Elucidating the pathogenesis of synchronous and metachronous tumors in a woman with endometrioid carcinomas using a whole-exome sequencing approach

Analysis of clinicopathological features and prognosis of double primary cervical cancer and ovarian cancer based on SEER database

OBJECTIVE

Double primary cervical cancer and ovarian cancer refer to the simultaneous or successive appearance of cervical cancer and ovarian cancer in the same patient. Due to the low incidence, there are few relevant reports. Therefore, this study is the first population-based analysis of the clinicopathological features as well as the prognostic status of double primary cervical cancer and ovarian cancer. We look forward to providing a reference for future clinical diagnosis and treatment.

METHODS

In this study, 473 cases of double primary cervical cancer and ovarian cancer were collected from 1975 to 2019 through the SEER database. Double primary cancers were considered non-synchronous when they were diagnosed more than 6 months apart and were classified as Group A. Double primary cancers were considered synchronous when the interval between diagnosis of the two tumors was less than or equal to 6 months and was classified as group B.

RESULTS

In this study, the incidence of double primary cervical cancer and ovarian cancer accounted for 0.39% of primary cervical cancer and 0.24% of primary ovarian cancer in the same period. 80% of patients developed second cancer within 107 months of their first cancer being diagnosed. Compared with non-synchronous cancer, synchronous cancer is mainly characterized by simultaneous bilateral ovarian involvement and early clinical stage, but highly malignant, high lymph node metastasis rate, and poor prognosis.

CONCLUSION

Most patients developed second cancer within 107 months of their first cancer being diagnosed. Age at diagnosis, bilateral ovarian invasion, the interval between diagnoses, pathological type and stage of ovarian cancer, and grade of cervical cancer are important factors affecting survival, which still needs to be confirmed by more extensive studies in future.

DNA Methylation Signature of Synchronous Endometrioid Endometrial and Ovarian Carcinomas

Next-generation sequencing (NGS) studies have demonstrated that co-occurring sporadic endometrioid endometrial carcinoma (EEC) and endometrioid ovarian carcinoma (EOC) are clonally related, suggesting that they originate from a single primary tumor. Despite clonality, synchronous EEC and EOC when diagnosed at early stage behave indolently, similar to isolated primary EEC or isolated primary EOC. In the present study, we compared the DNA methylation signatures of co-occurring EEC and EOC with those of isolated primary EEC and isolated primary EOC. We also performed targeted NGS to assess the clonal relatedness of 7 co-occurring EEC and EOC (4 synchronous EEC and EOC and 3 metastatic EEC based on pathologic criteria). NGS confirmed a clonal relationship in all co-occurring EEC and EOC. DNA methylation profiling showed distinct epigenetic signatures of isolated primary EEC and isolated primary EOC. Endometrial tumors from co-occurring EEC and EOC clustered with isolated primary EEC while their ovarian counterparts clustered with isolated primary EOC. Three co-occurring EEC and EOC cases with peritoneal lesions showed a closer epigenetic signature and copy number variation profile between the peritoneal lesion and EOC than EEC. In conclusion, synchronous sporadic EEC and EOC are clonally related but demonstrate a shift in DNA methylation signatures between ovarian and endometrial tumors as well as epigenetic overlap between ovarian and peritoneal tumors. Our results suggest that tumor microenvironment in the ovary may play a role in epigenetic modulation of metastatic EEC.

Uterine involvement in epithelial ovarian cancer and its risk factors

Background

Epithelial ovarian cancer (EOC) is an extremely aggressive and lethal carcinoma. Specific data that identify high-risk groups with uterine involvement are not available. Thus, this study aimed to evaluate a gross number of women with EOC to obtain the frequency of uterine involvement and its risk factors.

Methods

This retrospective observational study was conducted on 1900 histologically confirmed EOC women, diagnosed and treated in our tertiary hospital from March 2009 to September 2020. Data including their demographic, medical and pathological findings were collected.

