Complexity of glandular architecture should be reconsidered in the classification and management of endometrial hyperplasia

Integrated histological parameters define prognostically relevant groups in atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia

OBJECTIVE

To assess the risk of endometrial carcinoma following a diagnosis of atypical hyperplasia/endometrioid intraepithelial neoplasia by endometrial biopsy, stratified based on integrated histological parameters.

METHODS

All women with atypical hyperplasia/endometrioid intraepithelial neoplasia undergoing hysterectomy within 1 year of diagnosis without progestin treatment were included. Patients were subdivided into three study groups, based on two criteria: (a) grade of nuclear atypia and (b) foci (<2 mm) of confluent glands with no intervening stroma: low-grade, high-grade, and confluent glands. The rate of endometrial carcinoma on the subsequent hysterectomy was assessed in each study group, and differences between study groups were assessed using Fisher's exact test, with a significant p value <0.05. Reproducibility was assessed by using Cohen's κ.

RESULTS

Ninety-six patients were included. Overall, 36 of 96 patients (37.5%) had endometrial carcinoma on the subsequent hysterectomy. The number of endometrial carcinomas was 4 of 42 (9.5%) in the low-grade group, 14 of 28 (50.0%) in the high-grade group, and 18 of 26 (69.2%) in the confluent glands group. The rate of endometrial carcinoma was significantly higher in the high-grade group than in the low-grade group (p<0.001), whereas it did not significantly differ between the high-grade group and the confluent glands group (p=0.176). The reproducibility among pathologists was moderate for low-grade versus high-grade (κ=0.58) and substantial for confluent glands versus low-grade (κ=0.63) and high-grade (κ=0.63).

CONCLUSION

Atypical hyperplasia/endometrioid intraepithelial neoplasia can be stratified into prognostically relevant groups based on integrated histological parameters, with a possible major impact on patient management.

Conservative re-treatment of women with atypical endometrial hyperplasia and early endometrial carcinoma: We can hope, at least

BACKGROUND

In women with recurrent disease who were conservatively treated for atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EEC), the reasons why conservative treatment was chosen persist and outcomes of performing a conservative re-treatment are unclear, as pooled estimates on oncologic outcomes of such a re-treatment are lacking.

OBJECTIVES

To provide pooled estimates of oncologic outcomes of conservative re-treatment in women with recurrent AEH or EC.

SEARCH STRATEGY

A systematic review and meta-analysis was performed by searching six electronic databases from their inception to March 2022.

SELECTION CRITERIA

Studies that allowed extraction of data about oncologic outcomes of conservative re-treatment of women with recurrent AEH and EEC after a conservative treatment.

DATA COLLECTION AND ANALYSIS

Pooled prevalence of complete response (CR), poor response (PR), and recurrence after conservative re-treatment was calculated.

MAIN RESULTS

Fifteen studies (12 retrospective and 3 prospective) with 492 women (42.1% AEH and 57.9% EEC) were included in the systematic review, and 10 studies (8 retrospective and 2 prospective) were suitable for the meta-analysis. Pooled prevalence was 85.3% (95% confidence interval [CI] 77.0%-91.0%) for CR, 14.7% (95% CI 9.0%-23.0%) for PR, and 40.4% (95% CI 15.5%-71.4%) for recurrence.

CONCLUSIONS

Conservative re-treatment in AEH or EC recurrent women has a high CR rate and acceptable recurrence rate that might allow it to be considered a safe and viable option, at least as a first round of conservative treatment. Women with an unsatisfied desire for motherhood or with high surgical risk might avoid hysterectomy and attempt childbearing or spare high-risk surgery.

Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Magnetic resonance imaging (MRI) represents the second-line diagnostic method after ultrasound for the assessment of uterine masses.

OBJECTIVES

To assess the accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching five electronic databases from their inception to June 2023.

SELECTION CRITERIA

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma, which also comprehended a preoperative MRI evaluation of the uterine mass.

DATA COLLECTION AND ANALYSIS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic of MRI in differentiating uterine leiomyomas and sarcomas were calculated as individual and pooled estimates, with 95% confidence intervals (CI).

RESULTS

Eight studies with 2495 women (2253 with uterine leiomyomas and 179 with uterine sarcomas), were included. MRI showed pooled sensitivity of 0.90 (95% CI 0.84-0.94), specificity of 0.96 (95% CI 0.96-0.97), positive likelihood ratio of 13.55 (95% CI 6.20-29.61), negative likelihood ratio of 0.08 (95% CI 0.02-0.32), diagnostic odds ratio of 175.13 (95% CI 46.53-659.09), and area under the curve of 0.9759.

CONCLUSIONS

MRI has a high diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas.

Association of Urinary Levels of Estrogens and Estrogen Metabolites with the Occurrence and Development of Endometrial Hyperplasia Among Premenopausal Women

Endometrial cancer is known to be an estrogen-dependent cancer, and it is believed that exposure to estrogens increases the risk of developing endometrial cancer in the absence of progesterone. Estrogens and estrogen metabolites may help to predict the risk of endometrial hyperplasia (EH) with atypia. Estrogens and estrogen metabolites were measured by high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS) in the first morning urine sample collected from 150 patients with EH and 50 healthy premenopausal women in the study. In healthy premenopausal women, the level of 16α-hydroxyestrone (16α-OHE1) in the overweight group was significantly higher than that in the lean group (p < 0.05). The levels of 4-hydroxyestradiol (4-OHE2) and 16α-OHE1 were elevated in the AEH group as compared to that in the control group (p < 0.05). Overweight is related to EH incidence as it causes an imbalance of estrogen metabolites. This study provides identifies potential biomarkers for estrogen-induced AEH.

