Adenomyosis at a Glance: An Integrated Review of Transvaginal Ultrasound and MR Imaging Findings

Adenomyosis is a benign uterine disorder increasingly recognized in premenopausal women. Given its significant clinical burden, an accurate noninvasive diagnosis is paramount. Both transvaginal ultrasound (TVUS) and magnetic resonance (MR) provide an adequate assessment of adenomyosis, the former being recommended for first-line imaging evaluation and the latter being mainly used as a problem-solving technique. In this article, the authors review the TVUS and MR imaging findings of adenomyosis while referring to their histopathological background. Whereas direct signs correlate directly to ectopic endometrial tissue and are highly specific to adenomyosis, indirect signs result from myometrial hypertrophy and increase diagnostic sensitivity. Potential pitfalls, differential diagnoses, and frequently associated estrogen-dependent conditions are also discussed.

Effect of coexisting adenomyosis on tumour characteristics and prognosis of endometrial cancer: A systematic review and meta-analysis

To compare clinicopathological features and survival outcomes in patients with endometrial cancer, with and without associated adenomyosis. PubMed, Embase and Scopus databases were systematically searched for relevant observational studies. The pooled effect sizes were reported as either hazards ratio (HR) for survival-related outcomes or as odds ratio (OR) for other categorical outcomes. Weighted mean difference (WMD) was reported for continuous outcomes. All the analyses used the random effects model. A total of 21 studies (N = 46,420) were included. Compared to endometrial cancer patients without adenomyosis, patients with associated adenomyosis had improved overall 5-year survival (OS) (HR 0.62, 95% CI: 0.50, 0.79) and disease-free survival (DFS) (HR 0.60, 95% CI: 0.44, 0.82). Disease-specific survival was statistically similar in patients with and without adenomyosis (HR 0.60, 95% CI: 0.35, 1.05). Among patients with adenomyosis, the risk of having an advanced tumour grade (Grade 2 or 3) was lower (OR 0.51, 95% CI: 0.42, 0.62) and a risk of having International Federation of Gynaecology and Obstetrics (FIGO) stage I or II was higher (OR 2.23, 95% CI: 1.65, 3.01). Patients with adenomyosis had lower risk of tumour invasion of adnexa, cervical stromal invasion, deep myometrial involvement (DMI), lympho-vascular space invasion (LVSI) and peritoneal invasion. Presence of adenomyosis in patients with endometrial cancer is associated with favourable tumour characteristics and may improve the survival.

Endometrioid adenocarcinoma arising from adenomyosis: two case reports and a literature review

Background

Endometrioid adenocarcinoma is usually diagnosed by endometrial curettage with a positive rate of 94%, while a hysteroscopic examination can increase the positive rate. Differently, endometrioid adenocarcinoma arising from adenomyosis (EAAFA) is always misdiagnosed, even after endometrial curettage or hysteroscopy. EAAFA is rarely reported.

Case description

We reported two cases of EAAFA with long-term follow-ups of 9-10 years. The two cases were misdiagnosed even if endometrial curettage or hysteroscopy was performed. One case complained of postmenopausal vaginal bleeding with elevated CA199, and she was diagnosed by fast-frozen pathology during hysterectomy, followed by bilateral salpingo-oophorectomy and pelvic lymphadenectomy. In another case, a premenopausal woman with acquired progressive dysmenorrhea was diagnosed as EAAFA by the histopathological result after a transvaginal hysterectomy and had to undergo reoperation. The FIGO stage was IB in both cases. Chemotherapy or radiotherapy was performed after the operation. Patients were followed up for 9-10 years, with no metastasis or recurrence being observed.

Conclusion

The diagnosis of EAAFA is always delayed because of tumor-free eutopic endometrium and negative results of the endometrial curettage or hysteroscopy examination. Fast-frozen pathology of the whole uterus helps diagnose EAAFA precisely and avoids reoperation. Adenocarcinoma foci of EAAFA usually involve the myometrium deeply. A better prognosis of EAAFA should be expected due to good differentiation and negative lymphovascular space invasion.

Endometrioid adenocarcinoma arising in adenomyosis in a patient with pelvic organ prolapse-case report

BACKGROUND

Adenomyosis is a frequent finding in endometrial carcinoma patients. Endometrioid adenocarcinoma is the most common type of endometrial carcinoma; however, endometrioid adenocarcinoma arising from adenomyosis is extremely rare.

CASE PRESENTATION

In this case report, we describe a 69-year-old woman who required surgical treatment for pelvic organ prolapse (POP). The patient had been postmenopausal for 20 years and had no abnormal bleeding after menopause. The patient underwent transvaginal hysterectomy, repair of anterior and posterior vaginal walls, ischium fascial fixation and repair of an old perineal laceration. Histological examination of surgical specimens revealed endometrioid adenocarcinoma of the uterus. Bilateral adnexectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy were then performed. The postoperative histopathological diagnosis was stage IB endometrial cancer (endometrioid carcinoma G2).

