ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

Evaluating the quality of radiomics-based studies for endometrial cancer using RQS and METRICS tools

OBJECTIVE

To assess the methodological quality of radiomics-based models in endometrial cancer using the radiomics quality score (RQS) and METhodological radiomICs score (METRICS).

METHODS

We systematically reviewed studies published by October 30th, 2023. Inclusion criteria were original radiomics studies on endometrial cancer using CT, MRI, PET, or ultrasound. Articles underwent a quality assessment by novice and expert radiologists using RQS and METRICS. The inter-rater reliability for RQS and METRICS among radiologists with varying expertise was determined. Subgroup analyses were performed to assess whether scores varied according to study topic, imaging technique, publication year, and journal quartile.

RESULTS

Sixty-eight studies were analysed, with a median RQS of 11 (IQR, 9-14) and METRICS score of 67.6% (IQR, 58.8-76.0); two different articles reached maximum RQS of 19 and METRICS of 90.7%, respectively. Most studies utilised MRI (82.3%) and machine learning methods (88.2%). Characterisation and recurrence risk stratification were the most explored outcomes, featured in 35.3% and 19.1% of articles, respectively. High inter-rater reliability was observed for both RQS (ICC: 0.897; 95% CI: 0.821, 0.946) and METRICS (ICC: 0.959; 95% CI: 0.928, 0.979). Methodological limitations such as lack of external validation suggest areas for improvement. At subgroup analyses, no statistically significant difference was noted.

CONCLUSIONS

Whilst using RQS, the quality of endometrial cancer radiomics research was apparently unsatisfactory, METRICS depicts a good overall quality. Our study highlights the need for strict compliance with quality metrics. Adhering to these quality measures can increase the consistency of radiomics towards clinical application in the pre-operative management of endometrial cancer.

CLINICAL RELEVANCE STATEMENT

Both the RQS and METRICS can function as instrumental tools for identifying different methodological deficiencies in endometrial cancer radiomics research. However, METRICS also reflected a focus on the practical applicability and clarity of documentation.

KEY POINTS

The topic of radiomics currently lacks standardisation, limiting clinical implementation. METRICS scores were generally higher than the RQS, reflecting differences in the development process and methodological content. A positive trend in METRICS score may suggest growing attention to methodological aspects in radiomics research.

Practical guidance for assessing and reporting lymphovascular space invasion (LVSI) in endometrial carcinoma

Lymphovascular space invasion (LVSI) is an important prognostic parameter in endometrial carcinoma (EC) and has gained increasing interest in recent years due to an expanding body of evidence of its independent prognostic value, especially when the presence of LVSI is quantified. A key strength of LVSI as a prognostic factor is that it can be detected on routine microscopic examination, without ancillary tests, and thus can be used in low-resource settings. A weakness, however, is the lack of uniformly applied criteria for assessment and quantification of LVSI, resulting in interobserver variation in diagnosis. This is confounded by artefacts and other morphological features that may mimic LVSI (commonly referred to as pseudo-LVSI). Despite these issues, multiple studies have shown that LVSI is strongly associated with lymph node (LN) metastasis and is an independent risk factor for LN recurrence and distant metastasis. Consequently, the presence of substantial/extensive LVSI has become an important consideration in formulating adjuvant treatment recommendations in patients with EC, and this has been incorporated in the recent International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system. Herein, we review the current literature on LVSI in EC and discuss its role as a prognostic marker, the reproducibility of LVSI assessment and distinction between LVSI and its mimics. We provide illustrations of key diagnostic features and discuss the two-tiered (none/focal versus substantial) system of LVSI classification. This work is intended to provide guidance to practising pathologists and unify the approach towards LVSI assessment in EC.

Survival outcomes of endometrial cancer patients with disease involving the lower uterine segment: A meta-analysis

OBJECTIVES

Lower uterine segment (LUS) involvement is encountered in a small proportion of endometrial cancer patients and is associated with aggressive histological features. Despite the available evidence, there seems to be a lack of consensus concerning its actual impact on disease related survival.

STUDY DESIGN

The search strategy involved the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases. Nine studies were included in the present systematic review that recruited 3300 patients. Pooled hazard ratios (HR) were retrieved from Cox-regression analyses to limit the confounding effect of other factors that influence the course of the disease.

RESULTS

Nine articles were included in the present meta-analysis that involved 3300 endometrial cancer patients. The meta-analysis revealed a significant difference in progression free survival that was found increased in patients without LUS involvement (HR 1.59, 95 % CI 1.22, 2.05, data from 9 studies). Similarly, a significantly smaller overall survival was observed among patients with LUS involvement (HR 1.69, 95 % CI, 1.34, 2.13, data from 7 studies). Sensitivity analysis revealed that there were no outliers in either outcome, however, the possibility of data manipulation could not be ruled out entirely.

CONCLUSION

The results of this meta-analysis indicate that lower uterine segment involvement is associated with decreased survival outcomes. It remains unclear if these patients can benefit from adjuvant treatment in the absence of other negative prognostic indicators and this needs to be examined by future studies.

Mismatch repair, p53, and L1 cell adhesion molecule status influence the response to chemotherapy in advanced and recurrent endometrial cancer

OBJECTIVE

This study aimed to identify the recurrence and survival rates according to the mismatch repair (MMR), p53, and L1 cell adhesion molecule (L1CAM) status in patients with advanced and recurrent endometrial cancer (EC) receiving systemic chemotherapy.

METHODS

This single-center retrospective cohort study included chemotherapy-naïve patients with advanced-stage (III/IV) or recurrent EC between January 2015 and June 2022 (n = 156), who were administered chemotherapy as adjuvant therapy or first-line palliative treatment. MMR and p53 status were assessed, and L1CAM was tested using immunohistochemistry in the p53-wild and MMR-proficient (p53wt/pMMR) group. The primary outcomes were progression-free survival (PFS) and overall survival (OS).

RESULTS

Of the 156 patients, 62 (39.7%), 53 (34.0%), and 41 (26.3%) had p53wt/pMMR, abnormal p53 (p53abn), and MMR-deficient (dMMR) tumors, respectively. PFS and OS were longest in dMMR, followed by p53wt/pMMR, and were the least in p53abn tumors (PFS: p = 0.0006, OS: p = 0.0013). After p53wt/pMMR was classified according to positive or negative L1CAM status, the L1CAM negative group exhibited significantly shorter survival rates than the L1CAM positive group (PFS: p = 0.0001, OS: p = 0.0027). p53abn tumors were independent prognostic factors for poor PFS (PFS: p = 0.039 on multivariable analysis).

CONCLUSION

In chemotherapy-naïve patients with advanced and recurrent EC, there was a better prognosis in the order of MMR-D, p53wt/pMMR, and p53abn tumors after chemotherapy. L1CAM status is useful as a new marker to stratify p53wt/pMMR in advanced and recurrent groups.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Papillary and ductal patterns of mesonephric-like adenocarcinomas are often overlooked: a retrospective revaluation of over 1000 endometrial carcinomas

AIMS

Mesonephric-like adenocarcinoma (MLA) of the endometrium is often a diagnostic challenge, due to its morphological resemblance to other more common Müllerian neoplasms. This study aimed to retrospectively identify overlooked MLA in a large endometrial carcinoma cohort, using a combination of immunohistochemistry (IHC), morphology and KRAS sequencing.

METHODS AND RESULTS

IHC was conducted on 1094 endometrial carcinomas, identifying 16 potential MLA cases based on GATA3+ and/or TTF1+ and ER- staining patterns, which subsequently underwent detailed histological review, KRAS sequencing and ProMisE molecular classification. Of the IHC screen-positive cases, one was positive for both GATA3 and TTF1, nine were positive for GATA3 only and six were positive for TTF1 only. All IHC screen-positive cases were POLE wild-type. All five tumours in the NSMP category showed morphological features of MLA, while the three MMRd and eight p53abn tumours did not show MLA morphology. The five cases diagnosed as MLA on review were all originally diagnosed as low-grade endometrioid adenocarcinoma probably because of rare morphological patterns, being predominantly papillary or ductal. Four of the five cases harboured a KRAS mutation.

CONCLUSION

This study highlights the importance of a comprehensive diagnostic approach for accurately identifying endometrial MLA and for pathologists to be aware of papillary and ductal patterns in endometrial carcinoma assessment. Further exploration into the molecular landscape of MLA is essential for refining diagnostic criteria and developing targeted therapies.

Genomic Landscape of ctDNA and Real-World Outcomes in Advanced Endometrial Cancer

PURPOSE

ctDNA is a novel technique extensively studied in solid tumors, although not currently well defined in endometrial cancer.

EXPERIMENTAL DESIGN

A de-identified retrospective analysis of 1,988 patients with advanced/recurrent endometrial cancer was performed. In addition, an analysis of a real-world evidence cohort was completed (n = 1,266). Patients underwent ctDNA testing using Guardant360 during routine clinical care. The objective was to describe and assess molecular landscape using ctDNA.

RESULTS

Among 1,988 ctDNA samples, at least one somatic alteration was detected in 91.6% (n = 1,821). Most frequently altered genes were TP53 (64%), PIK3CA (29%), PTEN (25%), ARID1A (20%), and KRAS (14%). Overall, 18.5% had amplifications, with the majority identified in CCNE1 (40.9%), PIK3CA (22%), and EGFR (19.3%). From the real-world evidence cohort, those with TP53 mutations had a worse overall survival (OS) versus those without TP53 mutations (P = 0.02) and those with TP53 comutations had an inferior OS in comparison with TP53-mutated only (P = 0.016). Amongst these, patients with a PIK3CA comutation (P = 0.012) and CCNE1 amplification (P = 0.01) had an inferior OS compared with those with only TP53 mutations. Fifty-seven patients with newly diagnosed endometrial cancer had at least two serial ctDNA samples showing evolution in detected variants compared with baseline samples, with TP53 being the most frequent change.

