Management of Patients Diagnosed with Endometrial Cancer: Comparison of Guidelines

Diagnostic Value of ADC in Distinguishing Endometrial Cancer from Atypical Endometrial Hyperplasia and Within Molecular Subtypes

Purpose

The study aimed to evaluate the effectiveness of using specific indicators, particularly the apparent diffusion coefficient (ADC), alone or in combination to differentiate endometrial cancer (EC) from atypical endometrial hyperplasia (AEH) and to explore non-invasive biomarkers for the molecular classification of EC.

Methods

A retrospective analysis was conducted on 300 EC and 126 AEH cases who had undergone preoperative magnetic resonance imaging, complete blood count, coagulation profile testing, and tumor biomarkers assessment. Postoperative molecular classification was conducted on 76 EC samples. Diagnostic values were assessed using receiver operating characteristic (ROC) analysis and binary logistic regression with forward selection to determine the optimal indicator combinations. Furthermore, this study evaluated the variability of parameters across EC molecular subtypes.

Results

The ADC effectively balanced sensitivity and specificity in differentiating EC from AEH. An optimal diagnostic model including age, fibrinogen, and ADC achieved the area under the curve (AUC) of 0.9143, with 84.67% sensitivity and 88.89% specificity. ADC values were found to be lower in EC cases that exhibited a higher Ki-67 index or a higher histological grade. Notably, the NSMP subtype presented significantly higher ADC values compared to the other three molecular subtypes. The p53abn subtype exhibited the highest prevalence of abnormal HE4 levels and patients aged ≥65 (both 6/12, 50%) yet normal CA125 and CA19-9 levels.

Conclusion

This retrospective study demonstrated that ADC, especially when combined with age and fibrinogen, is a valuable biomarker for distinguishing EC from AEH. In addition to indicating the Ki-67 index and histological grade, ADC values also serve as a promising tool for identifying the NSMP subtype within EC. Future studies should focus on multi-center, prospective studies with larger sample sizes to validate and refine the diagnostic value of ADC in differentiating EC from AEH, as well as in the molecular classification of EC.

Comprehensive Review of Endometrial Cancer: New Molecular and FIGO Classification and Recent Treatment Changes

Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries, with rising incidence due to aging populations and obesity-related factors. This review explores the evolving molecular and FIGO classifications of EC, highlighting their significance in diagnosis, prognosis, and personalized treatment strategies. Molecular subtyping based on The Cancer Genome Atlas (TCGA) classification offers a more precise understanding of EC, dividing it into POLE ultramutated, microsatellite instability-high (MSI-H), copy-number low (CNL), and copy-number high (CNH) subtypes. Each subgroup has distinct genetic, histological, and prognostic characteristics. Recent updates to the FIGO staging system incorporate molecular features, allowing for more tailored treatment approaches. Advances in immunotherapy, targeted therapies, and novel therapeutic combinations have reshaped clinical management. This review emphasizes the integration of molecular diagnostics into routine practice, outlining challenges and future perspectives in managing EC for improved patient outcomes.

The exciting journey of progress: Exploring FIGO 2023 staging for endometrial cancer at a leading ESGO institution

INTRODUCTION

The 2023 FIGO staging of endometrial cancer integrates tumor grade and histology along with molecular features that recognize the prognostic significance of p53 and POLE mutations, accounting for potential conflicts such as lymphovascular space invasion and subserosal invasion.

MATERIALS AND METHODS

In this single-institution retrospective study, data were collected on 229 endometrial cancer patients from January 2020 to September 2024 and re-stage them according to FIGO 2023 criteria.

RESULTS

From FIGO stage 2009 IA, 70 patients do not cross stage (21 are FIGO 2023 IA1 and 49 IA2), 8 patients are upgraded to FIGO IC because of aggressive histotype; 1 is upstaged because of substantial LVSI, and 12 because of aggressive myoinfiltrating tumors (23 % of upstaging). From FIGO 2009 stage IB 34 patients remain in FIGO 2023 IB, while 5 become stage IIB (LVSI) and 27 IIC (aggressive myoinfiltrating), for a total of 32 upstages (48 % of upstaging). Within FIGO 2009 stage II, no proper upstage was possible. We observed a statistical correlation between stages and BMI, as well as between stages and age, for both FIGO 2009 (p = 0.009 and p < 0.001 respectively) and FIGO 2023 (p = 0.002 and p = 0.003 respectively) classifications. Additionally, a correlation was found between tumor grade and BMI (p = 0.02).

CONCLUSIONS

The FIGO 2023 staging system is gaining importance as recent studies highlight the role of molecular classification in prognosis and personalized therapy. Updating our study's follow-up data will clarify its impact in clinical practice.

Comparing the efficacy of different methods in assessing cervical stromal invasion in endometrial carcinoma: a retrospective study of 2,020 patients

Purpose

This study aimed to assess the preoperative diagnostic efficacy of magnetic resonance imaging (MRI), computed tomography (CT), and endometrial biopsy for cervical stromal invasion (CSI) in endometrial carcinoma (EC) and to discuss the influencing factors of CSI.

Material and methods

A total of 2,020 patients with EC were retrospectively analyzed in a tertiary hospital. Basic patient information, clinical pathology, and laboratory indicators were collected and analyzed. Using the postoperative pathological diagnosis as the gold standard, the diagnostic efficacies of different preoperative methods were analyzed. Additionally, influencing factors of CSI were examined by univariate and multivariate analyses.

Results

The sensitivity (Sens.), specificity (Spec.), accuracy (Acc.), diagnostic odds ratio (DOR), Youden's index, and Kappa value of the MRI vs. CT groups were 49.50% vs. 56.74%, 92.24% vs. 79.09%, 87.70% vs. 76.15%, 11.60 vs. 4.93, 0.42 vs. 0.36, and 0.392 vs. 0.256 (p < 0.001), respectively. The Sens., Spec., Acc., DOR, Youden's index, and Kappa value of the endometrial biopsy group were 41.74%, 93.25%, 87.08%, 9.97, 0.35, and 0.363 (p < 0.001), respectively. CSI was associated with cancer antigen 125, myometrial invasion, adnexal invasion, parametrial invasion, lymph node metastasis, and progesterone receptor.

Conclusions

MRI is relatively superior in assessing CSI, although diagnostic authenticity and consistency were unsatisfactory. Combining MRI and biopsy could improve diagnostic sensitivity, aiding in clinical decision making and prognostic prediction. Comprehensive consideration of high-risk factors for the occurrence of CSI may aid the diagnosis. Preoperative diagnostic methods of CSI in EC still need to be explored further to improve efficiency.

The impact of integrated genomic analysis on molecular classifications and prognostic risk stratification in endometrial cancer: a Chinese experience

Background

The molecular classification of endometrial cancer (EC), as proposed by The Cancer Genome Atlas (TCGA), has transformed tumor classification, but there is a lack of extensive research on the molecular profiles and subtyping of endometrial cancer patients in China.

Methods

200 EC patients were classified into the following four molecular types: (i) POLEmut; (ii) MSI-H; (iii) TP53mut; (iv) NSMP. This study aimed to investigate the molecular characteristics of EC patients at a single center by large-scale next generation sequencing(NGS), including clinicopathological features and gene mutations in patients with distinct molecular types, and to assess the relevance of molecular subtyping for postoperative adjuvant therapy.

