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Liang F, Xin W, Yang S, Wang H. Nomogram for predicting pathology upstaging in patients with EIN: is sentinel lymph node assessment useful in these patients? J Gynecol Oncol 2024; 36:36.e1. [PMID: 38872479 DOI: 10.3802/jgo.2025.36.e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/20/2024] [Accepted: 04/15/2024] [Indexed: 06/15/2024] Open
Abstract
OBJECTIVE The objective of this study was to identify the risk factors for postoperative pathological escalation of endometrial cancer in patients with a pathologic diagnosis of endometrial intraepithelial neoplasia (EIN) before surgery. Some of the clues from the preoperative assessment were used to build a nomogram to predict the likely pathological escalation after surgery, and to explore the feasibility of sentinel lymph node biopsy in these patients with possible pathological escalation. METHODS This was a retrospective analysis of patients who underwent surgical treatment for EIN diagnosed before surgery between 2018 and 2023 in The Obstetrics and Gynecology Hospital of Fudan University. parameters including clinical, radiological and histopathological factors were analyzed by univariate and multivariate logistic regression to determine the correlation with pathology upstaging. A nomogram based on the multivariate results was developed to predict the probability of pathology upstaging. A total of 729 patients were included, divided into training set and validation set. 484 patients were used to build the model. This nomogram was subsequently validated using 245 patients. RESULTS Upstaging to endometrial carcinoma occurred in 115 (23.8 percent) of 484 women treated between 2018 and 2023 in training set. A lager endometrial thickness (at least 15 mm), menopause, hypertension, HE4, and endometrial blood were significantly associated with upstaging. A nomogram developed using these factors demonstrated good predictive performance (area under the receiver operating characteristic curve (AUC)=0.6808; 95% confidence interval [CI]=0.6246-0.7369). The nomogram showed similar predictive performance in the validation data set, based on another 245 women (AUC=0.7821; 95% CI=0.7076-0.8567). CONCLUSION This study developed a novel nomogram based on the 5 most important factors, which can accurately predict invasive cancer. It is common for women with preoperative diagnosis of EIN to experience pathological progression to endometrial cancer. For some patients with postoperative pathological escalation, we found lymph node metastasis. This nomogram may be useful to help doctor decide whether to perform sentinel lymph node biopsy for surgical staging in these EIN patients. According to the nomogram, simultaneous sentinel lymph node biopsy in patients with high probability of postoperative pathological upgrading can provide better guidance for postoperative adjuvant treatment of endometrial cancer and avoid the occurrence of secondary surgery.
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Affiliation(s)
| | | | - Shaoliang Yang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Haiyan Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
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Chen J, Wang X, Xu Q, Zhang W, Chen H, Gu H, Tang W, Tian Y, Wang Z. Development and external validation of a nomogram for predicting overall survival of patients with non-endometrioid endometrial cancer: A population-based analysis. Heliyon 2024; 10:e28864. [PMID: 38596036 PMCID: PMC11002679 DOI: 10.1016/j.heliyon.2024.e28864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives The main objective of this study was to identify the key predictors and construct a nomogram that can be used to predict the overall survival of individuals with non-endometrioid endometrial cancer. Methods A total of 2686 non-endometrioid endometrial cancer patients confirmed between 1988 and 2018 were selected from the Surveillance, Epidemiology, and End Results database. They were divided into a training cohort and an internal validation cohort. Independent risk factors were chosen by Cox regression analyses. A predictive nomogram model for overall survival was constructed based on above factors. A Chinese cohort of 41 patients was collected to be an external validation cohort. Results Eight variables were estimated as independent predictors for overall survival. A nomogram was established using these factors. The C-index for predicting the overall survival of patients with non-endometrioid endometrial cancer from the nomogram was 0.734, 0.700, and 0.767 in training, internal, and external validation cohort, respectively. Calibration plots and decision curve analysis showed that the nomogram was valuable for further clinical application. Conclusion We constructed a nomogram which can be used as an effective tool to predict the 3- and 5-year overall survival of Non-endometrioid endometrial cancer patients.
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Affiliation(s)
- Jingya Chen
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | | | - Qinfeng Xu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei Zhang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hu Chen
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Hailei Gu
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Wenwei Tang
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Ying Tian
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhongqiu Wang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
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Brower JV, Bregar AJ, Klopp AH. Path to Precision: Refining Radiation Therapy Guidelines for Early Stage Endometrial Cancer Through Incorporation of Primary Tumor Size, Lower Uterine Segment Invasion, and Molecular Markers. Pract Radiat Oncol 2024; 14:154-160. [PMID: 38048989 DOI: 10.1016/j.prro.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Jeffrey V Brower
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Radiation Oncology Associates-New England, Manchester, New Hampshire.
| | - Amy J Bregar
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Liu T, Zhang H, Han C, Kong W. Construction and validation of nomograms for predicting the prognosis of elderly patients with uterine serous carcinoma: a SEER-based study. J Cancer Res Clin Oncol 2023; 149:14475-14492. [PMID: 37567988 DOI: 10.1007/s00432-023-05174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE To investigate the prognostic indicators, develop and verify nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) in elderly patients with uterine serous carcinoma (USC). METHODS Data of eligible USC patients aged ≥ 65 years from 2004 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database were collected for retrospective analysis. X-tile software was used to assess the optimal cut-off values. Univariate and multivariate Cox regression analyses were performed to explore the prognostic factors. Nomograms were developed to predict the probability of 1-, 3- and 5-year OS and CSS. Concordance indexes (c-index), receiver operating characteristic analysis and calibration curves were used to evaluate the model. Decision curve analysis (DCA) was introduced to examine the clinical value of the models. RESULTS Age, Federation International of Gynecology and Obstetrics stage, N stage, tumor size, number of lymph nodes resected, and adjuvant therapy were independent prognostic factors for OS and CSS. The C-indexes were 0.736 (OS), 0.754 (CSS) in the training set and 0.731 (OS), 0.759 (CSS) in the validation set. The area under the curve (AUCs) of OS and CSS for 1-, 3-, and 5-years all exceeded 0.75. The calibration plots for the probability of survival were in good agreement. As shown in DCA curves, the nomograms showed better discrimination power and higher net benefits than the 6th American Joint Committee on Cancer staging system. CONCLUSIONS The nomograms constructed based on prognostic risk factors could individually predict the prognosis of elderly USC patients and provide a reference for clinical decision-making.
