Fertility-Sparing Treatment for Endometrial Cancer or Atypical Endometrial Hyperplasia Patients With Obesity

Weight-Loss and Metformin-Use Improve the Reversal Rate in Patients with Endometrial Hyperplasia

Objective

To evaluate the therapeutic outcomes of weight loss and metformin use in patients with endometrial hyperplasia (EH), and to identify the factors influencing treatment efficacy.

Methods

This study included data from patients diagnosed with either EH or endometrial atypical hyperplasia (EAH). Patients selected a progestin treatment regimen based on their diagnosis. Those with concurrent obesity or insulin resistance received additional weight management support and metformin therapy. Follow-up assessments were conducted every 3-6 months.

Results

A total of 202 patients were included. The metformin group exhibited significantly greater improvement in abnormal uterine bleeding (91.5% vs 57.1%, p < 0.001) and in ultrasound findings (91.5% vs 66.7%, p < 0.001) than the non-metformin group. Patients who achieved >3% weight loss and those using metformin showed a significantly higher rate of disease reversal than those with ≤3% weight loss (91.2% vs 77.6%, p = 0.034) and the non-metformin group (93.2% vs 52.4%, p < 0.001). At follow-up durations exceeding 12 months, metformin use was associated with a significantly higher disease reversal rate (82.1% vs 42.9%, p = 0.048) and a lower recurrence rate (12.8% vs 28.6%, p = 0.048). Weight loss of >3% (odds ratio: 0.041, 95% confidence interval: 0.004-0.437, p = 0.008) and metformin use (odds ratio: 0.059, 95% confidence interval: 0.011-0.311, p = 0.001) were both independently associated with improved reversal rates in patients with EH/EAH.

Conclusion

Combining progestin therapy with weight loss and metformin is more effective in reversing EH than progestin alone. Regular metformin use, alongside weight loss, serves as a protective factor in EH management, with the protective effect of metformin increasing with longer use.

Integrated Identification and Immunotherapy Response Analysis of the Prognostic Signature Associated With m6A, Cuproptosis-Related, Ferroptosis-Related lncRNA in Endometrial Cancer

BACKGROUND

Endometrial cancer (EC) stands as the predominant gynecological malignancy impacting the female reproductive system on a global scale. N6-methyladenosine, cuproptosis- and ferroptosis-related biomarker is beneficial to the prognostic of tumor patients. Nevertheless, the correlation between m6A-modified lncRNAs and ferroptosis, copper-induced apoptosis in the initiation and progression of EC remains unexplored in existing literature.

AIMS

In this study, based on bioinformatics approach, we identified lncRNAs co-expressing with cuproptosis-, ferroptosis-, m6A- related lncRNAs from expression data of EC. By constructing the prognosis model in EC, we screened hub lncRNA signatures affecting prognosis of EC patients. Furthermore, the guiding value of m6A-modified ferroptosis-related lncRNA (mfrlncRNA) features was assessed in terms of prognosis, immune microenvironment, and drug sensitivity.

METHOD

Our research harnessed gene expression data coupled with clinical insights derived from The Cancer Genome Atlas (TCGA) collection. To forge prognostic models, we adopted five machine learning approaches, assessing their efficacy through C-index and time-independent ROC analysis. We pinpointed prognostic indicators using the LASSO Cox regression approach. Moreover, we delved into the biological and immunological implications of the discovered lncRNA prognostic signatures.

RESULTS

The survival rate for the low-risk group was markedly higher than that for the high-risk group, as evidenced by a significant log-rank test (p < 0.001). The LASSO Cox regression model yielded concordance indices of 0.76 for the training set and 0.77 for the validation set, indicating reliable prognostic accuracy. Enrichment analysis of gene functions linked the identified signature predominantly to endopeptidase inhibitor activity, highlighting the signature's potential implications. Additionally, immune function and drug density emphasized the importance of early diagnosis in EC.

CONCLUSION

Five hub lncRNAs in EC were identified through constructing the prognosis model. Those genes might be potential biomarkers to provide valuable reference for targeted therapy and prognostic assessment of EC.

Fertility-sparing re-treatment for endometrial cancer and atypical endometrial hyperplasia patients with progestin-resistance: a retrospective analysis of 61 cases

OBJECTIVE

This study aimed to evaluate the oncological and reproductive outcomes of fertility-preserving re-treatment in progestin-resistant endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) women who desire to maintain their fertility.

