Concordance between preoperative ESMO-ESGO-ESTRO risk classification and final histology in early-stage endometrial cancer

Morules and β-catenin predict POLE mutation status in endometrial cancer: A pathway to more cost-effective diagnostic procedures

OBJECTIVES

The characterization of DNA polymerase epsilon (POLE) mutations has transformed the classification of endometrial endometrioid carcinomas (EECs), highlighting the need for efficient identification methods. This study aims to examine the relationship between distinct morphologic features-namely, squamous morules and squamous differentiation (SD), as well as β-catenin expression-and the POLE mutation status in endometrial cancer (EC).

METHODS

Our study included 35 POLE-mutated (POLEmut) EC cases and 395 non-POLEmut EEC cases.

RESULTS

Notably, we observed no presence of morules in POLEmut cases, while SD was identified in 20% of instances. Conversely, morules and SD were identified in 12.7% and 26.1% of non-POLEmut EC cases, respectively, with morules consistently linked to a POLE wild-type status. The nuclear β-catenin expression is typically absent in tumors with wild-type POLE (wt-POLE) status.

CONCLUSIONS

Our findings suggest that the presence of either morules or nuclear β-catenin expression in EEC could practically rule out the presence of POLE mutations. These morphologic and immunohistochemical features can be used as preliminary screening tools for POLE mutations, offering significant savings in time and resources and potentially enhancing clinical decision-making and patient management strategies. However, further validation in larger, multi-institutional studies is required to fully understand the implications of these findings on clinical practice.

D&C has the best concordance between preoperative and postoperative grades among morbidly obese endometrial cancer patients

AIM

Endometrial cancer is diagnosed by obtaining uterine biopsies by pipelle, dilatation and curettage (D&C), or hysteroscopy. In 15%-25% of the cases, the preoperative and postoperative grades do not match. This discrepancy may carry significant clinical and prognostic consequences. We aimed to assess how body mass index (BMI) affects preoperative and postoperative grade mismatches and whether biopsy methods mitigate this effect.

METHODS

We conducted a retrospective review of patients with endometrial cancer who underwent surgery at our center between 2014 and 2022. We stratified patients into six classes of BMI based on the WHO classification. Preoperative and postoperative grades were compared for concordance with regards to patient BMI and sampling method.

RESULTS

A total of 158 patients were included, diagnosed by pipelle (n = 99), hysteroscopy (n = 15), or D&C (n = 44). For all methods, every unit increase in BMI increased the odds of having a gap between histology grades by 5.2%. In the pipelle group, the odds of a larger gap between the histology grades was 62% higher than that of women in the other groups. Among the D&C group, the odds of having a bigger difference between histology grades were 91.8% lower compared to the other groups. Patients with BMI over 30 had nearly 50% discrepancy when diagnosed with pipelle or hysteroscopy, but less than 10% with D&C.

CONCLUSIONS

Increasing BMI is associated with decreasing concordance between preoperative and postoperative grades in endometrial cancer, especially when it exceeds 30. This effect is much less pronounced, however, when the diagnostic method is D&C.

Five-year disease-free survival in FIGO IA stage endometrial cancer patients: Tertiary institution experience in a developing country

Purpose

Endometrial cancer is characterized as histopathological, molecular, genetic, biological, and very diverse group of malignancies. Due to the need to precisely define the indications for adjuvant treatment in recent years, there has been a division made according to risk groups based on prognostic factors, which identify patients at risk for disease relapse, who may benefit from adjuvant therapy. The aim of this research was to examine the clinical and morphological factors that influence disease-free survival (DFS) and overall survival (OS) in patients with FIGO IA stage endometrial cancer.

Material and methods

A retrospective clinical study was conducted, primarily based on the identification of factors that influence five-year DFS and OS. The study integrated data of FIGO IA stage endometrial cancer patients, who presented to gynecological oncology board for the first time after operative treatment, from January 1, 2016 to January 1, 2022. Adjuvant radiotherapy was applied to patients with an initially higher risk of disease progression. Length of survival was analyzed using Kaplan-Meier method, while log-rank test was used to assess differences between groups.

Results

The results show that 5-year OS for 93 patients was 89.2% and DFS was 88.2%. Application of adjuvant brachytherapy, number of deliveries, MRI staging, type of institution where the surgery was performed influenced DFS. Pathohistological characteristics of tumor indicated a statistically significant impact on DFS.

Conclusions

Application of adjuvant brachytherapy in high-intermediate and high-risk patients contributes to DFS increase. Moreover, the existence of a pre-operative MRI assessment of the stage of disease as well as the type of healthcare provided by an institution where the surgery was performed, significantly affect DFS.