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Affiliation(s)
- Tingting Liu
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - He Zhang
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - Chao Han
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - Weimin Kong
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China.
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Zheng C, Chen W, Zheng Z, Liang X, Xu X, Fang D, Ma R, Fan F, Ni Y, Zhang P, Wu X. Development and validation of a prognostic nomogram for predicting cancer-specific survival in advanced endometrial carcinoma after surgery: a retrospective analysis of the SEER Database. BMJ Open 2023; 13:e070893. [PMID: 37714671 PMCID: PMC10510925 DOI: 10.1136/bmjopen-2022-070893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 09/01/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVE We aimed to construct and validate a prognostic nomogram to predict cancer-specific survival (CSS) after surgery in patients with advanced endometrial carcinoma (EC). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS The Surveillance, Epidemiology, and End Results (SEER) Database contains cancer incidence and survival data from population-based cancer registries in the USA. A total of 5445 patients from the SEER Database diagnosed with advanced EC between 2004 and 2015 were included and randomised 7:3 into a training cohort (n=3812) and a validation cohort (n=1633). OUTCOME MEASURE CSS. RESULTS The nomograms for CSS included 10 variables (positive regional nodes, age, tumour size, International Federation of Gynecology and Obstetrics (FIGO) stage, grade, ethnicity, income, radiation, chemotherapy and historical stage) based on the forward stepwise regression results. They revealed discrimination and calibration using the concordance index (C-index) and area under the time-dependent receiver operating characteristic curve, with a C-index value of 0.7324 (95% CI=0.7181 to 0.7468) and 0.7511 (95% CI=0.7301 to 0.7722) for the training and validation cohorts, respectively. Using calibration plots, a high degree of conformance was shown between the predicted and observed results. Additionally, a comparison of the nomogram and FIGO staging based on changes in the C-index, net reclassification index and integrated discrimination improvement demonstrated that the nomogram had better accuracy and efficacy. CONCLUSIONS We successfully constructed an accurate and effective nomogram to predict CSS in patients with advanced EC, which may help clinicians determine optimal individualised treatment strategies for patients with advanced EC. The predictive performance of the nomogram was evaluated thoroughly, but only internally. Therefore, further validation using different data sources is warranted in future related studies.
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Affiliation(s)
- Chunqin Zheng
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Weiqiang Chen
- Department of Anesthesiology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Zhixiang Zheng
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Xiaoling Liang
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Xiuxia Xu
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Danmei Fang
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Ruijun Ma
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Fufang Fan
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Yanhong Ni
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Peili Zhang
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Xuanhua Wu
- Department of Obstetrics and Gynecology, Shantou Central Hospital, Shantou, Guangdong, China
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Development of MRI-based radiomics predictive model for classifying endometrial lesions. Sci Rep 2023; 13:1590. [PMID: 36709399 PMCID: PMC9884294 DOI: 10.1038/s41598-023-28819-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 01/25/2023] [Indexed: 01/30/2023] Open
Abstract
An unbiased and accurate diagnosis of benign and malignant endometrial lesions is essential for the gynecologist, as each type might require distinct treatment. Radiomics is a quantitative method that could facilitate deep mining of information and quantification of the heterogeneity in images, thereby aiding clinicians in proper lesion diagnosis. The aim of this study is to develop an appropriate predictive model for the classification of benign and malignant endometrial lesions, and evaluate potential clinical applicability of the model. 139 patients with pathologically-confirmed endometrial lesions from January 2018 to July 2020 in two independent centers (center A and B) were finally analyzed. Center A was used for training set, while center B was used for test set. The lesions were manually drawn on the largest slice based on the lesion area by two radiologists. After feature extraction and feature selection, the possible associations between radiomics features and clinical parameters were assessed by Uni- and multi- variable logistic regression. The receiver operator characteristic (ROC) curve and DeLong validation were employed to evaluate the possible predictive performance of the models. Decision curve analysis (DCA) was used to evaluate the net benefit of the radiomics nomogram. A radiomics prediction model was established from the 15 selected features, and were found to be relatively high discriminative on the basis of the area under the ROC curve (AUC) for both the training and the test cohorts (AUC = 0.90 and 0.85, respectively). The radiomics nomogram also showed good performance of discrimination for both the training and test cohorts (AUC = 0.91 and 0.86, respectively), and the DeLong test shows that AUCs were significantly different between clinical parameters and nomogram. The result of DCA demonstrated the clinical usefulness of this novel nomogram method. The predictive model constructed based on MRI radiomics and clinical parameters indicated a highly diagnostic efficiency, thereby implying its potential clinical usefulness for the precise identification and prediction of endometrial lesions.
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Fu R, Zhang D, Yu X, Zhang H. The association of tumor diameter with lymph node metastasis and recurrence in patients with endometrial cancer: a systematic review and meta-analysis. Transl Cancer Res 2022; 11:4159-4177. [PMID: 36523313 PMCID: PMC9745381 DOI: 10.21037/tcr-22-2595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 02/07/2024]
Abstract
BACKGROUND Tumor diameter (TD)/original lesion area has been reported to have a certain predictive effect on lymph node metastasis (LNM) and recurrence of endometrial cancer (EC) patients, but there is still controversy about their relationship. Therefore, we conducted a meta-analysis to provide reference for clinical management and follow-up studies of patients with EC. METHODS The databases of PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang were searched, from inception to 27 October 2022, for studies regarding the association of TD with LNM risk and recurrence rate in EC. The search strategy was developed using a combination of free terms and medical subject headings (MeSH). Stata 15.0 was used to conduct the statistical analysis. Odds ratio (OR) with the 95% confidence interval (CI) were calculated to evaluate the association of TD and the risk of LNM and recurrence in EC patients. The OR value obtained from the multivariate analysis is first extracted; the results of univariate analysis were extracted for articles without the results of multivariate analysis. Newcastle-Ottawa Scale (NOS) assessed the quality of the included articles, publication bias was evaluated by Egger's test with funnel plots. RESULTS There was a total of 69 studies 123,383 EC patients included. Meta-analysis showed higher LNM risk in EC patients with the TD >2 cm, which was 2.88 times higher than that in those with ≤2 cm, and the difference was statistically significant (OR =2.88; 95% CI: 2.12-3.89; P<0.001), publication bias had no effect on the results. The risk of recurrence in EC patients with a TD >2 cm was 2.45 times higher than that in those with ≤2 cm (OR =2.45; 95% CI: 1.73-3.48; P<0.001), publication bias exerted influence over the results. CONCLUSIONS TD is associated with LNM and recurrence in patients with EC. Therefore, TD should be considered in the scope of surgery and adjuvant therapy.
