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Kaur H, Qadri S, Nevill AM, Ewies AAA. The optimal endometrial thickness threshold for prediction of endometrial cancer in postmenopausal women without bleeding remains uncertain-Systematic review and meta-analysis. J Gynecol Obstet Hum Reprod 2024; 53:102831. [PMID: 39127112 DOI: 10.1016/j.jogoh.2024.102831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/22/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024]
Abstract
The incidental finding of endometrial thickness (ET) >4 mm in the absence of postmenopausal bleeding (PMB) is a common cause of referring women to secondary care. However, there is lack of consensus amongst gynecologists as regards the management. It is estimated that up to 15 % of endometrial cancers occur in women without PMB. The aim this study was to determine the optimal ET threshold, on trans-vaginal ultrasound scan, that discriminates normal endometrium from endometrial hyperplasia and cancer in this cohort. On using a thorough search strategy, a total 16 studies including 4088 women were deemed eligible. However, the data were not amenable to meta-analysis. There were wide variations in the thresholds reported with potential bias given the retrospective nature of the majority of the studies. Despite contacting authors, we could not obtain the primary data to generate a Receiver Operating Characteristic (ROC) Curve. No linear or curvilinear association was found between ET thresholds and the percentage of women diagnosed with endometrial hyperplasia and cancer using either Pearson's correlation, linear or curvilinear regression, or a simple visual scan/scatter diagram. The result of this study reveals the lack of evidence to inform clinical practice in this area, and there is a need for a well-designed multi-center prospective study.
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Affiliation(s)
- Harpreet Kaur
- Speciality trainee in Department of Gynecology, Sandwell and West Birmingham Hospitals NHS Trust (SWBH), Birmingham, UK
| | - Shahin Qadri
- Speciality registrar in Department of Gynecology, Sandwell and West Birmingham Hospitals NHS Trust (SWBH), Birmingham, UK
| | | | - Ayman A A Ewies
- Consultant Gynecologist in Sandwell and West Birmingham Hospitals NHS Trust (SWBH) and Visiting Senior Lecturer in University of Aston, Birmingham, UK.
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2
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Suzuki Y, Ferris JS, Chen L, Dioun S, Usseglio J, Matsuo K, Xu X, Hershman DL, Wright JD. Levonorgestrel-releasing intrauterine device therapy vs oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia: a systematic review and meta-analysis. J Natl Cancer Inst 2024; 116:653-664. [PMID: 38305500 DOI: 10.1093/jnci/djae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/14/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis to examine outcomes of patients with endometrial intraepithelial neoplasia treated with oral progestins or a levonorgestrel-releasing intrauterine device (IUD). METHODS We conducted a systematic review across 5 databases to examine outcomes of progestational treatment (oral progestins or levonorgestrel-releasing IUD) for patients with endometrial intraepithelial neoplasia. The primary outcome was the best complete response rate within 12 months of primary progestational treatment. Sensitivity analyses were performed by removing studies with extreme effect sizes. Secondary outcomes included the pooled pregnancy rate. RESULTS We identified 21 eligible studies, including 824 premenopausal patients with endometrial intraepithelial neoplasia, for our meta-analysis. Among these, 459 patients received oral progestin, and 365 patients received levonorgestrel-releasing IUD as a primary progestational treatment. The pooled best complete response proportion within 12 months was 82% (95% confidence interval [CI] = 69% to 91%) following oral progestin treatment and 95% (95% CI = 81% to 99%) following levonorgestrel-releasing IUD treatment. After removing outlier studies, the pooled proportion was 86% (95% CI = 75% to 92%) for the oral progestin group and 96% (95% CI = 91% to 99%) for the levonorgestrel-releasing IUD group, with reduced heterogeneity. The pooled pregnancy rate was 50% (95% CI = 35% to 65%) after oral progestin and 35% (95% CI = 23% to 49%) after levonorgestrel-releasing IUD treatment. CONCLUSIONS This meta-analysis provides data on the effectiveness of oral progestins and levonorgestrel-releasing IUD treatment within 12 months of treatment among premenopausal patients with endometrial intraepithelial neoplasia. Although based on small numbers, the rate of pregnancy after treatment is modest. These data may be beneficial for selecting progestational therapies that allow fertility preservation for patients with endometrial intraepithelial neoplasia.
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Affiliation(s)
- Yukio Suzuki
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jennifer S Ferris
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ling Chen
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shayan Dioun
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - John Usseglio
- Augustus C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Matsuo
- University of Southern California, Los Angeles, CA, USA
| | - Xiao Xu
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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3
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Shiwani H, Clement NS, Daniels JP, Atiomo W. Metformin for endometrial hyperplasia. Cochrane Database Syst Rev 2024; 5:CD012214. [PMID: 38695827 PMCID: PMC11064888 DOI: 10.1002/14651858.cd012214.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. OBJECTIVES To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. MAIN RESULTS We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low-certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health-related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low-certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health-related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low-certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health-related quality of life. AUTHORS' CONCLUSIONS Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long-term outcome data are still needed to address this clinical question.
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Affiliation(s)
- Hunain Shiwani
- Faculty of Population Health Sciences, University College London, London, UK
| | - Naomi S Clement
- Department of Obstetrics & Gynaecology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - William Atiomo
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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McCoy CA, Coleman HG, McShane CM, McCluggage WG, Wylie J, Quinn D, McMenamin ÚC. Factors associated with interobserver variation amongst pathologists in the diagnosis of endometrial hyperplasia: A systematic review. PLoS One 2024; 19:e0302252. [PMID: 38683770 PMCID: PMC11057740 DOI: 10.1371/journal.pone.0302252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVE Reproducible diagnoses of endometrial hyperplasia (EH) remains challenging and has potential implications for patient management. This systematic review aimed to identify pathologist-specific factors associated with interobserver variation in the diagnosis and reporting of EH. METHODS Three electronic databases, namely MEDLINE, Embase and Web of Science, were searched from 1st January 2000 to 25th March 2023, using relevant key words and subject headings. Eligible studies reported on pathologist-specific factors or working practices influencing interobserver variation in the diagnosis of EH, using either the World Health Organisation (WHO) 2014 or 2020 classification or the endometrioid intraepithelial neoplasia (EIN) classification system. Quality assessment was undertaken using the QUADAS-2 tool, and findings were narratively synthesised. RESULTS Eight studies were identified. Interobserver variation was shown to be significant even amongst specialist gynaecological pathologists in most studies. Few studies investigated pathologist-specific characteristics, but pathologists were shown to have different diagnostic styles, with some more likely to under-diagnose and others likely to over-diagnose EH. Some novel working practices were identified, such as grading the "degree" of nuclear atypia and the incorporation of objective methods of diagnosis such as semi-automated quantitative image analysis/deep learning models. CONCLUSIONS This review highlighted the impact of pathologist-specific factors and working practices in the accurate diagnosis of EH, although few studies have been conducted. Further research is warranted in the development of more objective criteria that could improve reproducibility in EH diagnostic reporting, as well as determining the applicability of novel methods such as grading the degree of nuclear atypia in clinical settings.
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Affiliation(s)
- Chloe A. McCoy
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Helen G. Coleman
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Charlene M. McShane
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - W. Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | - James Wylie
- Department of Obstetrics and Gynaecology, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, Northern Ireland, United Kingdom
| | - Declan Quinn
- Department of Obstetrics and Gynaecology, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, Northern Ireland, United Kingdom
| | - Úna C. McMenamin
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
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Giannella L, Grelloni C, Bernardi M, Cicoli C, Lavezzo F, Sartini G, Natalini L, Bordini M, Petrini M, Petrucci J, Terenzi T, Delli Carpini G, Di Giuseppe J, Ciavattini A. Atypical Endometrial Hyperplasia and Concurrent Cancer: A Comprehensive Overview on a Challenging Clinical Condition. Cancers (Basel) 2024; 16:914. [PMID: 38473276 DOI: 10.3390/cancers16050914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
The present review regarding atypical endometrial hyperplasia (AEH) focused on the main debated factors regarding this challenging clinical condition: (i) predictive variables of occult endometrial cancer (EC); (ii) the rate of EC underestimation according to different endometrial sampling methods; and (iii) the appropriateness of lymph node status assessment. When cancer is detected, approximately 90% of cases include low-risk EC, although intermediate/high-risk cases have been found in 10-13% of women with cancer. Older age, diabetes, high BMI, and increased endometrial thickness are the most recurrent factors in women with EC. However, the predictive power of these independent variables measured on internal validation sets showed disappointing results. Relative to endometrial sampling methods, hysteroscopic endometrial resection (Hys-res) provided the lowest EC underestimation, ranging between 6 and 11%. Further studies, including larger sample sizes of women undergoing Hys-res, are needed to confirm these findings. These data are urgently needed, especially for female candidates for conservative treatment. Finally, the evaluation of lymph node status measured on 660 of over 20,000 women showed a lymph node positivity of 2.3%. Although there has been an increase in the use of this procedure in AEH in recent years, the present data cannot recommend this option in AEH based on a cost/risk/benefit ratio.
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Affiliation(s)
- Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Camilla Grelloni
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Marco Bernardi
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Camilla Cicoli
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Federica Lavezzo
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Gianmarco Sartini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Leonardo Natalini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Mila Bordini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Martina Petrini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Jessica Petrucci
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Tomas Terenzi
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Giovanni Delli Carpini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Jacopo Di Giuseppe
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
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Henderson I, Black N, Khattak H, Gupta JK, Rimmer MP. Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020. PLoS Med 2024; 21:e1004346. [PMID: 38421942 PMCID: PMC10903889 DOI: 10.1371/journal.pmed.1004346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/12/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact. METHODS AND FINDINGS In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance. CONCLUSIONS The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.
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Affiliation(s)
- Ian Henderson
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Naomi Black
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Hajra Khattak
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Elizabeth Garret Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | | | - Janesh K. Gupta
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Hospital Trust, Birmingham, United Kingdom
| | - Michael P. Rimmer
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Medical Research Council Centre for Reproductive Health, Institute of Regeneration and Repair, University of Edinburgh, United Kingdom
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7
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Rotenberg O. Risk of Cancer Progression of Non-Atypical Endometrial Hyperplasia. Obstet Gynecol 2023; 142:1496-1499. [PMID: 37917950 DOI: 10.1097/aog.0000000000005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/21/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Ohad Rotenberg
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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8
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Ren H, Zhang Y, Duan H. Recent advances in the management of postmenopausal women with non-atypical endometrial hyperplasia. Climacteric 2023; 26:411-418. [PMID: 37577792 DOI: 10.1080/13697137.2023.2226316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/30/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
Non-atypical endometrial hyperplasia is a benign disease without significant somatic genetic changes. Postmenopausal women with non-atypical endometrial hyperplasia have a significant risk of progression to endometrial cancer and persistent endometrial hyperplasia. Most cases of atypical endometrial hyperplasia in postmenopausal women are treated surgically, including hysterectomy. At present, the treatment of postmenopausal women with non-atypical endometrial hyperplasia is still controversial. Correct and timely diagnosis and treatment are of great significance to prevent progression of the lesion. This study mainly provides an updated synthesis of the literature that investigates the etiology, diagnosis and treatment of postmenopausal women with non-atypical endometrial hyperplasia. As of December 2022, a literature search related to postmenopausal non-atypical endometrial hyperplasia was conducted on the PubMed database. For most postmenopausal patients with non-atypical endometrial hyperplasia, regular re-examination should be performed during conservative treatment. For postmenopausal patients with endometrial cancer risk factors, persistent non-atypical endometrial hyperplasia or progesterone contraindications, hysterectomy and bilateral salpingo-oophorectomy should be the first choice.