Risk factors of endometrial cancer in patients with endometrial hyperplasia: implication for clinical treatments

Background

Endometrial hyperplasia (EH) is commonly-seen in the patients with endometrial cancer (EC), we aimed to evaluated the risk factors of EC in patients with EH, to provide evidence to the clinical prevention and treatment of EC.

Methods

This study was a retrospective study design. EH patients confirmed by pathological examinations and treated with hysterectomy in our hospital from June 1, 2018 to February 28, 2021 were included. The clinical characteristics of EC and no-EC patients were compared and analyzed. Logistics regression analyses were conducted to evaluate the risk factors of EC in patients with EH.

Results

A total of 228 EH patients were included, the incidence of EC in the EH patients was 31.58%. There were significant differences in the age, BMI, diabetes, hypertension and pathology of EH between EC and no EC groups (all P < 0.05), no significant differences in the hyperlipidemia, preoperative CA₁₂₅, number of deliveries, menopause and endometrial thickness between EC and no EC groups were found (all P > 0.05). Logistic regression analyses indicated that age > 50 y (OR 3.064, 95% CI 1.945–5.931), BMI ≥ 25 kg/m² (OR 2.705, 95% CI 1.121–3.889), diabetes (OR 3.049, 95% CI 1.781–5.114), hypertension (OR 2.725, 95% CI 1.108–3.431) and severe hyperplasia (OR 3.181, 95% CI 1.496–4.228) were the risk factors of EC in patients with EH (all P < 0.05).

Conclusions

The risk of EC in EH patients is high, especially for those patients with age > 50 y, BMI ≥ 25 kg/m², diabetes, hypertension and severe hyperplasia, special attentions should be paid for occurrence of EC and early diagnosis and early treatment are needed for those patients.

Immunophenotype of Atypical Polypoid Adenomyoma of the Uterus: Diagnostic Value and Insight on Pathogenesis

Atypical polypoid adenomyoma (APA) is a rare uterine lesion constituted by atypical endometrioid glands, squamous morules, and myofibromatous stroma. We aimed to assess the immunophenotype of the 3 components of APA, with regard to its pathogenesis and its differential diagnosis. A systematic review was performed by searching electronic databases from their inception to January 2019 for immunohistochemical studies of APA. Thirteen studies with 145 APA cases were included. APA glands appeared analogous to atypical endometrial hyperplasia (endometrioid cytokeratins pattern, Ki67≤50%, common PTEN loss, and occasional mismatch repair deficiency); the prominent expression of hormone receptors and nuclear β-catenin suggest that APA may be a precursor of "copy number-low," CTNNB1-mutant endometrial cancers. Morules appeared as a peculiar type of hyperdifferentiation (low KI67, nuclear β-catenin+, CD10+, CDX2+, SATB2+, p63-, and p40-), analogous to morular metaplasia in other lesions and distinguishable immunohistochemically from both conventional squamous metaplasia and solid cancer growth. Stroma immunphenotype (low Ki67, α-smooth-muscle-actin+, h-caldesmon-, CD10-, or weak and patchy) suggested a derivation from a metaplasia of normal endometrial stroma. It was similar to that of nonatypical adenomyoma, and different from adenosarcoma (Ki67 increase and CD10+ in periglandular stroma) and myoinvasive endometrioid carcinoma (h-caldesmon+ in myometrium and periglandular fringe-like CD10 pattern).

Stanford parameters stratify the risk of recurrence in gynecologic smooth muscle tumors of uncertain malignant potential

Smooth muscle tumor of uncertain malignant potential (STUMP) is an ill-defined category of neoplasms, which represent a diagnostic challenge. We aimed to assess whether the Stanford parameters, that is, high mitotic index (≥10/10HPF), significant atypia (moderate-to-severe), and coagulative tumor cell necrosis (CTCN), even when focal or ambiguous, may be used to stratify the risk of recurrence in gynecological smooth muscle tumor of uncertain malignant potential (STUMP). Electronic databases were searched from their inception to October 2019. All studies assessing the Stanford parameters in gynecological STUMP series were included. STUMPs were subdivided according to the presence of the three Stanford parameters: high mitotic index, significant atypia, and CTCN. A Kaplan-Meier survival analysis was performed for recurrence-free survival; hazard ratio (HR) was calculated in each category. Fourteen studies with 219 STUMPs were included. In 15.5% of cases, none of the three Stanford parameters were present, with a recurrence risk of 5.9%; 2.7% of cases showed high mitotic index alone, with a recurrence risk of 0% (HR = not calculable); 43.8% of cases showed significant atypia alone, with a recurrence risk of 18.7% (HR = 3.3; p = 0.012); 26.5% of cases showed CTCN alone, with a recurrence risk of 17.2% (HR = 3.1; p = 0.029); and 11.4% of cases showed at least two Stanford parameters, with a recurrence risk of 32% (HR = 7.5; p = 0.003). Stanford parameters may stratify the risk of recurrence of STUMP. Significant atypia and CTCN, but not high mitotic index, may be stand-alone risk factors for recurrence in STUMP. The presence of at least two Stanford parameters, even if equivocal (e.g., uncertain or focal CTCN, focal significant atypia, mitotic index around 10/10HPF), might still be enough to support a diagnosis of leiomyosarcoma. Further studies are necessary in this field.