CONCLUSIONS

This study is one of the largest cohorts of ctDNA currently reported in endometrial cancer. The presence of TP53 mutation and other comutations detected by ctDNA have a negative effect on outcomes. This report suggests that ctDNA analysis is feasible and could become a useful biomarker for endometrial cancer.

Next-generation sequencing in the molecular classification of endometrial carcinomas: Experience with 270 cases suggesting a potentially more aggressive clinical behavior of multiple classifier endometrial carcinomas

Molecular classification of endometrial carcinomas (EC) divides these neoplasms into four distinct subgroups based on their molecular background. Given its clinical significance, genetic examination is becoming integral to the diagnostic process. This study aims to share our experience with the molecular classification of EC using immunohistochemistry (IHC) and next-generation sequencing (NGS). We included all ECs diagnosed at two institutions from 2020 to the present. All cases were prospectively examined by IHC for MMR proteins and p53, followed by NGS using a customized panel covering 18 genes, based on which ECs were classified into four molecular subgroups: POLE mutated, hypermutated (MMR deficient), no specific molecular profile (NSMP), and TP53 mutated. The cohort comprised 270 molecularly classified ECs: 18 (6.6%) POLE mutated, 85 (31.5%) hypermutated, 137 (50.7%) NSMP, and 30 (11.1%) TP53 mutated. Twelve cases (4.4%) were classified as 'multiple classifier' EC. Notably, most of these cases with available follow-up (6/9) behaved aggressively. Within the POLEmut EC group, 3/4 cases had advanced tumors, including one patient who died of the disease. Similarly, in the MMRd/TP53mut group, 3/5 patients with available follow-up had metastatic disease, leading to death of the patient in 1 case. ECs of NSMP showed multiple genetic alterations, with the most common mutations being PTEN (44% within the group of NSMP), followed by PIK3CA (30%), ARID1A (21%), and KRAS (9%). Our findings suggest that combining immunohistochemistry with NGS offers a more reliable classification of ECs, including 'multiple classifier' cases, which, based on our observations, tend to exhibit aggressive behavior. Additionally, our data highlight the complex genetic background of NSMP ECs, which can facilitate further stratification of tumors within this group and potentially help select patients for dedicated clinical trials.

Implementation of the ProMisE classifier and validation of its prognostic impact in Brazilian endometrial carcinomas

Purpose

Molecular classification of endometrial cancer (EC) has emerged as a key approach to individualize therapy and define prognostic outcomes. This study aimed to implement the traditional ProMisE classification in a Brazilian population, compared with a molecular setting of ProMisE biomarkers, and evaluate its impact on patients' prognosis.

Patient and methods

A prospective cohort of 114 patients with primary EC treated at Barretos Cancer Hospital (BCH) between October 2020 and December 2022 was conducted. Pathology diagnosis, staging, treatment, and follow-up data were collected. The traditional ProMisE methodology was carried out by POLE hotspot sequencing and immunohistochemistry (IHC) for p53 and mismatch repair (MMR) proteins. We further evaluate the MMR and TP53 status by molecular approach, namely microsatellite instability (MSI) by PCR-based and TP53 mutation analysis by next-generation sequencing (NGS). The results of the 4 molecular groups in both methodologies were compared regarding agreement accuracy and survival outcomes.

Results

Among the 114 cases, the traditional ProMisE groups were: POLEmut 15.8%, MMRd 28.1%, p53abn 27.2%, and no specific molecular profile (NSMP) 28.9%. Considering the molecular classification approach, we observed a POLEmut group of 15.8%, MSI group of 23.7%, TP53 mutation of 27.2%, and NSMP of 33.3%. The concordance rate of both approaches was 86.8% (99/114 cases) with an overall accuracy of 0.87. Importantly, both traditional and molecular ProMisE approaches were associated with significant distinct overall survival (OS) and progression-free survival (PFS) outcomes, with POLEmut patients exhibiting a better prognosis (93.8% OS, at 24 months), whereas the p53abn having a worse survival time (68.9% of OS, at 24 months).

Conclusion

We reported for the first time the Brazilian profile of the ProMisE classification of endometrial cancer and demonstrated the prognostic impact of the traditional and molecular ProMisE classification on patient outcomes.

Prediction of HIF-1α expression in endometrial carcinoma by enhanced T2 ∗ weighted angiography and dynamic contrast-enhanced magnetic resonance imaging

Purpose

To explore the value of quantitative imaging parameters by enhanced T2 * weighted angiography (ESWAN) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for evaluating the expression of Hypoxia-inducible factor-1α (HIF-1α) in endometrial carcinoma (EC).

Methods

Data from 122 patients with EC confirmed by clinical pathology were retrospectively analyzed. According to the number of positive cells stained with HIF-1α by immunohistochemistry, patients were divided into two groups: 65 cases with high expression of HIF-1α and 57 cases with low expression of HIF-1α. Clinical data included age, FIGO stage, menopausal status, abnormal uterine bleeding, and pathological type. All patients underwent preoperative 1.5T MRI scans, including ESWAN and DCE-MRI. The amplitude, phase, and R2 * values derived from ESWAN and the volume transfer constant (Ktrans), rate constant (Kep), and extravascular volume fraction (Ve) values derived from DCE-MRI were measured by two observers, respectively. The intra-class correlation coefficient (ICC) was used to assess the measurement of reproducibility across observers, and the differences in imaging parameters between the two groups were compared using the independent sample t-test or Mann-Whitney U-test. Binary logistic regression analysis was used to find independent risk factors for HIF-1α expression. The efficacy of selected imaging parameters for predicting HIF-1α expression was assessed using receiver operating characteristic (ROC) curves, and the Delong test was used to compare the area under ROC curves (AUC).

Results

The consistency between the two observers was good (ICC>0.75). The R2 *, Ktrans, and Kep values of the HIF-1α high expression group were higher than those of the HIF-1α low expression group (14.59 ± 4.06 vs. 11.99 ± 2.84 Hz, 0.45 ± 0.18 vs. 0.36 ± 0.14/min, and 2.17 ± 1.10 vs. 1.54 ± 0.80/min) (P< 0.001, P = 0.011, and P =0.001). Binary logistic regression analysis revealed that R2 * and Kep values were independent risk factors for HIF-1α expression. The AUC values of R2 *, Kep, and their combination for prediction of HIF-1α expression were 0.697, 0.677, and 0.781, respectively. The diagnostic efficacy was significantly improved with combination of R2 * and Kep.

Conclusions

Quantitative parameters by ESWAN and DCE-MRI showed significant differences between EC patients with low and high expression of HIF-1α, and the combination of ESWAN and DCE-MRI improves the efficacy in prediction of HIF-1α expression in EC, which has an excellent clinical application prospect.

Comparative analysis of surgical outcomes between the hinotori™ surgical robot system and da Vinci® Xi for simple hysterectomy with sentinel lymph node biopsy in low-risk endometrial cancer

OBJECTIVES

This study aimed to compare the surgical outcomes of simple hysterectomy with sentinel lymph node biopsy for low-risk endometrial cancer performed using the hinotori™ Surgical Robot System and the da Vinci® Xi system.

MATERIALS AND METHODS

We retrospectively analyzed the data of 234 patients who underwent simple hysterectomy with sentinel lymph node biopsy at Kagoshima University Hospital between January 2017 and June 2024. Amongst them, 20 patients underwent surgery using the hinotori™ Surgical Robot System and 214 using the da Vinci® Xi. Surgical factors, including operative time, cockpit/console time, blood loss and sentinel lymph node detection, were evaluated. Statistical analyses included chi-square and Wilcoxon tests, with significance set at P < 0.05.

RESULTS

The median operative and cockpit/console times were comparable between the two systems. However, the time from roll-in to the start of cockpit/console surgery was significantly longer for the hinotori™ Surgical Robot System than for the da Vinci® Xi (P = 0.0039). No significant differences were observed for blood loss, length of hospital stay, or complication rates. The sentinel lymph node detection rates and number of sentinel lymph nodes resected were similar between the two systems, with metastatic sentinel lymph node rates of 6% in both groups.

CONCLUSION

Simple hysterectomy with sentinel lymph node biopsy performed using the hinotori™ Surgical Robot System demonstrated outcomes comparable with those using the da Vinci® Xi system, with no significant differences in key surgical factors. These results suggest that the hinotori™ Surgical Robot System is a viable alternative for minimally invasive surgery in low-risk endometrial cancer. Further studies with larger sample sizes are required to validate these findings.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL TRIAL INFORMATION

NCT02730429.

Explainable machine learning for predicting recurrence-free survival in endometrial carcinosarcoma patients

Objectives

Endometrial carcinosarcoma is a rare, aggressive high-grade endometrial cancer, accounting for about 5% of all uterine cancers and 15% of deaths from uterine cancers. The treatment can be complex, and the prognosis is poor. Its increasing incidence underscores the urgent requirement for personalized approaches in managing such challenging diseases.

Method

In this work, we designed an explainable machine learning approach to predict recurrence-free survival in patients affected by endometrial carcinosarcoma. For this purpose, we exploited the predictive power of clinical and histopathological data, as well as chemotherapy and surgical information collected for a cohort of 80 patients monitored over time. Among these patients, 32.5% have experienced the appearance of a recurrence.