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Affiliation(s)
- H Ren
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Y Zhang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - H Duan
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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9
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Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia: ACOG Clinical Consensus No. 5. Obstet Gynecol 2023; 142:735-744. [PMID: 37590985 DOI: 10.1097/aog.0000000000005297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 08/19/2023]
Abstract
SUMMARY Endometrial intraepithelial neoplasia (EIN) or atypical endometrial hyperplasia (AEH) often is a precursor lesion to adenocarcinoma of the endometrium. Hysterectomy is the definitive treatment for EIN-AEH. When a conservative (fertility-sparing) approach to the management of EIN-AEH is under consideration, it is important to attempt to exclude the presence of endometrial cancer to avoid potential undertreatment of an unknown malignancy in those who have been already diagnosed with EIN-AEH. Given the high risk of progression to cancer, those who do not have surgery require progestin therapy (oral, intrauterine, or combined) and close surveillance. Although data are conflicting and limited, studies have demonstrated that treatment with the levonorgestrel-releasing intrauterine device results in a higher regression rate when compared with treatment with oral progestins alone. Limited data suggest that cyclic progestational agents have lower regression rates when compared with continuous oral therapy. After initial conservative treatment for EIN-AEH, early detection of disease persistence, progression, or recurrence requires careful follow-up. Gynecologists and other clinicians should counsel patients that lifestyle modification resulting in weight loss and glycemic control can improve overall health and may decrease the risk of EIN-AEH and endometrial cancer.
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10
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Lee SH, Ng C, Wee Ling P, Goh C, Lin XH, Mathur M, Chin FHX. Medical Management of Atypical Endometrial Hyperplasia: Oncological and Reproductive Outcomes at a Tertiary Center in Singapore. Cureus 2023; 15:e42685. [PMID: 37649948 PMCID: PMC10464862 DOI: 10.7759/cureus.42685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
Background Medical management of atypical endometrial hyperplasia (AEH) includes oral or intrauterine progestins. This study aims to evaluate the oncological and reproductive outcomes of these patients and the predictive factors for disease regression, as well as to compare the treatment efficacy of different forms of progestins. Methodology This retrospective study was conducted at KK Women's and Children's Hospital, Singapore. Women diagnosed with AEH on endometrial biopsy between January 2015 to October 2017 and treated with at least eight weeks of the same progestin were included for analysis. Results Of the 42 patients who met the inclusion criteria, 37 were treated with oral progestins and five with the levonorgestrel intrauterine device (LNG-IUS). In total, 28 (66.6%) patients achieved complete regression (CR), but eight recurred with AEH or endometrial carcinoma. Four (9.5%) progressed to grade 1 endometrioid adenocarcinoma. Patients under 39 years old were 9.75 times more likely (95% confidence interval (CI) = 1.12-85.16, p = 0.04) to achieve CR compared to those who were 40 years old and above. In multivariate analysis, older age and higher mean body mass index had a significantly lower chance of CR. The probability of CR plateaued at nine months at 0.63 (95% CI = 0.47-0.79). There was no significant difference in time to regression, chance of regression, and risk of recurrence between oral progestin and LNG-IUS. Nine patients were trying to conceive. The clinical pregnancy rate was 44.4% (n = 4), and the live birth rate was 22.2% (n = 2). Conclusions Younger patients, especially those below 39 years old, are more likely to achieve CR. The value of medical treatment beyond nine months needs to be re-evaluated. There was no difference in treatment outcomes between oral progestins and LNG-IUS.
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Affiliation(s)
- Shi Hui Lee
- Department of Obstetrics and Gynaecology, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
| | - Carissa Ng
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SGP
| | - Pearl Wee Ling
- Department of Obstetrics and Gynaecology, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
| | - Charissa Goh
- Department of Reproductive Medicine, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
| | - Xiao Hui Lin
- Department of Gynaecological Oncology, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
| | - Manisha Mathur
- Department of Obstetrics and Gynaecology, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
| | - Felicia Hui Xian Chin
- Department of Gynaecological Oncology, Kandang Kerbau Women's and Children's Hospital, Singapore, SGP
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11
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Kwinten KJ, Drissen MM, de Hullu JA, Vos JR, Hoogerbrugge N, van Altena AM. Yield of annual endometrial cancer surveillance in women with PTEN Hamartoma Tumor Syndrome. Eur J Med Genet 2023; 66:104785. [PMID: 37172779 DOI: 10.1016/j.ejmg.2023.104785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/15/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Expert-opinion based guidelines state that endometrial cancer surveillance (ECS) might be considered for patients with PTEN Hamartoma Tumor Syndrome (PHTS) based on an elevated lifetime risk of endometrial cancer. We aimed to evaluate the yield of ECS by annual transvaginal ultrasound (TVUS) and endometrial biopsy (EMB) in PHTS patients. METHODS PHTS patients who visited our PHTS expert center between August 2012 and September 2020 and opted for annual ECS were included. Data on surveillance visits, diagnostics, reports of abnormal uterine bleeding and pathology results were retrospectively gathered and analyzed. RESULTS Surveillance was initiated in 25 women with a total of 93 gynecological surveillance visits during 76 surveillance years. The median age at first visit was 39 years (range 31-60) with a median follow-up duration of 38 months (range 6-96). Hyperplasia with and without atypia was detected six and three times, respectively, in seven (28%) women. The median age at hyperplasia detection was 40 years (range 31-50). In six asymptomatic women hyperplasia was detected during annual surveillance visits, while in one patient hyperplasia with atypia was detected during an additional visit due to abnormal uterine bleeding. In seven out of nine hyperplasias detected with EMB, TVUS beforehand showed no abnormalities. No (interval) carcinomas occurred. CONCLUSIONS ECS in women with PHTS enables detection of a substantial number of asymptomatic premalignancies, such as hyperplasia with and without atypia, suggesting that ECS may be beneficial with regard to cancer prevention. The addition of EMB to TVUS likely improves the detection of premalignancies.
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Affiliation(s)
- Kevin Jj Kwinten
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Meggie McM Drissen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joanne A de Hullu
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Janet R Vos
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Anne M van Altena
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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12
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Zhang YF, Fan Y, Mu Y, Li JK. Efficacy of Oral Medications or Intrauterine Device-Delivered Progestin in Patients with Endometrial Hyperplasia with or without Atypia: A Network Meta-Analysis. J Clin Med 2023; 12:jcm12082980. [PMID: 37109316 PMCID: PMC10143726 DOI: 10.3390/jcm12082980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 04/29/2023] Open
Abstract
The aim of this systematic review was to evaluate the efficacy of oral medication or intrauterine device-delivered progestins in patients with endometrial hyperplasia (EH) with or without atypia. We systematically examined PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov to identify studies reporting the regression rate of patients with EH who received progestins or non-progestins. The regression rates after different treatments were compared using a network meta-analysis in terms of the relative ratios (RRs) and 95% confidence intervals (CIs). Begg-Mazumdar rank correlation and funnel plots were performed to evaluate the publication bias. Five non-randomized studies and 21 randomized controlled trials involving 2268 patients were included in the network meta-analysis. The levonorgestrel-releasing intrauterine system (LNG-IUS) was associated with a higher regression rate than medroxyprogesterone acetate (MPA) (RR 1.30, 95% CI 1.16-1.46) in patients with EH. Among those without atypia, the LNG-IUS was associated with a higher regression rate than any of the three types of oral medications (MPA, norethisterone, or dydrogesterone (DGT)) (RR 1.35, 95% CI 1.18-1.55). According to the network meta-analysis, combining the LNG-IUS with MPA or metformin increased regression rate, while DGT was associated with the highest regression rate among all oral medications. The LNG-IUS may be the best choice for patients with EH, and combining it with MPA or metformin may further improve its efficacy. DGT may be the preferred choice for patients who are unwilling to use the LNG-IUS or who cannot tolerate its side effects.
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Affiliation(s)
- Yu-Fei Zhang
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University, Chengdu 610041, China
| | - Yu Fan
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu 610041, China
| | - Yi Mu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University, Chengdu 610041, China
| | - Jin-Ke Li
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu 610041, China
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13
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Suzuki Y, Chen L, Hou JY, St Clair CM, Khoury-Collado F, de Meritens AB, Matsuo K, Melamed A, Hershman DL, Wright JD. Systemic Progestins and Progestin-Releasing Intrauterine Device Therapy for Premenopausal Patients With Endometrial Intraepithelial Neoplasia. Obstet Gynecol 2023; 141:979-987. [PMID: 37023446 DOI: 10.1097/aog.0000000000005124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/12/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To estimate trends in use and outcomes of progestin therapy for premenopausal patients with endometrial intraepithelial neoplasia. METHODS The MarketScan Database was used to identify patients aged 18-50 years with endometrial intraepithelial neoplasia from 2008 to 2020. Primary treatment was classified as hysterectomy or progestin-based therapy. Within the progestin group, treatment was classified as systemic therapy or progestin-releasing intrauterine device (IUD). The trends in use of progestins and the pattern of progestin use were examined. A multivariable logistic regression model was fit to examine the association between baseline characteristics and the use of progestins. The cumulative incidence of hysterectomy, uterine cancer, and pregnancy since initiation of progestin therapy was analyzed. RESULTS A total of 3,947 patients were identified. Hysterectomy was performed in 2,149 (54.4%); progestins were used in 1,798 (45.6%). Use of progestins increased from 44.2% in 2008 to 63.4% in 2020 (P=.002). Among the progestin users, 1,530 (85.1%) were treated with systemic progestin, and 268 (14.9%) were treated with progestin-releasing IUD. Among progestin users, use of IUD increased from 7.7% in 2008 to 35.6% in 2020 (P<.001). Hysterectomy was ultimately performed in 36.0% (95% CI 32.8-39.3%) of those who received systemic progestins compared with 22.9% (95% CI 16.5-30.0%) of those treated with progestin-releasing IUD (P<.001). Subsequent uterine cancer was documented in 10.5% (95% CI 7.6-13.8%) of those who received systemic progestins compared with 8.2% (95% CI 3.1-16.6%) of those treated with progestin-releasing IUD (P=.24). Venous thromboembolic complications occurred in 27 (1.5%) of those treated with progestins; the venous thromboembolism (VTE) rate was similar for oral progestins and progestin-releasing IUD. CONCLUSION The rate of conservative treatment with progestins in premenopausal individuals with endometrial intraepithelial neoplasia has increased over time, and among progestin users, progestin-releasing IUD use is increasing. Progestin-releasing IUD use may be associated with a lower rate of hysterectomy and a similar rate of VTE compared with oral progestin therapy.
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Affiliation(s)
- Yukio Suzuki
- Columbia University College of Physicians and Surgeons, the NewYork-Presbyterian Hospital, and the Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York; the University of Southern California, Los Angeles, California; and Massachusetts General Hospital, Boston, Massachusetts
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14
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Michalczyk K, Kapczuk P, Witczak G, Tousty P, Bosiacki M, Kurzawski M, Chlubek D, Cymbaluk-Płoska A. An Assessment of MT1A (rs11076161), MT2A (rs28366003) and MT1L (rs10636) Gene Polymorphisms and MT2 Concentration in Women with Endometrial Pathologies. Genes (Basel) 2023; 14:genes14030773. [PMID: 36981043 PMCID: PMC10048541 DOI: 10.3390/genes14030773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Several studies have indicated a relationship between metallothionein (MT) polymorphisms and the development of different pathologies, including neoplastic diseases. However, no studies thus far have been conducted on the influence of MT polymorphisms and the development of endometrial lesions, including endometrial cancer. This study included 140 patients with normal endometrial tissue, endometrial polyps, uterine myomas and endometrial cancer. The tissue MT2 concentration was determined using the ELISA method. MT1A, MT2A and MT1L polymorphisms were analyzed using TaqMan real-time PCR genotyping assays. We found no statistical difference between the tissue MT2 concentration in patients with EC vs. benign endometrium (p = 0.579). However, tissue MT2 concentration was significantly different between uterine fibromas and normal endometrial tissue samples (p = 0.019). Menopause status did not influence the tissue MT2 concentration (p = 0.282). There were no significant associations between the prevalence of MT1A, MT2A and MT1L polymorphisms and MT2 concentration. The age, menopausal status, and diabetes status of patients were identified as EC risk factors.