Results

NSMP group was the most prevalent, comprising 46.0% (92/200) of cases, followed by the TP53mut group at 17.5% (35/200), the MSI-H group at 23.5% (47/200), and the POLEmut group at 13.0% (26/200). CTNNB1 mutations were common in the POLEmut group but rare in the TP53mut group. With the application of the new European Society for Medical Oncology (ESMO) 2022 classification, 27 patients (14.1%) were reclassified. Concordance between the two classifications regarding postoperative risk was observed in 85.9% (165/192) of cases. Seven patients (3.6%) were downstaged, and twenty patients (10.4%) were upgraded. Additionally, the analysis revealed that eleven genes were significantly mutated in patients with lymphovascular space invasion (LVSI) compared to those without LVSI. Notably, NSD3 and POLD1 were highly mutated in patients with lymphatic metastasis compared to those without lymphatic metastasis. Conclusively, large-scale NGS has revolutionized EC management by facilitating rapid molecular subtype identification, guiding tailored adjuvant therapies, targeted treatments, and immunotherapies, and efficiently screening for Lynch syndrome, thereby significantly improving patient outcomes.

Robotic Surgery in Severely Obese Frail Patients for the Treatment of Atypical Endometrial Hyperplasia and Endometrial Cancer: A Propensity-Match Analysis at an ESGO-Accredited Center

BACKGROUND AND OBJECTIVES

Robotic-assisted laparoscopy (RS) has been widely adopted for the management of endometrial cancer (EC) due to favorable perioperative outcomes, especially in the context of obesity, which is an established risk factor for EC. This study retrospectively evaluated the perioperative outcomes of RS versus conventional laparoscopy (LS) in treating EC and atypical endometrial hyperplasia (AH).

METHODS

Between November 2021 and October 2023, 138 patients with AH or EC underwent surgery at the Clinic of Obstetric and Gynecological-Azienda Sanitaria Universitaria Friuli Centrale, Udine. All patients had total hysterectomy with bilateral salpingo-oophorectomy, with or without lymphadenectomy or sentinel lymph node biopsy. The study included 62 patients treated with LS and 62 with RS.

RESULTS

The median BMI was higher in the RS group (35.5 vs. 24 kg/m2, p = 0.001). There was no significant difference in operative time between the laparoscopic group and the robotic console time (median 130 vs. 130 min, p = 0.131). No significant differences were found in terms of blood loss, conversion to laparotomy, intraoperative complications, hospital stay, or early postoperative complications between the two groups.

CONCLUSIONS

Our data confirm the feasibility of robotic surgery in obese patients, allowing surgical results comparable to those of laparoscopy in normal-weight patients.

Quality of life and survival in patients with uterine carcinosarcoma: A tertiary center observational study

Objective

This study aimed to assess the QoL in patients with uterine carcinosarcoma (UCS) and identify factors influencing survival.

Methods

A prospective cohort study was conducted of patients with UCS who were treated between 2016 and 2022 in a Dutch academic hospital. QoL was evaluated using the EORTC QLQ-C30 and QLQ-EN24 questionnaires at baseline, end of treatment, and at one, two, and five years after treatment. Outcomes were described as mean scores in functioning and symptom domains. The mean scores of the QLQ-C30 were compared to those of a matched group from the general Dutch population. Clinical data were collected. Factors influencing survival were assessed via Cox proportional hazards models.

Results

The study included 64 patients, 56 of them participated in the QoL questionnaires. The median progression-free survival was 13 months, and overall survival was 20 months. QoL was significantly lower in all functional domains at one year after treatment compared to members of the general population. The most affected functioning domains were physical, role, cognitive, and social functioning and symptoms like fatigue, pain, and lymphedema. Long-term QoL remained compromised, with global health and insomnia notably impaired even five years after treatment. Significant prognostic factors for better overall survival included lower FIGO stage, surgery, and chemotherapy.

Conclusions

Patients with UCS experience significant deterioration in QoL. Despite extensive treatment, QoL remains poor, emphasizing the need for integrating QoL considerations into treatment decisions to balance the benefits of treatment with potential QoL impairments.

HLA-DMB correlates with antitumor immunity and an improved prognosis in endometrial carcinoma tumors

Introduction

Endometrial Carcinoma (UCEC) is a prevalent malignant tumor within the female reproductive system. HLA-DMB, the beta chain of the non-classical MHC class II protein HLA-DM, has been implicated in the progression of various cancers. However, its role in the development of endometrial carcinoma remains unclear. Therefore, we conducted a preliminary exploration of the prognostic value and potential mechanisms of HLA-DMB in uterine corpus endometrial carcinoma (UCEC).

Methods

The differential expression of HLA-DMB was analyzed in 554 tumor samples and 35 normal samples obtained from the TCGA database. The differential expression of HLA-DMB across various cancers, along with immune infiltration analysis, was conducted using the TIMER2.0 database. Additionally, the expression of HLA-DMB in endometrial carcinoma was examined in the GEPIA2 database, along with its relationship to prognosis. Furthermore, TISIDB was utilized to predict the relationships between HLA-DMB and various immune enhancement factors as well as immunosuppressive factors. Gene Ontology (GO) analysis and Gene Set Enrichment Analysis (GSEA) were employed to explore the signaling pathways associated with HLA-DMB in endometrial cancer. Univariate COX regression analysis was performed to identify prognostic factors for endometrial carcinoma (EC), and a multivariate COX proportional hazards regression model was used to confirm that HLA-DMB can serve as an independent prognostic factor for EC. The protein interaction network of HLA-DMB was constructed using the STRING database, and the chemical drugs related to HLA-DMB were predicted through the CTD database. Finally, the expression of HLA-DMB was validated by qPCR and immunohistochemistry.

Results

The expression of HLA-DMB at both mRNA and protein levels is significantly higher in UCEC tissues compared to normal tissues. Prognostic analyses indicate that increased expression of HLA-DMB correlates with improved patient prognosis, suggesting its potential as an independent prognostic factor for UCEC. Furthermore, in endometrial cancer, elevated levels of HLA-DMB are associated with higher immune infiltration scores and are closely related to various immune-enhancing factors. Mechanistically, HLA-DMB primarily participates in CD22-mediated regulation of B cell receptors (BCR), leading to BCR antigen activation and the production of second messengers. In our drug analysis, we identified several chemical agents associated with HLA-DMB, including cisplatin, dexamethasone, and ethinylestradiol.

Discussion

This study elucidates the function and underlying mechanisms of HLA-DMB in UCEC, providing a potential biomarker and target for immunotherapy in this disease.

Prognosis of premenopausal women with low-risk endometrial cancer but elevated CA125 levels

Introduction

Women with low-risk endometrial cancer, as defined by the Korean Gynecologic Oncology Group (KGOG) criteria, have a low risk of lymph node metastasis and an excellent prognosis without lymphadenectomy. However, it is unclear whether lymphadenectomy should be performed in premenopausal women who meet the KGOG criteria other than elevated cancer antigen 125 (CA125) levels, because the CA125 level can be elevated by benign conditions. We investigated the patterns of metastasis and recurrence to assess the value of lymphadenectomy in this population.

Methods

Premenopausal women with endometrial cancer meeting the KGOG criteria, except for those with elevated CA125 levels, were eligible. The characteristics of the eligible women were collected from seven institutes in the Republic of Korea by reviewing their medical records. Recurrence-free survival (RFS) was estimated using the Kaplan-Meier method and compared using the log-rank test.

Results

Seventy-three patients were included. Of 62 women who underwent lymphadenectomy, only two (3.2%) had lymph node metastasis. Eighteen women (24.7%) received adjuvant therapy. At a median follow-up of 59 months, the 5-year RFS was 88.8%. Five women (7%) experienced recurrence, two had lymph node recurrence, and three had non-nodal recurrence. RFS was similar between the women who did and did not undergo lymphadenectomy (P=0.737).

Conclusion

Premenopausal women who had elevated CA125 levels but met all other KGOG criteria showed a low risk of lymph node metastasis and recurrence as well as a good prognosis. Therefore, lymphadenectomy can be omitted in this population.

