A review of the pathology and management of uterine papillary serous carcinoma and correlation with outcome

Grade 1 Endometrioid Carcinoma With an Area of Serous Carcinoma Less than 5% Is More Aggressive than Stage IA Pure-type Grade 1 Endometrioid Carcinoma

BACKGROUND/AIM

In 2020, the percentages were removed from the World Health Organization's criteria for mixed carcinoma. The aim was to examine the clinical significance of an area of serous carcinoma (SC) <5%.

PATIENTS AND METHODS

Our study included 236 patients with the 2009 International Federation of Obstetrics and Gynecology (FIGO) stage IA grade 1 endometrioid carcinoma (EG1) from multiple hospitals. EG1 patients with an area of SC <5% and those with pure-type EG1 were retrospectively compared.

RESULTS

In the multivariate analysis for recurrence, an area of SC <5% was an independent risk factor [hazard ratio (HR)=101.51, p<0.01]. In the multivariate analysis for progression-free survival, an area of SC <5% was identified as a negative prognostic factor (HR=62.43, p<0.01).

CONCLUSION

EG1 with an area of SC <5% may be more aggressive than pure-type EG1 at FIGO stage IA.

The role of omentectomy in the surgical treatment of uterine serous carcinoma

OBJECTIVE

The aims of this study were to assess the role of omentectomy in the staging of uterine serous carcinoma (USC) and to evaluate its impact on patient outcomes.

STUDY DESIGN

Patients diagnosed with USC at the First Affiliated Hospital of Sun Yat-sen University of China were retrospectively reviewed. The clinicopathological characteristics and survival data of 187 patients were analyzed. Risk factors for omental metastasis were evaluated. Kaplan-Meier survival curves were used to compare survival status and the presence of omental metastasis.

RESULTS

We found that 35 of 187 patients (18.7%) had omental metastases. Omental metastasis was significantly associated with adnexal involvement (40.0% vs 19.1%, P = 0.008, OR 2.828, 95% CI 1.286-6.218). Multivariate analysis showed that in addition to lymph node metastases and suboptimal surgery, omental metastasis in USC remained an independent predictor of decreased PFS and OS (PFS, HR 1.48, 95% CI 1.14-4.63, P = 0.024; OS, HR 1.39, 95% CI 1.04-3.60, P = 0.043).

CONCLUSIONS

The incidence of omental metastasis is not low in patients with USC. Visual assessment and omental biopsy may be insufficient for recognizing occult metastases. Omentectomy should be part of the staging surgery in USC patients because it provides additional information about survival. Prospective studies are needed to confirm these results.

Omental Biopsy for Surgical Staging of Uterine Serous Carcinoma

OBJECTIVES

The aims of this study were to determine the role of omental sampling in staging of uterine serous carcinoma (USC) and to evaluate its impact on patient outcomes.

MATERIALS AND METHODS

A retrospective study of 106 women with USC who underwent primary surgery between 2005 and 2014 was done. Overall survival, disease-free survival, and progression and recurrence patterns were studied in 84 patients with follow-up over 1 year. Diagnostic characteristics were evaluated for preoperative imaging and operative findings. Univariate and multivariate analyses were performed to evaluate risk factors for omental metastasis. Survival curves were used to compare omental sampling status and the presence of omental metastasis.

RESULTS

Of the 106 patients, 66 underwent surgical staging with omental biopsy (54; 82%) or omentectomy (12, 18%). Eight (12%) patients had metastatic disease in the omental samplings. All 6 patients with macrometastasis had visible lesions or palpable nodules and preoperative computed tomography (CT) was suspicious in 3. In 2 (3%) patients, omentum was not suspicious on CT or intraoperatively but had micrometastases. The negative predictive value regarding the staging CT scan was 92% and of the operative findings was 97%. On multivariate analysis, no variable was associated with omental involvement. Disease progressed or recurred in 40 (48%) patients. The most frequent sites of recurrence or progression were the omentum (23; 27%), peritoneum (26; 31%), pelvis (15, 18%), lung (15, 18%), and liver (12, 14%). Comparing the groups with or without omental assessment, no significant difference was found regarding progression and recurrence patterns, overall survival, and disease-free survival.