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Affiliation(s)
- Kaja Michalczyk
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Patrycja Kapczuk
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wlkp. 72, 70-111 Szczecin, Poland
| | - Grzegorz Witczak
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Piotr Tousty
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Mateusz Bosiacki
- Department of Functional Diagnostics and Physical Medicine, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Mateusz Kurzawski
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University in Szczecin, Powstancow Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Dariusz Chlubek
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wlkp. 72, 70-111 Szczecin, Poland
| | - Aneta Cymbaluk-Płoska
- Department of Reconstructive Surgery and Gynecological Oncology, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
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15
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Golia D'Augè T, Cuccu I, Santangelo G, Muzii L, Giannini A, Bogani G, Di Donato V. Novel Insights into Molecular Mechanisms of Endometrial Diseases. Biomolecules 2023; 13:biom13030499. [PMID: 36979434 PMCID: PMC10046407 DOI: 10.3390/biom13030499] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Endometrial diseases are the most common gynecological pathologies in Western Countries [...].
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Affiliation(s)
- Tullio Golia D'Augè
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
| | - Ilaria Cuccu
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
| | - Giusi Santangelo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
| | - Andrea Giannini
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, 00185 Rome, Italy
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milano, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00100 Rome, Italy
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16
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Weng CH, Wu KY, Wang CJ, Huang HJ, Tsai CL, Lin CY, Ro A, Lai CH, Chao AS, Wu RC, Chao A. Massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical and non-atypical endometrial hyperplasia. Front Med (Lausanne) 2022; 9:1090788. [PMID: 36619620 PMCID: PMC9813484 DOI: 10.3389/fmed.2022.1090788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background Endometrial hyperplasia (EH), particularly with atypia, is considered an antecedent of endometrial adenocarcinoma. In this study, we aimed to apply massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical (AEH) and non-atypical endometrial hyperplasia (NEH). The identified alterations were compared with those detected in tissue samples. Materials and methods Endometrial lavage specimens and parallel biopsy samples (n = 11 for AEH and n = 9 for NEH) were obtained from 18 women (9 with AEH and 9 with NEH) who received an office hysteroscopy for suspected endometrial lesions. All samples were tested for somatic mutations in hotspot regions of 72 cancer-associated genes by massively parallel sequencing. Results On analyzing sequencing data, the presence of at least one cancer-associated gene mutation was identified in 72.7 and 44.4% of endometrial lavage specimens obtained from women with AEH and NEH, respectively (p = 0.362, 95% confidence interval = 0.72-3.70). The concordance rates between mutations identified in endometrial lavage specimens and endometrial biopsies were 54.5 and 0% from women with AEH and NEH, respectively (p = 0.014). A patient with NEH harbored mutations in endometrial lavage with the same mutations found in the tissue specimen at low allele frequency below detection cutoff, raising the suspicion of missed focal atypia. Conclusion Endometrial hyperplasia is characterized by a high burden of cancer-associated mutations, particularly in the presence of atypia. Our study, albeit performed with a relatively small number of samples, indicates that their detection by massively parallel sequencing of endometrial lavage is feasible. Our findings may allow tailoring of endometrial biopsies to the individual risk of AEH; additionally, they can pave the way toward less invasive surveillance protocols in patients with known EH.
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Affiliation(s)
- Cindy Hsuan Weng
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kai-Yun Wu
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chin-Jung Wang
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huei-Jean Huang
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Lung Tsai
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chiao-Yun Lin
- Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Aileen Ro
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Department of Obstetrics and Gynecology, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Ren-Chin Wu
- Department of Pathology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Ren-Chin Wu,
| | - Angel Chao
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan,Gynecologic Cancer Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan,*Correspondence: Angel Chao,
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17
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Matias-Guiu X, Selinger CI, Anderson L, Buza N, Ellenson LH, Fadare O, Ganesan R, Ip PPC, Palacios J, Parra-Herran C, Raspollini MR, Soslow RA, Werner HMJ, Lax SF, McCluggage WG. Data Set for the Reporting of Endometrial Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Int J Gynecol Pathol 2022; 41:S90-S118. [PMID: 36305536 DOI: 10.1097/pgp.0000000000000901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.
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18
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Stewart A, Gill G, Readman E, Grover SR, Mooney SS. Determining a threshold measurement of endometrial thickness for asymptomatic postmenopausal women: A tertiary centre case series. Aust N Z J Obstet Gynaecol 2022; 62:887-893. [PMID: 35989428 DOI: 10.1111/ajo.13604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND An incidental finding of a thickened endometrium on ultrasound in the postmenopausal patient without bleeding is a common presentation to gynaecological services; however there is limited evidence to guide clinical practice as to when hysteroscopic evaluation and endometrial sampling is required. AIMS To determine the endometrial thickness at which endometrial sampling is indicated in asymptomatic postmenopausal women referred with thickened endometrium on ultrasound. MATERIALS AND METHODS A single-centre retrospective case series of postmenopausal women without bleeding undergoing hysteroscopy was conducted. Logistic regression was used to examine the association between a range of variables and pre-malignant or malignant pathology and endometrial thickness. The optimal endometrial thickness threshold was identified to maximise model sensitivity. RESULTS A total of 404 postmenopausal women were included in this study, having undergone a hysteroscopy at the study site between 1 July 2008 and 30 June 2018. The mean (SD) age of patients at presentation was 65 (9.09) years and the mean body mass index was 29.86 kg/m2 (6.52). Of these women, nine (2.2%) were diagnosed with endometrial carcinoma and seven (1.7%) had endometrial hyperplasia with atypia. The most common histopathological finding was of a benign endometrial polyp (153: 37.9%). When including hyperplasia with or without atypia in histopathology of interest, a cut-off of ≥9 mm provides the greatest sensitivity (83.3%) and specificity (63.8%) for a diagnosis of pre-malignant or malignant pathology (classification accuracy of 64.8%; area under the receiver operating characteristic: 0.7358, 95% CI: 0.6439, 0.8278) in this cohort. CONCLUSIONS Using an endometrial thickness of ≥9 mm can be used as a cut-off for endometrial sampling in postmenopausal women without bleeding.
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Affiliation(s)
- Amy Stewart
- Department of Obstetrics and Gynaecology, Peninsula Health, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Gurjot Gill
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Readman
- Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Samantha S Mooney
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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19
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Peng H, Jiang J, Li X. Endometrial Cancer Following Levonorgestrel-Releasing Intrauterine System Insertion in Young Women with Atypical Hyperplasia: Two Case Reports and Literature Review. Reprod Sci 2022; 29:3278-3284. [PMID: 35641856 PMCID: PMC9154205 DOI: 10.1007/s43032-022-00982-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/19/2022] [Indexed: 11/17/2022]
Abstract
Levonorgestrel-releasing intrauterine system (LNG-IUS) insertion is the first-line treatment for atypical hyperplasia (AH) in young women who wish to retain their fertility. However, the procedure is not always effective, and may allow AH to progress to endometrioid endometrial cancer (EEC). Two young women with AH who wished to preserve their fertility developed EEC following 52-mg LNG-IUS in insertion at our institution. One was a 34-year-old woman diagnosed with endometrial cancer 2 years after LNG-IUS insertion. The second was a 30-year-old woman diagnosed 17 months after LNG-IUS insertion. Proactive molecular risk classification for endometrial cancer (ProMisE) classification revealed that the first and second patients had p53-abnormal (p53abn) EEC and mismatch repair deficient (MMR-d) EEC, respectively. MMR-d and p 53abn were frequently observed in both AH and EEC specimens. Studies suggest that MMR-d and p53abn are predictors of the occurrence adverse effects after fertility-preserving treatment for EEC. AH is a precursor of EEC. Therefore, p53 and mismatch repair (MMR) mutation may be used to identify women with AH who will not likely benefit from progestin therapy. Molecular assays in women with AH will likely be useful for identifying novel predictive biomarkers of progestin resistance and to improve the safety of conservative treatment. Combined assessment of progesterone receptor (PR) with these predictive molecular markers may improve the predictive ability.
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Affiliation(s)
- Hongfa Peng
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Hebei Province, Shijiazhuang City, 050000, China.
| | - Jingjing Jiang
- Department of Obstetrics and Gynecology, Hebei General Hospital, Hebei Province, Shijiazhuang City, 050051, China
| | - Xiaodong Li
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Hebei Province, Shijiazhuang City, 050000, China
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20
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Lim N, Hickey M, Young GP, Macrae FA, Kelly C. Screening and risk reducing surgery for endometrial or ovarian cancers in Lynch syndrome: a systematic review. Int J Gynecol Cancer 2022; 32:646-655. [PMID: 35437274 PMCID: PMC9067008 DOI: 10.1136/ijgc-2021-003132] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Lynch syndrome is a hereditary cancer syndrome caused by mismatch repair gene mutations, and female carriers are at an increased risk of endometrial and ovarian cancer. The best approach to screening is not yet clear and practice varies across countries and centers. We aimed to provide evidence to inform the best approach to screening and risk reduction. Methods A systematic search of the literature was conducted (Medline, Embase, PubMed). Studies evaluating the following were included: women with Lynch syndrome (by mismatch repair mutation or Amsterdam II criteria), screening methods for endometrial and/or ovarian cancer, intervention included endometrial biopsy, transvaginal ultrasound, or serum cancer antigen 125 (CA-125), outcomes evaluated were number of cancers and/or endometrial hyperplasia. Results A total of 18 studies of Lynch syndrome carriers which screened for endometrial cancer using transvaginal ultrasound and/or hysteroscopy/endometrial biopsy revealed an incidence of 3.9% at the time of screening. Most (64.1%) endometrial cancers detected were from screening, with the balance detected in symptomatic women at the first screening visits, regular review, or between screening intervals. In mismatch repair carriers, the overall sensitivity of endometrial screening was 66.7%, and the number needed to screen ranged between 4 and 38 (median 7). The sensitivity of endometrial biopsy was 57.1% and the number needed to screen was 23–380 (median 78). The sensitivity of transvaginal ultrasound was 34.4% and the number needed to screen was 35–973 (median 170). Fourteen studies which screened for ovarian cancer using transvaginal ultrasound and/or CA-125 revealed an incidence of 1.3% at the time of screening and 42.9% of ovarian cancers were detected at asymptomatic screening. The sensitivity of ovarian screening was 54.6%, and the number needed to screen was 9–191 (median 23) in mismatch repair carriers. Thirteen studies reported 5.8% incident endometrial cancers and 0.5% ovarian cancers at time of risk reducing surgery. Conclusions There is limited evidence to support screening for endometrial and ovarian cancer in Lynch syndrome and data on mortality reduction are not available. Further prospective, randomized trials comparing targeted screening methods are needed. Risk reducing surgery remains the most reliable way to reduce endometrial and ovarian cancer risk in Lynch syndrome.