Mismatch repair-deficiency specifically predicts recurrence of atypical endometrial hyperplasia and early endometrial carcinoma after conservative treatment: A multi-center study

OBJECTIVE

Deficient expression of mismatch repair proteins (MMR) has been suggested to be a predictor of resistance of atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EEC) to conservative treatment.

AIMS

To assess the predictive value of MMR immunohistochemistry in patients conservatively treated for AEH and EEC, and to calculate its predictive accuracy.

MATERIALS AND METHODS

All patients with AEH or EEC conservatively treated with hysteroscopic resection plus progestins in two referral centers from January 2004 to July 2019 were retrospectively assessed. Immunohistochemistry for MMR was ad hoc performed. Study outcomes were: (i) the association of a deficient immunohistochemical expression of MMR with resistance and recurrence of AEH and EEC after conservative treatment, and (ii) the accuracy of MMR immunohistochemistry in predicting the outcome of conservative treatment. Relative risk (RR) for the associations, and sensitivity, specificity and area under the curve (AUC) on receiver operating characteristic curve for the predictive accuracy were calculated.

RESULTS

Sixty-nine women, (47 AEH and 22 EEC) were included; deficient MMR expression was observed in 8.7% of cases. Resistance to conservative treatment was more common in MMR-deficient than MMR-proficient cases (33.3% vs 15.9%; RR = 2.1), but with no statistical significance (p = 0.2508). On the other hand, recurrence was significantly more common in MMR-deficient than MMR-proficient cases (100% vs 26.4%; RR = 3.8; p < 0.0001). In predicting recurrence, a deficient immunohistochemical expression of MMR showed sensitivity = 22.2%, specificity = 100%, and AUC = 0.61.

CONCLUSION

Deficient MMR immunohistochemical expression does not imply resistance of AEH/EEC to conservative treatment. On the other hand, MMR-deficiency appears as a highly specific predictor of recurrence of AEH/EEC after initial regression.

Prognostic value of Bcl2 and p53 in Hodgkin lymphoma: A systematic review and meta-analysis

AIMS

Several studies suggested that high expression of Bcl2 and/or p53 in Hodgkin/Reed-Sternberg cells is an unfavorable prognostic factor in Hodgkin lymphoma (HL). However, results in this field appear contrasting. We aimed to assess the prognostic value of p53 and Bcl2 in HL through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from January 2000 to December 2020 for all studies assessing the prognostic value of p53 and Bcl2 in HL. The association of high p53 or Bcl2 expression with overall survival (OS), progression-free survival (PFS) and response to treatment was assessed by using hazard ratio (HR) and odds ratio (OR).

RESULTS

Eighteen studies were included. Bcl2 overexpression was significantly associated with decreased PFS (HR = 2.202; p < 0.0001), while the associations with decreased OS (HR = 1.565; p = 0.257) and refractoriness to treatment (OR = 0.482; p = 0.068) were non-significant. p53 overexpression was not significantly associated with refractoriness to treatment (OR = 0.904; p = 0.155); the analysis of OS and PFS was not feasible, but published data suggested the absence of a significant association.

CONCLUSIONS

In HL, Bcl2 overexpression is associated with decreased PFS, while a significant prognostic value could not be demonstrated for p53. Defining optimal criteria for interpreting Bcl2 and p53 immunostaining is necessary to draw definitive conclusions.

Factors associated with endometrial cancer and hyperplasia among middle-aged and older Hispanics

OBJECTIVE

While disparities in endometrial hyperplasia and endometrial cancer are well documented in Blacks and Whites, limited information exists for Hispanics. The objective is to describe the patient characteristics associated with endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer, and assess factors contributing to racial/ethnic differences in disease outcomes.

METHODS

This single-center, retrospective study included women aged ≥50 years with ≥ two encounters for endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer between 2012 and 2016. Multivariate logistic regression models evaluated the predictors of endometrial cancer and hyperplasia.

RESULTS

We included 19,865 women (4749 endometrial hyperplasia symptoms, 71 endometrial hyperplasias with atypia, 201 endometrial cancers) with mean age of 60.45 years (SD 9.94). The odds of endometrial hyperplasia symptoms were higher in non-Hispanic Blacks (Odds Ratio [OR] 1.56, 95% Confidence Interval [CI] 1.20-1.72), Hispanics (OR 1.35, 95% CI 1.22-1.49), family history of female cancer (OR 1.25, 95% CI 1.12-1.39), hypertension (OR 1.24, 95% CI 1.14-1.35), and birth control use (OR 1.29, 95% CI 1.15-1.43). Odds of endometrial cancer and atypical hyperplasia increased for ages 60-64 (OR 7.95, 95% CI 3.26-19.37; OR 3.66, 95% 1.01-13.22) and being obese (OR 1.61, 95% CI 1.08-2.41; OR: 6.60, 95% CI 2.32-18.83). Odds of endometrial cancer increased with diabetes (OR 1.68, 95% CI 1.22-2.32).

CONCLUSION(S)

Patients with obesity and diabetes had increased odds of endometrial cancer and hyperplasia with atypia. Further study is needed to understand the exogenous estrogen effect contributing to the increased incidence among Hispanics.

