Contemporary clinical management of endometrial cancer

Estrogen receptors as potential therapeutic target in endometrial cancer

Endometrial cancer (EC) is one of the most common gynecological carcinomas in both developed and developing countries. Majority of the gynecological malignancies are hormonally driven where estrogen signaling acts as an oncogenic signal. Estrogen's effects are mediated via classical nuclear estrogen receptors; estrogen receptor alpha and beta (ERα and ERβ) and a trans-membrane G protein-coupled estrogen receptor (GPR30 and GPER). ERs and GPER through ligand binding triggers multiple downstream signaling pathways causing cell cycle regulation, cell differentiation, migration, and apoptosis in various tissues including endometrium. Although the molecular aspect of estrogen function in ER-mediated signaling is now partly understood, the same is not true for GPER-mediated signaling in endometrial malignancies. Understanding the physiological roles of ERα and GPER in EC biology therefore leads to the identification of some novel therapeutic targets. Here we review the effect of estrogen signaling through ERα-and GPER in EC, major types, and some affordable treatment approaches for endometrial tumor patients which has interesting implications in understanding uterine cancer progression.

DLGAP5 knockdown inactivates the Wnt/β-catenin signal to repress endometrial cancer cell malignant activities

Human discs large-associated protein 5 (DLGAP5), a microtubule-associated protein, has been reported to be upregulated in several tumors. However, the role of DLGAP5 in endometrial cancer (EC) progression and the related underlying mechanism were still unknown. A bioinformatics analysis was performed to analyze the expression and prognostic significance of DLGAP5 in EC tissues using TCGA, CPTAC, Human Protein Atlas, and GSE63678 databases, UALCAN web tool, and the Kaplan-Meier plotter. Effects of DLGAP on EC cell malignant properties were evaluated by CCK-8, flow cytometry analysis, TUNEL assay, caspase-3 activity assay, and Transwell invasion assay. The expression of DLGAP5, Wnt3, c-Myc, Ki67, and cleaved caspase-3 was detected by western blot analysis. DLGAP5 was highly expressed and correlated with poor prognosis in EC patients. DLGAP5 knockdown inhibited proliferation and invasion, triggered apoptosis, and increased caspase-3 activity in EC cells. Additionally, DLGAP5 knockdown inactivated the Wnt/β-catenin signaling pathway in EC cells. Moreover, β-catenin overexpression abolished the effects of DLGAP5 knockdown on the malignant phenotypes of EC cells. DLGAP5 silencing suppressed the malignant properties in EC cells by inactivating the Wnt/β-catenin pathway.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Endometrial cancer in women with abnormal uterine bleeding: Data mining classification methods

Background

Over the last decade, artificial intelligence in medicine has been growing. Since endometrial cancer can be treated with early diagnosis, finding a non-invasive method for screening patients, especially high-risk ones, could have a particular value. Regarding the importance of this issue, we aimed to investigate the risk factors related to endometrial cancer and find a tool to predict it using machine learning.

Methods

In this cross-sectional study, 972 patients with abnormal uterine bleeding from January 2016 to January 2021 were studied, and the essential characteristics of each patient, along with the findings of curettage pathology, were analyzed using statistical methods and machine learning algorithms, including artificial neural networks, classification and regression trees, support vector machine, and logistic regression.

Results

Out of 972 patients with a mean age of 45.77 ± 10.70 years, 920 patients had benign pathology, and 52 patients had endometrial cancer. In terms of endometrial cancer prediction, the logistic regression model had the best performance (sensitivity of 100% and 98%, specificity of 98.83% and 98.7%, for trained and test data sets respectively,) followed by the classification and regression trees model.

Conclusion

Based on the results, artificial intelligence-based algorithms can be applied as a non-invasive screening method for predicting endometrial cancer.

Subtotal hysterectomy reviewed: a stable or aperture for stump cervical malignancy. A referral hospital experience

Introduction

To review the malignant potential of the stump after subtotal abdominal hysterectomy. Material and methods: Thirty-three patients with stump malignancy were diagnosed and treated between January 2018 and January 2022. All patients primarily underwent subtotal hysterectomy (STH) outside our hospital due to different indications, most of which seemed non-convincing. Upon presentation, they were evaluated properly and offered the best management plan.

Results

The presenting symptoms were abnormal histopathology report in 8 patients (24.24%), abnormal bleeding in 7 patients (21.21%), and postcoital bleeding and abnormal Pap smear in 6 patients (18.18%). The primary site of malignancy was endometrial in 17 patients (51.51%), on top of fibroid in 6 patients (18.18%), and cervical in 5 patients (15.15%). Eighteen patients (54.54%) underwent proper surgery, 9 patients (27.277%) were referred for chemoradiation, and 6 patients (18.18%) were candidates for palliative therapy.

Conclusions

Stump cancer cases show a worse stage silhouette compared with cancer cases in intact uteruses. The high prevalence of cervical stump problems should be taken into account before a change in surgical approach from total to STH is deemed possible. Further prospective studies with prolonged follow-up periods are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Subtotal hysterectomy is easier, does not require distinct skills that lead to experience and follow-up, and must be limited to the narrowest limits of practice, provided that the woman knows that there are no health benefits to keeping the cervix in place.