METHODS

Our study included 61 progestin-resistant EC/AEH patients. These patients underwent treatment with gonadotropin-releasing hormone agonist (GnRHa) solely or a combination of GnRHa with levonorgestrel-releasing intrauterine system (LNG-IUD) or aromatase inhibitor (AI). Histological evaluations were performed every 3-4 months. Upon achieving complete remission (CR), we recommended maintenance treatments including LNG-IUD, cyclical oral contraceptives, or low-dose cyclic progestin until they began attempting conception. Regular follow-up was conducted for all patients. The chi-square method was utilized to compare oncological and fertility outcomes, while the Cox proportional hazards regression analysis helped identify risk factors for CR, recurrence, and pregnancy.

RESULTS

Overall, 55 (90.2%) patients achieved CR, including 90.9% of AEH patients and 89.7% of EC patients. The median re-treatment time was 6 months (ranging from 3 to 12 months). The CR rate for GnRHa alone, GnRHa + LNG-IUD and GnRHa + AI were 80.0%, 91.7% and 93.3%, respectively. After a median follow-up period of 36 months (ranging from 3 to 96 months), 19 women (34.5%) experienced recurrence, 40.0% in AEH and 31.4% in EC patients, with the median recurrence time of 23 months (ranging from 6 to 77 months). Among the patients who achieved CR, 39 expressed a desire to conceive, 20 (51.3%) became pregnant, 11 (28.2%) had successfully deliveries, 1 (5.1%) was still pregnant, while 8 (20.5%) suffered miscarriages.

CONCLUSION

GnRHa-based fertility-sparing treatment exhibited promising oncological and reproductive outcomes for progestin-resistant patients. Future larger multi-institutional studies are necessary to confirm these findings.

Levonorgestrel-releasing intrauterine device therapy vs oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia: a systematic review and meta-analysis

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.

Hysteroscopy and weight loss in treatment of endometrial cancer: case report and literature review

Fertility-sparing treatments have become important for young women with atypical endometrial hyperplasia (AEH) or endometrial carcinoma (EC) who wish to preserve their reproductive potential. Evidence indicates a strong relationship between weight and EC and the effect of weight loss on reducing the risk of EC. We report the case of a young obese woman with a body mass index (BMI) of 46.6 kg/m2, diagnosed with grade 2 endometrial endometrioid adenocarcinoma, who underwent a combined fertility-sparing treatment with hysteroscopic resection followed by insertion of a levonorgestrel intrauterine system. After twelve months of failure to achieve a complete response, bariatric surgery was proposed to lose weight and improve the response to treatment. Histologic regression was achieved three months after surgery, with a weight loss of 30 kg and fifteen months after combined treatment of endometrial cancer. We reviewed the literature to summarize the evidence on the role of bariatric surgery and weight loss in modifying the oncologic and reproductive outcomes of women undergoing fertility-sparing treatment for atypical endometrial lesions.

Prediction of complete regression in fertility-sparing patients with endometrial cancer and apical hyperplasia: the GLOBAL model in a large Chinese cohort

BACKGROUND

Fertility preservation treatment is increasingly essential for patients with apical endometrial hyperplasia (AEH) and early endometrial cancer (EEC) worldwide. Complete regression (CR) is the main endpoint of this treatment. Accurately predicting CR and implementing appropriate interventions during treatment are crucial for these patients.

METHODS

We conducted a retrospective study involving 193 patients diagnosed with atypical AEH or EEC, enrolled from January 2012 to March 2022 at our center. We evaluated 24 clinical parameters as candidate predictors and employed LASSO regression to develop a prediction model for CR. Subsequently, a nomogram was constructed to predict CR after the treatment. We evaluated the performance of the nomogram using receiver operator characteristic (ROC) curve and decision curve analysis (DCA) to assess its predictive accuracy. Additionally, we employed cumulative curves to determine the CR rate among patients.

RESULTS

Out of the 193 patients, 173 achieved CR after undergoing fertility preservation treatment. We categorized features with similar properties and provided a list of formulas based on their coefficients. The final model, named GLOBAL (including basic information, characteristics, blood pressure, glucose metabolism, lipid metabolism, immunohistochemistry, histological type, and medication), comprised eight variables identified using LASSO regression. A nomogram incorporating these eight risk factors was developed to predict CR. The GLOBAL model exhibited an AUC of 0.907 (95% CI 0.828-0.969). Calibration plots demonstrated a favorable agreement between the predicted probability by the GLOBAL model and actual observations in the cohort. The cumulative curve analysis revealed varying cumulative CR rates among patients in the eight subgroups. Categorized analysis demonstrated significant diversity in the effects of the GLOBAL model on CR among patients with different total points (p < 0.05).