HIV prevalence in primary central nervous system lymphoma: A systematic review and meta-analysis

HIV infection is considered a major risk factor for primary central nervous system lymphoma (PCNSL). However, the percentage of PCNSL that occurs in HIV + patients is not well defined. We aimed to assess the prevalence of HIV infection in patients with PCNSL through a systematic review and meta-analysis. Electronic databases were searched for studies assessing the presence of HIV infection in series of patients with PCNSL. Pooled prevalence of HIV infection in PCNSL was calculated, with a subgroup analysis based on the geographic area. Twenty-seven studies with 6422 patients were included. Overall, pooled prevalence of HIV infection among PCNSL patients was 6.1 % with high heterogeneity. In the subgroup analysis, pooled prevalence was 3.6 % in India with low heterogeneity, 30.2 % (overall) and 16.5 % (after 2000) in the USA with high heterogeneity, 5.7 % in Europe with high heterogeneity, 2.2 % in East Asia with null heterogeneity, 7.3 % in South America with moderate heterogeneity. In conclusion, only a minor part of PCNSL occurs in patients with HIV. The results stratified by geographic area reflect the different prevalence of HIV infection in the general population, except for India, probably due to the shorter life expectancy of HIV + patients.

Clinical Predictive Factors of Response to Treatment in Patients Undergoing Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer

Purpose: Predictive markers of response to conservative treatment of atypical endometrial hyperplasia (AEH) or early endometrial cancer (EEC) are still lacking. We aimed to assess clinical predictive factors of response to conservative treatment of AEH and EEC. Methods: All patients with AEH or EEC conservatively treated from January 2007 to June 2018 were retrospectively assessed. The associations between 23 clinical factors and outcomes of response to treatment were assessed with standard univariate analyses and multivariate logistic regression (significant p-value <0.05). The primary outcome was the association of each clinical factor with treatment failure (i.e., no regression or relapse of the disease). Secondary outcomes were the associations of each clinical factor with: (1) no regression, (2) relapse, or (3) pregnancy after treatment. Results: Forty-three women, 37 (86%) with AEH and 6 (14%) with EEC were included. At univariate analyses, treatment failure was associated with longer menstrual cycle (p = 0.002), infrequent menstrual bleeding (p = 0.04), and a diagnosis of EEC instead of AEH (p = 0.008). Among the secondary outcomes, no regression was associated with infrequent menstrual bleeding (p = 0.04), and a diagnosis of EEC instead of AEH (p < 0.001), while relapse was associated with longer menstrual cycles (p = 0.007). At multivariate analyses, odds ratio for treatment failure was 4.54 (95% confidence interval [CI], 0.24-84.4) for a diagnosis of EEC instead of AEH (p = 0.3), and 2.10 (95% CI, 1.03-4.29) for longer menstrual cycles (p = 0.042), while infrequent menstrual bleeding perfectly predicted treatment failure. Conclusions: Longer menstrual cycles and infrequent menstrual bleeding appear as independent predictive factors for conservative treatment failure in AEH and EEC. Further and larger studies are necessary to confirm these findings.

Involvement of Helicobacter Pylori in Ocular Adnexa Lymphoma

Helicobacter pylori has been proposed as a possible etiologic factor of ocular adnexa lymphoma (OAL), although with conflicting results. To assess the involvement of H. pylori in OAL, as (1) H. pylori DNA positivity on OAL specimens, and (2) prevalence of H. pylori gastric infection in patients with OAL. A systematic review of studies assessing H. pylori in patients with OAL was conducted by searching electronic databases from their inception to May 2019. Pooled positivity for H. pylori in OAL specimens detected by polymerase chain reaction, and pooled prevalence of H. pylori gastric infection, were calculated with 95% confidence interval (CI). Eleven studies with 308 patients were included. Pooled positivity for H. pylori was 16.8% in all OALs and 22.7% in MALT OAL, with high heterogeneity among studies. Pooled prevalence of H. pylori gastric infection in patients with OAL was 34.7%, with low statistical heterogeneity. In conclusion, H. pylori seems to be involved in a subset of OAL, but the heterogeneity found needs to be investigated in further studies. The prevalence of H. pylori gastric infection in patients with OAL does not seem to differ from that of the general population.

Diagnostic accuracy of p53 immunohistochemistry as surrogate of TP53 sequencing in endometrial cancer

Aberrant p53 immunohistochemical expression is used to identify the copy-number-high/TP53-mutant subgroup of endometrial cancer (EC). We aimed to determine the diagnostic accuracy of p53 immunohistochemistry as surrogate for TP53 sequencing through a systematic review and meta-analysis. Electronic databases were searched from their inception to June 2019. All studies assessing p53 expression and TP53 mutations in EC were included. Diagnostic accuracy was assessed based on area under the curve (AUC). Immunohistochemical criteria used to define aberrant p53 expression were "overexpression" and "overexpression or complete absence". Subgroup analysis was based on the sequencing technique adopted (Polymerase Chain Reaction + sequencing, or next generation sequencing, NGS). Thirteen observational studies with 727 endometrial cancers were included. Both "overexpression" and "overexpression or complete absence" showed high diagnostic accuracy (AUC = 0.9088 and 0.9030, respectively). The subgroup with "overexpression" and NGS showed the best results, with very high diagnostic accuracy (AUC = 0.9927). In conclusion, immunohistochemistry for p53 is a highly accurate surrogate of TP53 sequencing. Overexpression of p53 in ≥70-80% showed the best accuracy in predicting TP53 mutations. Further studies in this field should adopt optimized immunohistochemical procedures and take into account less common p53 patterns (e.g. cytoplasmic expression).