Results

From 1900 histologically confirmed EOC women, 347 patients were eligible for participations. The mean age of study patients was 51.31 ± 11.37 years with the age range of 25 to 87 years. Uterine involvement was detected in 49.6% (173) of the patients either macroscopic (47.4%) or microscopic (52.6%) types.

Uterine involvement was significantly associated with having AUB (P-value = 0.002), histological type of ovary tumor (P-value < 0.001), ovarian cancer stage (P-value < 0.001), and abnormal CA-125 concentration (P-value = 0.004).

Compared to the other study patient, the patients with metastatic uterine involvement had significantly higher stage (p-value< 0.001), higher grade of ovary tumor (p-value = 0.008), serous histological type (p-value< 0.001), and a higher level of CA-125 concentration (p-value< 0.001).

on the other hand, the patients with synchronous uterine cancer were significantly younger (p-value = 0.013), nulliparous (p-value< 0.001), suffered from AUB symptoms (p-value< 0.001) and had endometroid histological type (p-value = 0.010) of ovary cancer in comparison to other study patients.

Conclusion

Considering the high prevalence of uterine involvement in EOC patients, ultrasound evaluation and/or endometrium biopsy assessment should be done before planning any treatment.

Synchronous primary endometrial and ovarian cancers: how to diagnose, differentiate and treat in the light of recent available literature data

SEO – synchronous endometrial ovarian cancer is a well-known phenomenon, which has for years been managed as two primary independent cancers. The results of recent molecular studies, especially next-generation sequencing, suggest that the condition should be regarded as a continuum, with its origin probably lying in the endometrium or endometrial foci. It has been found that 0.7% to 1.0% of endometriosis patients may develop malignant lesions. Although SEO is being increasingly studied, diagnostics and treatment still leave many questions. The most important thing is to improve the diagnosis with rapid and simple detection. A few molecular methods are already known, but genetic diagnostic, still remains unclear. Old criteria implemented by Scully in 1998 should be nowadays complemented by immunohistochemical staining of estrogen and progestin receptors, bcl2 antibodies and molecular analyses of genes: B-catenin, PTEN, KRAS, TP53, PIK3CA and microsatellite instability. Will genetic diagnostics preserve fertility in young patients with SEO? This paper reviews relevant literature to determine a strategy for distinguishing between SEO and metastatic cancers, and presents management options for patients with SEO.

Mutation Spectra of the MRN (MRE11, RAD50, NBS1/NBN) Break Sensor in Cancer Cells

Simple Summary

A DNA double strand break cuts a chromosome in two and is one of the most dangerous forms of DNA damage. Improper repair can lead to various chromosomal re-arrangements that have been detected in almost all cancer cells. A complex of three proteins (MRE11, RAD50, NBS1 or NBN) detects chromosome breaks and orchestrates repair processes. Mutations in these “break sensor” genes have been described in a multitude of cancers. Here, we provide a comprehensive analysis of reported mutations from data deposited on the Catalogue of Somatic Mutations in Cancer (COSMIC) archive. We also undertake an evolutionary analysis of these genes with the aim to understand whether these mutations preferentially accumulate in conserved residues. Interestingly, we find that mutations are overrepresented in evolutionarily conserved residues of RAD50 and NBS1/NBN but not MRE11.

Abstract

The MRN complex (MRE11, RAD50, NBS1/NBN) is a DNA double strand break sensor in eukaryotes. The complex directly participates in, or coordinates, several activities at the break such as DNA resection, activation of the DNA damage checkpoint, chromatin remodeling and recruitment of the repair machinery. Mutations in components of the MRN complex have been described in cancer cells for several decades. Using the Catalogue of Somatic Mutations in Cancer (COSMIC) database, we characterized all the reported MRN mutations. This analysis revealed several hotspot frameshift mutations in all three genes that introduce premature stop codons and truncate large regions of the C-termini. We also found through evolutionary analyses that COSMIC mutations are enriched in conserved residues of NBS1/NBN and RAD50 but not in MRE11. Given that all three genes are important to carcinogenesis, we propose these differential enrichment patterns may reflect a more severe pleiotropic role for MRE11.