Significance of differential expression of OLFM4 in the development of endometrial adenocarcinoma

The incidence of endometrial adenocarcinoma (EA) has increased worldwide in recent years due to the widespread use of estrogen therapy and the overall increase in life expectancy. However, we know of no sensitive molecular index that can be used to predict the onset of EA, evaluate the therapeutic effects of treatment agents, or provide prognostic benefit in post-treatment follow-up. To explore the correlation between human olfactomedin 4 (OLFM4) and the clinicopathologic parameters of EA, and to determine the precise involvement of OLFM4 as a related factor in the occurrence and development of EA. We enrolled 61 gynecologic patients for a retrospective study at the Tai'an Central Hospital of Shandong Province from January 1, 2016, to June 30, 2022. We determined the expression levels of estrogen receptor α (ERα), progesterone receptor (PR), and OLFM4 proteins in endometrial tissue with the immunohistochemical S-P staining method, and analyzed the correlations among ERα, PR, and OLFM4 protein expression levels and with the pathologic stage, histologic grade, myometrial invasiveness, and lymphatic metastasis of EA. The expression levels of OLFM4 in EA were higher than in normal endometrium (P = .036). The expression level of OLFM4 protein in stage II-III patients was higher than that in stage I patients (P = .034), and the expression levels of ERα and PR proteins in EA were lower than those in normal endometrial tissue (P = .014 and P = .0005). While we observed no correlation in endometrial tissues of disparate pathologic types between OLFM4 and the expression levels of ERα and PR proteins, we noted a positive correlation between the expression levels of ERα and PR protein. The expression level of OLFM4 protein increased with the malignant degree of endometrial lesions and OLFM4 protein expression was related to the FIGO stage of EA. And OLFM4 protein can be used as 1 of the potential diagnostic factors for endometrial lesions, which is worthy of further study.

The association of tumor diameter with lymph node metastasis and recurrence in patients with endometrial cancer: a systematic review and meta-analysis

BACKGROUND

Tumor diameter (TD)/original lesion area has been reported to have a certain predictive effect on lymph node metastasis (LNM) and recurrence of endometrial cancer (EC) patients, but there is still controversy about their relationship. Therefore, we conducted a meta-analysis to provide reference for clinical management and follow-up studies of patients with EC.

METHODS

The databases of PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang were searched, from inception to 27 October 2022, for studies regarding the association of TD with LNM risk and recurrence rate in EC. The search strategy was developed using a combination of free terms and medical subject headings (MeSH). Stata 15.0 was used to conduct the statistical analysis. Odds ratio (OR) with the 95% confidence interval (CI) were calculated to evaluate the association of TD and the risk of LNM and recurrence in EC patients. The OR value obtained from the multivariate analysis is first extracted; the results of univariate analysis were extracted for articles without the results of multivariate analysis. Newcastle-Ottawa Scale (NOS) assessed the quality of the included articles, publication bias was evaluated by Egger's test with funnel plots.

RESULTS

There was a total of 69 studies 123,383 EC patients included. Meta-analysis showed higher LNM risk in EC patients with the TD >2 cm, which was 2.88 times higher than that in those with ≤2 cm, and the difference was statistically significant (OR =2.88; 95% CI: 2.12-3.89; P<0.001), publication bias had no effect on the results. The risk of recurrence in EC patients with a TD >2 cm was 2.45 times higher than that in those with ≤2 cm (OR =2.45; 95% CI: 1.73-3.48; P<0.001), publication bias exerted influence over the results.

CONCLUSIONS

TD is associated with LNM and recurrence in patients with EC. Therefore, TD should be considered in the scope of surgery and adjuvant therapy.

Diagnostic value and agreement of transrectal in comparison with transvaginal sonography among women with abnormal uterine bleeding

AIMS

Transvaginal sonography (TVS) is not applicable for evaluating the endometrium in some cases with abnormal uterine bleeding (AUB) such as virgin women. The aim of the present study was to investigate the diagnostic value of transrectal sonography (TRS), as a non-invasive alternative for TVS, among women with AUB.

METHODS

In this cross-sectional study, 40 women over 40 years of age with AUB first underwent TRS and then TVS. Endometrial biopsy was also performed as a gold standard method to evaluate endometrial pathologies. The findings of the two endometrial ultrasound methods were compared with the biopsy results. Also, the findings of the two methods were compared in terms of the agreement on other uterine markers and adnexal findings.

RESULTS

There was a high agreement between the findings of TVS and TRS for uterine size, endometrial thickness and homogeneity, endomyometrial junction, myometrial homogeneity, uterine lesions, uterine lesions size, ovarian size and ovarian echogenicity. When comparing the results of these two methods with biopsy findings, sensitivity, specificity as well as positive and negative predictive values of both methods were similar (82%, 100%, 100%, and 0%, respectively).

CONCLUSION

When it is not possible to use TVS in women with AUB, TRS is a suitable, non-invasive and inexpensive alternative method for evaluating the endometrium and other genital organs.

Low-Pressure Laparoscopy Using the AirSeal System versus Standard Insufflation in Early-Stage Endometrial Cancer: A Multicenter, Retrospective Study (ARIEL Study)

The aim of our study was to evaluate the benefits of a low-pressure insufflation system (AirSeal) vs. a standard insufflation system in terms of anesthesiologists’ parameters and postoperative pain in patients undergoing laparoscopic surgery for early-stage endometrial cancer. This retrospective study involved five tertiary centers and included 152 patients with apparent early-stage disease who underwent laparoscopic surgical staging with either the low-pressure AirSeal system (8−10 mmHg, n = 84) or standard laparoscopic insufflation (10−12 mmHg, n = 68). All the intraoperative anesthesia variables evaluated (systolic blood pressure, end-tidal CO2, peak airway pressure) were significantly lower in the AirSeal group. We recorded a statistically significant difference between the two groups in the median NRS scores for global pain recorded at 4, 8, and 24 h, and for overall shoulder pain after surgery. Significantly more women in the AirSeal group were also discharged on day one compared to the standard group. All such results were confirmed when analyzing the subgroup of women with a BMI >30 kg/m2. In conclusion, according to our preliminary study, low-pressure laparoscopy represents a valid alternative to standard laparoscopy and could facilitate the development of outpatient surgery.