Impact of optimal secondary cytoreductive surgery on survival outcomes in women with recurrent endometrial carcinoma: A systematic review and meta-analysis

BACKGROUND

Management of recurrent endometrial carcinoma (EC) represents a challenge. Although a complete resection of visible disease at secondary surgery (R0) is recommended, the impact of R0 on survival outcomes is unclear and pooled data are lacking.

OBJECTIVE

To quantitatively assess the impact of R0 on survival outcomes in women with EC recurrence.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching eight electronic databases from their inception up to January 2024.

SELECTION CRITERIA

All peer-reviewed studies that assessed quantitatively the impact of R0 on survival outcomes in women at first EC recurrence were included.

DATA COLLECTION AND ANALYSIS

Hazard ratio (HR) with 95% confidence interval (CI) for death of any cause and secondary recurrent or progressive disease in women with EC recurrence who underwent R0 compared to non-optimal secondary surgical cytoreduction (R1) were pooled and assessed at both univariable and multivariable analyses.

MAIN RESULTS

Three studies with 442 patients were included. At univariate analysis, in women with EC recurrence and R0 compared to women with EC recurrence and R1, pooled HR was 0.451 (95% CI: 0.319-0.638) for death from any cause, and 0.517 (95% CI: 0.298-0.895; p = 0.019) for recurrent or progressive disease. At multivariate analysis, in women with EC recurrence and R0 compared to women with EC recurrence and R1, pooled HR was 0.447 (95% CI: 0.255-0.783; p = 0.005) for death from any cause, and 0.585 (95% CI: 0.359-0.952; p = 0.031) for recurrent or progressive disease.

CONCLUSION

In women with EC recurrence, R0 is an independent prognostic factor, decreasing the risk of death from any cause by approximatively 55%, and of recurrent or progressive disease by approximatively 40%, compared to R1.

Poor accuracy of endometrial sampling in patients with uterine carcinosarcomas: a nationwide analysis

OBJECTIVE

To determine the accuracy of aspiration biopsy (AB), hysteroscopic biopsy (HB), and dilatation & curettage (D&C) in detecting uterine carcinosarcoma (UCS).

METHODS

Pathology reports were retrieved from the Dutch Nationwide Pathology Databank PALGA for patients with a certain or suggested diagnosis of UCS in pre- and/or postoperative histology between 2001 and 2021. Patients without available pre- or postoperative pathology reports were excluded. The accuracy measures sensitivity, positive predictive value (PPV), accuracy, and concordance using Cohen's kappa were calculated for AB, D&C, and HB, using postoperative histology as the reference. This was analyzed for 2 scenarios: Analysis A compared samples with a certain or suggested diagnosis of UCS vs. no mention of UCS. Analysis B compared samples with a certain diagnosis of UCS vs those without UCS.

RESULTS

The study included 1,481 patients, totaling 1,685 samples. Sensitivity was similar for AB and HB (52.4% and 50.5%, respectively, for analysis A; 45.1% and 42.2% for analysis B). D&C showed the highest sensitivity (70.8% and 64.9% for analysis A and B, respectively). AB had the highest PPV (85.3% and 90.9% for analysis A and B, respectively), HB had the lowest PPV (79.7% and 80.9%, respectively). Accuracy was highest for D&C (44.4%) compared to AB (32.8%) and HB (29.5%). All Cohen's kappa values were below 0.20, indicating poor correlation between preoperative and postoperative diagnoses.

CONCLUSION

The study reveals low accuracy measures across all conventional endometrial sampling techniques, highlighting the need for research to identify markers or tools to diagnose UCS.

Risk factors for second primary cancer in a prospective cohort of endometrial cancer survivors: an Alberta Endometrial Cancer Cohort Study

We examined associations between modifiable and nonmodifiable cancer-related risk factors measured at endometrial cancer diagnosis and during early survivorship (~3 years postdiagnosis) with second primary cancer (SPC) risk among 533 endometrial cancer survivors in the Alberta Endometrial Cancer Cohort using Fine and Gray subdistribution hazard models. During a median follow-up of 16.7 years (IQR, 12.2-17.9), 89 (17%) participants developed an SPC; breast (29%), colorectal (13%), and lung (12%) cancers were the most common. Dietary glycemic load before endometrial cancer diagnosis (≥90.4 vs < 90.4 g/day: subhazard ratio [sHR] = 1.71; 95% CI, 1.09-2.69), as well as older age (≥60 vs < 60 years: sHR = 2.48; 95% CI, 1.34-4.62) and alcohol intake (≥2 drinks/week vs none: sHR = 3.81; 95% CI, 1.55-9.31) during early survivorship, were associated with increased SPC risk. Additionally, reductions in alcohol consumption from prediagnosis to early survivorship significantly reduced SPC risk (sHR = 0.34; 95% CI, 0.14-0.82). With 1 in 6 survivors developing an SPC, further investigation of SPC risk factors and targeted surveillance options for high-risk survivors could improve long-term health outcomes in this population. Reductions in dietary glycemic load and alcohol intake from prediagnosis to early survivorship showed promising risk reductions for SPCs and could be important modifiable risk factors to target among endometrial cancer survivors. This article is part of a Special Collection on Gynecological Cancer.

Murine Xenograft Models as Preclinical Tools in Endometrial Cancer Research

Murine xenograft models are valuable and increasingly used preclinical tools in cancer research to understand disease pathogenesis and guide treatment options. The aim of this narrative review is to summarize the studies that employed mouse xenograft models, using cell lines, patient-derived tumors, or organoids, in endometrial cancer (EC) research, detailing their methodology and main findings. We identified 27 articles reporting on heterotopic EC xenografts, including subcutaneous, subrenal capsule, intraperitoneal, and retro-orbital models, and 18 articles using orthotopic xenografts. Subcutaneous xenografts generated using either cell lines or patient tumors have been widely used; however, their low engraftment rates and the inability to recapitulate main clinical features such as metastases limit their translational value. Subrenal capsule models showed improved engraftment rates compared to subcutaneous models, but tumors exhibited slower and constrained tumor growth. Orthotopic models are technically more challenging to generate and monitor, but tumor growth occurs in a relevant microenvironment and EC ortho-xenografts exhibit high engraftment rates and metastases to clinically relevant sites. Cell line-based xenograft (CDX) models are attractive tools because they are convenient, easy to use, and amenable to genetic modifications, making them suitable for proof-of-concept approaches and large-scale studies. EC xenografts developed from patient tumors (PDTXs) are more labor/cost-intensive for their establishment but can capture the genetic and molecular heterogeneity within and across histologic subtypes and can inform personalized patient treatment. EC organoid-based xenograft (PDOX) models combine the advantages of both CDXs and PDTXs since they are more time- and cost-effective, faithfully maintain tumor characteristics and therapeutic responses, and can be genetically modified. Despite substantial progress in EC management, there are still several unmet needs. Efficient targeted treatments are currently indicated only for a small subgroup of patients, while women with recurrent or advanced-stage EC have very few therapeutic options and their prognosis remains unfavorable. Novel (targeted) drugs, combinational regimens and tools to predict the real drug response in patients are urgently needed. Xenograft models are expected to inform about disease mechanisms and to help identify novel therapeutic options and suitable target patients.

The relationship between metabolic syndrome and survival of patients with endometrial cancer: a meta-analysis

Background

Metabolic syndrome (MetS) is associated with a high risk of endometrial cancer (EC). However, its impact on EC progression remains unclear. This meta-analysis examined the association between MetS and survival outcomes in EC patients.

Methods

A comprehensive search of PubMed, EMBASE, and Web of Science databases up to May 22, 2024, was conducted. Two independent reviewers performed study selection, data extraction, and quality assessment. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using a random effects model.

