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Ciancio FF, Insalaco G, Millan S, Randazzo C, Grasso F, Trombetta G, Gulisano M, Bruno MT, Valenti G. Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment. Eur J Obstet Gynecol Reprod Biol 2024; 298:140-145. [PMID: 38756054 DOI: 10.1016/j.ejogrb.2024.05.015] [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: 03/08/2024] [Accepted: 05/12/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION/BACKGROUND Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC. METHODOLOGY From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard). RESULTS Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV. CONCLUSION HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.
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Affiliation(s)
| | - Giulio Insalaco
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy
| | - Simone Millan
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy
| | - Claudia Randazzo
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy
| | - Federica Grasso
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy
| | - Giuseppina Trombetta
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy
| | - Marianna Gulisano
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Maria Teresa Bruno
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Gaetano Valenti
- Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy.
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Miao H, Zhang L, Jiang Y, Wan Y, Yuan L, Cheng W. Preoperative hysteroscopy shortened progression-free survival in advanced FIGO stage in endometrial cancer: Ten year analysis. Int J Gynaecol Obstet 2024; 164:1195-1204. [PMID: 37799024 DOI: 10.1002/ijgo.15180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To investigate the impact of preoperative hysteroscopy on progression-free survival (PFS) and disease-specific survival (DFS), and to explore the factors which contribute to poor clinical outcomes between hysteroscopy and dilation and curettage (D&C) in endometrial cancer (EC). METHODS A retrospective study was designed by collecting data from women diagnosed with EC through hysteroscopy or D&C from January 2010 to December 2019 in a tertiary hospital in China. A propensity score was used for 1:1 matching of advanced stage patients. Univariate and multivariate analysis were conducted to determine whether hysteroscopy was a prognostic factor in EC and to identify factors associated with its impact on PFS and DFS in different subgroups. RESULTS Overall, 543 and 272 women who underwent D&C and hysteroscopy, respectively were included. Compared to D&C, preoperative hysteroscopy was related to reduced PFS and DFS, with a hazard ratio (HR) of 1.904 and 3.905, respectively. Hysteroscopy contributed to an increased risk of positive wash cytology (48.27% vs 24.13%), recurrence (48.28% vs 20.69%) and shorter PFS after matching in FIGO Stage I-IV EC, while there was no significance in positive ascites cytology (14.04% vs 13.45%), PFS and DFS in FIGO Stage I EC. CONCLUSIONS Hysteroscopy was an independent predictive factor for poor prognosis in EC. Hysteroscopy appeared to be a safe diagnostic method as D&C in FIGO Stage I EC but was a risk factor for increased recurrence and reduced PFS in advanced stage disease. Its impact on DFS is uncertain.
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Affiliation(s)
- Huixian Miao
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Zhang
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yi Jiang
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yicong Wan
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Yuan
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Wenjun Cheng
- Department of Gynecology, Jiangsu Province Hospital and The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Markowska A, Baranowski W, Pityński K, Chudecka-Głaz A, Markowska J, Sawicki W. Metastases and Recurrence Risk Factors in Endometrial Cancer-The Role of Selected Molecular Changes, Hormonal Factors, Diagnostic Methods and Surgery Procedures. Cancers (Basel) 2023; 16:179. [PMID: 38201606 PMCID: PMC10778296 DOI: 10.3390/cancers16010179] [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: 10/03/2023] [Revised: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 01/12/2024] Open
Abstract
The presence of metastatic endometrial cancer (EC) is a key problem in treatment failure associated with reduced overall survival rates. The most common metastatic location is the pelvic lymph nodes, and the least common is the brain. The presence of metastasis depends on many factors, including the molecular profile of cancer (according to the TCGA-Genome Atlas), the activity of certain hormones (estrogen, prolactin), and pro-inflammatory adipocytokines. Additionally, an altered expression of microRNAs affecting the regulation of numerous genes is also related to the spread of cancer. This paper also discusses the value of imaging methods in detecting metastases; the primary role is attributed to the standard transvaginal USG with the tumor-free distance (uTFD) option. The influence of diagnostic and therapeutic methods on EC spread is also described. Hysteroscopy, according to the analysis discussed above, may increase the risk of metastases through a fluid medium, mainly performed in advanced stages of EC. According to another analysis, laparoscopic hysterectomy performed with particular attention to avoiding risky procedures (trocar flushing, tissue traumatization, preserving a margin of normal tissue) was not found to increase the risk of EC dissemination.
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Affiliation(s)
- Anna Markowska
- Department of Perinatology and Women’s Diseases, Poznan University of Medical Sciences, 60-535 Poznan, Poland;
| | - Włodzimierz Baranowski
- Department of Gynecological Oncology, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Kazimierz Pityński
- Department of Gynecology and Oncology, Jagiellonian University Medical College, 31-501 Krakow, Poland;
| | - Anita Chudecka-Głaz
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Janina Markowska
- Gynecological Oncology Center Poznań, Poznanska 58A, 60-850 Poznan, Poland;
| | - Włodzimierz Sawicki
- Department of Obstetrics, Gynecology and Gynecological Oncology, Medical University of Warsaw, 02-091 Warsaw, Poland;
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Rodolakis A, Pergialiotis V, Thomakos N. New boundaries for fertility sparing management in endometrial cancer. Curr Opin Oncol 2023; 35:394-400. [PMID: 37498119 DOI: 10.1097/cco.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW The increasing rates of endometrial cancer in premenopausal women that accompanies modern lifestyle options that enhance the prevalence of obesity as well as the trend of delayed childbearing are expected to increase the need for fertility sparing techniques. Currently, the cornerstone of fertility sparing treatment is hormonal handling with progestin treatment and is reserved for women with well differentiated endometrioid lesions that are limited in the myometrial layer. RECENT FINDINGS Innovative approaches in the surgical treatment of patients with the use of operative hysteroscopy seem to offer decreased intervals to remission of lesions and longer progression free survival. Recent small case series also dictate that patients with endometrioid lesions of medium differentiation as well as those with superficial myometrial invasion may be adequately treated with the use of operative hysteroscopy. Moreover, the novel classification system may help better understand patients that will likely respond better to hormonal treatment. SUMMARY In the near future, further data from clinical trials will be available that will help optimize patient selection as well select surgical and medical options that will help establish a personalized approach of fertility preservation in endometrial cancer patients.