Does Prophylactic Paraortic Lymph Node Irradiation Improve Outcomes in Women With Stage IIIC1 Endometrial Carcinoma?

PURPOSE

To evaluate the impact of prophylactic paraortic lymph node (PALN) radiation therapy (RT) on clinical outcomes in patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 endometrial cancer (EC).

METHODS AND MATERIALS

A multi-institutional retrospective study included patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 EC lymph node assessment, status postsurgical staging, followed by adjuvant chemotherapy and RT using various sequencing regimens. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated by the Kaplan-Meier method. Univariable and multivariable analysis were performed by Cox proportional hazard models for RFS/OS. In addition, propensity score matching was used to estimate the effect of the radiation field extent on survival outcomes.

RESULTS

A total of 378 patients were included, with a median follow-up of 45.8 months. Pelvic RT was delivered to 286 patients, and 92 patients received pelvic and PALN RT. The estimated OS and RFS rates at 5 years for the entire cohort were 80% and 69%, respectively. There was no difference in the 5-year OS (77% vs 87%, P = .47) and RFS rates (67% vs 70%, P = .78) between patients treated with pelvic RT and those treated with pelvic and prophylactic PALN RT, respectively. After propensity score matching, the estimated hazard ratios (HRs) of prophylactic PALN RT versus pelvic RT were 1.50 (95% confidence interval, 0.71-3.19; P = .28) for OS and 1.24 (95% confidence interval, 0.64-2.42; P = .51) for RFS, suggesting that prophylactic PALN RT does not improve survival outcomes. Distant recurrence was the most common site of first recurrence, and the extent of RT field was not associated with the site of first recurrence (P = .79).

CONCLUSIONS

Prophylactic PALN RT was not significantly associated with improved survival outcomes in stage IIIC1 EC. Distant metastasis remains the most common site of failure despite routine use of systemic chemotherapy. New therapeutic approaches are necessary to optimize the outcomes for women with stage IIIC1 EC.

The multistep process of vaginal cancer arising from deep infiltrating endometriosis: a case report

BACKGROUND

Malignant transformation of endometriosis in extraovarian sites remains rare. Furthermore, the process is not definitely understood.

CASE PRESENTATION

Herein, we report the case of a 40-year-old premenopausal nulligravida woman who presented with vaginal bleeding and who was finally diagnosed with a vaginal cancer originating from endometriosis and with a synchronous endometrial cancer. A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix. Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall, and in the rectovaginal septum. The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy and low anterior resection of the rectum. The lesions were diagnosed as endometriosis, endometriosis-associated complex hyperplasia and endometrioid cancer. Furthermore, a synchronous endometrioid endometrial cancer was reported.

CONCLUSIONS

This case revealed the multistep process of malignant transformation of deep infiltrating endometriosis. The progression was individualized between implantation sites and in the same organ.

An ecological evaluation of the increasing incidence of endometrial cancer and the obesity epidemic

BACKGROUND

The prevalence of obesity has increased significantly in recent decades, particularly among younger women, and is a known risk factor for endometrial cancer.

OBJECTIVE

This study aimed to evaluate the trend in the prevalence of obesity and the incidence of type I endometrial cancer over time in various age categories to determine whether an ecological relationship exists.

STUDY DESIGN

Data from the Surveillance, Epidemiology, and End Results Program and the National Health and Nutrition Examination Survey were used. The overall trend in the incidence of type 1 endometrial cancer and prevalence of obesity were observed over time from 1988 to 2016 and further categorized by age group (<45, 45-54, and ≥55 years).

RESULTS

The prevalence of obesity has increased for all women, but most significantly for women younger than 45 years with a 16.3% increase among women aged 20 to 34 years and a 17.9% increase for women aged 35 to 44 years. The incidence of endometrial cancer has also increased across all age categories, and although it has increased in patients younger than 45 years by more than 14-fold (from <0.1 per 100,000 in 1988 to 1.4 per 100,000 in 2016), a more pronounced increase of 63-fold and 50-fold was observed among women aged 45 to 54 years (0.2 per 100,000 in 1988 to 12.6 per 100,000 in 2016) and women aged 55 years and older (from 0.6 per 100,000 in 1988 to 30 per 100,000 in 2016), respectively. The mean age of women diagnosed as having endometrial cancer also decreased from 64.1 years from 1988 to 1990 to 61.0 years from 2014 to 2016.

CONCLUSION

The prevalence of obesity has increased significantly in women of all ages. This increase, particularly among women aged <45 years, occurred simultaneously with an increase in the incidence of endometrial cancer in young women, with an even more pronounced increase among women aged ≥45 years.

Outcomes of sentinel lymph node mapping for patients with FIGO stage I endometrioid endometrial carcinoma

OBJECTIVE

Investigate the overall survival of patients with FIGO stage I endometrioid endometrial carcinoma who underwent sentinel lymph node biopsy (SLNBx).

METHODS

Patients diagnosed between 2012 and 2015 with pathological stage I endometrioid endometrial carcinoma who underwent minimally invasive hysterectomy and had at least one month of follow-up were identified in the National Cancer Database (NCDB). Patients who underwent SLNBx or systematic lymphadenectomy (LND) (defined as at least 20 lymph nodes removed) were selected. Overall survival (OS) was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders.