Results

Nine studies comprising 13,579 endometrial cancer (EC) patients were included. Among these, 2,896 patients (21.3%) had MetS at the time of enrollment. The follow-up durations ranged from 3.4 to 14.2 years. The results showed that EC patients with MetS at baseline demonstrated significantly poorer overall survival (HR = 1.57, 95% CI = 1.19-2.07, p = 0.002; I2 = 25%) and progression-free survival (HR = 1.33, 95% CI = 1.08-1.63, p = 0.007; I2 = 16%). A similar association was observed for cancer-specific survival (HR = 1.26, 95% CI = 1.10-1.44, p = 0.001; I2 = 0%). Subgroup analyses based on study characteristics showed consistent results across studies conducted in countries with different follow-up durations.

Conclusion

This meta-analysis suggests that MetS is associated with poor survival outcomes in EC patients. Further prospective studies are required to validate our findings.

Systematic review registration

PROSPERO, identifier CRD42024561654.

Survival benefit of cytoreductive surgery in patients with primary stage IV endometrial cancer: a systematic review & meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to investigate the survival outcomes following cytoreductive surgery (CRS) in patients with primary stage IV endometrial cancer (EC).

METHODS

We systematically searched the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Science for original studies reporting survival outcomes of primary stage IV EC after complete, optimal, and incomplete CRS. Pooled hazard ratios (HRs) for overall survival (OS) comparing optimal CRS with incomplete CRS were calculated using a random-effects model. Heterogeneity was assessed using the I2 and the Q-test.

RESULTS

Twelve studies, including 748 patients, were analysed. 187 patients underwent complete CRS, and 146 patients optimal CRS. Ten studies reported a significant OS benefit after complete (18-48 months) and optimal CRS (13-34 months) compared to incomplete CRS (7-19 months). A benefit was also observed in patients with serous EC or extra- abdominal metastasis. Meta-analysis showed improved OS after complete/optimal vs. incomplete CRS (HR = 0.38, 95% CI 0.21-0.69, p = 0.0016). Heterogeneity was substantial between studies (I2 = 76.7%, p < 0.0001).

CONCLUSION

Our study supports considering CRS in all patients with primary stage IV EC if complete resection is deemed feasible, while also emphasizing the importance of weighing the harms and benefits of this extensive treatment and adopting shared decision-making.

PROSPERO REGISTRATION

CRD42022302968 on May 10th, 2022.

Evaluating pretreatment serum CA-125 levels as prognostic biomarkers in endometrial cancer: a comprehensive meta-analysis

Background

In recent years, the incidence of endometrial cancer (EC) has been rising. This meta-analysis aims to clarify the prognostic significance of serum CA-125 levels in EC.

Methods

Articles up to March 1, 2024, were systematically searched in EMBASE, Cochrane Library, PubMed, and Web of Science. This analysis pooled hazard ratios (HR) and 95% confidence intervals (CI) from qualifying studies to evaluate the association of CA-125 levels with overall survival (OS), progression-free survival (PFS), disease-free/relapse-free survival (DFS/RFS), and disease-specific survival (DSS).

Results

25 studies involving 7,716 patients were included. The analysis revealed that elevated CA-125 levels correlate with poorer OS (HR = 1.848, 95% CI: 1.571-2.175, p < 0.001). This association persisted across various study regions and sample sizes, and was notably strong in subgroups with a CA-125 cut-off value of less than 35 (HR = 2.07, 95% CI: 1.13-3.80, p = 0.019) and equal to 35 (HR = 2.04, 95% CI: 1.49-2.79, p < 0.001), and among type II pathology patients (HR = 1.72, 95% CI: 1.07-2.77, p = 0.025). Similarly, high CA-125 levels were linked to reduced PFS, particularly in subgroups with a CA-125 cut-off value less than 35 (HR = 1.87, 95% CI: 1.15-3.04, p = 0.012) and equal to 35 (HR = 4.94, 95% CI: 2.56-9.54, p < 0.001), and in endometrioid endometrial cancer patients (HR = 2.28, 95% CI: 1.18-4.40, p = 0.014). Elevated CA-125 levels were also indicative of worse DFS/RFS (HR = 2.17, 95% CI: 1.444-3.262, p < 0.001) and DSS (HR = 2.854; 95% CI: 1.970-4.133, p < 0.001).

Conclusion

Serum CA-125 levels before treatment was highly associated with prognosis of EC patients.

Pelvic Sentinel Lymph Node Biopsy for Endometrial Cancer with Multi-Modal Infrared Signal Technology: A Video Article

This video article summarizes a case study involving the use of pelvic sentinel lymph node (SLN) biopsy for endometrial cancer (EC) staging and treatment utilizing a multi-modal infrared signal technology. This innovative approach combines cervical injection of fluorescent dye indocyanine green (ICG) and near-infrared imaging to enhance SLN detection rates in early-stage EC patients. The study showcases the successful application of advanced technology in improving surgical staging procedures and reducing postoperative morbidity for patients. Multi-modal infrared signal technology consists of different modes of fluorescence imaging used to identify lymph nodes based on near-infrared signals. Each mode serves a specific purpose: overlay image combines white light and near-infrared signals in green, monochromatic visualization shows near-infrared signal in greyscale, and intensity map combines signals in a color scale to differentiate signal intensity. Yellow denotes strong near-infrared signals while blue represents weaker signals. By utilizing a multi-modal approach, surgeons can accurately identify and remove SLN, thus avoiding unnecessary removal of secondary or tertiary echelons.

Implementation of sentinel node biopsy in high-risk endometrial cancer

PURPOSE OF REVIEW

Endometrial cancer is the most common gynecologic malignancy and sentinel lymphnode biopsy is accepted as a valid alternative to lymphadenectomy for staging purposes. Recently, sentinel node biopsy has been also extended to high-risk disease where risk of nodal involvement is higher.

RECENT FINDINGS

Our review focuses on the definition of high-risk disease and how there are different concepts of high-risk in the scientific community. While the sensitivity of sentinel node biopsy has been established and accepted in lower risk endometrial cancers, only in recent years retrospective and prospective evidence has been published. Ultrastaging allows to identify more nodal disease that would normally be overlooked by traditional staging, allowing proper adjuvant therapy to be administered. The longstanding question of whether lymphadenectomy in high-risk settings is a therapeutic or a staging procedure remains open. Retrospective data, however, show that oncologic outcomes are not compromised by sentinel node biopsy.

SUMMARY

Sentinel node biopsy is a valid alternative to traditional, more extensive nodal staging: with the addition of ultrastaging, it has more sensitivity than lymphadenectomy with less surgical morbidity. Ongoing trials will definitively establish if oncological outcomes are affected by sentinel node biopsy, but retrospective data are encouraging.

Locally advanced and metastatic endometrial cancer: Current and emerging therapies

Until recently, patients diagnosed with locally advanced and metastatic endometrial cancer faced significant challenges in their treatment due to limited options and poor prognostic outcomes. The sequencing of tumors has been a major advancement in its management. It has led to The Cancer Genome Atlas classification currently used in clinical practice and the initiation of several clinical trials for innovative treatments targeting principally signaling pathways, immune checkpoints, DNA integrity, growth factors, hormonal signaling, and metabolism. Numerous clinical trials are investigating a combinatorial approach of these targeted therapies to counter tumoral resistance, cellular compensatory mechanisms, and tumor polyclonality. This review provides a comprehensive overview of historical, current, and promising therapies in advanced and metastatic endometrial cancer. It particularly highlights clinical research on targeted and hormonal therapies, but also immunotherapy, reflecting the evolving landscape of treatment modalities for this disease.