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Affiliation(s)
- Natalie Lim
- The University of Melbourne Melbourne Medical School, Melbourne, Victoria, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Graeme P Young
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Finlay A Macrae
- Department of Medicine, The University of Melbourne Medicine at Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christabel Kelly
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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21
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Prip CM, Stentebjerg M, Bennetsen MH, Petersen LK, Bor P. Risk of atypical hyperplasia and endometrial carcinoma after initial diagnosis of non-atypical endometrial hyperplasia: A long-term follow-up study. PLoS One 2022; 17:e0266339. [PMID: 35413062 PMCID: PMC9004759 DOI: 10.1371/journal.pone.0266339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 03/19/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The strong association between atypical endometrial hyperplasia and endometrial carcinoma is well established, but data on the risk of atypical hyperplasia and carcinoma in Danish women with non-atypical endometrial hyperplasia are almost non-existent. This study aimed to investigate the prevalence of atypical hyperplasia and endometrial carcinoma diagnosed within 3 months of initial diagnosis (defined as concurrent disease) and the risk of atypical hyperplasia and carcinoma more than 3 months after initial diagnosis (classified as progressive disease) in Danish women initially diagnosed with non-atypical endometrial hyperplasia. DESIGN This cohort study recruited 102 women diagnosed with non-atypical endometrial hyperplasia at Randers Regional Hospital in Randers, Denmark, between 2000 and 2015. METHODS The endometrium was evaluated by transvaginal ultrasound examination and office mini-hysteroscopy with biopsies in all non-hysterectomized women. Data regarding subsequent hysterectomy or endometrial sampling were obtained from medical records and the Danish Pathology Registry (Patobank). RESULTS A total of 15 women were diagnosed with atypical hyperplasia or carcinoma during follow-up. Concurrent atypical hyperplasia or carcinoma was seen in 2.9% (3/102), and among women who remained at risk for more than 3 months after initial diagnosis of non-atypical endometrial hyperplasia (n = 94), progression to atypical hyperplasia or carcinoma was seen in 13% (median follow-up 5.2 years, range 3.6 months to 15.1 years). Sixty-six percent of the women with progressive disease were diagnosed with atypical hyperplasia or carcinoma more than 1 year after initial diagnosis, but only two were diagnosed later than 5 years (5.2 and 9 years). CONCLUSIONS The risk of being diagnosed with atypical endometrial hyperplasia or endometrial carcinoma more than 5 years after an initial diagnosis of non-atypical endometrial hyperplasia seems to be low in Danish women. Specialized follow-up more than 5 years after diagnosis of non-atypical endometrial hyperplasia may not be warranted.
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Affiliation(s)
- Clara M. Prip
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
- * E-mail:
| | - Maria Stentebjerg
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Mary H. Bennetsen
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Lone K. Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Open Patient Explorative Data Network, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pinar Bor
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
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22
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Ganesan R, Gilks CB, Soslow RA, McCluggage WG. Survey on Reporting of Endometrial Biopsies From Women on Progestogen Therapy for Endometrial Atypical Hyperplasia/Endometrioid Carcinoma. Int J Gynecol Pathol 2022; 41:142-150. [PMID: 33935157 PMCID: PMC10284089 DOI: 10.1097/pgp.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Histologic assessment of response to progestogen therapy is a cornerstone of nonsurgical management of atypical hyperplasia/low-grade endometrioid carcinoma. Pathologists are required to assess whether there is ongoing preneoplastic or neoplastic change in the biopsies (often multiple) taken during therapy. There have been few studies documenting the specific histologic changes induced by therapeutic progestogens and currently there are no guidelines on terminology used in this scenario. Given the need for uniformity in reporting and the lack of guidance in the current literature, we initiated an online survey (including questions, categories of reporting, and scanned slides for assessment) which was sent to all members of British Association of Gynaecological Pathologists (BAGP) and the International Society of Gynecological Pathologists (ISGyP) with the aim to assess the variability among pathologists in reporting these specimens and to come up with a consensus-based terminology for reporting of endometrial biopsies from women on progestogen therapy for endometrial atypical hyperplasia/endometrioid carcinoma. In total, 95 pathologists participated in this survey. This manuscript elaborates on the results of the survey with recommendations aimed at promoting uniform terminology in reporting these biopsies.
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Affiliation(s)
- Raji Ganesan
- Department of Cellular Pathology, Birmingham Women’s Hospital, Birmingham, United Kingdom
| | - C Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, United Kingdom
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23
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MacLean JA, Hayashi K. Progesterone Actions and Resistance in Gynecological Disorders. Cells 2022; 11:647. [PMID: 35203298 PMCID: PMC8870180 DOI: 10.3390/cells11040647] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Estrogen and progesterone and their signaling mechanisms are tightly regulated to maintain a normal menstrual cycle and to support a successful pregnancy. The imbalance of estrogen and progesterone disrupts their complex regulatory mechanisms, leading to estrogen dominance and progesterone resistance. Gynecological diseases are heavily associated with dysregulated steroid hormones and can induce chronic pelvic pain, dysmenorrhea, dyspareunia, heavy bleeding, and infertility, which substantially impact the quality of women's lives. Because the menstrual cycle repeatably occurs during reproductive ages with dynamic changes and remodeling of reproductive-related tissues, these alterations can accumulate and induce chronic and recurrent conditions. This review focuses on faulty progesterone signaling mechanisms and cellular responses to progesterone in endometriosis, adenomyosis, leiomyoma (uterine fibroids), polycystic ovary syndrome (PCOS), and endometrial hyperplasia. We also summarize the association with gene mutations and steroid hormone regulation in disease progression as well as current hormonal therapies and the clinical consequences of progesterone resistance.
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Affiliation(s)
- James A. MacLean
- Center for Reproductive Biology, School of Molecular Biosciences, Washington State University, 1770 NE Stadium Way, Pullman, WA 99164, USA
| | - Kanako Hayashi
- Center for Reproductive Biology, School of Molecular Biosciences, Washington State University, 1770 NE Stadium Way, Pullman, WA 99164, USA
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24
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Aldarazi K, Omran H, Jassim NM. Endometrial hyperplasia in asymptomatic subfertile population. J Gynecol Obstet Hum Reprod 2022; 51:102337. [DOI: 10.1016/j.jogoh.2022.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/15/2021] [Accepted: 02/09/2022] [Indexed: 10/19/2022]
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25
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Nees LK, Heublein S, Steinmacher S, Juhasz-Böss I, Brucker S, Tempfer CB, Wallwiener M. Endometrial hyperplasia as a risk factor of endometrial cancer. Arch Gynecol Obstet 2022; 306:407-421. [PMID: 35001185 PMCID: PMC9349105 DOI: 10.1007/s00404-021-06380-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/23/2021] [Indexed: 12/30/2022]
Abstract
Endometrial hyperplasia (EH) is the precursor lesion for endometrioid adenocarcinoma of the endometrium (EC), which represents the most common malignancy of the female reproductive tract in industrialized countries. The most important risk factor for the development of EH is chronic exposure to unopposed estrogen. Histopathologically, EH can be classified into EH without atypia (benign EH) and atypical EH/endometrial intraepithelial neoplasia (EIN). Clinical management ranges from surveillance or progestin therapy through to hysterectomy, depending on the risk of progression to or concomitant EC and the patient´s desire to preserve fertility. Multiple studies support the efficacy of progestins in treating both benign and atypical EH. This review summarizes the evidence base regarding risk factors and management of EH. Additionally, we performed a systematic literature search of the databases PubMed and Cochrane Controlled Trials register for studies analyzing the efficacy of progestin treatment in women with EH.
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Affiliation(s)
- Lisa K Nees
- Department of Obstetrics and Gynecology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Sabine Heublein
- Department of Obstetrics and Gynecology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Sahra Steinmacher
- Department of Obstetrics and Gynecology, Universität Tübingen, Tübingen, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Universität Freiburg, Freiburg, Germany
| | - Sara Brucker
- Department of Obstetrics and Gynecology, Universität Tübingen, Tübingen, Germany
| | - Clemens B Tempfer
- Comprehensive Cancer Center, Ruhr University Bochum (RUCCC), Bochum, Germany
| | - Markus Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
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26
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Abstract
Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.
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27
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Wong CLH, So PL. Prevalence and risk factors for malignancy in hysteroscopy-resected endometrial polyps. Int J Gynaecol Obstet 2021; 155:433-441. [PMID: 33621356 DOI: 10.1002/ijgo.13656] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION To determine the prevalence of malignant lesions in endometrial polyps by hysteroscopic polypectomy, and risk factors for malignant transformation. The secondary aim was to evaluate background endometrium of atypical hyperplasia in endometrial polyps, and the risk of coexisting endometrial carcinoma after hysterectomy. METHODS This retrospective study included women who underwent hysteroscopic polypectomy between January 2015 and December 2019. Demographic characteristics, hysteroscopic findings, and histopathology results of the polyp and the uterus, in the case of a hysterectomy, were collected. RESULTS In all, 946 women were included in the study. Endometrial carcinoma in a polyp was found in 10 women (1.06%), and atypical hyperplasia was found in 11 women (1.16%). At the multivariate logistic regression model of risk factors, old age (P = 0.022) and obesity (P = 0.011) were significantly associated with (pre-)malignant polyp. Five of the ten women (50%) with atypical hyperplasia confined to a polyp had coexisting endometrial carcinoma in the hysterectomy specimen. CONCLUSION Women with risk factors should be offered hysteroscopic polypectomy to allow a reliable histologic evaluation. Furthermore, hysterectomy is recommended in women with atypical hyperplasia in endometrial polyps even after complete resection.
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Affiliation(s)
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Hong Kong
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28
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Cochrane Review Summaries-July 2021. Obstet Gynecol 2021; 138:947. [PMID: 34794163 DOI: 10.1097/aog.0000000000004615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barr CE, Ryan NA, Derbyshire A, Wan YL, MacKintosh ML, McVey RJ, Bolton J, Fitzgerald C, Awad D, Slade RJ, Syed AA, Ammori BJ, Crosbie EJ. Weight Loss During Intrauterine Progestin Treatment for Obesity-associated Atypical Hyperplasia and Early-Stage Cancer of The Endometrium. Cancer Prev Res (Phila) 2021; 14:1041-1050. [PMID: 34348914 PMCID: PMC9306269 DOI: 10.1158/1940-6207.capr-21-0229] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/23/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
Intrauterine progestin is a treatment option for women with atypical hyperplasia or low-risk endometrial cancer who wish to preserve their fertility, or whose poor surgical fitness precludes safe hysterectomy. We hypothesized that in such women with obesity, weight loss during progestin treatment may improve oncological outcomes. We conducted a prospective nonrandomized study of women with obesity and atypical hyperplasia or low-grade stage 1a endometrial cancer undergoing progestin treatment. Women with a body mass index (BMI) ≥ 35 kg/m2 were offered bariatric surgery; those who declined and those with a BMI of 30 to 34.9 kg/m2 were encouraged to lose weight by low-calorie diet. We assessed uptake of bariatric surgery; weight lost during progestin treatment; and the impact of more than 10% total body weight loss on progestin treatment response at 12 months. 71 women [median age 58 years (interquartile range; IQR 35-65); mean BMI 48 kg/m2 (SD 9.3)] completed the study. Twenty-three women (32%) had bariatric surgery, on average 5 months (IQR 3-8) after progestin treatment commenced. Weight change during progestin treatment was -33.4 kg [95% confidence interval (CI) -42.1, -24.7] and -4.6 kg (95% CI -7.8, -1.4) in women receiving bariatric surgery and low-calorie diet, respectively (P < 0.001). Forty-three women (61%) responded to progestin, while 23 (32%) showed stabilized and 5 (7%) progressive disease. Response at 12 months was not predicted by age or baseline BMI, but women who lost more than 10% of their total body weight were more likely to respond to progestin than those who did not (adjusted odds ratio 3.95; 95% CI 1.3, 12.5; P = 0.02). Thus weight loss may improve oncological outcomes in women with obesity-associated endometrial neoplastic abnormalities treated with progestin. PREVENTION RELEVANCE: This study found that weight loss improves response rates in women with obesity and atypical hyperplasia or low-risk endometrial cancer undergoing conservative management with intrauterine progestin. Given the additional benefits of weight loss for fertility, cardiovascular health and quality of life, future research should focus on how best to accomplish it.