CONCLUSIONS

Omental involvement in USC upstages patients to stage IV disease and traditional risk factors fail to predict extrauterine disease. Although omental sampling does not influence disease progression or survival, a comprehensive intraoperative evaluation of the omentum is advised as most cases have grossly visible lesions.

Function and regulation of MTA1 and MTA3 in malignancies of the female reproductive system

The family of metastasis-associated (MTA) genes is a small group of transcriptional co-regulators which are involved in various physiological functions, ranging from lymphopoietic cell differentiation to the development and maintenance of epithelial cell adhesions. By recruiting histone-modifying enzymes to specific promoter sequences, MTA proteins can function both as transcriptional repressors and activators of a number of cancer-relevant proteins, including Snail, E-cadherin, signal transducer and activator of transcriptions (STATs), and the estrogen receptor. Their involvement in the epithelial-mesenchymal transition process and regulatory interactions with estrogen receptor activity has made MTA proteins highly interesting research candidates, especially in the field of hormone-sensitive breast cancer and malignancies of the female reproductive tract. This review focuses on the current knowledge about the function and regulation of MTA1 and MTA3 proteins in gynecological cancer, including ovarian, endometrial, and cervical tumors.

Pure compared with mixed serous endometrial carcinoma: two different entities?

OBJECTIVE

To analyze whether mixed compared with pure uterine papillary serous carcinoma histology affects clinical outcome, and to assess uterine papillary serous carcinoma for its association with the precursor lesion endometrial intraepithelial carcinoma.

METHODS

A multi-institution observational study of stage I-IV uterine papillary serous carcinoma patients was performed. Histopathologic slides were reviewed by four expert pathologists, with determination of the percentage serous histology within each tumor. The pre-existent endometrium was evaluated for the presence of endometrial intraepithelial carcinoma.

RESULTS

We included 108 uterine papillary serous carcinoma patients. Fifty-eight patients had mixed and 50 patients had pure uterine papillary serous carcinoma histology. On multivariable analysis, advanced International Federation of Gynecology and Obstetrics (FIGO) stage (hazard ratio [HR] 3.15, 95% confidence interval [CI] 1.57-6.32), mixed uterine papillary serous carcinoma histology (HR 0.35, 95% CI 0.19-0.66), and lymphovascular space invasion (HR 2.10, 95% CI 1.07-4.16) were significantly associated with recurrence. International Federation of Gynecology and Obstetrics stage (HR 4.67, 95% CI 2.25-9.70) and mixed uterine papillary serous carcinoma histology (HR 0.39, 95% CI 0.20-0.76) were significantly and independently associated with survival. Endometrial intraepithelial carcinoma was identified in 83.9% of all cases, with no significant difference between mixed and pure uterine papillary serous carcinoma patients. Atrophic or weakly proliferative endometrium was found in 90.7% of pure uterine papillary serous carcinoma cases, whereas hyperplastic endometrium with atypia was more commonly found in 34.7% of mixed carcinoma patients with uterine papillary serous carcinoma (P=.004).

CONCLUSION

Pure uterine papillary serous carcinoma histology and FIGO stage are the most important risk factors for recurrence and survival in patients with uterine papillary serous carcinoma. Adjusted for covariates, patients with pure uterine papillary serous carcinoma had a 2.9-times greater risk for recurrence and a 2.6-times higher risk of death compared with patients with mixed uterine papillary serous carcinoma. Furthermore, endometrial intraepithelial carcinoma was equally found among pure and mixed uterine papillary serous carcinoma cases, whereas the nonneoplastic endometrium was atrophic or weakly proliferative in pure uterine papillary serous carcinoma cases compared with more hyperplastic endometrium with atypia in mixed uterine papillary serous carcinoma cases.