Molecular classification of endometrial carcinoma on endometrial biopsy: an early prognostic value to guide personalized treatment

OBJECTIVE

Molecular features are essential for estimating the risk of recurrence and impacting overall survival in patients with endometrial cancer. Additionally, the surgical procedure itself could be personalized based on the molecular characteristics of the tumor. This study aims to assess the feasibility of obtaining reliable molecular classification status from biopsy specimens collected during hysteroscopy to better modulate the appropriate surgical treatment.

METHODS

This monocentric, retrospective, observational study was conducted on 106 patients who underwent a biopsy procedure followed by radical surgery for endometrial cancer, with concurrent molecular investigation. The molecular classification was determined through immunohistochemical staining for p53 and mismatch repair proteins, along with gene sequencing for POLE.

RESULTS

Overall, 106 patients underwent molecular investigation, which was finally achieved on 99 patients (93.4%). Among these, the molecular analysis was conducted in 71 patients (67%) on the pre-operative endometrial biopsy and on the final uterine specimen in 28 patients (26.4%). Most of the endometrial biopsies were performed using Bettocchi hysteroscopy (66%). Molecular analysis was not possible in seven patients (6.6%), with six cases due to sample inadequacy and one case attributed to intra-mucosal carcinoma. The molecular results showed that the copy number low sub-group was the most common, and five cases of 'multiple classifiers' were observed in the low-risk category.

CONCLUSION

Our experience in obtaining molecular information from biopsy samples underscores the feasibility and efficacy of this technique, even in small tissue samples. This capability helps define the prognostic group of patients, facilitates timely decision-making, and develops a personalized strategy for each patient.

A 10-Year Retrospective Cohort Study of Endometrial Cancer Outcomes and Associations with Lymphovascular Invasion: A Single-Center Study from Germany

This 10-year retrospective cohort study at a single-center clinic in Germany aimed to analyze the outcomes of endometrial cancer patients and explore the impact of lymphovascular invasion (LV) on patient outcomes and disease-free survival (DFS). Identifying correlations among demographic data, tumor characteristics, treatment modalities, and survival outcomes could enhance patient management and improve survival rates. The study encompassed patients diagnosed and treated for endometrial cancer from January 2010 to December 2020. Clinical and pathological data were extracted from medical records for 311 patients, focusing on variables such as age, histological type, tumor grade, type of surgical treatment, and adjuvant therapies. Survival analysis was conducted using the Kaplan-Meier method and multivariate Cox proportional hazard models to identify factors independently associated with survival. The study demonstrated that lymphovascular invasion significantly impacted survival outcomes on Kaplan-Meier analysis (log-rank p-value = 0.0058). Patients with LV showed a marked decrease in DFS compared to those without LV invasion, with a median DFS of 3.2 years and a hazard ratio of 2.18 (95% CI: 1.56-3.04, p < 0.001). Furthermore, high-grade tumors and p53 positivity were strongly associated with reduced DFS, with hazard ratios of 1.93 (p = 0.001) and 2.11 (p < 0.001), respectively. Patients with distant metastasis exhibited the most significant decline in survival, with a hazard ratio of 5.56 (95% CI: 2.45-10.18, p < 0.001). Despite comprehensive surgical and adjuvant therapies, these high-risk factors dictated poorer outcomes. The presence of lymphovascular invasion, high-grade tumors, and genetic markers like MSI and p53 are pivotal in predicting the course of endometrial cancer. This study underscores the necessity for aggressive management strategies in patients exhibiting these high-risk features to potentially improve prognosis and survival outcomes. The findings advocate for enhanced therapeutic strategies tailored to the biological behavior of the tumor, thereby aiming to elevate the overall survival rates for women diagnosed with endometrial cancer.

Endometrial cancer treatment and outcomes in Argentina: ECHOS-A real-world study

Objective

Real-world data for patients with endometrial cancer (EC) are limited, particularly in Latin America. We present treatment pattern findings from ECHOS-A - Endometrial Cancer Health Outcomes Study in Argentina.

Materials and methods

A retrospective study using clinical data from privately insured patients with EC diagnosed from 2010 to 2019. Index (diagnosis proxy) was first date of an EC-related health term or treatment. Demographics, clinical characteristics, and FIGO staging were described. Disease progression and survival were assessed until study end, loss to follow-up, or death.

Results

Of 805 patients with EC, 77.4 % (n = 623/805) received any treatment and 22.6 % (n = 182/805) received none. Among those treated, 31.8 % (n = 198/623) had first-line (1L) systemic therapy, and 45.5 % (n = 90/198) proceeded to second-line (2L) therapy. Mean follow-up was 33.6 (SD 31.8) months. Of those receiving any treatment, 87.3 % (n = 544/623) had FIGO stage data (I, 62.9 %; II, 18.6 %; III, 13.6 %; IV, 5.0 %). Treatment by class in 1L and 2L, respectively, were platinum chemotherapy, 73.7 %, 36.7 %; non-platinum chemotherapy, 73.7 %, 62.2 %; immunotherapy, 1.0 %, 11.1 %; hormone therapy, 17.7 %, 26.7 %. Carboplatin/paclitaxel was the most frequent 1L (52.5 %) and 2L (14.4 %) regimen. Mean time to progression was 14.1 (SD 16.3) and 8.8 (SD 8.3) months in 1L and 2L, respectively. Adjusted 1- to 5-year risk of progression/death was 46.5-77.5 % and 65.0-86.2 % in 1L and 2L, respectively.

Conclusions

Approximately one-quarter of patients with EC received no treatment, and approximately two-thirds were not treated with 1L systemic therapy. Efforts to better understand the reasons for these treatment patterns are crucial for improving patient outcomes.

Is fluorometric sentinel lymph node biopsy in endometrial cancer necessary?

Objective

In this study, we collected perioperative and postoperative follow-up data from patients with endometrial cancer (EC) at different stages to evaluate the role of sentinel lymph node biopsy (SLNB) in endometrial cancer surgery.

Methods

A total of 186 endometrial cancer patients undergoing radical hysterectomy from January 2018 to April 2022 were retrospectively analyzed. Patients were classified into four groups. Group A comprised patients diagnosed with stage IA grade 1 and 2 endometrioid EC who underwent SLNB. Group B comprised patients with stage IA grade 1 and 2 endometrioid EC who did not undergo SLNB. Group C comprised patients with higher-grade endometrioid EC, wherein systematic lymph node dissection was performed based on SLNB results. Group D comprised patients with higher-grade endometrioid EC who did not undergo SLNB and instead underwent direct systematic lymph node dissection. Clinical, pathological data, and follow-up information for all patients were collected.

Results

In Group A and B, SLNB was performed on 36 out of 67 patients with IA stage 1 and 2 endometrial cancer, yielding a SLN positivity rate of 5.6%. There were no significant differences observed between the two groups regarding perioperative outcomes and postoperative follow-up. Conversely, among 119 patients with higher-grade endometrial cancer, 52 underwent SLNB, with 20 patients exhibiting SLN positivity, resulting in a SLN positivity rate of 38.4%. However, the decision to undergo SLNB did not yield significant differences in perioperative outcomes and postoperative follow-up among these patients.

Conclusion

For stage IA grade 1 and 2 endometrioid EC, the incidence of lymph node positivity is low, omitting SLNB in this subpopulation is a feasible option. In other stages of endometrioid EC, there is no significant difference in perioperative and postoperative follow-up data between patients undergoing routine systematic lymphadenectomy and those undergoing systematic lymphadenectomy based on SLNB results. Therefore, if SLNB is not available, the standard procedure of PLND remains an option to obtain information about lymph node status, despite the surgical complications associated with this procedure.

Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO)

Cervical cancer continues to have a significant incidence, despite global efforts in HPV vaccination campaigns. Managing this condition involves a diverse team of healthcare professionals. Research in this field is undergoing a period of great revolution in multiple areas, and international guidelines will soon have to adapt to new scientific evidence. This could be true mainly in locally advanced stages, and it could also be true for minimal invasive surgery. This paper aims to summarize and compare the most recent recommendations published by international gynecological oncological societies for patients with cervical cancer. From their comparison, common aspects and disagreements emerged, especially in the diagnostic pathway and follow-up strategies. Several issues that remain to be debated in the literature were addressed and compared, highlighting similarities and differences, from the role of the sentinel lymph node in early stages to that of the adjuvant hysterectomy in locally advanced tumors. On the surgical side, for this last subset of patients, currently, a laparotomic approach is recommended. At the same time, the advent of immunotherapy has just opened up new and promising scenarios in systemic treatment for locally advanced cervical cancer, and international guidelines will soon introduce it into their algorithms.

Mixed Large Cell Neuroendocrine Carcinoma and Endometrioid Adenocarcinoma: A Rare Case Report with Review of Literature

We report the case of a 60-year-old female who presented with postmenopausal bleeding after she underwent investigations followed by a total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. A diagnosis of low-grade endometrioid adenocarcinoma admixed with large cell neuroendocrine carcinoma (NEC) was made based on the histomorphology and immunohistochemical profile. NEC of the endometrium is a rare and highly aggressive neoplasm requiring a multidisciplinary approach for its treatment. As treatment strategies are changing over time, preoperating imaging evaluation and histopathological examination with molecular characterization whenever possible are essential to follow, to offer the appropriate information to surgeons and/or oncologists for optimal management in these patients.

Application of novel algorithm on a retrospective series to implement the molecular classification for endometrial cancer

INTRODUCTION

The study aimed to validate the Betella algorithm, focusing on molecular analyses exclusively for endometrial cancer patients, where molecular classification alters risk assessment based on ESGO/ESTRO/ESP 2020 guidelines.

MATERIALS AND METHODS

Conducted between March 2021 and March 2023, the retrospective research involved endometrial cancer patients undergoing surgery and comprehensive molecular analyses. These included p53 and mismatch repair proteins immunohistochemistry, as well as DNA sequencing for POLE exonuclease domain. We applied the Betella algorithm to our population and evaluated the proportion of patients in which the molecular analysis changed the risk class attribution.

RESULTS

Out of 102 patients, 97 % obtained complete molecular analyses. The cohort exhibited varying molecular classifications: 10.1 % as POLE ultra-mutated, 30.3 % as mismatch repair deficient, 11.1 % as p53 abnormal, and 48.5 % as non-specified molecular classification. Multiple classifiers were present in 3 % of cases. Integrating molecular classification into risk group calculation led to risk group migration in 11.1 % of patients: 7 moved to lower risk classes due to POLE mutations, while 4 shifted to higher risk due to p53 alterations. Applying the Betella algorithm, we can spare the POLE sequencing in 65 cases (65.7 %) and p53 immunochemistry in 17 cases (17.2 %).

CONCLUSION

In conclusion, we externally validated the Betella algorithm in our population. The application of this new proposed algorithm enables assignment of the proper risk class and, consequently, the appropriate indication for adjuvant treatment, allowing for the rationalization of the resources that can be allocated otherwise, not only for the benefit of settings with low resources, but of all settings in general.

Proficiency-based progression training in robot-assisted laparoscopy for endometrial cancer: peri-operative and survival outcomes from an observational cohort study

Introduction

Over the last decade there has been a transition from traditional laparoscopy to robotic surgery for the treatment of endometrial cancer. A number of gynecological oncology surgical fellowship programmes have adopted robot-assisted laparoscopy, but the effect of training on complications and survival has not been evaluated. Our aim was to assess the impact of a proficiency-based progression training curriculum in robot-assisted laparoscopy on peri-operative and survival outcomes for endometrial cancer.

Methods

This is an observational cohort study performed in a tertiary referral and subspecialty training center. Women with primary endometrial cancer treated with robot-assisted laparoscopic surgery between 2015 and 2022 were included. Surgery would normally include a hysterectomy and salpingo-oophorectomy with some form of pelvic lymph node dissection (sentinel lymph nodes or lymphadenectomy). Training was provided according to a training curriculum which involves step-wise progression of the trainee based on proficiency to perform a certain surgical technique. Training cases were identified pre-operatively by consultant surgeons based on clinical factors. Case complexity matched the experience of the trainee. Main outcome measures were intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and 5-year disease-free and disease-specific survival for training versus non-training cases. Mann-Witney U, Pearson's chi-squared, multivariable regression, Kaplan-Meier and Cox proportional hazard analyses were performed to assess the effect of proficiency-based progression training on peri-operative and survival outcomes.

Results

Training cases had a lower BMI than non-training cases (30 versus 32 kg/m2, p = 0.013), but were comparable in age, performance status and comorbidities. Training had no influence on intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theater rates and median 5-year disease-free and disease-specific survival. Operating time was longer in training cases (161 versus 137 min, p = < 0.001). The range of estimated blood loss was smaller in training cases. Conversion rates, critical care unit-admissions and lymphoedema rates were comparable.

Discussion

Proficiency-based progression training can be used safely to teach robot-assisted laparoscopic surgery for women with endometrial cancer. Prospective trails are needed to further investigate the influence of distinct parts of robot-assisted laparoscopic surgery performed by a trainee on endometrial cancer outcomes.

Endometrial Cancer: 2023 Revised FIGO Staging System and the Role of Imaging

The FIGO endometrial cancer staging system recently released updated guidance based on clinical evidence gathered after the previous version was published in 2009. Different imaging modalities are beneficial across various stages of endometrial cancer (EC) management. Additionally, ongoing research studies are aimed at improving imaging in EC. Gynecological cancer is a crucial element in the practice of a body radiologist. With a new staging system in place, it is important to address the role of radiology in the EC diagnostic pathway. This article is a comprehensive review of the changes made to the FIGO endometrial cancer staging system and the impact of imaging in the staging of this disease.

Type and approach of hysterectomy and oncological survival of women with stage II cancer of endometrium: a large retrospective cohort study

Objective

To explore the association between the Type and approach of hysterectomy and oncological survival of women with stage II cancer of the endometrium.

Patients and methods

684 women with stage II endometrial cancer were included. Eligible cases were grouped by type of hysterectomy (simple hysterectomy or radical hysterectomy)and approach of hysterectomy (laparoscopy or laparotomy). The baseline characteristics were compared among groups. The survival outcomes (disease-free survival and overall survival) were calculated and compared among groups, and the underlying confounding factors were adjusted by the Cox proportional hazard regression analysis.

Results

The radical hysterectomy group and the simple hysterectomy group had 217 cases and 467 cases, respectively. Between the groups, the difference in 5-year disease-free survival (87.3% versus 87.9%, HR=0.97, P=0.87) and 5-year overall survival (83.8% versus 83.8%, HR=0.95, P=0.95) was not statistically significant. The laparotomy group and the laparoscopy group had 277 cases and 407 cases, respectively. Between the groups, the difference in 5-year disease-free survival (88.7% versus 87.1%, HR=1.22, P=0.34) and 5-year overall survival (85.5% versus 82.7%, HR=1.00, P=0.99) was not statistically significant.

Conclusion

For long-term oncological survival, radical hysterectomy is not superior to total hysterectomy in stage II endometrial cancer. Also, for stage II cancer of the endometrium, laparoscopic hysterectomy is as oncologically safe as open hysterectomy.

Comparative effects of progestin-based combination therapy for endometrial cancer or atypical endometrial hyperplasia: a systematic review and network meta-analysis

Objectives

The objective of this network meta-analysis is to systematically compare the efficacy of diverse progestin-based combination regimens in treating patients diagnosed with endometrial cancer or atypical endometrial hyperplasia. The primary goal is to discern the optimal combination treatment regimen through a comprehensive examination of their respective effectiveness.