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Affiliation(s)
- Chloe E. Barr
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Neil A.J. Ryan
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - A.E. Derbyshire
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Y. Louise Wan
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Michelle L. MacKintosh
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Rhona J. McVey
- Department of Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - James Bolton
- Department of Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Cheryl Fitzgerald
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Dina Awad
- Department of Radiology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Richard J. Slade
- Department of Gynaecological Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Akheel A. Syed
- Department of Obesity Medicine, Diabetes & Endocrinology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.,Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Basil J. Ammori
- Department of Obesity Medicine, Diabetes & Endocrinology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.,Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Emma J. Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Corresponding Author: Emma J. Crosbie, Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, 5th Floor Research, St Mary's Hospital, Oxford Road, Manchester M13 9PL, United Kingdom. Phone: 4416-1701-6942; E-mail:
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30
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Rate of premalignant and malignant endometrial lesion in "low-risk" premenopausal women with abnormal uterine bleeding undergoing endometrial biopsy. Obstet Gynecol Sci 2021; 64:517-523. [PMID: 34555870 PMCID: PMC8595040 DOI: 10.5468/ogs.21150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/07/2021] [Indexed: 11/21/2022] Open
Abstract
Objective To determine the incidence of endometrial hyperplasia and endometrial cancer (EH/EC) in low-risk premenopausal women with abnormal uterine bleeding (AUB) undergoing endometrial biopsy and to build a predictive model that includes clinical variables for predicting EH/EC in these women. Methods This retrospective study was conducted between January 2015 and March 2020. All premenopausal women aged <55 years with AUB who underwent endometrial sampling during a specified time period were included. Data regarding baseline characteristics, sonographic findings, and histological reports were collected from patient record sheets. Results
During the specified time period, 1,089 premenopausal women underwent endometrial biopsy for AUB. Complete data analysis was done for 1,084 women. Of the endometrial samples, 95.3% revealed benign pathology, whereas 4.7% of the samples had major endometrial pathology EH/EC. On step-wise logistic regression analysis, intermenstrual bleeding (IMB) (OR, 3.15), body mass index (BMI) >25 kg/m2 (odds ratio [OR], 4.4705), age >40 years (OR, 1.14), endometrial thickness (ET) >13 mm (OR, 2.59), and hypothyroidism (OR, 1.35) were significantly associated with EH/ EC. Considering the pretest probability for an EH/EC of 4.7%, this prediction model with a likelihood ratio of 14.2% demonstrated a post-test probability of 41% in the presence of the above-mentioned variables. Conclusion The risk of EH/EC was lower in low-risk premenopausal women with AUB. However, premenopausal women with IMB aged >40 years, hypothyroidism, BMI >25 kg/m2, and thickened endometrium (ET >13 mm) are at high risk of EH/EC; therefore, endometrial biopsy should be considered early in their management plan.
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31
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Orazov M, Radzinskiy V, Khamoshina M, Mullina I, Artemenko Y. «VULNERABLE» ENDOMETRIUM: A MODERN VIEW ON THE PATHOGENESIS AND PATHOGENETIC THERAPY OF ENDOMETRIAL HYPERPLASTIC PROCESSES. REPRODUCTIVE MEDICINE 2021. [DOI: 10.37800/rm.3.2021.54-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Relevance: Endometrium is a unique human tissue with a strong regenerative potential which is implemented after desquamation during each menstrual cycle. At that, regeneration in the endometrium is not accompanied by scarring. Endometrial hyperplasia as a variant of defect transformation is a widespread disease which remains an urgent problem of modern medicine. In recent years, endometrial hyperplasia is becoming more common among patients of reproductive age. This problem is even more significant due to the spread of endometrial cancer in developed countries, and endometrial hyperplasia being its precursor.
Purpose: The article describes modern views on the pathogenesis and pathogenetic therapy of endometrial hyperplastic processes.
Materials and Methods: Sources available in the Pubmed, Embase, Cochrane databases were analyzed and international reviews of randomized controlled studies in that area were selected for the last few years using the keywords «endometrial hyperplasia,» «atypical hyperplasia,» «endometrial cancer,» «progestins,» and «hysterectomy.»
Results: The article discusses the modern ideas about etiopathogenesis and the tactics of management of patients, according to the data of foreign literature.
Conclusion: Early diagnostics and timely treatment of endometrial hyperplasiaare an important preventive factor due to the high risk of malignancy. The patient management algorithm depends on many factors: the type of hyperplastic conditions, the patient’s age, unrealized reproductive function, and etc. Progestin therapy is more preferable for young patients wishing to preserve reproductive function. If cellular atypia is present, panhysterectomy is the first line of treatment for women who have realized their reproductive function and have endometrial hyperplasia with atypia.
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32
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Alblas M, Peterse EFP, Du M, Zauber AG, Steyerberg EW, van Leeuwen N, Lansdorp-Vogelaar I. Cost-effectiveness of prophylactic hysterectomy in first-degree female relatives with Lynch syndrome of patients diagnosed with colorectal cancer in the United States: a microsimulation study. Cancer Med 2021; 10:6835-6844. [PMID: 34510779 PMCID: PMC8495276 DOI: 10.1002/cam4.4080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/15/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
Background To evaluate the cost‐effectiveness of prophylactic hysterectomy (PH) in women with Lynch syndrome (LS). Methods We developed a microsimulation model incorporating the natural history for the development of hyperplasia with and without atypia into endometrial cancer (EC) based on the MISCAN‐framework. We simulated women identified as first‐degree relatives (FDR) with LS of colorectal cancer patients after universal testing for LS. We estimated costs and benefits of offering this cohort PH, accounting for reduced quality of life after PH and for having EC. Three minimum ages (30/35/40) and three maximum ages (70/75/80) were compared to no PH. Results In the absence of PH, the estimated number of EC cases was 300 per 1,000 women with LS. Total associated costs for treatment of EC were $5.9 million. Offering PH to FDRs aged 40–80 years was considered optimal. This strategy reduced the number of endometrial cancer cases to 5.4 (−98%), resulting in 516 quality‐adjusted life years (QALY) gained and increasing the costs (treatment of endometrial cancer and PH) to $15.0 million (+154%) per 1,000 women. PH from earlier ages was more costly and resulted in fewer QALYs, although this finding was sensitive to disutility for PH. Conclusions Offering PH to 40‐ to 80‐year‐old women with LS is expected to add 0.5 QALY per person at acceptable costs. Women may decide to have PH at a younger age, depending on their individual disutility for PH and premature menopause.
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Affiliation(s)
- Maaike Alblas
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisabeth F P Peterse
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mengmeng Du
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
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33
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Zhang Y, Zhang J, Wang S. The Role of Rapamycin in Healthspan Extension via the Delay of Organ Aging. Ageing Res Rev 2021; 70:101376. [PMID: 34089901 DOI: 10.1016/j.arr.2021.101376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/07/2021] [Accepted: 05/30/2021] [Indexed: 12/17/2022]
Abstract
Aging can not only shorten a healthy lifespan, but can also lead to multi-organ dysfunction and failure. Anti-aging is a complex and worldwide conundrum for eliminating the various pathologies of senility. The past decade has seen great progress in the understanding of the aging-associated signaling pathways and their application for developing anti-aging approaches. Currently, some drugs can improve quality of life. The activation of mammalian target of rapamycin (mTOR) signaling is one of the core and detrimental mechanisms related to aging; rapamycin can reduce the rate of aging, improve age-related diseases by inhibiting the mTOR pathway, and prolong lifespan and healthspan effectively. However, the current evidence for rapamycin in lifespan extension and organ aging is fragmented and scattered. In this review, we summarize the efficacy and safety of rapamycin in prolonging a healthy lifespan by systematically alleviating aging in multiple organ systems, i.e., the nervous, urinary, digestive, circulatory, motor, respiratory, endocrine, reproductive, integumentary and immune systems, to provide a theoretical basis for the future clinical application of rapamycin in anti-aging.
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Affiliation(s)
- Yan Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jinjin Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Uptake and Outcomes of Sentinel Lymph Node Mapping in Women With Atypical Endometrial Hyperplasia. Obstet Gynecol 2021; 137:924-934. [PMID: 33831939 DOI: 10.1097/aog.0000000000004352] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the utilization, morbidity, and cost of sentinel lymph node mapping in women undergoing hysterectomy for complex atypical endometrial hyperplasia. METHODS Women with complex atypical endometrial hyperplasia who underwent hysterectomy from 2012 to 2018 in the Perspective database were examined. Perioperative morbidity, mortality, and cost were examined based on performance of sentinel lymph node mapping, lymph node dissection or no nodal evaluation. RESULTS Among 10,266 women, sentinel lymph node mapping was performed in 620 (6.0%), lymph node dissection in 538 (5.2%), and no lymphatic evaluation in 9,108 (88.7%). Use of sentinel lymph node mapping increased from 0.8% in 2012 to 14.0% in 2018, and the rate of lymph node dissection rose from 5.7% to 6.4% (P<.001). In an adjusted model, residence in the western United States, treatment by high-volume hospitals and use of robotic-assisted hysterectomy were associated with sentinel lymph node mapping (P<.05 for all). The complication rates were similar between the three groups. The median cost for sentinel lymph node mapping ($9,673) and lymph node dissection ($9,754) were higher than in those who did not undergo nodal assessment ($8,435) (P<.001). CONCLUSION Performance of sentinel lymph node mapping is increasing rapidly for women with complex atypical endometrial hyperplasia but is not associated with increased perioperative morbidity or mortality.
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D'Angelo E, Espinosa I, Cipriani V, Szafranska J, Barbareschi M, Prat J. Atypical Endometrial Hyperplasia, Low-grade: "Much ADO About Nothing". Am J Surg Pathol 2021; 45:988-996. [PMID: 34105519 DOI: 10.1097/pas.0000000000001705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atypical endometrial hyperplasia (AEH) is considered a precursor of endometrioid carcinoma. The 2020 World Health Organization (WHO) classification divides endometrial hyperplasia into 2 categories: hyperplasia without atypia and atypical hyperplasia/endometrioid intraepithelial neoplasia (EIN); however, this classification does not consider the degree of nuclear atypia. We graded nuclear atypia for estimating the risk of finding carcinoma at hysterectomy. Also, we investigated genes involved in endometrial carcinogenesis including mismatch repair (MMR) genes and ARID1A, PIK3CA, PTEN, KRAS, and CTNNB1. We reviewed 79 biopsies of AEH from 79 patients who underwent hysterectomy within a 1-year interval. Intraobserver and interobserver agreement of grading nuclear atypia and the relationship between the grade of nuclear atypia at biopsy and the findings at hysterectomy were evaluated. Immunohistochemistry for MMR status was performed in all cases and targeted sequencing in 11. Using low-grade versus high-grade nuclear atypia, κ values ranged from 0.74 to 0.91 (89% to 96%) and from 0.72 to 0.81 (87% to 91%) for the intraobserver and the interobserver agreement, respectively. The degree of nuclear atypia at biopsy was highly predictive of the findings at hysterectomy (P=1.6×10-15). Of 53 patients with low-grade AEH, none had carcinoma at hysterectomy, whereas 6 (6/26; 23%) with high-grade AEH in the biopsy also had high-grade AEH in the uterus and 16 (16/26; 61%) had FIGO grade 1 carcinoma. MMR deficiency was found in 3 of the 79 patients. None of the genes showed a mutational load significantly associated with the degree of nuclear atypia. In summary, our data show high reproducibility within and between observers for the diagnosis of low-grade and high-grade AEH. Most cases of AEH had low-grade nuclear atypia and neither high-grade AEH nor carcinoma was encountered in the corresponding hysterectomy specimens.