CONCLUSION

We have developed and validated a model that significantly enhances the predictive accuracy of CR in AEH and EEC patients seeking fertility preservation treatment.

Fertility-sparing surgery: a hopeful strategy for young women with cancer

Fertility preservation in cancer patients is currently based on either assisted reproductive technology or fertility-sparing surgery. Loss of fertility may be caused by excisional surgery associated with an adnexal or uterine pathology or secondary to gonadal insufficiency caused by chemotherapy or radiation. The counseling of these patients is very important, being carried out jointly by the oncologist, gynecologist, and reproductive medicine specialist. Reproductive surgery usually requires avoiding laparotomy to significantly reduce the formation of adhesions and trauma or tissue damage. This is done using standard laparoscopic surgery or robotic surgery (computer-assisted laparoscopy), a method increasingly used and accessible to all specialists who want to maintain the fertility of their patients with various oncological diseases.

Medical Management of Atypical Endometrial Hyperplasia: Oncological and Reproductive Outcomes at a Tertiary Center in Singapore

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.

Progestin Resistance and Corresponding Management of Abnormal Endometrial Hyperplasia and Endometrial Carcinoma

With a younger tendency in morbidity age, endometrial cancer (EC) incidence has grown year after year. Worse, even more commonly occurring is endometrial hyperplasia (EH), which is a precancerous endometrial proliferation. For young women with early EC and EH who want to preserve fertility, progestin therapy has been utilized as a routine fertility-preserving treatment approach. Nevertheless, progestin medication failure in some patients is mostly due to progestin resistance and side effects. In order to further analyze the potential mechanisms of progestin resistance in EH and EC, to provide theoretical support for effective therapeutic strategies, and to lay the groundwork for searching novel treatment approaches, this article reviews the current therapeutic effects of progestin in EH and EC, as well as the mechanisms and molecular biomarkers of progestin resistance, and systematically expounds on the potential therapeutic methods to overcome progestin resistance.

Effects of Weight Status and Related Metabolic Disorders on Fertility-Sparing Treatment Outcomes in Endometrial Atypical Hyperplasia and Endometrial Cancer: A Retrospective Study

Simple Summary

Fertility-sparing treatment for young women with endometrial atypical hyperplasia or endometrioid endometrial cancer has become an important priority. The aim of our retrospective study was to evaluate the effects of different weight statuses and related metabolic disorders on the oncological and reproductive outcomes of fertility-sparing treatment. We found that there was a parabola-shaped relationship between the cumulative complete response rate of treatment and BMI. The apex of the curve was observed at a BMI of 21–22 kg/m². Furthermore, we demonstrated that hyperuricemia was an independent risk factor for the failure of conservative treatment, correlating with a lower cumulative 32-week CR rate and longer treatment duration. Our results indicate that a target BMI interval for weight management should be appropriately established for patients with EAH/EEC. Early active interventions for related metabolic disorders, preferably before 32 weeks of treatment, should be provided to improve treatment efficacy.

Abstract

Background: Although obesity was an independent risk factor for fertility-sparing treatment in endometrial atypical hyperplasia (EAH) and endometrioid endometrial cancer (EEC), the roles of other weight statuses and related metabolism were unclear. This study aimed to investigate the body mass index (BMI) interval that produced optimal treatment efficacy and the effects of related metabolic disorders in EAH/EEC patients. Methods: A total of 286 patients (including 209 EAH and 77 well-differentiated EEC) under progestin therapy were retrospectively analyzed. The cumulative complete response (CR) rate, relapse rate, and fertility outcomes were compared among different weight or metabolic statuses. Results: Underweight and overweight/obese status significantly decreased the cumulative 16-week and 32-week CR rate (p = 0.004, p = 0.022, respectively). The highest 16-week CR rate was observed at a BMI of 21–22 kg/m² in the overall population (p = 0.033). Obesity (HR 0.37, 95%CI 0.15–0.90, p = 0.029) and PCOS (HR 0.55, 95%CI 0.31–0.99, p = 0.047) were associated with lower 16-week CR rate. Hyperuricemia (HR 0.66, 95%CI 0.45–0.99, p = 0.043) was associated with lower 32-week CR rate. The 16-week and 32-week CR rate (p = 0.036, p = 0.008, respectively) were significantly lower in patients exhibiting both obesity and hyperuricemia. Conclusions: The optimal fertility-sparing treatment efficacy was observed at a BMI of 21–22 kg/m² in EAH/EEC. Hyperuricemia was an independent risk factor for long-term treatment outcomes.