CONCLUSIONS

In summary, endometrioid adenocarcinoma arising from adenomyosis (EC-AIA) is a rare entity and the early diagnosis is difficult. Adequate preoperative assessment and enhanced inquiry of occult clinical symptoms of postmenopausal women before hysterectomy may contribute to the diagnosis of EC-AIA preoperatively.

Endometrial Cancer Arising in Adenomyosis (EC-AIA): A Systematic Review

Endometrial cancer arising in adenomyosis (EC-AIA) is a rare uterine disease characterized by the malignant transformation of the ectopic endometrium within the adenomyotic foci. Clinicopathological and survival data are mostly limited to case reports and a few cohort studies. We aimed to assess the clinicopathological features and survival outcomes of women with EC-AIA through a systematic review of the literature. Six electronic databases were searched, from 2002 to 2022, for all peer-reviewed studies that reported EC-AIA cases. Thirty-seven EC-AIA patients from 27 case reports and four case series were included in our study. In our analysis, EC-AIA appeared as a rare disease that mainly occurs in menopausal women, shares symptoms with endometrial cancer, and is challenging to diagnose preoperatively. Differently from EC, it shows a higher prevalence of the non-endometrioid histotype, advanced FIGO stages, and p53-signature, which might be responsible for its worse prognosis. Future studies are necessary, to confirm our findings and further investigate this rare condition.

Carcinosarcoma of the uterus, derived from subserous cystic adenomyosis, presenting as an acute abdomen: A case report and review of the literature

When a woman presents with an acute abdomen with cystic lesions in the abdominal cavity, the differential diagnosis includes torsion or rupture of an ovarian tumor. We report our experience with a 54-year-old nulliparous woman who underwent emergency surgery for a suspected ruptured ovarian tumor. Intraoperative examination revealed disruption of a cystic tumor that had developed externally from the fundus of the uterus. The patient, who was taking aspirin because of a history of medullary infarction, reported lower abdominal discomfort for several days. When she sought care, she was referred to the gynecology department where transvaginal ultrasonography and contrast-enhanced computed tomography showed a poorly toned mass with a maximum diameter of 20 cm posterior to the uterus. She also had a large amount of ascites reaching around the liver and the spleen. She underwent an emergency laparotomy for a presumed diagnosis of acute abdomen caused by a ruptured ovarian tumor with intra-abdominal bleeding. Intraoperative examination revealed normal adnexae bilaterally, but there was a cystic tumor in the pouch of Douglas that was strongly adherent to the surrounding intestines. This mass was connected to the posterior uterus by a stalk and appeared to be continuous with the uterine tissue. The postoperative pathological diagnosis was carcinosarcoma derived from subserous cystic adenomyosis. This is the first case report of carcinosarcoma developing from subserous cystic adenomyosis in the English literature as far as we know.

MicroRNA-641 Inhibits Endometrial Cancer Progression via Targeting AP1G1

MicroRNA-641 (miR-641) was significantly decreased in various cancers, but its roles in endometrial cancer (EC) remain unclear. We explored the influences of miR-641 on the EC cells. In our study, the miR-641 expression was reduced in EC cells. Overexpression of miR-641 inhibited viability and proliferation of HEC-1A and HECCL-1 cells by CCK-8 and colony formation assays. Additionally, flow cytometry revealed that overexpression of miR-641 could remarkably promote apoptosis and arrest the cell cycle at the G1 phase of HEC-1A and HECCL-1 cells. Besides, forced expression of miR-641 suppressed the migration and invasion of HEC-1A and HECCL-1 cells as evidenced by wound healing and transwell assay. Moreover, AP1G1 was confirmed as a target gene of miR-641 by StarBase prediction and DLR assay and their expressions were negatively correlated. Overexpression of AP1G1 neutralized the roles of miR-641 mimic on the viability, proliferation, apoptosis, and migration of HEC-1A and HECCL-1 cells. Our findings illustrated that miR-641 was reduced in the EC cells and AP1G1 antagonized the miR-641 mimic-induced inhibition of the EC progression in vitro. Therefore, miR-641 may emerge as an effective molecule for EC treatment.

The Sonographic Appearance of Endometrial Intraepithelial Neoplasia

OBJECTIVES

To describe the sonographic findings of endometrial intraepithelial neoplasia (EIN), a precursor of endometrial cancer.

METHODS

Cases were found by word search of pathology database 1/2013 to 6/2019. One hundred and seventy-eight patients with ultrasound <1 year prior to biopsy were included. Medical records were searched for patient data. Two radiologists blindly classified images. Differences of opinion were decided by clinical report. Univariate and multivariate analyses were performed.