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Affiliation(s)
- Emanuela D'Angelo
- Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio"
- Laboratory of Diagnostic Molecular Oncology, Center for Advanced Studies and Technology (CAST), Chieti-Pescara
| | - Iñigo Espinosa
- Department of Pathology, Clínica Universidad de Navarra, Madrid
| | - Valentina Cipriani
- William Harvey Research Institute, Queen Mary University of London
- UCL Institute of Ophthalmology
- UCL Genetics Institute, University College London
- Moorfields Eye Hospital NHS Foundation Trust, London, London, UK
| | - Justyna Szafranska
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research (IIB Sant Pau), Autonomous University of Barcelona, Barcelona, Spain
| | | | - Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research (IIB Sant Pau), Autonomous University of Barcelona, Barcelona, Spain
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Puechl AM, Spinosa D, Berchuck A, Secord AA, Drury KE, Broadwater G, Wong J, Whitaker R, Devos N, Corcoran DL, Strickland KC, Previs RA. Molecular Classification to Prognosticate Response in Medically Managed Endometrial Cancers and Endometrial Intraepithelial Neoplasia. Cancers (Basel) 2021; 13:cancers13112847. [PMID: 34200374 PMCID: PMC8201008 DOI: 10.3390/cancers13112847] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether molecular classification prognosticates treatment response in women with endometrial cancers and endometrial intraepithelial neoplasia (EIN) treated with levonorgestrel intrauterine system (LNG-IUS). METHODS Patients treated with LNG-IUS for endometrial cancer or EIN from 2013 to 2018 were evaluated. Using immunohistochemistry and single gene sequencing of POLE, patients were classified into four groups as per the Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE): POLE-mutated, mismatch repair-deficient (MMRd), p53 wild type (p53wt), and p53-abnormal (p53abn). Groups were assessed relative to the primary outcome of progression or receipt of definitive treatment. RESULTS Fifty-eight subjects with endometrioid endometrial cancer or EIN treated with LNG-IUS were included. Of these, 22 subjects (37.9%) had endometrial cancer and 36 subjects (62.1%) had EIN. Per the ProMisE algorithm, 44 patients (75.9%) were classified as p53wt, 6 (10.3%) as MMRd, 4 (6.9%) as p53abn, and 4 (6.9%) as POLE-mutated. Of the 58 patients, 11 (19.0%) progressed or opted for definitive therapy. Median time to progression or definitive therapy was 7.5 months, with p53abn tumors having the shortest time to progression or definitive therapy. CONCLUSIONS Molecular classification of endometrial cancer and EIN prior to management with LNG-IUS is feasible and may predict patients at risk of progression.
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Affiliation(s)
- Allison M. Puechl
- Atrium Health, Division of Gynecologic Oncology, Levine Cancer Institute, Charlotte, NC 29204, USA
- Correspondence: ; Tel.: +1-980-442-2000
| | - Daniel Spinosa
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | - Andrew Berchuck
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Angeles Alvarez Secord
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Kerry E. Drury
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | | | - Janice Wong
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | - Regina Whitaker
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Nicolas Devos
- GCB, Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA;
| | - David L. Corcoran
- Duke Center for Genomics and Computational Biology, Durham, NC 27710, USA;
| | - Kyle C. Strickland
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA;
| | - Rebecca A. Previs
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
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Cong Q, Luo L, Fu Z, Lu J, Jiang W, Sui L. Histopathology of women with non-uniform endometrial echogenicity and risk factors for atypical endometrial hyperplasia and carcinoma. Am J Transl Res 2021; 13:4500-4509. [PMID: 34150030 PMCID: PMC8205758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE In sonography, homogeneous endometrium is defined as uniform endometrial echogenicity and heterogeneous, asymmetrical or cystic endometrium is defined as non-uniform. However, the relationship between the non-uniform endometrial echogenicity and the presence or absence of pathology is not known. A retrospective study of the patients with ultrasound non-uniform endometrium who underwent hysteroscopy-directed biopsy was performed to explore its clinical meaning in the diagnosis of endometrial lesions. MATERIALS AND METHODS Patients with non-uniform endometrial echogenicity who underwent hysteroscopy-directed biopsy were enrolled in the Obstetrics and Gynecology Hospital of Fudan University from January 2015 to May 2018 as the primary cohort. In total, 692 patients with non-uniform endometrial echogenicity were diagnosed and underwent hysteroscopy-directed biopsy. Characteristics were assessed using univariate logistic regression between patients with and without atypical endometrial hyperplasia and carcinoma (atypical EH+). Multivariate analyses were used to develop the predicting model. We incorporated statistically significant variables and presented with nomogram. Internal validation was assessed. An independent validation cohort consisted of 237 consecutive patients from June 2018 to February 2019. RESULTS Hysteroscopy-directed biopsy showed that 55.20% (382/692) of the patients with non-uniform endometrium had normal endometrium, while 44.80% (310/692) had endometrial lesions, including 39.31% (272/692) benign lesions and 5.49% (38/692) atypical EH+. Univariate logistic analysis showed that older age (P=0.027), abnormal uterine bleeding (AUB) before menopause (P=0.011), postmenopausal bleeding (P<0.001) and endometrial thickness ≥7 mm (P=0.013) were statistically significant for atypical EH+. Multivariate logistic regression analysis showed that age ≥50 years old (OR: 3.97, 95% CI: 1.17-13.43, P=0.027), endometrial thickness ≥7 mm (OR: 8.08, 95% CI: 1.86-35.08, P=0.005) and postmenopausal bleeding (OR: 8.98, 95% CI: 3.26-24.76, P<0.001) were risk factors for atypical EH+. Predictors in the individualized predicted nomogram included age ≥50 years old, AUB before menopause, postmenopausal bleeding and endometrial thickness ≥7 mm. The model showed good discrimination with area under curve (AUC) of 77.09%. With cutoff value of 0.0089267, the recall of atypical EH+ is 100% with precision 6.52% and 6.22% in both primary and validation cohort, respectively. Conclusion Non-uniform endometrial echogenicity is clinically meaningful in assessment of atypical EH+ with risk factors of age ≥50 years old, postmenopausal bleeding and endometrial thickness ≥7 mm. The model can help clinician to predicate the probability of atypical EH+ and make clinical decision.
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Affiliation(s)
- Qing Cong
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
| | - Lingxiao Luo
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
| | - Zhongpeng Fu
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
| | - Jiaqi Lu
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
| | - Wei Jiang
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
| | - Long Sui
- Obstetrics and Gynecology Hospital of Fudan UniversityShanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghai, China
- Shanghai Medical Center of Key Programs for Female Reproductive DiseasesShanghai, China
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Fertility-Sparing Treatment for Atypical Endometrial Hyperplasia and Endometrial Cancer: A Cochrane Systematic Review Protocol. Adv Ther 2021; 38:2717-2731. [PMID: 33830463 DOI: 10.1007/s12325-021-01693-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/02/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endometrial cancer is the fifth most common cancer in women and atypical endometrial hyperplasia is a precancerous lesion. Obesity is an important risk factor for endometrioid endometrial adenocarcinoma and endometrial hyperplasia. Progesterone is recommended as first-line treatment in endometrial cancer or atypical endometrial hyperplasia in women who wish to preserve fertility, but optimal treatment schedules have not been defined. Metformin or bariatric surgery may also be useful in these women. The effectiveness and safety of fertility-preserving treatments being used for women with atypical endometrial hyperplasia and stage IA grade 1 endometrial cancer is unclear. Therefore, the systematic review aims to determine this point. METHODS We will search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registers, conference proceedings, abstracts, cooperative trial groups and reference lists. We will include randomised controlled trials (RCTs) that compare fertility-preserving therapy including orally administered progesterone versus a levonorgestrel-releasing intrauterine system (IUS), metformin, other pharmacological interventions or bariatric surgery, and any of these interventions with womb-removing surgery. Quasi-randomised trials, non-randomised trials and cohort studies will be included. Two review authors will independently assess study eligibility and risk of bias and extract data. The primary outcomes are complete pathologic response and live birth rate. Secondary outcomes include overall survival, progression-free survival, pregnancy rate, need for hysterectomy, adverse events, psychological symptoms and quality of life. PLANNED OUTCOMES This review aims to clarify the effectiveness and risks of fertility-preserving treatments, including complete pathologic response rate, live birth rates, need for surgical treatment, adverse events, psychological symptoms and quality of life. The broad scope of the review includes the use of progesterone, metformin to reverse insulin resistance, and bariatric surgery or operative hysteroscopy. RESULTS The results may help to determine the optimal fertility-sparing treatment in endometrial cancer and atypical endometrial hyperplasia. SYSTEMATIC REVIEW REGISTRATION Prospero 2019 number CRD42019145991.
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Non-atypical endometrial hyperplasia: risk factors for occult endometrial atypia and malignancy in patients managed with hysterectomy. Obstet Gynecol Sci 2021; 64:300-308. [PMID: 33631068 PMCID: PMC8138077 DOI: 10.5468/ogs.20294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022] Open
Abstract
Objective To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy. Methods All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis. Results In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m2. Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m2, P=0.033), and BMI ≥30 kg/m2 (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia. Conclusion Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.
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Rajadurai VA, Chivers P, Ayres C, Mohan GR, Stewart CJR, Leung YC, Wan KM, Cohen PA. Predictors of endometrial carcinoma in patients with atypical endometrial hyperplasia at a tertiary gynaecological cancer centre in Western Australia. Aust N Z J Obstet Gynaecol 2021; 61:275-283. [PMID: 33403680 DOI: 10.1111/ajo.13300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/07/2020] [Indexed: 11/27/2022]
Abstract
AIM Our objective was to assess clinical and pathological factors associated with a final diagnosis of endometrial carcinoma in patients with atypical endometrial hyperplasia with a particular emphasis on the grading of atypia. MATERIALS AND METHODS A retrospective review over five years on patients (N = 97) who underwent hysterectomy for a diagnosis of atypical endometrial hyperplasia at a statewide public tertiary gynaecologic oncology centre. Clinical and pathological characteristics were obtained. RESULTS The rate of concurrent endometrial carcinoma was 34% (n = 33) with most being stage 1A endometrioid. A significant group difference was reported for age at diagnosis (t = -2.20 P = 0.031 d = 0.43) with carcinoma patients on average older (Mage = 60.2 (8.9) years) than patients without carcinoma (Mage = 55.5 (12.3) years). No significant group differences were found for body mass index, endometrial thickness or time between diagnosis and treatment. Significantly higher rates of carcinoma were reported in patients with moderate atypical hyperplasia (27.6%) and severe atypical hyperplasia (66.7%), compared to mild atypical hyperplasia (7.1%). Only severe atypical hyperplasia (odds ratio (OR) = 21.5, 95% CI 2.8-163.1, P = 0.003) and postmenopausal status (OR = 13.2, 95% CI 1.3-139.0, P = 0.032) significantly increased the risk of carcinoma in a multivariate model. CONCLUSION Severe atypical hyperplasia and postmenopausal status were significant predictors of concurrent endometrial carcinoma in patients with atypical endometrial hyperplasia. The grading of atypical hyperplasia may be utilised by gynaecologic oncologists in the triage and referral process of managing these patients; however, the grading system requires external validation in larger prospective studies.
