Dilatation and curettage is more accurate than endometrial aspiration biopsy in early-stage endometrial cancer patients treated with high dose oral progestin and levonorgestrel intrauterine system

An Overview of Endometrial Cancer with Novel Therapeutic Strategies

Endometrial cancer (EC) stands as the most prevalent gynecologic malignancy. In the past, it was classified based on its hormone sensitivity. However, The Cancer Genome Atlas has categorized EC into four groups, which offers a more objective and reproducible classification and has been shown to have prognostic and therapeutic implications. Hormonally driven EC arises from a precursor lesion known as endometrial hyperplasia, resulting from unopposed estrogen. EC is usually diagnosed through biopsy, followed by surgical staging unless advanced disease is expected. The typical staging consists of a hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node biopsies, with a preference placed on a minimally invasive approach. The stage of the disease is the most significant prognostic marker. However, factors such as age, histology, grade, myometrial invasion, lymphovascular space invasion, tumor size, peritoneal cytology, hormone receptor status, ploidy and markers, body mass index, and the therapy received all contribute to the prognosis. Treatment is tailored based on the stage and the risk of recurrence. Radiotherapy is primarily used in the early stages, and chemotherapy can be added if high-grade histology or advanced-stage disease is present. The risk of EC recurrence increases with advances in stage. Among the recurrences, vaginal cases exhibit the most favorable response to treatment, typically for radiotherapy. Conversely, the treatment of widespread recurrence is currently palliative and is best managed with chemotherapy or hormonal agents. Most recently, immunotherapy has emerged as a promising treatment for advanced and recurrent EC.

Feasibility and clinical applicability of genomic profiling based on cervical smear samples in patients with endometrial cancer

Purpose

Cervical smear samples are easily obtainable and may effectively reflect the tumor microenvironment in gynecological cancers. Therefore, we investigated the feasibility of genomic profiling based on tumor DNA analysis from cervical smear samples from endometrial cancer patients.

Materials and methods

Preoperative cervical smear samples were obtained via vaginal sampling in 50 patients, including 39 with endometrial cancer and 11 with benign uterine disease. Matched blood samples were obtained simultaneously. Genomic DNA (gDNA) from cervical smear and/or cell-free DNA from whole blood were extracted and sequenced using the Pan100 panel covering 100 endometrial cancer-related genes.

Results

Cervical swab-based gDNA analysis detected cancer with 67% sensitivity and 100% specificity, showing a superior performance compared to that of the matched blood or Pap smear tests. Cervical swab-based gDNA effectively identified patients with loss of MSH2 or MSH6 and aberrant p53 expression based on immunohistochemistry. Genomic landscape analysis of cervical swab-based gDNA identified PTEN, PIK3CA, TP53, and ARID1A as the most frequently altered genes. Furthermore, 26 endometrial cancer patients could be classified according to the Proactive Molecular Risk Classifier for Endometrial Cancer.

Conclusion

Cervical swab-based gDNA test showed an improved detection potential and allowed the classification of patients, which has both predictive and prognostic implications.

LNG-IUS combined with progesterone ameliorates endometrial thickness and pregnancy outcomes of patients with early-stage endometrial cancer or atypical hyperplasia

OBJECTIVE

To determine the positive effect of levonorgestrel-releasing intrauterine system (LNG-IUS) combined with progesterone on endometrial thickness and pregnancy outcomes of patients with atypical endometrial hyperplasia (AEH) or early-stage endometrial cancer (EEC).

METHODS

Patients with AEH or EEC admitted to our hospital were enrolled, and assigned to a control group (con group) and a combination group (com group). Patients in the con group were treated with LNG-IUS, while those in the com group were treated with LNG-IUS combined with progesterone. After treatment, the two groups were compared in efficacy, menstrual blood volume (pictorial blood loss assessment chart (PBAC) score), and changes in endometrial thickness. In addition, the incidence of adverse drug reactions and pregnancy outcomes of the patients were analyzed.