Results

The designed model was able to well describe the observed sequence of events, providing a reliable ranking of the survival times based on the individual risk scores, and achieving a C-index equals to 70.00% (95% CI, 59.38-84.74).

Conclusion

Accordingly, machine learning methods could support clinicians in discriminating between endometrial carcinosarcoma patients at low-risk or high-risk of recurrence, in a non-invasive and inexpensive way. To the best of our knowledge, this is the first study proposing a preliminary approach addressing this task.

Unusual synchronous and metachronous association of hematologic neoplasms with gynecologic neoplasms: A case series and literature review

The aim of the present study was to evaluate the occurrence of synchronous or metachronous hematologic and gynecologic malignancies. The medical database of the pathology department at a tertiary center was searched from 2016 to 2024 for cases involving both hematologic and gynecologic tumors. A literature search using Google Scholar and PubMed was also conducted between May and June 2024. Articles reporting surgical pathology data were included, while radiologic studies and those lacking pathology data were excluded. Cases involving one gynecologic cancer and one hematologic malignancy were analyzed. Three cases from our center and 25 cases from 15 English-language articles were identified. The mean age of the cases at diagnosis was 61.4 ± 9.4 years. A total of 19 patients (68%) were diagnosed with synchronous cancers, while the rest had metachronous diagnoses. Endometrial cancer was seen in 20 cases (71.4%): 14 synchronous and five metachronous endometrioid adenocarcinomas, and one unspecified metachronous endometrial cancer. This was followed by five cases of ovarian cancer (17.9%): three synchronous serous ovarian carcinomas, one metachronous serous ovarian carcinoma, and one synchronous ovarian adenocarcinoma. Additionally, there were two cases of cervical cancer (7.1%): one synchronous adenosquamous carcinoma and one metachronous invasive squamous carcinoma, and one case of carcinosarcoma (3.6%). Involvement of more than one site is possible for hematolymphoid cancer, commonly affecting the pelvic or para-aortic lymph nodes in 16 patients (57.1%), with other sites including the cervix (4 cases, 14.3%), ovary (4 cases, 14.3%), uterus (2 cases, 7.1%), iliac/inguinal lymph nodes (2 cases, 7.1%), fallopian tube (1 case, 3.6%), vagina (1 case, 3.6%), liver (1 case, 3.6%), abdomen (1 case, 3.6%), and appendix (1 case, 3.6%). Two cases were unspecified. Non-Hodgkin lymphoma (NHL), primarily of B cell lineage, was the most common hematologic malignancy (25 cases, 89.3%, with 22 cases being B cell lineage). In contrast, Hodgkin lymphoma was observed in two cases (7.1%), and acute leukemia in one case (3.6%). Among 21 patients with available follow-up data, eight died during the follow-up period. The co-occurrence of NHL, Hodgkin lymphoma, and acute leukemia with gynecologic cancers is rare. However, during surgery for gynecologic cancers, the potential of synchronous lymphoma should be considered, particularly in cases with unusual retroperitoneal lymphadenopathy.

The impact of delay from diagnosis to surgery in endometrial cancer

PURPOSE

When oncological waiting lists are prolonged, gynecological oncology units are forced to delay operations, especially for endometrial cancer (EC) due to its good prognosis among gynecological cancers. The aim of this study is to evaluate the impact of delay in the oncological outcomes of these patients.

METHODS

This is a retrospective analysis of all women with EC treated in our clinic, 2012-2019. Delay was calculated as the time interval between histological diagnosis of endometrial biopsy and definite surgery. The cutoff point was set at 8 weeks. Patients' characteristics, treatment options and follow-up information were collected. Primary outcomes were the need of adjuvant treatment and survival rates.

RESULTS

259 Patients met the inclusion criteria. Based on the 8-week cutoff point, patients were divided into 2 groups: 119 underwent surgery up to 8 weeks (group A) and 140 over 8 weeks (group B). There was no statistical difference in the FIGO stage or the preoperative CA-125 levels between the two groups. However, patients in group A were younger, with lower body mass index (BMI) and less comorbidities. Furthermore, patients in group B had a significantly higher probability of receiving pelvic radiation with or without brachytherapy (p = 0.0053). Concerning survival rates, there was a statistically difference in disease-free (p = 0.0312), but no difference was found in overall survival (p = 0.146).

CONCLUSION

Delaying EC surgery over 8 weeks may not have an impact on the mortality of the patients, but increases the need of adjuvant pelvic radiation and worsens recurrence rates. As a result, patients experience more side effects which subsequently had negative impact on their quality of life.

Reirradiation Practice in Gynecological Cancer: Insights from a National Survey in Spain

PURPOSE

Given the lack of standardisation in gynecological cancer reirradiation, the Gyneacologial Radiation Oncology (GINECOR) working group on behalf of the Spanish Society of Radiation Oncology (SEOR), works towards to inquire the current state of reirradiation practices among the radiation oncology departments in Spain.

METHODS

An online 37-question survey was sent to all GINECOR members, representing most Spanish centers. The survey addressed general aspects of reirradiation, including experience, reirradiation sites, and techniques used. It included seven clinical case scenarios on reirradiation, and a final section on technical aspects of external beam radiotherapy (EBRT) and brachytherapy (BT) treatment. Descriptive statistics were used for data analysis.

RESULTS

Out of 58 centers, 29 responded, with 51.7% performing ≥ 5 reirradiation cases annually. While most centers offer multiple techniques, only 16/29 have access to BT. For in-field local relapse with surgery contraindicated, 79.3% performed BT in endometrial cancer, but only 27.5% treated with BT in cervical cancer recurrence. In this case, 17.2% used SBRT. For endometrial and cervical cancer, 44.8% and 65.4% of centers prescribed doses based on organ-at-risk tolerance, respectively. For pelvic wall/parametrial in-field relapse, 46.4% of the centres reirradiated with stereotactic body radiotherapy (SBRT), and 32.1% with BT. In nodal reirradiation, SBRT was preferred by 90% of centers. Variability was observed in target volume definitions for EBRT and proton therapy.

CONCLUSIONS

Reirradiation for gynecological cancer remains unstandardized, presenting significant challenges in clinical practice. To improve reirradiation protocols in gynecological cancer, the GINECOR working group is currently conducting a systematic review and formulating Delphi recommendations.

Safety and Efficacy of Brachytherapy in Inoperable Endometrial Cancer

Background/Objectives: Radiotherapy represents the only treatment option for patients with inoperable endometrial cancer (EC). The aim of our study was to evaluate the efficacy and safety of brachytherapy (BT) in this selected patient population. Methods: Between 1990 and 2019, 18 patients with inoperable EC in stage FIGO I-IV were treated with intracavitary brachytherapy using the "Heyman Packing technique". BT was performed either as sole PDR- or HDR-brachytherapy with a median cumulative dose up to 60.0 Gy (67.9 Gy EQD2 α/β = 3Gy) and 34.0 Gy (75.6 Gy EQD2 α/β = 3Gy), respectively. Results: The median follow-up was 46 months (6-219). The mean age was 71 years. The 5-year cumulative local recurrence rate (CLRR) for the whole cohort was 27.3%. The 5-year overall survival (OS), distant metastasis-free survival (DMFS), and disease-free survival (DFS) were 51%, 79%, and 69%. The 5-year DFS for low-, intermediate-, and high-risk EC was 89%, 50%, and 44% (p = 0.51). No significant difference in DFS was observed in patients over 70 (p = 0.526). No late side effects of grade > 1 were documented. Conclusions: Brachytherapy for inoperable EC is a safe and effective treatment option, offering good local control and OS with minimal toxicity. Moreover, brachytherapy effectively controls hemoglobin-relevant bleeding. Therefore, BT should be considered a viable alternative to non-curative treatment strategies in gynecological multidisciplinary conferences.

Optimizing patient selection for secondary cytoreductive surgery in recurrent endometrial cancer

OBJECTIVE

This retrospective, multicenter, observational study aimed to refine patient selection criteria for secondary cytoreductive surgery in recurrent endometrial cancer. The objective was to identify preoperative predictors of complete cytoreduction, assess surgical complexity, and propose a preoperative predictive scoring system to identify suitable candidates for secondary cytoreductive surgery.

METHODS

Data from 331 women with recurrent endometrial cancer were analyzed across three Italian centers from January 2010 to December 2021. Patients were categorized based on treatment received (medical treatment, diagnostic laparoscopy/examination under anesthesia, or secondary cytoreductive surgery). Preoperative predictors, surgical complexity, complications, and a predictive scoring system were assessed. Logistic regression and receiver operating characteristic analysis were used for statistical evaluation.

RESULTS

Of the cohort, 56.2% underwent debulking surgery, 17.2% had diagnostic laparoscopy, and 26.6% received medical treatment. Patients undergoing secondary cytoreductive surgery were younger, with a lower body mass index, better performance status, and fewer comorbidities. Single site locoregional relapse was common in secondary cytoreductive surgery patients. Age <65 years, single site relapse, lymph node, and hematogenous relapse were independent predictors of complete cytoreduction. A predictive scoring system demonstrated a clear relationship between the score and the likelihood of complete cytoreduction.