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Affiliation(s)
- Vinita Angeline Rajadurai
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Paola Chivers
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Exercise Medicine Research Institute & School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Chloe Ayres
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Ganendra Raj Mohan
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.,School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Colin John Reid Stewart
- Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Department of Histopathology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Yee Chit Leung
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - King Man Wan
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Paul Andrew Cohen
- Department of Gynaecological Oncology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.,Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Division of Gynaecological Oncology, St John of God Subiaco Hospital, Perth, Western Australia, Australia
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Lee N, Lee KB, Kim K, Hong JH, Yim GW, Seong SJ, Lee B, Lee JM, Cho J, Lim S, Ouh YT, Kim YB. Risk of occult atypical hyperplasia or cancer in women with nonatypical endometrial hyperplasia. J Obstet Gynaecol Res 2020; 46:2505-2510. [PMID: 32945047 DOI: 10.1111/jog.14474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/20/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Abstract
AIM The aim of this study was to identify subsets of patients diagnosed with nonatypical endometrial hyperplasia (NAEH) by endometrial biopsy who had high risk for occult atypical endometrial hyperplasia (AEH) or endometrial cancer (EC). METHODS We retrospectively reviewed the medical records of 281 patients who underwent hysterectomy within 6 months after a diagnosis of NAEH. We collected data on age, body mass index, menopausal status, tamoxifen use, previous history of NAEH, details of endometrial biopsy (location, curettage vs. pipelle sampling), NAEH subtype (simple vs. complex), interval between endometrial biopsy and hysterectomy, indication of hysterectomy and the presence of occult AEH or EC in hysterectomy specimen. Associations between variables and occult AEH or EC were analyzed. Risk of occult AEH or EC in subsets were calculated and visualized using a heatmap. RESULTS Among 281 patients, 34 (12.1%) and 9 (3.2%) had occult AEH and EC in hysterectomy specimens, respectively. Using univariate analysis, we found age, menopausal status and subtype were associated with occult AEH or EC. Using multivariate analysis, older age (odds ratio = 1.09, P < 0.01) and complex subtype (odds ratio = 3.34, P < 0.01) were independent risk factors. Patients at an age ≥ 51 years with complex NAEH had about 50% risk of occult AEH or EC. CONCLUSION Women at an age ≥ 51 years with complex NAEH had high risk for occult AEH or EC and surgical treatment can be considered for these patients.
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Affiliation(s)
- Nara Lee
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Kwang-Beom Lee
- Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin Hwa Hong
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Ga Won Yim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jong-Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Kyung Hee University, Seoul, Republic of Korea
| | - Jaehyun Cho
- Department of Obstetrics and Gynecology Soon Chun Hyang University Hospital Seoul, Seoul, Republic of Korea
| | - Soyi Lim
- Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Yung-Taek Ouh
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul National University, Seoul, Republic of Korea
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Risk factors of progression to endometrial cancer in women with endometrial hyperplasia: A retrospective cohort study. PLoS One 2020; 15:e0243064. [PMID: 33259545 PMCID: PMC7707482 DOI: 10.1371/journal.pone.0243064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022] Open
Abstract
Objective This study aimed to investigate risk factors of progression to endometrial cancer (EC) in women with non-atypical and atypical endometrial hyperplasia (EH). Methods The data of 62,333 women with EH diagnostic codes from 2007 to 2018 were sourced from the Korean Health Insurance Review and Assessment Service databases. The data from 11,525 women with non-atypical EH and 2,219 women with atypical EH who met the selection criteria were extracted for analysis. Results Risk of EC in women with EH decreased in 40–49 year olds compared to other ages (non-atypical EH: [≤39 vs. 40–49 years] HR, 0.557; 95% CI, 0.439–0.708; P<0.001; [≤39 vs. ≥50 years] P = 0.739; atypical EH: [≤39 vs. 40–49 years] HR, 0.391; 95% CI, 0.229–0.670; P = 0.001; [≤39 vs. ≥50 years] P = 0.712). Risk of EC increased with increase in number of follow-up biopsies in women with non-atypical EH (1 biopsy: HR, 1.835; 95% CI, 1.282–2.629; P = 0.001; ≥2 biopsies: HR, 3.644; 95% CI, 2.585–5.317; P<0.001) and in women receiving ≥2 follow-up biopsies with atypical EH (HR, 3.827; 95% CI, 1.924–7.612; P = 0.001). Time of progression to EC decreased in women ≥50 years old with non-atypical EH compared to other ages (P = 0.004) and showed no differences among ages in women with atypical EH (P = 0.576). Progestational agents were a protective factor for EC in women with non-atypical EH (HR, 0.703; 95% CI, 0.565–0.876; P = 0.002). Conclusions In this claim data analysis, women ≤39 and ≥50 years old with EH were at a high risk for progression to EC, and repeat follow-up biopsy after a diagnosis of EH increased detection of EC. Progestational agents were an effective modality to prevent EC in women with non-atypical EH.
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Vitale SG, Riemma G, Carugno J, Chiofalo B, Vilos GA, Cianci S, Budak MS, Lasmar BP, Raffone A, Kahramanoglu I. Hysteroscopy in the management of endometrial hyperplasia and cancer in reproductive aged women: new developments and current perspectives. Transl Cancer Res 2020; 9:7767-7777. [PMID: 35117379 PMCID: PMC8799018 DOI: 10.21037/tcr-20-2092] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/06/2020] [Indexed: 11/08/2022]
Abstract
Over the last twenty years, the incidence of early endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) among women of reproductive age is increasing rapidly, likely due to a combination of factors including increased prevalence of obesity and delayed of childbirths. Regarding preoperative diagnosis of endometrial neoplasia, it is still debated which is the most accurate and reliable method to obtain endometrial histopathological samples with fractional dilatation and curettage (D&C) having been considered, for a long time, as the method of choice. Nowadays, the advent of in-office endometrial biopsy with or without hysteroscopy has radically changed the approach, giving the opportunity to perform the endometrial biopsy under direct visualization. However, the lack of agreement about its diagnostic accuracy is still relevant. Since a significant number of women with AEH and/or EC are of childbearing age, a fertility-sparing diagnostic and therapeutic approach should be considered in all cases. The feasibility, safety and efficacy of fertility-sparing strategies involving hysteroscopic focal resections in conjunction with hormonal therapies have been evaluated and beneficial effects have been confirmed in several studies and one meta-analysis. Both local and systemic administration of hormonal therapies are currently used. Oral progestin, including medroxyprogesterone acetate (MPA) and megestrol acetate, are the most commonly used therapies. Nowadays, new therapeutic approaches, such as levonorgestrel intrauterine systems (LNG-IUS), gonadotropin-releasing hormone (GnRH) agonists, combined megestrol acetate and metformin, and other combinations of therapies are also used as first line therapies or after the hysteroscopic resection of the lesion. However, it is still unclear which approach provides higher clinical response with lower relapse rate, in addition to preserving fertility in women desiring to conceive. The aim of this narrative review is to summarize the available evidence regarding the evaluation and management with fertility-sparing treatments options of women with AEC and EC.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Benito Chiofalo
- Department of Experimental Clinical Oncology, IRCCS-Regina Elena National Cancer Institute, Rome, Italy
| | - George Angelos Vilos
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Stefano Cianci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Mehmet Sukru Budak
- Department of Obstetrics and Gynecology, Health Sciences University Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
- Estacio de Sá University (UNESA), Rio de Janeiro, Brazil
| | - Bernardo Portugal Lasmar
- Department of Gynecological Endoscopy, Hospital Central Aristarcho Pessoa (HCAP-CBMERJ), Rio de Janeiro, Brazil
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Ilker Kahramanoglu
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Specific Biomarker Expression Patterns in the Diagnosis of Residual and Recurrent Endometrial Precancers After Progestin Treatment: A Longitudinal Study. Am J Surg Pathol 2020; 44:1429-1439. [PMID: 32931681 DOI: 10.1097/pas.0000000000001537] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Conservative management with progestin is a treatment option for atypical hyperplasia (AH). However, pathologic diagnosis of residual/recurrent lesions is often problematic because of the profound morphologic changes induced by progestin and the lack of established diagnostic criteria for progestin-treated residual AH. METHODS We conducted a longitudinal study of 265 endometrial biopsies from 54 patients with a history of AH on progestin therapy. Patient outcomes were divided into 3 categories after morphologic review and immunohistochemical staining with phosphatase and tensin homolog (PTEN) and paired box 2 (PAX2): (1) persistent or residual disease; (2) recurrent disease; (3) complete response. All specimens were classified into 3 categories based on morphology: (1) persistent/recurrent disease (nonresponse), (2) morphologically uncertain response, (3) optimally treated (complete response). The staining patterns of PTEN/PAX2 were tracked over time in individual patients and correlated with morphologic findings before and after progestin therapy. RESULTS Our data showed that aberrant expression patterns of PTEN and/or PAX2 were identified in 48 (88.9%) of the 54 primary biopsies and persisted in persistent/recurrent AH across serial endometrial biopsies (n=99, P<0.00001), while normal PTEN and PAX2 expressions were consistently observed in optimally treated cases (n=84, P<0.00001). More importantly, follow-up biopsies that showed a morphologically uncertain response but a PTEN/PAX2 expression pattern identical to the initial biopsy were significantly correlated with persistent or recurrent disease (n=18, P=0.000182), as evidenced by areas with morphologic features diagnostic of AH on subsequent biopsy. CONCLUSIONS Biomarker PTEN/PAX2 signatures offer a valuable diagnostic aid to identify residual AH in progestin-treated endometrial samples for which the biomarker status from preprogestin treated AH is known. The findings of this study are promising for a possible future change of diagnostic practice.
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Li L, Yue P, Song Q, Yen TT, Asaka S, Wang TL, Beavis AL, Fader AN, Jiao Y, Yuan G, Shih IM, Song Y. Genome-wide mutation analysis in precancerous lesions of endometrial carcinoma. J Pathol 2020; 253:119-128. [PMID: 33016334 DOI: 10.1002/path.5566] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/27/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022]
Abstract
Clinicopathological evidence supports endometrial atypical hyperplasia (AH) or endometrial intraepithelial neoplasia as the precursor of uterine endometrioid carcinoma (EC), the most common gynecologic malignancy. However, the pathogenic progression from AH to EC remains unclear. Here, we employed whole-exome sequencing to identify somatic mutations and copy number changes in micro-dissected lesions from 30 pairs of newly diagnosed AH and EC. We found that all but one pair of AHs shared the same DNA mismatch repair status as their corresponding ECs. The percentage of common mutations between AH lesions and corresponding ECs varied significantly, ranging from 0.1% to 82%. Microsatellite stable AHs had fewer cancer driver mutations than ECs (5 versus 7, p = 0.017), but among microsatellite unstable AHs and ECs there was no difference in mutational numbers (36 versus 38, p = 0.65). As compared to AH specimens, 19 (79%) of 24 microsatellite stable EC tumors gained new cancer driver mutations, most of which involved PTEN, ARID1A, PIK3CA, CTNNB1, or CHD4. Our results suggest that some AH lesions are the immediate precursor of ECs, and progression depends on acquisition of additional cancer driver mutations. However, a complex clonal relationship between AH and EC can also be appreciated, as in some cases both lesions diverge very early or arise independently, thus co-developing with distinct genetic trajectories. Our genome-wide profile of mutations in AH and EC shines new light on the molecular landscape of tumor progression. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Lihong Li
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China.,Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Pinli Yue
- State Key Lab of Molecular Oncology, Laboratory of Cell and Molecular Biology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Qianqian Song
- State Key Lab of Molecular Oncology, Laboratory of Cell and Molecular Biology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Ting-Tai Yen
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Shiho Asaka
- Department of Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tian-Li Wang
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anna L Beavis
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Amanda N Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yuchen Jiao
- State Key Lab of Molecular Oncology, Laboratory of Cell and Molecular Biology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Guangwen Yuan
- Department of Gynecology Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Ie-Ming Shih
- Department of Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yan Song
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
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Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding. Diagnostics (Basel) 2020; 10:diagnostics10110884. [PMID: 33142970 PMCID: PMC7692264 DOI: 10.3390/diagnostics10110884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/16/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022] Open
Abstract
Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system's resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.