Role of Machine Learning (ML)-Based Classification Using Conventional 18F-FDG PET Parameters in Predicting Postsurgical Features of Endometrial Cancer Aggressiveness

PURPOSE

to investigate the preoperative role of ML-based classification using conventional ¹⁸F-FDG PET parameters and clinical data in predicting features of EC aggressiveness.

METHODS

retrospective study, including 123 EC patients who underwent ¹⁸F-FDG PET (2009-2021) for preoperative staging. Maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV), and total lesion glycolysis (TLG) were computed on the primary tumour. Age and BMI were collected. Histotype, myometrial invasion (MI), risk group, lymph-nodal involvement (LN), and p53 expression were retrieved from histology. The population was split into a train and a validation set (80-20%). The train set was used to select relevant parameters (Mann-Whitney U test; ROC analysis) and implement ML models, while the validation set was used to test prediction abilities.

RESULTS

on the validation set, the best accuracies obtained with individual parameters and ML were: 61% (TLG) and 87% (ML) for MI; 71% (SUVmax) and 79% (ML) for risk groups; 72% (TLG) and 83% (ML) for LN; 45% (SUVmax; SUVmean) and 73% (ML) for p53 expression.

CONCLUSIONS

ML-based classification using conventional ¹⁸F-FDG PET parameters and clinical data demonstrated ability to characterize the investigated features of EC aggressiveness, providing a non-invasive way to support preoperative stratification of EC patients.

Assessing the role of low volume disease in endometrial cancer

The role of retroperitoneal staging in endometrial cancer is still unclear. Although the prognostic value of lymphadenectomy has been demonstrated no data support the therapeutic value of nodal dissection. Sentinel node mapping represents an evolution of lymphadenectomy. Sentinel node mapping allows a more accurate identification of low-volume diseases (i.e., micrometastasis and isolated tumor cells) that are not always detectable via conventional histopathological evaluation. Adjuvant therapy might play a role in patients with low-volume disease. However, the presence of isolated tumor cells alone seems to not impact outcomes of endometrioid endometrial cancer patients. Hence, the choice to deliver adjuvant therapies has to be tailored based on uterine factors only. The introduction of molecular and genomic profiling would be useful in selecting appropriate surgical and adjuvant treatments. The molecular-integrated risk profile should be integrated in clinical practice to overcome the need of retroperitoneal staging (in case of non-bulky nodes) in patients at low risk.

Clinical Value and Molecular Function of Circulating MicroRNAs in Endometrial Cancer Regulation: A Systematic Review

This systematic review of literature highlights the different microRNAs circulating in the serum or plasma of endometrial cancer patients and their association with clinical and prognostic characteristics in endometrial cancer. This study also investigates the molecular functions of these circulating microRNAs. According to this systematic review, a total of 33 individual circulating miRs (-9, -15b, -20b-5p, -21, -27a, -29b, -30a-5p, -92a, -99a, -100, -135b, -141, -142-3p, -143-3p, -146a-5p, -150-5p, -151a-5p, -186, -195-5p, -199b, -200a, -203, -204, -205, -222, -223, -301b, -423-3p, -449, -484, -887-5p, -1228, and -1290) and 6 different panels of miRs (“miR-222/miR-223/miR-186/miR-204”, “miR-142-3p/miR-146a-5p/miR-151a-5p”, “miR-143-3p/miR-195-5p/miR-20b-5p/miR-204-5p/miR-423-3p/miR-484”, “mir-9/miR-1229”, “miR-9/miR-92a”, and “miR-99a/miR-199b”) had a significant expression variation in EC patients compared to healthy patients. Also, seven individual circulating miRs (-9, -21, -27a, -29b, -99a, -142-3p, and -449a) had a significant expression variation according to EC prognostic factors such as the histological type and grade, tumor size, FIGO stage, lymph node involvement, and survival rates. One panel of circulating miRs (“-200b/-200c/-203/-449a”) had a significant expression variation according to EC myometrial invasion. Further studies are needed to better understand their function and circulation.