RESULTS

Before treatment, there was no significant difference in PBAC score and endometrial thickness between patients with AEH or EEC in the con group and those in the com group, but after 3 months and 6 months of treatment, the com group got a better PBAC score and better changes of endometrial thickness than the con group, and the incidence of adverse drug reactions in the com group was also significantly lower than that in the con group. In addition, the follow-up results of pregnancy outcomes of patients showed that the fertility rate and total effective rate of the com group were both significantly higher than those of the con group (both P<0.05).

CONCLUSION

LNG-IUS combined with progesterone is more effective in treating patients with AEH or EEC. It can effectively improve the endometrial thickness of patients and fertility rate of those with fertility requirements after treatment.

Clinical Impact of Preoperative Magnetic Resonance Imaging in the Evaluation of Myometrial Infiltration and Lymph-Node Metastases in Stage I Endometrial Cancer

Abstract: Purpose: In the developed world, endometrial cancer is one of the most common malignant gynecological cancer types. Due to the highly available diagnostic modalities and patient education, the early detection of the tumor leads to high overall survival.

Methods: In this study we analyzed the reliability of preoperative MRI findings in the staging of early stage endometrial cancer, as well as the clinical characteristics of patients underwent radical hysterectomy and the histopathologic evaluation of their tumor, with the retrospective data of radical hysterectomies performed in our hospital between 2010 and 2019.

Results: The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI regarding stage were 94.7, 63.3, 94.8, 83.8, and 83.8%, respectively. The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI for the detection of the myometrial invasion were 69.8, 80.0, 60.8, 64.3, and 77.5%, respectively. The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI for the detection of lymph node metastases were 78.1, 28.6, 82, 11.1, and 93.6%, respectively.

Conclusions: Based on our results, MRI is the method of choice in terms of evaluating overall staging, as well as myometrial invasion, as its specificity and negative predictive value are relatively high. However, systematic lymphadenectomy showed improved cancer-related survival and recurrence-free survival. Our studies showed that the diagnosis of lymph node metastases is difficult with MRI modality since hyperplastic and metastatic nodes cannot easily differentiate, leading to a high percentage of false-positive results. Therefore, other imaging modalities may be used for more accurate evaluation. New findings of our study were that the role of the radiologist’s expertise in the evaluation of MR imaging plays an essential role in lowering false-negative and false-positive results. Therefore, findings evaluated by a radiologist with high-level expertise in gynecological imaging can complement the clinical findings and help substantially define the needed treatment.

Chemotherapy-associated foam cell aggregates as a prognostic factor in patients with pelvic high-grade serous carcinoma receiving neo-adjuvant chemotherapy

High-grade serous carcinoma (HGSC) tends to recur after treatment; therefore, the Chemotherapy Response Score (CRS) has been proposed as a histopathological prognostic scoring system for measuring the response to neo-adjuvant chemotherapy and the risk of recurrence. This study aimed to evaluate the CRS in only those with an R0 debulking status and to investigate new prognostic factors for progression-free survival (PFS). We reviewed the CRS of HGSC patients with R0 using surgical specimens of the omental sections. Patients were categorized according to foam cell change (FCC), defined as foam cells occupying more than half of the area of the chemotherapy-associated scar. In total, 100 HGSC patients were evaluated. PFS was significantly different according to the CRS. For CRSs of 1/2 and 3, the median PFS were 18 and 27 months, respectively (HR, 1.84; 95% CI 1.01-3.33, p = 0.045). Moreover, the FCC group showed significantly longer PFS than did the non-FCC group (20 vs 59 months; HR 2.43; 95% CI 1.15-5.14; p = 0.020). The present study validated the CRS of those in the R0 cohort. Furthermore, an increase in foam cells in the regression scar reflects the chemotherapy response and the FCC may be a useful novel prognostic factor for patients undergoing R0 resection. This finding must be further validated independently.