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Affiliation(s)
- Alexandros Rodolakis
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
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Zhou H, Lai KF, Xiang Q, Xu Y, Zhang QW, Hu C, Mao XG, Chen C, Huang W, Mi GS, Shen J, Tian Y, Ke FM. Oncological Safety of Diagnostic Hysteroscopy for Apparent Early-Stage Type II Endometrial Cancer: A Multicenter Retrospective Cohort Study. Front Oncol 2022; 12:918693. [PMID: 35814398 PMCID: PMC9259840 DOI: 10.3389/fonc.2022.918693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo study the oncological safety of diagnostic hysteroscopy for women with apparent early-stage type II endometrial cancer.Patients and MethodsA total of 429 women with presumed early-stage type II endometrial cancer were included. The 5-year disease-free survival (DFS) and overall survival (OS) were estimated and compared using the Kaplan-Meier method and the log-rank test among patients diagnosed by Dilation & Curettage (D&C) or diagnostic hysteroscopy. The Cox proportional hazards regression model was employed to adjust for potential confounding factors.Results160 cases underwent D&C and 269 cases were diagnosed by diagnostic hysteroscopy. The 5-year DFS rate was 72.17% in the diagnostic hysteroscopy group and 76.16% in the D&C group, diagnostic hysteroscopy was not associated with deteriorated 5-year DFS rate (HR 1.25, 95% CI 0.84-1.86, P=0.281). The 5-year OS rate was 67.23% in the diagnostic hysteroscopy group and 70.71% in the D&C group, diagnostic hysteroscopy did not increase the risk of all-cause death (HR 1.11, 95% CI 0.78-1.57, P=0.573). Multivariable analysis showed that the method of endometrial sampling was not independently associated with DFS (aHR 1.38, 95% CI 0.92-2.07, P=0.122) and OS (aHR 1.23, 95% CI 0.85-1.77, P=0.272).ConclusionFor apparent early-stage type II endometrial cancer, endometrial sampling by diagnostic hysteroscopy was as safe as D&C.
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Affiliation(s)
- Hui Zhou
- Department of Obstetrics and Gynecology, 363 Hospital, Chengdu, China
- Department of Obstetrics and Gynecology, Chengdu 363 Hospital Affiliated of Southwest Medical University, Chengdu, China
- *Correspondence: Hui Zhou,
| | - Kai-Fa Lai
- Department of Obstetrics and Gynecology, 363 Hospital, Chengdu, China
- Department of Obstetrics and Gynecology, Chengdu 363 Hospital Affiliated of Southwest Medical University, Chengdu, China
| | - Qian Xiang
- Department of Obstetrics and Gynecology, 363 Hospital, Chengdu, China
- Department of Obstetrics and Gynecology, Chengdu 363 Hospital Affiliated of Southwest Medical University, Chengdu, China
| | - Yu Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qian-Wen Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Cui Hu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xi-Guang Mao
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cheng Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Wu Huang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Gong-Sheng Mi
- Department of Obstetrics and Gynecology, Mianyang Central Hospital, Mianyang, China
| | - Juan Shen
- Department of Obstetrics and Gynecology, Mianyang Central Hospital, Mianyang, China
| | - Yong Tian
- Department of Obstetrics and Gynecology, Enshi Clinical College of Wuhan University, Enshi, China
| | - Feng-Mei Ke
- Department of Obstetrics and Gynecology, Enshi Clinical College of Wuhan University, Enshi, China
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Endometrial Cancer Management in Young Women. Cancers (Basel) 2022; 14:cancers14081922. [PMID: 35454829 PMCID: PMC9033146 DOI: 10.3390/cancers14081922] [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: 02/04/2022] [Revised: 03/30/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Endometrial cancer (EC) rarely develops in young women. Most cases are associated with known risk factors: BMI > 30, history of Polycystic Ovary Syndrome (PCOs), and race differentiation. The molecular EC classification based on The Cancer Genome Atlas Research Network divides these heterogeneous cancers into four types: Polymerase Epsilon Mutation (POLE), Microsatellite Instability (MSI), Copy Number Low (CNL), and Copy Number High (CNH). This division was introduced to allow for early assessment of neoplastic changes and clinical management, including targeted therapies. The basic technique for imaging endometrium changes is transvaginal sonography. Hysteroscopy is the standard for obtaining endometrial material for histological evaluation. The MRI result permits assessment of the extent of EC cancer infiltration. In young women who want to preserve fertility, apart from surgery, conservative management is often implemented after strict selection based on clinical and pathological data. This pharmacological treatment involves the administration of progestogens MPA (medroxyprogesterone acetate) and MA (megestrol acetate). The use of metformin may increase the effectiveness of such treatment. An alternative option is to apply progestogens locally—via the levonorgestrel-releasing intrauterine device. In addition to pharmacological treatment, hysteroscopic resection may be used—part of the uterine muscle adjacent to the pathologically changed endometrium may also undergo resection. An alternative is the administration of estrogen receptor modulators (e.g., SERMs) or aromatase inhibitors, or GnRH agonists.
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