RESULTS

Median time between ultrasound and first sampling procedure was 49 days. Median age was 55 (range 28-85) years. Endometrial thickness ranged from 2 to 90 mm. Mean endometrial thickness was 13 ± 6 mm in the noncancer group and 16 ± 11 mm in the cancer group (P = .02). The endometrium was almost always heterogeneous 175/178 (98%). Cysts were almost always multiple (89/109, 82%) and >1 mm (72/109, 66%). Masses were most often >5 mm (56/105, 55%) and ill-defined (41/105, 39%). Vascularity was present in 93/178 examinations (52%) and always associated with cysts and/or mass. There were 92 cancers, 25 with invasion (including 4 with tumor extension into adenomyosis). In 47 cases, the endometrial-myometrial interface was graded as ill-defined, 39 of whom had hysterectomy. There was macroscopic cancer in 11, microscopic cancer in 4, and invasive carcinoma in 12 patients (P for invasive cancer versus other outcomes = .02). Depth of invasion was 5- >95%, with 6 cancers >50%. Multivariate analysis showed thickness, polyps, and type of bleeding as the best set of independent variables for cancer (area under the receiver operating characteristic (ROC) curve [AUC] = .75). Replacing type of bleeding with age or menopausal status had AUC of .73 and .74, respectively.

CONCLUSIONS

EIN has a variety of sonographic appearances with thickened endometrium with cysts and masses being common. Ill-definition of the endometrial-myometrial interface is a poor prognostic finding when seen in the absence of adenomyosis.

Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse – A retrospective cohort study

Background

Adenomyosis can cause symptoms like dysmenorrhea, dyspareunia, pelvic pain and bleeding disorders and is related to subfertility and obstetrical complications. The disease is probably underestimated and underdiagnosed because of difficulties in reliable clinical examination and imaging results. The age-related prevalence of adenomyosis still remains unclear. In this retrospective analysis we describe the rate of adenomyosis in two independent cohorts of patients undergoing hysterectomy for benign diseases (2011–2013 and 2015–2018) and its correlation to presurgical symptoms respectively indications for hysterectomy.

Materials and methods

All surgeries have been performed in the same department of minimally invasive gynecological surgery by a total of two experienced surgeons following a surgical internal standard for the indication bleeding disorder, dysmenorrhea. We analyzed the overall rate of patients with adenomyosis in both cohorts and related the histological presence of adenomyosis to presurgical symptoms. We also analyzed a subgroup of postmenopausal patients with uterine prolapse.

Results

In 307 patients we detected 42.0% of cases with histologically proven adenomyosis. In the group of patients with bleeding disorders and dysmenorrhea as indication for surgery we found the highest rate of adenomyosis (59.3%, cohort 1). 81,1% patients with adenomyosis (cohort 1) reported symptoms. In the subgroup of 42 postmenopausal patients, we found 23.8% of cases with adenomyosis.

Conclusion

Our data shows that a positive anamnesis regarding the symptoms bleeding disorders and dysmenorrhea is suspicious for adenomyosis. In hysterectomy specimen adenomyosis can be found in more than 40%. The role of adenomyosis-related symptoms requires further investigation, especially in adolescent and postmenopausal patients.

•

In 307 patients undergoing hysterectomy we detected 42.0% of cases with adenomyosis.

•

In patients with bleeding disorders and dysmenorrhea we found the highest rate of adenomyosis (59.3%).

•

81,1% of patients with adenomyosis reported symptoms.

•

In 58.9% of patients with adenomyosis we found additional fibroids.

•

In 42 postmenopausal patients we found adenomyosis in 23.8% of cases.

Long-term incidence of endometrial cancer after endometrial resection and ablation: A population based Swedish gynecologic cancer group (SweGCG) study

INTRODUCTION

Minimally invasive methods to reduce menorrhagia were introduced in the 1980s and 1990s. Transcervical endometrial resection (TCRE) and endometrial ablation (EA) are two of the most frequently used methods. As none of them can guarantee a complete removal of the endometrium, there are concerns that the remaining endometrium may develop to endometrial cancer (EC) later in life. The primary aim was to analyze the long-term incidence of EC after TCRE and EA in a nationwide population. The secondary aim was to assess the two treatment modalities separately.

MATERIAL AND METHODS

The Swedish National Patient Registry and National Quality Registry for Gynecological Surgery were used for identification of women who had TCRE or EA performed between 1997-2017. The cohort was followed from the first TCRE or EA until hysterectomy, diagnosis of EC, or death. Follow-up data were retrieved from the National Cancer Registry and the National Death Registry. Expected incidence for EC in Swedish women was calculated using Swedish data retrieved from the NORDCAN project after having taken into account differences of age and follow-up time. Cumulative incidence of EC after TCRE and EA, was calculated. A standardized incidence ratio was calculated based on the expected and observed incidence, stratified by age and year of diagnosis.