Methods

We systematically searched four prominent databases: PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials, for randomized controlled trials addressing the efficacy of progestins or progestin combinations in the treatment of patients with endometrial cancer or atypical endometrial hyperplasia. The search spanned from the inception of these databases to December 2023. Key outcome indicators encompassed survival indices, criteria for assessing efficacy, as well as pregnancy and relapse rate. This study was registered in PROSPERO (CRD42024496311).

Results

From the 1,558 articles initially retrieved, we included 27 studies involving a total of 5,323 subjects in our analysis. The results of the network meta-analysis revealed that the mTOR inhibitor+megestrol acetate (MA)+tamoxifen regimen secured the top rank in maintaining stable disease (SD) (SUCRA=73.4%) and extending progression-free survival (PFS) (SUCRA=72.4%). Additionally, the progestin combined with tamoxifen regimen claimed the leading position in enhancing the partial response (PR) (SUCRA=75.2%) and prolonging overall survival (OS) (SUCRA=80%). The LNG-IUS-based dual progestin regimen emerged as the frontrunner in improving the complete response (CR) (SUCRA=98.7%), objective response rate (ORR) (SUCRA=99.1%), pregnancy rate (SUCRA=83.7%), and mitigating progression (SUCRA=8.0%) and relapse rate (SUCRA=47.4%). In terms of safety, The LNG-IUS-based dual progestin regimen had the lowest likelihood of adverse events (SUCRA=4.2%), while the mTOR inhibitor regimen (SUCRA=89.2%) and mTOR inbitor+MA+tamoxifen regimen (SUCRA=88.4%) had the highest likelihood of adverse events.

Conclusions

Patients diagnosed with endometrial cancer or atypical endometrial hyperplasia exhibited the most favorable prognosis when undergoing progestin combination therapy that included tamoxifen, mTOR inhibitor, or LNG-IUS. Notably, among these options, the LNG-IUS-based dual progestin regimen emerged as particularly promising for potential application.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024496311.

A Case of Well-Differentiated Endometrial Adenocarcinoma in a Postmenopausal Woman

Endometrial adenocarcinoma is a prevalent malignancy among postmenopausal women, often presenting with symptoms such as abnormal vaginal bleeding and pelvic pain. We present a case of a 60-year-old postmenopausal female who exhibited abnormal vaginal bleeding for three months, accompanied by pelvic pain and unintentional weight loss. Clinical evaluation, including physical examination, imaging studies, and histopathological examination, led to the diagnosis of well-differentiated endometrial adenocarcinoma. The patient underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy, and histopathological analysis confirmed invasive tumor involvement in the lower uterine segment and cervix. The final pathological tumor, node, and metastasis (TNM) staging was reported as pT1b No Mx, FIGO (International Federation of Gynecology and Obstetrics) stage II. This case underscores the importance of considering endometrial adenocarcinoma in the differential diagnosis of postmenopausal bleeding and highlights the significance of timely diagnosis and multidisciplinary management for optimizing patient outcomes.

Potential role of lncRNA LOXL1-AS1 in human cancer development: a narrative review

Background and Objective

Long non-coding RNAs (lncRNAs) are a group of non-coding RNAs consisting of more than 200 nucleotides that are widely involved in various physiological and pathobiological processes in the body. LncRNA plays a crucial role in tumorigenesis and development with its unique functions, such as playing a role in a variety of biological processes of malignant tumors as a cancer-promoting factor or a cancer-suppressor factor. Lysyl oxidase-like protein 1-antisense RNA1 (LOXL1-AS1) is a novel functional lncRNA recently reported. This article reviews the current findings on the role of LOXL1-AS1 in cancer, and discusses the potential clinical significance and application prospects, in order to provide a theoretical basis and reference for the clinical diagnosis, treatment and screening of prognostic markers for malignant tumors.

Methods

The PubMed and Embase databases were searched using the keywords "cancer" or "tumor" or "neoplasm" and "LOXL1-AS1" for publications from 2018 to the present. The English literature was searched, with a focus on relevant articles. These articles validated the role and mechanism of LOXL1-AS1 in different cancers.

Key Content and Findings

LOXL1-AS1 is a recently reported novel lncRNA, which is abnormally expressed and upregulated in more than ten cancers, and is positively correlated with adverse clinical features and poor prognosis in cancer patients. LOXL1-AS1 competently binds to a variety of microRNAs to regulate the expression of downstream target genes and regulate related signaling pathways, including proliferation, migration, invasion and inhibition of malignant biological behaviors such as apoptosis.

Conclusions

LOXL1-AS1 is expected to become a novel biomarker for cancer diagnosis and treatment, with great potential as an independent prognostic indicator.

Risk factors associated with false negative rate of sentinel lymph node biopsy in endometrial cancer: a systematic review and meta-analysis

Objective

Currently, sentinel lymph node biopsy (SLNB) is increasingly used in endometrial cancer, but the rate of missed metastatic lymph nodes compared to systemic lymph node dissection has been a concern. We conducted a systematic review and meta-analysis to evaluate the false negative rate (FNR) of SLNB in patients with endometrial cancer and to explore the risk factors associated with this FNR.

Data sources

Three databases (PubMed, Embase, Web of Science) were searched from initial database build to January 2023 by two independent reviewers.

Research eligibility criteria

Studies were included if they included 10 or more women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I or higher endometrial cancer, the study technique used sentinel lymph node localization biopsy, and the reported outcome metrics included false negative and/or FNR.

Study appraisal and synthesis methods

Two authors independently reviewed the abstracts and full articles. The FNR and factors associated with FNR were synthesized through random-effects meta-analyses and meta-regression.

The results

We identified 62 eligible studies. The overall FNR for the 62 articles was 4% (95% CL 3-5).There was no significant difference in the FNR in patients with high-risk endometrial cancer compared to patients with low-risk endometrial cancer. There was no difference in the FNR for whether frozen sections were used intraoperatively. The type of dye used intraoperatively (indocyanine green/blue dye) were not significantly associated with the false negative rate. Cervical injection reduced the FNR compared with alternative injection techniques. Indocyanine green reduced the FNR compared with alternative Tc-99m. Postoperative pathologic ultrastaging reduced the FNR.

Conclusions

Alternative injection techniques (other than the cervix), Tc-99m dye tracer, and the absence of postoperative pathologic ultrastaging are risk factors for a high FNR in endometrial cancer patients who undergo SLNB; therefore, we should be vigilant for missed diagnosis of metastatic lymph nodes after SLNB in such populations.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023433637.

Pattern of recurrence in endometrial cancer. The murderer always returns to the scene of the crime

BACKGROUND

Endometrial cancer recurrence occurs in about 18 % of patients. This study aims to analyze the pattern recurrence of endometrial cancer and the relationship between the initial site of primary disease and the relapse site in patients undergoing surgical treatment.

METHODS

We retrospectively reviewed all surgically treated patients with endometrial cancer selecting those with recurrence. We defined primary site disease as uterus, lymph nodes, or peritoneum according to pathology analysis of the surgical specimen. The site of recurrence was defined as vaginal cuff, lymph nodes, peritoneum, and parenchymatous organs. Our primary endpoint was to correlate the site of initial disease with the site of recurrence.

RESULTS

The study enrolled 1416 patients. The overall recurrence rate was 17,5 % with 248 relapses included in the study. An increase of 9.9, 5.7, and 5.7 times in the odds of relapse on the lymph node, peritoneum, and abdominal parenchymatous sites respectively was observed in case of nodal initial disease (p < 0.001). A not significant difference in odds was observed in terms of vaginal cuff relapse (OR 0.9) between lymph node ad uterine primary disease (p = 0.78). An increasing OR of 8.7 times for nodal recurrences, 46.6 times for peritoneum, and 23.3 times for parenchymatous abdominal recurrences were found in the case of primary peritoneal disease (p < 0.001).