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Affiliation(s)
- Ruifang Fu
- Department of Gynecology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Dongli Zhang
- Department of Gynecology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Xiaohan Yu
- Department of Gynecology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Hongxia Zhang
- Department of Gynecology, Huaihe Hospital of Henan University, Kaifeng, China
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Matias-Guiu X, Selinger CI, Anderson L, Buza N, Ellenson LH, Fadare O, Ganesan R, Ip PPC, Palacios J, Parra-Herran C, Raspollini MR, Soslow RA, Werner HMJ, Lax SF, McCluggage WG. Data Set for the Reporting of Endometrial Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Int J Gynecol Pathol 2022; 41:S90-S118. [PMID: 36305536 DOI: 10.1097/pgp.0000000000000901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.
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Ambrosio M, Raffone A, Alletto A, Cini C, Filipponi F, Neola D, Fabbri M, Arena A, Raimondo D, Salucci P, Guerrini M, Travaglino A, Paradisi R, Mollo A, Seracchioli R, Casadio P. Is preoperative ultrasound tumor size a prognostic factor in endometrial carcinoma patients? Front Oncol 2022; 12:993629. [PMID: 36212493 PMCID: PMC9538669 DOI: 10.3389/fonc.2022.993629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/12/2022] [Indexed: 12/02/2022] Open
Abstract
Objective We aimed to assess the prognostic value of preoperative ultrasound tumor size in EC through a single center, observational, retrospective, cohort study. Methods Medical records and electronic clinical databases were searched for all consecutive patients with EC, preoperative ultrasound scans available to ad hoc estimate tumor size, and a follow-up of at least 2-year, at our Institution from January 2010 to June 2018. Patients were divided into two groups based on different dimensional cut-offs for the maximum tumor diameter: 2, 3 and 4 cm. Differences in overall survival (OS), disease specific survival (DSS) and progression-free survival (PFS) were assessed among the groups by using the Kaplan-Meier estimator and the log-rank test. Results 108 patients were included in the study. OS, DSS and PFS did not significantly differ between the groups based on the different tumor diameter cut-offs. No significant differences were found among the groups sub-stratified by age, BMI, FIGO stage, FIGO grade, lymphovascular space invasion status, myometrial invasion, lymph nodal involvement, histotype, and adjuvant treatment. Conclusions Preoperative ultrasound tumor size does not appear as a prognostic factor in EC women.
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Affiliation(s)
- Marco Ambrosio
- Mother-Child Department, Ospedale Maggiore, Azienda Unità Sanitaria Locale di Bologna, Bologna, Italy
| | - Antonio Raffone
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Alletto
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Chiara Cini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Filipponi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Daniele Neola
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Densitry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Matilde Fabbri
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Arena
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Salucci
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Manuela Guerrini
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Travaglino
- Gynecopathology and Breast Pathology Unit, Department of Woman’s Health Science, Agostino Gemelli University Polyclinic, Rome, Italy
| | - Roberto Paradisi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry “Schola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Casadio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Zhang J, Liu Q, Li J, Liu Z, Wang X, Li N, Huang Z, Xu H. Magnetic resonance spectroscopy associations with clinicopathologic features of estrogen-dependent endometrial cancer. BMC Med Imaging 2022; 22:127. [PMID: 35850646 PMCID: PMC9295509 DOI: 10.1186/s12880-022-00856-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We studied the magnetic resonance spectroscopy (MRS) associations with clinicopathologic features of estrogen-dependent endometrial cancer (type I EC). METHODS Totally 45 patients with type I EC who underwent preoperative multi-voxel MRS at 3.0 T were enrolled. The mean ratio of the Cho peak integral to the unsuppressed water peak integral (Cho/water) of the tumor was calculated. The Cho/water and apparent diffusion coefficient (ADC) of type I EC with and without local invasion, as well as with different levels of Ki-67 staining index (SI) (≤ 40% and > 40%), were compared. Correlation test was used to examine the relationship of Cho/water, as well as mean ADC, with Ki-67 SI, tumor stage, and tumor grade. RESULTS The mean Cho/water of EC with Ki-67 SI ≤ 40% (2.28 ± 0.93) × 10-3 was lower than that with Ki-67 SI > 40% (4.08 ± 1.00) × 10-3 (P < 0.001). The mean Cho/water of EC with deep and superficial myometrial invasion was (3.41 ± 1.26) × 10-3 and (2.43 ± 1.11) × 10-3, respectively (P = 0.011). There was no significant difference in Cho/water between type I EC with and without cervical invasioin ([2.68 ± 1.00] × 10-3 and [2.77 ± 1.28] × 10-3, P = 0.866). The mean Cho/water of type I EC with and without lymph node metastasis was (4.02 ± 1.90) × 10-3 and (2.60 ± 1.06) × 10-3, respectively (P = 0.014). The Cho/water was positively correlated with the Ki-67 SI (r = 0.701, P < 0.001). There were no significant differences in ADC among groups (all P > 0.05). CONCLUSION MRS is helpful for preoperative assessment of clinicopathological features of type I EC.