RESULTS

In total, 17 296 women (mean age 45.1 years) underwent TCRE (n = 8626) or EA (n = 8670). Excluded were 3121 who had a hysterectomy for benign causes during follow up. During a median follow-up time of 7.1 years (interquartile range 3.1-13.3 years) the numbers of EC were 25 (0.3%) after TCRE and 2 (0.02%) after EA, respectively. The observed incidence was significantly lower than expected (population-based estimate) after EA but not after TCRE, giving a standardized incidence ratio of 0.13 (95% confidence interval [CI] 0.03-0.53) after EA and 1.27 (95% CI 0.86-1.88) after TCRE. Median times to EC were 3.0 and 8.3 years after TCRE and EA, respectively.

CONCLUSIONS

There was a significant reduction of EC after EA, suggesting a protective effect, whereas endometrial resection showed an incidence within the expected rate.

The Role of mTOR and eIF Signaling in Benign Endometrial Diseases

Adenomyosis, endometriosis, endometritis, and typical endometrial hyperplasia are common non-cancerous diseases of the endometrium that afflict many women with life-impacting consequences. The mammalian target of the rapamycin (mTOR) pathway interacts with estrogen signaling and is known to be dysregulated in endometrial cancer. Based on this knowledge, we attempt to investigate the role of mTOR signaling in benign endometrial diseases while focusing on how the interplay between mTOR and eukaryotic translation initiation factors (eIFs) affects their development. In fact, mTOR overactivity is apparent in adenomyosis, endometriosis, and typical endometrial hyperplasia, where it promotes endometrial cell proliferation and invasiveness. Recent data show aberrant expression of various components of the mTOR pathway in both eutopic and ectopic endometrium of patients with adenomyosis or endometriosis and in hyperplastic endometrium as well. Moreover, studies on endometritis show that derangement of mTOR signaling is linked to the establishment of endometrial dysfunction caused by chronic inflammation. This review shows that inhibition of the mTOR pathway has a promising therapeutic effect in benign endometrial conditions, concluding that mTOR signaling dysregulation plays a critical part in their pathogenesis.

The impact of uterine adenomyosis on the histopathological risk factors and survival in patients with endometrial adenocarcinoma

A retrospective cohort study was performed on patients diagnosed with endometrial adenocarcinoma (EC) during a 9-year period to investigate the impact of co-existing adenomyosis on patients with EC. Group A included women with EC and adenomyosis and Group B EC cases without the presence of adenomyosis. Group A was more likely to have early-stage disease, tumours without deep myometrial invasion, low-grade tumours and tumours with negative lymphovascular space invasion when compared to Group B (p = 0.012, p = 0.004, p < 0.001, p = 0.02). There were no statistically significant difference between Group A and Group B for lymph node metastasis (p = 0.064). There was no significant relation between the adenomyosis and survival outcomes in the multivariant analysis (p = 0.437). As a conclusion, patients with adenomyosis were more likely to accompany good histopathologic prognostic factors. Multivariate analysis showed no significant effect of adenomyosis on recurrence and survival parameters.IMPACT STATEMENTWhat is already known on this subject? Adenomyosis is one of the most common accompanying benign histopathological findings of type 1 endometrial carcinomas (EC). Adenomyosis comprises some characteristics similar to malignant tumours, such as invasion, abnormal tissue growth and angiogenesis. Despite concerns have arisen due to both their high incidence and similar molecular links, the possible relation between EC and adenomyosis is still not well grounded.What the results of this study add? We presented a 9-year period retrospective cohort of a tertiary referring single centre and evaluated the prognostic effect of adenomyosis in patients with EC as well as the survival outcomes of these patients. The co-occurrence of adenomyosis was more likely to accompany early-stage (stages 1-2) disease, low-grade tumours (grades 1-2) and tumours with negative LVSI in patients with EC. However, multivariate and survival analysis showed no significant effect of adenomyosis on recurrence and survival parameters.What the implications are of these findings for clinical practice and/or further research? Based on these findings, we suggest that the presence of adenomyosis should not be considered as a prognostic factor in EC. Our results support the overriding opinion about the prognostic value of co-occurrence of adenomyosis and EC. However, further studies exploring the molecular and genomic markers in these two groups are needed to uncover the exact relation of adenomyosis on the prognosis of EC.

Adenomyosis as a Risk Factor for Myometrial or Endometrial Neoplasms-Review

Adenomyosis is a common benign gynecological condition, defined as an extension of endometrial tissue into the myometrium. Some studies suggest that adenomyosis could be a favorable prediction factor associated with survival outcomes in endometrial cancer. The aim of our systematic review was to investigate the current knowledge regarding adenomyosis and a possible molecular mechanism of carcinogenesis in adenomyotic lesions. In addition, the long-term prognosis for patients with endometrial cancer and coexisting adenomyosis (and endometriosis) was a key point of the research. The current literature was reviewed by searching PubMed, using the following phrases: "adenomyosis and endometrial cancer" and "malignant transformation of adenomyosis". According to the literature, genetic mutations, epigenetic changes, and inactivation of specific tumor suppressor genes in adenomyosis are still poorly understood. Data regarding the influence of adenomyosis on survival outcomes in endometrial cancer seem to be contradictory and require further clinical and molecular investigation.