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Mittermeier T, Farrant C, Wise MR. Levonorgestrel-releasing intrauterine system for endometrial hyperplasia. Cochrane Database Syst Rev 2020; 9:CD012658. [PMID: 32909630 PMCID: PMC8200645 DOI: 10.1002/14651858.cd012658.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the absence of treatment, endometrial hyperplasia (EH) can progress to endometrial cancer, particularly in the presence of histologic nuclear atypia. The development of EH results from exposure of the endometrium to oestrogen unopposed by progesterone. Oral progestogens have been used as treatment for EH without atypia, and in some cases of EH with atypia in women who wish to preserve fertility or who cannot tolerate surgery. EH without atypia is associated with a low risk of progression to atypia and cancer; EH with atypia is where the cells are structurally abnormal, and has a higher risk of developing cancer. Oral progestogen is not always effective at reversing the hyperplasia, can be associated with side effects, and depends on patient adherence. The levonorgestrel-intrauterine system (LNG-IUS) is an alternative method of administration of progestogen and may have some advantages over non-intrauterine progestogens. OBJECTIVES To evaluate the effectiveness and safety of the levonorgestrel intrauterine system (LNG-IUS) in women with endometrial hyperplasia (EH) with or without atypia compared to medical treatment with non-intrauterine progestogens, placebo, surgery or no treatment. SEARCH METHODS We searched the following databases: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO, and conference proceedings of 10 relevant organisations. We handsearched references in relevant published studies. We also searched ongoing trials in ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, and other trial registries. We performed the final search in May 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) and cross-over trials of women with a histological diagnosis of endometrial hyperplasia with or without atypia comparing LNG-IUS with non-intrauterine progestogens, placebo, surgery or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. Our primary outcome measures were regression of EH and adverse effects associated with the LNG-IUS device (such as pelvic inflammatory disease, device expulsion, uterine perforation) when compared to treatment with non-intrauterine progestogens, placebo, surgery or no treatment. Secondary outcomes included hysterectomy, hormone-related adverse effects (such as bleeding/spotting, pelvic pain, breast tenderness, ovarian cysts, weight gain, acne), withdrawal from treatment due to adverse effects, satisfaction with treatment, and cost or resource use. We rated the overall quality of evidence using GRADE methods. MAIN RESULTS Thirteen RCTs (1657 women aged 22 to 75 years) met the inclusion criteria. Two studies had insufficient data for meta-analysis, thus the quantitative analysis included 11 RCTs. All trials evaluated treatment duration of six months or less. The evidence ranged from very low to moderate quality: the main limitations were risk of bias (associated with lack of blinding and poor reporting of study methods), inconsistency and imprecision. LNG-IUS versus non-intrauterine progestogens Primary outcomes Regression of endometrial hyperplasia The LNG-IUS probably improves regression of EH compared with non-intrauterine progestogens at short-term follow-up (up to six months) (OR 2.94, 95% CI 2.10 to 4.13; I² = 0%; 10 RCTs, 1108 participants; moderate-quality evidence). This suggests that if regression of EH following treatment with a non-intrauterine progestogen is assumed to be 72%, regression of EH following treatment with LNG-IUS would be between 85% and 92%. Regression of EH may be improved by LNG-IUS compared with non-intrauterine progestogens at long-term follow-up (12 months) (OR 3.80, 95% CI 1.75 to 8.23; 1 RCT, 138 participants; low-quality evidence), Adverse effects associated with LNG-IUS There was insufficient evidence to determine device-related adverse effects; only one study reported on expulsion with insufficient data for analysis. Secondary outcomes The LNG-IUS may be associated with fewer hysterectomies (OR 0.26, 95% CI 0.15 to 0.46; I² = 19%; 4 RCTs, 452 participants; low-quality evidence), fewer withdrawals from treatment due to hormone-related adverse effects (OR 0.41, 95% CI 0.12 to 1.35; I² = 0%; 4 RCTs, 360 participants; low-quality evidence) and improved patient satisfaction with treatment (OR 5.28, 95% CI 2.51 to 11.10; I² = 0%; 2 RCTs, 202 participants; very low-quality evidence) compared to non-intrauterine progestogens. The LNG-IUS may be associated with more bleeding/spotting (OR 2.13, 95% CI 1.33 to 3.43; I² = 78%; 3 RCTs, 428 participants) and less nausea (OR 0.52, 95% CI 0.28 to 0.95; I² = 0%; 3 RCTs, 428 participants) compared to non-intrauterine progestogens. Data from single trials for mood swings and fatigue had a similar direction of effect as for bleeding/spotting, nausea and weight gain. There was insufficient evidence to determine cost or resource use. LNG-IUS versus no treatment Regression of endometrial hyperplasia One study demonstrated that the LNG-IUS is associated with regression of EH without atypia (OR 78.41, 95% CI 22.86 to 268.97; I² = 0%; 1 RCT, 190 participants; moderate-quality evidence) compared with no treatment. This study did not report on any other review outcome. AUTHORS' CONCLUSIONS There is moderate-quality evidence that treatment with LNG-IUS used for three to six months is probably more effective than non-intrauterine progestogens at reversing EH in the short term (up to six months) and long term (up to two years). Adverse effects (device-related and hormone-related) were poorly and incompletely reported across studies. Very low quality to low-quality evidence suggests the LNG-IUS may reduce the risk of hysterectomy, and may be associated with more bleeding/spotting, less nausea, less withdrawal from treatment due to adverse effects, and increased satisfaction with treatment, compared to non-intrauterine progestogens. There was insufficient evidence to reach conclusions regarding device-related adverse effects, or cost or resource use.
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Affiliation(s)
- Theresa Mittermeier
- Department of Obstetrics and Gynaecology, Auckland District Health Board, Auckland, New Zealand
| | | | - Michelle R Wise
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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Raffone A, Travaglino A, Flacco ME, Iasevoli M, Mollo A, Guida M, Insabato L, Di Spiezio Sardo A, Carugno J, Zullo F. Clinical Predictive Factors of Response to Treatment in Patients Undergoing Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer. J Adolesc Young Adult Oncol 2020; 10:193-201. [PMID: 32799597 DOI: 10.1089/jayao.2020.0100] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: Predictive markers of response to conservative treatment of atypical endometrial hyperplasia (AEH) or early endometrial cancer (EEC) are still lacking. We aimed to assess clinical predictive factors of response to conservative treatment of AEH and EEC. Methods: All patients with AEH or EEC conservatively treated from January 2007 to June 2018 were retrospectively assessed. The associations between 23 clinical factors and outcomes of response to treatment were assessed with standard univariate analyses and multivariate logistic regression (significant p-value <0.05). The primary outcome was the association of each clinical factor with treatment failure (i.e., no regression or relapse of the disease). Secondary outcomes were the associations of each clinical factor with: (1) no regression, (2) relapse, or (3) pregnancy after treatment. Results: Forty-three women, 37 (86%) with AEH and 6 (14%) with EEC were included. At univariate analyses, treatment failure was associated with longer menstrual cycle (p = 0.002), infrequent menstrual bleeding (p = 0.04), and a diagnosis of EEC instead of AEH (p = 0.008). Among the secondary outcomes, no regression was associated with infrequent menstrual bleeding (p = 0.04), and a diagnosis of EEC instead of AEH (p < 0.001), while relapse was associated with longer menstrual cycles (p = 0.007). At multivariate analyses, odds ratio for treatment failure was 4.54 (95% confidence interval [CI], 0.24-84.4) for a diagnosis of EEC instead of AEH (p = 0.3), and 2.10 (95% CI, 1.03-4.29) for longer menstrual cycles (p = 0.042), while infrequent menstrual bleeding perfectly predicted treatment failure. Conclusions: Longer menstrual cycles and infrequent menstrual bleeding appear as independent predictive factors for conservative treatment failure in AEH and EEC. Further and larger studies are necessary to confirm these findings.
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Affiliation(s)
- Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Mara Iasevoli
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Italy
| | - Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Luigi Insabato
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Attilio Di Spiezio Sardo
- Gynecology and Obstetrics Unit, Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Jose Carugno
- Obstetrics, Gynecology, and Reproductive Science Department, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
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Williams AT, Ganesan R. Role of the pathologist in assessing response to treatment of ovarian and endometrial cancers. Histopathology 2020; 76:93-101. [PMID: 31846531 DOI: 10.1111/his.13994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Standardisation of pathological evaluation of tissue responses to therapy permits robust stratification of patient outcomes for management decisions and allows comparison of results across clinical trials. In gynaecological pathology there are two major areas where pathological assessment of treatment response is currently used to determine ongoing therapy. High-grade serous carcinoma (HGSC) of tubo-ovarian origin frequently presents as high-stage disease and may be managed by neoadjuvant chemotherapy with debulking surgery. The chemotherapy response score (CRS) is a reproducible, validated three-tiered morphological scoring system to assess the response of HGSC to treatment. Interobserver agreement is shown to be substantial following online training, and women with CRS3 have significantly improved progression-free and overall survival. Low-grade endometrioid endometrial cancer and atypical hyperplasia/endometrioid intraepithelial neoplasia may be managed by progestogenic therapy in women who wish to preserve fertility or for whom medical co-morbidities preclude surgical management. The response to treatment is assessed histologically in successive endometrial biopsies. The histological parameters are well described, but the pathological classification of treatment response is still under development. Pathological assessment of the response to treatment is incorporated into clinical guidelines.
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Affiliation(s)
- Anthony T Williams
- Department of Cellular Pathology, 1st Floor Laboratories, Birmingham Women's Hospital, Birmingham, UK
| | - Raji Ganesan
- Department of Cellular Pathology, 1st Floor Laboratories, Birmingham Women's Hospital, Birmingham, UK
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50
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Tehranian A, Ghahghaei-Nezamabadi A, Arab M, Khalagi K, Aghajani R, Sadeghi S. The impact of adjunctive metformin to progesterone for the treatment of non-atypical endometrial hyperplasia in a randomized fashion, a placebo-controlled, double blind clinical trial. J Gynecol Obstet Hum Reprod 2020; 50:101863. [PMID: 32652300 DOI: 10.1016/j.jogoh.2020.101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/23/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Endometrial hyperplasia (EH) is a premalignant neoplasm. Most recently, metformin has been suggested as an adjuvant medication for treating of EH with better outcome. Recent evidence has suggested that metformin has anticancer activity by inhibiting cell proliferation and tumor growth. The aim of this study was to evaluate the effect of metformin plus megestrol acetate versus megestrol acetate alone on patient with EH without atypia. STUDY DESIGN This double blind placebo-controlled clinical trial was conducted among 60 women with EH without atypia. Participants were allocated to two equal groups. Treatment group (M + M) received 40 mg megestrol acetate for 14 days of one month and 1000 mg metformin daily for three months. In placebo group (M + P) each patient received the same dose of megestrol acetate plus two tablets of placebo. Endometrial biopsy was performed in all patients three weeks after the last day of medication RESULTS: Data were evaluated based on 29 and 27 women in the M + M group and M + P group, respectively. After 3 months of therapy 27 (93.1 %) women in M + M group had not EH and responded to treatment, which was statistically higher than the rate of response (19 women, 70.4 %) in M + P group. CONCLUSIONS This study showed that megestrol plus metformin was significantly better than megestrol alone for the treatment of endometrial hyperplasia without atypia.
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Affiliation(s)
- Afsaneh Tehranian
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Akram Ghahghaei-Nezamabadi
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Arab
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kazem Khalagi
- Osteoprosis Research Center Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Aghajani
- Medical Student, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Sadeghi
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
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