RESULTS

A total of 13,010 patients with endometrioid endometrial carcinoma who met the inclusion criteria were identified; 9861 (75.8%) and 3149 (24.2%) patients had systematic LND and SLNBx, respectively. Patients who had LND were more likely to receive radiation therapy (27.4% vs 19.3%, p < 0.001) and chemotherapy (13% vs 8.7%, p < 0.001) compared to those who had SLNBx. After controlling for patient age, race, insurance status, depth of myometrial invasion, tumor grade, tumor size, presence of lymph-vascular invasion and receipt of radiation therapy, the performance of SLNBx was not associated with worse survival (HR: 0.99, 95% CI: 0.80, 1.21). For high-intermediate risk patients (based on GOG-99 criteria) after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.07, 95% CI: 0.80, 1.44). For intermediate risk patients who did not receive external beam radiation therapy or chemotherapy after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.58, 95% CI: 0.94, 2.65).

CONCLUSIONS

SLNBx had no negative impact on the survival of patients with FIGO stage I endometrioid endometrial carcinoma who undergo hysterectomy.

The Prognostic Value of Retroperitoneal Lymphadenectomy in Apparent Stage IA Endometrial Endometrioid Cancer

STUDY DESIGN

Retrospective cohort study.

INTRODUCTION

Debates remain regarding the role of lymphadenectomy in patients with apparent stage IA endometrial cancer, especially subtypes with a favorable prognosis. This study aimed to explore the prognostic value of staging surgeries in apparent stage IA endometrial endometrioid cancer patients in a retrospective cohort study.

METHODS

Cases from June 1, 2010 to June 1, 2017 were reviewed in patients with pathologically confirmed endometrial endometrioid carcinoma limited to <1/2 of the myometrium, without extrauterine metastasis on preoperative evaluation and during surgical inspection. Survival outcomes were compared between patients with and without lymphadenectomy and between patients with and without metastasis to lymph nodes.

RESULTS

In total, 1,312 eligible patients were included, among which 836 underwent staging surgeries and 476 underwent simple hysterectomy. Twenty-eight patients were found with metastasis to retroperitoneal lymph nodes. After a median follow-up of 57.4 months, lost to follow-up, recurrence, death, and cancer-specific death occurred in 28, 39, 24, and 16 patients, respectively. In a univariate analysis, lymphadenectomy of the pelvis with or without para-aortic lymph nodes had no significant impact on disease-free survival, overall survival or cancer-specific overall survival (p values >0.05). However, after adjusting for important baseline risk factors [menopausal status, tumor differentiation, maximum diameter and location, lymph-vascular space invasion (LVSI) status, and postoperative adjuvant therapy), lymphadenectomy resulted in significantly improved survival outcomes (p values <0.05). Menopause (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.3-16.4, p=0.015), tumor diameter larger than 2 cm (OR 4.6, 95% CI 1.3-16.0, p=0.016), grade 3 tumors (OR 3.0, 95% CI 1.0-8.5, p=0.042), positive LVSI (OR 8.7, 95% CI 3.7-20.4, p<0.001) and lower uterine segment involvement (OR 3.1, 95% CI 1.4-7.2, p=0.007) had more extrauterine metastases.

CONCLUSION

In cases of apparent stage IA endometrioid endometrial carcinoma, staging surgeries should be considered in patients with larger, higher grade tumors, positive LVSI, or lower uterine segment involvement.

[Prevalence of lymph node involvement in patients with endometrial cancer, Colombia 2009-2016: Exploratory analysis of associated factors]

OBJECTIVE

To determine the prevalence of lymph node involvement in patients with endometrial cancer and to explore factors associated with lymph node invasion.

METHODS

Prevalence study with exploratory analysis. The study included patients with endometrial cancer who underwent total abdominal hysterectomy plus bilateral salpyingooophorectomy and pelvic lymphadenectomy with or without para-aortic lymphadenectomy in seven oncology centers in Colombia between 2009 and 2016. Patients who had received prior radiotherapy or chemotherapy, with a histological diagnosis of neuroendocrine tumors, carcinosarcomas or synchronous or metachronous lesions were excluded. Non-probabilistic sampling. Sample size n=290. Measured variables: sociodemographic, clinical and histopathological, and pelvic or para-aortic lymph node involvement. The prevalence for the period is presented. The exploratory analysis was conducted using crude odds ratio (OR) and adjusted OR by means of a multivariate model (unconditional logistic regression).

RESULTS

Overall, 467 cases were retrieved. Of them, 163 were excluded because of non-availability of all the variables. In total, 304 patients were studied. The prevalence of lymph node involvement was 15.8 % (48/304). In the crude and adjusted analysis, factors associated with lymph node involvement were lymphovascular invasion (adjusted OR: 9.32; 95 % CI 4.27-21.15) and myometrial invasion (adjusted OR: 3.95; 95 % CI 1.29-14.98).

CONCLUSIONS

Of the patients undergoing lymphadenectomy, 15 % have lymph node involvement. Less invasive diagnostic options than radical surgery to ascertain lymph node invasion should be assessed.

