ARG1 expression was evaluated as a potential prognostic marker for metastatic EC in endometrial hyperplasia and cancer of mice with Pten mutation as well as Pten and Mig-6 double mutations. While Pten mutation in the uterus is not sufficient for distant metastasis, mice with concurrent ablation of Mig-6 and Pten develop distant metastasis. Our immunostaining and RT-qPCR analysis revealed that the expression of ARG1 in early stage of EC as well as endometrial hyperplasia from mice deficient in Mig-6 and Pten mutations significantly increased compared to Pten mutation in the uterus. The results suggest that a high level of ARG1 is associated with poor prognosis in association with EC of mouse.

Molecular Classification of Endometrial Cancer and Its Impact on Therapy Selection

Endometrial cancer (EC) accounts for 90% of uterine cancer cases. It is considered not only one of the most common gynecological malignancies but also one of the most frequent cancers among women overall. Nowadays, the differentiation of EC subtypes is based on immunohistochemistry and molecular techniques. It is considered that patients' prognosis and the implementation of the appropriate treatment depend on the cancer subtype. Patients with pathogenic variants in POLE have the most favorable outcome, while those with abnormal p53 protein have the poorest. Therefore, in patients with POLE mutation, the de-escalation of postoperative treatment may be considered, and patients with abnormal p53 protein should be subjected to intensive adjuvant therapy. Patients with a DNA mismatch repair (dMMR) deficiency are classified in the intermediate prognosis group as EC patients without a specific molecular profile. Immunotherapy has been recognized as an effective treatment method in patients with advanced or recurrent EC with a mismatch deficiency. Thus, different adjuvant therapy approaches, including targeted therapy and immunotherapy, are being proposed depending on the EC subtype, and international guidelines, such as those published by ESMO and ESGO/ESTRO/ESP, include recommendations for performing the molecular classification of all EC cases. The decision about adjuvant therapy selection has to be based not only on clinical data and histological type and stage of cancer, but, following international recommendations, has to include EC molecular subtyping. This review describes how molecular classification could support more optimal therapeutic management in endometrial cancer patients.

Impact of sentinel lymph node mapping on survival in patients with high-risk endometrial cancer in the early stage: A matched cohort study

OBJECTIVE

The aim of this study was to compare patient survival using sentinel lymph node (SLN) procedure and pelvic lymphadenectomy for stating early-stage high risk endometrial cancer.

METHODS

Patients who underwent surgery for early-stage high risk endometrial cancer between 2010 and 2017 were extracted from the incidence registry of the SEER program. We identified patients who underwent SLN mapping. Patients who initially underwent pelvic lymphadenectomy were selected as the comparison group. One-to-one matching was performed according to age, ethnicity, histology, extension and grade. The primary outcome was disease-specific survival. The secondary outcome was overall survival.

RESULTS

A total of 326 patients who underwent SLN mapping and 326 who underwent pelvic lymphadenectomy initially were included in the study. The three-year analysis did not find a significant difference between the SLN and lymphadenectomy groups on disease-specific survival probability (88.2% vs 82.7, P = 0.07) and on overall survival probability (82.7% vs 78.2%, P = 0.57). Patients who underwent SLN mapping had a lower mean number of lymph nodes removed (mean 3 vs 16, P < 0.001) and there was a higher rate of patients with positive pelvic lymph nodes (18% vs 14%, P = 0.04). Following adjustment for confounding factors, disease-specific survival did not vary according to the lymph node intervention performed (P = 0.056), but the SLN group had better overall survival than those in the lymphadenectomy group (P = 0.047).

CONCLUSION

The SLN technique was not associated with poorer disease-specific survival than pelvic lymphadenectomy even after adjustment. These results suggest that SLN is an acceptable and safe procedure in surgical staging for early-stage high-risk endometrial cancer.

Transcriptome analysis of an AKT inhibitor-resistant endometrial cancer cell line

BACKGROUND

Drug resistance in endometrial cancer (EC) is a serious problem and a barrier to improving prognosis. The PI3K/AKT/mTOR pathway is highly activated in EC and can serve as a potential therapeutic target. Inhibitors against AKT have been developed, but resistance to these inhibitors is a concern. This study aimed to establish AKT inhibitor resistant cell lines and identify differentially expressed genes (DEGs) between parental and AKT inhibitor resistant cell lines to understand the mechanism of drug resistance to AKT inhibitors in EC.

METHODS

The sensitivity of eight EC cell lines to AKT inhibitor was analyzed. One of them was used to establish a drug-resistant cell line. DEGs were examined using RNA sequencing (RNA-seq). Furthermore, DEGs were comprehensively analyzed to identify hub genes. Hub genes were evaluated using quantitative real-time polymerase chain reaction.

RESULTS

RNA-seq identified 617 DEGs. Hub genes were selected using bioinformatics analysis. The top 10 hub genes were TNF, CDH1, CCND1, COL1A1, CDH2, ICAM1, CAV1, THBS1, NCAM1, and CDKN2A. Relative mRNA expression was significantly upregulated for TNF, CDH1, CCND1, THBS1, p16INK4a, and p14ARF and significantly downregulated for CDH2, ICAM1, and NCAM1 in borussertib-resistant EC cell line.

CONCLUSIONS

Drug resistance to AKT inhibitors may depend on genes related to cell adhesion-mediated resistance and transforming growth factor β signaling.

Oncologic, fertility, and obstetric outcomes with MPA therapy in women with endometrial cancer and atypical endometrial hyperplasia

AIM

Medroxyprogesterone acetate (MPA) is one of the treatments of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) to preserve the fertility. Efficacy of MPA therapy and fertility and obstetric outcomes after remission were evaluated in EC or AEH patients.

METHODS

Among patients diagnosed with EC or AEH at Tokushima University Hospital between January 2002 and October 2020, we retrospectively analyzed patients, ages range from 26 to 40, who underwent conservative management using MPA (400-600 mg/day).

RESULTS

In total, 19 patients underwent MPA therapy. The 18 (94%) patients achieved complete response (CR), and 1 (5%) patient achieved partial response (PR). Relapse occurred in 6 (32%) patients who had achieved CR. Of the patients who relapsed, 4 patients resumed MPA therapy and were in remission. Among 19 patients, 13 patients attempted pregnancy after CR. All of them underwent ovulation induction or assisted reproductive technology. As a result, 20 pregnancies in 10 (77%) patients and 12 live births in 9 (69%) patients were achieved. Rate of spontaneous abortion was 35% (7/20).

CONCLUSIONS

MPA therapy can produce a high remission rate, and be considered an effective treatment for patients who wish fertility preservation. Around 70% patients who attempt to pregnancy can have at least one baby by infertility treatments. Because recurrence rate after MPA therapy is high, it may be desirable to aim for early pregnancy by active intervention.