Sjögren Syndrome in Primary Salivary Gland Lymphoma

OBJECTIVES

Sjögren syndrome (SS) is considered as a major etiologic factor for primary salivary gland lymphoma (SGL). However, the percentage of SGL that is caused by SS (and thus the real impact of SS on SGL epidemiology) is unclear. We aimed to assess the prevalence of SS in patients with SGL through a systematic review and meta-analysis.

METHODS

Electronic databases were searched for studies assessing the presence of SS in patients with SGL. Pooled prevalence of SS in SGL was calculated, with a subgroup analysis based on histotype (mucosa-associated lymphoid tissue [MALT] vs non-MALT).

RESULTS

Sixteen studies with 665 SGLs were included. Pooled prevalence of SS in SGL was 18.2%, with high heterogeneity among studies. In MALT SGL, the prevalence of SS was 29.5%, with moderate heterogeneity. In non-MALT SGL, the prevalence of SS was 0%, with null heterogeneity.

CONCLUSIONS

SS seems to be responsible for a significant but minor portion of SGLs. SS appears involved in MALT-type SGL but not in other histotypes.

Impact of endometrial carcinoma histotype on the prognostic value of the TCGA molecular subgroups

BACKGROUND

The Cancer Genome Atlas (TCGA) identified four prognostic subgroups of endometrial carcinoma: copy-number-low/p53-wild-type (p53wt), POLE-mutated/ultramutated (POLEmt), microsatellite-instability/hypermutated (MSI), and copy-number-high/p53-mutated (p53mt). However, it is still unclear if they may be integrated with the current histopathological prognostic factors, such as histotype.

OBJECTIVE

To assess the impact of histotype on the prognostic value of the TCGA molecular subgroups of endometrial carcinoma.

METHODS

A systematic review and meta-analysis was performed by searching 7 electronic databases from their inception to April 2019 for studies assessing prognosis in all TCGA subgroups of endometrial carcinoma. Pooled hazard ratio (HR) for overall survival (OS) was calculated in two different groups ("all-histotypes" and "endometrioid"), using p53wt subgroup as reference standard; HR for non-endometrioid histotypes was calculated indirectly. Disease-specific survival and progression-free survival were assessed as additional analyses.

RESULTS

Six studies with 2818 patients were included. In the p53mt subgroup, pooled HRs for OS were 4.322 (all-histotypes), 2.505 (endometrioid), and 4.937 (non-endometrioid). In the MSI subgroup, pooled HRs were 1.965 (all-histotypes), 1.287 (endometrioid), and 6.361 (non-endometrioid). In the POLEmt subgroup, pooled HRs were 0.763 (all-histotypes), 0.481 (endometrioid), and 2.634 (non-endometrioid). Results of additional analyses were consistent for all subgroups except for non-endometrioid POLEmt carcinomas.

CONCLUSION

Histotype of endometrial carcinoma shows a crucial prognostic value independently of the TCGA molecular subgroup, with non-endometrioid carcinomas having a worse prognosis in each TCGA subgroup. Histotype should be integrated with molecular characterization for the risk stratification of patients in the future.

Metabolomics in endometrial cancer diagnosis: A systematic review

INTRODUCTION

Endometrial cancer (EC) is the most common gynecological malignancy in the developed world. The prognosis of EC strongly depends on tumor stage, hence the importance of improving diagnosis. Metabolomics has recently appeared as a promising test for a non-invasive diagnosis of several diseases. Nevertheless, no metabolic marker has been approved for use in the routine practice. We aimed to provide an overview of metabolomics findings in the diagnosis of EC.

MATERIAL AND METHODS

A systematic review was performed by searching eight electronic databases from their inception to October 2019 for studies assessing metabolomics in EC diagnosis. Extracted data included characteristics of patients and EC, serum concentration of metabolites in women with and without EC and its association with EC diagnosis, tumor behavior and pathological characteristics.

RESULTS

Six studies with 732 women (356 cases and 376 controls) were included. Several metabolites were found able to predict the presence of EC, tumor behavior (progression and recurrence) and pathological characteristics (histotype, myometrial invasion and lymph vascular space invasion).

CONCLUSIONS

Metabolomics might be suitable for a non-invasive diagnosis and screening of EC, offering the possibility to predict tumor behavior and pathological characteristics. Further studies are necessary to validate these results.

TCGA molecular subgroups and FIGO grade in endometrial endometrioid carcinoma

BACKGROUND

International Federation of Gynecology and Obstetrics (FIGO) grade is a crucial factor in the current system for the risk stratification of endometrial endometrioid carcinoma (EC). The Cancer Genome Atlas (TCGA) demonstrated four molecular prognostic subgroups for EC: POLE (good prognosis), microsatellite-instable (MSI, intermediate prognosis), copy-number-high (CNH, poor prognosis), and copy-number-low (CNL, variable prognosis).

OBJECTIVE

To assess how the prevalence of the TCGA molecular subgroups changes from low-grade (G1-2) to high-grade (G3) EC, to understand how it may affect the current risk-assessment system.

METHODS

A systematic review and meta-analysis was carried out by searching seven electronic databases from January 2013 to September 2019 for studies assessing the TCGA classification G1-2 and G3 EC. Pooled prevalence of the TCGA subgroups was calculated in EC. The association of each subgroup with grade was assessed using odds ratio (OR), with a significant p value < 0.05.