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Affiliation(s)
- Jie Zhang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Qingwei Liu
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Jie Li
- Special Inspection Department, Taian City Central Hospital Branch, No. 336, Wanguan Road, Taian, 271000, Shandong, China
| | - Zhiling Liu
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Ximing Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Na Li
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
| | - Han Xu
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
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Piedimonte S, Feigenberg T, Drysdale E, Kwon J, Gotlieb WH, Cormier B, Plante M, Lau S, Helpman L, Renaud MC, May T, Vicus D. Predicting recurrence and recurrence-free survival in high-grade endometrial cancer using machine learning. J Surg Oncol 2022; 126:1096-1103. [PMID: 35819161 DOI: 10.1002/jso.27008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/06/2022] [Accepted: 06/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To develop machine-learning models to predict recurrence and time-to-recurrence in high-grade endometrial cancer (HGEC) following surgery and tailored adjuvant treatment. METHODS Data were retrospectively collected across eight Canadian centers including 1237 patients. Four models were trained to predict recurrence: random forests, boosted trees, and two neural networks. Receiver operating characteristic curves were used to select the best model based on the highest area under the curve (AUC). For time to recurrence, we compared random forests and Least Absolute Shrinkage and Selection Operator (LASSO) model to Cox proportional hazards. RESULTS The random forest was the best model to predict recurrence in HGEC; the AUCs were 85.2%, 74.1%, and 71.8% in the training, validation, and test sets, respectively. The top five predictors were: stage, uterus height, specimen weight, adjuvant chemotherapy, and preoperative histology. Performance increased to 77% and 80% when stratified by Stage III and IV, respectively. For time to recurrence, there was no difference between the LASSO and Cox proportional hazards models (c-index 71%). The random forest had a c-index of 60.5%. CONCLUSIONS A bootstrap random forest model may be a more accurate technique to predict recurrence in HGEC using multiple clinicopathologic factors. For time to recurrence, machine-learning methods performed similarly to the Cox proportional hazards model.
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Affiliation(s)
- Sabrina Piedimonte
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Erik Drysdale
- Genetics and Genome Biology, AI in Medicine, SickKids, Toronto, Ontario, Canada
| | - Janice Kwon
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | | | - Beatrice Cormier
- Centre Hospitalier Universitaire de Montreal, Montreal, Quebec, Canada
| | - Marie Plante
- Centre Hospitalier Universitaire de Quebec, Quebec City, Quebec, Canada
| | - Susie Lau
- Jewish General Hospital, Montreal, Quebec, Canada
| | | | | | - Taymaa May
- University Health Network, Toronto, Ontario, Canada
| | - Danielle Vicus
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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12
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Restaino S, Buda A, Puppo A, Capozzi VA, Sozzi G, Casarin J, Gallitelli V, Murgia F, Vizzielli G, Baroni A, Corrado G, Pasciuto T, Ferrari D, Novelli A, Berretta R, Legge F, Vizza E, Chiantera V, Ghezzi F, Landoni F, Scambia G, Fanfani F. Anatomical distribution of sentinel lymph nodes in patients with endometrial cancer: a multicenter study. Int J Gynecol Cancer 2022; 32:517-524. [PMID: 35110375 DOI: 10.1136/ijgc-2021-003253] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Sentinel lymph node (SLN) mapping represents the standard approach in uterine confined endometrial cancer patients. The aim of this study was to evaluate the anatomical distribution of SLNs and the most frequent locations of nodal metastasis. METHODS This was an observational retrospective multicenter study involving eight high volume gynecologic cancer centers in Italy. We reviewed 1576 patients with a histologically confirmed diagnosis of endometrial cancer from September 2015 to June 2020. All patients underwent total hysterectomy with salpingo-ophorectomy and SLN mapping. RESULTS A total of 3105 SLNs were mapped and removed, 2809 (90.5%) of these were bilateral and 296 (9.5%) unilateral. The overall detection rate was 93.4% (77.9% bilateral and 15.5% unilateral). The majority of SLNs (80%) and positive SLNs (77.8%) were found at the external iliac and obturator level in both endometrioid and non-endometrioid endometrial cancer. Negative SLNs were more frequent in patients with endometrioid compared with non-endometrioid cancer (91.9% vs 86.1%, p<0.0001). Older patients, a higher body mass index, and non-endometrioid histology were more likely to have 'no mapping' (p<0.0001). Univariate and multivariate analysis showed that higher body mass index and age at surgery were independent predictive factors of empty node packet and fat tissue (p=0.029 and p<0.01, respectively). CONCLUSION The most frequent sites of SLNs and metastases were located in the pelvic area below the iliac vessel bifurcation. Our findings showed that older age, a higher body mass index, and non-endometrioid histology had a negative impact on mapping.
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Affiliation(s)
- Stefano Restaino
- Department of Obstetrics, Gynecology, and Pediatrics, Obstetrics and Gynecology Unit, Udine University Hospital, DAME, Udine, Italy
| | - Alessandro Buda
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,Ospedale Michele e Pietro Ferrero, Verduno, Italy
| | - Andrea Puppo
- Clinic of Obstetrics and Gynecology, Santa Croce e Carle Hospital, Cuneo, Italy
| | | | - Giulio Sozzi
- Department of Gynecologic Oncology, Università di Palermo, Palermo, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Women's and Children's Del Ponte Hospital, Varese, Italy
| | | | - Ferdinando Murgia
- Obstetrics and Gynecology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Giuseppe Vizzielli
- Department of Obstetrics, Gynecology, and Pediatrics, Obstetrics and Gynecology Unit, Udine University Hospital, DAME, Udine, Italy.,Department of Medicine, University of Udine, Gynecology and Obstetrics Clinic, Udine, Italy
| | | | | | - Tina Pasciuto
- Research Core Facilty Data Collection G-STeP, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Largo Agostino Gemelli 8, Rome, Italy
| | - Debora Ferrari
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Antonia Novelli
- Department of Gynaecology and Obstetrics, Regina Montis Regalis Hospital, Mondovì, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Legge