Weight control is vital for patients with early-stage endometrial cancer or complex atypical hyperplasia who have received progestin therapy to spare fertility: a systematic review and meta-analysis

Objectives: This study aimed to identify potential prognostic factors for patients with complex atypical hyperplasia (CAH) or early-stage endometrial cancer (EC) who received progestin therapy to spare fertility and, thus, improve the management of this patient group. Materials and methods: The PubMed, PMC, EMBASE, Web of Science, and Cochrane databases were searched for correlational studies published in English. Studies that evaluated the prognosis of patients with CAH or early-stage EC were pooled for a systematic review and meta-analysis. Results: In total, 31 eligible studies, including 8 prospective and 23 retrospective studies involving 1099 patients, were included in this analysis. The most commonly used progestin agents were medroxyprogesterone acetate (MPA, 47.0%) and megestrol acetate (MA, 25.5%). The total complete response (CR) rate was 75.8% (833/1099), and the median time to CR with first-line progestin therapy was 6 months. In total, 294 (26.8%) patients who achieved CR became pregnant spontaneously (28 cases) or through assisted reproductive technology (127 cases). During the median follow-up of 39 months, 245 (22.3%) women developed recurrence. Only one patient (0.09%) died of the disease. The meta-analysis showed that compared to a BMI<25 kg/m² and CAH, a body mass index (BMI) ≥25 kg/m² (P=0.0004, odds ratios (OR), 0.4; 95% confidence interval, 0.3-0.6) and EC (P=0.0000, OR, 0.3; 95% confidence interval, 0.2-0.6) were significantly associated with a higher likelihood of a CR. Patients with a BMI≥25 kg/m² (P=0.0007, OR, 2.5; 95% confidence interval, 1.4-4.3), PCOS (P=0.0006, OR, 3.4; 95% confidence interval, 1.5-7.9), and EC (P=0.0344, OR, 2.8; 95% confidence interval, 1.4-5.3) had a significantly higher risk of recurrence. Conclusion: In general, patients with CAH or early-stage EC who were treated with progesterone therapy had a favorable prognosis. However, the recurrence risk was not insignificant. Weight control is crucial for improving the clinical management of this patient group.

Six months response rate of combined oral medroxyprogesterone/levonorgestrel-intrauterine system for early-stage endometrial cancer in young women: a Korean Gynecologic-Oncology Group Study

OBJECTIVE

To evaluate the efficacy of combined oral medroxyprogesterone acetate (MPA)/levonorgestrel-intrauterine system (LNG-IUS) treatment and to compare the diagnostic accuracy of endometrial aspiration biopsy with dilatation & curettage (D&C) in young women with early-stage endometrial cancer (EC) who wished to preserve their fertility.

METHODS

A prospective phase II multicenter study was conducted from January 2012 to January 2017. Patients with grade 1 endometrioid adenocarcinoma confined to the endometrium were treated with combined oral MPA (500 mg/day)/LNG-IUS. At 3 and 6 months of treatment, the histologic change of the endometrial tissue was assessed. The regression rate at 6 months treatment and the consistency of the histologic results between the aspiration biopsy and the D&C were evaluated.

RESULTS

Forty-four patients were enrolled. Nine voluntarily withdrew and 35 patients completed the protocol treatment. The complete regression (CR) rate at 6 months was 37.1% (13/35). Partial response was shown in 25.7% of cases (9/35). There were no cases of progressive disease and no treatment-related complications. A comparison of the pathologic results from aspiration biopsy and D&C was carried out for 33 cases. Fifteen cases were diagnosed as "EC" by D&C. Among these, only 8 were diagnosed with EC from aspiration biopsy, yielding a diagnostic concordance of 53.3% (κ=0.55).

CONCLUSION

Combined oral MPA/LNG-IUS treatment for EC showed 37.1% of CR rate at 6 months. Considering the short treatment periods, CR rate may be much higher if the treatment continued to 9 or 12 months. So, this treatment is still a viable treatment option for young women of early-stage EC. Endometrial aspiration biopsy with the LNG-IUS in place is less accurate than D&C for follow-up evaluation of patients undergoing this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01594879.