CONCLUSION

This study identified age <65 years, single site recurrence, as well as nodal and hematogenous recurrence, as predictive factors for achieving optimal cytoreduction. A predictive scoring system incorporating these factors has been proposed to identify optimal candidates for secondary cytoreductive surgery in recurrent endometrial cancer. The scoring system showed promising predictive accuracy and could aid in refining the decision making process, ensuring appropriate patient selection for secondary cytoreductive surgery. Further prospective studies are warranted to validate and enhance the predictive model.

A randomized controlled trial on the oncologic outcomes of use of the intrauterine manipulator in the treatment of apparent uterine-confined endometrial carcinoma: the MANEC Trial

BACKGROUND

The intrauterine manipulator used during a hysterectomy for endometrial cancer has been suggested as a reason for worsening oncologic outcomes. However, only a few non-randomized retrospective studies have investigated this association.

PRIMARY OBJECTIVES

To compare 4-year recurrence-free survival in the group of patients who undergo hysterectomy using an intrauterine manipulator with that of those who undergo hysterectomy without it.

STUDY HYPOTHESIS

Patients with endometrial cancer who undergo laparoscopic hysterectomy performed with an intrauterine manipulator would have a lower recurrence-free survival than patients who undergo laparoscopic hysterectomy without a manipulator.

TRIAL DESIGN

Multicenter, parallel arm, open-label, randomized controlled trial.

MAJOR INCLUSION/EXCLUSION CRITERIA

Adult women diagnosed with apparently uterine-confined endometrial cancer of any histology are eligible. We exclude women who had synchronous or previous (<5 years) invasive cancer, had a WHO performance score >2, and had inadequate baseline organ function.

PRIMARY ENDPOINTS

4-Year recurrence-free survival defined as any relapse or death related to endometrial cancer or treatment calculated from randomization to the date of the first recurrence-free survival event.

SAMPLE SIZE

With an accrual time of 4 years, a minimum follow-up length of 4 years, and a two-sided type I error of 0.05, we need to enroll 515 women per arm to have a statistical power of 80% to reject the null hypothesis (HR for recurrence=1), assuming that patients who undergo hysterectomy with the use of the intrauterine manipulator have a 3-year recurrence rate of 12.5% and without the use of the intrauterine manipulator of 8.5% (HR for recurrence=1.50), and that 5% of patients are lost at follow-up in each arm, with a median time of 24 months.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

Accrual completion is expected in 2028, and result presentation in 2032.

TRIAL REGISTRATION

ClinicalTrial.gov ID NCT05687084.

British Gynaecological Cancer Society and British Menopause Society guidelines: Management of menopausal symptoms following treatment of gynaecological cancer

These guidelines have been developed jointly by the British Gynaecological Cancer Society and British Menopause Society to provide information for all healthcare professionals managing women treated for gynaecological cancer. Menopausal symptoms can have a significant impact on quality of life for women. Cancer therapies, including surgery, pelvic radiotherapy, chemotherapy and endocrine therapy, can all affect ovarian function. The benefits and risks of using hormone replacement therapy are considered by cancer type with guidance on the type of HRT and optimal time of commencement after cancer treatment. Vaginal estrogens can be very effective for improving urogenital symptoms and are safe for the majority of women, including those for whom systemic HRT is contraindicated with rare exceptions. Alternative options to HRT are reviewed including pharmacological and non-pharmacological approaches.

Should we prioritise proper surgical staging for patients with Atypical endometrial hyperplasia (AEH)? Experience from a single-institution tertiary care oncology centre

OBJECTIVE

The study aimed to evaluate the incidence of concurrent endometrial cancer (EC) and lymph node positivity in patients with Atypical Endometrial Hyperplasia (AEH) who underwent surgical staging with sentinel lymph node evaluation. It also sought to identify the risk factors associated with detecting concurrent endometrial cancer in patients with a preoperative diagnosis of AEH.

STUDY DESIGN

A retrospective study was conducted at Amrita Institute of Medical Sciences, involving 54 cases of AEH diagnosed on pre-operative biopsy specimens and undergoing staging surgery between January 1, 2015, and December 31, 2020. The study analysed demographic parameters, clinical presentations, pathological features, and clinical outcomes. Categorical variables were expressed in numbers and percentages, normal distribution data were presented as mean, and non-normal distribution data were presented as median and range.

RESULTS

Fifty-four patients diagnosed with AEH underwent surgical staging. The median age was 54 years. Final HistoPathology Report (HPR) showed 48.14 % with AEH and 51.85 % with concurrent EC. Among those with concurrent EC, 96.4 % had type I EC, and one patient was upgraded to type 2 EC. Among them, 17.8 % patients belonged to high-intermediate and high-risk categories. Patients with AEH and concurrent EC were more likely to be diabetic (OR: 3.56, p = 0.04), have a BMI ≥25 kg/m2 (OR: 1.47, p = 0.04), exhibit a thickened endometrial lining of ≥9 mm (OR: 3.13, p = 0.05) on ultrasound, and undergo preoperative biopsy at a non-oncology centre (OR: 8.33, p = 0.001) whereas experiencing heavy menstrual bleeding had a substantially lower likelihood (OR: 0.29, p = 0.01) of developing concurrent EC.

CONCLUSION

The study revealed that more than half of patients undergoing staging surgery for AEH were found to be at risk of having concurrent EC in their final HPR. The research also pointed out that surgical staging can help identify both low-risk and high-risk ECs, which may require additional treatment. Higher BMI, diabetes mellitus, and an endometrial thickness of ≥9 mm were identified as significant risk factors for concurrent EC. Additionally, heavy menstrual bleeding was associated with a decreased risk of concurrent EC.

The oncological and reproductive outcomes of fertility-preserving treatments for stage 1 grade 1 endometrial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The number of patients desiring fertility-preserving treatment for endometrial cancer rather than standard surgical management continues to increase.

OBJECTIVE

We aimed to evaluate the efficacies of fertility-preserving treatments on the live birth rate, remission and relapse rates for women with stage 1a grade 1 endometrial carcinoma to support patient counselling.

METHODS

We performed a meta-analysis for our primary outcomes of overall remission and relapse rate, and for secondary analysis, we divided papers into treatment type: systemic progestins, intrauterine progestins or hysteroscopic resection and adjuvant hormonal treatment.

RESULTS

Thirty-five observational studies met inclusion criteria, with a total of 624 patients. Overall, conservative treatment of endometrial cancer showed a remission rate of 77% (95% CI: 70-84%), a relapse rate of 20% (95% CI: 13-27%) and a live birth rate of 20% (95% CI: 15-25%) with more favourable outcomes for the hysteroscopic resection group.

CONCLUSIONS

Hysteroscopic resection and adjuvant hormonal treatment had the most favourable fertility and oncological outcomes. Further high-quality prospective multi-centre trials are warranted to determine the optimal treatment regimen and dosage and risk stratification for these patients.

Less is more? Comparison between genomic profiling and immunohistochemistry-based models in endometrial cancer molecular classification: A multicenter, retrospective, propensity-matched survival analysis

BACKGROUND

Genomic profiling-based model (GP-M) is the gold-standard for endometrial cancer (EC) molecular classification, but several issues related to the availability of genomic sequencing in low-income settings remain and health disparities in the management are increasing. This study aims to investigate the non-inferiority of the immunohistochemistry-alone model in classifying ECs compared to the standard genomic profiling-based model in terms of oncologic outcomes.

METHODS

All preoperative uterine-confined ECs undergoing surgical staging were retrospectively included. Patients classified by IHC-M were stratified into: MMR-proficient (MMRp), p53 wild type (p53wt) and estrogen receptor (ER) positive, 2) MMRp, p53wt and ER-negative, 3) MMRd, and 4) p53abn. A case-control comparison was performed between the IHC-M and GP-M cohorts. Then, a propensity-matched analysis was performed: ECs classified by IHC-M were matched in a 3:1 ratio with patients classified by GP-M.

RESULTS

1587 patients with EC were included. The Kaplan-Meier survival curves for disease-free survival and overall survival demonstrated that the two models performed similarly in risk-stratifying the study population (p < 0.0001). Moreover, the AUC-ROC showed overlapping results: 0.77 (0.66-0.87) for IHC-M and 0.72 (0.63-0.81) for GP-M, indicating that both models were able to successfully identify patients at high-risk and low-risk of disease recurrence/progression.

CONCLUSION

The IHC-M showed overlapping classification performance compared to the GP-M in terms of oncologic outcomes. This study may lay the basis to further investigate the real-life clinical impact of POLE sequencing in molecular classification and the potential stand-alone prognostic role of ER status for further allocation of EC patients into risk classes.

Stage distribution and prognostic accuracy of the 2023 FIGO (the International Federation of Gynecology & Obstetrics) staging system for endometrial cancer: A retrospective cohort study

OBJECTIVE

To assess the stage distribution and stage-related disease-specific survival rates for endometrial cancer using the FIGO (the International Federation of Gynecology & Obstetrics) 2009 and 2023 staging systems. Further, we sought to evaluate the prognostic utility of additional covariates beyond the FIGO 2023 stage.

METHODS

Endometrial carcinomas were molecularly classified by the Proactive Molecular Risk Classifier for Endometrial Cancer and staged according to FIGO 2009 and 2023 criteria. Disease-specific survival was calculated as the time from surgery to death from endometrial cancer.

RESULTS

Data from 604 patients were analyzed. Median follow-up time was 81 months. A total of 118 stage shifts (19.5%) occurred between the FIGO 2009 and FIGO 2023 systems, with upshifts accounting for 107 (90.7%) of these changes. Within the FIGO 2023 system, molecular classification resulted in restaging of 69 patients (11.4%). Shifts that could alter adjuvant therapy decisions were identified in 23 patients (3.8%). The FIGO 2023 system effectively categorized endometrial cancers into prognostic subgroups. The FIGO 2023 stage, tumor size, positive peritoneal cytology, and mismatch repair deficiency were associated with disease-specific survival in a multivariable analysis, whereas age and adjuvant therapy were not.