The effect of adenomyosis on endometrial cancer: a university hospital-based cohort study

Endometrial cancer (EC) can coexist with gynaecological diseases including adenomyosis which can be defined as the location of endometrial cells within the myometrium. Our aim was to clarify the impact of adenomyosis on the clinical and survival outcomes of EC. We included the patients who underwent an operation for EC and had concurrent adenomyosis in this retrospective cohort study. All clinicodemographical and tumour characteristics with survival outcomes of the patients were analysed comparatively. A total of 763 patients who met the eligibility criteria were included. Of those, 591 patients in the non-adenomyosis group and 172 patients in the adenomyosis group were examined. Disease-specific survival (DSS) was significantly prolonged while progression-free survival (PFS) was not affected by the presence of adenomyosis (p = .004 vs. p = .161). However, adenomyosis did not remain as an independent prognostic factor for EC in multivariate analysis (p = .341). These patients with coexistent adenomyosis and EC have better clinicopathological characteristics and less advanced tumour. Although adenomyosis is associated with prolonged DSS, it has no prognostic importance for survival outcomes of the patients with EC.IMPACT STATEMENTWhat is already known on this subject? Endometrial cancer (EC) can coexist with other gynaecological diseases including uterine adenomyosis. Adenomyosis is typically diagnosed by the pathological evaluation of the uterus following hysterectomy, although diagnosis is possible with imaging methods However, the coexistence of adenomyosis and EC is controversial in the literature.What do the results of this study add? To the best of our knowledge, our study is the largest study performed at a single university hospital. All potential confounding factors including clinicodemographical characteristics of the patients, examination of histopathology slides by the experienced gynaecological pathologists, evaluation of all included factors that may affect the survival outcomes of EC by multivariate analysis were examined. Although adenomyosis is associated with prolonged disease-specific survival (DSS), it has no prognostic importance for survival outcomes of the patients with EC.What are the implications of these findings for clinical practice and/or further research? Women having coexistent adenomyosis and EC should be informed about the impact of adenomyosis on the survival outcomes of EC.

Long non-coding RNA SOS1-IT1 promotes endometrial cancer progression by regulating hypoxia signaling pathway

Endometrial cancer (EC) is one of the most common types of gynecological cancer. Hypoxia is an important clinical feature and regulates various tumor processes. However, the prognostic value of hypoxia-related lncRNA in EC remains to be further elucidated. Here, we aimed to characterize the molecular features of EC by the development of a classification system based on the expression profile of hypoxia-related lncRNA. Based on univariate Cox regression analysis, we identified 17 hypoxia-related lncRNAs significantly associated with overall survival. Next, the least absolute shrinkage and selection operator Cox regression model was utilized to construct a multigene signature in the TCGA EC cohort. The risk score was confirmed as an independent predictor for overall survival in multivariate Cox regression analysis and receiver operating characteristic (ROC) curve analysis. Besides, the survival time of EC patients in different risk group was significantly correlated to clinicopathologic factors, such as age, stage and grade. Furthermore, hypoxia-related lncRNA associated with the high-risk group were involved in various aspects of the malignant progression of EC via Gene Ontology, Kyoto Encyclopedia of Genes and Genomes pathway, and Gene Set Enrichment Analysis. Moreover, the risk score was closely correlated to immunotherapy response, microsatellite instability and tumor mutation burden. Finally, we select one hypoxia-related lncRNA SOS1-IT1 to validate its role in hypoxia and EC progression. Interestingly, we found SOS1-IT1 was overexpressed in tumor tissues, and closely correlated with clinicopathological parameters of EC. The expression level of SOS1-IT1 was significantly increased under hypoxia condition. Additionally, the important hypoxia regulatory factor HIF-1α can directly bind SOS1-IT1 promoter region, and affect its expression level. In summary, this study established a new EC classification based on the hypoxia-related lncRNA signature, thereby provide a novel sight to understand the potential mechanism of human EC development.

Ectopic Endometrium: The Pathologist's Perspective

Endometriosis and adenomyosis are two frequent diseases closely linked, characterized by ectopic endometrium. Despite their benign nature, endometriosis and adenomyosis impair women's quality of life by causing pain and infertility and an increase in the incidence of gynecological malignancies has been reported. Since the first description of ectopic endometrium in 1860, different attempts have been made to describe, classify and understand the origin of these diseases. Several theories have been proposed to describe the pathogenic mechanism leading to the development of adenomyosis or endometriosis. However, all the hypotheses show some limitations in explaining all the different aspects and manifestations of these diseases. Despite the remarkable progress made over recent years, the pathogeneses of endometriosis and adenomyosis remain unclear. Moreover, because of the lack of standardized protocols and diagnostic criteria in pathology practice it is difficult to study and to classify these disorders. The goal of this review is to summarize the pathological aspects of adenomyosis and endometriosis, spanning a historical perspective to newly reported data.