The Origin and Pathogenesis of Endometriosis

Recent molecular genetic findings on endometriosis and normal endometrium suggest a modified model in which circulating epithelial progenitor or stem cells intended to regenerate uterine endometrium after menstruation may become overreactive and trapped outside the uterus. These trapped epithelium-committed progenitor cells form nascent glands through clonal expansion and recruit polyclonal stromal cells, leading to the establishment of deep infiltrating endometriosis. Once formed, the ectopic tissue becomes subject to immune surveillance, resulting in chronic inflammation. The inflammatory response orchestrated by nuclear factor-κB signaling is exacerbated by aberrations in the estrogen receptor-β and progesterone receptor pathways, which are also affected by local inflammation, forming a dysregulated inflammation-hormonal loop. Glandular epithelium within endometriotic tissue harbors cancer-associated mutations that are frequently detected in endometriosis-related ovarian cancers. In this review, we summarize recent advances that have illuminated the origin and pathogenesis of endometriosis and have provided new avenues for research that promise to improve the early diagnosis and management of endometriosis.

Synchronous recurrence of concurrent colon adenocarcinoma and dedifferentiated liposarcoma

A 62-year-old man presented with concurrent sigmoid colon adenocarcinoma and small bowel mesenteric dedifferentiated liposarcoma. Following surgical resection of the colon cancer, complete excision of the mesenteric sarcoma and adjuvant folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy, the patient demonstrated no radiological evidence of disease for more than 2 years. The patient then developed synchronous recurrence of both cancers: the colon cancer metastasised to the liver and a pelvic lymph node, and the liposarcoma recurred in the original location. The patient underwent additional chemotherapy with complete response of the metastatic colon cancer and stable disease for the liposarcoma. The recurrent mesenteric tumour was subsequently resected. Although concurrent cancers have been reported, this unique case of synchronous recurrence raises interesting hypotheses regarding host-tumour interaction and immune surveillance.

Comparative genetic profiling aids diagnosis and clinical decision making in challenging cases of CUP syndrome

Cancer of unknown primary (CUP) denotes cancer cases where metastatic spread is histologically confirmed, but no respective primary tumor can be identified. The challenging diagnosis of CUP is further complicated in cases with previously identified malignancies or with dubious clonal relationship between metastatic sites due to ambiguous histology. Our study aims at elucidating clonal relationships by comparing the respective mutational spectra. Targeted next-generation sequencing (NGS) employing formalin-fixed and paraffin-embedded (FFPE) tumor tissue was performed on 174 consecutive CUP patients. Among these, 43/174 (24.7%) patients had a documented prior malignancy. Data on pairwise targeted NGS testing to address clonal relationships between the previous malignancy and the presumed CUP (n = 11) or between different CUP metastatic sites (n = 7) was available in 18 patients. NGS could clarify clonal relationships in 16/18 cases. Among the 11 CUP patients with antecedent malignancies, four cases were clonally independent of the previous malignancy but harbored deleterious germline mutations in BRCA/BAP1/ATM genes. Seven CUP cases were clonally related to the antecedent malignancy, changing the CUP diagnosis to relapse of the prior malignancy. In the seven CUP cases, with doubtfully related metastatic sites, NGS confirmed clonal relationship in five cases and was inconclusive in two. In conclusion, NGS proved an efficient tool to elucidate clonal relationships in clinically challenging CUP cases. Our study cautions against a premature diagnosis of CUP. Relapses of antecedent malignancies should be carefully considered. CUPs clonally independent from the antecedent malignancy should raise a red flag of a potential cancer-predisposing germline mutation.

Diagnostic efficacy of MRI for pre-operative assessment of ovarian malignancy in endometrial carcinoma: A decision tree analysis

AIM

Accurate preoperative assessment of ovarian malignancy in endometrial carcinoma helps in determining the decision to preserve the ovaries in individualized treatment. This study adopted decision tree method to evaluate the diagnostic efficiency of pelvic MRI and clinical data of patients for preoperative identification of endometrial carcinoma-combined ovarian malignancy (EC-OM).