CONCLUSION

Endometrial cancer tends to recur at the initial site of the disease. Intraoperative inspection of the adjacent sites of primary disease and targeted instrumental examination of the initial sites of disease during follow-up are strongly recommended.

Predictive Value of Magnetic Resonance Imaging in Risk Stratification and Molecular Classification of Endometrial Cancer

This study evaluated the magnetic resonance imaging (MRI) findings of endometrial cancer (EC) patients and identified differences based on risk group and molecular classification. The study involved a total of 175 EC patients. The MRI data were retrospectively reviewed and compared based on the risk of recurrence. Additionally, the associations between imaging phenotypes and genomic signatures were assessed. The low-risk and non-low-risk groups (intermediate, high-intermediate, high, metastatic) showed significant differences in tumor diameter (p < 0.001), signal intensity and heterogeneity on diffusion-weighted imaging (DWI) (p = 0.003), deep myometrial invasion (involvement of more than 50% of the myometrium), cervical invasion (p < 0.001), extrauterine extension (p = 0.002), and lymphadenopathy (p = 0.003). Greater diffusion restriction and more heterogeneity on DWI were exhibited in the non-low-risk group than in the low-risk group. Deep myometrial invasion, cervical invasion, extrauterine extension, lymphadenopathy, recurrence, and stage discrepancy were more common in the non-low-risk group (p < 0.001). A significant difference in microsatellite stability status was observed in the heterogeneity of the contrast-enhanced T1-weighted images (p = 0.027). However, no significant differences were found in MRI parameters related to TP53 mutation. MRI features can be valuable predictors for differentiating risk groups in patients with EC. However, further investigations are needed to explore the imaging markers based on molecular classification.

Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for the Detection of Myometrial Infiltration in Endometrial Cancer: A Systematic Review and Meta-Analysis

In endometrial cancer (EC), deep myometrial invasion (DMI) is a prognostic factor that can be evaluated by various imaging methods; however, the best method of choice is uncertain. We aimed to compare the diagnostic performance of two-dimensional transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the preoperative detection of DMI in patients with EC. Pubmed, Embase and Cochrane Library were systematically searched in May 2023. We included original articles that compared TVS to MRI on the same cohort of patients, with final histopathological confirmation of DMI as reference standard. Several subgroup analyses were performed. Eighteen studies comprising 1548 patients were included. Pooled sensitivity and specificity were 76.6% (95% confidence interval (CI), 70.9-81.4%) and 87.4% (95% CI, 80.6-92%) for TVS. The corresponding values for MRI were 81.1% (95% CI, 74.9-85.9%) and 83.8% (95% CI, 79.2-87.5%). No significant difference was observed (sensitivity: p = 0.116, specificity: p = 0.707). A non-significant difference between TVS and MRI was observed when no-myometrium infiltration vs. myometrium infiltration was considered. However, when only low-grade EC patients were evaluated, the specificity of MRI was significantly better (p = 0.044). Both TVS and MRI demonstrated comparable sensitivity and specificity. Further studies are needed to assess the presence of myometrium infiltration in patients with fertility-sparing wishes.

Prognosis of Stage I Endometrial Cancer According to the FIGO 2023 Classification Taking into Account Molecular Changes

Optimum risk stratification in an early stage of endometrial cancer (EC) combines molecular and clinicopathological features. The purpose of the study was to determine the prognostic value of molecular classification and traditional pathological factors in a sample group of patients with stage I EC according to the FIGO 2023 criteria, to achieve a more personalized approach to patient care and treatment. The immunohistochemistry for p53 and mismatch repair (MMR) proteins, and DNA sequencing for POLE exonuclease domain and clinicopathological parameters, including disease disease-free survival (DFS) and overall survival (OS) in 139 patients, were analyzed. It has been shown that the independent recurrence risk factors are stage IC (p < 0.001), aggressive histological types EC (p < 0.001), and the presence of p53abn protein immunoexpression (p = 0.009). Stage IC (p = 0.018), aggressive histological types EC (p = 0.025) and the presence of p53abn protein immunoexpression (p = 0.010) were all significantly associated with lower 5-year OS rates. Our research studies confirm that the molecular category corresponds to a different prognosis in clinical stage I EC according to the new 2023 FIGO classification, with POLEmut cases presenting the best outcomes and p53abn cases showing the worst outcomes. Beyond the previous routine clinicopathological assessment, the new EC staging system represents an important step toward improving our ability to stratify IC stage EC risk.

Real-world perioperative treatment patterns and burden of recurrent disease in patients with high-risk endometrial cancer: a SEER-Medicare study

OBJECTIVES

To elucidate unmet needs in high-risk endometrial cancer (EC), this study described perioperative treatment patterns in Medicare beneficiaries with high-risk EC and quantified the impact of disease recurrence on clinical and economic outcomes among patients receiving adjuvant therapy.

METHODS

Patients aged ≥66 years with high-risk EC (stage I/II EC of non-endometrioid histology or stage III/IVA EC of any histology) receiving hysterectomy with bilateral salpingo-oophorectomy from SEER-Medicare data (2007-2019) were identified; perioperative treatment patterns were described. Post-operative treatment patterns were described among patients receiving adjuvant therapy; overall survival (OS), all-cause and EC-related healthcare resource utilization and costs were evaluated from recurrence date (using a claims-based algorithm developed with clinical input) for recurrent patients and from a frequency-matched date for non-recurrent patients.

RESULTS

Of 2,279 patients receiving EC surgery, 3.1% received neoadjuvant therapy and 55.3% received adjuvant therapy. Among 1,199 patients receiving adjuvant therapy, systemic adjuvant therapy with radiation (38.9%) was most common. Median OS was 1.4 years among 378 (31.5%) recurrent patients identified over a median follow-up of 3.7 years. Recurrent patients had significantly higher per-patient-year rates of all-cause outpatient visits (37.7 vs. 22.6), EC-related outpatient visits (14.5 vs. 3.0), and all-cause hospitalizations (1.3 vs. 0.4) than non-recurrent patients, and an excess of $84,562 and $62,128 in all-cause and EC-related annual costs, predominantly driven by hospitalizations.

CONCLUSIONS

Our findings highlight the considerable clinical and economic burden experienced by patients with high-risk EC experiencing recurrence and emphasize the unmet need for novel therapies in early settings to mitigate this burden.

Impact of COVID-19 Pandemic on the Diagnostic and Therapeutic Management of Endometrial Cancer: A Monocentric Retrospective Comparative Study

Endometrial cancer represents an ideal target to evaluate the impact of COVID-19 being the most frequent gynecological malignancy in Italy, generally detected at early stages and correlated with favorable oncological outcomes. The present comparative retrospective study carried out at Campus Bio-medico University Foundation in Rome aims to evaluate the impact of the COVID-19 pandemic on the presentation, diagnosis and treatment of EC. All women with a histological diagnosis of non-endometrioid and endometrioid endometrial cancer between 1 March 2018 and 31 October 2022 were included. The number of cases was higher in period 2 (95 vs. 64 cases). Time to diagnosis did not show statistically significant differences but in period 2, 92.06% of the diagnoses were made following abnormal uterine bleeding, while in period 1, only 67.02% were. The waiting time for the intervention was significantly shorter in period 2. Definitive histology, FIGO staging, surgical technique and adjuvant therapy did not show significant differences between the two periods. The study demonstrates that the impact of the COVID-19 pandemic did not have a direct effect on the diagnostic delay, tumor staging and type of therapy but rather on the presentation pattern of endometrial cancer.