Controversy on Positive Peritoneal Cytology of Endometrial Carcinoma

Endometrial carcinoma (EC) is one of the most common gynecological malignancies. Its incidence rate has been increasing year by year. The prognostic factors and treatment strategies of EC have aroused wide concern. The effects of peritoneal cytology on the prognosis and treatment of EC remain controversial. Some factors, such as differentiation degree, muscle invasion, and tumor size, are related to positive peritoneal cytology. Hysteroscopy is commonly used in the diagnosis and treatment of endometrial cancer, but hysteroscopic surgery may cause the tumor to spread into the abdominal cavity, resulting in positive peritoneal cytology. In this review, we discuss the factors related to positive peritoneal cytology and the influence of positive peritoneal cytology on the prognosis of endometrial cancer. Suspicious positive peritoneal cytology may be an independent risk factor for endometrial cancer. The positive rate of peritoneal tumor cells in type II endometrial cancer is higher than other cells and is an independent risk factor for type II endometrial cancer. We also discuss the effects of peritoneal cytology on treatment decisions. Aggressive treatments seem to be more beneficial for patients with positive ascites cytology, but there is a lack of large-scale prospective clinical studies on their effectiveness and safety. The application of peritoneal cytology for endometrial cancer has been decreased in recent years. We believe that peritoneal cytology is necessary for this type of cancer. However, more studies on peritoneal cytology in endometrial cancer should be carried out.

MRI in female pelvis: an ESUR/ESR survey

Objectives

While magnetic resonance imaging (MRI) is considered the gold standard for the imaging of female pelvis, there is an ongoing debate about the most appropriate indications and optimal imaging protocols. The European Society of Urogenital Radiology (ESUR) launched a survey to evaluate the current utilization of female pelvic MRI in clinical practice.

Methods

The ESUR female imaging subgroup developed an online survey that was then approved by the ESR board and circulated among the ESR members. The questions in the survey encompassed training and experience, indications for imaging and MR imaging protocols, reporting styles and preferences. The results of the survey were tabulated, and subgroups were compared using χ2 test.

Results

A total of 5900 ESR members with an interest in both MRI and female pelvic imaging were invited to participate; 840 (14.23%) members completed the survey. Approximately 50% of respondents were academic radiologists (50.6%) and nearly 60% women (59.69%). One third of the respondents were subspecialized in Gynecological imaging. Nearly half of the survey participants were aware of the presence of ESUR guidelines for imaging of the female pelvis (47.1%). The adoption of the ESUR recommendations was higher among subspecialized and/or academic and/or senior and/or European radiologists compared to all others. The current ESUR recommendations about female pelvic MRI protocols were generally followed. However wide variations in practice were identified with respect to the use of contrast media.

Conclusion

Female pelvic MRI protocol was generally following the ESUR recommendations, especially among subspecialized and academic radiologists. However, the fact that they are followed by only half of the participants highlights the need for wider awareness of these recommendations.

Hybrid PET/MRI in Staging Endometrial Cancer: Diagnostic and Predictive Value in a Prospective Cohort

AIM

The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost importance in the preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. The main aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and lymphnodal involvement detection.

PATIENTS AND METHODS

Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI (December 2018-March 2021) for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean with a threshold of 40% of SUVmax-SUVmean40, metabolic tumor volume, total lesion glycolysis) and MRI (volume index [VI], total tumor volume, tumor volume ratio [TVR], mean apparent diffusion coefficient, minimum apparent diffusion coefficient) parameters were calculated on the primary tumor, and their role in predicting EC risk group, the presence of lymphovascular space invasion (LVSI), and MI was assessed. Receiver operating characteristics analysis was used to assess the predictive value of PET and MRI parameters on EC characteristics.

RESULTS

Patients' median age was 66.57 years (SD, 10.21 years). 18F-FDG PET/MRI identified the primary tumor in all patients. Twenty-two of 35 patients had high-risk EC and 13/35 low-risk disease; 13/35 presented LVSI, 22/35 had deep MI at histological examination, and 13/35 had p53 hyperexpression.PET/MRI was able to detect lymphnodal involvement with high accuracy and high specificity (sensitivity of 0.8571, specificity of 0.9286, accuracy of 0.9143), also showing a high negative predictive value (NPV) for lymphnodal involvement (NPV of 0.9630, positive predictive value [PPV] of 0.7500).The assessment of deep MI using PET/MRI correctly staged 27 patients (77.1%; sensitivity of 0.7273, specificity of 0.8462, accuracy of 0.7714), with also a good PPV (PPV of 0.8889, NPV of 0.647).MRI-derived total tumor volume, VI, and TVR were significant in predicting EC groups (high-risk vs low-risk patients) (P = 0.0059, 0.0235, 0.0181, respectively). MRI-derived volume, VI, TVR, and PET-derived metabolic tumor volume and total lesion glycolysis were able to predict LVSI (P = 0.0023, 0.0068, 0.0068, 0.0027, 0.01394, respectively). Imaging was not able to predict grading, presence of deep MI, nor hyperexpression of p53.

CONCLUSIONS

18F-FDG PET/MRI has good accuracy in preoperative staging of EC; PET and MRI parameters have synergic role in preoperatively predicting LVSI, with MRI parameters being also predictive for EC risk group.