- Obstetrics and Gynecology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Enrico Vizza
- Department of Experimental Clinical Oncology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, Università di Palermo, Palermo, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Women's and Children's Del Ponte Hospital, Varese, Italy
| | - Fabio Landoni
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, University of Insubria, Women's and Children's Del Ponte Hospital, Varese, Italy.,UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Francesco Fanfani
- Department of Obstetrics and Gynecology, University of Insubria, Women's and Children's Del Ponte Hospital, Varese, Italy .,UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
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13
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Feigenberg T, Cormier B, Gotlieb WH, Jegatheeswaran K, Helpman L, Kim SR, Lau S, May T, Saab D, Plante M, Renaud MC, Samouelian V, Shamiya S, Vicus D, Wright K, Kwon JS. Factors associated with an increased risk of recurrence in patients diagnosed with high-grade endometrial cancer undergoing minimally invasive surgery: A study of the society of gynecologic oncology of Canada (GOC) community of practice (CoP). Gynecol Oncol 2021; 162:606-612. [PMID: 34183164 DOI: 10.1016/j.ygyno.2021.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is a standard surgical approach for comprehensive surgical staging in women with endometrial cancer. As rates and complexity of MIS are steadily increasing, it is important to identify potential risk factors which may be associated with this approach. This study evaluates the impact of local factors on the risk of disease recurrence. METHODS A retrospective cohort study was conducted of patients diagnosed with high grade endometrial cancer (HGEC) who underwent MIS between 2012 and 2016 at eight Canadian centers. Data was collected from medical records. The 75th percentile was calculated for estimated uterine volume and weight. All recurrences were categorized into two groups; intra-abdominal vs. extra-abdominal. To search for significant covariates associated with recurrence-free survival a Cox proportional hazard model was performed. RESULTS A total of 758 patients were included in the study. Intra-uterine manipulator was used in 497 (35.8%) of patients. Vaginal lacerations were documented in 9.1%. Median follow-up was 30.5 months (interquartile range 20-47). There were 157 who had disease recurrence (20.71%), including 92 (12.14%) intra-abdominal and 60 (7.92%) extra-abdominal only recurrences. In univariate analysis myometrial invasion, LVI, stage, uterine volume and weight > 75th percentile and chemotherapy were associated with increased risk of intra-abdominal recurrence. In multivariable analysis only stage, and specimen weight > 75th percentile (OR 2.207, CI 1.123-4.337) remained significant. Uterine volume, and weight were not associated with increased risk of extra-abdominal recurrences. CONCLUSION For patients diagnosed with HGEC undergoing MIS, extracting a large uterus is associated with a significantly increased risk for intra-abdominal recurrence.
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Affiliation(s)
- Tomer Feigenberg
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Trillium Health Partners, Ontario, Canada.
| | - Beatrice Cormier
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Université de Montreal, Québec, Canada
| | - Walter Henri Gotlieb
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
| | - Kizanee Jegatheeswaran
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Limor Helpman
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, McMaster University, Ontario, Canada
| | - Soyoun Rachel Kim
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of British Columbia, British Columbia, Canada
| | - Susie Lau
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
| | - Taymaa May
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Center, Ontario, Canada
| | - Dima Saab
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Marie Plante
- Gynecologic Oncology Division, CHU de Québec-Hôtel-Dieu de Québec-Université Laval, Québec, Canada
| | - Marie Claude Renaud
- Gynecologic Oncology Division, CHU de Québec-Hôtel-Dieu de Québec-Université Laval, Québec, Canada
| | - Vanessa Samouelian
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Université de Montreal, Québec, Canada
| | - Sarah Shamiya
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Danielle Vicus
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Kristin Wright
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, McMaster University, Ontario, Canada
| | - Janice S Kwon
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of British Columbia, British Columbia, Canada
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14
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Capozzi VA, Monfardini L, Sozzi G, Butera D, Armano G, Riccò M, Giovanna G, Berretta R. Obesity, an independent predictor of pre and postoperative tumor grading disagreement in endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2021; 262:160-165. [PMID: 34022594 DOI: 10.1016/j.ejogrb.2021.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/01/2021] [Accepted: 05/12/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Obesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent. Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement. MATERIALS AND METHODS A retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy. RESULTS Of the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m2) as significant factor influencing pre and postoperative grading agreement (p = 0.014, Odds Ratio 2.036, 95 % Confidence Interval 1.141-3.635). CONCLUSIONS Our study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.
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Affiliation(s)
- Vito Andrea Capozzi
- Department of Gynecology and Obstetrics of Parma, University of Parma, 43125, Parma, Italy.
| | - Luciano Monfardini
- Department of Gynecology and Obstetrics of Parma, University of Parma, 43125, Parma, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Diana Butera
- Department of Gynecology and Obstetrics of Parma, University of Parma, 43125, Parma, Italy
| | - Giulia Armano
- Department of Gynecology and Obstetrics of Parma, University of Parma, 43125, Parma, Italy
| | - Matteo Riccò
- Service for Health and Safety on the Workplaces, AUSL - I.R.C.C.S. di Reggio Emilia, Reggio Emilia, Italy
| | - Giordano Giovanna
- Departments of Biomedical, Biotechnological and Translational Sciences, Pathological Anatomy and Histology Unit, Faculty of Medicine, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics of Parma, University of Parma, 43125, Parma, Italy
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15