RESULTS

Nine studies with 3185 patients were included. G3 EC showed significantly higher prevalence of the POLE subgroup (12.1% vs 6.2%; OR = 2.13; p = 0.0001), of the MSI subgroup (39.7% vs 24.7%; OR = 2.15; p = 0.0003) and of the CNH subgroup (21.3% vs 4.7%; OR = 5.25; p < 0.00001), and significantly lower prevalence of the CNL subgroup (28% vs 63.5%; OR = 0.2; p < 0.00001) than G1-2 EC.

CONCLUSION

The prevalence of the TCGA subgroups is not in accordance with the prognostic value of FIGO grade, indicating that the current risk stratification of EC will be heavily affected by molecular signature.

Prevalence of Chlamydia psittaci, Chlamydia pneumoniae, and Chlamydia trachomatis Determined by Molecular Testing in Ocular Adnexa Lymphoma Specimens

OBJECTIVES

To assess the prevalence of Chlamydia psittaci, Chlamydia pneumoniae, and Chlamydia trachomatis in ocular adnexa lymphoma (OAL) determined by molecular testing in different countries and the potential association of Chlamydia infection with mucosa-associated lymphoid tissue (MALT) histotype by performing a systematic review and meta-analysis.

METHODS

Electronic databases were searched for studies assessing the presence of Chlamydia in OAL. Pooled prevalence of the three Chlamydia species was calculated in each country. An odds ratio was calculated for the association between Chlamydia and MALT histotype, with a significant P < .05.

RESULTS

Thirty-seven studies with 1,188 OALs were included. Pooled prevalence of C psittaci, C pneumoniae, and C trachomatis by country was done. Chlamydia infection was significantly associated with MALT histotype (odds ratio, 2.183; P = .027).

CONCLUSIONS

The involvement of C psittaci in OAL is highly variable, with the highest prevalence in Italy and Korea. Chlamydia is associated with MALT histotype.

Hepatitis C virus in MALT-lymphoma of the ocular adnexa

OBJECTIVE

Hepatitis C virus (HCV) has been proposed as a possible etiologic factor in ocular adnexal marginal zone lymphoma (OAML). We aimed to assess the prevalence of HCV infection in patients with OAML through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to August 2019 for studies assessing HCV seroprevalence in patients with OAML. Pooled prevalence of HCV infection was calculated with 95 % confidence interval (CI). Statistical heterogeneity among studies was quantified via the inconsistency index (I²). Funnel plot symmetry was used to assess the risk of bias across studies.

RESULTS

Nine studies with 360 patients were included. Overall pooled prevalence of HCV in OAML was 12.7 %, with low statistical heterogeneity (I² = 17.4 %) and with asymmetrical funnel plot. The studies clustered into two groups: 5 studies (3 from Italy and 2 multicenter with a major Italian contribution) showed a higher HCV prevalence in OAML (15.6 %), while the other 4 (from countries other than Italy) showed a lower prevalence (4.7 %); in both subgroups, statistical heterogeneity was null (I² = 0%) and funnel plot was symmetrical.

CONCLUSION

HCV might be a significant etiologic factor of OAML in Italy.

Histopathological characterization of ProMisE molecular groups of endometrial cancer

BACKGROUND

After the Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) development, endometrial cancer (EC) may be reclassified in four novel prognostic groups: POLE-mutated (POLE-mt), mismatch-repair-deficient (MMR-d), p53-abnormal (p53abn), p53-wild-type (p53wt). However, histopathological characteristics of each ProMisE group are still undefined. Such characterization may be useful to understand how this novel molecular classifier may change the current patient management, reducing over- and undertreatment.

AIM

To provide a histopathological characterization of ProMisE groups of EC, in terms of histological grade (G3 vs G1-2), histotype, lymphovascular space invasion (LVSI), deep myometrial invasion (>50%), lymph node involvement, and European Society for Medical Oncology (ESMO) risk category.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed by searching seven electronic databases from their inception to May 2019, for studies that reported histopathological characteristics of each ProMisE group. Pooled prevalence of each histopathological characteristic of EC in each ProMisE group was calculated.

RESULTS

Four studies with 1171 patients were included in the systematic review, out of which three studies with 912 patients were included in the meta-analysis. Pooled prevalence estimates were: CONCLUSIONS: The histopathological characterization of the ProMisE groups suggests that many patients are currently undertreated or overtreated (especially in the POLE-mt and MMR-d groups).

Clinical features associated with high pathological grade in primary thyroid lymphoma

This study aimed to identify clinical features associated with high pathological grade (HG) in primary thyroid lymphoma (PTL), through a systematic review and meta-analysis. Electronic databases were searched for studies assessing PTL. Extracted data were age, sex, lymph node involvement, symptoms, lymphocytic thyroiditis, serum tumor markers; the association with HG was assessed by using odds ratio (OR), with a significant p-value<0.05. Twenty-four studies with 1916 PTLs were included. HG was significantly associated with age≤55 (OR = 0.54; p < 0.0001); female sex (OR = 1.31; p = 0.02), lymph node involvement (OR = 2.23; p < 0.00001), compressive symptoms (OR = 2.61; p < 0.0001), absence of lymphocytic thyroiditis (OR = 0.45; p = 0.0002), and increased LDH levels (OR = 4.90; p < 0.00001), but not with age>60 (OR = 0.74; p = 0.24), age>70 (OR = 1.16; p = 0.66), and B symptoms (OR = 1.30; p = 0.54). In conclusion, Age≤55, female sex, lymph node involvement, compressive symptoms and absence of lymphocytic thyroiditis may be predictive factors for HG in PTL. On the other hand, B symptoms does not seem to be associated with pathological grade.