CONCLUSION

The FIGO 2023 staging system for endometrial cancer appears highly prognostic. Prognostic assessment of the patients can be further enhanced by readily accessible covariates. A stage shift between the FIGO 2009 and 2023 systems occurs in about one-fifth of patients. The implementation of molecular classification within the FIGO 2023 system bears implications for decisions regarding adjuvant therapy.

Evaluation of Different Risk Factors for Metastatic Sentinel Lymph Nodes in Endometrial Cancer

Background/Objectives: This study investigates which demographic, clinical and pathological factors of women with early-stage presurgical EC could be considered risk factors for the presence of different subtypes of metastases in sentinel lymph nodes (SLNs). Methods: This is a retrospective single-center study that collected data between December 2015 and April 2024. EC patients who underwent total hysterectomy with salpingo-oophorectomy and SLN mapping with indocyanine green (ICG) were recorded. Results: Data from 98 women with EC were analyzed. The endometrioid histotype was present in 85 (86%) women, and the non-endometrioid histotype was present in 13 (13%) women. High-grade EC (G3) was present in 21 (21.4%) patients, and low-grade EC (G1-G2) was present in 77 (78.6%) patients. The total number of women with SLN metastasis was 21/98 (21%). Of 21 women, 5 had MAC, 6 had MIC and 10 had ITCs. Conclusions: Preliminary analysis identified three risk factors for nodal involvement: age greater than 67 years, high-grade endometrial carcinomas and myometrial invasion greater than or equal to 50%. Lymphovascular space invasion, histotype 2 and p53 mutation showed a slight, but not statistically significant, tendency to be risk factors for SLN positivity. A deeper analysis with univariate uninominal logistic regression showed that high-grade EC is related to a greater probability of MACs, as shown in other studies, and that low-grade EC (grades 1 and 2) had a strong relationship with low-volume metastasis (LVM); further studies are needed to confirm these results.

Abnormal preoperative haematological parameters in Endometrial cancer; reflecting tumour aggressiveness or reduced response to radiotherapy?

BACKGROUND

In endometrial cancer (EC), preoperative anaemia, thrombocytosis and leucocytosis appear to be associated with worse prognosis. It remains unclear whether these parameters solely reflect tumour aggressiveness, or also impact response to adjuvant treatment. Therefore, our primary aim is to evaluate the prognostic relevance of anaemia, thrombocytosis and leucocytosis on survival in EC. Secondary, to explore their predictive relevance in response to radiotherapy in EC.

METHODS

A retrospective multicentre cohort study was performed within 10 hospitals. Preoperative haematological parameters were defined as: Anaemia - haemoglobin <7.45 mmol/L (<12 g/Dl), thrombocytosis - platelets >400 × 109 platelets/L, leucocytosis - leukocytes >10 × 109/L. The relationship of haematological parameters with clinicopathological characteristics, ESGO/ESTRO/ESP risk groups and survival were evaluated. Furthermore, the predictive value of haematological parameters was determined on the overall response to adjuvant radiotherapy and for the ESGO/ESTRO/ESP intermediate-risk group solely receiving radiotherapy.

RESULTS

A total of 894 patients were included with a median follow-up of 4.5 years. Anaemia was present in 103 (11.5%), thrombocytosis in 79 (8.8%) and leucocytosis in 114 (12.7%) patients. The presence of anaemia or thrombocytosis was significantly associated with ESGO/ESTRO/ESP high-risk (respectively, P = 0.002 and P = 0.041). In the entire cohort, anaemia remained independently associated with decreased disease-specific survival (HR 2.31, 95% CI (1.19-4.50), P = 0.013) after adjusting for age, the abnormal haematological parameters and ESGO/ESTRO/ESP risk groups. In patients that were treated with adjuvant radiotherapy (n = 239), anaemia was associated with significant reduced 5-year disease-specific and recurrence-free survival (P = 0.005 and P = 0.025, respectively). In ESGO/ESTRO/ESP intermediate risk patients that received solely vaginal brachytherapy (n = 74), anaemia was associated with reduced disease-specific survival (P = 0.041).

CONCLUSIONS

Current data demonstrate the importance of preoperative anaemia as independent prognostic factor in patients with EC. Moreover, anaemia seems to be associated with reduced response to radiotherapy. Prospective validation in a larger study cohort is needed to verify anaemia as predictive biomarker for radiotherapy.What is already known on this subject? In endometrial cancer, preoperative abnormal haematological parameters like, anaemia, thrombocytosis and leucocytosis appears to be associated with FIGO advanced-stage and unfavourable outcome.What do the results of this study add? It remains unclear whether anaemia, thrombocytosis or leucocytosis solely reflecting worse prognosis by advanced tumour stage, or also impact response to adjuvant treatment. Current data demonstrate that anaemia is independent associated with decreased disease-specific survival and anaemia seems related with reduced response to radiotherapy and in specific to vaginal brachytherapy in ESGO/ESTRO/ESP intermediate risk patients.What are the implications of these findings for clinical practice and/or further research? Specific applied adjuvant treatment is needed if patients with anaemia have a reduced response to radiotherapy in EC. Prospective validation in a larger study cohort is required to verify anaemia as predictive biomarker for radiotherapy and to further evaluate the prognostic/predictive impact of anaemia in addition to the molecular subgroups.

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

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

The impact of Substantial LYMphovascular space invasion on sentinel lymph nodes status and recurrence in Endometrial Cancer patients: SLYM-EC a multicenter retrospective study

INTRODUCTION

To evaluate the prognostic impact of substantial lymph vascular space invasion (LVSI) on the sentinel lymph node involvement and recurrence rate of patients with apparent uterine-confined endometrial cancer.

MATERIALS AND METHODS

We enrolled consecutive patients with apparent confined endometrial cancer who underwent surgical staging with sentinel node mapping from 14 European reference centers. LVSI was analyzed semi-quantitatively, according to a 3-tiered scoring system classified as absent, focal, and substantial.

RESULTS

Among 2352 eligible patients, 1980 were included in the analysis. Upon final pathology 226 patients (11.4 %) had SLNs involvement. LVSI was diagnosed focal in 152 patients (7.7 %), whereas 357 patients (18.0 %) showed substantial LVSI. Focal or substantial LVSI rate were significantly higher in patients with positive SLNs when compared to patients without SLNs involvement (p < 0.0001). On overall patient-based analysis, the sensitivity, specificity, positive predictive value, and negative predictive value of LVSI for sentinel lymph node metastases were 73 %, 80 %, 32 %, and 96 %, respectively. The 3-year multivariate analysis of recurrence-free survival showed that only the presence of substantial LVSI, and grade 3 disease were associated with relapse. Neither positive sentinel lymph node, deep myometrial infiltration, nor age at surgery were statistically significant.

CONCLUSIONS

In patients having undergone sentinel node biopsy, positive LVSI demonstrated moderate sensitivity and reasonable specificity in detecting SLN involvement. LVSI positivity does not correlate with nodal involvement. The presence of substantial LVSI remains a strong independent risk factor for recurrence, indicating a role for potential hematogenous dissemination in patients with early-stage disease.

Molecular classification in fertility-sparing treatment of early-stage endometrial cancer: A potential tool for optimizing patient selection

OBJECTIVE

To investigate the prognostic significance of molecular classification on treatment outcomes of fertility-sparing treatment (FST) in early-stage endometrial cancer (EC), and its potential in optimizing fertility-sparing management.

METHODS

Patients with early-stage EC who received FST with ProMisE classification were investigated. Oncological and reproductive outcomes were compared across four molecular subtypes. Factors influencing complete response (CR) were analyzed.

RESULTS

Among 116 molecularly classified patients, 80 were evaluated for therapeutic effects, including 64 (80.0 %) p53wt, 7 (8.7 %) MMR-D, 5 (6.3 %) POLE EDM, and 4 (5.0 %) p53abn. Overall CR rates were comparable across four molecular subtypes, with 92.2 % of p53wt, 71.4 % of MMR-D, 100.0 % of POLE EDM, and 75.0 % of p53abn (P = 0.145). MMR-D patients needed the longest median treatment time to achieve CR (7.9 months, range 3.5-15.9), while POLE EDM required the shortest (3.0 months, range 2.8-6.4), followed by p53abn (3.5 months, range 3.0-3.7) and p53wt (3.7 months, range 2.2-22.8) (P = 0.049). Among 14 p53wt patients with superficial myometrial invasion (MI) or G2 histology, 13 (92.9 %) achieved CR, and of 8 who attempted to conceive,4 delivered. Multivariable analysis identified MMR-D, superficial MI and insulin resistance negatively predicted CR, while POLE EDM was a positive factor.

CONCLUSIONS

Molecular classification of EC may serve as a tool for predicting response to FST and assist in identifying candidates for FST. POLE EDM patients tended to obtain promising outcomes. MMR-D cases should be cautiously administrated for FST with close surveillance. Patients with p53wt demonstrated favorable outcomes, including those with superficial MI or G2 EC. Patients with endometrium-confined p53abn tumors may benefit from FST. However, given the small sample sizes of certain subtypes, further investigation is necessary to validate these findings.