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The Prediction of Recurrence in Low-Risk Endometrial Cancer: Is It Time for a Paradigm Shift in Adjuvant Therapy? Reprod Sci 2021; 29:1068-1085. [DOI: 10.1007/s43032-021-00565-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
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16
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Fasmer KE, Hodneland E, Dybvik JA, Wagner-Larsen K, Trovik J, Salvesen Ø, Krakstad C, Haldorsen IHS. Whole-Volume Tumor MRI Radiomics for Prognostic Modeling in Endometrial Cancer. J Magn Reson Imaging 2020; 53:928-937. [PMID: 33200420 PMCID: PMC7894560 DOI: 10.1002/jmri.27444] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background In endometrial cancer (EC), preoperative pelvic MRI is recommended for local staging, while final tumor stage and grade are established by surgery and pathology. MRI‐based radiomic tumor profiling may aid in preoperative risk‐stratification and support clinical treatment decisions in EC. Purpose To develop MRI‐based whole‐volume tumor radiomic signatures for prediction of aggressive EC disease. Study Type Retrospective. Population A total of 138 women with histologically confirmed EC, divided into training (nT = 108) and validation cohorts (nV = 30). Field Strength/Sequence Axial oblique T1‐weighted gradient echo volumetric interpolated breath‐hold examination (VIBE) at 1.5T (71/138 patients) and DIXON VIBE at 3T (67/138 patients) at 2 minutes postcontrast injection. Assessment Primary tumors were manually segmented by two radiologists with 4 and 8 years' of experience. Radiomic tumor features were computed and used for prediction of surgicopathologically‐verified deep (≥50%) myometrial invasion (DMI), lymph node metastases (LNM), advanced stage (FIGO III + IV), nonendometrioid (NE) histology, and high‐grade endometrioid tumors (E3). Corresponding analyses were also conducted using radiomics extracted from the axial oblique image slice depicting the largest tumor area. Statistical Tests Logistic least absolute shrinkage and selection operator (LASSO) was applied for radiomic modeling in the training cohort. The diagnostic performances of the radiomic signatures were evaluated by area under the receiver operating characteristic curve in the training (AUCT) and validation (AUCV) cohorts. Progression‐free survival was assessed using the Kaplan–Meier and Cox proportional hazard model. Results The whole‐tumor radiomic signatures yielded AUCT/AUCV of 0.84/0.76 for predicting DMI, 0.73/0.72 for LNM, 0.71/0.68 for FIGO III + IV, 0.68/0.74 for NE histology, and 0.79/0.63 for high‐grade (E3) tumor. Single‐slice radiomics yielded comparable AUCT but significantly lower AUCV for LNM and FIGO III + IV (both P < 0.05). Tumor volume yielded comparable AUCT to the whole‐tumor radiomic signatures for prediction of DMI, LNM, FIGO III + IV, and NE, but significantly lower AUCT for E3 tumors (P < 0.05). All of the whole‐tumor radiomic signatures significantly predicted poor progression‐free survival with hazard ratios of 4.6–9.8 (P < 0.05 for all). Data Conclusion MRI‐based whole‐tumor radiomic signatures yield medium‐to‐high diagnostic performance for predicting aggressive EC disease. The signatures may aid in preoperative risk assessment and hence guide personalized treatment strategies in EC. Level of Evidence 4 Technical Efficacy Stage 2
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Affiliation(s)
- Kristine E Fasmer
- Department of Radiology, Mohn Medical Imaging and Visualization Centre (MMIV), Haukeland University Hospital, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erlend Hodneland
- Department of Radiology, Mohn Medical Imaging and Visualization Centre (MMIV), Haukeland University Hospital, Bergen, Norway.,NORCE Norwegian Research Centre, Bergen, Norway
| | - Julie A Dybvik
- Department of Radiology, Mohn Medical Imaging and Visualization Centre (MMIV), Haukeland University Hospital, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kari Wagner-Larsen
- Department of Radiology, Mohn Medical Imaging and Visualization Centre (MMIV), Haukeland University Hospital, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jone Trovik
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.,Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øyvind Salvesen
- Unit for applied Clinical Research, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Camilla Krakstad
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.,Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ingfrid H S Haldorsen
- Department of Radiology, Mohn Medical Imaging and Visualization Centre (MMIV), Haukeland University Hospital, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
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17
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Liu C, Zhao J, Liu S, Ma Y, Yang Y, Qu P. Effect of Pelvic Lymphadenectomy on Survival in Patients with Low-Risk Early-Stage Endometrial Cancer Diagnosed Intraoperatively Using Frozen Tissue Sections: A Retrospective Analysis. Cancer Manag Res 2020; 12:10715-10723. [PMID: 33149678 PMCID: PMC7605598 DOI: 10.2147/cmar.s274992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To determine whether pelvic lymphadenectomy improved survival in patients diagnosed with low-risk early-stage endometrial cancer by intraoperative pathology. Methods This retrospective analysis included 238 patients at our hospital. Results The lymphadenectomy and non-lymphadenectomy groups contained 121 and 117 patients, respectively. In both groups, more than half the patients had tumor size ≥2 cm, and most had myometrial invasion <50%, stage Ia disease and no lymphovascular space invasion. Age, tumor size, myometrial invasion, surgical-pathologic stage and postoperative adjuvant therapy use were comparable between groups. The non-lymphadenectomy group had more patients treated laparoscopically (36.8% vs 10.7%; P<0.001) and fewer patients with histologic grade 2 disease (35.9% vs 62.8%; P<0.001) than the lymphadenectomy group. In the non-lymphadenectomy group, intraoperative frozen section pathology disagreed with postoperative pathology in only 31/117 cases for histologic grade (none upgraded to grade 3), 1/117 cases for myometrial invasion (one case revised from <50% to ≥50%) and 3/117 cases for surgical-pathologic stage (upgraded from Ia to Ib or II). Disease recurrence rate and overall survival did not differ significantly between the lymphadenectomy and non-lymphadenectomy groups. In multivariate Cox regression analysis, only surgical-pathologic stage >Ia (odds ratio, 47.7; 95% confidence interval, 6.7–340.8; P=0.031) was associated with increased odds of disease recurrence. Conclusion Pelvic lymphadenectomy may not be necessary in patients with an intraoperative diagnosis of low-risk endometrial cancer.