DNA ploidy may be a prognostic marker in stage I and II serous adenocarcinoma of the endometrium

In patients with serous adenocarcinoma (SAC) of the endometrium, we evaluated the prognostic importance of clinicopathological parameters, DNA ploidy, and immunoexpression of p53, estrogen receptor (ER), progesterone receptor (PR), and Ki-67. In a series of 73 stage I and II SAC, DNA ploidy analysis was performed on hysterectomy specimens using DNA image cytometry. Immunohistochemical analysis of p53, ER, PR, and Ki-67 expression was additionally performed. In the review of the histological slides by three gynecologic pathologists, the presence of a serous component was not agreed upon in 17 (23 %) cases. The remaining 56 cases, consisting of pure SAC or SAC mixed with endometrioid adenocarcinoma, were further analyzed. Tumor recurrence was observed in 14 patients, and 28 patients died during the follow-up period. Patients with diploid (n = 19), aneuploid (n = 29), and tetraploid (n = 8) tumor had 5-year recurrence rates of 10, 38, and 53 %, respectively (p = 0.09). A DNA ploidy parameter, 5c exceeding rate, was found to be a prognostic marker for recurrence (p = 0.03), progression-free survival (p < 0.01), and overall survival (p = 0.02). Immunoexpression of p53, ER, PR, and Ki-67 did not have prognostic value, and the same was true for FIGO stage, lymphovascular invasion, the extent of myometrial invasion, and lymphadenectomy. The histological diagnosis of SAC may be difficult in some cases. Established clinicopathological parameters do not seem to be strong prognosticators in stage I and II disease. A DNA ploidy parameter, 5c exceeding rate, may be a prognostic marker in this patient group and should be further validated in larger series.

The importance of chemotherapy and radiation in uterine papillary serous carcinoma

PURPOSE

To identify prognostic and predictive factors of overall survival (OS), relapse-free survival (RFS) and toxicity for patients with uterine papillary serous carcinoma (UPSC).

MATERIALS AND METHODS

Patient, tumor, treatment and relapse characteristics of 135 women with Stages I-IVA UPSC treated between 1980 and 2006 at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) were analyzed using Cox regression models to determine prognostic and predictive factors for OS, RFS and toxicity.

RESULTS

Mean follow-up was 5.5 years (range, 0.01-25.2). Median 5-year OS was 52%, and RFS was 42% for all patients. On Cox regression analysis, increasing age, stage, and myometrial invasion were prognostic factors associated with shorter OS and RFS. A paclitaxel-platinum chemotherapy regimen was significantly associated with longer OS (hazard ratio [HR]=0.34, 95% confidence interval [CI] 0.15-0.74, p=0.007) and RFS (HR=0.45, 95% CI 0.22-0.92, p=0.03). RFS was improved for patients treated with RT (HR=0.44, 95% CI 0.25-0.77, p=0.004). The 5-year grade 3+ toxicity rate was 3.5% for those who received RT and was 2.9% for those who did not (p=NS).

CONCLUSION

Uterine papillary serous cancer can be an aggressive tumor type with a poor prognosis. RFS was improved by radiation and chemotherapy with few grade 3 or higher complications. Using radiation and paclitaxel-platinum chemotherapy should be attempted whenever feasible for patients with UPSC who do not have distant metastases at diagnosis.

Prognostic factors in stages II/III/IV and stages III/IV endometrioid and serous adenocarcinoma of the endometrium

AIMS

To explore and to compare the outcome of patients diagnosed with stage II/III/IV and stage III/IV endometrioid adenocarcinoma (EAC) with their serous carcinoma (USC) counterparts.

MATERIALS AND METHODS

A total of 107 patients (73 EAC and 34 USC) were evaluated. For statistical analysis, the following baseline variables were considered for their prognostic value: the patient's age at presentation, the tumor size, the depth of myometrial invasion (MI), the lympho-vascular involvement (LVI) and the USC and the EAC subtypes (considered as binary variables). Disease free survival (DFS), death of disease (DOD) and overall survival (OS) were assessed using univariate and multiple Cox proportional hazards models.

RESULTS

In univariate analysis, USC tends to recur more frequently than EAC (p = 0.004), a finding that disappeared in multivariate analysis. Furthermore, tumor histology had no significance in predicting the tumor outcomes. Among all of the prognostic factors and after adjusting for the aforementioned variables, MI ≥50% was the only independent factor in predicting DOD in stages II/III/IV (p = 0.009) and in stages III/IV (p = 0.004). MI was also an independent predictive factor for OS (p = 0.02) and early recurrences in stages III/IV. LVI was the only independent factor in predicting recurrences (p = 0.004) in stages II/III/IV but not in stages III/IV.

CONCLUSION

Based on our study, tumor histology was not a significant factor in predicting disease outcome in stages II/III/IV and II/IV. Despite our limited sample size, we believe that our findings provide meaningful insights into the clinical study of endometrial cancer patients which in turn warrants further investigation.

Inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid carcinomas: prognostic significance and clinical implications

Inhibins, dimeric peptide hormones composed of an alpha-subunit and one of two possible beta-subunits (betaA or betaB), exhibit substantial roles in human reproduction and in endocrine-responsive tumours. However, the prognostic significance and clinical implications of the inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid cancers are still quite unclear. A series of 41 uterine non-endometrioid carcinomas were immunohistochemically analysed with monoclonal antibodies against inhibin-subunits. The staining reactions were correlated with several clinicopathological characteristics and clinical outcome. The inhibin-alpha subunit showed a significant association with age although the loss of this subunit did not affect the survival of patients with non-endometrioid carcinomas and did not constitute an independent prognostic parameter. The inhibin-betaA expression was not associated with any of the analysed clinicopathological parameters and did not affect patients' survival. In contrast, a low betaB-subunit demonstrated a significant better cause-specific survival. Moreover, inhibin-betaB did constitute an independent prognostic parameter in uterine non-endometrioid cancer patients. In contrast to inhibin-alpha and -betaA subunits, the inhibin-betaB subunit seems to have a substantial role in the carcinogenesis and pathology of uterine non-endometrioid carcinomas and might be used as a marker to identify high-risk patients and may aid in the selection of patients for a more aggressive adjuvant therapy.

IMP3 distinguishes uterine serous carcinoma from endometrial endometrioid adenocarcinoma

Differentiating uterine serous carcinoma (USC) from endometrioid adenocarcinoma (EAC) could be problematic, especially in high-grade EACs and tumors exhibiting architectural variations. To address this issue, we evaluated 103 endometrial carcinoma cases using 4 immunomarkers, beta-catenin, IMP3, PTEN, and p53. Cases included 31 USCs, 57 EACs, and 15 mixed EAC-USCs. Of 31 USCs and 57 EACs, 8 and 9, respectively, were considered diagnostically difficult and challenging. beta-catenin was more frequently expressed in EAC (P = .001); p53, PTEN, and IMP3 were more frequently found in USC (P < .001 for each). IMP3 was the best independent predictive marker for USCs. The best marker combination for predicting USCs was PTEN+/IMP3+ (exact odds ratio, 163.87; 95% confidence interval, 19.62 to infinity; P < .001). IMP3 was consistently negative in all 9 challenging EAC cases and consistently positive in all 8 challenging USC cases. None of the markers or their combinations demonstrated any value in making the diagnosis of serous component in mixed EAC-USC tumors. IMP3 immunoexpression and the IMP3+/PTEN+ pattern are the best independent and combination markers, respectively, to predict USCs. We strongly recommend using them in difficult and challenging cases.

Pure papillary serous tumors of the endometrium: a clinicopathological analysis of 61 cases from a single institution

OBJECTIVE

The aim of this study was to evaluate the clinicopathological data and prognosis factors corresponding to patients with papillary serous carcinoma of the endometrium treated at a single institution.

METHODS

Medical and anatomopathological records were reviewed in the Department of Gynecological Oncology of the Canarian University Hospital between 1989 and 2006. Only pure cases of papillary serous carcinoma of the endometrium were included. Survival rates were analyzed using the Kaplan-Meier technique.

RESULTS

The study included 61 patients. Stages I, II, III, and IV were identified in 32.8%, 19.7%, 31.1%, and 8.2% of patients, respectively. Event-free survival rates after 5 and 10 years were 59% and 40%, respectively, with a median time of 83 months (95% confidence interval, 63-110). Relapse occurred in 40.5% of the patients. Overall survival rates after 5 and 10 years were 37.7% and 29%, respectively, with a median time of 55 months (95% confidence interval, 40-70). A univariate analysis showed that prognosis factors were tumor markers, stage, myometrial infiltration, lymphovascular invasion, and ganglia involvement. A multivariate analysis showed that tumor markers, stage, and myometrial infiltration had an independent influence on overall survival.

CONCLUSIONS

Papillary serous carcinoma of the endometrium is a very aggressive type of endometrial carcinoma that behaves more similar to ovarian carcinoma than to endometrial carcinoma. Tumor markers at diagnosis, stage, and myometrial infiltration mainly determine prognosis at our institution.