SOX17, β-catenin and CyclinD1 expression in the endometrioid adenocarcinoma and influence of 5-AZA on expression

The present study discusses the expression and effect of the SOX17 gene in endometrioid adenocarcinoma. MTT assay is performed to determine the growth inhibition ratio of the DNA methyltransferase inhibitor 5-AZA for endometrial carcinoma cells, and the real-time fluorescence quantification PCR (qRT-PCR) was used to detect the mRNA expression of SOX17, β-catenin, and CyclinD1 in endometrial carcinoma tissues before and after using 5-AZA to treat the endometrial carcinoma cell line. There were 30 cases on endometrioid adenocarcinoma tissues and 10 cases on normal endometrial tissues. The results revealed that the expression of SOX17 in endometrioid adenocarcinoma tissues was downregulated (P < 0.05), the expression of β-catenin and CyclinD1 was upregulated (P < 0.05), and the expression of SOX17, CyclinD1, and β-catenin was negatively correlated (r = -0.353, P > 0.05; R = -0.463, P < 0.05). The higher the histological grade and FIGO staging were, the lower the expression level of SOX17 was (P < 0.05). After HEC1A cells were treated by 5-AZA, the cell growth inhibition was most obvious (IC₅₀ = 12.033) at 72 h, as determined by MTT assay. After cell treatment by 5-AZA, the genetic expression of SOX17 significantly increased, when compared with that before treatment (P < 0.05), while the genetic expression of β-catenin and CyclinD1 significantly declined (P < 0.05). These results indicate that the expression level of SOX17 in endometrioid adenocarcinoma declined, and the upregulated expression level of SOX17 in cells inhibited the growth of tumor cells.

Effect of microRNA-29b on proliferation, migration, and invasion of endometrial cancer cells

Objective

Aberrant expression of microRNAs is a key regulator of tumorigenesis and progression in endometrial cancer. We assessed the effect of microRNA-29b (miR-29b) on proliferation, chemosensitivity, migration, and invasion of endometrial cancer cells.

Methods

The proliferation of endometrial cancer cells was examined by water-soluble tetrazolium (WST)-1 assay. The effects of miR-29b on migration and invasion were evaluated by transwell migration and Matrigel invasion assays. Western blotting was used to assess protein expression levels after altered expression of miR-29b. The effect of miR-29b on cisplatin-induced apoptosis was examined by Caspase-Glo 3/7 assay.

Results

miR-29b inhibited proliferation and decreased migration and invasion of endometrial cancer cells. It also enhanced the sensitivity of endometrial cancer cells to cisplatin and increased cisplatin-induced apoptosis by regulating expression of BAX and Bcl-2. Moreover, miR-29b changed the expression level of phosphatase and tensin homolog (PTEN) and p-AKT by directly binding to the 3′ untranslated region of PTEN.

Conclusion

miR-29b played important roles in proliferation and progression in endometrial cancer cells by direct regulation of PTEN. It might be used as a biomarker to predict chemotherapy response and prognosis in endometrial cancer.

Women's preferences for cancer risk management strategies in Lynch syndrome

OBJECTIVE

We assessed preferences for cancer risk management strategies for Lynch syndrome (LS) in LS-affected women.

METHODS

Women with LS aged ≥25 years evaluated 9 cancer risk management strategies using a visual analog scale (VAS) and modified standard gamble (SG). For the VAS, women ranked each strategy ranging from 0 (least preferred) to 100 (most preferred). VAS scores were calculated by dividing the corresponding number by 100. Scores closer to 1.0 reflected more favorable strategies. For the SG, participants were asked to specify their expected threshold of lifetime risk of endometrial or colorectal cancer, ranging from 0 to 100%, at which they would consider undertaking each strategy. Strategies included chemoprevention, cancer screening, and preventive surgery. Cancer worry and perceived cancer risk measures were collected on a subset of participants.

RESULTS

Sixty-one women completed preference assessments. By VAS, annual combined screening was the most preferred, followed by annual screenings and chemoprevention with oral contraceptives. By SG, women were the most willing to endorse oral contraceptives and biannual screening strategies at the lowest threshold of lifetime risk followed by annual screening strategies. Surgical interventions were the least preferred strategies using both VAS and SG. Women with a family history of gynecologic or colorectal cancer were less likely to consider prevention or screening options compared to women without a family history. Cancer worry was higher among women with a positive family history of LS cancer.

CONCLUSION

Understanding women's preferences may facilitate optimal use and adherence to cancer risk management strategies.

Estrogen Signaling in Endometrial Cancer: a Key Oncogenic Pathway with Several Open Questions

Endometrial cancer is the most common gynecological cancer in the developed world, and it is one of the few cancer types that is becoming more prevalent and leading to more deaths in the USA each year. The majority of endometrial tumors are considered to be hormonally driven, where estrogen signaling through estrogen receptor α (ER) acts as an oncogenic signal. The major risk factors and some treatment options for endometrial cancer patients emphasize a key role for estrogen signaling in the disease. Despite the strong connections between estrogen signaling and endometrial cancer, important molecular aspects of ER function remain poorly understood; however, progress is being made in our understanding of estrogen signaling in endometrial cancer. Here, we discuss the evidence for the importance of estrogen signaling in endometrial cancer, details of the endometrial cancer-specific actions of ER, and open questions surrounding estrogen signaling in endometrial cancer.

MicroRNA-423 promotes proliferation, migration and invasion and induces chemoresistance of endometrial cancer cells