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Affiliation(s)
- Caiyan Liu
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Jianguo Zhao
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Shasha Liu
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Yaomei Ma
- Department of Gynecological Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, People's Republic of China
| | - Yun Yang
- Department Of Gynecology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Pengpeng Qu
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
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18
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Capozzi VA, Merisio C, Rolla M, Pugliese M, Morganelli G, Cianciolo A, Gambino G, Armano G, Sozzi G, Riccò M, Berretta R. Confounding factors of transvaginal ultrasound accuracy in endometrial cancer. J OBSTET GYNAECOL 2020; 41:779-784. [DOI: 10.1080/01443615.2020.1799342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Vito Andrea Capozzi
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Carla Merisio
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Martino Rolla
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Martina Pugliese
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Giovanni Morganelli
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Alessandra Cianciolo
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Giulia Gambino
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Giulia Armano
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Matteo Riccò
- Service for Health and Safety on the Workplaces, AUSL - I.R.C.C.S. di Reggio Emilia, Reggio Emilia, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics of Parma, University of Parma, Parma, Italy
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19
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Sozzi G, Fanfani F, Berretta R, Capozzi VA, Uccella S, Buono N, Giallombardo V, Di Donna MC, Monterossi G, Restaino S, Capasso I, Dinoi G, Scambia G, Chiantera V. Laparoscopic sentinel node mapping with intracervical indocyanine green injection for endometrial cancer: the SENTIFAIL study – a multicentric analysis of predictors of failed mapping. Int J Gynecol Cancer 2020; 30:1713-1718. [DOI: 10.1136/ijgc-2020-001724] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 11/03/2022] Open
Abstract
ObjectivesLaparoscopy is commonly used for endometrial cancer treatment, and sentinel lymph node (SLN) mapping has become the standard procedure for nodal assessment. Despite the standardization of the technique, there is no definitive data regarding its failure rate. The objective of this study is to identify factors associated with unsuccessful SLN mapping in endometrial cancer patients undergoing laparoscopic SLN mapping after intracervical indocyanine green (ICG) injection.MethodsWe retrospectively evaluated a consecutive series of endometrial cancer patients who underwent laparoscopic SLN mapping with intracervical ICG injection, in four oncological referral centers from January 2016 to July 2019. Inclusion criteria were biopsy-proven endometrial cancer, total laparoscopic approach, and intracervical ICG injection. Exclusion criteria were evidence of lymph node involvement or extrauterine disease at pre-operative imaging, synchronous invasive cancer, the use of tracers different from ICG, and the use of neoadjuvant treatment. Bilateral and failed bilateral SLN mapping groups were compared for clinical and pathological features. In patients with an unsuccessful procedure, side-specific lymphadenectomy was performed. Logistic regression was used to identify predictors of failure.ResultsA total of 376 patients were included in the study. The overall bilateral and unilateral SLN detection rates were 96.3%, 76.3%, and 20.0% respectively. The failed bilateral mapping detection rate was 23.7%. The median number of sentinel nodes removed was 2.2 (range, 0–5). After multivariate analysis, lymph vascular space involvement [OR 2.4 (1.04–1.12), P=0.003], non-endometrioid histology [OR 3.0 (1.43–6.29), P=0.004], and intraoperative finding of enlarged lymph node [OR 2.3 (1.01–5.31), P=0.045] were identified as independent predictors of failure of SLN mapping.ConclusionLymph vascular space involvement, non-endometrioid histology, and intra-operative finding of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.
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Nasioudis D, Frey MK, Chapman-Davis E, Caputo TA, Holcomb K. Outcomes of minimally invasive surgery for patients with endometrial carcinoma involving the cervix. Int J Gynecol Cancer 2020; 30:619-625. [PMID: 32276935 DOI: 10.1136/ijgc-2019-001023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/09/2020] [Accepted: 01/14/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Most studies evaluating the oncologic safety of minimally invasive surgery for endometrial cancer focus on patients with stage I disease. The aim of this study was to investigate the outcomes of minimally invasive surgery for patients with endometrial carcinoma involving the cervix. METHODS Patients diagnosed between January 2010 and December 2015, with clinical stage II endometrial carcinoma, who underwent hysterectomy with lymphadenectomy, were drawn from the National Cancer Database. Inclusion criteria were clinical International Federation of Gynecology and Obstetrics (FIGO 2009) stage II, patients who underwent hysterectomy with lymphadenectomy, and known route of surgery (open or minimally invasive). Patients who received radiation therapy prior to surgery, those who had subtotal/supracervical hysterectomy, or unknown type of hysterectomy were excluded. The exposure of interest was performance of minimally invasive surgery either laparoscopic or robotic-assisted. Overall survival (primary endpoint) was assessed for patients diagnosed between January 2010 and December 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders. RESULTS A total of 2175 patients were identified and 1282 (58.9%) had minimally invasive surgery. Of these, 339 and 943 patients had laparoscopic or robotic-assisted laparoscopic hysterectomy, respectively. Minimally invasive surgery was converted to open surgery in 74 (5.8%) patients. Those undergoing minimally invasive surgery had shorter hospital stay (median 1 vs 3 days, p<0.001), lower unplanned readmission rate (2.7% vs 4.7%, p=0.014), and 90-day mortality (0.8% vs 1.8%, p=0.05). Patients who had open surgery (n=796) had worse overall survival compared with those who had minimally invasive surgery (n=1048, p=0.003); 3-year overall survival rates were 76.8% and 83.6%, respectively. After controlling for patient age, race, type of insurance, presence of co-morbidities, performance of extensive lymphadenectomy, presence of positive lymph nodes, tumor histology, presence of lymphovascular space invasion, tumor size, and administration of radiotherapy, performance of minimally invasive surgery was not associated with worse survival (HR 0.90, 95% CI 0.73 to 1.11). CONCLUSIONS In this retrospective analysis, minimally invasive surgery in patients with stage II endometrial carcinoma was associated with superior short-term peri-operative outcomes and improved 3-year overall survival.
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Affiliation(s)
- Dimitrios Nasioudis
- Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa K Frey
- Division of Gynecologic Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Eloise Chapman-Davis
- Division of Gynecologic Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Thomas A Caputo
- Division of Gynecologic Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Weill Cornell Medical College, New York, New York, USA
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Onderdonk BE, Wu T, Al-Hallaq H, Son CH, Waller J, Hasan Y. Clinical and Dosimetric Implications of Intrafractional Cylinder Movement During Vaginal Cuff Brachytherapy. Cureus 2019; 11:e6165. [PMID: 31890373 PMCID: PMC6913955 DOI: 10.7759/cureus.6165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction To quantify the dosimetric and clinical effects of intrafractional cylinder movement in patients receiving high-dose-rate vaginal cuff brachytherapy (VBT) without a formal immobilization device and the implication of motion on institutional clinical outcomes. Methods From 2013-2018, 119 patients were treated with VBT with no formal immobilization device at a single institution. As a quality assessment study, pre-and post-cylinder brachytherapy kilovoltage (kV) images were acquired for 37 fractions in nine consecutive patients who underwent VBT and clinical care representative of institutional practice standards. The D90 and D90 EqD2 were calculated according to each patient's average intrafractional movement throughout the treatment course. The D2cc for organs-at-risk (OARs) were also re-evaluated following the simulated movements. The survival outcomes and toxicity were recorded from the 119 patients. Toxicity was graded as per Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results The measured mean ± standard deviation movement was 5.0 mm ± 3.5, with 62% moving caudad. The D90 from each patient's maximum and average movements were lower than the pre-planned doses: 71%, and 89%, respectively. The doses to the OARs were lower than the pre-planned doses. After a median follow-up of 20 months, there were three local recurrences with a median time of 14.5 months (range: 10-31). There were two acute grade 3+ toxicities and one late grade 3+ toxicity. There was a moderate correlation (r = 0.40) between body mass index (BMI) and intrafraction movement with caudad being more common in smaller BMIs (p = 0.0216). Conclusions Intrafractional vaginal cylinder movement without a table fixation device is about 5.0 mm, with the majority of movements moving caudad. While institutional outcomes suggest that local control may not be compromised, consideration of more formal immobilization devices is warranted, especially for those patients with lower BMIs.