[S2k guidelines for the diagnosis and treatment of endometriosis-Recommendations for pathology]

Die vorliegende Übersicht fasst die relevanten Aspekte der S2k-Leitlinie Endometriose zusammen. Die Empfehlungen umfassen die Aufarbeitung und Befunderhebung bei Biopsien und Resektaten, die bei der klinischen Diagnose einer Endometriose entnommen wurden. Die Leitlinie berücksichtigt neben praktischen Aspekten der Pathologie ebenso die klinischen Notwendigkeiten an die Histopathologie für eine optimale Diagnostik und Therapie der Patientinnen.

Basierend auf der in der pathologischen Literatur gebräuchlichsten Definition der Endometriose des Corpus uteri (Adenomyosis uteri) wurde diese in der Leitlinie definiert als der Nachweis des Endometrioseherdes im Myometrium in einem Abstand zur endomyometranen Grenze von einem mittelgroßen Gesichtsfeld (100fache Vergrößerung), was metrisch rund 2,5 mm entspricht. Bei Darmresektaten soll zum Status der Resektionsränder Stellung genommen werden.

Ebenso definiert werden Anforderungen im Kontext endometrioseassoziierter Karzinome (z. B. Hormonrezeptorbestimmungen, immunhistochemische Untersuchung auf Ausfall der DNA-Mismatch-Reparaturproteine).

Clinical Characteristics of Patients with Endometrial Cancer and Adenomyosis

Simple Summary

Endometrial cancer (EC) reportedly have a better prognosis in patients with coexistent adenomyosis. It is possible to hypothesize that this difference may be attributable to different clinical profiles. On this account, we aimed to define the clinical profile of endometrial cancer (EC) patients with and without adenomyosis through a systematic review and meta-analysis. We included 8 studies with 5681 patients and found that EC women with adenomyosis were less likely to be nulliparous than EC women without adenomyosis, while no significant differences were found with regard to age, BMI, and premenopausal status.

Abstract

A better endometrial cancer (EC) prognosis in patients with coexistent adenomyosis has been reported. Unfortunately, it is still unclear if this better prognosis is related to a more favorable clinical profile of adenomyosis patients. We aimed to evaluate differences in the clinical profiles of EC patients with and without adenomyosis. A systematic review and meta-analysis was performed by searching seven electronics databases for all studies that allowed extraction of data about clinical characteristics in EC patients with and without adenomyosis. Clinical characteristics assessed were: age, Body Mass Index (BMI), premenopausal status, and nulliparity. Mean difference in mean ± standard deviation (SD) or odds ratio (OR) for clinical characteristics between EC patients with and without adenomyosis were calculated for each included study and as a pooled estimate, and graphically reported on forest plots with a 95% confidence interval (CI). The Z test was used for assessing the overall effect by considering a p value < 0.05 as significant. Overall, eight studies with 5681 patients were included in the qualitative analysis, and seven studies with 4366 patients in the quantitative analysis. Pooled mean difference in mean ± SD between EC women with and without adenomyosis was −1.19 (95% CI: −3.18 to 0.80; p = 0.24) for age, and 0.23 (95% CI: −0.62 to 1.07; p = 0.60) for BMI. When compared to EC women without adenomyosis, EC women with adenomyosis showed a pooled OR of 1.53 (95% CI: 0.92 to 2.54; p = 0.10) for premenopausal status, and of 0.60 (95% CI: 0.41 to 0.87; p = 0.007) for nulliparity. In conclusion, there are not significant differences in clinical characteristics between EC patients with and without adenomyosis, with the exception for nulliparity. Clinical features seem to not underlie the better EC prognosis of patients with adenomyosis compared to patients without adenomyosis.

Impact of adenomyosis on the prognosis of patients with endometrial cancer

Background

Despite the high prevalence of adenomyosis in hysterectomy specimens of endometrial carcinoma (EC) patients, the relationship between adenomyosis and EC prognosis appears unclear.

Objective

To assess the prognostic value of coexistent adenomyosis in patients with EC.

Methods

A systematic review and meta‐analysis was performed by searching six electronic databases for studies reporting data on prognosis of EC patients with and without coexistent adenomyosis. Studies with patient selection based on prognostic factors were excluded. Pooled univariate hazard ratio (HR) analyses for overall survival (OS) and disease‐free survival (DRF) were performed, using EC patients without adenomyosis as a control group. For DFS, pooled multivariate HR analysis was also evaluable.