Altered microRNA expression serves essential roles in tumorigenesis and progression in endometrial cancer. In the present study the effect of miR-423 on proliferation, chemosensitivity, migration and invasion of endometrial cancer cells was examined. A WST-1 assay was used to examine the proliferation of HEC-1B and Ishikawa endometrial cancer cells with either upregulation or downregulation of miR-423, with or without cisplatin treatment. The migration and invasion of HEC-1B and Ishikawa endometrial cancer cells were examined via Transwell migration and Matrigel invasion assays. Protein expression levels, including B cell lymphoma-2 (Bcl-2), Bcl-2 associated X protein, E- and N-cadherin, snail, vimentin, phosphatase and tensin homolog (PTEN) and protein kinase B (AKT) were examined by western blotting. A caspase-Glo3/7 assay was carried out to evaluate the effect of miR-423 on cisplatin-induced apoptosis in HEC-1B and Ishikawa endometrial cancer cells. Overexpression of miR-423 enhanced the proliferation, and increased migration and invasion in endometrial cancer cells. miR-423 also decreased the sensitivity of endometrial cancer cells following cisplatin treatment. miR-423 inhibited cisplatin-induced apoptosis in endometrial cancer cells by regulation of caspase 3/7 and Bcl-2 expression. Furthermore, the E-cadherin expression was significantly decreased, and the expression of N-cadherin, snail and Vimentin were increased in both HEC-1B cells and Ishikawa cells following overexpression of miR-423. Conversely, downregulation of miR-423 increased the expression of E-cadherin and decreased the expression of N-cadherin, snail and Vimentin. Further experiments demonstrated that the expression levels of PTEN and phosphorylated-AKT in HEC-1B and Ishikawa endometrial cancer cells was decreased and increased, respectively, following aberrant expression of miR-423. miR-423 displayed an important role in tumorigenesis and progression in endometrial cancer cells, and may therefore be used as a potential biomarker to predict chemotherapy response and prognosis in endometrial cancer.

Androgen receptor as potential therapeutic target in metastatic endometrial cancer

PURPOSE

The expression and involvement of estrogen (ER) and progesterone receptor (PR) is extensively studied in endometrial cancer. Androgen receptor (AR) is a hormone receptor less studied in female cancers, and we here aim to investigate the expression level of AR in endometrial cancer precursor lesions, primary tumors and metastases, and its potential as therapeutic target.

RESULTS

Expression of AR was observed in 93% of hyperplasias, but only in 41% of non-endometrioid tumors. Compared to estrogen and progesterone receptor AR is more commonly expressed in metastatic lesions, and AR status is discordant in primary and metastatic lesions in a large proportion of cases. AR protein level was significantly associated with survival (P < 0.001), and a calculated AR to ERα ratio identified a subgroup of patients with particular poor outcome. The anti-androgen enzalutamide may have a growth inhibitory effect in endometrial cancer cells based on experiments with primary endometrial tumor cells.

MATERIALS AND METHODS

718 primary endometrial cancers and 298 metastatic lesions (from 142 patients) were investigated for expression of AR in relation to survival, clinical and histopathological data. Protein levels were investigated by immunohistochemistry and reverse phase protein array; mRNA levels by DNA oligonucleotide microarray. The effect of androgen stimulation and inhibition was tested on primary endometrial tumor cells.

CONCLUSIONS

A large proportion of metastatic endometrial cancer lesions express AR, which may be a potential target in these patients. Treatment targeting AR may be of particular benefit in patients with high AR levels compared to ERα levels.

The clinical significance of occult gynecologic primary tumours in metastatic cancer

OBJECTIVE

We estimated the frequency of occult gynecologic primary tumours (gpts) in patients with metastatic cancer from an uncertain primary and evaluated the effect on disease management and overall survival (os).

METHODS

We used Manitoba administrative health databases to identify all patients initially diagnosed with metastatic cancer during 2002-2011. We defined patients as having an "occult" primary tumour if the primary was classified at least 6 months after the initial diagnosis. Otherwise, we considered patients to have "obvious" primaries. We then compared clinicopathologic and treatment characteristics and 2-year os for women with occult and with obvious gpts. We used Cox regression adjustment and propensity score methods to assess the effect on os of having an occult gpt.

RESULTS

Among the 5953 patients diagnosed with metastatic cancer, occult primary tumours were more common in women (n = 285 of 2552, 11.2%) than in men (n = 244 of 3401, 7.2%). In women, gpts were the most frequent occult primary tumours (n = 55 of 285, 19.3%). Compared with their counterparts having obvious gpts, women with occult gpts (n = 55) presented with similar histologic and metastatic patterns but received fewer gynecologic diagnostic examinations during diagnostic work-up. Women with occult gpts were less likely to undergo surgery, waited longer for radiotherapy, and received a lesser variety of chemotherapeutic agents. Having an occult compared with an obvious gpt was associated with decreased os (hazard ratio: 1.62; 95% confidence interval: 1.2 to 2.35). Similar results were observed in adjusted analyses.

CONCLUSIONS

In women with metastatic cancer from an uncertain primary, gpts constitute the largest clinical entity. Accurate diagnosis of occult gpts early in the course of metastatic cancer might lead to more effective treatment decisions and improved survival outcomes.

Does hysteroscopy worsen prognosis in women with type II endometrial carcinoma?

Background

Prior studies evaluating the impact of hysteroscopy on outcomes in endometrial cancer have predominantly evaluated type I tumors. We sought to evaluate whether hysteroscopy worsens prognosis in type II endometrial cancer.

Methods

A retrospective cohort analysis of 140 patients from two institutions with type II endometrial cancer was performed. Women who underwent either diagnostic hysteroscopy (HSC) or dilation and curettage (D&C) for cancer diagnosis from June 2001 until June 2010 were included. The clinical and pathologic characteristics, including peritoneal cytology results were reviewed. The primary endpoint was disease-specific survival (DSS). The exposure of interest was hysteroscopy. Survival curves were projected using the Kaplan-Meier method and compared using the log-rank test.

Results

There was no difference in age, histology, stage, depth of myometrial invasion, adnexal involvement, or nodal metastasis between HSC and D&C patients. Positive cytology was found in 16/54 (30%) patients following HSC and in 10/86 (12%) following D&C (p = 0.008). Fourteen patients with stage I and II disease had positive peritoneal cytology, with 11/40 (27.5%) patients in the HSC group and 3/59 (5%) patients in the D&C group(p = 0.002). Median DSS was clinically different for the HSC and D&C groups, but statistical significance was not reached (53 versus 63.5 months, p = 0.34). For stage I and II patients, 18/99 (18%) were dead of EC, with a median DSS of 60 months for HSC and 71 months for D&C (p = 0.82). Overall 46 (33%) patients developed a recurrence, with 18/54 (33%) in the HSC group compared to 28/86 (32%) in the D&C group (p = 0.92). There was no difference in recurrence location between groups.