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Affiliation(s)
- Benjamin E Onderdonk
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Tianming Wu
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Hania Al-Hallaq
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Joseph Waller
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
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Çakır C, Kılıç İÇ, Yüksel D, Karyal YA, Üreyen I, Boyraz G, Durmuş Y, Gültekin M, Özgül N, Karalök MA, Salman MC, Yüce K, Turan AT. Does tumor size have prognostic value in patients undergoing lymphadenectomy in endometrioid-type endometrial cancer confined to the uterine corpus? Turk J Med Sci 2019; 49:1403-1410. [PMID: 31650820 PMCID: PMC7018323 DOI: 10.3906/sag-1902-224] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/03/2019] [Indexed: 01/19/2023] Open
Abstract
Background/aim We aimed to define the effect of tumor size on recurrence and survival rates in patients with stage I–II endometrioid-type endometrial cancer. Materials and methods A total of 550 patients who had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic-paraaortic lymphadenectomy were included. Patients with extrauterine spread, sarcomatous components, or synchronized tumor and those who did not undergo lymphadenectomy or did not have data on tumor size were excluded. Results The median tumor size was 35 mm (range: 3–335 mm). According to the 2009 International Federation of Obstetrics and Gynecology (FIGO) criteria, 245 cases were defined as stage IA, 271 as stage IB, and 34 as stage II. The 5-year disease-free survival (DFS) rate was 92% and the 5-year disease-specific survival (DSS) rate was 99%. The effects of prognostic factors on DFS were evaluated. Older age, stage II disease, deep myometrial invasion, and receiving adjuvant radiotherapy were associated with decreased DFS. There was no statistically significant association between tumor size and DFS. The 5-year DFS for patients with a tumor diameter of <35 mm, which was the median tumor size of the entire group, was 94%, while it was 89% for patients having a tumor diameter of >35 mm (P = 0.128). Conclusion Tumor size was not a risk factor predicting recurrence in patients with stage I or II endometrioid-type endometrial cancer who had lymphadenectomy.
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Affiliation(s)
- Caner Çakır
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - İsmet Çiğdem Kılıç
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Dilek Yüksel
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Yalın Ay Karyal
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Işın Üreyen
- Gynecologic Oncology Clinic, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Gökhan Boyraz
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Yasin Durmuş
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Murat Gültekin
- Gynecologic Oncology Clinic, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Nejat Özgül
- Gynecologic Oncology Clinic, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Alper Karalök
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
| | - Mehmet Coşkun Salman
- Gynecologic Oncology Clinic, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kunter Yüce
- Gynecologic Oncology Clinic, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ahmet Taner Turan
- Gynecologic Oncology Clinic, Etlik Zübeyde Hanım Women’s Health Teaching and Research Hospital,University of Health Sciences, Ankara, Turkey
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Candido EC, Rangel Neto OF, Toledo MCS, Torres JCC, Cairo AAA, Braganca JF, Teixeira JC. Systematic lymphadenectomy for intermediate risk endometrial carcinoma treatment does not improve the oncological outcome. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100020. [PMID: 31403112 PMCID: PMC6687380 DOI: 10.1016/j.eurox.2019.100020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate the indication and performance of systematic lymphadenectomy (SL) in Stage I endometrioid endometrial carcinoma (EEC), at intermediate risk (FIGO IAG2/G3, IBG1/G2) on recurrence, disease-free survival (DFS) and survival. Study design 194 women underwent hysterectomies by laparotomy, with SL (n = 95) or without SL (n = 99) between 1990 and 2014 was evaluated. Diagnosis period, age, BMI, comorbidities, stage, and adjuvant radiotherapy were analyzed. DFS and cancer-specific survival were analyzed by Kaplan-Meier and log-rank test, and recurrences by Cox regression. Results SL was performed in 93% (41/44) of women managed before 1998 and decreasing after that (p < 0.001). SL was also more frequent if BMI under 35.0 kg/m2 (p < 0.001) and in women without comorbidities (p = 0.017). Distribution of age, stage and postoperative radiotherapy were not different between groups. There were 14 recurrences (7.4%), concentrated in the SL group (12 cases) and associated with Stage IAG3 (35.7%, p = 0.009). Longitudinal evaluation exhibited 95% of 5-year cancer-specific survival rate for non-SL group vs. 88% for the SL group (p = 0.039), and DFS rate was 97% for the non-SL group vs. 85% for the SL group (p = 0.004). Cox regression analyses exhibited Stage IAG3 (HR 6.48, IC95% 1.88–22.39; p = 0.003) associated with less DFS. Conclusion SL in surgical staging of EEC at intermediate risk presented no benefits regarding recurrences, DFS, and cancer-specific survival rate when compared to patients not submitted to complete surgical staging. Stage IAG3 had poor prognosis regardless treatment modality. Our results provide further evidence to support the current trend to avoid SL in the surgical approach to selected women.
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Affiliation(s)
- Elaine C Candido
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
| | - Osmar F Rangel Neto
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
| | - Maria Carolina S Toledo
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
| | - José Carlos C Torres
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
| | - Aurea A A Cairo
- Department of Obstetrics and Gynecology, Pontifical Catholic University of Campinas, Av. John Boyd Dunlop, s/n - Jd. Ipaussurama, Campinas, SP, 13060-904 Brazil
| | - Joana F Braganca
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
| | - Julio C Teixeira
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Rua Alexander Fleming, 101, Cidade Universitaria, Campinas, SP, 13083-881, Brazil
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