Hashimoto Thyroiditis in Primary Thyroid Non-Hodgkin Lymphoma

OBJECTIVES

To assess the prevalence of Hashimoto thyroiditis (HT) in primary thyroid lymphoma (PTL) and whether it differs between mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL).

METHODS

Electronic databases were searched for studies assessing HT prevalence in PTL, based on antithyroid antibodies, clinical history, or pathology. Pooled prevalence of HT and its association with histotype (MALT or DLBCL) were calculated.

RESULTS

Thirty-eight studies with 1,346 PTLs were included. Pooled prevalence results were 78.9% (any HT evidence), 65.3% (antithyroid antibodies), 41.7% (clinical history), and 64% (pathology). HT prevalence was significantly higher in MALT lymphoma than in DLBCL (P = .007) and in mixed DLBCL/MALT than in pure DLBCL (P = .002).

CONCLUSIONS

Overall, 78.9% of patients with PTL have any HT evidence, but only half of these had been clinically followed. The difference in HT prevalence suggests that a subset of DLBCL may not derive from MALT lymphoma.

Congruence Between 1994 WHO Classification of Endometrial Hyperplasia and Endometrial Intraepithelial Neoplasia System

OBJECTIVES

To assess congruence between World Health Organization (WHO) 1994 and endometrial intraepithelial neoplasia (EIN) classification systems of endometrial hyperplasia.

METHODS

Systematic review and meta-analysis were performed by searching electronic databases for studies that classified endometrial hyperplasia according to both WHO 1994 and EIN systems. Congruence was based on the rate of specimens classified as EIN in WHO categories, which should be virtually 0.000 in nonatypical hyperplasia (NAH) and 1.000 in atypical hyperplasia (AH). Subgroup analyses were performed based on architecture complexity.

RESULTS

Eight studies with 1,352 hyperplasias were included. Congruence with EIN criteria was fair in NAH (0.241) and moderate in AH (0.815). Subgroup analyses of NAH showed high congruence in simple NAH (0.065), null in complex NAH (0.517), null in simple AH (0.148), and high in complex AH (0.901).

CONCLUSIONS

WHO 1994 system is not congruent with the EIN system and cannot be directly translated into a dual classification.

Prognostic factors in Krukenberg tumor

BACKGROUND

Krukenberg tumor (KT) is a rare secondary ovarian tumor. Little is known about clinicopathologic factors affecting prognosis in KT.

OBJECTIVE

To assess the prognostic value of clinicopathologic factors in KT through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to February 2019 for studies assessing the association of clinicopathologic factors with overall survival in KT. Pooled hazard ratio (HR) was calculated for each factor; a p value < 0.05 was considered significant.

RESULTS

Twenty-three studies with 1743 patients were included. A decreased overall survival was significantly associated with peritoneal involvement (HR 1.944; p = 0.003), ascites (HR 2.055; p = 0.034), synchronous presentation (HR 1.679; p = 0.034) and increased serum CEA levels (HR 1.380; p = 0.010), but not with age > 50 (HR 0.946; p = 0.743), menopausal status (HR 1.565; p = 0.204), gastric origin (HR 1.600; p = 0.201), size > 5 cm (HR 1.292; p = 0.119), size > 10 cm (HR 0.925; p = 0.714), bilateral ovarian involvement (HR 1.113; p = 0.347), non-peritoneal extaovarian metastases (HR 1.648; p = 0.237), liver metastases (HR 1.118, p = 0.555), predominant signet ring cell morphology (HR 1.322; p = 0.208) and levels of CA125 (HR 0.933; p = 0.828) and CA19.9 (HR 0.996; p = 0.992).

CONCLUSION

Peritoneal involvement, synchronous presentation, ascites and increased serum CEA levels appear as unfavorable prognostic factors in KT and might affect the patient management.

Nuclear expression of β-catenin in endometrial hyperplasia as marker of premalignancy

We aimed to assess (1)-whether nuclear β-catenin is a marker of endometrial precancer, and (2)-the diagnostic accuracy of β-catenin immunohistochemistry in the differential diagnosis between benign and premalignant endometrial hyperplasia (EH), defining criteria for its use. Electronic databases were searched for studies evaluating β-catenin immunohistochemistry in normal endometrium (NE), benign and/or premalignant EH, and endometrioid carcinoma (EC). Odds ratio (OR; p < 0.05), sensitivity, specificity, diagnostic OR (DOR), positive and negative likelihood ratios (LR+, LR-) were calculated. Subgroup analyses were based on the classification system used (WHO or EIN) and criteria to define aberrant β-catenin expression (only nuclear or cytoplasmic/nuclear). Twelve studies with 1510 specimens were included. Nuclear β-catenin rate significantly increased from NE to benign EH (OR = 26.01; p = 0.0002, only in WHO subgroup), and from benign EH to premalignant EH (OR = 3.89; p = 0.0002; more markedly in EIN subgroup), but not from premalignant EH to EC (OR = 0.78; p = 0.29). Nuclear β-catenin accuracy was very low in WHO subgroup (sensitivity = 0.40, specificity = 0.76, LR+ = 1.85, LR- = 0.72; DOR = 2.89) and moderate in EIN subgroup (sensitivity = 0.19, specificity = 1.00, LR+ = 14.80, LR- = 0.83; DOR = 18.14). Cytoplasmic/nuclear β-catenin accuracy was absent in WHO subgroup (sensitivity = 0.45, specificity = 0.54, LR+ = 1.01, LR- = 1.01; DOR = 0.99) and low in EIN subgroup (sensitivity = 0.57, specificity = 0.86, LR+ = 3.63, LR- = 0.51; DOR = 8.30). Considering nuclear expression and using EIN system, β-catenin immunohistochemistry might be reliable as rule-in test for diagnosis of endometrial precancer, with perfect specificity and moderate overall accuracy.