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

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

Murine Xenograft Models as Preclinical Tools in Endometrial Cancer Research

Murine xenograft models are valuable and increasingly used preclinical tools in cancer research to understand disease pathogenesis and guide treatment options. The aim of this narrative review is to summarize the studies that employed mouse xenograft models, using cell lines, patient-derived tumors, or organoids, in endometrial cancer (EC) research, detailing their methodology and main findings. We identified 27 articles reporting on heterotopic EC xenografts, including subcutaneous, subrenal capsule, intraperitoneal, and retro-orbital models, and 18 articles using orthotopic xenografts. Subcutaneous xenografts generated using either cell lines or patient tumors have been widely used; however, their low engraftment rates and the inability to recapitulate main clinical features such as metastases limit their translational value. Subrenal capsule models showed improved engraftment rates compared to subcutaneous models, but tumors exhibited slower and constrained tumor growth. Orthotopic models are technically more challenging to generate and monitor, but tumor growth occurs in a relevant microenvironment and EC ortho-xenografts exhibit high engraftment rates and metastases to clinically relevant sites. Cell line-based xenograft (CDX) models are attractive tools because they are convenient, easy to use, and amenable to genetic modifications, making them suitable for proof-of-concept approaches and large-scale studies. EC xenografts developed from patient tumors (PDTXs) are more labor/cost-intensive for their establishment but can capture the genetic and molecular heterogeneity within and across histologic subtypes and can inform personalized patient treatment. EC organoid-based xenograft (PDOX) models combine the advantages of both CDXs and PDTXs since they are more time- and cost-effective, faithfully maintain tumor characteristics and therapeutic responses, and can be genetically modified. Despite substantial progress in EC management, there are still several unmet needs. Efficient targeted treatments are currently indicated only for a small subgroup of patients, while women with recurrent or advanced-stage EC have very few therapeutic options and their prognosis remains unfavorable. Novel (targeted) drugs, combinational regimens and tools to predict the real drug response in patients are urgently needed. Xenograft models are expected to inform about disease mechanisms and to help identify novel therapeutic options and suitable target patients.

Co-reactivity pattern of glucose metabolism and blood perfusion revealing DNA mismatch repair deficiency based on PET/DCE-MRI in endometrial cancer

BACKGROUND

Identifying DNA mismatch repair deficiency (MMRd) is important for prognosis risk stratification in patients with early-stage endometrial cancer (EC), but there is a notable absence of cost-effective and non-invasive preoperative assessment techniques. The study explored the co-reactivity pattern of glucose metabolism and blood perfusion in EC based on hybrid [18F]fluorodeoxyglucose ([18F]FDG) PET/dynamic contrast enhanced (DCE)-MRI to provide an imaging biomarker for identifying MMRd.

METHODS

Patients with a history of postmenopausal bleeding and initially diagnosed with EC on ultrasound were recruited to perform a PET/DCE-MRI scan. Glucose metabolism parameters were calculated on PET, and blood perfusion parameters were calculated semi-automatically by the DCE-Tofts pharmacokinetic model. The MMRd of early-stage EC was evaluated by immunohistochemistry. The synchronous variation of PET and DCE-MRI parameters was compared between the MMRd and mismatch repair proficiency (MMRp). The association between PET/DCE-MRI and MMRd was analyzed by logistic regression to establish the digital biomarker for predicting MMRd. Receiver operating characteristic curve, decision curve analysis, and the net reclassification index (NRI) were used to evaluate the value of the digital biomarker in identifying MMRd.

RESULTS

Eighty-six early-stage EC cases (58.92 ± 10.13 years old, 34 MMRd) were enrolled. The max/mean standardized uptake value (SUVmax/SUVmean), metabolic tumor volume, total lesion glycolysis, transfer constant (Ktrans), and efflux rate (Kep) were higher in MMRd than those in MMRp (P < 0.001, < 0.001, 0.002, 0.004, < 0.001, and 0.005, respectively). The correlations between glucose metabolism and blood perfusion were different between the MMRd and MMRp subgroups. SUVmax was correlated with Kep (r = 0.36) in the MMRd. SUVmean (odds ratio [OR] = 1.32, P = 0.006) and Ktrans (OR = 1.90, P = 0.021) were independent risk factors for MMRd. And the digital biomarker that combined SUVmean and Ktrans outperformed in identifying MMRd in early-stage EC more than DCE-MRI (AUC: 0.83 vs. 0.78, NRI = 13%).

CONCLUSION

A potential digital biomarker based on [18F]FDG PET/DCE-MRI can identify MMRd for prognosis risk stratification in early-stage EC.

Real-world patient characteristics and survival outcomes in patients with advanced or recurrent endometrial cancer in England: a retrospective, population-based study

OBJECTIVE

This study defined a retrospective cohort of patients in England with primary advanced or recurrent (A/R) endometrial cancer (EC) who may have been eligible for clinical trials evaluating immune checkpoint inhibitors (ICIs) in the first-line (1L) setting within a real-world dataset, and described the characteristics, treatment patterns and outcomes within this cohort.

DESIGN

This was a retrospective, population-based study.

SETTING

Routine population-level data from the National Cancer Registration and Analysis Service in England were used. Patients diagnosed with A/R EC between 1 January 2013 and 31 December 2019 were included (follow-up until 23 August 2021). ICI-eligible patients who received any 1L therapy (defined as first systemic treatment for A/R EC with or without radiotherapy) and met key eligibility criteria for the RUBY trial (NCT03981796; 1L cohort) were included. A subpopulation who solely received carboplatin-paclitaxel at 1L (carboplatin-paclitaxel subcohort) was identified.

METHODS

Demographics, characteristics and therapy received were reported. Overall survival (OS), time to next treatment (TTNT) and time to treatment discontinuation (TTD) from 1L chemotherapy initiation were assessed using Kaplan-Meier methodology.

RESULTS

Of 13 954 patients identified, 2376 ICI-eligible patients were included in the 1L cohort (median [range] age: 67.9 [26.7-94.0] years); 902 patients received solely carboplatin-paclitaxel at 1L. Demographics and disease characteristics were generally similar between cohorts. Median (95% CI) OS, TTNT and TTD from 1L chemotherapy were 27.2 (24.7, 30.2), 16.9 (15.8, 18.5) and 3.4 (3.4, 3.4) months, respectively, in the 1L cohort, and 17.2 (15.5, 19.0), 12.4 (11.6, 13.5) and 3.4 (3.4, 3.4) months, respectively, in the carboplatin-paclitaxel subcohort.

CONCLUSION

Long-term outcomes were poor for both cohorts, particularly the carboplatin-paclitaxel subcohort, where patients did not receive radiotherapy and had predominantly metastatic disease. This reflects the unmet need for more durable treatment options to prevent relapse and prolong survival in this patient population. This real-world study will help contextualise outcomes from ongoing phase III clinical trials investigating 1L ICI treatments.

Advances in Immunotherapy for Endometrial Cancer: Insights into MMR Status and Tumor Microenvironment

Endometrial cancer is one of the most common gynecological malignancies, and while early-stage cases are highly treatable, recurrent or advanced EC remains challenging to manage. Immunotherapy, particularly immune checkpoint inhibitors, has revolutionized treatment approaches in oncology, and its application in EC has shown promising results. Key to immunotherapy efficacy in EC is the tumor's mismatch repair status, with MMR-deficient tumors demonstrating a higher tumor mutational burden and increased PD-L1 expression, making them more susceptible to immune checkpoint inhibitors (ICIs) such as pembrolizumab, durvalumab, and dostarlimab. However, not all mismatch repair-deficient (MMRd) tumors respond to ICIs, particularly those with a "cold" tumor microenvironment (TME) characterized by poor immune infiltration. In contrast, some MMR-proficient tumors with a "hot" TME respond well to ICIs, underscoring the complex interplay between MMR status, tumor mutational burden (TMB), and TME. To overcome resistance in cold tumors, novel therapies, including Chimeric Antigen Receptor (CAR) T cells and tumor-infiltrating lymphocytes are being explored, offering targeted immune-based strategies to enhance treatment efficacy. This review discusses the current understanding of immunotherapy in EC, emphasizing the prognostic and therapeutic implications of MMR status, TME composition, and emerging cell-based therapies.

Undifferentiated endometrial carcinoma diagnosed during perimenopausal hormone therapy: a case report and literature review

Uterine corpus endometrial carcinoma, one of the three most frequent cancers of the female reproductive system, primarily affects women who are perimenopausal or postmenopausal. Moreover, it is an epithelial cancer that develops in the endometrium, which is classified as either estrogen-dependent (type I) or non-estrogen-dependent (type II). Non-estrogen-dependent endometrial cancers include plasma cell carcinoma and undifferentiated/dedifferentiated endometrial carcinoma. Undifferentiated endometrial carcinoma is a rare but aggressive endometrial epithelial cancer that lacks any histologic differentiation and is classified as a high-grade endometrial cancer. This case presents that a patient had uterine corpus endometrial carcinoma during perimenopausal hormone therapy, and the patient was treated with sequential estrogen-progestin treatment for 3 years. During that period, she did not undergo a follow-up examination for the last 2 years due to the pandemic. Undifferentiated endometrial carcinoma is a special type of endometrial cancer that is not hormone-dependent, and whether the occurrence of this case is related to perimenopausal hormone therapy needs to be verified by more evidence-based clinical cases and further studies.

Uterine Carcinosarcoma (UCS): A Literature Review and Survival Analysis from a Retrospective Cohort Study

BACKGROUND/OBJECTIVES

Uterine carcinosarcomas (UCSs) are rare and aggressive malignancies with limited epidemiological data. This study aims to evaluate the clinical and pathological features and prognostic factors of UCS in a retrospective cohort of 80 patients, contributing to improved management strategies.