Conclusions

Diagnostic hysteroscopy significantly increased the rate of positive peritoneal cytology at the time of surgical staging in this cohort of patients with type II EC. However, we were unable to detect a difference in prognosis as measured by DSS.

Overexpression of microRNA-205 predicts lymph node metastasis and indicates an unfavorable prognosis in endometrial cancer

As an integral component of the surgical staging system, lymphadenectomy for patients with endometrial cancer (EC) remains controversial, particularly in clinical stage I disease that includes not only low-risk, but also high-risk subgroups. In order to maximize the therapeutic effect of lymph node excision for high-risk patients who can potentially obtain survival benefits from it while minimizing its reverse effects in low-risk patients, pre-operative risk stratification of lymph node metastasis is necessary. The upregulation of microRNA-205 (miR-205) in carcinoma of the endometrium has been consistently reported recently and has been found to correlate with poor survival. The current study aimed to investigate whether the overexpression of miR-205 in curettage samples of EC could identify patients who are at a high risk for lymph node metastasis prior to surgery and validate the role of miR-205 as a prognostic marker in EC. Relative quantification detection of miR-205 in curettage and hysterectomy specimens of patients with EC was performed. Prediction of lymph node metastasis based on miR-205 expression, as well as tumor type and grade in curettage samples, was performed for all EC patients and patients with clinical stage I disease. Moreover, survival analysis was conducted. It was observed that miR-205 was significantly and consistently elevated in the curettage and hysterectomy samples of EC relative to normal controls. Furthermore, the overexpression of miR-205 could predict lymph node metastasis with a high accuracy and was revealed again to be associated with a poor prognosis in EC. Prospective and multicentric studies are required to further clarify the value of miR-205 as a promising predictor to stratify risk for lymph node metastasis in EC.

Microsatellite instable and microsatellite stable primary endometrial carcinoma cells and their subcutaneous and orthotopic xenografts recapitulate the characteristics of the corresponding primary tumor

OBJECTIVE

Well-characterized, low-passage, primary cell cultures established directly from patient tumors are an important tool for drug screening because these cultures faithfully recapitulate the genomic features of primary tumors. Here, we aimed to establish these cell cultures from primary endometrial carcinomas (ECs) and to develop subcutaneous and orthotopic xenograft models as a model to validate promising treatment options for EC in the in vivo setting.

METHODS

Primary cell cultures of EC tumors were established and validated by analysing histologic and genetic characteristics, telomerase activity, and in vitro and in vivo growth characteristics. Using these primary cell cultures, subcutaneous and orthotopic mouse models were subsequently established.

RESULTS

We established and characterized 7 primary EC cell cultures and corresponding xenograft models of different types of endometrioid tumors. Interestingly, we observed that the chance to successfully establish a primary cell culture seems higher for microsatellite instable than microsatellite stable tumors. For the first time, we also established an orthotopic murine model for EC derived from a primary cell culture. In contrast to EC cell lines, grafted tumor cultures preserved the original tumor structure and mimicked all histologic features. They also established abdominal and distant metastases, reflecting the tumorigenic behavior in the clinical setting. Remarkably, the established cell cultures and xenograft tumors also preserved the genetic characteristics of the primary tumor.

CONCLUSIONS

The established EC cultures reflect the epithelial genetic characteristics of the primary tumor. Therefore, they provide an appropriate model to investigate EC biology and apply high-throughput drug screening experiments. In addition, the established murine xenograft models, in particular the orthotopic model, will be useful to validate promising therapeutic strategies in vivo, as the grafted tumors closely resemble the primary tumors from which they were derived. Microsatellite instable status seems to determine the success rate of establishing primary cell cultures.

Elevation of ω-3 Polyunsaturated Fatty Acids Attenuates PTEN-deficiency Induced Endometrial Cancer Development through Regulation of COX-2 and PGE2 Production

Endometrial cancer is one of the most common gynecologic malignancies. Phosphatase and tensin homologue (PTEN)-mutation is frequently identified in endometrial cancer patients. Although high dietary intake of ω-3 polyunsaturated fatty acids (PUFAs) has been associated with reduced risk of endometrial cancer, the underlying mechanisms is still unknown. To this end, we evaluated the impact of ω-3 PUFAs using several endometrial cancer cellular and animal models. While ~27% and 40% of heterozygotic PTEN mutant mice developed endometrial cancer and atypical complex hyperplasia, respectively, none of the PTEN(+/-) mice developed cancer when we overexpressed an mfat-1 transgene, which allowed endogenous production of ω-3 PUFAs. Fish oil-enriched diet or expression of mfat-1 transgene significantly inhibited the growth of xenograft tumor derived from RL95-2 cells bearing a PTEN null mutation. At cellular level, ω-3 PUFAs treatment decreased the viability of RL95-2 cells, AKT phosphorylation, and cyclin D1 expression. These molecular events are primarily mediated through reduction of cyclooxygenase-2 (COX-2) expression and prostaglandin E2 (PGE2) production. Exogenous PGE2 treatment completely blunted the impact of ω-3 PUFAs on endometrial cancer. Thus, we revealed the direct inhibitory effects of ω-3 PUFAs on endometrial cancer development and the underlying mechanisms involving reduction of COX-2 and PGE2.

Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival

BACKGROUND

Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. This study determined the prognostic significance of preoperative neutrophil:lymphocyte (NLR), platelet:lymphocyte (PLR) and monocyte:lymphocyte (MLR) ratios in endometrial cancer.

METHODS

Clinicopathological and 5-year follow-up data were obtained for a retrospective series of surgically treated endometrial cancer patients (n=605). Prognostic significance was determined for overall (OS) and cancer-specific survival (CSS) using Cox proportional hazards models and Kaplan-Meier analysis. Receiver-operator characteristic and log-rank functions were used to optimise cut-offs. NLR, PLR and MLR associations with clinicopathological variables were determined using non-parametric tests.

RESULTS

Applying cut-offs of ⩾2.4 (NLR), ⩾240 (PLR) and ⩾0.19 (MLR), NLR and PLR (but not MLR) had independent prognostic significance. Combining NLR and PLR scores stratified patients into low (NLR-low and PLR-low), intermediate (NLR-high or PLR-high) and high risk (NLR-high and PLR-high) groups: multivariable hazard ratio (HR) 2.51; P<0.001 (OS); HR 2.26; P<0.01 (CSS) for high vs low risk patients. Increased NLR and PLR were most strongly associated with advanced stage (P<0.001), whereas increased MLR was strongly associated with older age (P<0.001).

CONCLUSION

Both NLR and PLR are independent prognostic indicators for endometrial cancer, which can be combined to provide additional patient stratification.

The vaginal and gastrointestinal microbiomes in gynecologic cancers: a review of applications in etiology, symptoms and treatment

The human microbiome is the collection of microorganisms in the body that exist in a mutualistic relationship with the host. Recent studies indicate that perturbations in the microbiome may be implicated in a number of diseases, including cancer. More specifically, changes in the gut and vaginal microbiomes may be associated with a variety of gynecologic cancers, including cervical cancer, uterine cancer, and ovarian cancer. Current research and gaps in knowledge regarding the association between the gut and vaginal microbiomes and the development, progression, and treatment of gynecologic cancers are reviewed here. In addition, the potential use of probiotics to manage symptoms of these gynecologic cancers is discussed. A better understanding of how the microbiome composition is altered at these sites and its interaction with the host may aid in prevention, optimization of current therapies, development of new therapeutic agents and/or dosing regimens, and possibly limit the side effects associated with cancer treatment.

ZEB1 expression in endometrial biopsy predicts lymph node metastases in patient with endometrial cancer

Purpose. The purpose of this study was to analyze the expression of zinc-finger E-box-binding homeobox 1 (ZEB1) in endometrial biopsy and its correlation with preoperative characteristics, including lymph node metastases in patient with endometrial cancer. Methods. Using quantitative RT-PCR, ZEB1 expressions in endometrial biopsy from 452 patients were measured. The relationship between ZEB1 expression and preoperative characteristics was analyzed. Results. ZEB1 expressions were significantly associated with subtype, grade, myometrial invasion, and lymph node metastases. Lymph node metastases could be identified with a sensitivity of 57.8% at specificity of 74.1% by ZEB1 expression in endometrial biopsy. Based on combination of preoperative characteristics and ZEB1 expression, lymph node metastases could be identified with a sensitivity of 62.1% at specificity of 96.2% prior to hysterectomy. Conclusion. ZEB1 expression in endometrial biopsy could help physicians to better predict the lymph node metastasis in patients with endometrial cancer prior to hysterectomy.

Mutational analysis of the tyrosine kinome in serous and clear cell endometrial cancer uncovers rare somatic mutations in TNK2 and DDR1

BACKGROUND

Endometrial cancer (EC) is the 8th leading cause of cancer death amongst American women. Most ECs are endometrioid, serous, or clear cell carcinomas, or an admixture of histologies. Serous and clear ECs are clinically aggressive tumors for which alternative therapeutic approaches are needed. The purpose of this study was to search for somatic mutations in the tyrosine kinome of serous and clear cell ECs, because mutated kinases can point to potential therapeutic targets.

METHODS

In a mutation discovery screen, we PCR amplified and Sanger sequenced the exons encoding the catalytic domains of 86 tyrosine kinases from 24 serous, 11 clear cell, and 5 mixed histology ECs. For somatically mutated genes, we next sequenced the remaining coding exons from the 40 discovery screen tumors and sequenced all coding exons from another 72 ECs (10 clear cell, 21 serous, 41 endometrioid). We assessed the copy number of mutated kinases in this cohort of 112 tumors using quantitative real time PCR, and we used immunoblotting to measure expression of these kinases in endometrial cancer cell lines.

RESULTS

Overall, we identified somatic mutations in TNK2 (tyrosine kinase non-receptor, 2) and DDR1 (discoidin domain receptor tyrosine kinase 1) in 5.3% (6 of 112) and 2.7% (3 of 112) of ECs. Copy number gains of TNK2 and DDR1 were identified in another 4.5% and 0.9% of 112 cases respectively. Immunoblotting confirmed TNK2 and DDR1 expression in endometrial cancer cell lines. Three of five missense mutations in TNK2 and one of two missense mutations in DDR1 are predicted to impact protein function by two or more in silico algorithms. The TNK2(P761Rfs*72) frameshift mutation was recurrent in EC, and the DDR1(R570Q) missense mutation was recurrent across tumor types.

CONCLUSIONS

This is the first study to systematically search for mutations in the tyrosine kinome in clear cell endometrial tumors. Our findings indicate that high-frequency somatic mutations in the catalytic domains of the tyrosine kinome are rare in clear cell ECs. We uncovered ten new mutations in TNK2 and DDR1 within serous and endometrioid ECs, thus providing novel insights into the mutation spectrum of each gene in EC.