BAG3 expression correlates with the grade of dysplasia in squamous intraepithelial lesions of the uterine cervix

INTRODUCTION

Bcl-2-associated athanogene 3 (BAG3) is a protein involved in apoptosis and stress response, which is overexpressed in invasive cervical cancer. However, nothing is known about BAG3 expression in precancerous lesions of the uterine cervix. We aimed to evaluate the expression of BAG3 in cervical intraepithelial neoplasia/squamous intraepithelial lesions (CIN/SIL).

MATERIAL AND METHODS

Forty patients (16 CIN1/L-SIL, 11 CIN2/H-SIL and 13 CIN3/H-SIL) were assessed by immunohistochemistry for BAG3. The intensity of BAG3 expression was categorized as null, minimal, weak, moderate or strong. The association of BAG2 intensity of expression with the grade of dysplasia was assessed using Chi-square test (significant P value <0.05).

RESULTS

In all normal controls, BAG3 expression was negative. In L-SIL specimens, BAG3 expression was confined to the basal third of the epithelium, with an intensity minimal in nine cases (56.3%), weak in six (37.5%) and strong in one (6.3%). In H-SIL specimens, BAG3 expression involved also the two upper thirds of the epithelium, with an intensity moderate in 13 cases (54.2%; 8 CIN2 and 5 CIN3) and strong in 11 cases (45.8%; 3 CIN2 and 8 CIN3). The distribution of BAG3 expression correlated perfectly with the grade of dysplasia (P = 0.0); a moderate/strong expression of BAG3 was significantly associated with H-SIL (P < 0.0001), with no significant difference between CIN2 and CIN3 (P = 0.1228).

CONCLUSIONS

In CIN/SIL, both distribution and intensity of BAG3 expression correlate directly with the grade of dysplasia, supporting the involvement of BAG3 in all phases of cervical carcinogenesis and its possible diagnostic and prognostic role in cervical premalignant lesions.

Accuracy of One-Step Nucleic Acid Amplification in Detecting Lymph Node Metastases in Endometrial Cancer

One-step nucleic acid amplification (OSNA) is used to intraoperatively detect sentinel lymph node metastases in breast cancer. OSNA has also been proposed in endometrial cancer, but evidence in this regard is unclear to define the diagnostic accuracy of OSNA in detecting lymph node metastases in endometrial cancer. A systematic review and meta-analysis was performed by searching 8 electronic databases from their inception to March 2019 for studies testing the diagnostic accuracy of OSNA in detecting sentinel lymph node metastasis in endometrial cancer. Pathologic ultrastaging was the reference standard. Sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-), diagnostic odds ratio (DOR) and area under the curve (AUC) on SROC curve were calculated. Four studies with 237 patients and 691 lymph nodes were included. OSNA showed sensitivity = 0.88, specificity = 0.93, LR + =17.95, LR- = 0.15, DOR = 191.23 and high diagnostic accuracy (AUC = 0.959). OSNA appears as a highly accurate tool for intraoperative assessment of sentinel lymph node in endometrial cancer.

PTEN expression in endometrial hyperplasia and risk of cancer: a systematic review and meta-analysis

PURPOSE

Rates of progression of endometrial hyperplasia (EH) to endometrial cancer (EC) are highly variable. Among several prognostic markers, PTEN has been recommended by ESMO-ESGO-ESTRO to identify premalignant EH. However, its prognostic accuracy is unclear. Thus, we aimed to assess: (1) the association between PTEN loss in EH and risk of cancer, and (2) the prognostic accuracy of PTEN immunohistochemistry in EH.

METHODS

Electronic databases were searched from their inception to June 2018. All studies assessing PTEN immunohistochemistry in EH and the presence of EC on subsequent hysterectomy were included. Odds ratio (OR), sensitivity, specificity, positive and negative predictive value (PPV and NPV), positive and negative likelihood ratio (LR + and LR-) and area under the curve (AUC) on SROC curves were calculated with subgroup analysis (short/long-term; atypical/non-atypical EH).

RESULTS

Nine retrospective studies assessing 933 EH were included. PTEN loss in EH was significantly associated with increased risk of EC (OR = 3.32, p = 0.001). The association was significant only on the short term ( < 1 year) (OR = 3.45, p = 0.002) and in atypical EH (OR = 1.89, p = 0.01). For overall analysis and short-term/atypical EH subgroup the prognostic accuracy was low, with sensitivity = 0.58 and 0.68, specificity = 0.60 and 0.48, VPp = 0.41 and 0.54, VPN = 0.75 and 0.63, LR +  = 1.80 and 1.37, LR - =  0.62 and 0.56, AUC = 0.687 and 0.721, respectively.

CONCLUSION

PTEN loss in EH is a risk factor for EC, but is not reliable in predicting the risk of EC. In atypical EH, PTEN loss is associated with a risk of concurrent EC of over 50%. This information might integrate the patients' informed consent for the choice of treatment (conservative/hysterectomy), especially in borderline cases. In conservative approach, PTEN loss might suggest closer follow-up.