Results

Three studies of 2505 EC patients (553 with and 1952 without adenomyosis) were included. Compared with EC patients without adenomyosis, EC patients with coexistent adenomyosis showed a pooled HR of 0.533 (CI 95%, 0.329–0.864) for OS at univariate analysis; 0.536 (CI 95%, 0.334–0.859) for DFS at univariate analysis; and 0.875 (CI 95%, 0.331–2.315) for DFS at multivariate analysis.

Conclusion

In EC patients with coexistent adenomyosis, the risk of death is halved compared with EC patients without adenomyosis. However, the independence of this association needs to be verified in future studies.

The risk of death is halved in EC patients with coexistent adenomyosis compared with EC patients without adenomyosis, whereas the risk of EC recurrence does not appear to be affected.

Benign Uterine Disease: The Added Role of Imaging

Benign uterine diseases are very common gynecologic conditions that affect women mostly in reproductive age. Ultrasound examination is the first-line imaging technique, but MRI is more accurate for diagnosis, characterization, and patient management. In this review, we especially highlight the added value of MRI in the diagnosis of benign uterine disease, discuss their imaging characteristics, and describe the therapeutic options and the added value of MRI in the treatment planning.

Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis

INTRODUCTION

Several studies have assessed the histological co-existence of endometrial carcinoma (EC) and adenomyosis. However, the significance of this association is still unclear.

OBJECTIVE

To assess the prevalence of adenomyosis in women with EC for a better understanding of the association between the two diseases.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed by searching electronics databases from their inception to March 2020, for all studies that allowed extraction of data about prevalence of adenomyosis in EC patients. Adenomyosis prevalence was calculated for each included study and as pooled estimate, with 95% confidence interval (CI).

RESULTS

Eight retrospective cohort studies assessing 5573 EC patients were included in our analysis. Of total, 1322 were patients with adenomyosis, and 4251 were patients without adenomyosis. Pooled prevalence of adenomyosis in EC patients was 22.6% (95% CI 12.7-37.1%).

CONCLUSION

Adenomyosis prevalence in EC patients was not different from that reported for other gynecological conditions. The supposed association between the two diseases appears unsupported.

Eye to the Future in Adenomyosis Research

Adenomyosis is a poorly understood and clinically underappreciated gynecologic disorder associated with substantial morbidity including dysmenorrhea, pelvic pain, heavy menstrual bleeding, infertility, and poor pregnancy outcomes. Substantial gaps persist in our understanding of essentially all aspects of this disorder - epidemiology, risk factors, pathogenesis, pathophysiology, diagnosis, and treatment. In this article, we summarize current thoughts on future directions in basic, translational, and clinical adenomyosis research.

Report of the National Cancer Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development-sponsored workshop: gynecology and women's health-benign conditions and cancer

The Division of Cancer Prevention and the Division of Cancer Biology at the National Cancer Institute and the Gynecologic Health and Disease Branch in the National Institute of Child Health and Human Development organized a workshop in April 2019 to explore current insights into the progression of gynecologic cancers from benign conditions. Working groups were formed based on 3 gynecologic disease types: (1) Endometriosis or Endometrial Cancer and Endometrial-Associated Ovarian Cancer, (2) Uterine Fibroids (Leiomyoma) or Leiomyosarcoma, and (3) Adenomyosis or Adenocarcinoma. In this report, we highlight the key questions and current challenges that emerged from the working group discussions and present potential research opportunities that may advance our understanding of the progression of gynecologic benign conditions to cancer.

Origin and Pathogenic Mechanisms of Uterine Adenomyosis: What Is Known So Far

Uterine adenomyosis is a benign disease, commonly encountered in reproductive-age women and responsible for chronic pelvic pain, abnormal uterine bleeding, and infertility. Although the exact origin and pathogenic mechanisms involved in adenomyosis still need to be elucidated, significant progress has been made over recent years. Ever since the theory of endometrium invaginating the myometrium via a traumatized interface was first proposed, numerous molecular mechanisms have been reported to participate in this process. At the same time, an alternative theory has suggested de novo development of adenomyotic lesions from metaplasia of Müllerian remnants or adult stem cells. Hence, our understanding of the pathogenesis of adenomyosis has been greatly enhanced and is anticipated to pave the way for development of an effective and safe treatment. The goal of this review is to analyze current knowledge on the origin and pathogenic mechanisms of adenomyosis, ranging from the most widely accepted theories to newly reported data.

Quercetin Inhibits Adenomyosis by Attenuating Cell Proliferation, Migration and Invasion of Ectopic Endometrial Stromal Cells

Purpose

To evaluate the effects of quercetin on proliferation, invasion and migration of endometrial stromal cells (ESCs) from adenomyosis patients.

Methods

Primary ectopic ESCs (EESCs) and eutopic ESCs (EuESCs) were obtained and purified from patients undergoing total hysterectomy for adenomyosis and identified by immunocytochemistry staining. The cytotoxicity and inhibition rate were determined by CCK-8 assay to obtain the IC₅₀ value. Cell proliferative, migratory, and invasive abilities were detected by BrdU, wound scratch, transwell assays, respectively. Western blot analysis was employed to explore the effects of quercetin on the expression of MMP-2, MMP-9, Ezrin and Fascin proteins in cells.