MATERIAL AND METHODS

This retrospective study included a total of 801 patients, and postoperative pathological examinations identified 58 EC-OM group and 743 endometrial carcinoma cases without ovarian malignancy (EC group). Diagnostic efficiency of pelvic MRI in EC-OM was calculated by comparing the clinical data and imaging features of patients in the two groups. Decision tree analysis was performed to screen out associative indexes and establish a diagnostic model for EC-OM.

RESULTS

Pelvic MRI showed that, EC-OM group showed deeper invasion into the myometrium, and higher percentages of patients with cervical or cornual involvement, or metastasis of lymph nodes or peritoneum than EC group (P = 0.00). Preoperative pelvic MRI showed a sensitivity of 51.72% and a specificity of 99.87% when detecting ovarian malignancy in endometrial carcinoma. Decision tree model obtained a sensitivity of 89.66%, with an AUC (area under ROC curve) of 0.949 (95% CI 0.906, 0.993, P < 0.001).

CONCLUSION

Decision tree analysis based on pelvic MRI and clinical data of patients showed that the detection rate of ovarian malignancy could be increased for patients with endometrial carcinoma.

Synchronous endometrioid endometrial and ovarian carcinomas are biologically related: A clinico-pathological and molecular (next generation sequencing) study of 22 cases

The criteria for distinction between independent primary tumors and metastasis from one site to the other in synchronous endometrioid endometrial and ovarian carcinoma (SEO) has been a matter of dispute for a long time. In our study we performed a comprehensive clinico-pathological and molecular analysis of 22 cases of SEO. Based on conventional clinico-pathological criteria the cases were classified as independent primary tumors (10 cases) and metastasis from one location to the other (12 cases). All tumors were analyzed by NGS with a panel of 73 genes (219 kbp). Clonal origin was confirmed in all cases by at least one shared mutation in PTEN, AKT1, PIK3CA, KRAS, TP53 and ARID1A. Two patients carried germline pathogenic mutation in cancer-predisposing genes BRCA1 or BARD1. Microsatellite instable phenotype was detected in 5/22 (22.7%) SEO, but in one case only in the endometrial tumor. In conclusion, our results showed that all 22 SEOs were clonally related, irrespectively of their clinico-pathological features. Even low grade and low stage tumors classified as independent primaries, according to the conventional morphological criteria, have a clonal origin. From the practical point of view, only the conventional morphological criteria should be used for the classification (staging) of these tumors. However, molecular profiling of these tumors may have prognostic and predictive meaning.

Potential for Mitochondrial DNA Sequencing in the Differential Diagnosis of Gynaecological Malignancies

In the event of multiple synchronous gynecological lesions, a fundamental piece of information to determine patient management, prognosis, and therapeutic regimen choice is whether the simultaneous malignancies arise independently or as a result of metastatic dissemination. An example of synchronous primary tumors of the female genital tract most frequently described are ovarian and endometrial cancers. Surgical findings and histopathological examination aimed at resolving this conundrum may be aided by molecular analyses, although they are too often inconclusive. High mitochondrial DNA (mtDNA) variability and its propensity to accumulate mutations has been proposed by our group as a tool to define clonality. We showed mtDNA sequencing to be informative in synchronous primary ovarian and endometrial cancer, detecting tumor-specific mutations in both lesions, ruling out independence of the two neoplasms, and indicating clonality. Furthermore, we tested this method in another frequent simultaneously detected gynecological lesion type, borderline ovarian cancer and their peritoneal implants, which may be monoclonal extra-ovarian metastases or polyclonal independent masses. The purpose of this review is to provide an update on the potential use of mtDNA sequencing in distinguishing independent and metastatic lesions in gynecological cancers, and to compare the efficiency of molecular analyses currently in use with this novel method.