METHODS

We conducted a retrospective analysis of UCS cases treated from 1995 to 2024 at three institutions. Data on demographics, clinical features, histopathology, treatment, and outcomes were collected. Overall survival (OS) and prognostic factors were assessed using Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

The median age of patients was 66 years, with a median overall survival of 34.5 months. Disease recurrence occurred in 32.5% of cases, with a median disease-free interval of 17.92 months. Age, tumour stage, and size emerged as significant predictors of survival. Stage I-II patients had a significantly better prognosis than those with Stage III-IV (HR = 0.438, p = 0.008). Tumour size >4 cm was associated with increased mortality (HR = 2.154, p = 0.019). Lymphadenectomy was not independently associated with improved survival. Adjuvant chemotherapy, mainly carboplatin and paclitaxel, was administered to 67.5% of patients, achieving a complete response in 66.67%.

CONCLUSIONS

Tumour stage and age are significant independent predictors of survival in UCS, underscoring the need for early diagnosis and intervention. Tumour size is also crucial in determining prognosis. The role of lymphadenectomy remains uncertain, emphasizing the importance of individualized treatment approaches. Future research should explore molecular profiling to further refine prognostication and therapeutic strategies for this challenging malignancy.

Molecular classification of endometrial cancer: Impact on adjuvant treatment planning

Objective

The traditional histopathological analysis of endometrial cancer (EC) is the main risk group classification tool (low, intermediate, high-intermediate, and high) for the implementation of adjuvant treatment. The International Federation of Gynecology and Obstetrics staging system of EC has incorporated a new molecular classification that serves as a new triage tool for optimal treatment planning for these patients. Our study aimed to investigate the prognostic role of the new molecular classification in EC.

Material and Methods

A prospective study was conducted in the 1st Department of Obstetrics and Gynecology from January 1, 2022, to March 30, 2024, and included all new EC cases that presented the multidisciplinary tumor (MDT) board after surgery. We considered the traditional pathologic analysis and new molecular classification after performing tests on microsatellite instability (MSI), DNA polymerase epsilon (POLE) mutation, and p53 immunohistochemistry testing.

Results

The study included 65 patients with presumed early endometrial. All patients underwent surgery and subsequent molecular testing. Among the patients, 35 (54%) had a "positive" result in all of the three markers of molecular classification: 14 patients presented with MSI-H, 5 with POLE gene mutation, and 17 with p53 abnormal expression. One case of multiple classifiers was presented. After the integration of molecular classification, a change was observed in the final MDT board decision in 23 cases (35.4%), including six cases of overtreatment and 17 cases of undertreatment, with statistical significance (P = 0.03469).

Conclusion

The data suggest that the new molecular classification, that is, testing for POLE mutation, MSI, and p53 mutation and for endometrial carcinoma, is a valuable tool for the recurrence risk prognosis and improved planning of adjuvant treatment for EC.

First-line treatments for advanced or recurrent endometrial cancer: Systematic literature review of clinical evidence

Novel therapies are driving meaningful changes to the management of endometrial cancer (EC). Herein, a systematic literature review was conducted to evaluate the efficacy and safety of first-line treatments for advanced/recurrent EC. Searches were conducted using multiple databases through October 26, 2023. In total, 108 records of 57 unique trials (48 of first-line therapies) met the inclusion criteria. Baseline characteristics varied by study, and sample sizes ranged from 28 to 1328. Median progression-free survival was reported in 28 trials (range, 1.9-18.8 months), median overall survival in 26 trials with mature data (range, 6.9-41 months), and safety in 21 trials evaluating first-line systemic therapy ± maintenance. The potentially high risk of adverse events may outweigh the suboptimal efficacy benefits reported for conventional chemotherapy or hormonal therapies. The safety and efficacy of immunotherapies identified within are expected to contribute to a paradigm shift in the management of primary advanced/recurrent EC.

Role of artificial intelligence applied to ultrasound in gynecology oncology: A systematic review

The aim of this paper was to explore the role of artificial intelligence (AI) applied to ultrasound imaging in gynecology oncology. Web of Science, PubMed, and Scopus databases were searched. All studies were imported to RAYYAN QCRI software. The overall quality of the included studies was assessed using QUADAS-AI tool. Fifty studies were included, of these 37/50 (74.0%) on ovarian masses or ovarian cancer, 5/50 (10.0%) on endometrial cancer, 5/50 (10.0%) on cervical cancer, and 3/50 (6.0%) on other malignancies. Most studies were at high risk of bias for subject selection (i.e., sample size, source, or scanner model were not specified; data were not derived from open-source datasets; imaging preprocessing was not performed) and index test (AI models was not externally validated) and at low risk of bias for reference standard (i.e., the reference standard correctly classified the target condition) and workflow (i.e., the time between index test and reference standard was reasonable). Most studies presented machine learning models (33/50, 66.0%) for the diagnosis and histopathological correlation of ovarian masses, while others focused on automatic segmentation, reproducibility of radiomics features, improvement of image quality, prediction of therapy resistance, progression-free survival, and genetic mutation. The current evidence supports the role of AI as a complementary clinical and research tool in diagnosis, patient stratification, and prediction of histopathological correlation in gynecological malignancies. For example, the high performance of AI models to discriminate between benign and malignant ovarian masses or to predict their specific histology can improve the diagnostic accuracy of imaging methods.

Effect of fragmentation of surgery and adjuvant treatment in high-grade nonendometrioid endometrial cancer: a population-based cohort study

BACKGROUND

Fragmented care (FC) occurs when patients receive treatment across several different hospitals. Regionalization of surgery for patients with high-grade endometrial cancer means that patients must travel longer distances to receive care; these patients often require adjuvant treatment after surgery.

OBJECTIVE

To determine whether the fragmentation of surgery and adjuvant treatment impacts survival in patients with high-grade nonendometrioid endometrial cancer.

METHODS

This population-based retrospective cohort study included patients diagnosed between 2003 and 2017 with high-grade nonendometrioid endometrial cancer who received adjuvant treatment postoperatively. Nonfragmented care was defined as receiving surgery and adjuvant treatment at the same institution. The primary outcome was overall survival.

RESULTS

We identified 1795 patients, of whom 583 (32.5%) had FC. Patients with nonfragmented care were more likely to have had surgery by a gynecologic oncologist (92.4 vs 58.8%, P<.001), surgical staging (66.6 vs 44.8%, P<.001), and less travel for surgery (mean 30.8 km vs 93.7 km, P<.001). They were less likely to receive chemotherapy (26.3 vs 30%, P<.001) and chemoradiation (38.4 vs 41.3%, P<.001). Median survival was 9 years. There was no significant difference in overall survival between patients who received FC and nonfragmented care; 92.4% and 93.5% of the patients in the FC and nonfragmented care groups were treated at a specialized gynecologic oncology center for at least part of their treatment (surgery, adjuvant treatment, or both).

CONCLUSION

We have previously shown that regionalization of surgery in high-grade endometrial cancer is associated with improved survival. Fragmentation of surgery and adjuvant treatment in this population does not have an adverse effect on survival. After receiving surgical treatment with a gynecologic oncologist, these patients may receive adjuvant treatment closer to home to decrease financial and travel burden.

[Practical application of the 2023 FIGO classification for endometrial cancer]

Since the last FIGO classification in 2009, numerous studies and recommendations have contributed to improving the management of endometrial cancer. The introduction of molecular classification (including POLE, MMR, and P53 status) has enabled better categorization of these cancers by defining specific patient groups, thus allowing for more tailored surgical management and adjuvant treatment. The data and analyses on molecular and histological classification developed in the 2021 guidelines from the European Societies of Gynecologic Oncology (ESGO), Radiation Therapy and Oncology (ESTRO), and Anatomical Pathology (ESP) have been utilized to develop the new 2023 FIGO classification for endometrial cancer. We are witnessing an evolution of the FIGO classification, shifting from a purely anatomical classification to a risk-based classification. It is important in pathology reports to specify the histological type of the tumor, the grade for endometrioid tumors, the presence or absence of lymphovascular space invasion, and the extent of the tumor (myometrial invasion, involvement of the serosa, cervix, vagina, adnexa, or neighboring organs). These essential points are included in the 2023 FIGO classification and will enable precise staging of the tumor. This article aims to clarify and simplify the classification of patients according to the new 2023 FIGO classification for endometrial cancer.

Autophagy Involvement in Non-Neoplastic and Neoplastic Endometrial Pathology: The State of the Art with a Focus on Carcinoma

Autophagy is a cellular process crucial for maintaining homeostasis by degrading damaged proteins and organelles. It is stimulated in response to stress, recycling nutrients and generating energy for cell survival. In normal endometrium, it suppresses tumorigenesis by preventing toxic accumulation and maintaining cellular homeostasis. It is involved in the cyclic remodelling of the endometrium during the menstrual cycle and contributes to decidualisation for successful pregnancy. Such a process is regulated by various signalling pathways, including PI3K/AKT/mTOR, AMPK/mTOR, and p53. Dysregulation of autophagy has been associated with benign conditions like endometriosis and endometrial hyperplasia but also with malignant neoplasms such as endometrial carcinoma. In fact, it has emerged as a crucial player in endometrial carcinoma biology, exhibiting a dual role in both tumour suppression and tumour promotion, providing nutrients during metabolic stress and allowing cancer cell survival. It also regulates cancer stem cells, metastasis and therapy resistance. Targeting autophagy is therefore a promising therapeutic strategy in endometrial carcinoma and potential for overcoming resistance to standard treatments. The aim of this review is to delve into the intricate details of autophagy's role in endometrial pathology, exploring its mechanisms, signalling pathways and potential therapeutic implications.