Results

Both EESCs and EuESCs were characterized with strongly positive staining for vimentin and almost negative for cytokeratin. Quercetin inhibited the viability of EESCs and EuESCs in a dose- and time-dependent manner, with an IC₅₀ = 33.00 μM for EuESCs and IC₅₀ = 74.88 μM for EESCs at 72 h. Thus, the final concentrations and action time of quercetin in EuESCs (0, 20, 40, and 80 μM for 72 h) and EESCs (0, 40, 80, and 160 μM for 72 h) were selected. BrdU assay showed that quercetin dose-dependently suppressed the proliferation of EESCs and EuESCs, while the inhibition rate in EESCs was higher. Similarly, administration of quercetin in EESCs and EuESCs significantly decreased the motility and invasiveness in a dose-dependent fashion, with stronger inhibitory effects on EESCs. Finally, Western blot analysis demonstrated that invasion- and migration-related proteins (MMP-2, MMP-9, Erzin, and Fascin) were significantly downregulated with the quercetin concentration increasing. Moreover, the decreased level of these proteins in EESCs under quercetin exposure was greater than that in EuESCs.

Conclusion

Quercetin can inhibit the proliferation of EESCs in adenomyosis and reduce their mobility and invasiveness. These inhibitory effects may be related to the downregulation of MMP-2, MMP-9, Fascin, and Erzin proteins.

The clinicopathological characteristics and survival outcomes of endometrial carcinoma coexisting with or arising in adenomyosis: A pilot study

Little is known about the epidemiological and clinicopathological characteristics of endometrial endometrioid carcinoma (EEC) coexisting with or arising in adenomyosis (EEC-A or EEC-AIA) due to their rarity. This study compared EEC-A and EEC-AIA with endometrial carcinoma without adenomyosis. Cases of endometrial cancer treated at the study center from June 1, 2010, to June 1, 2017, were reviewed. The epidemiological, clinicopathological characteristics and survival outcomes were compared among three groups of endometrioid subtypes: group A, stage IA endometrial carcinoma patients without coexisting adenomyosis; group B, patients with EEC-A; and group C, patients with EEC-AIA. Among the 2080 patients reviewed, groups A, B, and C included 1043, 230 and 28 patients, respectively. Patients in group A and group B had similar clinicopathological and survival outcomes. Patients in group C were significantly younger and had less gravidity and parity than patients in groups A and B. More tumors from group C were grade 1, and they had a smaller maximum diameter and less mismatch repair deficiency than those from groups A and B. After a median follow-up of 57.0 months, the 5-year disease-free survival (DFS) rates of groups A, B and C were 96%, 91% and 100% (p = 0.045), respectively; the 5-year overall survival (OS) rates were 98%, 93% and 100%, respectively (p = 0.001), in the Kaplan-Meier analysis. However, these difference disappeared in a subgroup of stage IA patients in univariate and multivariate analysis. Cox regression analysis in stage IA patients also revealed no significant differences in survival outcome across the three groups. In conclusion, EEC-AIA exhibited specific clinicopathological characteristics that were probably associated with favorable survival outcomes. The characteristics and survival outcomes of EEC-A were similar to those of EEC without adenomyosis in stage IA patients.

Co-existence of leiomyomas, adenomyosis and endometriosis in women with endometrial cancer

Leiomyomas, adenomyosis, and endometriosis are reported to be risk factors for endometrial carcinoma (EC), and adenomyosis and endometriosis also for ovarian carcinoma (OC). We aimed to describe the prevalence of these conditions in EC patients with or without an OC diagnosis, and to investigate their relationship with EC risk and prognostic factors in these patients. We evaluated the co-existence of these three conditions in 1399 EC patients, and compared the prevalence of epidemiological risk factors and tumor prognostic features in patients with each condition versus not. Prevalence of conditions was also assessed in the subset of patients with prior/concurrent OC. The observed coexistence of leiomyomas, adenomyosis and endometriosis significantly deviated from that expected (P = 1.2 × 10-8). Patients were more likely to: report a younger age at menarche (PTrend = 0.004) if they had leiomyomas; have used oral contraceptives (P = 6.6 × 10-5) or had ≥2 full-term pregnancies (PTrend = 2.0 × 10-9) if they had adenomyosis; be diagnosed with EC at younger age (P = 5.0 × 10-11) if they had endometriosis. Patients with prior/concurrent OC were more likely to be diagnosed at younger age (P = 5.0 × 10-5), have endometriosis (P = 9.9 × 10-7), and present with higher stage EC (PTrend = 6.6 × 10-5). These findings justify further consideration of these gynecologic conditions as independent risk and prognostic factors for EC.