Lymph node dissection after neoadjuvant chemotherapy improves overall survival in clinical stage III endometrial cancer

OBJECTIVE

To investigate whether performing a lymph node dissection during hysterectomy improves overall survival in patients with clinical stage III endometrial cancer who received neoadjuvant chemotherapy.

METHODS

The National Cancer Database was queried to identify all patients with clinical stage III endometrial cancer who had undergone pre-operative chemotherapy as first course of treatment followed by hysterectomy with or without lymph node dissection between the years 2004 and 2020. Univariable and multivariable models were performed to investigate prognostic factors on overall survival.

RESULTS

This study analyzed 2882 patients with clinical stage III endometrial cancer who received upfront chemotherapy. Among those who underwent lymph node dissection, 38% had positive lymph nodes. Factors found to be independently associated with improved survival included lymph node dissection (p<0.001), adjuvant radiation (p<0.001), histology (p<0.001), tumor grade (p<0.001), pathologic node status (p<0.001), age (p<0.001), type of insurance (p=0.027), and race (p<0.001). Patients who underwent lymph node dissection at time of hysterectomy had a significantly better overall survival (107 vs 85 months; p<0.001). Multivariate and propensity score analyses robustly demonstrated that lymph node dissection significantly improved overall survival (HR 0.69, 95% CI 0.57 to 0.84, p<0.001), even among patients with pathologically negative lymph nodes.

CONCLUSION

Our study suggests that performing lymph node dissection at the time of hysterectomy is associated with improved overall survival in all patients with stage III endometrial cancer who receive upfront chemotherapy, regardless of age, race, insurance status, histologic subtype, tumor grade, pathologic node status, adjuvant radiation or chemotherapy. Notably, patients with high-risk disease may particularly benefit from this approach.

Tumoral programmed cell death 1 (PD1) expression in endometrial carcinoma is a prognostic marker for patient outcome

OBJECTIVE

Immune checkpoint inhibitors have recently demonstrated benefit in patients with advanced and recurrent endometrial carcinoma. This retrospective study investigated immune checkpoint molecules in endometrial carcinoma as they pertain to the molecular subtypes, clinical outcomes, and predictive value.

METHODS

Tumoral RNA expression of genes controlling the immune checkpoint, programmed cell death 1 (PD1, encoded by PDCD1), its ligand (PDL1, encoded by CD274), and interferon gamma (IFNG) was determined in 239 endometrial carcinoma tissues by quantitative polymerase chain reaction (qPCR) and compared with endometrial tissue from 25 controls. A total of 81 endometrial carcinoma tissues were analyzed using the ProMiSe molecular classification, and patient trajectories were analyzed for the entire cohort. Findings were validated in an independent cohort from The Cancer Genome Atlas (TCGA; n=548).

RESULTS

PD1, PDL1, and IFNG expression was significantly higher in endometrial carcinoma when compared with non-malignant control tissue with a mean expression of 0.12, 0.05, and 0.05 in control tissue and 0.44, 0.31, and 0.35 in endometrial carcinoma, respectively. POLE-mutated and mismatch repair-deficient (MMRd) (immunologically hot) tumors showed the highest expression of PD1 and IFNG. Increased expression of PD1, PDL1, and IFNG was associated with improved recurrence-free (HR 0.32, p<0.001; HR 0.30, p<0.001; HR 0.47, p=0.012, respectively), disease-specific (HR 0.38, p<0.001; HR 0.29, p<0.001; HR 0.45, p=0.017, respectively), and overall survival (HR 0.56, p=0.003; HR 0.38, p<0.001; HR 0.58, p=0.006, respectively). Cox regression confirmed the prognostic significance of PD1 for recurrence-free survival (HR 0.39, p=0.009) and PDL1 for overall survival (HR 0.55, p=0.037). The prognostic value of tumoral PD1 on recurrence-free survival, disease-specific survival, and overall survival was confirmed in the TCGA cohort.

CONCLUSIONS

Tumoral gene expression controlling the PD1 immune checkpoint, particularly expressed in "hot tumors", predicted recurrence-free, disease-specific, and overall survival in patients with endometrial carcinoma in two independent cohorts. Evaluation of these genes could be used to stratify patients who qualify for immune checkpoint inhibitors, which warrants prospective clinical trials.

Elevation of circulating neutrophil extracellular traps in endometrial cancer: Poor prognostic value of cell-free double-stranded DNA

OBJECTIVE

Neutrophils produce neutrophil extracellular traps (NETs) by releasing nuclear contents into the extracellular environment. NETs are associated with systemic inflammation and cancer development and progression. We aimed to investigate whether NET markers are associated with the prognosis of endometrial cancer.

METHODS

Circulating levels of three NET markers (histone-DNA complex, cell-free double-stranded DNA (dsDNA), and neutrophil elastase) were measured in 98 patients with endometrial cancer who underwent surgery as primary treatment between January 2015 and June 2018 and 45 healthy women. Area under the receiver operating characteristic curve (AUC) analyses were conducted to investigate the diagnostic and prognostic utility of the markers for endometrial cancer.

RESULTS

Patients with endometrial cancer showed significantly higher levels of the three NET markers than those in healthy controls. In discriminating endometrial cancer patients from healthy controls, the three NET markers showed AUC values in the following order: cell-free dsDNA (0.832; 95 % CI, 0.760-0.889), histone-DNA complex (0.740; 95 % CI, 0.660-0.809), and neutrophil elastase (0.689; 95 % CI, 0.607-0.764), comparable to those of CA-125 (0.741; 95 % CI, 0.659-0.813). Multivariate analysis adjusting for FIGO stage, histology, and lymphovascular space invasion, and lymph node involvement revealed that cell-free dsDNA level (cutoff: 95.2 ng/mL) was an independent prognostic marker for poor progression-free (adjusted HR, 2.75; 95 % CI, 1.096.92; P = 0.032) and overall survival (adjusted HR, 11.51; 95 % CI, 2.0664.22; P = 0.005) for patients with endometrial cancer.

CONCLUSION

High levels of circulating NET markers were observed in patients with endometrial cancer. Cell-free dsDNA levels may play a role as prognostic markers for endometrial cancer.

International Federation of Gynecology and Obstetrics Endometrial 2023 Is Better For Radiation Oncology Patients

The International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system for endometrial cancer has marked changes from the previous staging system instituted 14 years prior in 2009. The new staging system includes nonanatomic factors for the first time (lymphovascular space invasion and histology) and molecular classification, which impacts the stage in early-stage disease (IAmPOLEmut and IICmp53abn). The purpose of these changes was to provide (1) high accuracy in the predictive prognosis for patients and (2) identification of distinct treatment-relevant subgroups. Our understanding of the biology and natural history of endometrial cancer has undergone a radical transformation since the Cancer Genome Atlas results in 2013. The 2023 FIGO staging system harmonizes and integrates old and new knowledge on anatomic, histopathologic, and molecular features. Moreover, FIGO 2023 has distinct substages that improve adjuvant treatment decision making. Although the practicality of the new staging system has been debated, we postulate that FIGO 2023 is more useful for radiation oncologists aiming to provide personalized care recommendations. FIGO 2023 requires a change in our perception of a staging system, from a traditional anatomic borders-based system to a staging system integrating anatomy and tumor biology as pivotal prognostic factors for patients while providing important information for treatment decision making.

Prognostic performance of FIGO 2023 endometrial carcinoma staging: a comparison to FIGO 2009 staging in the setting of known and unknown molecular classification

AIMS

The 2023 FIGO staging criteria for endometrial cancer (EC) introduced marked changes from the 2009 version. The full implication of these changes for patient diagnosis and treatment is unknown. We evaluate the differences in staging and prognostication between the two systems, with and without inclusion of molecular classification.

METHODS AND RESULTS

We assigned (1) FIGO 2009, (2) 2023 molecular-agnostic and (3) 2023 molecular-informed stages to 404 fully staged and molecularly classified patients with EC. Disease-specific and progression/relapse-free survival were analysed via the Kaplan-Meier method and compared with log-rank testing; 118 of 252 (47%) FIGO 2009 stage I patients were upstaged based on histopathological findings alone. Stage I/II subgroup survival distribution analysis showed a worse prognosis in FIGO 2023 IIB and IIC patients. In the molecular-informed FIGO 2023 system, three of 15 (20%) POLE-mutated stage I/II cases were downstaged from FIGO 2009 and eight (53%) were downstaged from molecular-agnostic FIGO 2023. Fifty-one of 60 (85%) p53-abnormal tumours were upstaged from the FIGO 2009, whereas 13 of 60 (22%) were upstaged from the 2023 molecular-agnostic stage. Molecular classification improved prognostic stratification for both 2009 and 2023 FIGO systems.

CONCLUSIONS

Downstaging based on POLE mutation more accurately represents patient outcomes. However, in the absence of known POLE status, applying molecular-agnostic FIGO 2023 criteria for stage I/II disease should be conducted with caution. For aggressive histotypes, additionally reporting FIGO 2009 stage should be considered. Upstaging based on substantial lymphovascular space invasion, aggressive histotype with any myometrial invasion and abnormal p53 improves prognostic discernment. Further subdivisions within stage I/II provide minimal additional prognostic information.